AGENDA: Part 1

Please note that minutes from this meeting are a public document and will be published on the Internet and may be requested under the Freedom of Information Act (2000). Any attendee that would like their name omitted from the minutes should discuss this with the minute taker. Note that it may not always be possible to oblige as this is dependent on the persons role and the business being discussed.

web site: www.slam.nhs.uk

Board of Directors Meeting

To be held 30th October 2018 2:30pm - 5:00pm ORTUS, Maudsley Hospital

AGENDA: Part 1

Quality Improvement Focus Presentation by teams about their QI Projects (located at the back of the room)

2:30pm

Opening Matters 154/18 Welcome, apologies for absence & declarations of interest

155/18 Minutes, Action log review 2:40pm Page 1 Quality 156/18 Patient/Carer Story 2:45pm Page 11

157/18 CQC Update & Risk Focus: BAF Risk – 7 3:00pm Page 13

158/18 Emergency Department pressure and patient flow 3:20pm Page 61

159/18 Performance & Quality Report 3:35pm Page 74 Great Place to Work 160/18 Freedom to Speak up Guardian 3:50pm Page 126

161/18 Freedom to Speak Up Guidance for Boards – Development of Improvement Action Plans

4:05pm Page 142

Innovation 162/18 Quality Improvement Update 4:10pm Page 148 Value 163/18 Finance Report & N2 NHSI Report 4:20pm Page 155 Updates 164/18 Chief Executive’s Report 4:30pm Page 178

165/18 Council of Governors Update 4:35pm Page 181

166/18 Equalities & Workforce Committee update 4:40pm Page 183

167/18 Business & Development Investment Committee update Page 185

168/18 Finance & Performance Committee update Page 187

169/18 Audit Committee update Page 191

170/18 Quality Committee update Page 196 For Noting 171/18 Changing Lives Strategy – communications material 4:50pm Page 201

172/18 South London Mental Health & Community Partnership Board Minutes Page 217

173/18 Report from previous month’s Part II Page 223

174/18 Wrap-up and Next Meeting Page 224

175/18 Meeting Evaluation 4:55pm Verbal

The next Board of Directors Meeting will be held on 27th November 2018 2:30pm, at the ORTUS, Learning Centre, 82-96 Grove Lane, SE5 8SN.

Maudsley Hospital

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MINUTES OF THE HUNDRED AND TWENTY-FIRST MEETING OF THE BOARD OF DIRECTORS OF THE SOUTH LONDON AND MAUDSLEY NHS FOUNDATION TRUST

HELD ON 18 SEPTEMBER 2018 PRESENT

Roger Paffard Chair Kristin Dominy Chief Operating Officer Rachel Evans Director of Corporate Affairs Professor Ian Everall Non-Executive Director Mike Franklin Non-Executive Director Duncan Hames Non-Executive Director Gus Heafield Chief Financial Officer Dr Michael Holland Medical Director Altaf Kara Director of Strategy and Commercial June Mulroy Non-Executive Director Beverley Murphy Director of Nursing Dr Matthew Patrick Chief Executive Sally Storey Interim HR Director Dr Geraldine Strathdee Non-Executive Director Anna Walker Non-Executive Director

IN ATTENDANCE

Christine Andrews Governor Colan Ash Head of Risk & Assurance Sulanga Chakrabarti Locum Consultant Psychiatrist (CAMHS) Jenny Cobley Lead Governor Charlotte Hudson Deputy Director of Corporate Affairs Russell Mascarenhas NExT Director Zoë Reed

Director of Organisation and Community & Freedom to Speak Up Guardian

Susan Scarsbrook Governor Tutiette Thomas Governor

APOLOGIES

Béatrice Butsana-Sita Non-Executive Director BOD 136/18 WELCOME, APOLOGIES FOR ABSENCE, DECLARATIONS OF INTEREST CONFLICTS OF INTEREST REGISTER (14.44)

Mike Franklin corrected an entry in the Conflicts of Interest Register relating to his position as an independent member of Ministry of Defence Police Committee.

BOD 137/18 MINUTES, ACTION LOG REVIEW (14.44)

Board members were asked to note the inclusion in the Board pack of a letter to the management team at the Ladywell Unit following a NED / Governor visit in July, which included the Chair’s reflection on that visit. Feedback was due to be given at the last Board meeting, but time was prohibitive.

BOD 138/18 PATIENT / CARER STORY (14.44) Unfortunately, the carer due to present the story to the Board was unwell, and so the story will be taken at the next meeting.

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BOD 139/18 CQC INSPECTION UPDATE & RISK FOCUS: BAF RISK 7 (14.45) Beverley Murphy, Director of Nursing, recapped that the Trust had recently undertaken its first inspection under the new CQC methodology. Five service lines were subject to announced inspections in July, with one additional unannounced inspection that month. There was a Well Led inspection in August. The Trust has so far received high-level, verbal feedback. There are areas of work of which the Trust should be very proud, thanks to staff, but there is work to do to ensure that every day, every service user receives the quality of care that they should. A Regulation 29A warning notice was issued by the CQC in July, with clear expectations and a timetable for the Trust to make improvements to its acute pathway, where the CQC found too much variation in quality. Senior Trust leadership has now met eight times to develop an improvement plan (“Our Improvement Plan”) to address the inconsistent offer of quality. The priority areas for improvement are: fundamental standards of care; flow; governance; leadership and culture. The Board was presented with the proposed model for monitoring and oversight of Our Improvement Plan; it was noted that the model has been subject to extensive discussion between Board members ahead of this meeting. A Delivery Board has been put in place and has already met twice. This Board will receive plans and scrutinise them in order to ensure that they are in the best place to deliver improvements. These plans will then track through a Quality Portfolio Board and the Quality Committee, assisted by an Oversight and Scrutiny function. Audit Committee will also receive assurance reports as required. The responsibility for designing the Our Improvement Plan work streams has sat with the broader leadership of the organisation; Senior Management Team members are sponsors, but the design has been led by those who will deliver and own the improvements. Matthew Patrick stressed the critical importance of improving flow in the system as a key to unlocking quality improvements. All jobs in mental health are hard and there has been relentless pressure in particular over the last 9-12 months, and it will not ease until flow issues are resolved. He called for the time period for Our Improvement Plan to be referred to by weeks, not months, in order to focus the mind. Roger Paffard called for a stocktake on progress at the December Board and for ongoing stakeholder engagement to deliver flow improvement by way of Multi-Agency Discharge Events (MADE). Action: Schedule stocktake on Our Improvement Plan for December 2018 Anna Walker and Duncan Hames, as Chairs of the Quality and Audit Committees respectively, were content with the proposed governance. Anna Walker felt that these developments provide a wider opportunity for the Quality Committee to clarify its purpose and remit. An extraordinary meeting of the Quality Committee will be held to scrutinise Our Improvement Plan across work streams and make recommendations to the Board. Beverley Murphy also presented proposed amendments to the risk rating allocated to Board Assurance Framework Risk 7 (Quality & Statutory Compliance) in light of the CQC’s findings. The Senior Management Team has also identified amendments to be made to the expression of the risk and narrative around it. Anna Walker welcomed changes to the narrative, which she did not feel adequately expresses the key controls or gaps in control; the risk should not focus on delivering quality care in order to satisfy

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a regulator, but for the benefit of the population and should be expressed as such. Geraldine Strathdee felt there could be an improved articulation of basic clinical standards. Beverley Murphy undertook to bring BAF Risk 7 back to the Quality Committee for refinement; there are also implications for BAF Risk 2 (Operational Delivery Structure) which will be revisited. Roger Paffard requested a deep dive at the Board within the next two months. Action: Schedule deep dive into BAF Risks 2 (Operational Delivery Structure) and 7 (Quality and Statutory Compliance) within the next two months. It is anticipated that the final CQC inspection reports will be in the public domain in or around the second week of October. The deadline for the delivery of the necessary improvements set out in the warning notice is 31 March 2019, after which the CQC will re-inspect.

BOD 140/18 Q1 LESSONS LEARNED (15.10)

Beverley Murphy, Director of Nursing, presented this quarterly report, which was also recently discussed at the Quality Committee. Incident reporting varies a little over time, but generally the Trust’s reporting rates are static. In terms of incidents relating to violence and aggression, there is variation across the Trust but the overall levels have not changed. An independent review of themes from Serious Incidents Requiring Investigation (SIRIs) was commissioned by the Trust from Dr Jane Carthey, Human Factors and Patient Safety Consultant, to enhance learning across the Trust. Sixteen cross-cutting themes were identified, of which six were found in all operational directorates (formerly CAGs). This themed learning can be used to gain traction around improvements. There are mechanisms to ensure that lessons learned are disseminated across the Trust, but the CQC inspection has prompted a review of how effective and consistent those processes are. Depending on the information to be shared, the methodology is different. Blue light bulletins, for example, are a quick and effective way to bring urgent safety issues to the attention of frontline staff. Serious Incident review group meetings are a way to share and test learning across the Trust and with commissioners. There is a reliance on frontline teams having regular business meetings – separate from multi-disciplinary team clinical meetings – at which learning from complaints and incidents is a standing item, but the CQC inspection has highlighted that these are not happening consistently or to a set agenda. Geraldine Strathdee welcomed the inclusion of Mental Health Act-related incidents in this report, but reflected that there has not been much movement in terms of improving outcomes or having an impact on the volume of incidents. Beverley Murphy explained that the Serious Incident Review Group has moved to pushing the “why” more consistently, so that the focus is not on what happened that led to an SI, but why something happened. This approached is more likely to deliver change over time.

BOD 141/18 Q1 LEARNING FROM DEATHS (15.25)

Michael Holland, Medical Director, presented this quarterly report. One of the key areas of learning this quarter has been following up on those service users who do not attend appointments, particularly in older adult services. Anna Walker asked if the Board could look more closely at deaths of those service users with learning disabilities (LD); Michael Holland explained that CCGs are

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responsible for carrying out those reviews but that they are not consistently completed in a timely fashion. This issue has been escalated and has been flagged by acute Trusts too. The Trust reviews every death anyway – including older adults’ services, which not all Trusts do – so any learning would be picked up. However, to date no specific learning has been identified as a result of LD reviews.

BOD 142/18 CHANGING LIVES – STRATEGY REFRESH (15.33) Altaf Kara, Director of Strategy and Commercial, presented a refreshed narrative of the Trust’s Changing Lives Strategy for Board approval. The articulation of the strategy has been strengthened based on feedback from consultation with key stakeholders including staff, Governors, service users and carers. The language is now clearer about working fully and completely with patients and the aspiration for population health is emphasised. If approved, the next check point for the Strategy at the Board will be in March 2019.

Anna Walker requested, and Altaf Kara agreed, that there is more in the strategy around addressing Staff Survey results and the digital strategy. The Board advocated the clear articulation of how Our Improvement Plan aligns with the Changing Lives Strategy. The Board also considered whether it would be beneficial to draw out one single measure from the Strategy e.g. improving flow, and to make it the absolute focus for all staff. There is evidence that where other organisations have done this, there has been demonstrable change as a result. The Board was happy to proceed with the changes as set out in the supporting paper and with additional narrative around the Staff Survey and the digital strategy.

BOD 143/18 CHIEF EXECUTIVE’S REPORT (15.42) Matthew Patrick, Chief Executive, reflected on an exceptionally busy quarter, particularly in light of CQC-related work. He offered a note of thanks to all those people who have worked – and continue to work – ferociously hard during this time. It had been a busy fundraising month and was likely to get busier. He and Ian Everall have spent an increasing amount of time on the Centre for Children and Young People, including trying to find an alternative word for “Centre” which does not do justice to how broad the project is. The Programme Board is working on the Strategic Outline Case.

Mary Foulkes OBE has been appointed as SLaM’s new Director of People and Organisational Development, but the Trust will continue to benefit from the continued support of Sally Storey for some time yet. SLaM is also very lucky that, further to a terrific talk quite recently by Yvonne Coghill OBE (Director, Workforce Race Equality Standards Implementation, NHS England) to SLaM staff, she is generously coming back in November to work with the Board to help shape and emphasise its WRES work.

BOD 144/18 COUNCIL OF GOVERNORS’ UPDATE (15.48) Jenny Cobley, Lead Governor, attended to present the Governors’ update.

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The Governors have had a number of good conversations regarding the CQC inspection and warning notice with both Executive and Non-Executive Directors, and are encouraged by the improvement plans. They would like to echo Anna Walker’s observation that community services must not be overlooked. Jenny Cobley thanked the Directors who attended the extraordinary meeting of the Governors’ Quality Working Group that week to discuss bed pressures, flow, length of stay and Multi-Agency Discharge Events. Governors remain concerned about the patients who need to wait weeks for beds. Governors also think that communications within the Trust could improve, and are encouraged that the new intranet has been launched. The new directorate structure should also help communications. The Governors’ lobbying activity continues and with the help of Helen Hayes MP, a letter will be sent this week to the Secretary of State, asking for mental health funding in long-term plans for the NHS. A small group of Governors also met three Lewisham MPs, who are willing to ask mental health-related questions in parliament.

BOD 145/18 READOUT FROM NED / GOVERNOR SERVICE VISIT (15.51)

Anna Walker reported on a recent Non-Executive Director / Governor visit to three acute wards at the Maudsley Hospital. The information provided in advance was excellent preparation for an effective and useful visit, allowing more time to be spent talking to staff. Two of the wards have made significant improvements of late in terms of quality of care, which provides a positive message about how it is possible to turn poorer performance around. She and one of the Governors visited the other ward – a female PICA – and found it inspirational. The attitudes of staff (who had, for example, applied for grants to improve the sensory experience for service users) were very impressive. A theme of the visit was length of stay and the challenges around both admission and discharge. It was reported that pressure on beds on the Trust as a whole means they are sometimes keeping people on the ward longer than they need to owing to demand elsewhere. Roger Paffard endorsed these visits, which are enormously helpful to NEDs and Governors alike.

BOD 146/18 PERFORMANCE & FINANCE REPORT (15.57)

Kristin Dominy (KD) presented the performance report, summarising those indicators which are reported on routinely. She also focused on the ongoing Multi-Agency Discharge Events (MADE), which have been introduced to address flow issues. The first event was in Southwark and the learning from that will be rolled out as the process develops. MADEs are common in acute Trusts but SLaM is leading the way by holding them in Mental Health. The first step in addressing barriers to discharge is to look internally at where the Trust may be the reason for the blockage. The next step is meeting with external partners. A key challenge is where the barrier to discharge is outside of SLaM’s control e.g. where a service user lives in one borough but their GP is in another. The MADE work needs to dovetail with Complex Care Placements.

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Kristin Dominy congratulated teams for improving compliance with statutory and mandatory training. The Ann Moss Unit closed on 31 August. The closure was planned for a considerable amount of time; it was a costly, stand-alone unit and it was agreed with commissioners that better patient care would be provided when combined with Greenvale in Lambeth. Mike Franklin expressed profound concern at the volume of young people who have been on a waiting list for CAMHS services in Lewisham for over twelve months, asking what an acceptable waiting time is across the boroughs. Kris Dominy agreed that the wait is too long, but the Trust is not commissioned to the right capacity. Matthew Patrick reported that CAMHS access targets are now a national priority, and that he is meeting regulators in the next week to look at South East London access times. The national target is 35%, which is unacceptable. No time frame target is specified. Geraldine Strathdee pointed to population health metrics which suggest that borough-focused prevention strategies would ease the demand for CAMHS services. Duncan Hames was interested in understanding how the data breaks down in terms of responsibility for delayed transfers of care. He noted a significant increase in bed use in Croydon over the last quarter and asked what the drivers are and if this level of occupancy is sustainable. Kris Dominy explained that there has been a dramatic rise in people coming through Croydon and the capacity and flow through community services is also challenging, putting staff under a lot of pressure. The Board discussed pressure placed on the mental health system as acute Trusts try to avoid 12-hour breaches; some admissions to SLaM are those where there has not been time to assess home treatment options. The Board agreed that MADEs must have an impact that lead to sustainable processes; it is not just about dealing with the current crisis. The Board also discussed whether it would be feasible to set a very clear target and discharge people who are medically fit and awaiting external actions.

Gus Heafield presented the Finance Report, highlighting the particular pressures driving the overall financial position. At Month 5, the Trust is in the right place, but all non-recurrent spend has been applied for the whole year. Key drivers for the finances include flow issues, overspill, agency usage and medical agency costs. Finance Portfolio Board meetings are being held over the forthcoming weeks to look at overall financial delivery, and the Finance and Performance Committee is likely to want a detailed dive into the issues. There are significant risks around the Trust delivering its control total for 2018-19, some of which are within the Trust’s control and some are not e.g. the pay award shortfall. The paper set out mitigations in place. Duncan Hames flagged agency spend as an issue, and asked whether the gap is likely to shrink or whether it is a trend. Gus Heafield pointed to plans in place to reduce spend e.g. recruitment of Nursing Associates. The South London Partnership won £1.6m to train Nursing Associates, and SLaM attracted over a hundred applications within a day of the advert going out. September is a peak recruitment point for registered nurses, so it is hoped that will address some of the challenge. Although the Trust was well within its cap for agency spend last year, that cap has been lowered significantly, so it is not possible to compare performance by year.

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BOD 147/18 BOARD ASSURANCE FRAMEWORK (16.27) Colan Ash, Head of Risk and Assurance, attended to present updates to the Board Assurance Framework (BAF). Summaries on progress against action plans have now been added to each individual risk so that the Board can see where gaps in assurance are being addressed and can therefore challenge whether those actions are the right ones. The Board Assurance Framework now has four red-rated risks: BAF Risk 1: Workforce BAF Risk 2: Operational Delivery Structure BAF Risk 7: Quality and statutory compliance BAF Risk 9: Estates Changes to BAF Risks 2 and 7 were discussed at BOD139/18 above, and a review will be arranged at Executive level before proposed amendments are taken to Committees. The Corporate Risk Register has been re-named the Executive Risk Register. Duncan Hames reported that the Audit Committee has discussed the BAF at length. It is clearly becoming embedded in the governance of the organisation, but committees would no doubt benefit from a clear steer of what is expected of them in their oversight of those risks and how risk reviews should be recorded and reported. Action: Guidance on scrutinising and reporting BAF risks to be prepared for Board sub-committees with oversight function (BM, RE) The Board noted that it is a sign of health that the BAF changes, both in terms of ratings and narrative; it means that it is becoming part of business as usual. Colan Ash was commended for his work in developing and embedding the BAF.

BOD 148/18 BRIEFING FROM THE FINANCE AND PERFORMANCE COMMITTEE (16.35)

The report was taken as read. Geraldine Strathdee queried whether SLaM’s position in the lowest quintile of commissioner funding should be articulated as a key risk. She also supported the idea of all new Trust policies including a “Policy on a Page” summary, but only if it includes the key metrics to measure implementation. She noted the FPC Chair’s remark in the report that community services associated with the Ladywell Unit are performing “strongly”, but sought the evidence base for that assertion. Gus Heafield felt that BAF Risk 8 (Finance – Contracts) could be rephrased to incorporate commissioner contracts, and that a review of both BAF financial risks was underway and to be reported back to the next meeting of the FPC. He suggested that the rating for BAF risk 12 finance delivery would need to be increased in the current context. Duncan Hames acknowledged the risk escalated to the Board arising from the Capital, Estates and Facilities report to the Finance and Performance Committee, namely that the focus of the CEF Director must be on strategic matters and the likelihood of being drawn in to day-to-day matters reduced.

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BOD 149/18 BRIEFING FROM THE BUSINESS DEVELOPMENT AND INVESTMENT COMMITTEE

The report was noted.

BOD 150/18 BRIEFING FROM THE QUALITY COMMITTEE The report was noted. Anna Walker, Chair of the Quality Committee, drew the Board’s attention to the Committee’s plans to undertake a deep dive into waiting times across all services.

BOD 151/18 REPORT FROM PREVIOUS MONTH’S PART II MEETING (16.42) The report was noted.

BOD 152/18 WRAP UP AND PROPOSED NEXT MEETING AGENDA (16.42)

The proposed agenda for the next meeting (30 October 2018) was noted.

BOD 153/18 MEETING EVALUATION (16.43)

Gus Heafield, Chief Financial Officer, led the meeting evaluation. Starting the Board meeting with a QI presentation means that there is a good level of energy in the room from the outset; it was agreed that the posters presented will be included in Board packs going forward so that the positive and helpful projects discussed do not go unrecorded. Gus Heafield highlighted the emphasis on quality care every day and for every one as an important feature of the CQC discussion. He felt it was important that the things the Trust should be proud of were also reiterated, as it would be easy to only focus on improvements needed. He noted the Chief Executive’s expression of thanks to all for their hard work. He also noted a constructive discussion around the Performance and Finance report and the acknowledgement that the Board Assurance Framework is becoming embedded in business as usual. He felt that the Board had used the data presented to it well and there had been some useful challenge to data in the Lessons Learned and performance reports. The balance of issues was right and the meeting did not feel pressured, time-wise. The meeting closed at 16.47.

The date of the next meeting will be: 30 October 2018, 14.30 – 17.00, ORTUS CENTRE

Representatives of the press and members of the public were asked to withdraw from the remainder of the meeting having regard to the confidential nature of the business to be transacted, publicity on which would be prejudicial to the public interest. (Section 1 (2) Public Bodies Admission to Meetings Act 1960

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The Problems 1. 22% of children on medication for ADHD were not being offered

review appointments within the 6 month timeframe

2. 33% of parents and carers of children with ADHD surveyed felt

that they were not supported at all by services in Lambeth. No

parents and carers felt fully supported

3. Significant variation was observed in practice in assessment,

diagnosis and treatment of ADHD in Lambeth CAMHS

4. CAMHS Practitioners rated themselves as 64% (average)

confidence on supporting young people and families with a new

diagnosis of ADHD

These problems were impacting on safety and quality of care

AIM 1

90% of children on medication for ADHD to be offered a review

appointment within the 6 month timeframe by the end of May 2018

Oct 2017 changes made:

Dedicated administrator

Separate clinic created

on ePJS

AIM 2

Develop an ADHD Care Pathway for Lambeth CAMHS and improve

knowledge and confidence in ADHD care in all CAMHS practitioners

Nov 2017 changes made:

Database commenced

Letter templates and protocol

AIM 1: Results

Change 3: CAMHS Practitioner Feedback on ADHD Assessment Skills Session

% CAMHS

Practitioners

responding

Yes-definitely

The Next Steps

1. Deep dive into DNA rates and improving attendance

2. Focus on parent and school questionnaires and optimising return

rates

3. Ongoing monitoring of offered appointments to ensure enduring

improvement in quality

4. Service User Involvement—parent group are engaged but we need

to involve the young people—logo competition, ADHD specific PPI

events

5. Ongoing improvements in staff training—induction into ADHD care

pathway for new staff

The Implications for Practice

1. ADHD Care Pathways carry a high administrative burden —

cost effective improvements to quality can be achieved with

dedicated admin support

2. A clear ADHD care pathway and training programme increase

confidence in non-ADHD-specialist CAMHS practitioners

For 5 consecutive months, since May 2018, 100% of children on

medication for ADHD have been offered a medication review

within the 6 month timeframe, despite staff changes

SUSTAINED IMPROVEMENT ACHEIVED

Change 1: Create ADHD Care Pathway Flowchart

Circulated to CAMHS Practitioners

Informal feedback taken from stakeholders

AIM 2: PDSA Cycle

Change 2: Amend ADHD care Pathway

Flowchart & Hold ADHD Care Pathway Event

Formal feedback highlights areas where

confidence is low

Change 3: Hold ADHD

Assessment Skills Session

CAMHS Practitioners now rate themselves as 86% (average) in confidence

ratings on how to seek help and identify next steps in ADHD care

Correspondence: [email protected] Thanks to: Nirusha Nicholas, Natasha Hayward and Elizabeth Alder

Lambeth CAMHS ADHD Care Pathway—A Quality Improvement Project

Dr Jane Anderson, Katherine Cheesman, Signe Fog—Lambeth CAMHS

Driver Diagram

May 2018 changes made:

Induction Handbook introduced

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Public Board meeting 30 October 2018 – Action points

Ref Issue/Board Paper Action By When Status RAG

September 2018

BOD 139/18

CQC Inspection Update and Risk Focus

Schedule stocktake on Our Improvement Plan for December 2018

RE Dec 18 Scheduled for December 18

BOD 139/18

CQC Inspection Update and Risk Focus

Schedule deep dive into BAF Risks 2 (Operational Delivery Structure) and 7 (Quality and Statutory Compliance) within the next two months.

RE Oct 18 – Nov 18 BAF Risk 7 scheduled for October; BAF Risk 2 for November

BOD 147/18

Board Assurance Framework review

Guidance on scrutinising and reporting BAF risks to be prepared for Board sub-committees with oversight function

BM, RE

Dec 18 / Jan 19 Not yet due

Key: Green – completed Amber – on schedule Red – not on schedule

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REPORT TO THE TRUST BOARD: PUBLIC

30 October 2018

Title

Patient’s / Carer’s Story

Author Parent Carer supported by Marianne Caitane, Patient and Public Involvement Facilitator, CAMHS Directorate

Presenter Parent Carer, supported by Marianne Caitane

Purpose of the paper

Parent presentation about being a carer to her daughter who is also her carer and the issues and risks they face. To give an example of the complexities faced when the service user is also a carer for her mother and both their needs need to be considered during a crisis. The young person has now transitioned into adult services.

Risks / issues for escalation

BAF Risk 5 – Partnership working with service users - If the Trust fail to listen to the experience of people that use services and / or fail to implement the learning from all sources of adverse incidents there is a risk that services will not learn, not improve safety and present unacceptable risks for people that use services.

The Service User Story My name is ….. and my daughter was a service user in CAMHS and has now moved into adult services. I am a carer to my daughter, and my daughter is my carer. How we got to CAMHS

• Referral to Faces in Focus for counselling by GP • Then we were referred to CAMHS as we needed specialist treatment that only CAMHS could provide • Overall experience at CAMHS has been positive • As a parent, I’ve been involved in the decision-making, I’m always in the room and I'm given the

choice to stay in the room • My daughter also has a choice in whether I’m in the room

What makes my situation difficult? An example of a difficult situation was when my daughter was in A&E during a mental health crisis

• She was assessed and had to wait in an interview room in A&E, as at that time she was too old to go to a paediatric ward and too young for an adult ward.

• We had to stay overnight, and I only had an uncomfortable chair to sit and my daughter on the two-seater sofa.

• I have a chronic physical health condition and had to make the difficult choice of going home, therefore leaving her in the hospital, or end up being admitted myself.

• I was naturally worried about my daughter staying alone without me in A&E, but also she was left with a male nurse and I was not comfortable with it.

• Thankfully my daughter told me the nurse was really nice

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• The next day my daughter was reassessed, the A&E staff contacted CAMHS as soon as I mentioned she was a user of the service, and we saw our clinician the same day

What help did I need?

If there was a bed for me I would have stayed What effect did it have on my child?

She was anxious about me leaving her, especially as it was her first experience and she did not know what was going to happen

What we did not do well / what can SLaM do to help?

That my health issues should be included in her care plan and clear actions indicated of what to do if I am in a crisis.

Put things in place that help health and social care link up to support families

A risk assessment that includes impact of both our health issues addressed in her care plan What would you like to see?

I would like support to be in place for my daughter to have health and social care professional help to make sure she is eating, taking her medication, bathing etc. These are the risks if I am unwell and not able to care for her.

An awareness of how the risk to me is increased when stressed in a catch-22 situation and makes things worse.

What we have done well/ will do now/ what we are doing as a Trust? (identified by the parent carer

and PPI facilitator)

We have listened. The Parent carer told her story of her experience at the Family and Carers’ Listening event in June 2018

Katherine Allen, Lead for recovery and service user, carer and family experience, Birmingham and Solihull Mental Health NHS Foundation Trust gave a talk about ‘Planning for the future and Emergency Planning’ and the Trust is looking into creating information for families addressing this issue.

CAMHS will discuss this issue and make recommendations for staff re considering more focussed care planning considering family’s needs and people caring responsibilities as family members. Resources: Think Family Strategy, new community care plan.

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30 October 2018

Title

CQC inspection July – August 2018: Report findings and outcomes

Author Mary O’Donovan, Head of Quality

Accountable Director Beverley Murphy, Director of Nursing


1. To report the outcome of the announced CQC inspection in July – August 2018. 2. To share the updated corresponding BAF risk. 3. To outline the improvement work underway and to seek approval of the submission of the plans

to the CQC.

Executive summary

This paper follows a report to the Board September 2018 when full details of the inspection process and verbal feedback were shared. The September paper also outlined the governance structures for overseeing the developing improvement plans. Following on, this paper shares in full the outcome and ratings of the inspection including the findings from the Well Led inspection. The full report is available on https://www.cqc.org.uk/provider/RV5 The Senior Management Team has considered the associated risks and accordingly BAF risk 7 (Quality and Statutory Compliance) has been updated and is included for consideration by the Board. As set out in the September paper, the Trust leadership team has worked collaboratively to understand the risks to consistent quality of care and has worked together to design an improvement plan. Using the improvement plan as a basis for responding to the recommendations set out by the CQC (should do and must do actions), each operational directorate has now developed a local implementation plan for the improvement actions. The Board is asked to approve the submission of the implementation plans to the CQC as a part of the regulatory process. The implementation plans address the immediate priorities to address the issues identified by the CQC. There is more work to do outside of the regulatory process to ensure our improvement plan delivers the necessary systemic changes over time and that locally implemented improvements are sustainable.


Quality Priorities

Reducing violence by 50% over three years with the aim of reducing all types of restrictive

practices

All patients will have access to the right care at the right time in the appropriate setting

Within three years we will routinely involve service users and carers in: service design,

improvement, governance and the planning and delivery of their loved one’s care.

Over the next three years we will enable staff to experience improved satisfaction and joy at work

Board Assurance Framework BAF Risk 1 - Workforce BAF Risk 2- Operational delivery structure BAF Risk 7 - Quality and statutory compliance

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https://www.cqc.org.uk/provider/RV5

Committees where this item has been considered

Date Committee / Meeting

17/10/18 Quality Committee

CQC Inspection July–August 2018

Outcomes and Response to Regulation 29A Warning Notice

1.0 Introduction

This report updates the Board on the findings of the CQC inspection as set out in the report published by

the CQC on 23rd October. It also provides information about the improvement plans underway.

As part of the Chief Inspector of Hospitals (CIH) inspection regime the Trust was subject to a planned

comprehensive Care Quality Commission Well Led Inspection (CQC) during the months of July and August

2018. There were six service pathway lines inspected as part of this inspection process, table one outlines

the most current ratings prior to the July 2018 inspection.

Table one: CQC Trust Ratings: June 2018 (before the inspection)

2.0 CQC Inspection Process

Last month Board received a detailed paper setting out the process of inspection. The table below shares

the final stages of the process.

Date - Month/Week Inspection process

20 September 2018 CQC Draft reports received and factual accuracy stage initiated

21-08 October 2018 Factual accuracy review by SLaM

08 October 2018 Factual accuracy submission to CQC by SLaM

23rd October 2018 Final CQC reports published

30th October 2018 Improvement plans considered by the Trust Board

30th October 2018 Improvement plans submitted to the CQC

Table two: CQC inspection timeframe/process March- October 2018

3.0 Final report findings and outcomes

3.1 Overall Trust Ratings

The new CQC inspection findings are outlined below.

Safe Effective Caring Responsive Well-led Overall

TRUSTWIDE Requires

ImprovementGood Good Good Good Good

Acute wards for adults of working age and psychiatric

intensive care units- Inspected 2017Requires

Improvement

Requires

ImprovementGood Good

Requires

Improvement

Requires

Improvement

Community-based mental health services for older people-

Inspected 2015

Requires


Forensic inpatient/secure wards- Inspected 2015 Requires

ImprovementGood Good

Requires

ImprovementGood

Requires

Improvement

Mental health crisis services and health-based places of

safety- Inspected 2015

Requires


Specialist Services- Eating Disorders - yet to be ratedAwaiting rating Awaiting rating Awaiting rating Awaiting rating Awaiting rating Awaiting rating

Specialist Services- Lishman- yet to be ratedAwaiting rating Awaiting rating Awaiting rating Awaiting rating Awaiting rating Awaiting rating

Rating KeyInadequate

Requires

ImprovementGood Outstanding

Page 14 of 224

Table three: CQC Ratings for whole Trust 2018

Trust wide ratings

The table above outlines the CQC ratings for the whole Trust. This demonstrates that the Trust retains an overall GOOD rating as well as being rated GOOD for WELL LED. Forensic Inpatient services improved from requires improvement to good, this is a great achievement. The CQC provide overall ratings for mental health services by combining their ratings for services. Their decisions on overall ratings take into account the relative size of services. The individual pathway ratings inspected in 2018 alongside the other existing pathway ratings are outlined in Table four. The ratings are made up of all current ratings from this and the previous inspections. Safe Domain The rating in the domain of safe remains as requires improvement. Three of the clinical pathways inspected in 2018 and two new services were all rated as GOOD in the safe domain. Acute wards in the safe domain remain as requires improvement and three services not inspected this time have a standing rating of requires improvement. Effective Domain The overall rating in the domain of effective remains as GOOD. Three of the clinical pathways inspected in 2018 and two new services were all rated as GOOD in this domain. Acute wards in the effective domain remain as requires improvement alongside one other service not inspected this time; long stay/rehab. Four other clinical pathways not inspected this time have a standing rating of GOOD whilst two other pathways have OUTSTANDING. Caring Domain The overall rating in the domain of caring remains as GOOD. All six pathways inspected in 2018 were rated GOOD in this domain. Two pathways not inspected this time have a standing rating of OUTSTANDING, whilst the remaining five pathways are GOOD. Responsive Domain The overall rating in the domain of Responsive remains as GOOD. Five of the pathways inspected in 2018 obtained a rating of GOOD, with Forensic Inpatient services improving from a previous rating in 2015 of requires improvement. However, the acute pathway received an Inadequate rating due bed flow and subsequent patient experience. Of the pathways not inspected this time one has a standing rating of requires improvement whilst the remaining pathways GOOD. Well Led The overall rating in the domain of Well Led remains as GOOD. Four of the pathways inspected in 2018 obtained a rating of GOOD, whilst the pathway Mental Health Older Adults community services obtained a rating of OUTSTANDING. However the acute pathway received an inadequate rating due areas of concern outlined in the previous board report resulting in Regulation 29A (HSCA) warning notice. The Improvement notice covered the areas below:

Page 15 of 224

(i) The systems and processes you have in place to ensure you are compliant with the Health and Social Care Act 2008 are not operating effectively in the acute wards for adults of working age and the psychiatric intensive care units.

(ii) Sometimes you were not assessing and monitoring the quality and safety of the services you

provide.

(iii) At other times you were assessing and monitoring, but then not taking the necessary steps to mitigate the risks to the health safety and welfare of patients using your services.

(iv) This meant that we found significant variation between wards that was impacting on the care and

treatment received by patients. The above areas resulted in the following priority areas for improvement:

(i) Fundamental standards of care (ii) Governance; ie. (Board to Ward- Improvement plan- Trustwide Must do #1.3.2) (iii) Leadership and culture (iv) Clinical pathways including flow and discharge planning.

3.2 CQC Ratings 2018

Table four: CQC Ratings for SLaM mental health services 2018

The CQC reports both comprehensive and evidence appendices combined are available at the link outlined

below and contain the detailed findings.


The key points from the findings and outcomes following the inspection are:

The rating in the domain of safe remains as requires improvement for reasons explained above.

Page 16 of 224


Acute inpatient units (including PICU) have been graded as inadequate in both the responsive and well

led domains. The responsive rating is the result of bed flow and subsequent patient experience, while the

well-led domain rating is related to the warning notice fully detailed in the previous report to the Board. This

results in the overall rating for acute wards moving to inadequate. Immediate action was taken on feedback

from the CQC, the Trust Improvement Plan has been developed by the Leadership Team and the Operational

Directorate Implementation plans are summarised in the Gantt chart attached in appendix 1.

Forensic inpatient services have moved from requires improvement overall to good, this follows focussed

and sustained work over time.

Crisis teams the Health Based Place of Safety have moved from requires improvement in the safe domain

to GOOD and maintained its overall rating of GOOD.

Older people’s community services have moved from requires improvement in safe to a good rating and the

leadership team succeeded in attracting an outstanding rating for well led. These are fantastic achievements

- well done to everyone involved!

Specialist Neuropsychiatry Inpatient service was the only service line subject to an unannounced inspection,

the ratings are good across all domains and overall.

Specialist Eating disorder service, which had been inspected earlier in the year (although not rated) had

incurred specific actions from issues raised. The inspection highlighted the improvements made and is now

assessed as good across the board.

3.3 WELL LED Ratings

The CQC report highlights the rationale for rating the Trust GOOD for WELL LED which is summarised below.

The trust had a high calibre board, with a wide range of appropriate skills and experience, who were open and determined to make the necessary changes to provide high quality care to their local communities.

Effective participation in local care systems, most developed in Lambeth. The South London Partnership was delivering new models of care for patients receiving national and specialist services.

Strong academic and research links

Progress with quality improvement programme

Good staff engagement (as shown in the staff survey) promoting good communication via Leadership walkabouts, Freedom to Speak Up Guardians.

The trust was working with the BME staff network to implement a range of measures to improve career progression and address discrimination for BME staff.

The trust had many excellent examples of working with people who use services and carers.

Staff were proactive in addressing the needs of people with protected characteristics.

The governors were performing their role well and holding non-executive directors to account. This had significantly improved since the last inspection and reflected the desire of the board to be open and transparent.

Systems in place to identify risk and the board assurance framework had recognised the pressures on the system including the unavailability of beds to people in crisis.

The quality of the investigation reports following a serious incident were of a high standard.

The trust was actively engaged in pioneering and developing digital innovations. This included the piloting of electronic observations and a personal health record to digitally engage patients in their care.

The trust had made significant improvements to care environments since the comprehensive inspection in September 2015. This was particularly noticeable in the introduction of a single, centralised, purpose-built health based place of safety at the Maudsley Hospital.

The areas where the CQC found required further work to improve in the WELL LED and have been incorporated into the Improvement plans currently underway.

Unwarranted variations in standards of care in both inpatient and adult community mental health teams.

Page 17 of 224

Variation of quality of leadership at ward and team level.

Breaches of fundamental standards of care on the acute inpatient wards, which included the flow of patients into and out of the acute care pathway was poor. Bed occupancy was above 100% on most of the acute wards.

Governance systems within Acute had not identified the unacceptable practice and escalated where necessary. This included poor communication with teams and wards, lack of local quality governance meetings and shared learning.

Environmental risks within acute pathway not always thorough and significant risk mitigated. of findings

4.0 Improvement Plans

Following the inspection in 2018 and previous inspections in 2015 and 2017 the CQC highlighted and

summarised both new and existing improvement actions which are highlighted below.

Date of Inspection

Number of MUST Dos

Number of SHOULD Dos

Trustwide 2018 3 9

Acute wards for adults of working age and psychiatric intensive care units

2018 11 10

Community-based mental health services for adults of working age

2017 4 9

Mental health crisis services and health-based place of safety

2018 0 6

Wards for children and young people 2015 0 12

Community-based mental health services for children and young people

2015

Forensic inpatient/secure wards 2018 0 4

Wards for long-stay/rehabilitation - working age adults

2015 4 14

Wards for older adults 2017 1 11

Community-based mental health services for older adults

2018 0 4

Community-based mental health services - learning disabilities or autism

2015 0 0

Wards for people with learning disabilities or autism

2015 0 0

Specialist services - eating disorders 2018 0 6

Specialist National Psychosis Unit 2015 0 7

Specialist services - Lishman/neuropsychiatry

2018 0 10

Total

22 102

Table five: Mental health services CQC actions

These plans are outlined in detail in Appendix 1 Gantt chart.

The corresponding BAF (BAF 7) has been reviewed and is attached at appendix 2 for consideration and approval. The work to improve flow through the system is a key part of our plans and is explored more fully in the separate paper being brought to the Board this month.

Page 18 of 224

5.0 Development of operational directorate implementation plans Using the work of the trust leadership over the summer months, the Service Directors have led the work to develop local implementation plans. There is one plan for each Operational Directorate. These plans will address the priority actions although Our Improvement Plan will address wider issues and be implemented across a longer time period and is designed to underpin sustainable improvements. The improvement plans have been closely considered by SMT, early drafts were considered by the Delivery Board and the Quality Portfolio Board. An extraordinary Quality committee with a focus on the implementation plans was held on 17th October 2018 where it was confirmed that a measurement strategy was being developed to ensure impact of the actions could be both monitored and measured. Each of the plans is slightly different to reflect the structures and position in each Borough but they cover the same key requirements. The plans in their entirety run to more than 250 papers and are not included in the Board pack but are readily available upon request. The Board of Directors is asked to approve the submission of the implementation plans to the CQC as the final inspection process task. Once approved the plans will be delivered in the operational directorates, the delivery will be governed as detailed in a paper to the Board in September 2018.

6.0 Conclusion

It is positive to note improvements to three of the pathways inspected, Forensic Inpatient, Crisis Services and

Older Adults Community services as well as the positive good results for specialist services, Eating Disorders

and Neuropsychiatry previously unrated. These represent significant achievements that are the result of

considerable hard work. It was also positive that the Trust maintained its overall GOOD rating.

However, as outlined in last month’s Board report, the receipt of a warning notice regulation 29A (HSCA) warning notice for the Acute and PICU pathway is very concerning. The improvement work streams developed over the summer in response to this warning notice have helped underpin the individual pathway implementation of local action plans which will help reduce the variation in fundamental standards of care highlighted during the inspection. The move to Operational Directorates has now had time to embed and will further help with the implementation of these plans. There is also considerable work being undertaken to improve flow and this is the subject of a separate paper at the October Board. It is still planned that the improvement plans be delivered in three six-month phases so that we can prioritise the actions that will have the greatest impact, monitor outcomes and deliver maximum engagement.

Appendix 1: GANTT Improvement Plan Appendix 2: BAF risk 7

Page 19 of 224

TOP LEVEL GOVERNANCE SCHEDULE

PROJECT NAME: Corporate CQC delivery plan BY: PMO

Action complete Action on track Action not on track

OCTOBER 2018 NOVEMBER 2018 DECEMBER 2018 JANUARY 2019 FEBRUARY 2019 MARCH 2019 2019 - 2020

1 8 15 22 29 5 12 19 26 3 10 17 24 7 14 21 28 4 11 18 25 4 11 18 25 Q1 Q2 Q3

W1 W2 W3 W4 W5 W6 W7 W8 W9 W10 W11 W12 W13 W14 W15 W16 W17 W18 W19W2

0

W2

1

W2

2W23

W2

4W25

1.1.1 The Trust will ensure that all fundamental standards of care are clearly

communicated and available to all staff.

Service Directors/Head of

Nursing01/10/18 TBC

1.1.2Training on key policy standards will be offered to all members of staff,

including on physical healthcare post Rapid Tranquilisation. Trust Policy leads 01/10/18 TBC

1.1.3Operational Directorates will have effective plans in place to identify, monitor

and implement required standards of care.Service Directors 01/10/18 TBC

1.1.4 Obstacles to FSOC adherence will be identified and tackled or mitigated. Service Directors 01/10/18 TBC

1.1.5The Trust will introduce a package of measures to improve patient flow and

help ensure patients always have a bed when receiving inpatient care

Chief Operating Officer/Medical

Director01/10/18 TBC

1.2.1Immediate actions will be taken forward at Operational Directorate level to

address the immediate specific issues identified in the inspection reports.Service Directors 01/10/18

1.2.2

Individual action-plans and team objectives will be developed for all wards

and teams where the CQC have raised concerns to provide support and

drive improvement, including group and individual wrap-around support

Service Directors 01/10/18

1.2.3Team development days and team appraisals will be organised for named

teams, to be delivered by SLaM Partners.

SLaM Partners/Service

Directors01/10/18

1.2.4All senior vacancies, including matrons, within the new Operational

Directorates will be filled.Service Directors 01/10/18

1.2.5Executive sponsors from Operational Directorate leadership teams will be

identified for each ward or team and will visit the ward / team regularly.Service Directors 01/10/18

1.2.6

New inpatient and Community QuESTT scores launched and will be

triangulated with feedback from visits and Leadership Walkarounds. These

will be monitored at the Quality

Director of Nursing/Chief

Operating officer01/10/18

1.3.1 The Trust dashboard (Deming) will set out 12 KPIs that drill down to

Directorate and team / ward level. Deputy Medical Director 01/10/18

1.3.2

A single monthly package of wider information (Quality and Performance

Review Data) from the Nursing Team, the PMO, Business Intelligence,

Complaints etc. will be provided for each Directorate in advance so that a

single pack can be considered at the executive Quality and Performance

meetings. This will be consistent with the information provided to the Board.

Director of Nursing/ Chief

Operating Officer/Medical

Director

01/10/18

2.1.1 Review opportunities currently available HR Director 01/10/18 16/11/18

2.1.2Capture requirements in directorate training plans and agree plans to close

gaps that existHR Director 01/10/18 30/11/18

2.1.3Refresh Talent Management Strategy and Action Plan for approval at the

Equalities and Workforce CommitteeHR Director 01/10/18 30/11/18

2.2.1 The final narrative of the Strategy to come to the Board for approval in

September [complete]

Director of Strategy and

Commercial01/10/18 30/09/18

2.2.2The Strategy should be launched to all staff and engagement with service

users and local communities


Commercial01/10/18 31/10/18

2.2.3 A detailed plan to return to the Board.Director of Strategy and

Commercial01/10/18 30/06/19

Ref: Activity or Milestone Title Responsible

Oversight

& Scrutiny

Delivery

Board

Planned Start

Date

Planned End

Date

Portfolio

Board

2.1 The trust should ensure that leadership development opportunities are available for aspirant and current ward

and team managers.

2.2 The trust should complete the work needed to consult on and launch the refreshed strategy.

2. TRUST should dos

1. TRUST Must dos

1.1 The trust must ensure fundamental standards of care (FSOC) are understood and implemented across the trust.

This must include ensuring that patients always have a bed when receiving inpatient care.

1.2 The trust must identify and provide timely support to wards and teams where standards of care need to improve

1.3 The trust must have effective systems in place to ensure information is shared consistently with wards and

teams

Page 20 of 224

2.3.1 Deliver year 2 of the WRES action plan as monitored by the Equalities and

Workforce Committee.HR Director 01/10/18 31/09/19

2.3.2Yvonne Coghill work with the Board to deliver step change in culture led from

the topHR Director 01/10/18 30/11/18

2.3.3Two individuals supported to become WRES Experts on Yvonne Coghill

programmeHR Director 01/10/18 31/12/19

2.3.4 Staff network support in place HR Director 01/10/18 Ongoing

2.4.1 The FTSU Steering Group will continue to drive an ambitions

Communications Plan.

Chief Executive

Chair

Freedom to Speak Up Guardian

01/10/18 30/06/19

2.4.2

Open advertising for Advocates will continue in addition to asking

Management Teams to identify staff who would benefit from the

development opportunity.

Chief Executive

Chair


01/10/18 30/06/19

2.4.3

Training package will be developed including Coaching Skills course for all

advocates as well as production of Advocates Information Pack containing

links to all relevant Policies and Procedures

Chief Executive

Chair


01/10/18 30/06/19

2.5.1 Delivery of NHSI retention strategy HR Director 01/10/18 31/03/19

2.6.1 All evidence to the NHSE assessment process will be submitted [action

complete].Chief Operating Officer 01/10/18 31/10/19

2.6.2 Assessment with NHSE will be undertaken during November and will result

in a work plan.Chief Operating Officer 01/10/18 30/11/19

2.7.1 a.

Trust wide campaign to increase recording of NHS AIS field with a view to

30% of the Trust’s service users by Mar 19 (Trust Integrated Equalities

Action plan commitment). This will include:

a. Clear message about the mandatory requirement to ask and record

accessible communications needs promoted to all staff through Trust-wide

communications and clinical structures.


Commercial01/10/18 31/03/19

2.7.1 b. b. Promotion of resources to support good practice available on Maud.Director of Strategy and

Commercial01/10/18 30/11/18

2.7.1 c. c. Monthly reports of completion rates sent to Service Directors from Nov 18

to Mar 19.


Commercial01/11/18 31/03/19

2.7.2 New ePJS patient over-view screen goes live and includes accessible

information flag


Commercial01/10/18 01/01/19

2.7.3 Accessible communication e-learning module is launched on LEAP Director of Strategy and

Commercial01/10/18 01/04/19

2.7.4 Trust will continue work to improve overall quality and accessibility of

information whether in written format or through the trust website.


Commercial01/10/18 Ongoing

2.7.5 Annual trust communications survey will measure staff awareness of AIS

requirements and resources from Q1 2019-20.


Commercial01/10/18 30/04/19

2.8.1 Application to NHSI re Board Development programme on Quality

ImprovementMedical Director 01/10/18 31/10/18

2.8.2 Quality huddles introduced in all Directorates Medical Director 01/10/18 31/10/18

2.8.3

Action plans for teams recognised as requiring additional support will include

elements on QI. Medical Director 01/10/18 31/10/18

2.7 The trust should continue the work to embed the accessible information standard (AIS).

2.8 The trust should continue to embed quality improvement and support staff from across the trust to participate in

the work.

2.3 The trust should continue to take steps to further improve the results of the workforce race equality standards.

They should also continue to support the staff networks to ensure staff with protected characteristics have their

diversity and human rights protected and promoted.

2.6 The trust should complete the work to ensure adequate arrangements are in place for emergency planning and

business continuity.

2.4 The trust should continue to promote the work of the Freedom to Speak Up Guardian and ensure advocates are

selected openly and offered training to perform their role.

2.5 The trust should continue the work to improve the retention of staff.

Page 21 of 224

2.8.4

QI skills development will continue with:

a. Introduction to QI as part of induction into the Trust (online) is in

development

b. On line learning- in place KHP investigate further online learning

c. Introduction to QI one day training for anyone interested in QI

d. QI Foundation Programme

e. Recovery college QI course

f. Intermediate QI programme to develop QI coach capacity and capability

across directorates supported through the central QI team

g. Data training and coaching to develop capacity and capability within

services to use data to inform decisions and improvement work

Medical Director 01/10/18 31/10/18

Page 22 of 224


PROJECT NAME: Lambeth CQC delivery plan BY: PMO


OCTOBER 2018 NOVEMBER 2018 DECEMBER 2018 JANUARY 2019 FEBRUARY 2019 MARCH 2019

1 8 15 22 29 5 12 19 26 3 10 17 24 7 14 21 28 4 11 18 25 4 11 18 25 Q1 Q2 Q3 Q4

W1 W2 W3 W4 W5 W6 W7 W8 W9 W10 W11 W12 W13 W14 W15 W16 W17 W18 W19 W20 W21 W22 W23 W24 W25

1.1.1

Conduct a baseline audit of the FSoC on each ward and use these results to

generate an individualised action plans for each ward for delivery within 2 months.

This will be conducted by the ward manager and their Executive Sponsor (end of

October 2018)

Team leader, reporting to the

General Manager, Health and

Safety Advisor and oversight by

the Deputy Director

01/10/18 31/10/18

1.1.2

A review of progress against the action plan per ward will take place after 1 month

(end of November 2018) and again at the end of the 2-month period (December

2018). It will then become a rolling 2 monthly cycle carried out by modern matron

and ward manager.

Modern Matron accountable to the

Head of Nursing and Deputy

Director

01/10/18 31/12/18

1.1.3

The Executive will ensure the following policies are fully embedded through the

rolling audit programme by December 2018.

• PSTS, seclusion, physical health care policy and cardiopulmonary resuscitation

managing medically deteriorating patient and the rapid tranquilisation nursing

protocol (aligned to RT section of the user medicines policy)

• Risk assessment and care planning

• The ‘4 steps to safety’ quality improvement programme and

• Learning from clinical incidents

Lambeth Executive 01/10/18 31/12/18

1.1.4 Additionally Executive Sponsors will develop an individualised action plan for each

sponsored ward Lambeth Executive 01/10/18 30/11/18

1.1.5Nelson ward : We have completed a review the visibility of confidential information

to people outside of the nursing office.Modern Matron 01/10/18 Complete

1.1.6

Nelson ward :Computer privacy screen shields for each computer in the nursing

office will be in place by end of October 2018 Modern Matron 01/10/18 31/10/18

1.1.7

Nelson ward :Staff have been formally reminded to ensure that the white board

within the nursing office is covered by screens and closed when not in use. We will

continue to monitor this on an on-going basis.Modern Matron 01/10/18 Complete

1.1.8Nelson ward :The Nelson ward manager post is currently being advertised (October

2018)Modern Matron 01/10/18 31/10/18

1.1.9Nelson ward : The nursing vacancies have reduced due to new recruits starting in

post (see vacancy table).Modern Matron 01/10/18 Complete

1.1.10LEO ward : The LEO ward manager post is currently being advertised (October

2018). Modern Matron 01/10/18 31/10/18

1.1.11LEO ward : We are currently providing additional 1 day support from a modern

matron for the interim Ward Manager.Modern Matron 31/10/18 Ongoing

1.1.12

LEO ward: We are recruiting to the vacant posts via the Trust’s central recruitment

processes and will also be holding a Lambeth specific recruitment programme in

November 2018.

Modern Matron 31/10/18 Ongoing

1.1.13Eden Ward: We are currently working with the team to review their establishment

and use of enhanced observations to be finished by end of November 2018.Modern Matron 01/10/18 30/11/18

1.1.14Eden Ward: At the time of the inspection, once alerted to the concerns re: sight

line/blind spot on the ward, we immediately installed a mirror to mitigate this risk.Modern Matron 01/10/18 Complete

1.1.15Eden Ward: We have ordered a drinking fountain which will be situated in the

communal dining room. This will be installed by end of October 2018.Modern Matron 01/10/18 31/10/18

1.1.16

Rosa Parks staff have formally been reminded to ensure that the white board within

the nursing office is covered by screens and closed when not in use. We will

continue to monitor this on an on-going basis.

Modern Matron 01/10/18 Complete

1.1.17

Rosa Parks : We are recruiting to the vacant posts via the Trust’s central

recruitment processes and will also be holding a Lambeth specific recruitment

programme in November 2018.

Modern Matron 01/10/18 30/11/18

1.2.1

In addition to our weekly QI huddle, we will add an additional fortnightly safety

huddle looking at the following domains:

• V&A

• Rapid Tranquilisation

• All incidents recorded as C and above on DATIX over the previous 2 weeks

• MHAA cancellations and action plans (first huddle 15th October 2018)




the Deputy Director

01/10/18 Complete

2019 - 2020


Portfolio

Board

Oversight

& Scrutiny

Delivery

Board

Planned Start

Date

Planned End

Date

1. MUST Dos: Acute wards for adults of working age and psychiatric intensive care unit

1.1 The trust must identify and provide timely support to wards and teams where standards of care need to improve

1.2 The trust must ensure that governance processes are sufficiently robust so that they identify where improvements

need to be made and ensure that action is taken to make the required improvements

Page 23 of 224

1.2.2

The Lambeth Governance Executive agenda has been reviewed to include the

following standard items:

• FSoC

• Leadership & Governance

• Flow

• Learning Lessons

Lambeth Executive 01/10/18 Complete

1.2.3Additionally, Lessons Learnt has been incorporated into the Lambeth Leadership

Interface meeting agendaLambeth Executive 01/10/18 Complete

1.2.4All clinical service governance meeting minutes will be centrally stored and reviewed

quarterly




the Deputy Director

01/10/18 30/11/18

1.2.5

We will develop a pictogram highlighting the clear lines of accountability so that the

right people consider all the right issues and cascade this to all staff so they are

aware of this


1.3.1 A new drinking fountain has been ordered for Eden ward to widen the availability of

drinking water on this unit. This will be available in communal dining area by


General Manager, Health and 01/10/18 31/10/18

1.3.2 Any faults will be reported via Planet FM for resolution. Team leader, reporting to the


1.4.1 All nursing staff to attend the RT training which emphasises the requirement to

conduct physical health checks on people after they receive rapid tranquilisation by


Modern Matron 01/10/18 30/11/18

1.4.2 This will be monitored in supervision and via the ward manager regularly to ensure

completion on an ongoing basis.General manager for inpatients 31/10/18 Ongoing

1.4.3The ward manager and Modern Matron/CSL will review each incident within 24

hours. They will record their review update on DATIX stating if reviews have


Modern Matron 01/10/18 31/10/18

1.4.4Issues of non-compliance will be escalated to the General Manager, Head of


Modern Matron 31/10/18 Ongoing

1.4.5 Lessons learnt will be reviewed in team meetings, service governance meetings,

serious Incidents/Lessons Learnt panel and LODGE by October 2018.General manager for inpatients 01/10/18 31/10/18

1.5.1 We will review all Risk assessments – for all wards (ligature, H&S) and ensures

these are signed off by general manager and wards are aware of any mitigation and



1.5.2 These will be continued to be reviewed annuallyTeam leader, reporting to the

General Manager, Health and 01/10/18 Ongoing

1.5.3We will ensure that the potential ligature anchors are added to the induction pack

and a picture of it is added to the ligature picture list by 31st October 2018.



1.5.4We will ensure all laundry baskets are available in all wards and meet trust standard

by end of October 2018



1.5.5Compliance will be reported and monitored via the Trus wide Health & Safety

committee on an on-going basis.



1.5.6All staff will be informed that for people under our care who present with specific or

different needs the risks in relation to that patient will be reviewed and



1.5.7We will now utilise team business meetings to update on risks assessed on an

ongoing basis.



1.6.1All wards will implement ‘4 steps to safety’ and the PSTS policy by 30th November

2018


Modern Matron and General 01/10/18 30/11/18

1.6.2Data will be reviewed monthly in the safety huddle to monitor escalations of violence

and action plans to address these will be developed. This will also be presented at



1.6.3Teams that do not engage will have an individual meeting with members from the

Lambeth Executive to understand the barriers to implementation and develop an



1.6.4Deputy Directors/General Managers will respond to all DATIX relating to violence; to

ascertain if support is required/how involved service users/staff after the incident on


Modern Matron and General 01/10/18 Ongoing

2.7.1There will be a rolling programme of DATIX training that all staff will complete by

end of January 2019. This will include the use of DATIX action modules for all

Lambeth Executive,

Ward Managers and Team 01/10/18 31/01/19

2.7.2All staff to be aware that unspecified recordings on DATIX will be reviewed and

specified accordingly by ward manager and charge nurses on an on-going basis and

Lambeth Executive,


2.7.3Lessons learnt will be a standard agenda time for every team governance meeting

and LODGE (governance) meeting as well as a regular item at the monthly Lambeth

Lambeth Executive,


2.7.4Information about themes from lessons learned will be communicated to all team

leaders/ward managers from the Lambeth Governance team on a monthly basis via

Lambeth Executive,


1.8.1 We will fully embed the Trust plan for addressing flow within the borough and the

aim to work at 85% occupancy from October 2018.

Team leader and General

Manager accountable with 01/10/18 31/10/18

1.8.2Red to Green will be implemented across acute wards and PICU. With Daily action

planning meetings in place by 31st December 2018.



1.8.3Weekly bed management meetings with a focus on discharge planning/identification

of barriers includes senior leadership with authority to make decisions are on-going.


Manager accountable with 31/07/18 Ongoing

1.8.4Escalation regarding external barriers will be taken to the fortnightly Alliance

management team meeting from October 2018.



1.5 The trust must ensure that all environmental risks are recorded on environmental risk assessments, that staff are

aware of these risks and know how these risks are mitigated. This includes all ligature anchor points, blind spots and the

use of plastic bin liners.

1.6 The trust must continue to implement plans to reduce the number of patients being restrained and make sure all staff

are aware of the actions they need to take

1.7 The trust must ensure that staff record all incidents appropriately and are aware of incidents from the service and

across the trust, and the lessons learned from investigations into these incidents.

1.8 The trust must ensure that all wards plan effectively for patients’ discharge and are pro-active in addressing barriers to

discharge

1.3 The trust must ensure that all patients can have direct access to drinking water on the psychiatric intensive care units

1.4 The trust must ensure that staff carry out physical health checks on patients after they receive rapid tranquilisation

Page 24 of 224

1.8.5We will be undertaking quarterly MADE events to embed these process from

October 2018 and repeated in December 2018.



1.8.6We will also work with community teams to understand the precipitating factors and

ensure they are addressed and that all known patients have a robust crisis and Alliance Management team 01/10/18 30/11/18

2.9.1 We will fully embed the Trust plan for addressing flow within the borough and the

aim to work at 85% occupancy from October 2018.



2.9.2All incidents must be escalated to the director or the director on call out of hours for

immediate resolution from October 2018.



2.9.3The Deputy Director will review the compliance record monthly and discussed

quarterly at LODGE from October 2018.



2.9.4We will inform the Director of Nursing of such events should they occur within 1

working day from October 2018.



2.10.1 We will embed the Trust policy on supervision Team leader and General


2.10.2 Compliance with the policy standard will be completed each month on shared drive

(OneDrive) and reviewed monthly in LODGE .


Manager accountable with 01/1/12/18 Ongoing

2.10.3Ward manager will review their team supervision tree and confirm with staff who

their supervisor is. This will be visible within each team


Manager accountable with 01/10/18 31/1/2/18

2.10.4The ward manager will review compliance with supervision on a monthly basis and

address any gaps in supervision with the supervisee and associated actions.


Manager accountable with 01/12/18 Ongoing

2.10.5 Additionally, reflective practice and shift reflections will be embedded on each ward Team leader and General


2.10.6We have actively promoted the completion of the Trust supervision survey to identify

any areas for development within the supervision process during September and



1.11.1 Replacement Equipment has arrived, in use on Lambeth site, in date and being

monitored monthly.Modern Matron 01/10/18

1.11.2Weekly checks conducted on all wards and sign. Expiry date to be included within

these checks from October 2018.


Modern Matron and General 01/10/18 Ongoing

1.11.3Modern Matron to check bags every 3 months and identify expiry date from October

2018.Modern Matron 01/10/18 Ongoing

1.11.4 Refine site-based approach for re-ordering equipment prior to expiry date General Manager 01/10/18 30/11/18

2.1.1 We will update signed Induction proforma of substantial and agency staff to clarify

this requirement with all staff by November 2018.

Team Leaders reporting to the

General Managers and 01/10/18 30/11/18

2.1.2

1.1.2 We have provided training in relation to risk assessment documentation to all

community teams May – June 2018.Team Leaders reporting to the


2.1.3We will incorporate this standard into community team objectives and appraisal/job

by from October 2018 and reviewed in April 2019.



2.1.4We are auditing the quality of risk assessment documentation monthly at team level

(10 per team) on an on-going basis.



2.1.5We are developing team/individual action plans to address quality gaps and holding

all staff to account for delivering this standard and their role in this. For completion



2.1.6We learn from areas where this is routinely implemented to a high standard and

share this good practice for adoption across all teams by November 2018.



2.2.1 We will update the signed Induction proforma of substantial and agency staff to

clarify this requirement with all staff by November 2018.



2.2.2Community team representatives are currently participating in quality improvement

work with QI team and service users to understand barriers to person centred care


General Managers and 01/07/18 Ongoing

2.2.3We will incorporate this standard into community team objectives and appraisal/job

by April 2019.



2.2.4We are auditing the quality of care plans & documentation monthly (10 per team)

and developing team/individual action plans to address quality gaps on an on-going



2.2.5Staff are held to account for delivering this standard and their role in this. This will

be through the oversight of the team leader on an ongoing basis.



2.2.6We will learn from areas where this is routinely implemented to a high standard and

share this good practice for adoption across all teams by April 2019.



2.3.1 We are currently holding weekly MHA community assessment phone conference

with police, medical lead, social care and senior SLaM management to coordinate

Medical lead/Deputy Director –

community 01/08/18 Ongoing

2.3.2We would like to work with key stakeholders to test coordinating 10 x MHAA during

pm and evaluate impact of this approach in comparison to am assessments and


community 01/10/18 30/04/19

2.3.3We have a clear escalation procedure in place to facilitate the access to a bed for

anyone requiring a bed on an urgent basis on an on-going basis.


community 01/10/18 Ongoing

2.4.1

Whilst this action is not directly applicable to Lambeth – we are in the process of

redesigning our community services to ensure there is a better flow within the

system overall

lambeth Executive 01/10/18 30/04/19

2. MUST Dos: Community-based mental health services for working age adults (from inspection in July 2017)

2.1 The trust must ensure that risk assessments and risk management plans are always completed and reviewed after

changes in patients’ circumstances and risk events and stored where other staff can find them easily.

2.2 The trust must ensure that each patient has a care plan, which is person-centred and includes information about how

staff will support them.

2.3. The trust must ensure that patients who require a Mental Health Act assessment are assessed without undue delay to

ensure their safety and that of others.

2.4 The trust must ensure that patients referred to the Croydon assessment and liaison team, receive an assessment

within trust target timescales.

3. MUST Dos: Long stay/rehabilitation mental health wards for adults of working age (from inspection in September 2015)

1.9 The trust must ensure that patients are able to access a bed when they return from authorised or unauthorised leave

and are not required to sleep on sofas or in other temporary facilities.

1.10 The trust must ensure that all staff receive regular managerial and clinical supervision in line with trust policy.

1.11 The trust must ensure that all staff receive regular managerial and clinical supervision in line with trust policy.

Page 25 of 224

3.1.1 All clinical staff will have up to date Engagement and observation competencies by

30 November 2018.




the Deputy Director

01/10/18 30/11/18

3.1.2Quarterly Audit of Observation records by modern matron of all wards on an on-

going basis.




the Deputy Director

31/08/18 Ongoing

3.1.3 Reviewed quarterly in LODGE from October 2018.




the Deputy Director

01/10/18 31/10/18

3.1.4

We will review all ligature anchor points and ensure there are clear plans to mitigate

against any risk and that this is widely communicated to staff through the ligature

pictogram on the ward, reinforced via supervision, ward induction and team

business meetings by November 2018.




the Deputy Director

01/10/18 30/11/18

3.1.5

Environmental checks are completed hourly per shift and discussion in handover will

identify a risk management plan in accordance with identified risks and service user

presentation on an on-going basis.




the Deputy Director

01/09/18 Ongoing

4.2.1 Each service user has a personalised care plan tailored to their needs and recovery

goals and will include any restrictions that pertinent to their care and needs at that



4.2.2 This is reviewed whenever there is a change in need/goal and updated accordingly.Team leader, reporting to the


3.3.1 This not specific to THU but we will ensure that all fire safety precautions will be

reviewed under 5.1 by December 2018.




the Deputy Director

01/10/18 31/12/18

3.3.2We will also ensure there is a personalised emergency evacuation plan (PEEP) for

any person under our care with a mobility problem on an on-going basis.




01/10/18 Ongoing

3.4.1 The Lambeth Operational Directorate will continue to participate actively in the

Trust's recruitment initiatives which include rebranding and improved recruitment



3.4.2We will collate and report monthly safe staffing levels to the trust Board and NHSE

and review safe staffing minimum levels on a 6 monthly basis with the Director of



3.4.3

Vacancies will be circulated weekly to Directorate operational leads via General

Managers for review and action from October 2018 onwards.Team leader, reporting to the


3.4.4Staffing will be a standard item on supervision for the team leader and general

Manager on an on-going basis.



3.4.5THU Executive sponsor will also support rapid escalation of any issues raised and

action plans implemented via operational structure from October 2018.



4.1.1 Head of Nursing to develop local training strategy for autism. We will implement

training for all ward staff to equip them working with people with autism based on

Team leader accountable to the

General Manager and oversight 01/10/18 31/03/19

4.1.2 This will be reviewed monthly within LODGE from October 2018.Team leader accountable to the


4.1.3Nurse consultant in ID being recruited by October 2018 and will support strategy

implementation plan



4.2.1 All clinical staff will have up to date Engagement and observation competencies

Team Leader/Modern Matron

accountable to the Head of

Nursing and Deputy Director

01/10/18 30/11/18

4.2.2Quarterly Audit of Observation records by modern matron of all wards on an on-

going basis


accountable to the Head of 01/10/18 Ongoing

4.2.3 Reviewed quarterly in LODGE




01/10/18 Ongoing

4.2.4

We will build observation practice and recording into every staff induction and

highlight the need for purposeful engaging/intentional rounding through the delivery

of the 4 steps improvement programme




01/10/18 31/12/18

4.2.5

We will develop a culture of feedback on performance in relation to this action within

individual supervision sessions by including this as standard agenda item under the

heading of fundamental standards of care




01/10/18 31/12/18

4.3.1 Each team will identify key staff to attend DATIX training which will include the use

of the DATIX action module by December 2018.




01/10/18 31/12/18

4.3.2Following training ward managers and charge nurses to review coding when closing

down DATIX from November2018.




01/10/18 30/11/18

4.3 The trust should ensure all patient restraints are recorded in sufficient detail.

3.3 The trust must ensure that at Heather Close fire safety precautions are all in place

3.1 The trust must ensure that at Heather Close and McKenzie ward that where there are still high-risk ligature points or

patients who may harm themselves, that the appropriate steps to mitigate these risks are in place and staff are able to

clearly articulate how these are managed

4.2 The trust must ensure that at Heather Close and the Tony Hillis unit blanket restrictions are not imposed that do not

reflect the needs of people using the service

4. SHOULD Dos : Acute wards for adults of working age and psychiatric intensive care units

3.4 The trust must ensure senior management support local staff and address issues of staffing

4.2 The trust should ensure that staff carry out observations on patients and keep accurate records of this, including for

patients who are on intermittent observations.

4.1 The trust should ensure staff receive training in autism

Page 26 of 224

4.3.3

All unspecified recordings on DATIX will be reviewed and specified accordingly by

ward manager and charge nurse on an on-going basis. Issues with data quality will

be raised in supervision and an action plan placed to address quality gaps.




01/10/18 Ongoing

4.3.4

The Modern Matron will support wards staff to audit restraint recordings on a

monthly basis and work with team leaders to develop an action plan if any gaps are

identified from October 2018.




01/10/18 31/10/18

4.4.1 Care plan audits through SNAP (completed on a monthly basis) by team leaders

and modern matrons on an on-going basis.Team Leader/Modern Matron 01/05/18 Ongoing

4.4.2 Monthly review by LODGE Team Leader/Modern Matron 01/10/18 31/10/18

4.4.3We will also monitor this in supervision by including care plan reviews as a standard

supervision agenda item Team Leader/Modern Matron 01/10/18 30/11/18

4.5.1

This action aligns FSoC (Must Do’s action 2.1). We will ensure that the FSoC are

embedded into every staff induction and reviewed as a standard agenda item within

supervision thereafter from November 2018.

Team Leader/Modern Matron 01/10/18 30/11/18

4.5.2

Embedding physical health care implementation strategy and Trust physical health

care policy – including the Trust promises re: physical health care from October

2018.

Team Leader/Modern Matron 01/10/18 31/10/18

4.5.3We will roll out the EObs implementation across all Lambeth wards for completion

by December 2018.Team Leader/Modern Matron 01/10/18 31/12/18

4.5.4An update on FoSC will be provided to the Lambeth Governance Exec on a monthly

then two monthly basis moving forward from October 2018.Team Leader/Modern Matron 01/10/18 31/10/18

4.5.5 FSoC audit will be completed every 2 months on an on-going basis. Team Leader/Modern Matron 01/06/18 Ongoing

4.5.6The ward manager will work with the General Manager to communicate these and

hold the team to account in their delivery from October 2018.Team Leader/Modern Matron 01/10/18 31/10/18

4.6.1

We will make use of community meetings to hear service user concerns about any

environmental issues, including the cleanliness of the bathroom and toilet areas.

This will become a standard agenda item from October 2018

Shift coordinator, reporting to

team leader ward manager 01/10/18 31/10/18

4.6.2Actions to address this will be implemented per shift by ward clinical staff as part of

hourly environmental checks from October 2018.Hotel service manager 01/10/18 31/10/18

4.6.3

Unresolved issues are escalated with hotel service manager and ward manager.

Repeated issues will be escalated to the Head of Estates for resolution from October

2018.

Shift coordinator, reporting to

team leader ward manager 01/10/18 31/10/18

4.7.1 We will run a Lambeth specific rolling recruitment campaign to supplement the Trust

central recruitment programme

General manager with Deputy

Director 01/10/18 31/12/18

4.7.2

A monthly vacancy review and recruitment trajectory will be a standing item on the

supervision agenda for each team leader with the General Manager and for the

General Manager with the Deputy Director

General manager 01/10/18 Ongoing

4.7.3Ward manager continue to participate in the Trust wide Band 5 recruitment

programme on an on-going basis.Ward manager 01/10/18 Ongoing

4.7.4We will review THU establishment and consider opportunities for an adjusted skill

mix including Band 4 Assistant Practioners/Nursing Associates General manager 01/10/18 30/11/18

4.7.5We will also consider the opportunity for the introduction of peer support workers

within the establishment General manager 01/10/18 31/01/19

4.7.6We will develop an escalation process by which any leave cancelled due to staff

shortage will be reviewed and appropriate strategies put in place to address this.Deputy Director 01/10/18 30/11/18

4.8.1 We are currently advertising for substantive ward manager for LEO and Nelson

wards and will continue to do so as a rolling advert until recruited too

General Manager with Deputy

Director oversight01/10/18 30/11/18

4.8.2 We will advertise for a substantive ward manager for ES2 in November 2018 General Manager 01/10/18 30/11/18

4.8.3We have introduced a Lambeth specific ward manager development programme

which will commence in November 2018.

General manager and HR

business partner 01/10/18 30/11/18

4.8.4We will identify emerging ward managers via supervision and appraisal and enrol

them on the SLP band 6-7 development programme by April 2019.

Team leaders and General

manager 01/10/18 30/04/19

4.9.1 Computer privacy screen shields for each computer in the nursing office will be in

place by end of October 2018

Team leader accountable to

General Manager with oversight

from Deputy Director

01/10/18 31/10/18

4.9.2Staff have been reminded to ensure that the white board within the nursing office will

be covered by screens and closed when not in use by October 2018.Team Leader 01/10/18 31/10/18

4.4 The trust should ensure that all patients have care plans to meet their physical and mental health needs.

4.9 The trust should ensure that patient information is not visible to other patients and visitors in Nelson Ward..

4.5 The trust should ensure that staff take a pro-active approach in supporting patients with their physical health needs,

including taking regular blood tests when required, and ensuring they act on concerns identified in food and fluid intake

monitoring

4.6 The trust should ensure that all bathroom and toilet areas are kept clean.

4.8 The trust should consider recruiting more permanent, rather than interim, ward managers to increase stability on the

wards and improve the consistency of care.


Page 27 of 224

4.10.1

Whilst this is not applicable to Lambeth we will be reintroducing the Trust 5

commitments (which include kindness) within our programme of work related to

leadership and culture


4.10.2

This will be tested through the following mechanisms:

• Executive sponsor activity & observation

• Complaints data

• PEDIC and SUCAG feedback

• Telephone calls to services to test their response

• 360 feedback mechanisms


5.1.1 The team leader has developed a protocol to manage this in collaboration with the

Trust pharmacy. This was introduced in September 2018.




01/10/18 30/09/18

5.1.2 Implementation will be monitored via pharmacy audits and reviewed at LODGE on

quarterly basis from December 2018Pharmacy 01/10/18 31/12/18

5.2.1 The team leader has developed a protocol to manage this in collaboration with the

Trust pharmacy. This was introduced in September 2018.

Modern Matron accountable to the

Head of Nursing and Deputy 01/10/18 30/09/18

5.2.2 Implementation will be monitored via pharmacy audits and reviewed at LODGE on

quarterly basis from December 2018.Pharmacy 01/10/18 31/12/18

5.2.3 We will ensure that all clinical team members have up to date medicine

competencies in place by November 2018.Modern matron 01/10/18 30/11/18

5.3.1 The Freedom to Speak Up Ambassador for the Borough (who works outside of the

Borough) has recently presented to the Lambeth Leadership Interface meeting to Lambeth Execs 01/10/18 31/10/18

5.3.2This presentation and leaflets will also be made available for cascading at individual

team meetings during October 2018.General Managers 01/10/18 31/10/18

6.1.1 We have reviewed the team processes for facilitating discharge and identified that

this requires additional work during October 2018.

General manager – community,

Deputy director – community and

Medical lead

01/10/18 31/10/18

6.1.2QI approaches will be used to identify actions necessary to facilitate regular

discharges from the LEO team on an on-going basis from October 2018.

Team leader, accountable to the

General manager01/10/18 Ongoing

6.1.3The team will be piloting the use of a caseload weighting tool to establish if this is a

useful tool in supporting caseload management during October/November 2018.Team leader 01/10/18 30/11/18

6.2.1

Each team to provide a trajectory for outstanding Tier 1A and 1B mandatory

Training Team Leaders and General

Managers01/10/18 30/11/18

6.3.1 Update signed Induction proforma of substantial and agency staff to clarify this

requirement with all staff by November 2018.QI team with HoN, Deputy 01/10/18 30/11/18

6.3.2

Community team representatives participating in quality improvement work with QI

team and service users to understand barriers to

person centred care planning and PDSA cycles to address these for completion by

April 2019.

Director –community,

General Manager and care

planning project group

01/10/18 30/04/19

6.3.3 Incorporate this standard into community team objectives and appraisal/job by April

2019.

Appraising manager/Medical

Lead01/10/18 30/04/19

6.3.4Audit quality of care plans & documentation monthly (10 per team) and discuss

gaps in quality in supervision and actions to address this on an on-going basis.

Audits to be conducted by

Team leaders/clinical practice

leads & reports generated by

Governance Officer

01/07/18 Ongoing

6.3.5Develop team/individual action plans to address quality gaps throughout the PDSA

cycle.

Team leader/individual

supervisor with oversight from

General Manager

01/10/18 28/02/19

6.3.6Hold all staff to account for delivering this standard and their role in this by April

2019 and then on an on-going basis.Team leader/individual Supervisor 01/10/18 30/04/19

6.3.7Learn from areas where this is routinely implemented to a high standard and share

this good practice for adoption from October 2018 and then on an on-going basis.

Team leader/Clinical

Practice Leads/General Manager 01/10/18 31/10/18

6.4.1 Use weekly reporting from MHA office for reminders and identify any additional

Training per team on an on-going basis.

General Manager Community and

Medical Lead01/10/18 Ongoing

4.10 The trust should ensure that staff on Ruskin/AL2 and Croydon PICU always demonstrate kindness and compassion in

their interactions with patients.

5. Mental health crisis services and health based place of safety

5.1 The trust should ensure that when staff supply medicines to patients at home that it is packaged and labelled in

accordance with the Human Medicines Regulations 2012.

5.2 The trust should ensure staff follow the trust policy for assessing and recording the suitability of patient’s own

medicines before administering them.

5.3 The trust should ensure staff are aware of the role of the Freedom to Speak up Guardian and how to contact them.

6. Community-based mental health services for working age adults (from inspection in July 2017)

6.1 The trust should continue to take action to reduce the caseloads of care coordinators in the early intervention teams,

so that they can consistently provide effective support to patients experiencing a first episode of psychosis.

6.2 The trust should ensure that staff complete all mandatory training including annual basic life support, infection

control and fire safety training.

6.3 The trust should ensure that staff clearly record patient involvement in their care records, and offer each patient a copy

of their care plan.

6.4 The trust should ensure that staff explain patients’ rights in respect of community treatment orders consistently in

accordance with the Mental Health Act (MHA) Code of Practice, and keep accurate records of consent to treatment in line

with the MHA and when patients’ rights have been explained.

Page 28 of 224

6.4.2Additionally, we have introduced a monthly audit programme where this is reviewed

within teams from September 2018General Manager 01/10/18 Ongoing

6.5.1 Lambeth will review its psychological therapy service provision throughout all

pathways of care by January 2019

Head of Psychology &

Deputy Director & Trust 01/10/18 31/01/19

6.5.2Lambeth is working in an alliance to redesign all of its mental health services

including the provision of psychological therapies to be completed by April 2019.Alliance Management team 01/10/18 30/04/19

6.5.3Monthly reporting of psychology waiting times in all pathways to will be reviewed in

Lambeth Business and Performance Executive from October 2018.

Head of Psychology &

Deputy Director01/10/18 31/10/18

6.6.1 We have introduced a monthly interface meeting for team leaders and consultants in

all teams to foster relationships, share information across pathways and work Lambeth Executive 01/10/18 30/06/18

6.6.2We have set clear expectations with regards to community attendance at weekly bed

management meeting IP General manager 01/10/18 30/06/18

6.6.3QI approach to relapse prevention (Relapse Prevention Forum) for those with high

use/frequent use of inpatient beds and/or Complexity

QI lead and Clinical Director (with

Executive support)01/10/18 30/11/18

6.6.4

Within the Lambeth Alliance we are redesigning the crisis pathway to in bed HTT

and front door community services together – first joined up service will be operation

in January 2019

Senior responsible officers for

Crisis PID Commenced April 2018

(for completion January 2019)

01/10/18 31/01/19

6.7.1

Within the Lambeth Living Well Network Alliance (LLWNA) we are redesigning the

community and inpatient pathways with the following principles for launch during

April 2019.


6.7.2

We facilitate 3 days focusing on ‘unblocking barriers and creating flow’ to begin

reviewing and cleansing team caseloads during September 2018 we will also:

• Ensure that staff clearly understand their roles and Responsibilities

• Clarify referral criteria and Thresholds

• Ensure specialist teams can accept referrals and support community staff to make

more effective referrals. These actions will be completed


6.8.1 Re-confirm roles and responsibilities clarified, communicated to all staff and

incorporated in Appraisals/job plans by April 2019Lambeth Executive 01/10/18 30/04/19

6.8.2Within the Lambeth Living Well Network Alliance (LLWNA) we are redesigning the

community and inpatient pathway. A key part of this redesign is clarifying the Lambeth Executive 01/10/18 30/04/19

6.8.3We will support community staff to make more effective placement funding

Applications by November 2018.Lambeth Executive 01/10/18 30/11/18

6.9.1 Identified BI resource per service is in place and Supporting this agenda as of

October 2018.Lambeth Executive 01/10/18 31/10/18

6.9.2

Lambeth Executive and management teams are engaged in training sessions to

support the utilisation of These systems for completion by end of November 2018. Lambeth Executive 01/10/18 30/11/18

6.9.3Data will be used in supervision and team meetings by the team manager to

improve quality in risk assessments and care plans.Lambeth Executive 01/11/18 Ongoing

6.9.4Data will be used by the Lambeth Operational Directorate to identify unreasonable

waiting times and actions to address these on a monthly basis in the LODGELambeth Executive 01/10/18 Ongoing

7.1.1 All clinical staff will have up to date Engagement and observation competencies by

30 November 2018.

Team leader with oversight from

General Manager01/10/18 30/11/18

7.1.2Quarterly Audit of Observation records by modern matron of all wards from October

2018 and then on-going.


General Manager01/10/18 Ongoing

7.1.3 Reviewed quarterly in LODGE from October 2018.Team leader with oversight from


7.1.4

We will build observation practice and recording into every staff induction and

highlight the need for purposeful engaging/intentional rounding through the delivery

of the 4 steps improvement programme from December 2018.



7.2.1

The team now conduct weekly environmental walk rounds and raise any requests

via Planet FM. Ward housekeepers also raise concerns via the system on an on-

going basis.


General Manager and Modern

Matron

01/08/18 Ongoing

7.2.2Escalation for any outstanding works is via local management systems for

action/entry onto the risk register as required

Lambeth Estates officer & Hotel

service manager 01/10/18 TBC

7.3.1

A monthly vacancy review and recruitment trajectory will be a standing item on the

supervision agenda for the THU team leader from October 2018 and then on an on-

going basis.




01/10/18 31/10/18

7.3.2Ward manager continue to participate in the Trust wide Band 5 recruitment

programme on an on-going basis.


General Manager with oversight 01/08/18 Ongoing

7.3.3We will review THU establishment and consider opportunities for an adjusted skill

mix including Band 4 Assistant Practioners/Nursing Associates by the end of


General Manager with oversight 01/10/18 30/11/18

7.3.4We will also consider the opportunity for the introduction of peer support workers

within the establishment by January 2019.


General Manager with oversight 01/10/18 31/01/19

6.8 The trust should ensure that staff clearly understand their roles and responsibilities, clarify referral criteria and

thresholds, ensure specialist teams can accept referrals, and support community staff to make more effective placement

6.7 The trust should continue to address barriers to effective patient movement along the

care pathway.

6.5 The trust should ensure that patients have access to psychological therapies without undue delay in line with best

practice guidance.

6.6 The trust should continue to develop more effective working relationships between the community teams, home

treatment teams and inpatient wards; and improve the quality and frequency of contact between community staff, ward

staff and patients admitted to the wards.

6.9 The trust should ensure that quality management systems are further improved to ensure that significant gaps in the

quality of risk assessments and care plans, and unreasonable waiting times for patients are addressed swiftly.

7. Long stay/rehabilitation mental health wards for adults of working age (from inspection in September 2015)

7.1 The trust should ensure that staff are clear about the observation of patients at 3 Heather Close.

7.2 The trust should ensure that at Heather Close and the Tony Hillis unit maintenance and repairs are carried out in a

timely fashion.

7.3 The trust should ensure recruitment processes are ongoing to reduce the dependence on temporary staff who may not

all know the services.

Page 29 of 224

7.4.1 We will actively promote meaningful engagement as a preventative measure to

AWOL on an on-going basis.


General Manager and oversight

by Deputy Director

01/10/18 Ongoing

7.4.2

The Trust has implemented the use of miocare devices to take photographs of the

service users (secured safely on epjs) whilst in hospital to share with the police if

they go missing. This is on-going.



by Deputy Director

01/08/18 Ongoing

7.4.3

Additionally, the ward routinely collate a ‘grab pack’ per patient as per Trust policy

for easy access to core information, including a photograph, should AWOL occur.

This is shared with police as required and is also on-going.



by Deputy Director

01/08/18 Ongoing

7.5.1

Each service user will have a personalised care plan tailored to their needs and

recovery goals and will include any restrictions that pertinent to their care and needs

at that time. This will be reviewed whenever there is a change in need/goal and

updated accordingly by November 2018. Monthly care plan audits will be conducted

to ensure these are in place.




the Deputy Director

01/10/18 30/11/18

7.5.2

We will develop a culture of feedback on performance in relation to this action within

individual supervision sessions by including this as standard agenda item under the

heading of fundamental standards of care




the Deputy Director

01/10/18 31/12/18

7.6.1

The team have engaged in a training programme (Defining Complex Care) focusing

on the approach to rehabilitation and recovery and necessary skills to implement

this. This was completed in March 2018.

Team Leader, General Manager

with oversight from the Head of


01/10/18 30/03/18

7.7.1

Ensure all staff are up to date on an on-going basis with regards to:

• MHAA training

• MCA training

• DOLs training



by Deputy Director

01/07/18 Ongoing

7.7.2The Trust Mental Health office delivered in house training specific to the areas for

development identified during the 2015 inspection.



by Deputy Director

01/01/15 31/12/15

7.7.3

The Trust Mental Health office delivered in house training specific to the areas for

development identified during the 2015 inspection.

10.9.3 In addition – training has been delivered on the following:

• 29/01/16 MH Code of Practice, Informal rights in restrictive settings, blanket

restrictions, MCA, duty of care and Trust policy reviews 17 People attended

• PDN provided training in-house on two occasions 20.5.17 132 rights training

update and 30.06.17 capacity to consent update



by Deputy Director

01/01/15 31/12/15

7.8.1

The ward has a cordless phone which people can use within a quiet room identified

within the ward communal area or within their bedroom. This has now been

completed in October 2018.



by Deputy Director

01/10/18 31/10/18

7.8.2We will amend the ward welcome pack to ensure this is clearly communicated in the

patient welcome pack received at the time of admission by end of November 2018.Ward manager 01/10/18 30/11/18

7.9.1 The ward has a self-serve beverage area where hot drinks can be accessed 24

hours per day. This is on-going.



7.9.2We will also review the provision and quality of food with the Head of Hotel Services

by December 2018.Team leader 01/10/18 31/12/18

7.10.1

The team have a clear display of complaints leaflets and posters in communal

patient areas, including CQC contact number. Complaints are shared and recorded

via the complaints department. Service users have also been briefed on how to

make a complaint in community meetings which occur on a Wednesday of every

week and is also part of the ward induction pack. Additionally, the ward manager

routinely offers a complaints surgery. This is on-going.



by Deputy Director

01/08/18 Ongoing

7.11.1This is not applicable to THU however we are in the process of establishing a staff

reflective practice group for the ward



by Deputy Director

01/10/18 31/01/19

7.9 The trust should ensure food across the wards is consistently of a good quality and quantity and there are facilities to

access hot drinks and snacks 24 hours a day.

7.8 The trust should ensure patients across all the wards can make phone calls in private.

7.10 The trust should ensure at Heather Close that patients are aware of how to make a formal complaint and the findings

are recorded and shared for learning

7.11 The trust should ensure there is a positive culture of staff engagement at Heather Close.

7.4 The trust should implement measures to monitor patients who go AWOL. This includes clearly recording for patients

on section 17 leave what time they are expected to return. Also consider having photos of patients to share with the police

if they are missing

7.5 The trust should ensure care plans are reviewed regularly and reflect patient risks and the support they need.

7.6 The trust should ensure that across the rehabilitation wards staff are able to clearly articulate the model of care and

how they are promoting patients’ rehabilitation.

7.7 The trust should ensure on Tony Hillis and Heather Close that staff understand how to apply the Mental Health Act.

Page 30 of 224


PROJECT NAME: Southwark CQC delivery plan BY: PMO



1 8 15 22 29 5 12 19 26 3 10 17 24 7 14 21 28 4 11 18 25 4 11 18 25 Q1 Q2 Q3 Q4


1.1.1 Immediate action taken to address the immediate issues raised by the inspection

report (Add names of wards here ).

Head of Nursing &

quality (interim),01/10/18 31/10/18

1.1.2

Wards and teams where standards of care need to be improved will be identified

using tools such as QuESTT, incident reports and data from BI dashboard, visits,

as well as information provided in the inspection reports.

General Manager

inpatients, 01/10/18 31/10/18

1.1.3Action plans will be developed for each teams identified as needing improvement

to provide support, including providing group and individual wrap-around support.

Clinical service lead01/10/18 31/10/18

1.1.4

Compliance with fundamental standards of care will be delivered through training

and by ensuring that policies to meet the FSoC are embedded into practice

(PSTS, seclusion, physical health care, Cardiopulmonary resuscitation managing

deteriorating patient and the rapid tranquilisation nursing protocol )

Clinical service lead01/10/18 31/10/18

1.1.5Daily contact with wards and will escalate concerns to Head of Nursing and

Quality who is based on site for timely escalation.Inpatient Modern Matron 01/10/18 31/10/18

1.2.1

The Southwark & Addictions Directorate Governance structure as agreed

through the Governance Work stream will be agreed by end of October 2018

and will be published and accessible to staff.

Clinical Director 01/10/18 30/11/18

1.2.2Team meetings will happen on a regular basis in all teams and wards, where key

quality indicators are scrutinised and lessons learned can be shared.Clinical Director 01/10/18 30/11/18

1.2.3Monthly Wards Governance meeting chaired by Consultant-will be centrally

stored and reviewed quarterly Clinical Director 01/10/18 30/11/18

1.2.4Executive sponsors from Operational Directorate leadership teams will be

identified for each ward or team and will visit the ward / team regularly.Clinical Director 01/10/18 30/11/18

1.3.1 All patients on PICU and Acute wards to have access to drinking water

Head of Nursing &

quality (interim)

Inpatient Modern Matron

and Ward Manager.

01/10/18 31/10/18

1.4.1 All Southwark Wards to have Rolling training programme to imbed the Trust

Rapid Tranquilisation Nursing Guidance.

Head of Nursing &

quality (interim) 01/10/18 30/11/18

1.4.2Review of all RT incidents within 24 hrs by ward manager and Modern

Matron/HON. Email sent from Datix to staff if RT guidance not followed.Ward Managers 01/10/18 31/10/18

1.4.3Weekly RT audit to be completed by ward PDN and issues of non-compliance

escalated to the Ward manager, Modern Matron, Head of Nursing & Quality.PDN on each ward 01/10/18 01/11/18

1.4.4 Explore compliance during supervision and Modern Matron to have oversightWard Managers and

Modern Matrons01/10/18 02/11/18

1.4.5Lessons learnt to be reviewed at Monthly team governance meeting and exec

monthly serious incident panel

Ward Managers and


1.5.1

Alert staff to ligature anchor Points, blind spots and the use of plastic bin liners

and the management plans shared with the team at business meetings and as

part of induction.

Ward Managers 01/10/18 30/11/18

1.5.2Risks to specific service users (e.g. because rare, unusual, specific risk

behaviours) within the environment to be addressed during handoverWard Managers 01/10/18 30/11/18

2019 - 2020

Delivery

Board

Ref: Activity or Milestone Title ResponsiblePlanned Start

Date

Portfolio

Board

Oversight

& Scrutiny

1.5 The trust must ensure that all environmental risks are recorded on environmental risk assessments, that

staff is aware of these risks and know how these risks are mitigated. This includes all ligature anchor points,

blind spots and the use of plastic bin liners.

Planned End

Date

1. MUST Dos : Acute wards for adults of working age and psychiatric intensive care units

1.1 The trust must identify and provide timely support to wards and teams where standards of care need to

improve

1.2 The trust must ensure that governance processes are sufficiently robust so that they identify where

improvements need to be made and ensure that action is taken to make the required improvements

1.3 The trust must ensure that all patients can have direct access to drinking water on the psychiatric

intensive care units

1.4 The trust must ensure that staff carry out physical health checks on patients after they receive rapid

tranquilisation

Page 31 of 224

1.5.3All Southwark wards and POS to have their ligature audits re-assessed and

signed off by H&S and ward Managers with support of inpatient Modern Matron

Head of Nursing &

quality (interim)01/10/18 30/11/18

1.6.1 All wards to implement 4 steps to safety.Head of Nursing &


1.6.2 Data to be available to all wards for discussion at business meetings. Governance Team Lead 01/10/18 31/10/18

1.6.3 Review of all incidents of Violence and aggression on Datix daily Head of Nursing &


1.6.4 Bimonthly Exec RRP Committee that each ward lead attends.Head of Nursing &


1.6.5 Weekly Qi huddle Head of Nursing &


1.7.1 All incidents to be recorded on Datix.

Governance Team

Lead, Ward Managers,

Modern Matrons

01/10/18 31/10/18

1.7.2Quarterly Southwark lessons learnt ½ day Workshop – to include training on

completing of Datix, complaints, fact finders and SI

Governance Team

Lead, Ward Managers,

Modern Matrons

01/10/18 30/11/18

1.7.3 Recording to be reviewed during supervision Ward Managers 01/10/18 30/11/18

1.7.4 Review incidents on a weekly basis to ensure accurate reporting.Ward Manager and

Consultant01/10/18 30/11/18

1.8.1 Embedding of the trust plan for addressing flow within the borough with the aim

to work at 85% occupancy from October 2018 – see Appendix

Service Director


1.8.2 Use of Length of stay data for the medical lead to support consultants to

understand variation in practice.

Service Director


1.9.1 Datix reports will be completed for all incidents where a bed is not available for

patients returning from leave

Service Director

Clinical Director01/10/18 31/10/18

1.9.2All incidents of a bed not being available are to be immediately escalated to the

ARC, Directorate Senior Management and the On Call Director

Service Director


1.9.3Standard Operating Protocol to be developed for any returning patient and others

who need a bed.

Service Director


1.10.1 Embed the Trust policy that all staff are to receive monthly supervision.

General Manager

Inpatient & Experience

Manager

01/10/18 31/12/18

1.10.2Review their supervision tree and confirm with staff that their supervisor is. This

will be visible within each team by 1st December 2018.Ward managers 01/10/18 31/12/18

1.10.3 All staff providing or receiving supervision will record each session on leap.Ward Managers for

each ward. 01/10/18 31/12/18

1.10.4 Compliance will be reviewed in the Directorate Monthly Governance meeting General Manager

Inpatient01/02/19 Ongoing

1.11.1All emergency equipment to be checked weekly with expiry dates included in

checks and replaced as per Trust Policy.

Ward Managers,

Modern Matron &

General Manager

01/10/18 31/10/18

1.11.2 Modern Matrons clinic room auditWard Managers,

Modern Matron & 01/10/18 31/10/18

1.11.3 Refine site based approach to re-ordering equipment prior to expiryWard Managers,

Modern Matron & 01/10/18 31/10/18

2.1.1 Implementation of rolling training programme in teams for risk assessment

HON

Modern Matrons

Team Leaders

Clinical Charge Nurses

01/10/18 31/10/18

2.2.1 Implementation of rolling training programme in teams on care planningHON


2. MUST Dos : Community-based mental health services for working age adults

(from inspection in July 2017)

1.6 The trust must continue to implement plans to reduce the number of patients being restrained and make

sure all staff is aware of the actions they need to take

1.7 The trust must ensure that staff record all incidents appropriately and are aware of incidents from the

service and across the trust, and the lessons learned from investigations into these incidents.

1.8 The trust must ensure that all wards plan effectively for patients’ discharge and are pro-active in

addressing barriers to discharge.

1.9 The trust must ensure that patients are able to access a bed when they return from authorised or

unauthorised leave and are not required to sleep on sofas or in other temporary facilities.

1.10 The trust must ensure that all staff receives regular managerial and clinical supervision in line with trust

policy.

1.11 The trust must ensure that all emergency equipment is replaced prior to the expiry date.

2.1 The trust must ensure that each patient has a care plan, which is person-centred

and includes information about how staff will support them.

2.2 The trust must ensure that patients who require a Mental Health Act assessment are assessed without

undue delay to ensure their safety and that of others.

Page 32 of 224

2.2.2 Draft a proforma for care plan HON


2.3.1 Protocol in place for teams to escalate any delays in MHA. General Manager

Clinical Governance 01/10/18 31/1/2/2018

2.3.2 All delays reported on datix.This should be in line with the overall flow plan General Manager

Clinical Governance 01/10/18 31/1/2/2018

3.1.1 The Trust Learning Disability strategy is being developed by the Southwark

Interim head of Nursing. Strategy Lead 01/10/18 30/11/18

3.1.2 Training implemented for all staff based on the strategy, by March 2019. All ward Managers 01/10/18 31/03/19

3.1.3 Nurse Consultant for LD recruited and will support strategy implementation. Nurse Consultant ID 01/10/18 31/10/18

3.2.1 All clinical staff will have up to date observation and engagement competency

completed by February 2019.

Head of Nursing &


3.2.2All clinical staff will have up to date medication competency completed by March

2019.

Head of Nursing &

quality (interim)01/10/18 31/03/18

3.3.1 Support Team leads to ensure all restraints are recorded on Datix with sufficient

details.Team leads 01/10/18 31/10/18

3.3.2 Review Datix and to discuss in supervision Ward Managers 01/10/18 31/10/18

3.3.3complete monthly Audit of restraint recording and Modern Matrons to support

them to develop an action plan where gaps are identified.PDN & Matron 01/10/18 31/10/18

3.4.1 This action aligns with the FSOC (Must do 2.1) which will be implemented and

will be monitored in supervision.

Head of Nursing &

quality 01/10/18 31/10/18

3.4.2Care plan audits through SNAP completed on monthly basis by Team leaders

and Modern Matrons.

Head of Nursing &

quality 01/10/18 31/10/18

3.4.3 Care plan audit results reviewed at Directorate Quality Committee.Head of Nursing &

quality 01/10/18 31/10/18

3.5.1 This action aligns with the FSOC (Must do 2.1) which will be implemented and

will be monitored in supervision.

Head of Nursing &

quality 01/10/18 20/11/18

3.5.2Embedding the implementation of Trust Physical health strategy and Trust

Promise as of 5th November, 2018.

Head of Nursing &

quality 01/10/18 20/11/18

3.5.3 All wards to have a named Physical Health LeadHead of Nursing &

quality 01/10/18 20/11/18

3.6.1 Hourly Environment check included on the new observation checklist to ensure

bathroom and toilets are clean.

Ward Manager 31/10/18 Ongoing

3.6.2Escalation to Hotel services via ward manager. With repeated issues escalated

to the Head of estates for resolution from 31st October 2018.Ward Manager 31/10/18 Ongoing

3.6.3Estates will check service user experience in Community meetings.

Estates 31/10/18 Ongoing

3.7.1 Continue trust recruitment initiatives.General Manager

HR Business Partner 31/10/18 Ongoing

3.7.2 Employment of commissioned studentsGeneral Manager

HR Business Partner 01/10/18 31/10/18

3.7.3Review of nursing establishment to incorporate Nursing associates and associate

practitioners.

General Manager


3.7.4Identify any trends / controllable issues for staff leaving and draft action plan to

address the issues

General Manager


3.7.5 Vacancies reviewed monthly in performance executive.General Manager


3.7.6 Recruitment phone calls lead by HR Business Partner and Team leads.General Manager


3.7.7 Carry out exit interviewsGeneral Manager


2.3.The trust must ensure that patients who require a Mental Health Act assessment are assessed without


3.1 The trust should ensure staff receive training in autism

3. SHOULD Dos: Acute wards for adults of working age and psychiatric intensive care units

3.2 The trust should ensure that staff carry out observations on patients and keep accurate records of this,

including for patients who are on intermittent observations


3.4. The trust should ensure that all patients have care plans to meet their physical and mental health needs.

3.5 The trust should ensure that staff take a pro-active approach in supporting patients with their physical

health needs, including taking regular blood tests when required, and ensuring they act on concerns

identified in food and fluid intake monitoring


3.7 The trust should continue to address the high number of nursing vacancies on some wards through

active recruitment and retention strategies to improve the consistency of care.

3.8 The trust should consider recruiting more permanent, rather than interim, ward managers to increase

stability on the wards and improve the consistency of care.

Page 33 of 224

3.8.1 Permanent Recruitment to all interim posts. General Manager 31/10/18 Ongoing

3.8.2 Monitored via monthly performance exec meeting. General Manager 31/10/18 Ongoing

3.9.1 In line with the Leadership & Culture plan, we will gather feedback on staff

against the Trust Commitments.

Southwark executive

Team 01/10/18 30/111/2018

3.9.2Action plans for teams requiring additional support will include focus on kindness

and compassion in interactions with service users.

Southwark executive

Team 01/10/18 30/111/2018

4.1.1 CSL to develop a protocol with pharmacy that will be added to the Operational

policy General Manager 01/10/18 30/11/18

4.2.1 CSL to develop a protocol with pharmacy that will be added to the Operational

policy by end of November 2018.General Manager 01/10/18 30/11/18

4.3.1 Updated poster in the health-based place of safety assessment rooms clearly

explains patients’ rights in line with the Mental Health Act

Head of Nursing &

quality 01/10/18 31/10/18

4.3.2Modern Matrons to check that poster is displayed and inform HON by email by

end of October 2018.

Head of Nursing &

quality01/10/18 31/10/18

4.4.1 Embedding of the trust plan for addressing flow within the borough with the aim

to work at 85% occupancy

Service Director &


4.5.1 We will embed practice consistent with Trust policy on supervision. General Manager

Inpatient01/10/18 31/12/18

4.5.2Review of capacity assessments for consent to treatment documentation in

supervision any concerns to be escalated to CSL and general manager.

General Manager

Inpatient01/10/18 31/12/19

4.6.1 Freedom to speak up ambassador to be invited to the Borough Executive

meeting and attend team meetings as needed to inform staff about the role and

Southwark

Freedom to speak up 01/10/18 31/10/18

5.1.1 Caseloads continue to be reviewed in line with national guidance for EIGeneral Manager

Community Teams01/10/18 31/10/18

5.2.1 Teams to monitor their training levels, to be reviewed at monthly exec

performance meetings to identify an gaps and action plan around this where

General Manager


5.2.2Operational Directorate Monthly performance meetings which includes reviewing

training.

General Manager


5.3.1 Supervision to be used as a mechanism for improving Care plans. General Manager


5.3.2 Organise Co-production in Care planning workshops refresh (February 2019)General Manager


5.3.3 Incorporate standards into objectives and appraisal/job.General Manager


5.3.4Continue to audit quality of care plans & documentation monthly. Monthly care

planning audit programme per team; reviewed locally with teams in monthly

General Manager


5.3.5 Develop team/individual action plans to address quality gaps.General Manager


5.4.1 Utilise weekly reminder reports circulated by Mental Health Act Office. Clinical Director

01/10/18 31/10/18

5.4.2 Revisit governance processes in relation to patients’ rights and CTOsClinical Director

01/10/18 30/11/18

5.5.1 Review psychology access and waiting times in all community services with the

support of the Trust HOPP (by January 2019).

Trust Head of

Psychology & 01/10/18 31/01/19

5.5.2Borough Community redesign to account for review findings in the redesign (by

April 2019).

Trust Head of

Psychology & 01/10/18 30/04/19

4.1 The trust should ensure that when staff supplies medicines to patients at home that it is packaged and

labelled in accordance with the Human Medicines Regulations 2012.

3.9 The trust should ensure that staff on Ruskin/AL2 and Croydon PICU always demonstrates kindness and

compassion in their interactions with patients.

4 SHOULD Dos : Mental health crisis services and health based place of safety


5.2 The trust should ensure that staff complete all mandatory training including annual basic life support,

infection control and fire safety training.

5.3 The trust should ensure that staff clearly record patient involvement in their care records, and offer each

patient a copy of their care plan

5.4 The trust should ensure that staff explain patients’ rights in respect of community treatment orders

consistently in accordance with the Mental Health Act (MHA) Code of Practice, and keep accurate records of

5.5 The trust should ensure that patients have access to psychological therapies without undue delay in line

with best practice guidance.

5.6 The trust should continue to develop more effective working relationships between the community

teams, home treatment teams and inpatient wards; and improve the quality and frequency of contact

between community staff, ward staff and patients admitted to the wards.

4.2 The trust should ensure staffs follow the trust policy for assessing and recording the suitability of

patient’s own medicines before administering them.

4.3 The trust should ensure that the patient s.132 rights poster displayed in the health-based place of safety

assessment

4.4 The trust should continue to monitor and work towards making sure patients do not stay in the health-

based place of safety for longer than 24 hours.

4.5. The trust should ensure that staff in the health-based place of safety clearly document how they arrive at

their decision when completing mental capacity assessments for consent to treatment.

4.6 The trust should ensure staff are aware of the role of the Freedom to Speak up Guardian and how to

contact them.

5.1 The trust should continue to take action to reduce the caseloads of care coordinators in the early

intervention teams, so that they can consistently provide effective support to patients experiencing a first

episode of psychosis.

Page 34 of 224

5.6.1 Monthly interface meeting to be introduced for team leaders and consultants in all

teams to be introduced to foster relationships, share information across pathways

and work together to address barriers. Monitoring by Operational Executive.

General Manager


5.7.1 Patient flow design group plan will be fully implemented, which is set to address

this – see Appendix.

Service Director 01/10/18 TBC

5.8.1 Support via Borough and trust wide MADE events.

General Manager

Complex Care01/10/18 Ongoing

5.8.2Support to community and inpatient services with regards to making funding

applications.

General Manager

Complex Care01/10/18 31/10/18

5.9.1 Request BI support to enable Teams to translate local and Trustwide data, as

part of the Enablers design group.Service Director 01/10/18 TBC

5.9.2Teams to use BI data in their Team business meetings.

Service Director 01/10/18 31/12/18

5.9 The trust should ensure that quality management systems are further improved to ensure that significant

gaps in the quality of risk assessments and care plans, and unreasonable waiting times for patients are

addressed swiftly.

5.7 The trust should continue to address barriers to effective patient movement along the care pathway.

5.8 The trust should ensure that staff clearly understand their roles and responsibilities, clarify referral

criteria and thresholds, ensure specialist teams can accept referrals, and support community staff to make

more effective placement funding applications.

Page 35 of 224


PROJECT NAME: Lewisham CQC delivery plan BY: PMO


OCTOBER 2018 NOVEMBER 2018 DECEMBER 2018 JANUARY 2019 FEBRUARY 2019 MARCH 2019 2019 - 2020

1 8 15 22 29 5 12 19 26 3 10 17 24 7 14 21 28 4 11 18 25 4 11 18 25 Q1 Q2 Q3

W1 W2 W3 W4 W5 W6 W7 W8 W9 W10 W11 W12 W13 W14 W15 W16 W17 W18 W19W2

0

W2

1

W2

2W23

W2

4W25

1.1.1 Immediate action taken to address the immediate issues raised by

the inspection report.

1.1.2

Action plans will be developed for each teams identified as needing

improvement to provide support, including providing group and

individual wrap-around support.

1.1.3Team Development days and Team appraisals will be organised for

named teams, to be delivered by SLaM partners

1.1.4

Wards and teams to be identified and supported in a timely way

where standards of care need to be improved using tools such as

QuESST resulting in improvement required on all wards.

1.1.5Clear guidance is in draft form with engagement planned for

inpatient units on 9 Oct 2018, with a follow up on 30 Oct 2018.

1.1.6

Capacity has been released for the general manager for inpatients

by utilising the CSL resource thus supporting a more immediate

support response during the improvement timeline.

1.1.7Modern Matron is having daily contact with wards.

1.1.8 Head of Nursing and Quality is working closely with ward managers

to ensure timely escalation.

1.1.9 Ward leadership competency is being managed by the Medical

Lead and General Manager with escalations to the Service Director.

1.1.10Support has been made available to Clare Ward and a review of the

leadership team has occurred.

1.2.1

Team meetings will happen on a regular basis in all teams and

wards, where key quality indicators are scrutinised and lessons

learned can be shared

1.2.2We will review and align our governance structure as has been

agreed through the design group workstream.

1.2.3Safety huddles continue, focussing on violence & aggression data

and patient flow.

1.2.4Twice yearly themed learning event – next event in January 2019.

1.2.5 Implement wards and teams to have a local monthly governance

meeting chaired by a Consultant.

1.2.6In the spirit of encouraging engagement with regards to safety, we

will be exploring ward huddles that include an MDT.

1.3.1 Visual evidence of water being available.

31/10/18

1.3.2Spot checks as to availability by matron audit and walkabouts

(weekly).

1.3.3Patient feedback.

1.3.4Focus of scrutiny on Exec walkabouts.

1.4.1 Daily review of all incidents with individualised feedback to ward

managers.

1.4.2

Ward managers to review all incidents daily and only approve when

they are assured that the necessary action and follow up has

occurred.

1.5.1 The Health and Safety Advisor will review all Environmental Risks.

1.5.2The Health and Safety Advisor and Ward Manager will undertake

reviewed Ligature Audits.

1.5.3Training will be provided to all Ward Managers to ensure

compliance with Health and Safety.

1.5.4Ward Managers will be reminded about use of plastic bags on ward

areas. Blue Light bulletin to be recirculated.

Portfolio Oversight Delivery


Date

Planned End

Date

01/10/18 31/10/18

1.2 The trust must ensure that governance processes are sufficiently robust so that they identify

where improvements need to be made and ensure that action is taken to make the required

improvements

Medical Lead 01/10/18 31/10/18

1.1 The trust must identify and provide timely support to wards and teams where standards of care

need to improve

Head of Nursing and

Quality

1.3 The trust must ensure that all patients can have direct access to drinking water on the

psychiatric intensive care units

01/10/18 31/12/18

01/10/18

1.4 The trust must ensure that staff carry out physical health checks on patients after they receive

rapid tranquilisation

Head of Nursing & quality 01/10/18 30/11/18

1.5 The trust must ensure that all environmental risks are recorded on environmental risk

assessments, that staff is aware of these risks and know how these risks are mitigated. This

includes all ligature anchor points, blind spots and the use of plastic bin liners.

Head of Nursing and

Quality

Head of Nursing &

Quality


Page 36 of 224

1.5.5Compliance Report to the Trust Wide Health and Safety Committee

1.5.6Environmental risk assessments to be completed weekly by team

managers.

1.5.7Standardisation of management of blind spots implemented.

1.6.1 2.6.1 All wards to implement Four Steps to Safety by

December 2018.

1.6.2Head of Nursing reviews all incidents of violence & aggression on a

daily basis. Each ward to have a named lead.

1.7.1Ward manager and Consultant to review incidents on a weekly

basis to ensure accurate reporting.

1.7.2 Dissemination plan for lessons learned to be devised and updated

monthly at SI Panel.

1.7.3Quarterly Learning lessons event within the Directorate.

1.7.4Anonymised summary of investigation to be made available to

ward/team governance meetings for review.

1.8.1 Embedding of the Trust plan for addressing flow within the borough

with the aim to work at 85% occupancy – see Appendix

1.8.2We will fully implement the patient flow design group plan.

1.8.3This will include working with individual teams looking at their data

to improve their practice.

1.9.1 We will fully implement the patient flow design group plan.

1.9.2We will implement SOP to ensure that patient will always have a

bed.

1.10.1

Supervisory structures across the Directorate have been embedded

which are monitored via the Service Performance meeting in

accordance to Trust Policy on supervision.

1.10.2Ward Manager to ensure that this occurs

1.11.1All emergency equipment to be checked weekly and replaced as per

Trust Policy.

1.11.2Monthly Matrons clinic audit tool.

2.1.1The results of risk assessment audits should be discussed in

supervision where there are any gaps.

2.1.2We will provide training in relation to risk assessment

documentation to all community teams.

2.1.3We will incorporate this standard into community team objectives

and appraisal/job.

2.1.4We are auditing the quality of risk assessment documentation

monthly at team level.

2.1.5

We are developing team/individual action plans to address quality

gaps and holding all staff to account for delivering this standard and

their role in this.

2.1.6We will introduce learning from areas of good practice via the

Directorate Quality sub exec meeting.

2.2.1 Complete monthly care plan audits. The results will be discussed in

supervision.

2.2.2Organise Care planning workshops to support staff with quality

assurance and completion.

2.2.3 We are auditing the quality of care plans & documentation monthly

and developing team/individual action plans to address quality gaps.

2.2.4We will introduce learning from areas of good practice via the


2.3.1 Risk forum continues to be developed in partnership with social care

and Metro Police/Ambulance service.

1.7 The trust must ensure that staff record all incidents appropriately and are aware of incidents

from the service and across the trust, and the lessons learned from investigations into these

incidents.

Governance Team Lead

1.9 The trust must ensure that patients are able to access a bed when they return from authorised

or unauthorised leave and are not required to sleep on sofas or in other temporary facilities.

Service Director

01/10/18 31/12/18

1.6 The trust must continue to implement plans to reduce the number of patients being restrained

and make sure all staff is aware of the actions they need to take

Head of Nursing & quality 01/10/18 31/12/18

Head of Nursing &

Quality

01/10/18 31/03/19

1.10 The trust must ensure that all staff receives regular managerial and clinical supervision in line

with trust policy.

Deputy director 01/10/18 31/01/19

01/10/18 31/01/19

1.8 The trust must ensure that all wards plan effectively for patients’ discharge and are pro-active

in addressing barriers to discharge.

Service Director

01/10/18 31/03/19


2.2 The trust must ensure that each patient has a care plan, which is person-centred and includes

information about how staff will support them.

Deputy director01/10/18 31/11/18


Head of Nursing &

Quality01/10/18 31/10/18



2.3.The trust must ensure that patients who require a Mental Health Act assessment are assessed

without undue delay to ensure their safety and that of others.

Medical Lead 01/10/18 31/12/18

2.1 The trust must ensure that risk assessments and risk management plans are always completed

and reviewed after changes in patients’ circumstances and risk events, and stored where other

Page 37 of 224

2.3.2Actions will be taken to follow up on external issues that prevent a

mental health act assessment.

2.3.3

Robust governance structures are being developed for the Risk

Forum which will monitor those most at risk and are likely to require

an MHAA at some point.

2.3.4

We will fully implement the plan for patient flow as designed by the

patient flow work group. This includes ring-fencing four Lewisham

beds for Lewisham patients needing MHAA or emergency

admission.

3.1.1

Annual ligature risk assessments in all rehab inpatient areas will be

carried out as per Trust policy. Any risks identified will have clear

mitigation plans put in place.

3.1.2All Team managers to collate and share evidence relating to how

ligatures are being managed and any risks mitigated.

3.1.3Environmental works are referred to Estates and Facilities.

3.2.1

Ward Manager and Responsible Clinician to review any ward

regulations identifying any blanket restrictions, make changes as

required and email summary to Clinical Service Lead. Ward

Manager and Responsible Clinician to discuss findings with clinical

team.

3.2.2

Monthly care plan audits to be carried out by the clinical charge

nurse on all patients to ensure care plans are personalised and do

not breach an individual’s rights relating to the MHA code of

practice.

3.3.1

Monthly fire safety and environmental checks to be carried out by

the ward lead for Health and safety. This to be reviewed by the

Ward Manager monthly.

3.3.2 All patients with mobility issues or other disability have PEEP plans

(Personal Evacuation Plans) devised.

3.4.1

The Lewisham Directorate will continue to participate actively in the

Trust's recruitment initiatives which include rebranding and

improved recruitment advertising campaigns to ensure that staffing

levels are maintained at a safe and satisfactory level.

3.4.2To collate and report monthly safe staffing levels to the trust Board

and NHSE. To review safe staffing minimum levels on a 6 monthly

basis with the Director of Nursing and report to the Trust Board.

3.4.3Vacancies will be circulated weekly to Directorate operational leads

via Head of Service for review and action.

4.1.1 Head of Nursing to develop local training strategy for autism.

Head of Nursing &

Quality01/10/18 31/01/19

4.2.1

All clinical staff will have up to date Engagement and observation

competencies by January 2019.

4.2.2 Ward manager will review this through supervision structures.

4.3.1

To support Team Leads to ensure all restraints to be recorded on

Datix in enough detail.

Head of Nursing and

Quality01/10/18 31/10/18

4.4.1

We will implement fully the FSOC as developed by the FSOC

design group and monitored by supervision.

Head of Nursing and

Quality01/10/18 30/11/18

4.5.1

We will implement fully the FSOC as developed by the FSOC

design group and monitored by supervision.

Head of Nursing and

Quality01/10/18 31/12/18

4.6.1

Hourly environmental checks will be introduced across the inpatient

wards.

4.6.1 Escalations to the Clinical Service Lead.

4.6.1 This will be discussed in community meetings.


3.2 The trust must ensure that at Heather Close and the Tony Hillis unit blanket restrictions are not

imposed that do not reflect the needs of people using the service


Medical Lead 01/10/18 31/12/18

3. Long stay/rehabilitation mental health wards for adults of working age (from inspection in

September 2015) 3.1 The trust must ensure that at Heather Close and McKenzie ward that where there are still high-

risk ligature points or patients who may harm themselves, that the appropriate steps to mitigate

4. Should Do's: Acute wards for adults of working age and psychiatric intensive care units

4.1 The trust should ensure staff receive training in autism.

4.2 The trust should ensure that staff carry out observations on patients and keep accurate

records of this, including for patients who are on intermittent observations.

Head of Nursing and

Quality

01/10/18 31/01/19

3.3 The trust must ensure that at Heather Close fire safety precautions are all in place



Deputy Director01/10/18 31/10/18

31/12/18

4.7 The trust should continue to address the high number of nursing vacancies on some wards

through active recruitment and retention strategies to improve the consistency of care.


4.4 The trust should ensure that all patients have care plans to meet their physical and mental

health needs.

4.5 The trust should ensure that staff take a pro-active approach in supporting patients with their

physical health needs, including taking regular blood tests when required, and ensuring they act

on concerns identified in food and fluid intake monitoring.


General Manager 01/10/18

Page 38 of 224

4.7.1 Continue with Trust wide recruitment initiatives.

4.7.2 Employment of locally commissioned nursing students.

4.7.3

Review of nursing establishment to ensure modernised nursing

workforce.

4.7.4 To continue scrutiny of vacancy via HR business support.

4.7.5

Recruitment phone calls led by HR Business Partner with team

leads to continue.

4.8.1

Permanent recruitment has been undertaken and staff recruited to

posts.General Manager 01/10/18 31/03/19

5.1.1

Clinical Service Lead for Home Treatment will develop a protocol

with Pharmacy to be incorporated into the Operational Policy

document.

General Manager 01/10/18 30/11/18

5.2.1

The trust should ensure staff follow the trust policy for assessing

and recording the suitability of patient’s own medicines before

administering them.

5.2.2

Clinical Service Lead for Home Treatment will develop a protocol

with Pharmacy to be incorporated into the Operational Policy

document.

5.2.3 All staff will have medication management competency completed.

5.3.1 n/a- Southwark action plann/a



5.6.1

To ensure all staff are aware of the role of the Freedom to speak up

Guardian, ambassador and advocates by inviting the Lewisham

representative to the Operational Exec meeting in preparation for

cascading across the Lewisham services (quarterly Way Forward

meetings).


6.1.1 Caseloads continue to be reviewed in line with national guidance for

EI.

6.1.2Weighting tool to be used.

6.1.3Oversight of caseloads by Clinical Service Lead.

6.2.1

Teams to monitor their training levels, to be reviewed at monthly

performance meetings to identify an gaps and action plan around

this where necessary.

6.2.2Introduction of monthly performance meetings by new Borough

Operational Directorate which includes reviewing training

6.3.1 Supervision to be used as a mechanism for improving Care plans.

6.3.2 Organise Co-production in Care planning workshops refresh

(February 2019)

6.3.3 Incorporate standards into objectives and appraisal/job.

6.3.4

Continue to audit quality of care plans & documentation monthly.

Monthly care planning audit programme per team; reviewed locally

with teams in monthly Quality sub meeting and reported to

Governance Exec.

6.3.5 Develop team/individual action plans to address quality gaps.

01/10/18 30/11/18


4.8 The trust should consider recruiting more permanent, rather than interim, ward managers to

increase stability on the wards and improve the consistency of care.

5.3 The trust should ensure that the patient s.132 rights poster displayed in the health-based place

of safety assessment rooms clearly explains patients’ rights in line with the Mental Health Act.

5.4 The trust should continue to monitor and work towards making sure patients do not stay in the

health-based place of safety for longer than 24 hours.

5.5 The trust should ensure that staff in the health-based place of safety clearly document how

they arrive at their decision when completing mental capacity assessments for consent to

5.6 The trust should ensure staff are aware of the role of the Freedom to Speak up Guardian and

how to contact them.


6.1 The trust should continue to take action to reduce the caseloads of care coordinators in the

early intervention teams, so that they can consistently provide effective support to patients

5. Mental health crisis services and health based place of safety 5.1 The trust should ensure that when staff supply medicines to patients at home that it is

packaged and labelled in accordance with the Human Medicines Regulations 2012.

5.2 The trust should ensure staff follow the trust policy for assessing and recording the suitability

of patient’s own medicines before administering them.

General Manager

6.3 The trust should ensure that staff clearly record patient involvement in their care records, and

offer each patient a copy of their care plan


6.4 The trust should ensure that staff explain patients’ rights in respect of community treatment

orders consistently in accordance with the Mental Health Act (MHA) Code of Practice, and keep


6.2 The trust should ensure that staff complete all mandatory training including annual basic life

support, infection control and fire safety training.


Page 39 of 224

6.4.1 Utilise weekly reminder reports circulated by Mental Health Act

Office.

6.4.2Revisit governance processes in relation to patients’ rights and

CTOs

6.5.1 Review psychology access and waiting times in all community

services with the support of the Trust HOPP (by January 2019).

Trust Head of Psychology

& Psychotherapy01/10/18 31/01/19

6.5.2 Borough Community redesign to account for review findings in the

redesign (by April 2019).

Trust Head of Psychology

& Psychotherapy01/10/18 30/04/19

6.6.1 Community transformation in partnership with Alliance

collaborative has begun to address these issues.

6.6.2Transformation redesign scheduled for April 2019.

6.6.3Interim solutions have been implemented by local management

restructure of leadership of these services.

6.6.4Patient flow design group plan will be fully implemented, which is

set to address this.

6.7.1 Community transformation scheduled for April 2019.

6.7.2 Patient flow design group plan will be fully implemented, which is

set to address this.

6.8.1 Support via MADE events to community and inpatient services with

regards to making funding applicationsDeputy director 01/10/18 31/10/18

6.9.1BI support being requested to enable local translation of Trustwide

data, as part of the Enablers design group.

6.9.2Teams will use data in team meetings and supervision.

7.1.1

To review how current observation levels are managed in Number 3

(flats). Align this to the current Trust observation policy.

7.1.2

Local plans in place include observation levels on the patient status

at glance board. Observation levels will be communicated in

handover and recorded on the electronic record system.

7.1.3

A review of the engagement and observation policy and SLP

competencies of all staff. This will be reviewed during supervision.

7.1.4

10.1.4 Engagement policy requirements will be included in

temporary/ agency staff unit induction and documented and signed.

7.2.1

Team managers to provide a baseline of work repairs that are

required on the units and to list outstanding work items.

7.2.2

Escalation process to be agreed with the Estates and Facilities

Department to agree escalation to key managers.

7.2.3

Weekly review by ward staff of repairs to be logged or followed up

with estates and facilities.

7.2.4

To ensure escalations are followed by regular visits to Heather

Close by Exec members.

7.3.1

A review of establishments currently underway to match finances in

order to identify true gaps (October 2018).

7.3.2

Vacancies are reviewed monthly with team managers and action

taken to fill vacancies monthly within wider Directorate campaign, in

addition to unit specific recruitment at interim points as required.

7.3.3 Continue with Trust wide recruitment initiatives.

7.3.4

Review of nursing establishment to ensure modernised nursing

workforce.

7.3.5 To continue scrutiny of vacancy via HR business support.

7.3.6

Recruitment phone calls led by HR Business Partner with team

leads to continue.




6.8 The trust should ensure that staff clearly understand their roles and responsibilities, clarify

referral criteria and thresholds, ensure specialist teams can accept referrals, and support

6.9 The trust should ensure that quality management systems are further improved to ensure that

significant gaps in the quality of risk assessments and care plans, and unreasonable waiting times


6.5 The trust should ensure that patients have access to psychological therapies without undue

delay in line with best practice guidance.

6.6 The trust should continue to develop more effective working relationships between the

community teams, home treatment teams and inpatient wards; and improve the quality and


6.7 The trust should continue to address barriers to effective patient movement along the care

pathway.

7.3 The trust should ensure recruitment processes are ongoing to reduce the dependence on

temporary staff who may not all know the services.


7.4 The trust should implement measures to monitor patients who go AWOL. This includes clearly

recording for patients on section 17 leave what time they are expected to return. Also consider

7.1 The trust should ensure that staff are clear about the observation of patients at 3 Heather

Close.


7.2 The trust should ensure that at Heather Close and the Tony Hillis unit maintenance and repairs

are carried out in a timely fashion.


Page 40 of 224

7.4.1

We will review the following, recognising that procedures have not

been implemented satisfactorily across the inpatient units:

a) Standardise grab packs across wards as part of the Trustwide

AWOL reduction programme.

b) Risk assess patients prior to them taking their section 17 leave

and add a tick box to signing out book to indicate risk assessments

has been done.

c) Risk management plans/contracts/care plans in place for repeat

AWOLs.

d) Discuss AWOL policy and procedures in business meeting and

evidence in minutes, signature list of staff once policy has been

read.

e) Use of photographs for patients is being reviewed through the

Trustwide AWOL Reduction Programme.


7.4.2

Ward managers will be supported via a half day workshop revisiting

meaningful engagement with patients to avoid AWOL, in addition to

implementing the above actions (November 2018).

7.5.1

Team managers to review control and bedroom access measures

ensuring these are effective to manage safety, privacy and dignity of

patients on mixed gender units particularly where patients could

enter bedroom areas of the opposite gender.

7.5.2

Ward managers to review and report mixed sex breaches as

required and when breaches do occur actions to mitigate will be put

in place and reviewed by Clinical Service Lead and team manager.

7.5.3

Ensure plans in place for secure access to gender specific bedroom

areas

7.6.1 A defibrillator is in place at No 1 Heather Close.

7.6.2 Staff training compliant in Intermediate and Basic Life Support.

7.6.3 Medical devices competencies to be completed and up-to-date.

7.7.1

Complete monthly care plan audits. The results should be discussed

in supervision.

7.7.2

Organise Care planning workshops to support staff with quality

assurance and completion.

7.7.3

We are auditing the quality of care plans & documentation monthly

and developing team/individual action plans to address quality gaps.

7.7.4

We will introduce learning from areas of good practice via the


7.8.1

The Associate Clinical Director and Deputy Director will circulate the

proposed outcome measures to be used in the Complex Care

pathway.


7.9.1

Site based specialist MHA training has been offered to staff on

Heather Close which will focus on the issues highlighted by the

CQC.

7.9.1

Compliance with the MHA will be audited weekly on the wards and

monthly by the pathway assurance audits.

7.10.1

Senior pathway managers to review current space for therapeutic

activities, including observation of activity sessions, to ensure this is

adequate making any required adjustments.

7.10.2 Meet service users to get their feedback on space for activities.

7.11.1 Staff make a private room available for patients to make calls.Deputy director 01/10/18 30/11/18

10.12.1

Review all local beverage arrangements and ensure that patients

have access to drinks and snacks 24 hours a day.

10.12.2

Review the provision and quality of food with the Head of Hotel

Services.

7.13.1

Complaints posters are displayed and leaflets available in all

buildings and communal areas.

7.13.2 All complaints reviewed and themes collated by ward manager.

7.13.3

Ward manager continues to offer a regular complaint surgery for

patients and carers access.

7.5 The trust should ensure that staff have considered the vulnerability of patients on mixed

gender wards where patients of the opposite gender could enter bedroom areas.

01/10/18 30/11/18

7.8 The trust should ensure that across the rehabilitation wards staff are able to clearly articulate

the model of care and how they are promoting patients’ rehabilitation.

7.9 The trust should ensure on Tony Hillis and Heather Close that staff understand how to apply

the Mental Health Act.


7.6 The trust should ensure that staff at Heather Close can access a defibrillator in a timely

manner in the event of an emergency.

Head of Nursing & Quality 01/10/18 31/10/18



7.12 The trust should ensure food across the wards is consistently of a good quality and quantity

and there are facilities to access hot drinks and snacks 24 hours a day.


10.13 The trust should ensure at Heather Close that patients are aware of how to make a formal

complaint and the findings are recorded and shared for learning.


7.10 The trust should ensure there is adequate space for therapeutic activities at Heather Close.


7.7 The trust should ensure care plans are reviewed regularly and reflect patient risks and the

support they need.

General Manager

Page 41 of 224

7.14.1 A staff reflection group to be organised lead by the Psychologist.

7.14.2

Forums for staff and community meetings for patients will explore

any concerns about the way in which staff interact with each and

with patients.

7.14.3 Ward manager to develop communication standards with the team.

7.14 The trust should ensure there is a positive culture of staff engagement at Heather Close.


Page 42 of 224

Page 43 of 224


PROJECT NAME: Croydon CQC delivery plan BY: PMO


NOVEMBER 2018 DECEMBER 2018 JANUARY 2019 FEBRUARY 2019 MARCH 2019

1 8 15 22 29 5 12 19 26 3 10 17 24 7 14 21 28 4 11 18 25 4 11 18 25 Q1 Q2 Q3 Q4


1.1.1 Immediate action taken to address the immediate issues raised by the inspection

in relation to Croydon PICU. Action plans will be developed for each team

identified as needing improvement to provide support, including providing group

and individual wrap-around support

Service Director

1.1.2 Team Development days and Team appraisals will be organised for named

teams, to be delivered by SLaM partners Service Director

1.1.3 Robust Directorate governance structures will be embedded in all clinical areas

and will be published and accessible to all staff.

Head of Nursing and

Quality

1.1.4 Development of ward Governance Meetings that will feed into the Directorate

Governance structures. Deputy Director

1.1.5Quality indices will be monitored by the SMT and Executive on a weekly basis.

Head of Nursing and

Quality

1.1.6 Data will be provided via Business Intelligence Dashboards and Directorate

Quality Dashboard.

Senior Business

Manager

1.1.7 Senior clinical leadership will be visible on clinical services by means of ‘walk

round’. Deputy Director

1.2.1 Robust Directorate governance structures will be embedded in the Directorate and

all clinical areas to ensure Senior Management and Executive oversight of safety,

Head of Nursing &

quality

1.2.2Structures will be published and accessible to all staff.

Ward Managers

1.3.1 A water dispenser will be installed on Croydon PICU. Ward manager will ensure

this is always in working order. Currently on order. Ward Manager

1.3.2To ensure patients have access to water prior to the installation of the water

dispenser a temporary arrangement is in place of a small portable water urn.

Health & Safety

Advisor.

1.3.3Direct access to drinking water will feature as a three monthly audit, which will

feed into the wider review of all audits in the ward Governance Meetings that will Deputy Director

1.4.1 All registered nurses will receive training on rapid tranquilisation and physical

healthcare. A rolling programme of training will be developed to ensure all staff

Head of Nursing and

Quality

1.4.2An extend MEWS nurse champion role will be developed which will include the

monitoring of the use of rapid tranquilisation and physical healthcare. Clinical Services Lead

1.4.3Rapid tranquilisation data will be a standing agenda item on: General Manager

1.4.4Ward Governance Agenda Ward Manager

1.4.5Directorate Quality Governance Agenda Modern Matron

1.5.1 The Health and Safety Advisor will review all Environmental Audits.

Health and Safety

Advisor

1.5.2The Health and Safety Advisor and Ward Manager will undertake reviewed

Ligature Audits which will take into account blind spots.

Health and Safety

Advisor

1.5.3A protocol will be developed for the management of blind spots. Clinical Services Lead

1.5.4Training will be provided to all Ward and Deputy Ward Managers to ensure

compliance of Health and Safety requirements. Clinical Services Lead

1.5.5Ward Managers will be reminded about the use of plastic bags on ward areas.

Blue Light Bulletin to be recirculated. Clinical Services Lead

1.5.6Compliance report to the Trust wide Health & Safety Committee.

Health and Safety

Advisor

1.5.7Health and Safety will be a standing agenda item for the ward Business Meeting

(issues around environmental risks can be discussed further here). Ward Manager

1.6.1 The ‘4 steps to safety’ quality improvement programme will be re-launched in all

wards by December 2018. General Manager01/10/18 31/12/18

Portfolio

Board

Oversight &

Scrutiny

Delivery

Board

Planned Start

Date

OCTOBER 2018Planned End

Date

01/10/18 30/11/18

1.5 The trust must ensure that all environmental risks are recorded on environmental risk assessments, that

staff is aware of these risks and know how these risks are mitigated. This includes all ligature anchor points,

blind spots and the use of plastic bin liners.

01/10/18 31/10/18

1.3 The trust must ensure that all patients can have direct access to drinking water on the psychiatric

intensive care units

01/10/18 31/10/18

1.2 The trust must ensure that governance processes are sufficiently robust so that they identify where

improvements need to be made and ensure that action is taken to make the required improvements

1.4 The trust must ensure that staff carry out physical health checks on patients after they receive rapid

tranquilisation

1.6 The trust must continue to implement plans to reduce the number of patients being restrained and make

sure all staff is aware of the actions they need to take

2019 - 2020


1.1 The trust must identify and provide timely support to wards and teams where standards of care need to

improve

01/10/18 31/10/18


01/10/18 30/11/18

Page 44 of 224

1.6.2

Restraint data will be a standing agenda item in the:

- Ward Governance Meeting

- Directorate Quality Governance Meeting

- Staff supervision template General Manager

1.6.3Restraint incidents will be discussed within the community meetings. Ward Manager

1.6.4RRP Meeting to be embedded to include service user representation. General Manager

1.6.5Quality data to be provided to the clinical teams on a monthly basis.

Senior Business

Manager

1.7.1Training on the use of ‘Datix’ to be provided to all wards.

Head of Nursing and

Quality01/10/18 31/12/18

1.7.2Quality data to be provided monthly to the wards from the Governance team.

Senior Business

Manager

1.7.3Incidents and lessons learnt to be a standing agenda item in the ward Governance

Meeting. Clinical Services Lead

1.7.4Quarterly Thematic analysis to be undertaken and presented to the Quality

Governance Meeting and disseminated to the wards via Business Meeting.

Head of Nursing and

Quality

1.7.5Incidents and lessons learnt to be a standing agenda item in the supervision

template Ward Manager

1.8.1 New borough bed management meeting to be in place with senior staff in

attendance. Medical Lead01/10/18 30/11/18

1.8.2Clear actions and timelines allocated and documented for the ward and

Community Mental Health Teams General Manager01/10/18 31/12/18

1.8.3General Manager for Community has been appointed who will be leading on

addressing interface issues. Deputy Director

1.8.4‘Red to Green’ Quality Improvement tool to be implemented in all services by end

December 2018. QI Team

1.8.5Regular (at least 3 per year) MADE events to embed processes to escalate and

manage internal and external barriers to flow/discharge. Service Director

1.8.6Medical Lead to use LOS data to support teams to understand variations in

clinical practice. Medical Lead

1.8.7Embedding of the Trust plan for addressing flow within the borough with the aim

to work at 85% occupancyDeputy Director 01/10/18 31/12/18

1.9.1 Datix reports will be completed for all incidents where a bed is not available for

patients returning from leave. Ward Manager

1.9.2

All incidents of a bed not being available are to be immediately escalated to the:

- ARC.

- Directorate Senior Management Team: Service Director, Clinical Director,

Medical Lead and Deputy Director.

- On-call Director (out of hours). Deputy Director

1.9.3 Standard Operating Protocol to be developed for any returning patient to access a

bed. Deputy Director01/10/18 30/11/18

1.10.1 All staff are to receive monthly supervision as per Trust policy. Clinical Services Lead

1.10.2Supervision compliance to be monitored via Performance Management Meetings. General Manager

1.10.3Supervision compliance to be monitored at ward level via Business Meeting. Ward Manager

1.10.4Ward managers to review team supervision tree and make visible in each team by

end December 2018. Ward Manager

1.10.5All gaps in supervision to ward staff to be followed up, and resolved. Modern Matron

1.11.1Weekly audits are to be undertaken of resuscitation equipment as per Trust

Policy. Clinical Service Leads

1.11.2Audit tool to take into account stock that is nearing expiration date. Ward Managers

2.1.1 Risk assessment workshops for all community teams to be completed from April

2018. General Manager

2.1.2 Risk Management training compliance will be monitored through Directorate

Performance Meetings General Manager

01/10/18 31/10/18



2.1 The trust must ensure that risk assessments and risk management plans are always completed and

reviewed after changes in patients’ circumstances and risk events, and stored where other staff can find them

easily.

01/10/18 31/10/18

01/10/18 31/10/18

1.10 The trust must ensure that all staff receives regular managerial and clinical supervision in line with trust

policy.

01/10/18 31/10/18

1.9 The trust must ensure that patients are able to access a bed when they return from authorised or

unauthorised leave and are not required to sleep on sofas or in other temporary facilities.


01/10/18 30/11/18

1.8 The trust must ensure that all wards plan effectively for patients’ discharge and are pro-active in

addressing barriers to discharge.

01/10/18 31/10/19

01/10/18 31/10/18

1.7 The trust must ensure that staff record all incidents appropriately and are aware of incidents from the

service and across the trust, and the lessons learned from investigations into these incidents.

01/10/18 31/10/18

Page 45 of 224

2.1.3 Risk assessment and management plans to be a standing agenda item on the

Supervision template Clinical Service Lead

2.1.4 Monthly risk assessment audits will be completed and results disseminated to the

team and discussed in their Business Meetings General Manager

2.2.1 Piloting of new community care plan to be completed with care coordinators using

Quality Improvement methodology General Manager

2.2.2Development of a comprehensive training package which includes community

care plan quality standards and sustainability plan building on current team

processes to maintain changes General Manager

2.2.3 Care plans to be audited monthly and disseminated to the team via Business

Meetings Clinical Service Lead

2.2.4Care plans to be a standing agenda item on the Supervision template Clinical Service Lead

2.2.5Care plans to be drafted from the perspective of the service user

2.3.1 Development of a protocol for escalation for teams including the recording of

delay on ‘DATIX’ and rationale. Deputy Director

2.3.2 The AMHPs Manager to escalate promptly to the Service Director and Medical

Lead for the Borough for action. Service Director

2.3.3 In the event of a delay (DATIX) there should be a clear safety and clinical plan

which should be actively implemented until admission is effected. Deputy Director

2.3.4This should be in line with the overall flow plan ( as per action 2.8.7) Deputy Director

31/01/19

2.4.1 Development of screening tool and clearer referral criteria to streamline process. General Manager01/10/18 31/10/18

2.4.2

Implementation of Quality Improvement programme to ensure Croydon Duty

system is robust. General Manager

01/10/18 30/11/18

2.4.3

Three additional band 6 agency staff have been recruited to increase assessments

available. Deputy Director 01/10/18 31/10/18

2.4.4

Work with Social Services and commissioners to develop ‘Hub & Front’ door to

Social Services. General Manager01/10/18 31/01/19

2.4.5 Waiting list for assessments will be monitored and escalated as appropriate. Ward Manager01/10/18 31/10/18

3.1.1 Rehab Recruitment campaign – to ensure that staff attend the nursing

assessment centres.

3.1.2Staff to be actively involved in Trustwide workforce development plans.

3.1.3Senior Management oversight of vacancies and recruitment issues.

3.1.4

Senior Management to engagae in developing workstreams in comples care in

South London Partnership Complex Care workstream (in relation to worksforce

development and engagement .

30/11/18

4.1.1 Autism training will be commissioned for all wards. Deputy Director

4.1.2 Training compliance to be monitored via Directorate Performance Meetings. General Manager

4.2.1

To ensure that purposeful observation and engagement is part of all staff

induction and all staff practice according to Trust Policy. Clinical Service Leads

4.2.2

Engagement and Observation Policy and nursing competency to be discussed at

ward Governance Meetings. Ward Managers

4.2.3

The Engagement and Observation of patients to be of the senior staff leadership

walk around. Deputy Director

4.2.4

Engagement and Observation paperwork to be audited by the Ward Manager on a

weekly basis. Results to be disseminated to the team via the Governance

Meetings. Ward Manager

01/10/18 31/10/18

4. Should Do's: Acute wards for adults of working age and psychiatric intensive care units

4.1 The trust should ensure staff receive training in autism.

01/10/18 30/11/18

4.2 The trust should ensure that staff carry out observations on patients and keep accurate records of this,

including for patients who are on intermittent observations.



Deputy Director 01/10/18

31/10/18

01/10/18

30/11/18

31/10/18

2.3.The trust must ensure that patients who require a Mental Health Act assessment are assessed without


01/10/18

31/10/18

2.4 The trust must ensure that patients referred to the Croydon assessment and liaison team, receive an

assessment within trust target timescales.

01/10/18 31/10/18

2.2 The trust must ensure that each patient has a care plan, which is person-centred and includes information

about how staff will support them.

Page 46 of 224

4.3.1 Datix training will be provided as required to clinical services. Clinical Service Lead

4.3.2 Ward Managers will review all Daitix’s and discuss in supervision as required. Ward Manager

4.3.3

Restraint documentation standards presently being developed by the Trust Lead

Nurse for RRP. These will be disseminated to all teams. Clinical Service Lead30/11/18

4.3.4

Monitoring and assurance of dissemination will be via ward Business Meeting

minutes. Ward Manager31/10/18

4.4.1 Monthly care plan clinics to be held on the ward. Ward Manager

4.4.2

Weekly care plan audits to be undertaken with results being disseminated to the

team via Business Meetings. Modern Matron

4.4.3

Monthly quality audit of care plans to be undertaken by the Matron. Results to be

disseminated to the team via Business Meeting. Modern Matron

4.4.4 Physical Health to be a standing agenda item on the supervision template Ward manager

4.4.5 Directorate Performance Meeting to monitor audit result. General Manager

4.5.1

Dissemination and Implementation of Trust Physical Health Strategy within the

Directorate. Clinical Service Leads31/12/18

4.5.2 All wards to have a named Physical Health Lead. Ward Managers31/10/18

4.5.3 Monthly Physical Health Forum for Physical Health Leads established. Modern Matrons31/12/198

4.5.4 Monthly Directorate Physical Health Meeting established.

Head of Nursing and

Quality31/11/18

4.6.1 Bathroom and toilet areas are to be included in the environmental checklist. Ward Managers.

4.6.2 Concerns are to be escalated to the domestic contractor immediately. Hotel Services Manager

4.6.3

Patients to be supported to raise concerns regarding environmental issues in the

community meeting Ward Manager

4.7.1 Ensure Directorate attendance at Trust rolling recruitment assessment events. Deputy Director

4.7.2

Vacancies specific for Croydon female Acute wards advertised locally and

nationally. General Manager

4.7.3 Monthly review of nursing establishments (in comparison to agency usage) at

ward and directorate levels. Clinical Service Leads

4.7.4 Ward Managers to escalate where difficulties are increasing Ward manager

4.8.1 All ward managers are in substantive posts. Deputy Director31/10/18

4.8.2 Quarterly review of non-substantive positions in all multiprofessional posts. General Manager30/11/18

4.8.3Directorate integration in the forthcoming SLP development programme. Deputy Director

31/01/19

4.9.1 Trust 5 Commitments to be disseminated to all staff Deputy Director

4.9.2

Regulated nursing staff to be reminded of the 6C’s and the NMC code.

Information to be disseminated.

Head of Nursing and

Quality

4.9.3

Unregulated staff to be reminded of the Trust code. Information to be

disseminated.

Head of Nursing and

Quality31/10/18

4.9.4

Ensure at least 80% of patients complete PEDIC monthly. Results to be

disseminated to the team and discussed in the Business Meeting Ward Manager

4.9.5

Feedback from Hear Us Link workers who attend the ward to be sent directly to

General Manager for review and to be disseminated to Directorate Quality

Governance Meeting General Manager

4.9.6

SLaM partners to work with Ward Manager and Consultant to put in place staff

development initiatives reviewing leadership processes SLAM Partners

4.9.7 Supportive structures in place for reflective practice following significant incidents. Modern Matron

5.1.1 Datix training will be provided as required to clinical services Deputy Director

5.1.2

Restraint documentation standards presently being developed by the Trust Lead

Nurse for RRP. These will be disseminated to all teams. Monitoring and

assurance of dissemination will be via ward Business Meeting minutes Deputy Director

5. Forensic inpatient/secure wards

5.1 The trust should ensure that staff maintain detailed restraint records that include the specific type of hold, duration and staff members

involved.

10/1/2018 30/11/18

4.8 The trust should consider recruiting more permanent, rather than interim, ward managers to increase

stability on the wards and improve the consistency of care.

01/10/18

4.9 The trust should ensure that staff on Ruskin/AL2 and Croydon PICU always demonstrate kindness and

compassion in their interactions with patients.

01/10/18

31/12/18

30/11/18


01/10/18 31/10/18

4.7 The trust should continue to address the high number of nursing vacancies on some wards through active

recruitment and retention strategies to improve the consistency of care.

01/10/18 31/10/18

4.4 The trust should ensure that all patients have care plans to meet their physical and mental health needs.

01/10/18 30/11/18

4.5 The trust should ensure that staff take a pro-active approach in supporting patients with their physical

health needs, including taking regular blood tests when required, and ensuring they act on concerns

01/10/18


01/10/18

31/10/18

Page 47 of 224

5.1.3

Monthly audit of restraint data to be undertaken and disseminated to the teams for

discussion in their Business Meeting

Head of Nursing and

Quality

5.1.4 Restraint data to be on the supervision template and discussed in supervision Ward Manager

5.2.1

Nursing shifts will be booked in advance and in a planned manner to ensure that

patients’ s.17 leave is facilitated. Clinical Service Leads

5.2.2

Incidence of leave that has not been facilitated will be escalated to the Deputy

Director for review and a Datix will be raised. Clinical Service Lead

5.2.3

A quarterly thematic analysis of Datix alerts will be undertaken to ensure trends

and themes are captured

Head of Nursing and

Quality

5.3.1Effra ward will hold Business Meetings for all ward staff members to attend. Ward Manager

01/10/18 30/11/18

5.4.1All clinical audits will have clear SMART action plans Deputy Director

5.4.2Action plans will be monitored at Directorate Performance Management Meeting Deputy Director

6.1.1 Ensure all Medication Competencies are up to date Clinical Services Lead30/11/18

6.1.2

Medication competency compliance to be monitored via Directorate Performance

Meetings Team Leaders31/10/18

6.1.3

Weekly clinic room audits to be commenced to ensure all medication are

appropriately labelled. Modern Matrons31/10/18

6.2.1 Ensure all Medication Competencies are up to date Clinical Service Lead30/11/18

6.2.2

Medication competency compliance to be monitored via Directorate Performance

Meetings General Manager31/10/18

6.2.3

Weekly clinic room audits to be commenced to ensure all medication

appropriately labelled. Results to be disseminated to team via business meetings. Modern Matron31/10/18

6.3.1

Information about the Freedom to Speak up Guardian and role is available to staff

in team bases. Clinical Service Leads

6.3.2

Role of the Freedom to Speak up Guardian to be discussed in the Business

Meeting Team Leaders

7.1.1 Develop proposal to present to the senior management team to safely manage

early intervention caseloads by November 2018. Deputy Director

7.1.2Additional staffing has been put into teams to provide closer alignment between

current and nationally recommended caseload sizes Deputy Director

7.1.3Commissioner engagement via core contract meetings Service Director

7.2.1 Review baseline for mandatory training compliance and identify areas for

improvement. General Manager

7.2.2Action plan for improvement to be developed to include the planning and

prebooking of training and options for site based training. Modern Matron

7.2.3Training compliance to be monitored through Directorate Performance Meetings. Deputy Director

7.3.1Monthly care plan clinics to be held on the ward General Manager

7.3.2Weekly care plan audits to be undertaken with results being disseminated to the

team via Business Meetings Team Leader

7.3.3Monthly quality audit of care plans to be undertaken by the Matron. Modern Matron

7.3.4Results to be disseminated to the team via Business Meeting. Team Leader

7.3.5Directorate Performance Meeting to monitor audit result Deputy Director

7.4.1 Cascade revised CTO policy General Manager

7.3 The trust should ensure that staff clearly record patient involvement in their care records, and offer each

patient a copy of their care plan

01/10/18 30/11/18

7.4 The trust should ensure that staff explain patients’ rights in respect of community treatment orders

consistently in accordance with the Mental Health Act (MHA) Code of Practice, and keep accurate records of

01/10/18 30/11/18

01/10/18 31/10/18

7.2 The trust should ensure that staff complete all mandatory training including annual basic life support,

infection control and fire safety training.

01/10/18 30/11/18

6.3 The trust should ensure staff are aware of the role of the Freedom to Speak up Guardian and how to

contact them.

01/10/18 31/10/18


7.1 The trust should continue to take action to reduce the caseloads of care coordinators in the early

intervention teams, so that they can consistently provide effective support to patients experiencing a first

6. Mental health crisis services and health based place of safety 6.1 The trust should ensure that when staff supply medicines to patients at home that it is packaged and

labelled in accordance with the Human Medicines Regulations 2012.

01/10/18

6.2 The trust should ensure staff follow the trust policy for assessing and recording the suitability of patient’s

own medicines before administering them.

01/10/18

10/1/2018 30/11/18

5.3 The trust should ensure that staff on Effra Ward are able to access meetings where lessons learned from incidents in the service and

across the trust are discussed.

5.4 The trust should ensure that where clinical audits identify areas for improvement that action plans are in place.

01/10/18 30/11/18

10/1/2018 30/11/18

5.2 The trust should ensure there is adequate staffing cover across all the wards and that there are sufficient staff to provide escorted leave.

Page 48 of 224

7.4.2 Work with MHA Policy Advisor to develop and deliver comprehensive training

programme for community staff re: CTO policy implementation Clinical Service Leads

7.4.3 Use weekly reporting/reminder tables from MHA Office to identify any additional

training required per team Medical Lead

7.4.4Cascade monthly MHA reports to community teams. Clinical Service Lead

7.5.1 Review psychological therapies policies across and update in line with best

practice guidelines. Deputy Director01/10/18 31/01/19

7.5.2Monthly reporting of psychology waiting times to be reviewed in Business and

Performance Meetings (quarterly).

Directorate Psychology

Lead(s)01/10/18 30/10/18

7.6.1 Build on current borough interface forums. Deputy Director

7.6.2Community teams to pilot the electronic discharge planning proforma. General Manager

7.6.3Clear expectations for community attendance at weekly bed management

meetings. General Manager

7.6.4Regular (at least 3 per year) MADE events. Deputy Director

7.6.5Engage in LSI and associated quality improvement projects. General Manager

7.7.1Engage in LSI and associated quality improvement projects Deputy Director

31/10/18

7.7.2Develop clear protocols for transfer between pathways Deputy Director

7.7.3Internal community transfer tool to be developed Deputy Director

7.7.4Regular (at least 3 per year) MADE events. Deputy Director

31/10/18

7.8.1 ICare Community redesign, a wholesale redesign of the community offer at SLaM

to provide a service that meets the needs of the community. Deputy Director

01/10/18 31/01/19

7.9.1Work with Business Intelligence colleagues to develop a clinically useful support

quality management Deputy Director31/01/19

7.9.2Use supervision to monitor quality of risk assessments and care plans monthly General Manager

7.9.3Monthly audits of risk assessment and care plans to be disseminated to the team

for discussion in Business Meeting General Manager

8.1.1 Rehab Recruitment campaign TRUST HR

8.1.2 Staff to be involved in Trust wide workforce development plans TRUST HR

8.1.3 Senior Management oversight of vacancies and recruitment issues Deputy Director30/11/18

8.2.1

Implementation of Grab Packs which will include a photograph of the patient and

monthly audits of contents to be undertaken Ward Manager

8.2.2 Results to be disseminated to the team via Business Meetings. Ward Manager

8.2.3

AWOL data to be audited on a monthly basis. Results to be disseminated to the

team via Business Meetings

Head of Nursing and

Quality

8.3.1 Gender signage required Ward Manager

8.3.2 Updated general observation checklists Ward Manager

8.3.3 Ensure staff aware of how to report mixed accommodation breaches via datix General Manager

8.3.4 Ensure risk assessments and risk management plans are updated as required Ward Manager

8.2 The trust should implement measures to monitor patients who go AWOL. This includes clearly recording

for patients on section 17 leave what time they are expected to return. Also consider having photos of

patients to share with the police if they are missing.

01/10/18 30/11/18

8.3 The trust should ensure that staff have considered the vulnerability of patients on mixed gender wards

where patients of the opposite gender could enter bedroom areas.

01/10/18 30/11/18

01/10/18

30/11/18


8.1 The trust should ensure recruitment processes are ongoing to reduce the dependence on temporary staff

who may not all know the services.

01/10/18

31/12/18

7.7 The trust should continue to address barriers to effective patient movement along the care pathway.

01/10/18 31/12/18

7.8 The trust should ensure that staff clearly understand their roles and responsibilities, clarify referral

criteria and thresholds, ensure specialist teams can accept referrals, and support community staff to make

more effective placement funding applications.

7.9 The trust should ensure that quality management systems are further improved to ensure that significant

gaps in the quality of risk assessments and care plans, and unreasonable waiting times for patients are

addressed swiftly.

7.5 The trust should ensure that patients have access to psychological therapies without undue delay in line

with best practice guidance.

7.6 The trust should continue to develop more effective working relationships between the community teams,

home treatment teams and inpatient wards; and improve the quality and frequency of contact between

01/10/18

30/11/18

31/10/18

01/10/18 30/11/18

Page 49 of 224

8.4.1

New Trust Care plan audit incorporates risk assessment. Audit to be undertaken

weekly with results being disseminated to staff via the Business Meeting Ward Manager

8.4.2 Care plan training /DECC training Clinical Service Lead

8.5.1

The Associate Clinical Director and Deputy Director will circulate the proposed

outcome measures to be used in the Complex Care pathway.


8.6.1 Provision of phones/ opportunity to use phones to preserve patients’ privacy Ward Manager01/10/18 30/11/18

8.7.1 WW have access to tea room, personal menus, fruit bowl, snacks on request

8.7.2 FM2 provided drinks area

8.7.3 Update welcome packs with food and drink provision

9.1.1 To ensure that all staff practice according to Trust Policy. Ward Manager

9.1.2

Engagement and Observation Policy and nursing competency to be discussed at

ward Governance Meetings Ward Manager

9.1.3

The Engagement and Observation of patients to be of the senior staff leadership

walk around Service Director

9.1.4

Engagement and Observation paperwork to be audited by the Ward Manager on a

weekly basis. Results to be disseminated to the team via the Governance

Meetings Ward Manager

9.2.1The Health and Safety Advisor and Ward Manager will undertake reviewed

Ligature Audits which will take into account blind spots. Ward Manager31/10/18

9.2.2A protocol will be developed for the management of blind spots Deputy Director

30/11/18

9.3.1

Checklist for green and blue zone corridors reviewed and updated to include

control measures for checking women’s bedroom area of the ward is secure and

locked. ward Manager

10/1/2018 31/10/18

9.4.1

All temporary workers are inducted on the first shift worked. This will be monitored

by asking temporary workers to confirm they have received an induction each

time they work a shift where workers are asked to sign the manpower each shift to

confirm they have received induction.

31/10/18

9.4.2

Nursing team to be reminded of the induction policy and ward induction process

with rationale in business meeting30/11/18

9.5.1

The redecoration of the lounge was completed. This included:

- Repairing roof leak

- Addressing damp walls

- Redecoration of walls

- Improved soft furnishings ward Manager

10/1/2018 31/10/18

9.6.1

Monthly clinical risk assessment audits are undertaken. Results are disseminated

to the team in the Business Meeting

9.6.2

Reviewing risk assessment is undertaken in clinical supervision to check the risk

assessment is up-to-date and reflects new risks.

9.7.1

Safeguarding issues and safeguarding alerts are handed over every shift and

recorded on the handover document.

9.7.2 Mandatory safeguarding training booked and attended by all staff 2018.

9.7.3

To run immediate training session with staff to review new process &

responsibilities

ward Manager

10/1/2018 31/10/18

9.6 The trust should ensure that risk assessments are kept updated as new potential risks are identified.

Ward Manager

10/1/2018 31/10/18

9.7 The trust should ensure that where a safeguarding alert is made, that the patient records are kept up to date to ensure any actions

identified as part of that process are followed through.

9.3 The trust should ensure that the door to the women's bedroom area of the ward is kept secured when needed.

9.4 The trust should ensure that all temporary staff working on the ward receive a timely local induction.

ward Manager

10/1/2018

9.5 The trust should ensure that the ongoing refurbishment work includes the redecoration of the communal lounge.

9.1 The trust should ensure that where patients are being observed that this is recorded correctly.

01/1018 31/10/18

9.2 The trust should ensure the ligature risk assessment covers all areas of the ward used by patients.

01/10/18

8.7 The trust should ensure food across the wards is consistently of a good quality and quantity and there are

facilities to access hot drinks and snacks 24 hours a day.

Ward Manager 01/10/18 30/11/18

9. Other specialist services (National Psychosis Unit) (from inspection in September 2015)

8.4 The trust should ensure care plans are reviewed regularly and reflect patient risks and the support they

need.

01/10/18 30/11/18

8.5 The trust should ensure that across the rehabilitation wards staff are able to clearly articulate the model of

care and how they are promoting patients’ rehabilitation.


Page 50 of 224

9.7.4

An Initial audit of safeguarding tracker was undertaken by Trust Safeguarding

Lead & feedback to team through reflective sessions & immediate feedback to

Ward Manager

9.7.5

To carry out audit of compliance with Safeguarding Adults mandatory training

2015.

9.7.6

Clearer safeguarding systems and processes displayed. We have created a

safeguarding display board in nursing office that includes: safeguarding posters,

updated protocol, escalation process & implementation flowchart

9.7.7

Safeguarding included as a standard item in Ward Rounds, Supervision, and

Business Meetings. TRUST

9.7.8

The Trust safeguarding Lead has worked closely with the Local Authority to clarify

the process for response to safeguarding alerts they receive from the ward, and

this has been incorporated into the ward’s updated implementation and

safeguarding process flowchart. Safeguarding accountabilities by the Local

Authority is formalised in an updated Trustwide SGA policy that reflects

implementation of The Care Act.

ward Manager

ward Manager

10/1/2018 31/10/18

Page 51 of 224


PROJECT NAME: CAMHS CQC delivery plan BY: PMO



1 8 15 22 29 5 12 19 26 3 10 17 24 7 14 21 28 4 11 18 25 4 11 18 25 Q1 Q2 Q3 Q4


1.1.1There will be a rolling programme of both RN and CSW recruitment

to ensure there are no delays in recruitment. Emma Addison, Workforce Lead

1.1.2Where possible in-patient units will over-recruit RNs and CSW’s to

ensure safer staffing levels can be consistently met.

Deborah Heron, Senior Finance Business

Partner

1.1.3

Where there are surplus staff they can be utilised to cover on sister

units to reduce the need to use temporary staff. All staff will receive

an induction on sister units to enable a rapid response to providing

cross cover. Ellie Barnfather

1.1.4

There will be continued workforce development to understand the

challenges with retention with the aim of improving the retention of

newly qualified RNs

Richard King, HR Business Partner – Chair of

Workforce and Education Committee

1.1.5

Safer staffing levels reported by ward manager and shared at

performance meeting, specific difficulties escalated via QUESTT to

CSM.

Richard King, HR Business Partner – Chair of

Workforce and Education Committee

1.1.6 Explore the implementation of trainee Nursing Associates (thereby

reducing reliance on RNs).

Oversight

Deb Parsons, Deputy Director Quality / Head of

Nursing

1.2.1

All children and young people will have a relevant and current care

plan which they (and carers) have been involved with and understand,

written by a member of their care team. Ellie Barnfather

1.2.2

All units undergo care plan audits (of a sample) weekly by the ward

and quarterly by Matrons, discussed in ward CG meetings (minutes

on shared drive) and quarterly at Exec. Amanda Broughton

1.2.3

Expectations for ward manager use of My Ward Report tp be agreed.

Monitored monthly by Business manager who send reports to ward

managers & CSM.

1.3.1This has not taken place and currently the Trust is in agreement with

NELFT to transfer the unit. Harold Bennison01/10/18 31/12/18

1.4.1CAMHS to take part in tender process to award new contractor to

ensure understanding of needs of children. Completed

1.4.2Staff from Acorn in conjunction with dietician and contractor (now ISS)

to develop child appropriate menus.Completed

1.4.3

Regular feedback to be collected from children on Acorn.

(action 3 to be tested within performance

management process – Lou Hellard, Deputy

Director, Operations)

01/10/18 31/11/2018

1.5.1All units will have a supervision tree explicitly identifying each staff

members supervisor.

Deb Parsons, Deputy Director, Quality / Head of

Nursing

1.5.2

Senor managers/ Matrons/PDN will be available to provide ad hoc

supervision in the case of sickness (of supervisors) – the ward

managers will request this.

Local managers, matrons and service managers

to ensure supervision is consistently in place as

per actions.

1.5.3When system available, all staff who provide or receive supervision

will record each session on LEAP LEAP – Sally Storey

1.6.1 1.KMAU to ensure sufficient staff are trained appropriately (there is

currently only gym equipment within KMAU)

Vicky Slater, Clinical Service Manager KMAU –

local record 01/10/18 31/12/18

1.7.1The basement in Black Prince Road has been renovated and there

has been an improvement in Estates focus since 2015. David Grafton, Lambeth Service Manager Completed

1.8.1there will be a clear schedule of IC audits across CAMHS detailing

who should be involved and responsible for actions

1.8.2all completed IC audits will be monitored in performance meeting to

ensure actions completed

1.9.1 Wheelchair access is constrained at Black Prince Rd (Lambeth) to

the one downstairs clinic room. Scheduling takes this into account.

David Grafton, Lambeth Service Manager

(Lambeth)

01/10/19 Completed

Portfolio Oversight & Delivery


Date

1.3 The trust should ensure that it develops a clear timetable for planning, approving and commencing redesign work to separate the wards on the

Woodlands unit.

1.4 The trust should ensure that it looks into developing a child friendly menu for Acorn Lodge.

1.5 The trust should ensure that all staff receive regular one-to-one formal supervision.

2019 - 2020

1. SHOULD dos : Child and adolescent mental health wards (from September 2015)

Planned End

Date

01/10/18 31/12/18

01/10/18 31/12/18

1.1 The trust should continue to recruit new staff to fill vacancies and that it ensures safe staffing numbers are met at all times.

1.2 The trust should ensure that it continues to monitor risk assessments and care plans on Acorn Lodge to ensure that all are up-to-date.

01/10/18 30/11/18

1.9 The trust should continue to monitor and review the services to ensure that all children and young people can access the service in a timely manner.

Gillene Thomas, Matron 01/09/18 31/10/18

1.6 The trust should ensure that sufficient staff are trained in using the gym equipment, so young people can access this resource at more times.

1.7 The trust should ensure that the environment at Lambeth is safe for those people who use or work in the service.

1.8 The trust should ensure that infection control audits are carried out across all CAMHS.

Page 52 of 224

1.9.2

Overarching access to CAMHS services is now a national priority with

active engagement of commissioners in meeting the national

trajectory to see 35% of children and young people with a

diagnosable mental health illness by 2020/2021.

Lou Hellard, Deputy Director, Operations

(access rate)

BAU

1.10.1Business managers escalate concerns through Digital Services

process. Lou Hellard, Deputy Director Operations BAU

1.10.2

Develop a report from Digital Services of completed and outstanding

actions (including equipment requests) – that way teams can monitor

actions and ensure overdue problems are not closed down without

action. Ricky Mackennon, Deputy IT Director

See CQC

Should Do 5.1

1.11.1

Review and confirm care plan design and usage for children and

young people. Create a one page summary of the expectations

regarding care and treatment plans plus assessing and

documentation of consent in community teams.

1.11.2 Each community team will provide refresher training where necessary

to ensure all staff are aware and able to fulfil requirements.

Deb Parsons, Deputy Director Quality / Head of

Nursing

1.10 The trust should ensure that all staff have IT equipment and patient record systems that enable them to access the information they need in a

timely manner.

1.11 The trust should ensure that there is a consistent approach to the documentation of patient care and treatment, including risk assessments, care

plans and consent.

01/10/18 31/12/18

Page 53 of 224


PROJECT NAME: PMOA CQC delivery plan BY: PMO



1 8 15 22 29 5 12 19 26 3 10 17 24 7 14 21 28 4 11 18 25 4 11 18 25 Q1 Q2 Q3 Q4


1.1.1Ward Managers will be provided with information on how to book

staff into training on LEAP.01/10/18

1.1.2All staff will receive an automated email from the LEAP system

within 12 weeks of their training expiring.01/10/18

1.1.3Supervisors will review staff mandatory training completion during

supervision01/10/18

1.1.4Deputy Director of Nursing will monitor ILS, BLS, Fire training

completion rates for 85% compliance in the CAG operational 01/10/18

1.1.5The service manager will review Mandatory training compliance in

the ward managers supervision.01/10/18

2.1.1ICT to review the needs of the CMHTs; CHiT; Memory Services;

HTT Chief Information Officer 01/10/18 31/10/18

2.1.2 Agree timeline for delivery of required devices Chief Information Officer 01/10/18 30/11/18

2.2.1 Team Managers will plan supervision sessions a minimum of one

month ahead and the dates will be available to staff. 01/11/18 TBC

2.2.2All staff will who provide or receive supervision will record each

session on LEAP01/10/18 TBC

2.3.1 The Trust will provide all teams with a standard agenda for their

team business and governance meeting01/10/18 31/10/18

2.3.2The Clinical Service Manager will attend an initial meeting and at

least one more to support staff to use the template.01/10/18 31/12/18

3.1.1 The HoN will identify the inpatient competency framework for

nursing staff 01/10/18 31/12/18

3.1.2 The ED nurses will be part of this process. 01/10/18 31/12/18

3.1.3 The framework will be ratified by the Nursing Executive 01/10/18 31/01/19

3.1.4 The Clinical Leads and HoN will agree an implementation plan 01/10/18 30/04/19

3.2.1

The relevant documentation must be completed immediately

following the application of a restrictive intervention. Details of the

incident must be documented within the events section of the

clinical records and on datix, this will include:

a. Datix incident number

b. Precipitating factors leading up to incident

c. The reason for the use of restrictive interventions

d. De-escalation methods use and level of success

e. All staff involved in the incident

f. Start time and end time of restrictive intervention

g. Details of any medication administered

h. Any physical health issue that has been observed, or reported

by the service user

17/10/18 Ongoing

Delivery

Board


Portfolio

Board

Oversight &

Scrutiny

Head of Nursing,

Clinical Service Manager,

Eating disorders ,General

Manager & Nurse Executive

3.2 The trust should ensure staff record incidents of restraint accurately including the type of restraint,

position of restraint, members of staff involved, length of time the restraint took place and whether the

patient received a physical health check for any injuries post restraint.

Clinical Service Managers

Lead Nurse - Reducing

Restrictive Practice

Pharmacy Dept

Service Director and Clinical

Director 31/10/18

Associate Director of Human

Resources, OD, Education &

Development,Clinical Service

Managers & Team Managers

2019 - 2020

Planned Start

Date

Planned End

Date

1. MUST Dos : Wards for older people with mental health problems (from inspection in March 2017)

1.1 The provider must ensure that all relevant staff complete training in mandatory areas including

intermediate life support, basic life support, and fire safety

Deputy Director

2.3 The trust should ensure that learning from incidents and complaints is discussed at team business

meetings to support improvements.

3. Specialist eating disorder services

3.1 The trust should put in place a formal eating disorders competency framework for staff to ensure

that have all the specialist skills they need to care for a patient with an eating disorder

2. SHOULD Dos : Community-based mental health services for older people

2.1 The trust should enable more effective mobile working in all teams through the provision of

appropriate technology.

2.2 The trust should ensure that systems for capturing the completion of staff supervision are effective

and accurately record the supervision taking place

Page 54 of 224

3.2.2 Record changes and updates to care plan/risk assessments. 17/11/18 Ongoing

3.2.3

Record level of observations following an incident:

a. Position(s) of restraint used

b. All members of staff involved in restraint and their position

during restraint

c. All members of staff involved in restraint and their position

during restraint

17/11/18 Ongoing

3.2.4 Datix will be completed as soon as possible after the incident. 17/11/18 Ongoing

3.2.5

All incidents will be recorded as a C and each will have a

Factfinder (unless agreed and documented in progress notes on

datix by the HoN or Service Director). A FF will identify if any of

the required actions were missed; if so what; what is the learning

and how it will be addressed.

17/11/18 Ongoing

3.2.6

PMOA incidents are reviewed in a number of meetings including

the weekly Quality huddle; the Governance Committee and SI

meetings. Learning will be shared via the individual team business

meetings (linked to action 5.4 above.

31/1/2/18 Ongoing

3.3.1 Review of available budget 01/10/18 12/11/18

3.3.2Decision re any additional dietician or social work sessions to be

agreed 01/10/18 30/11/18

3.4.1

The Service Director will make explicit the expectation that all non-

medical staff receive monthly managerial supervision (10 out of 12

occasions)

01/10/18 12/10/18

3.4.2The CSM will plan supervision sessions a minimum of one month

ahead and the dates will be available to staff 01/11/18 Ongoing


session on LEAPTBC TBC

3.5.1

The expectation that all patients will be offered a copy of their care

plan and this will be recorded on ePJs will be communicated by

the HoN to the EDU CSM

01/10/18 31/10/18

3.5.2 The CSM will communicate this to the clinical team 01/10/18 31/10/18

3.5.3The ward will have a welcome booklet that contains information

that is required to support an induction to admission.01/10/18 30/11/18

3.5.4All patients will have an induction to the ward on admission by

their allocated nurse within 24 hours of admission.01/10/18 31/10/18

3.5.5The CSM will review at least 2 clinical records in supervision to

ensure that that this is happening from 1 November 201801/11/18 Ongoing

3.6.1

The result of the care plan and risk assessment audit will be

discussed in the monthly business meeting and identified

improvements will be recorded in the minutes with updates from

subsequent meetings

01/11/18 Ongoing

3.6.2

Additional audits will be discussed as above or the GM & HoN will

agree and communicate an alternative plan via email 01/11/18 Ongoing

4.1.1

The Service Director will make explicit the expectation that all non-

medical staff receive monthly managerial supervision (10 out of 12

occasions)

Service Director

01/10/18 12/10/18

4.1.2The CSM will plan supervision sessions a minimum of one month

ahead and the dates will be available to staff. 01/11/18 ongoing


session on LEAPTBC TBC

Clinical Service Managers

Lead Nurse - Reducing

Restrictive Practice

Pharmacy Dept

3.3 The trust should ensure that the service continues to review the dietitian and social worker input to

the ward, as well as to the Step Up to Recovery team

Finance Business Partner

Deputy Director

3.4 The trust should ensure that all staff receive regular monthly supervision

Service Director



Development

3.5 The trust should ensure that patients are given a copy of their care plan and an induction to the

ward on admission.

Business Manager

Head of Nursing

Clinical Service Manager,

Eating Disorders IP

Allocated Nurse

3.6 The trust should ensure that learning and improvements result from audits.

Clinical

Service Manager

Head of Nursing,

Matron,

General manager



Development

4.2 The trust should ensure that all areas of the ward identified as a risk are consistently monitored to

mitigate the risks to patients, especially when staffing levels are low.

4.1 The trust should ensure that all staff receive regular clinical supervision, to support them in

carrying out their duties effectively.

4. Specialist neuropsychiatric services

Page 55 of 224

4.2.1

A one page information sheet detailing the environmental risks

identified in the ligature audit will be made available to all staff as

part of induction (including bank and agency staff)

01/10/18 31/10/18

4.2.2 This will detail the expectation around monitoring 01/10/18 31/10/18

4.2.3 The nurse allocated the hourly general observations will

undertake 4 times an hour intermittent environmental checks 31/10/18 Ongoing

4.2.4

Each patient will have a risk assessment and the mental health

care plan will identify any risks and the care that is required to

mitigate them.

0/10/18 30/11/18

4.3.1The Housekeeper will undertake a stock review of the clinical

equipment by 12th November 2018.01/10/18 12/11/18

4.3.2The Housekeeper in conjunction with the Matron and the CSM will

ensure that the stock is sufficient to meet patient need. 01/10/18 30/11/18

4.3.3The Housekeeper Staff will check the expiry date a minimum of

monthly of equipment and replace prior to expiry commencing 7th 07/12/18 Ongoing

4.3.4 The clinical staff will check the expiry date before use 01/10/18 12/10/18

4.4.1 The CSM will ensure that all staff complete their mandatory

training to Trust target – 85% for ILS.01/10/18 31/10/18

4.5.1 All patients will be given a key to their bedrooms 01/10/18 31/10/18

4.5.2This will be included in the information about the ward and the

Welcome booklet 01/10/18 31/10/18

4.5.3

Exceptions will be agreed with the patient and/or their family and

the least restrictive option of access to the bedroom will be

documented in the care plan and reviewed as per patient need

with this evaluation recorded on the care plan from 31st October

2018

31/10/18 Ongoing

4.6.1 The directorate will create a one page aide memoir on grading and

categorising incidents. 01/10/18 31/10/18

4.6.2Staff will receive a face to face refresher session on incident

reporting.01/10/18 15/11/18

4.6.3 The CSM will review all datix and document any actions required 01/10/18 08/10/18

4.7.1

The OT and the CSM will lead a MDT review of activities to be

completed by 30th November 2018. This will be conducted in

conjunction with the current service users.

01/10/18 30/11/18

4.7.2 A 7 day a week, including evening, offer of activities will be

coproduced with the current inpatients 01/10/18 30/11/18

4.7.3 The programme will be reviewed 4 times a year. 01/10/18 28/02/19

4.7.4An alternative television will be available so that patients who

chose to can watch the television in an alternative location01/10/18 30/11/18

4.8.1

A weekly community meeting will be held and minutes recorded

and visible for patients and visitors to see. Minutes to commence

from 15th October 2018.

15/10/18 Ongoing

4.8.2Hear us attend the ward once a week to speak to patients about

their experience01/10/18 Ongoing

4.9.1 The Carer’s PEDIC will be available in all teams for staff to use.

01/10/18 31/10/18

4.9.2 The ‘You Said, We Did’ will include carer feedback. 01/10/18 30/11/18

4.9.3The PMOA PPI Lead and the CSM will agree a range of

opportunities for carer feedback for eg this may be virtual as 01/10/18 28/02/19

4.4 The trust should ensure that staff complete their mandatory training, especially in life support.

4.6 The trust should ensure that incidents relating to the service, especially medicines incidents are

categorised correctly to ensure that appropriate learning is shared with staff.

Head of Nursing,

Clinical Governance Officer

Clinical Service Manager

4.5 The trust should review the blanket restriction with regard to no

patients having keys to their bedrooms, which means that they have to

Matron

Nurse in Charge


4.3 The trust should ensure that staff check the expiry date of all items in the clinic room to ensure that

these are removed and replaced before expiry.

Housekeeper

Matron


4.10 The trust should ensure that that patient details recorded on the office whiteboard are not visible

to people outside the room.

Director of estates



Head of OT

4.7 The trust should ensure that patients have access to appropriate leisure activities and not spend

too much time watching television during the day.

4.8 The trust should ensure that patients have opportunities to give feedback on the service they

received, for example by holding regular community meetings.


4.9 The trust should ensure that family members of patients on the ward are encouraged to give

feedback about the service.

Experience Manager

Page 56 of 224

4.10.1 Until an alternative is available the NiC each shift will ensure that

no identifiable patient information is visible to patients and visitors01/10/18 05/10/18

4.10.2No identifying patient information will be visible in the nursing

office 01/10/18 12/10/18

4.10.3

The CSM and Matron will work with the nursing team to establish

what is required and where the information is available by the 12th

October 2018

01/10/18 12/10/18

5.1.1

Nurse Consultant for Violence Reduction to work with PSTS

trainers to develop training to make alternative IM injection sites

available.

01/04/17 31/08/17

5.1.2

The Deputy Director of Nursing will oversee a training package

which will include both the CAG and Trust pharmacist undertaking

refresher training in the administration and management of rapid

tranquilisation on Wards.

01/04/17 31/08/17

5.1.3

Wards will be monitored via the operations management meeting

by Deputy Director of Nursing for 85% compliance with promoting

safe and therapeutic services training on wards.

01/04/17 31/08/17

5.1.4The administration and management of rapid tranquilisation at a

glance poster will be updated and circulated to the Wards.01/04/17 31/08/17

5.1.5

The Deputy Director of nursing will monitor all incidents involving

the use of rapid tranquillisation to ensure minimum standards

have been achieved in the correct post administration monitoring

procedures are have been followed.

01/04/17 31/08/17

5.1.6This will be used to support and identify if staff need extra training

or support01/04/17 31/08/17

5.2.1

All clinical areas will be reviewed for blind spots and where

possible eliminated or added to unit risk register and all staff

advised.

01/04/17 30/09/17

5.2.2 All ward induction packs will be reviewed. 01/04/17 30/09/17

5.2.3 Information about blind spots will be added. 01/04/17 30/09/17

5.2.4All new staff including temporary staff will have a formal induction

using the pack alerting them to blind spots.01/04/17 30/09/17

5.3.1 Clinical supervision rates will be reviewed during ward managers

supervision.01/04/17 30/09/17

5.3.2

The Inpatient service manager will oversee a system to ensure as

many staff have access to group and individual supervision as

much as possible.

01/04/17 30/09/17

5.3.3 Supervision records will be kept and staff will receive a copy. 01/04/17 30/09/17

5.3.4 Survey of staff regarding supervision will be carried out 6 monthly. 01/04/17 30/09/17

5.4.1

The Deputy Director of Nursing will write to all inpatient staff

reminding staff of clinical standards in maintaining privacy and

dignity.

01/04/17 31/07/17

5.4.2

Staff will offer all patients to have any clinical intervention in a

private area. Where a person lacks capacity a decision will be

made in their best interest as to where the intervention will take

place.

01/04/17 31/07/17

5.4.3The CAG will contribute a MHOA&D specific privacy and dignity

section to the Trust Policy.01/04/17 31/07/17

5.5.1 Minimum compliance rate across all inpatient registered nursing

staff will be 85% with MHA training.01/04/17 30/09/17

5.5.2

Teach registered nurse will ask to discuss their understanding of

the rights of informal patients during ward nursing councils and

supervision.

01/04/17 30/09/17


Director


Director

5.5 The provider should review the policy regarding ensuring that informal patients are given clear

information about their right to leave each ward.

5.3 The provider should ensure that all staff receive regular supervision sessions in line with the trust

policy and that this is monitored effectively.

5.4 The provider should ensure that staff provide patients with the option of having clinical

observations carried out in a private area such as the ward clinic room or their bedroom.

5.1 The provider should ensure that accurate records are maintained of post dose vital sign monitoring

after patients receive rapid tranquilisation


Director


Director


Director


5. Wards for older people with mental health problems (from inspection in March 2017)

5.2 The provider should ensure that records are maintained of blind spots on each ward, to ensure that

new staff are aware of these risk areas.

Page 57 of 224

5.5.3 Policy to be reviewed by Trust MHA Lead. 01/04/17 30/09/17

5.6.1

The CAG will hold a consultation event with patients', carers, staff

and the Trust window supplier to review all available options, this

will determine a solution to improve patient privacy via different

window options.

01/04/17 30/09/17

5.6.2Staff on Al1 will be communicated with to remind them to ask

patients' their preference for the management of the window.01/04/17 30/09/17

5.6.3Where patient lack capacity staff will make a decision in their best

interest to maintain privacy via closure of the window.01/04/17 30/09/17

5.6.4The CAG will contribute an MHOA&D specific privacy and dignity

section to the Trust Policy.01/04/17 30/09/17

5.7.1 The CAG with Estates and Facilities will consider and know the

options which will inform decisions going forward.


Director01/04/17 14/08/17

5.8.1

The Deputy Director of Nursing will write to all inpatient staff

informing them of expectations of supporting patients' to maintain

independence through the use of laundry rooms.

01/04/17 30/09/17

5.8.2

All Laundry rooms on the acute admission wards will be risk

assessed and the information of how patients' can be supported to

use them added to the unit welcome packs and staff induction

booklet.

01/04/17 30/09/17

5.9.1 The CAG will work in conjunction with the Trust catering provider

to develop picture menus for clients with dementia.


Director01/04/17 31/12/17

5.10.1 The CAG senior management team will review the Trust risk

framework and ensure it is correctly implemented.01/04/17 30/11/17

5.10.2Ward manager will be informed when risk issues are added to the

CAG risk register. 01/04/17 30/11/17

5.10.3

The CAG senior Management Team will hold focus groups with

staff on wards. 01/04/17 30/11/17

5.10.4All staff will be provided with a copy of the CAG organisational

chart.01/04/17 30/11/17

5.10.5The CAG senior management team will conduct regular walk

round visits to wards to meet staff informally01/04/17 30/11/17

5.11.1Hayworth ward will display the updated poster from the Informal

rights policy01/04/17 31/07/17

5.11.2All staff on Hayworth ward will be reminded of the informal rights

policy during the business meeting and nurse council.01/04/17 31/07/17

5.11.3All informal patients on Hayworth ward will be provide with copies

of the patient information leaflet explaining their rights.01/04/17 31/07/17

5.8 The provider should ensure that patients have access to the laundry rooms on the wards, following

a risk assessment, to ensure and they are supported to maintain their independent living skills.


Director

5.11 The provider should ensure that informal patients on Hayworth ward are given clear information

about their right to leave the ward in the posters on display


Director


Director

5.9 The provider should ensure that accessible menus are available to patients with dementia, and

improve consistency in ensuring that patients have a choice of meals.

5.10 The provider should ensure that ward managers are made aware of the issues recorded on the

clinical academic group risk register and further develop links between senior management and ward

level.


Director


Director

5.6 The provider should ensure that staff and patients are aware of how to ensure their privacy in the

identified bathroom on Aubrey Lewis 1 ward, by closing the frosted windows.

5.7 The provider should consider the addition of an accessible bathroom within the female patients’

area on Aubrey Lewis 1 ward.

Page 58 of 224

Owner: Initial Current Target Trend

Committee: Likelihood 3 4 2

Proximity: Consequence 4 4 3

Risk Category: Level 12 16 6

Risk Appetite Last reviewed Sep-18 Next review Dec-18

Key Controls Gaps in Control

Internal: Established, well led Board of Directors experienced Service and Clinical Directors, clear

operational and professional structure, quality governance, operational performance

management, and recruitment of sufficient high quality staff. Good knowledge of regulatory

standards and best practice. CQC PID and Improvement action plan addressing; fundamental

standards of care, leadership, governance and patient flow. Individual Directorate action plan to

deliver CQC must and should do’s and local implementation of Our Improvement Plan. Delivery

Board, Oversight and Scrutiny Committee and borough teams in place to oversee

implementation plans arising from the CQC report. Bi monthly Quality Committee meetings and

regular Board discussions with clear agreement as to the governance structure on quality and

the flow of information from Board to floor so as to allow challenge/ exploration of variances

and an appropriate level of Board assurance. Monthly Operational Directorate Quality

Governance Compliance meeting embedded. Risk management strategy and incident reporting

structure in place. Established health safety and fire management procedures and governance

arrangements. Ligature anchor point audit and management procedures and annual risk

reduction programme. CQC preparation meetings. SMT quality visits (to all sites within the year).

Mitigations in place to address issues accessing beds - multi-agency discharge events (MADE)

events, waiting lists etc.

External: Established relationships with commissioners, full engagement with alliance boards,

engagement / leadership of transformation programmes (locally and nationally). CQRG clinical

quality review group chaired by CCG

Variations in fundamental standards of care in both inpatient and adult community mental health teams.

High bed occupancy levels and bottlenecks, obstacles & lack of agreed processes/protocols and clarity on

pathway, flow and discharge management. Inconsistent delivery of physical healthcare checks following

rapid tranquillisation, environmental risk assessments, sharing lessons learnt at ward level and reducing

restraint (as identified by CQC). Delays accessing beds when patients return from leave leading to sleeping

on sofas or in other temporary facilities. iCare yet to fully to define principles for community design.

Variations in Directorate governance structures, effectiveness and staffing leading to problems with 'floor to

Board' escalation and oversight of risks. Governance framework and outcome measures agreed as part of

Alliance development but not yet fully tested in practice. Short of staff in some areas (e.g. CPNs). Vacancies

in Directorate management teams impacting on the effectiveness of Directorates leadership and

governance. Southwark Head of Nursing not yet recruited. Variation in quality of leadership at ward and

team level. Interim ward managers affecting stability on the wards and improvements in the consistency of

care. Contacts and effective working relationships and contact between the community teams, home

treatment teams and inpatient wards not fully established. Gaps in regular managerial and clinical

supervision in line with trust policy. Insufficient support to wards and teams where standards of care need

to improve. Gaps in the leadership of directorates.

Potential Causes (links to the CRR) Potential Consequences

The context of consistent delivery of mental health services across four London Boroughs;

significant need and deprivation; a time of unprecedented NHS financial challenge; current

levels of funding is amongst the lowest in the country; the transformation of services creates

significant pressure for people leading services and people delivering services. Inconsistent “floor

to Board” governance processes. Directorate management vacancies, variable experience and

quality of leadership at ward/team level and insufficient support to wards/teams where

standards of care need to improve, leading to unacceptable variations in delivering fundamental

standards of care. Challenges in bed occupancy and obstacles to patient flow.

This challenges the capacity and capability of an organisation to consistently embed standards of

care or make change and improvements.

Services and staff fail to maintain fundamental standards of care and quality or become overly focussed in

maintaining status quo and do not have the capacity to improve and transform. In the current context this

could lead to an adverse impact on the quality of care, patients outcomes and experience and staff morale

and attrition. This could ultimately lead to the trust failing to meet the standards of care set out in the

Health and Social Care Act regulations, NICE guidance and/or other best practice including the required

improvement actions (Must do / Should do) as set out in inspection reports. This could lead to regulatory

action and loss of services.

Cautious (nominal range 3-8)

Principal Risk 7 (Quality & statutory compliance): There is a significant risk that the quality and safety of care provided to people across inpatient and community services varies or is not adequately

monitored or addressed and at times falls below acceptable standards. This variance in standards could adversely impact the experience and safety of patients and staff and risk breaching regulatory and

statutory duties as set by the CQC, HSE and other regulators.

BM / DoN

Quality committee

6 months

Quality (patient safety, experience & clinical outcomes)

0

5

10

15

20

25

Inherent Sep 17 Dec 17 Mar 18 Jun-18 Sep-18

Page 59 of 224

Sources of Assurance Gaps in Assurance

Request for Closure

No

QI methodology is starting to build however the approach is new and will take time to embed. Data Quality,

compatibility & integrated report issues being addressed by data summit. Evidence of governance systems

within Acute and community care teams failing to identify or escalate unacceptable practices. Poor

communication with teams and Wards, lack of local quality governance meetings and shared learning. Lack

of agreed standardised data sets and metrics that evidence embedded and improvement. Need for

agreement on the flow of information from Board to floor to highlight any variants and ensure timely

challenge.Agreement needed on flow of information from Board to floor both on Trust information and

comparative information with other mental health trusts so as to allow appropriate challenge and action

Assurance on the effectiveness of Controls Action plan progress summary

CQC compliance inspection reports had previously provided good assurance that controls are

effective however the recent QCQ inspection (July-August 2018) has highlighted concerns

systems are not fully embedded or care consistently applied thought out the Trust.

Trust wide improvement plan developed following July – August 2018 CQC inspection.

Implementation governance structures developed to support implementation and evidence embedded

delivery and outcomes

Service Director led development of local implementation plans, one plan for each Operational Directorate,

to address the priority actions and the variation in fundamental standards of care highlighted during the

inspection.

Improvement plans to be delivered in three six-month phases with the Trust wide Our Improvement Plan to

be implemented across the longer time period designed to underpin sustainable improvements.

The improvement plans have been closely considered by SMT and subject of a detailed review Delivery

Board, Oversight and Scrutiny Committee and an extraordinary Quality Committee 17th October 2018. All

three bodies will continue to monitor implementation.

COO Quality report. Learning lessons reports. Compliance reports. CQUINN reports. Progress

reports of delivery of CQC inspection improvement actions. QUEST scores, safer staffing reviews.

QI progress reports. Reported progress on delivery of strategy. Monthly quality compliance

committees with Operational Directorates embedded and Quality matters governance meetings

embedded. CQC Improvement action plan governance with CEO led Portfolio Board, Delivery

Board, Oversight and Scrutiny Committee and bi monthly Quality Committees.

Page 60 of 224


30 October 2018

Title

Emergency Department Pressure & Patient Flow

Author

Mark Marriott, Interim Director of Transformation

Accountable Director

Kristin Dominy, Chief Operating Officer


To request the Board decide on costed options and recommendations for improving patient flow and inform the Board of the Emergency Department Assessment and Admission Policy for this winter .

Executive summary

The increasing pressure across the whole health system is making patient flow more challenging,

especially in Mental Health services where multiple internal and external stakeholders are involved in

discharge decision making. This was highlighted in the CQC warning notice where references to delayed

discharges, the use of private overspill and the lack of beds for people returning from AWOL were

identified as poor practice. Set out in this paper is a comprehensive costed flow improvement plan as

part of our overall Trust improvement plan.

The pressure in the system is also driving up the number of mental health 12-hour waits in ED, meaning SLaM has had up to 5 patients breaching 12 hours in the EDs we support. As winter approaches, we can expect even greater activity in ED and hence even greater pressure on SLaM to find beds for emergency admissions. An emergency department is not an appropriate setting for a patient once the decision to admit has been made. Patients who in effect become stranded also divert liaison resources that would otherwise be available for other pressing tasks. This paper summarises how we will manage winter flow from ED into SLaM beds, or into SLaM support in the community. The ED proposals are also included in the attached flow improvement plans. This paper presents four options to implement the flow improvement plans. A “buy it all” option that is split into two parts: ED & Flow and other improvements; and a “buy what we must, design what we can” option titled Optimum, also split into two parts. It is recommended that the Board approves both parts of the Optimum option for the implementation of ED and patient flow improvement plans.


BAF Risk 14 (New) - Patient flow - In the context of current capacity and increased demand, if there is a lack of integrated working by internal and external stake holders there is a risk of delays in patient discharge and optimum bed occupancy levels that may negatively affect patient outcomes and experience, staff morale and Trust finances. The new BAF assessment is attached at Appendix 4.

Page 61 of 224

Emergency Department Pressure and Patient Flow Plans 1. Executive Summary The increasing pressure across the whole health system is making patient flow more challenging,

especially in Mental Health services where multiple internal and external stakeholders are involved in

discharge decision making. This was highlighted in the CQC warning notice where references to delayed

discharges, the use of private overspill and the lack of beds for people returning from AWOL were identified

as poor practice. Set out in this paper is a comprehensive costed flow improvement plan as part of our

overall Trust improvement plan.

The pressure in the system is also driving up the number of mental health 12-hour waits in ED, meaning SLaM has had up to 5 patients breaching 12 hours in the EDs we support. As winter approaches, we can expect even greater activity in ED and hence even greater pressure on SLaM to find beds for emergency admissions. An emergency department is not an appropriate setting for a patient once the decision to admit has been made. Patients who in effect become stranded also divert liaison resources that would otherwise be available for other pressing tasks. This paper summarises how we will manage winter flow from ED into SLaM beds, or into SLaM support in the community. The ED proposals are also included in the attached flow improvement plans. This paper presents four options to implement the flow improvement plans. A “buy it all” option that is split

into two parts: ED & Flow and other improvements; and a “buy what we must, design what we can” option

titled Optimum, also split into two parts. It is recommended that the Board approves both parts of the

Optimum option for the implementation of ED and patient flow improvement plans.

The costs for the options are summarised below.

Full

Implementation

ED & Flow Other flow Optimum Option

ED & Flow

Optimum

Option Other

Year 18/19 19/20 18/19 19/20 18/19 19/20 18/19 19/20 18/19 19/20

Net

Cost £3,342k £5,505k £1,379k £2,205k £1,827k £3,274k £1,494k £2,068k 0 £1,871k

2. Patient Flow Through the Trust

There are 23 initiative on the flow improvement plan (enclosed at Appendix 1), the most significant initiatives are summarised below.

2.1 Initiatives related to bed flow in general. Several Flow initiatives are designed to achieve flow to establish a capacity that will meet demand, have zero 12 hour breaches, no cancelled MHAs, zero 136 suite 24 hour breaches and no patients staying overnight without a bed:

a. Ring Fenced Borough Beds. Ringfencing Borough beds incentivises each Borough to discharge and not expect an out of Borough admission.

b. Community redesign. A long-term programme to redesign and modernise our community services to keep people well in the community.

c. Multi Agency Discharge Events. MADE events have already started and have reviewed 235 patient cases and produced 123 discharge action plans. MADE will be embedded into the routine bed management process from April 2019. The outcome from the Southwark MADE is at Appendix 2.

d. Red to Green. Green days are days that add value to the patient journey, red days don’t. Red to green aims to turn red days into green days and will be rolled out across all wards by April 2019.

e. Managing Challenging Behaviour. Patients with challenging behaviour can consume all the resource on the ward, preventing flow. We are investigating the procurement of a set of beds for challenging behaviour, while we repurpose 8 SLaM beds for a more permanent solution.

Page 62 of 224

f. Social Care Discharge Team. There are up to 20 patients at any time delayed for complex social and welfare needs. Social care discharge teams in each Borough will actively manage those patients and aim to reduce the delayed patients from 20 to 8 across the Trust.

g. Crisis Café and peer networks. Crisis Cafés are being investigated for Southwark and Lewisham and along with peer networks to support people in crisis.

h. Medical Discharge Support. A floating junior doctor will be introduced to each Borough to support the increased discharge activity

2.2 Initiatives related to emergency and urgent admissions. Several Flow initiatives relate directly to resolving emergency and urgent admissions and achieving zero 12-hour breaches:

a. Enhanced HTT. HTTs will be enhanced to support ED assessment and to provide an in-reach discharge service to wards, including within 24 hours of an ED assessment admission.

b. Enhanced Liaison. Psychiatric liaison will be enhanced to give more resource for assessment and care of patients in ED.

c. Additional Bed capacity. 14 beds will be procured through ELFT to release the ED assessment beds within SLaM.

2.3 Initiatives related to Admission Avoidance. Some flow initiatives are designed to avoid admission or reduce crisis:

a. Predictive Care Planning. The most frequently readmitted patients are already known to us. The aim of the predictive care planning initiative is to provide a focussed and intensive winter care package around our frequently admitted patients to give them additional support in the community to avoid crisis.

b. Contingency plans and risk management. Sometimes attendance in crisis is rewarded in a way that promotes attendance rather than reduce it. Contingency planning for a response to crisis that discourages attendance should reduce repeated admissions and will be managed under risk forums in each Borough.

3. Emergency Department Assessment and Admission Flow (draft operations policy enclosed at

Appendix 3)

3.1 Flow in the Admission Department

a. Patients arrive and are triaged by ED staff, all patients with a suspected serious mental illness are referred to psychiatric liaison as normal. Currently this referral takes an average of 58 minutes to be made.

b. The psychiatric liaison team will start their assessment and contact the on-call Home Treatment Team assessor who will go to the ED and complete a joint, trusted assessment of the patient.

c. The patient will either be admitted to a medical bed, be discharged sometimes with a care package, or be referred to the Acute Referral Centre (ARC) with a decision to admit or decision to assess. The aim is to achieve this within 4 hours, but with a zero-breach tolerance of 12 hours in ED.

d. ARC will then find a bed for all decisions to admit and will allocate one of the vacant ED assessment beds for all decisions to assess.

3.2 Flow in ED Assessment Beds

Patients will be admitted to the bed to ensure their safety and quality of care; they will be reviewed by an HTT assessment team within 24 hours to facilitate early discharge. If the patient is discharged the bed is made available to the ED assessment pool, if the patient is admitted they will stay in the bed and another bed in the Borough released to the ED assessment pool.

The patient flow model is illustrated below.

Page 63 of 224

Emergency Department Patient Flow Model

4. Costs

The detailed flow plan at Appendix 1 shows full costs for 18/19 and 19/20 and winter money and mental health investment standard offsets, resulting in a net cost position showing part year for 18/19 and full year for 19/20. The part year costs assume 5 months’ expenditure for resourcing, one-off expenditure for procurement and specific part year costs where they have been identified. The options are:

a. Full implementation. Full implementation costs in 18/19 are £3,342k and in 19/20 are £5,505k. This assumes “buying” all resource and capacity straight away rather than taking time to design new pathways and teams. This option implements all initiatives at full cost so it has been split into two delivery elements:

i. ED & Flow. All initiatives that directly support ED admission and inpatient discharge. This excludes community enhancements and admission avoidance schemes. The costs for this element are 18/19 £1,379k, 19/20 £2,205k. This will provide an immediate solution to winter ED pressures and provide some solutions to overall flow and discharge, but adds the risk that community flow is not resolved hence adding a sustainability risk to flow in the Trust.

ii. Other Flow. All other initiatives outside the immediate ED flow. This includes improvements in

community flow, initiatives to reduce admissions and the introduction of alternative pathways (eg

crisis Cafes). The costs for this element are 18/19 £1,828k, 19/20 £3,274k. This will implement

the remaining initiatives, hence overcome the sustainability risk but there is a significant cost to

the Trust.

Page 64 of 224

b. Optimum Implementation. Following the principle of “buy-in where we have to and design-in where we

can” the Optimum option implements some of the initiatives at full cost where we have to “buy-in”; some

at partial cost where we “buy-in” a pilot, then “design-in” a long-term solution; and others at zero cost or

cost neutral through transformation and redesign. This results in some initiatives not being ready for

this winter, but only where Service Directors feel the impact on winter will be minimal. It will also give

very clear objectives for the ICare programme to either enhance the current ICare workstreams or add

new ones to the portfolio. The costs for this element have also been split and are: ED & Flow: 18/19

£1,494k, 19/20 £2,068k and other flow: 18/19 £0, 19/20 £1,871. As with the full implementation option,

choosing only to complete the ED & Flow elements would put the sustainability of the plan at risk and

not take forward important community and ward improvement elements. Therefore, the preferred

solution is both parts of the Optimum Option together.

The Board is requested to decide which option SLaM should take forward this winter and into next year, however it is recommended that both parts of the Optimum option are selected. A summary of costs is below and a full break down is at Appendix 1.

Full

Implementation

ED & Flow Other Flow Optimum Option

ED & Flow

Optimum

Option Other

Year 18/19 19/20 18/19 19/20 18/19 19/20 18/19 19/20 18/19 19/20

Net

Cost £3,342k £5,505k £1,379k £2,205k £1,827k £3,274k £1,494k £2,068k 0 £1,871k

Total Cost of recommended option: 18/19 £1,494k and 19/20 £3,939k.

M Marriott

Interim Transformation Director

30 Oct 2018

Appendices

1. Fully Costed Flow Action Plan

2. Southwark MADE 45 day review

3. Emergency Department Assessment Beds, draft operating policy

4. BAF 14 Risk Assessment

Page 65 of 224

Domain # What we need to change 18/19 19/20 Implementation requirement

Community 1

ICare Community redesign, a wholesale redesign of the community offer at SLaM to provide a service that meets the needs of the community.

Data analysis to support local redesign with pressure points being identified across the system with local design options to address solutions to

pressure points.

0 0not known, to be determined in a community business

case per Boroughn/a 0 0 n/a 0 0

complete Community redesign to include

initiative from flow plan0 0 0

2 Systematic review of patients presenting in crises at point to identify proactive support which will be needed to prevent future admissions. 231,979 556,750crisis review team

1x DBT B7 & 2xB5 per Boroughstop 0 0 full 231,979 556,750

implement as part of community redesign as a

cost neutral option0 0 0

3Mobilise HTT in reach pilot (cases remaining with the originating team) with support provided by additional HTT resource to ‘co work’ the case until

such point that the community team feel confident in the management of the patient. Zoning to be utilised as prevention indicator.36,645 87,948

HTT teams Costed in item 13

Lewisham request 6xPA specialty doctor to support

inreach discharge as a pilot

Croydon want 5xPA

full 36,645 87,948 n/a 0 0 full 36,645 87,948 0

Discharge 5 Implement Multi Agency Discharge Events and establish as normal business. 8,333 20,000no immediate cost. may be incidental costs (eg white

goods) to expedite dischargefull 8,333 20,000 n/a 0 0 full 8,333 20,000 0

Inpatient Flow

9 Introduce red to green once tested through I Care 0 0 no cost n/a 0 0 n/a 0 0 care process model 0 0 0

Admission

11 ARC admission procedures 0 0 no cost n/a 0 0 n/a 0 0 n/a 0 0 0

Winter Pressure Immediate Flow Actions Strengthening Clinical Decision Making

Operationalizing a single trusted assessment process and managing a single admissions prioritisation list overseen by ARC and supported borough

medical leads

Improving flow from ED

• Commissioning 15 escalation beds to add extra capacity (part of SLP Winter Pressures Bid)

• Ring-fence urgent ED admission in every borough.

• Out of hours Support (no internal overspill and general management of beds ARC) communicated to directors on call.

• Enhanced HTT to provide 24/7 assessment cover

Improving Productivity via Specialist Capacity

a) Commissioning up-to ‘12 High Care Beds’ (HCB) providing a structure ‘secure care offer’ for highly complex (disruptive patients) – identifying and

moving patients from current acute wards

b) Repurposing THU to take over commission in March 2019

Improving Efficiency via Capacity Distribution

Implementing a dedicated bed capacity model by repurposing LEO ward for Lambeth and Croydon only and then enabling Southwark and

Lewisham to manage local bed availability

Preventing admission through Predictive Care planning

Rapid needs assessment of current known patients and operationalize a targeted advance care plan for most un-stable community caseloads

Reducing ED presentations via improve community connections

Commission a peer support service dedicated to ED presence

Improving Capacity Efficiency (2) via Expensive Patients Discharge Strategy

Identifying a Chief Officers list of long term stranded patients and negotiating new packages with CCGs/LA

Winter Pressure Bid: Social Care Discharge Team

Taking learning from MADE event outcomes and a SLaM priority to create bed capacity

Winter Pressure Bid: Expanded KCH Liaison Team

Service expansion to meet increased demand experienced at KCH ED since service establishment

Winter Pressure Bid: SLaM Crisis Café near Denmark Hill

To divert patients from A&E crisis into a more appropriate step down / self-management pathway learning from best practice elsewhere

Crisis Café in Lewisham to be staffed by 3rd sector

Lewisham Risk Forum:

Building on success of the CAT model to prevent frequent flyers via strengthened multi-agency governance and information sharing

Maximum implementation Total 4,132,161 5,605,188 Total 2,169,140 2,305,699 Total 1,827,813 3,274,252 Total 2,283,951 2,168,429 1,871,054

Offsets (winter pressure, MHIS) 790,000 100,000 790,000 100,000 0 0 Offsets (winter pressure, MHIS) 790,000 100,000 0

Total net 3,342,161 5,505,188 1,379,140 2,205,699 1,827,813 3,274,252 Total net 1,493,951 2,068,429 1,871,054

Initiative being completed under the "design it in" method

Offsets (winter pressure, MHIS)

Total net

Appendix 1 to Emergency Department Pressure & Patient Flow SLaM Board Paper, dated 30 Oct 2018

19/20

impact

Other

0

0

0

0

0

0

0

0

1,448,000

0

0

0

0

0

0

200,000

223,054

4xB7 social worker

2xB5 link worker

covered in 13 costs

Croydon request 5xPA consultant @ CUH

crisis café cost - Maudlsey

crisis café contract - Lewisham

Safe place Lambeth (funded by alliance)

1 xB7 PM for 12 months,

£10K SQL coder

1 x B7 DBT per Borough

2 x B5 contingency worker per Borough

0

20,000

0

0

0 0

0

1,837,239

0

1,448,000

0

0

350,000

0

300,196

60,552

83,333 0

97,106 0

ED and flow only All other Optimum implementation

00

125,000 300,000

624,502 125,000 619,502

18/19

impact

ED&Flow

19/20

impact

ED&Flow

0 0

8,333 20,000

0 0

0 0

0 0

0 0

699,889 1,679,733

1,200,000 0

0 0

145,833 350,000

0 0

0 0

0 0

125,000 300,000

0 0

0 0

1,200,000 1,448,000

0 0

0 0

0 0

0 0

0 0

n/a

n/a

full

full

0

20,000

0

0

0

0

1,817,002

0

0

0

0

0

0

300,196

60,552

full

n/a

n/a

full

n/a

Keeping patients well in the community is key to

reducing admissions and allows service users to

live more independently

4Run Community Team MADE events to determine alternative models of care for community caseloads to reduce case load size and increase

community team capacity

Option

n/a0

18/19

impact

19/20

impact

Cost optionsFlow Action Plan, with costed options

may be incidental costs (eg white goods) to expedite

discharge

no cost n/a

Discharging in a timely way across 7 days a week

should have the most significant impact on our

current inpatient cohort

6 Standard processes to resolve barriers to discharge 8,333

0

0

8,333

no cost

full

7 Implement 7 days a week discharge as part of inpatient care process model 0 n/a

Better, standardised and proactive admissions

will improve flow, discharge and return to the

community by planning an inpatient pathway on

admission

10 ICare standard admission cycle

no cost n/a8 Design and roll out inpatient care process model 0

0

0

0

no cost, needs to be aligned to R2G programme

12 Better management of pathways between discharge and readmission funded under item 2 n/a0

HTT B7x19 (4 S, 5L,5C, 5L)

HTT B6x4 (4S)

100K KCH liaison uplift

1 x float doctor per Borough

Lambeth request B5 patient flow for 6 months

workforce elements included in item 13

ELFT Beds tbc cost

Croydon B7 bed coordinator

Actions to be put in place for winter pressure.

Some are temporary but where possible most

introduce new ways of working for a sustained

solution

14 1,200,000 full

13 765,516 765,516

1,200,000

0

0

0

0

0

125,082

25,230

0 0

SLP beds?

THU repurpose?

Is it just capital cost?

16 no cost

15 stop1,200,000

0

19 no cost

18

costs under item 12 n/a17 0

peer work contract under negotiation with D Monk

0

22

25,230 full21

0 0

Ensure standards of care maximise therapeutic

days, reduce lengths of stay, improve patient

outcomes, reduce variability across wards and

increase quality

n/a

260,209 stopEnsure that Lewisham service users who present at an ED department within the catchment area for the second time in a year has a crisis care

plan, and that their care co-ordinators - that proactively follow them up after presentation - are supported to develop the skills and alternative

sources of support to manage their crises without unnecessary re-presentation at ED. The bid will deliver a small, cohesive and expert team with

dedicated focus on frequent users that can be expanded to other SLaM boroughs.

stop

23

n/a

20 125,082 full

145,833

Option

full

community redesign

full

n/a

Option

n/a

18/19

impact

19/20

impact

0 0

0 0

stop

n/a

full

implement as part of inpatient care process

model

implement as part of inpatient care process

model

care process model

n/a

n/a

n/a

n/a

n/a

n/a

assess value after crisis café is established

n/a

full

start THU repurpose, with no SLP beds (costs are

loss of income from THU)

n/a

community redesign

remodel to HTT B7 x 20 (5L,5S,5L,5C)

£100k KCH liaison uplift

1 x float doctor per Borough

Lambeth request B5 patient flow for 6 months

complete in Lewisham where café is established

and assess the value of the model

Complete for Lewisham (already a winter plan),

develop other boroughs as part of community

redesign with minimal cost, using Lewisham as

proof of concept

full

0 0

0 0

0 0

0 0

125,082 300,196

25,230 60,552

Page 66 of 224

Appendix 2 to Emergency Department Pressure & Patient Flow SLaM Board Paper

Date 30 Oct 2018

www.slam.nhs.uk

19 September 2018 Southwark MADE 45-Day Review SLaM and NHS Southwark CCG jointly hosted a Multi Agency Discharge Event (MADE) on 25 July 2018. The MADE cycle ends with a 45 day review which is summarised below. MADE Impact 32 patients received an action plan during the MADE event and 17 of them have now been discharged, this represents a MADE discharge rate of 53% with a combined length of stay of 931 days. This is a significant reduction in bed utilisation and represents 31 patient’s worth of beds at an average length of stay of 30 days. MADE Complex Care Solutions Some of the more complex MADE solutions require strategic approaches and are being fed into the wider strategic programmes such as the SLaM housing strategy and the SLP complex care programme. Current Bed Status The SLaM health system is overflowing: patients are already in beds in overspill, out of area and A&E beds and other patients are joining the system through crisis suites, MHA assessments and referrals, so our beds were full before MADE and remain full. Therefore, we have completed a before and after analysis to determine a like for like view of the MADE cohort. The MADE cohort identified for the Southwark event included 47 patients with a combined length of stay of 3596 days; if we were to select a MADE cohort 45 days later it would include 55 patients with a combined length of stay of 4417 days. While this is a larger number, 29 of them are short stay patients within 2 weeks of discharge compared with 21 in the original cohort, and our average length of stay for the MADE cohort has dropped from 92 days to 80 days. This is summarised in the table below:

Status Volume Combined LOS Average LOS

Cohort Selected for MADE 47 3596 92.4

Cohort with MADE actions 32 3135 97.9

Discharges from MADE cohort 17 931 54.8

Cohort 45 days after MADE 55 4417 80.3

Conclusion MADE has successfully discharged 17 stranded patients with over 900 days of stay, and while the beds have been filled it’s with patients at the start of their journey where ongoing flow improvement plans should prevent them becoming stranded in the future. The event successfully reduced the average length of stay of our longest staying patients in Southwark from 92 days to 80 days. There is still much work to do, particularly around strategic issues but there are mechanisms in place to include the learning from MADE in SLaM and SLP strategic plans. A second MADE cycle will be carried out in Southwark in November with the internal event currently planned for 6 Nov and the external for 14 Nov.

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1

Appendix 3 to

Emergency Department Pressure & Patient Flow SLaM Board Paper

Date 30 Oct 2018

Allocation of Acute Beds and Emergency Assessment Beds (EABs)

Draft Operating Policy

October 2018

Allocation of Acute Beds

There is an agreement that acute beds will need to be available at all times for admission from the community, acute hospitals and other places such as custody and prison, this operating policy does not give priority to Emergency Department admissions above other emergency and urgent admissions, but specifies how transfers from Emergency Departments will be managed.

All four acute borough services will continue to ensure that empty beds are available for all admissions.

Emergency Department Assessment Beds (EDABs)

A gap in provision has been identified in meeting the needs of service users who are becoming ‘stranded’ in acute hospital settings whilst a comprehensive assessment of needs takes place. This is a particular issue for Emergency Departments and so it has been agreed to improve this pathway across Lambeth, Southwark, Lewisham and Croydon. Often it is a straightforward decision to admit a patient to hospital but sometimes it can take up to a day to work out if admission is necessary or if being treated at home would be a better plan. Therefore, when there is agreement between PLN and HTT that an admission is required the patient will be directly admitted to an acute mental health bed, when there is a requirement for further assessment for the decision to admit to be made the patient will be admitted to an EDAB. On these occasions, it has been agreed that a patient will be admitted from the emergency department and assessed for discharge within 24 hours by the Home Treatment Team. The discharge may or may not include a Home Treatment package of care depending on the needs of the service user.

Core principles for admitting to an EDAB

A pool of acute beds need to be available as EDABs and ready to receive patients 24 hours a day.

All admissions from an ED will have a joint assessment by the Liaison Team and Home Treatment Team.

All patients admitted to an EDAB bed will be 18 years old or above.

All admitted patients will have a risk assessment and detailed ePJS entry completed by PLN staff before been transferred. The accompanying HTT practitioner will begin to complete:

• SASS

• initial care plan

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2

• child risk assessment

• HONOS

• Cluster

• AUDIT

• consent to contact information

All patients will be clerked in by the ward doctors and a medication chart written.

Patients in the EDAB bed will receive a full clinical review in the morning which will be coordinated by a designated HTT practitioner. The HTT practitioner will complete any outstanding core data as part of the assessment.

If the patient requires admission then ARC will be notified and the patient will remain in the bed.

Each shift a ward nurse will have an allocated responsibility to provide direct care for patients who have been admitted via this route. The designated HTT practitioner will liaise directly with the designated nurse.

Each ward will clear a bed to be nominated as an EDAB by 4.00pm each day.

Exclusion Criteria

This pathway is not for patients under a section of the Mental Act, who will be directly admitted to an acute bed as a matter of priority.

Service users who are intoxicated will not be admitted.

Patients accepted will have been risk assessed to ensure that they do not require PICU or a more secure setting.

The inpatient wards will not be used for people on 136/135 section even when the Central Place of Safety is full.

Interventions

On entering the ward each patient is given an allocated nurse on arrival. The nurse will liaise with the HTT practitioner to ensure an assessment is completed. The allocated nurse will ensure that the basic needs of the patient are met. The allocated nurse will liaise with the family, significant others and other services as appropriate.

The allocated nurse ensures continuity of care to ensure effective communication between the team, the HTT practitioner and others involved in the resolution of crisis.

1:1 support will be given by the receiving ward when necessary, based on on-going risk and needs assessment.

A member of the HTT team will ensure a daily review happens each morning between 8am and 10am.

Discharge

Staff from the receiving ward will refer service users to other services and agencies, including statutory and non-statutory.

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3

If the HTT member of staff needs additional support in discharging the service user from the ward, for example attendance at the Homeless Persons Unit, this will be provided by staff from the ward.

Relapse Prevention

The receiving ward and HTT practitioner will work with service users and carers to identify factors which have contributed to the current crisis and help them develop relapse prevention strategies.

Each patient will leave the ward with a crisis and safety plan, formulated between patient and the HTT practitioner.

Referral and Acceptance

Referring clinicians from the PLN services will first contact ARC who will contact HTT through the fast track route. The PLN staff will record details and assess whether the individual is informal or detained, their address and area of origin. The details must be written up on ePJS.

The HTT practitioner will respond in person to the Emergency Departments at Kings College Hospital and Lewisham University Hospital within 30 minutes and to Croydon University Hospital and St Thomas’ within one hour.

Care Process

All patients will have a mental state and formulation assessment within the SASS document and clinical risk assessment (if one does not already exist, or out of date). Where issues of concern are identified, these will be dealt with on a joint basis with the CMHT and the HTT team.

All patients will have a physical examination, which will include temperature, pulse, respiration, blood pressure and weight. This will be carried out by ward staff on admission.

In view of the short duration of stay, blood tests, ECGs, x-rays and other investigations will be done where indicated rather than on a routine basis. Where needed these will be completed by the ward medical staff.

In the case of patients who have not been assessed by a medic prior to arrival in the assessment unit they will have a medical assessment as well as a physical examination.

All patients will be given an information pack and will be advised that they are in a short stay assessment bed. They will be advised of this on arrival and when reviewed at least once per shift.

Where a patient is known to the community services the Care Co-ordinator should be involved in the care planning process. There is an expectation that wherever possible, the care co-ordinator attends to discuss on-going plans and care.

Review

All patients admitted to an assessment bed will be reviewed the following day by a designated member of the HTT.

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4

The review will start each day from 8am.

At the end of the review it will be decided if the patient can be discharged home or needs admission to a treatment bed or acute ward.

If the patient needs to remain admitted, ARC will be contacted to inform them that the patient is remaining in the bed.

If the patient does not require admission they will be informed of this and options for on-going treatment considered. These options may include crisis and home treatment and CMHT support.

The designated HTT practitioner and the receiving ward will develop care plans in conjunction with community and other Crisis Services for clients who regularly attend A&E.

When the patient is assessed, and accepted by the crisis team, the team will, in discussion with staff in an assessment bed, draw up a care plan.

Every patient admitted to an assessment bed will be discharged with a written care plan and crisis/ safety plan, regardless of discharge destination.

If needed the patient will be conveyed home by HTT

Discharge documentation (letter) will be sent to GP within 24 hours of discharge and will include a Care Plan, with attached mental state and formulation and brief risk assessment.

Medical Cover

Ward medical team will assume medical responsibility for patients in admission beds.

Staffing

In Southwark, there will be a designated HTT assessment team comprising of one band 7 assessor and one band 6 senior practitioner on both early and late shifts, 7 days a week. Early shift is 0800-1600, late shift is 1400-2200.

The ARC will cover the night shift in Kings College Hospital.

Other Boroughs will publish their HTT assessment arrangement separately.

Prioritising Beds

When the only bed available to admit into is and EDAB bed and no EDAB qualifying patients are in ED the ARC will escalate bed prioritisation decisions using the ARC bed escalation policy.

Incidents and Complaints

Depending on the nature of the incident or the complaint this will be carried out by the acute wards or HTT. Ultimate decision making will be made by the General Manager for Acute and Crisis services.

This new model of working will be audited from the outset to monitor demand, clearance of beds, staffing issues and quality of crisis assessments and will be reviewed every 3 months.

PQuinn/JKirby 021018

Page 71 of 224

Owner: Initial Current Target Trend

Committee: Likelihood 5 5 2

Proximity: Consequence 4 4 4 New Risk

Risk Category: Level 20 20 8

Risk Appetite Last reviewed Next review

Principal Risk 14 (Patient flow): In the context of current capacity and increased demand, if there is a lack of integrated working by internal and external stake holders there is a risk of delays in

patient discharge and optimum bed occupancy levels that may negatively affect patient outcomes and experience, staff morale and Trust finances.

KD / COO

Quality Committee

6 months

Quality (patient safety, experience & clinical outcomes)

Potential Causes (links to the ERR) Potential Consequences

Capacity causes:- Operational external barriers to discharge. Strategic external barriers to

discharge e.g. gasps in specialist provision. Internal barriers to discharge. Lack of systematic

and timely clinical decisions making. Unwarranted variability in pathway.

Demand causes:- Increased pressure as a result of increased presentation at ED. High

Community caseload. Home treatment operating above capacity. Unwarranted variation in

decisions to admit. Increased pressure from increase external stakeholders on the acute

system to admit.

Increased risk to patient’s wellbeing, recovery and discharge when patients have to be placed in

private beds. New patients waiting longer in Acute beds to be transferred to the appropriate care.

Patients clinically FIT and ready to be discharged are in hospital beds, which increases the risk of their

condition deteriorating. Significant overspends on private beds, inefficient use of management time

and increased cost of running services. Patient facing time of clinical staff compromised, as the focus

remains of unblocking blockage and obstacles in patient flow. Ability of managers to deliver winter

flow plans in an increasingly high pressure health economy whilst delivering Trust BAU requirements

eg financial breakeven, cost improvements, national standards and CQC delivery plan. Decreased

staff morale and increased attrition. Negative impacts on Trust’s reputation.

Cautious (nominal range 3-8)

Key Controls Gaps in Control

MADE events restricted to adult inpatients - expansion to include MADE events for specialist units,

complex care and community yet to be developed. R2G and Inpatient Care process models new

initiative in early stage of roll out and needs embedding. Key control enhancements not fully staffed

or established. Community re-design (iCare) incomplete.

MADE events. Work with SLP to develop specialist placement portfolios. R2G introduced in

wards. Inpatient care process model especially around admission/discharge cycles. In-reach

Home Treatment and Social Care Discharge teams. Enhanced assessment and liaison in ED.

Additional purchased of 14+1 beds from NHS provider. Daily dashboard of key metrics. Twice

daily internal escalation conference calls. Daily surge calls. Weekly Gold meeting chaired by

CEO. Ring fenced Borough beds. Identified ED assessment beds by Borough. Ring fenced

male PICU beds by Borough. Block purchasing of male PICU beds to replace current spot

purchased overspill. Trust level pathway, flow and discharge management improvement

action plan. Individual Directorate action plans to deliver CQC must and should do’s, include

implementation of pathway, flow and discharge management improvement action plan.

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Request for Closure

New risk

Reduce LOS across all adult wards. Sustainable average number of discharge across the Trust

between 60-80. No 12 hour breaches in EDs. No 24 hour breaches in 126 suites. No cancelled

Mental Health Assessments. No “sofa surfing”. 85% occupancy across all adult wards.

Trust wide pathway, flow and discharge management improvement plan developed following July –

August 2018 CQC inspection.

Implementation governance structures developed to support implementation and evidence

embedded delivery and outcomes

Service Director led development of local implementation plans, one plan for each Operational

Directorate, to address the pathway, flow and discharge management priority actions.

Improvement plans to be delivered by March 2019..

The improvement plan has been closely considered by SMT and the subject of a detailed review at

extraordinary Quality Committee 17th October 2018.

Fully resourced ring fenced Borough beds by 1/11/18.

Quality Committee oversight. MADE events . Gold meetings. Daily dashboard. CQC

Improvement action plan governance with CEO led Portfolio Board, Delivery Board and

oversight and scrutiny group. Delivery Board monitoring delivery of Directorate pathway,

flow and discharge management improvement action plans.

Sources of Assurance Gaps in Assurance

MADE events post evet reviews yet to be inclkuded in COO report to Board.

Assurance on the effectiveness of Controls Action plan progress summary

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REPORT TO THE TRUST BOARD: PUBLIC 30 October 2018

Title

Performance and Quality Report

Author Rod Booth, Director of Performance, Contracts and Operational Assurance Mary O’Donovan, Head of Quality

Accountable Directors

Kristin Dominy, Chief Operating Officer Beverley Murphy, Director of Nursing


To report the Trust’s operational performance against a range of key national indicators and identify and analyse under-performance and report action plans.

The report outlines the key issues discussed at the Quality Governance Compliance Meetings (QGCM) against key quality indicators and the key actions proposed, including key risks and issues to flag and points of assurance.

The report provides an update regarding the Performance Management Framework review meetings, current contractual matters arising and the 18/19 Programme Management Office plans (CIP, QIPP and CQUIN).

To report the Trust’s financial position, risks and forecast for the year.

To report on the Trust’s emergency preparedness status and current actions.

Executive Summary:

This is the first iteration of the joint Quality and Performance Report and is a work in progress. The next iteration will include a more summary focussed narrative and include the detail for review in appendices.

The Trust continues to meet the NHS Improvement Single Oversight Framework indicators covered by this report.

There is continuing pressure increase across the adult acute pathway (inpatient and community) resulting in sustained usage of external overspill inpatient beds.

There are action plans in place for the four wards that had a RED score in the QUESTT indicator tool. Three of these wards were from Lambeth.

Improved response times for complaints and completion of investigations for serious incidents; and all annual ligature audits have been completed within the timeframe.

The Programme Management Office is supporting the 18/19 oversight process for CIP, QIPP and CQUIN. £3.7 million of the CIP programme is currently rated as high risk.

There is an agreed approach with commissioners to evaluate their investment plans and the Five Year Forward View transformation trajectories.

We continue to work with both Southwark Local Authority and CCG to evaluate the impact of the proposed changes regarding section 75 and to align CAMHS services to the outcome of the recent review; the risk from the reduction in placements budget by Southwark Local Authority is being assessed and forms part of a wider programme on reviewing placement options.

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http://sites.intranet.slam.nhs.uk/commteam/Picture Library2/1/SouthLond Maudsley FT Col A.jpg


BAF Risk 1 - Workforce BAF Risk 2 – Operational Delivery Structure BAF Risk 3 - Informatics BAF Risk 5 - Partnership working with service users BAF Risk 7 – Quality and statutory compliance BAF Risk 8 – Finance (Contracts) BAF Risk 9 – Estates BAF Risk 11 – QI Delivery BAF Risk 12 – Finance (Cost Management) BAF Risk 13 – Mandatory training



9 October 2018 Finance & Performance Committee

PERFORMANCE AND FINANCE REPORT

1. Report Summary

2. NHS Improvement Indicators 2.1 NHSI Indicators: Access, Effectiveness and Quality

2.1.1 Home Treatment Team Gatekeeping 2.1.2 Early Intervention in Psychosis 2-week standard 2.1.3 IAPT Waiting Times 2.1.4 IAPT Recovery 2.1.5 Seven Day Follow Up 2.1.6 Community Wait Times

2.2 Business Intelligence and Trust Information Developments

3 Operational Performance and Activity 3.1 In-Patient Activity and Performance

3.1.1 LSLC Admissions 3.1.2 Delayed Transfers of Care

3.2 Community Activity & Performance 3.2.1 Dementia Diagnosis Rates 3.2.2 A&E Mental Health Liaison 3.2.3 Community Teams

4. Quality Indicators Compliance 4.1 Patient Safety- Serious Incident Investigations 4.2 Patient Safety – Violence and Aggression 4.3 Patient Safety – Safeguarding 4.4 Patient Safety – Ligatures 4.5 Infection Control 4.6 Patient Experience – Complaints 4.7 Patient Experience– PEDIC Scores 4.8 Mental Health Act Visits 4.9 QUESTT 4.10 Risk Assessment and Care Plan Audits 4.11 NICE Guidance 4.12 Policies

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5. Directorate Performance Reviews Summary 5.1 Training

5.1.1 Mandatory Training Compliance 5.1.2 Current Compliance Rates 5.1.3 Specific Actions in Relation to Current Areas of Concern

6. Commissioning 6.1 Lambeth and Croydon Alliances 6.2 Ann Moss Unit / Older Adult Specialist Care 6.3 Commissioner-related Quality Impact Assessments (QIAs) 6.4 Commissioning Programmes 2017-18

6.4.1 Quality, Innovation, Productivity and Prevention (QIPP) programme 6.4.2 Commissioning for Quality and Innovation (CQUIN) Schemes

7. Programme Management Office (PMO) 7.1 Cost Improvement Programme (CIP)

8. Emergency Planning

9. Conclusion

Appendix 1 - Glossary

Appendix 2 - Pilot Community QuESTT report September 18

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1. Report Summary The following areas of the report contain noteworthy risks:

NHSI indicators – 7-day Follow-up performance

Pressure being experienced in adult acute inpatient activity

Growth in A&E Liaison presentations

Community activity – A&L, HTT and EI caseloads The report confirms an agreed approach with commissioners to evaluate the national transformation expectations and the available investment funding agreed for 18/19.

2. NHS Improvement Indicators NHS Improvement indicators for the Single Oversight Framework are detailed below, in addition to being reported to the Finance and Performance committee (Access and Effectiveness indicators) and the Quality Committee (Quality indicators).

There are no key risks identified for these indicators.

2.1 NHSI Indicators: Access, Effectiveness and Quality

2.1.1 Home Treatment Team Gatekeeping

Fig. 1 NHSI Indicators: HTT Gatekeeping.

The Trust achieved performance of 100% in August as it continues to exceed the 95% target and plan is to maintain this performance level.

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2.1.2 Early Intervention in Psychosis 2-week standard

Fig. 2 NHSI Indicators: Early Intervention in Psychosis

The Trust achieved 83% as it continues to exceed the 53% target for 2018/19 Early Intervention waiting time standard. The service continues to monitor the impact of increased growth and evaluating other factors influencing team workload.

2.1.3 IAPT Waiting Times

Fig. 3 NHSI Indicators: IAPT 18 week Waiting Time Standard

The Trust continues to surpass the 18 week standard across all four boroughs in 2018/19. The Trust is judged by its regulators and NHS England based upon information produced by NHS Digital as opposed to the locally reported information. NHS Digital targets are represented by the green line in the chart, the most recent data being May 2018. Local figures (in blue) are a snapshot of the live system and there will always be minor variation due to rounding practices used by NHS Digital. Another source of variation is late data entry and changes to data by clinical services – these additional charts have highlighted areas where this could be addressed with the intention of assisting teams to reduce this source of variation. This additional cross-monitoring will continue to be reported.

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Fig. 4 NHSI Indicators: IAPT 6 week Waiting Time Standard – aggregate and detail

Trust maintains its high aggregate achievement for the 6 week standard at 91% in August, with similar high achievements across the four boroughs. The individual borough performance is reported in Fig. 3, alongside the equivalent NHS Digital published data (red line) for each borough through to June 2018. Southwark IAPT has shown improvement towards meeting recovery target in the past few months (compared to last quarter of 2017/18). There is still no agreement with CCG yet regarding the access

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target in the last quarter of 2018/19 as we await their response on extra investment to enable the service to meet the 19% national access target for next year. Southwark IAPT moved into a different triage system at the end of August 2018, with patients no longer required to fill in some forms to complete the registration process after their initial telephone assessment. It is hoped that this will take away another barrier for Southwark patients to access our service. Lambeth Services has identified some funding to enable achievement of the nationally increased 16.8% access trajectory, however, additional funding will be required to achieve the 19% target for next year. Lewisham IAPT services are currently meeting all of the targets and are running above the access target, which presents challenges to overall delivery as they have more patients to treat.

2.1.4 IAPT Recovery

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Fig. 5 NHSI Indicators: IAPT Recovery Rate – aggregate and detail

Trust achieved the IAPT recovery rate at 50.15% in August 2018, which is above the 50% target. Croydon, Southwark and Lewisham services achieved the targets at 51.67%, 51.72% and 50% respectively, while Lambeth services performed marginally below the 50% target rate at 47.70%.

2.1.5 Seven Day Follow Up

Fig. 6 NHSI Quality Account Indicator: Seven Day Follow Up

Following the review of data assurance processes and Seven Day Follow Up across all community teams, there has been marked improvement in performance for June and July. Performance appears to have dipped for August but this is due to the small number of caseloads and small number of missed follow up recorded for August. At the time of writing, early data for September shows performance improvement above target.

Whilst Seven Day Follow Up is no longer a national target in the SOF, it remains a mandated component of the 2016/17 and 2017/18 Quality Account. Given the importance of the measure, it continues to be monitored and reported to the Board.

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2.1.6 Community Wait Times Community wait times were presented to the Quality Committee in April, reporting on the amount of

time that service users had to wait for their first face-to-face contact with services following referral,

and the number of service users still waiting after 12 months. Lewisham CAMHS remains at the

highest level of waits over 12 months at 254 patients, Croydon Personality Disorders and

Psychological Therapies persists at 150 patients and Southwark Psychological Therapies now at 130

patients.

Fig 7. Patients waiting over 12 months The deep dive work is progressing with BI team working to capture accurate definitions on all reporting

platforms.

Lewisham CAMHS have undertaken an initial assessment locally of the patients waiting over 52 week which indicated up to 80% may be data recording issues. The remaining 20% are being more carefully reviewed and decisions being made to either correct the data recording or arrange appropriate actions. This exercise will set the standard for managing any waits over 12 months across CAMHS and then the threshold will reduce in stages below 52 weeks. Croydon psychological therapies service waiting times for CAT assessments continue to be affected by staff sickness. There is a reduction in the numbers waiting for Psychodynamic therapy with new fixed term post-holders commencing (as part of the initiative for 2018/19). This will start to impact waiting times from next month. A CBT Psychologist has been appointed to fill the vacant post and will commence in November 2018. The one remaining vacant fixed term Psychodynamic Psychotherapy post is currently undergoing recruitment.

Southwark Psychological Therapies service has seen a reduction in their numbers from 184 to 130

patients. The high figure has been recognised by the new Borough Director and is being addressed

as one of her priorities for the new directorate.

2.2 Business Intelligence and Trust Information Developments During August and September, the BI team has reviewed the architecture of the underlying data tables and cubes which translate the information from the numerous SLaM data systems into integrated reports in Power BI. It has been clear in the review that more in-depth documentation is required for greater understanding, audit and sustainability of the system. A number of improvements have been implemented (including PEDIC and finance data) and the documentation approach has been defined and is on-going at the time of writing. A more detailed update can be provided if the committee desires. One aspect of the redesign has been data quality assurance. A number of low level problems have been identified and addressed including uncertainty around operational definitions and service directory changes not being set correctly in the source data system and therefore not flowing into the

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cube or MHSDS reports correctly. This learning is being fed back in to the documentation templates supporting definitions and changes. The Service Directory was discussed at the recent Data Summit on 28th September and a change management process has been agreed ready for documentation in October. The Trust Dashboard has been given a link on the front page of the new intranet Maud and usage is being monitored with around 20 visits a day. Continued promotion is required. The work on the Community QuESTT report continues with the next step being the inclusion of team-specific targets. This will enable the analysis to move from a comparison to previous months and/or the mean. The long term aspiration remains to achieve an automated red/green summary of parameters but this is not in the current development roadmap. Examples of the current drafts dashboards are displayed as Appendix 2. In addition to these two priority projects, BI is supporting Performance & Contracts in documenting all information reports which have been produced and are available – much of the desire for information has been met and it is clear that increasing the knowledge of and use of existing reports is an immediate opportunity for the Trust. The next version of the Mental Health Services Data Set (version 4) has confirmed detailed data specifications. This iteration will see an improved focus on employment, carers, restrictive interventions, medication, care plans and indirect activity. The Trust will need to be compliant by April 2019, a gap analysis is being documented, conversations with our system suppliers and NHS England have begun, and the BI team will be attending NHS Digital stakeholder events in October 2018. Also in October / November, we will be receiving support from NHSI regarding the CAMHS Access element of the MHSDS report. The Trust still carries risk around the sustainability of the BI Team. The plan to recruit at a lower band and then develop staff has resulted in two new members of staff being recruited (potentially starting in November). However, an experienced member of the team left in September due to the higher rates available outside the NHS.

3 Operational Performance and Activity

3.1 In-Patient Activity and Performance In order to improve the tracking of performance against contract, the following five run charts show the performance of the adult acute inpatient services for LSLC patients against the LSLC contract values. In order to enable monthly comparison, the charts show the average number of occupied beds during the month. There are 340 beds across all adult acute wards (EI, triage, acute, PICU), with approximately 20 beds being filled with non-LSLC inpatients.

The charts show LSLC performance on a monthly basis from April 2017 to August 2018 with the contract trajectory included through to March 2019, aiming at reaching 85% occupancy. It can be seen that the contracted level of activity was revised upwards in October / November 2017 as part of the contract refresh negotiations with Lambeth and Lewisham. Figures include foreign patients for which a further accounting adjustment is made (usually reducing the activity by c.2%). The data excludes leave and includes all overspills.

To support comparison, the y-axis scale for the four individual CCG charts has the same range (50 – 110 equivalent beds per month). The pressure in all systems is evident, particularly Croydon.

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Fig. 8 – LSLC Acute, Triage, PICU and EI performance against commissioned trajectory

A review of the Southwark MADE event that was held in July has been conducted to evaluate the impact of the event on the persistent pressure on the Trust’s cost due to external overspills. 32 patients received an action plan during the Southwark MADE event and 17 of them have now been discharged. This represents a MADE discharge rate of 53% with a combined length of stay of 931 days. This is a significant reduction in bed utilisation and represents 31 patient’s worth of beds at an average length of stay of 30 days. It is even more significant considering that the MADE cohort comprises our most stranded patients. While discharging 17 stranded patients is a success, many patients remain in SLaM waiting for complex care packages to enable discharge. The team in SLaM and our partners from the MADE event are working together to enable those discharges and to ensure stranded patients are discharged to safe and appropriate environments. However, some of the solutions require more strategic approaches such as the SLaM housing strategy and the SLP complex care programme. The MADE complex solution requirements are being introduced to the wider strategic programmes to ensure they are resolved.

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Lessons learned from Southwark and Croydon events will be taken forward into the Lambeth event on 3rd October where it is anticipated that over 100 patients will be reviewed with an LOS of over 50 days and 36 with an EDD within 2 weeks. The combined LOS for the Croydon patient cohort is 8,523 days which is an indication that many long term issues requiring resolution will be uncovered.

The following chart shows the overall position from August 2017- August 2018 and the increased, on-going pressure is evident. The colours represent the split between Acute (green) and PICU (grey) beds.

Fig. 9 – External Overspill, July 2017 through to end of August 2018

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Length of Stay: Acute Care Pathway

Fig. 10 – Length of Stay Breakdown Figure 10 clusters the inpatient cohort within the acute care pathway (wk4, September) by their length of stay at that point. The first colour is 0-30 days, then 31-60 days etc. and the final group is >180 days. The commissioners are in alphabetical order: Croydon, Lambeth, Lewisham, Southwark and “other”.

Patients with longer lengths of stay are reviewed weekly at clinical meetings. Longer lengths of stay can be attributed to delayed transfers of care, other reasons of social need and patient acuity. Lambeth CCG still maintains the highest number of inpatients whilst both Croydon and Lambeth continue to have a high proportion of patients with longer lengths of stay.

3.1.1 LSLC Admissions The following charts show the admissions by CCG for each month Apr 17 – August 18 with planned levels through to March 2019. The planned level was based on historical performance in 2016 and was set at a flat, consistent rate. Actual performance of admission levels remained broadly consistent with a marginal fall in the last two months, from July 2018 – August 2018.

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Fig. 11 – LSLC Admissions by month

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3.1.2 Delayed Transfers of Care The Trust makes a monthly submission to NHS England providing a snapshot of delays and lost bed days. The charts below plot these overall submissions alongside the most recent split across the different boroughs. The reporting is by local authority as the reason for delay can be attributable to NHS or social care. In August, the Trust logged 480 bed days lost due to delayed transfers of care. This represents a 2.4% loss, which is below the 3.5% target set from September 2017 by NHSE. There is continued progress in embedding the new DTOC approach that ensures consistency in the process for agreeing and recording DTOCs in addition to the existing weekly DTOCs calls.

Fig. 12 – Delayed Transfer of Care lost bed days by month

Fig. 13 – Delayed Transfers of Care, Lost Bed Days by Local Authority Figure 13 describes the number of days lost by local authority. The attribution of responsibility for delays is according to NHS England guidance and attribution process agreed in consultation with local authorities.

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3.2 Community Activity & Performance The increasing pressure in community system remains persistent in most areas. The next section reports on the pressure in individual areas of the system.

3.2.1 Dementia Diagnosis Rates The national ambition is for a dementia diagnosis rate of 67% with London diagnosis rate currently exceeding the target at 70.9% in August, with achievements varying between 59.5% to 93.3%. The diagnosis rates for Trust’s four boroughs are:

Lambeth 76.5%

Southwark 68.5%

Lewisham 75.6%

Croydon 67.8%

The Trust’s Memory Service Collaborative project (joint directorate/QI project) will look to reduce variation and reduce wait times; launch date is 8th October, 2018. There is now evidence of genuine progress with BME project (talks delivered to schools and links with faith groups in Lambeth.

3.2.2 A&E Mental Health Liaison The number of presentations to A&E Mental Health Liaison teams remains consistently above plan across board but particularly for Lambeth and Southwark teams. The impact of Core 24 investment and also the CQUIN work to identify very frequent users will need to be incorporated into a refresh of activity plans for 18/19.

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Fig. 14 Mental Health Liaison Team Presentations

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3.2.3 Community Teams The community redesign is taking place as part of the new delivery models in boroughs. These monthly snapshots of teams will continue to be provided in this report.

The following graphs show the position at August indicating continued growth in the caseload size of our Home Treatment and marginal reduction in that of the Early Intervention teams. The updated information to August 2018 is shown in Figs. 15 and 16.

Fig. 15 Adult Home Treatment Team caseload, referrals and discharges Apr 16 – August 18

Fig. 16 Early Intervention caseload, referrals and discharges Apr 16 – August 18

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4. Quality Indicators Compliance This section outlines the compliance and performance against current quality indicators. 4.1 Patient Safety Quality Indicators 4.1.1 Incidents

Fig 17: Total Incidents reported by week, Source; Datix

13, 077 incidents reported incidents reported on Datix:

Severity of incidents 27/08/18

–

01/09/18

August

2018

A - Death 589 53

B - Severe 129 19

C - Moderate 3336 395

D - Low 5637 418

E - No Adverse Outcome 3386 193

Total 13077 1078

Fig 18: Total incidents by severity, Source; Datix

The top 5 reported categories were:

Category 27/08/18 – 01/09/18

August 2018

Assault by patient

2361 204

Challenging behaviour

1905 152

Patient admission

898 73

Abscond - sectioned patient

794 61

Actual Self-harm

620 52

Total 6578 542

Fig 19: Total incidents by top five categories, Source; Datix

Fig 20: Total reported deaths, Source; Datix

150

200

250

300

350

Total incidents reported by week

0

5

10

15

20

25

Total reported deaths

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Deaths - A Aug 2018

Probable suicide 6

Natural causes 45

Death due to accidental overdose 1

Alleged murder of patient 1

Total 53

Fig 21: Total reported ‘Death’ incidents by category (Aug 2018), Source; Datix

Of the 53 deaths reported 6 were reported under probable suicide and subject to an incident investigation, one was an alleged murder of patient currently under police investigation and to be reviewed by Trust through Serious Incident investigation. PMOAD reported the most deaths (23). Natural causes (45) was the highest reported category of death, with the cause of death unknown in 16/45 cases. Deaths are further reviewed through the mortality review process. 4.1.2 Preventing Future Death (PFD) reports There have been three PFDs received over the last calendar year.

Operational Directorate

Data

Addictions 1

CAMHS 1

Psychological Medicine & Older Adults 1

Fig 22: Total Preventing Future Death reports by OD

In the case of the suicide of a young person under CAMHS, Miss Y, the issues raised by the Coroner were:

a) Failing to communicate in writing a care plan and changes to it b) Failing to provide a clear route or opportunity to challenge or appeal these changes to the care

plan c) Falling to communicate in writing all routes to raise concerns on a non-emergency or

emergency basis.

In the case of the death of an older adult inpatient, the issues raised by the Coroner were:

a) Inaccuracies in the recording of observations and cotemporaneous entries made to the record without reference and the impact of this on patient safety.

8 actions were identified by the PMOA Directorate and Director of Nursing including a Blue Light Bulletin on observations – completed on 06/07/2018, learning conversations, revised observation and engagement policy and learning lessons training for registered nurses. Monitoring on the observation and engagement standards will be completed through SNAP audits. In the case of a woman known to the Southwark and Addictions Directorate Wandsworth Consortium Drug and Alcohol Service (W-CDAS), the Coroner raised

a) W-CDAS staff are not applying their training in practice

b) As a result, vulnerable patients do not have their risks appropriately assessed and managed

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c) Communication between inpatient (St George’s Hospital) and community services (W-CDAS)

needs to be improved

d) Consideration be given to the use of one consistent set of clinical records for both inpatients

and for use in the community

e) Patients with complex needs should be treated in the core W-CDAS service, rather than in the

shared primary care setting.

The Directorate reviewed the concerns and put action place to address any deficits by the service.

4.1.3 CAS Alerts (Central alerting system)

Fig 23: CAS alerts received, Source; Datix

The Central Alerting System (CAS) is the system used to cascade patient safety alerts, important public health messages and other safety critical information and guidance to the Trust. In August 2018, 5 alerts were received by the Trust, 2 did not require action, 1 has had action completed and 1 is currently under review. These alerts related to amongst others, Estates and Facilities and Medical Devices. 4.1.4 Violence and aggression

Quality priority: Reducing violence by 50% over 3 years

Fig 24: Total reported ‘violence/aggression/assault’; Source; Datix

012345678

CAS Alerts received

507090

110130150

Total reported violence/aggression/assault

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Reported

violence/aggression/assault

August 2018

Physical Assault 215

Challenging Behaviour 152

Sexual Assault 10

Harassment 16

Total 393

Fig 25: Total reported ‘violence/aggression/assault’ (Aug 2018); Source; Datix

The highest numbers of reported incidents of violence and aggression in August have been in the Croydon and B&D Directorate (75), Southwark and Addictions (75) and Lewisham (64). 4.1.5 Use of restraint

Quality priority: Reduction in restraint by 50% in over 3 years

Fig 26: Total reported incidents of restraint, Source; Datix

Reported incidents of restraint August 2018

BDP 6

CAMHS 55

Croydon 40

Lambeth 24

Lewisham 20

Psychological Medicine & Older

Adults

15

Southwark 41

Total 201

Fig 27: Total reported incidents of restraint (Aug 2018); Source; Datix

20

30

40

50

60

70

80

Total reported incidents of restraint

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Highest type of incident type that associated with restraint was violence/aggression/assault (160) followed by self-harm (22). Total Duration of restraint minutes

Fig 28: Total duration of restraint (minutes), Source; Datix

Of the 201 restraints reported in August 2018, a total restraint of 9 minutes or under accounted for 85% (171) , 11-15 minutes 11 restraints (6%), 16-20 minutes 7 restraints (4%) with the remaining 5% over 20 minutes. The weekly safety huddle is an opportunity to look more closely at the circumsntaces of restraints of 10 minutes and over.

Fig 29: Average duration of restraint (minutes), Source; Datix

The data indicates that there is less variation in the length of restraints and fewer peaks, which may indicate that areas where there is longer durations of restraint are being managed more effectively.

0

50

100

150

200

250

300

350

400

450

500

1 2 3 4 5 6 7 8 9 10 11-15 16-20 21-25 26-30 31-45 46-60 61-75 76-90 >90

Total duration of restraint (minutes, 27/08/18 – 01/09/18)

02468

1012141618202224262830

Average of duration of restraint by week with standard deviation

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Reduction in prone restraint – zero by 3 years

Fig 30: Total reported incidents of prone restraint, Source; Datix

Reported incidents of prone

restraint

August 2018

CAMHS 8

Croydon 14

Lambeth 11

Lewisham 7

Psychological Medicine & Older

Adults

4

Southwark 15

Total 59

Fig 31: Total reported incidents of prone restraint (Aug 2018); Source; Datix

Duration of Prone restraint July 2017-Aug 2018

Fig 32: Total duration of prone restraint (minutes), Source; Datix

In August 55 (93%) incidents of of prone restraints were 4 minutes or less, 2 (3%) were 5 minutes, 1 (2%) was 6 minutes and 1 (2%) 10 minute restraint which is currenly being reviewed by the Directorate.

05

10152025303540

Total reported incidents of prone restraint

0

50

100

150

200

250

300

350

1 2 3 4 5 6 7 8 9 10 11-15 16-20 26-30

Total duration of prone restraint (minutes)

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4.1.6 Rapid tranquilisation

Quality priority: Reduction in the use of rapid tranquilisation by 25% in 3 years

Fig 33: Total reported incidents of rapid tranquilisation, Source; Datix

August 2018 update: 77 incidents of rapid tranquilisation, highest numbers in Croydon directorate (20), Southwark (24). Nurse Consultant for Physical Health and well-being and Lead Nurse for Reducing Restrictive Practices are currently designing an audit to monitor compliance with the Trust’s rapid tranquilisation standards. 4.1.7 Seclusion

Total incidents of seclusion

Fig 34: Total reported incidents of seclusion, Source; Datix

0

10

20

30

40

Total reported incidents of rapid tranquilisation

0

5

10

15

20

25

30

Total reported incidents of seclusion

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Ward August 2018

CAMHS Adolescent PICU 10

Norbury Ward, River House 5

Acorn Lodge Children’s Unit 1

Ash Adolescent Unit 2

Bethlem Adolescent Unit 1

Oak Adolescent Unit 1

Snowsfields Adolescent Unit 4

Croydon PICU 5

Eden Ward (PICU) 5

Eileen Skellern 1 5

Johnson PICU Ward 11

Place Of Safety 5

Total 55

Fig 35: Total reported incidents of seclusion (Aug 2018); Source; Datix

4.1.8 Incidents of section 136 expiring

Fig 36: Total number of s135-s136 overstays, 30/04/2018-02/09/2018, Source; as reported by the Central Place of Safety

On 11 December 2017 the Mental Health Act was changed with a reduction in the duration of section 136 from 72 hours to 24 hours. The Trust closely monitors 136 activity for compliance with the 24 hour duration. 4.1.9 No bed available

A fundamental and non-negotiable standard for patients is that they have an appropriate bed to seep in that is safe and safeguards their privacy and dignity. Where wards have been unable to meet this standard and compromises have been made for example using de-escalation rooms, quiet rooms or seclusion rooms as additional capacity. Ward staff report these occasions as an incident. The scale of this issue came to light in July 2018 and is now being closely monitored.

0

5

10

15

Total number of s135-s136 overstays - 30/04/2018 to 02/09/2018

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Fig 37: Total reported incidents of ‘no bed available/additional bed used’, Source; Datix

In August 2018, 19 incidents were reported, however after follow up it was clarified that 9 of these related to beds not being available. Many of the incidents reported under this category relate to AWOL patients returning to the ward and their beds being used in their absence, some are AWOL for days or even weeks. The Datix categorisation is currently being reviewed to ensure it accurately reflects reporting. 4.1.10 MHA cancellation

Fig 38: Total reported incidents of ‘MHA Assessment Cancelled’, Source; Datix

August 2018 update: 26 incidents reported under the ARC, this is monitored and managed via the Borough Service Directors.

02468

101214161820

Total reported incidents of 'no bed available/additional bed used'

0

2

4

6

8

10

12

Total reported incidents of 'MHA Assessment Cancelled'

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4.1.11 Staff shortage

Fig 39: Total reported incidents of ‘staff shortage’, Source; Datix

Total reported incidents of ‘staff shortage’ Aug 2018

CAMHS 1

Croydon 10

Lambeth 1

Lewisham 5

Psychological Medicine & Older Adults 5

Southwark 5

Total 27

Fig 40: Total reported incidents of seclusion (Aug 2018); Source; Datix

August 2018 update: In Croydon the highest reporting wards were Fitzmary 1 (7) incidents of staff shortage, Gresham 2 (3). 4.2 Compliance Indicators - Serious Incident Investigations

Fig. 41: Number of serious incident investigations commissioned

Fig. 42: Average number of days for investigations to be completed

There are currently 45 outstanding serious incident investigation reports. Addictions – 1 open investigation Lewisham – 12 open investigations

05

1015202530

Total reported incidents of 'staff shortage'

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BDP – 5 open investigations PMOA – 2 open investigation Croydon – 8 open investigations Southwark – 4 open investigations Lambeth – 11 open investigations Corporate – 2 open investigations 4.3 Compliance Indicators – Safeguarding

Fig. 43: Number of Safeguarding Adults

concerns reported on Datix

Fig. 44: Number of safeguarding adult

concerns where a SLAM employee is an

alleged source of risk

Fig. 45: Number of Safeguarding Children concerns reported on Datix

Safeguarding Adults: In 2018/19 Quarter 1 (April to June), Acute services had the highest number of

reported Safeguarding Adult concerns (65/188). Acute services also had the highest number of staff

as the alleged source of risk (8/14). This remains a continuing trend for July and August.

Safeguarding Children: In 2018/19 Quarter 1 (April to June), CAMHS had the highest number of

reported Safeguarding Children concerns (24/40). The number of reported cases overall has fallen

for July and August.

0

10

20

30

40

50

60

70

80

Safeguarding Adults

Number of adult safeguarding concerns raised as a datix incident

Number of concerns raised on Datix referred to LA

0

5

10

15

20

25

30

Apr2017

May2017

Jun2017

Jul2017

Aug2017

Sep2017

Oct2017

Nov2017

Dec2017

Jan2018

Feb2018

Mar2018

Apr2018

May2018

Jun2018

Jul2018

Aug2018

Safeguarding Children

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4.4 Compliance Indicators – Ligatures

CAG Operation Directorate Ward/Department Audit Date 2017/18

Audit Date 2018/19

CAMHS CAMHS Acorn Lodge 18/04/2017 15/05/2018

CAMHS CAMHS Ash Ward 27/06/2017 30/05/2018*

CAMHS CAMHS Bethlem Adolescent Unit 22/05/2017 14/05/2018

CAMHS CAMHS CAMHS PICU Closed all year. 09/04/2018

CAMHS CAMHS Oak Ward 27/06/2017 30/05/2018*

CAMHS CAMHS Snowsfields Adolescent Unit

02/05/2017 29/05/2018

BDP Croydon & Forensics Bridge House N/A closed 09/04/2018

BDP Croydon & Forensics Brook Ward 06/04/2017 19/04/2018

BDP Croydon & Forensics Chaffinch Ward 07/04/2017 23/04/2018

Acute Croydon & Forensics Croydon PICU 09/05/2017 04/04/2018

BDP Croydon & Forensics Effra Ward 06/04/2017 19/04/2018

Acute Croydon & Forensics Fitz Mary 1 22/05/2017 17/04/2018

Acute Croydon & Forensics Gresham 1 11/05/2017 17/04/2018

Acute Croydon & Forensics Gresham 2 29/03/2017 04/04/2018

BDP Croydon & Forensics National Autism Unit (NAU)

18/04/2017 23/04/2018

Psychosis Croydon & Forensics National Psychosis Unit (NPU)

07/06/2017 23/05/2018

BDP Croydon & Forensics Norbury Ward 19/04/2017 19/04/2018

BDP Croydon & Forensics Spring Ward 19/04/2017 19/04/2018

BDP Croydon & Forensics Thames Ward 19/04/2017 19/04/2018

Acute Croydon & Forensics Tyson West 1 26/04/2017 10/04/2018

BDP Croydon & Forensics Waddon Ward 25/04/2017 19/04/2018

BDP Croydon & Forensics Ward in the Community (WIC)

27/06/2017 07/05/2018

Psychosis Croydon & Forensics Westways 09/05/2017 23/05/2018

Acute Lambeth Eden PICU 23/05/2017 15/03/2018

Acute Lambeth ES2 Ward 09/02/2018 09/02/2018

Psychosis Lambeth LEO Unit (Early Intervention)

11/05/2017 04/05/2018

Acute Lambeth Luther King Ward 17/05/2017 09/04/2018

Acute Lambeth Nelson Ward 25/04/2017 09/04/2018

Outpatients Lambeth Outpatients Lambeth 02/08/2017 01/06/2018

Acute Lambeth Rosa Parks (Lambeth Triage)

19/04/2017 25/04/2018

Psychosis Lambeth Tony Hillis Unit (THU) 16/05/2017 15/05/2018

Psychosis Lewisham 1 & 5 Heather Close 11/05/2017 12 & 13/06/18

Acute Lewisham Clare Ward 18/05/2017 06/04/2018

Acute Lewisham Johnson Unit 10/05/2017 16/04/2018

Outpatients Lewisham Outpatients Ladywell 28/07/2017 01/06/2018

Acute Lewisham Powell Ward 10/05/2017 19/04/2018

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Acute Lewisham Virginia Woolfe (formerly Lewisham Triage)

16/05/2017 19/04/2018

Acute Lewisham Wharton Ward 12/06/2017 23/04/2018

PMIC PMOA ADRU Dower House 11/05/2017 11/05/2018

PMIC PMOA ADRU Longfield House 11/05/2017 11/05/2018

MHOA PMOA Ann Moss 08/11/2017 24/05/2018

MHOA PMOA Aubrey Lewis 1 Ward 16/10/2017 17/05/2018

MHOA PMOA Chelsham House 20/10/2017 25/05/2018

PMIC PMOA EDU 20/06/2017 25/05/2018

MHOA PMOA Greenvale 21/11/2017 23/05/2018

MHOA PMOA Hayworth Ward 03/11/2017 18/05/2018

PMIC PMOA Lishman 08/05/2017 08/05/2018

PMIC PMOA Perinatal Inpatient (MBU) 21/04/2017 04/05/2018

Acute Southwark & Addictions AL3 Ward 19/04/2017 21/03/2018

Addictions Southwark & Addictions Beresford 07/06/2017 20/03/2018

Acute Southwark & Addictions ES1 Ward 08/05/2017 11/04/2018

Addictions Southwark & Addictions Garratt Lane 07/06/2017 19/03/2018

Acute Southwark & Addictions Jim Birley Unit 16/05/2017 22/03/2018

Acute Southwark & Addictions John Dickson Ward 24/05/2017 11/04/2018

Addictions Southwark & Addictions Lorraine Hewitt House 02/08/2017 21/02/2018

Addictions Southwark & Addictions Marina House 12/04/2017 14/03/2018

Outpatients Southwark & Addictions Outpatients Maudsley 19/07/2017 01/06/2018

Addictions Southwark & Addictions Pier Project 07/06/2017 30/05/2018

Acute Southwark & Addictions Place of Safety 18/05/2017 13/03/2018

Addictions Southwark & Addictions Roehampton 01/06/2017 19/03/2018

Acute Southwark & Addictions Ruskin Unit 04/05/2017 25/04/2018

Addictions Southwark & Addictions St Johns 07/06/2017 19/03/2018 * One combined audit for Woodland House now wards combined

Fig. 46: Ligature Audits 2018/19 Ligature audits for 62 sites have been completed and are in date in 2018. 4.5 Compliance Indicators – Infection Control

April 2018 - June 2018

Operations Directorate MRSA, CMRSA, PVL* etc

C. difficile

Antibiotic resistant infections, e.g. ESBL**

Diarrhoea & Vomiting outbreaks

Croydon

1

Lambeth 1

Lewisham

1

PMOA

1

Jul-18

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Operations Directorate MRSA, CMRSA, PVL* etc

C. difficile



BDP 1

Croydon

1

PMOA 1

Aug-18

Operations Directorate MRSA, CMRSA, PVL* etc.

C. difficile



BDP 1

Croydon

1

PMOA 1

Fig. 47: Ligature Audits 2018/19Infection Control Outbreaks (April 2018 - July 2018) 4.6 Compliance Indicators – Patient Experience – Complaints

Fig. 48: Number of Formal Complaints received Fig. 49: Average number of days for complaint responses

Fig. 50: Number of Re-opened Complaints

Fig. 51: Number of Quality Alerts received

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4.7 Compliance Indicators – Patient Experience– PEDIC Scores

Fig. 52: PEDIC Scores (positive) Fig. 53: Family and Friends (FFT) scores (positive)

4.8 Compliance Indicators – Mental Health Act Visits

Fig. 54: MHA Visits The most common action theme from MHA Visits for the Trust was ‘care planning – lack of patient involvement’ (21/175 actions). This was followed by ‘consent to treatment > RC capacity test recording missing’ (15/175).

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4.9 Compliance Indicators – QUESTT

Fig. 55: QUESTT Scores

Level 0 (0-9)

Level 1 (10 - 16)

Level 2 (17 - 23)

Level 3 (24 - 33)

Fig. 56: Number of wards requiring action plans

In 2018/19 Quarter 1 (April to June), 4 wards scored Red. Action plans were received and recorded on Datix for monitoring and implementation. The issues and actions for each ward are outlined below: Johnson PICU (April and May): • Levels of Enhanced observations have incurred an increase of bank staff usage. • Sickness has decreased over past few months however still above 3% being met with HR procedures. • Appraisals are still underway- with members of staff being booked in however some staff are on long term sickness and annual leave. Supervision has been discussed in team meeting. The tracker is being completed. • Increased workload of repeat admissions, HIGH service demands, HIGH risk incidents occurring on the ward, inappropriate admissions have been flagged but overridden leading to high acuity on the ward and constant and difficult case mixes- a few environmental concerns re escalated to E&F, ASCOM ordered but not yet arrived. All have been escalated and discussed in PICU meeting. • Due to high levels of enhanced observations, bank/ agency staff have had to be booked to cover the ward. In appropriate admissions on the ward. High risk patients. • Due to high levels of enhanced observations, bank/ agency staff have had to be booked to cover the ward. In appropriate admissions on the ward. High risk patients. Nelson Ward (May) • The Acting Ward manager recently started in May 2018 and the Ward Consultant started April 2018 • There are 7 vacant RMN posts plus 1 band 6 acting post available • 1 RMN have started, 1 RMN starting in August, 3 in September, and 1 early next year. 1 post to be recruited. Acting Band 6 post currently advertised. • Bank shift rate high due to high level of Vacancy • Plan to do recruitment for the remaining vacancies • Long term sickness and also some short term sickness due to industrial injuries. Affected staff have been referred to OH. E-roster is being used to ensure staff have sufficient breaks between their shifts to ensure staff are not burnt out and annual leave are distributed across the year. Also to ensure RTW is completed. Sickness reviews are taking place. Discussing staff sickness in supervision. Ensuring staff get necessary support to promote their health and well-being. • Clinical supervision not completed for staff who is on long term sickness. Also for other members of staff who was off sick during the mid/end of July. Currently no action until staff return to work for

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the staff who is long term off sick. The rest of the staff to be reminded to book their supervision in advance. • Patient on ward escorted to general hospital. Patient placed to 1:1 due to risk of violence. Staff to be aware of the risks and observations to be reviewed in morning MDT handover as well as on every shift. Eden PICU (May and June) • Bank shift and enhanced observations have been high due to staff sickness • 2 long term sicknesses; 1 industrial injury. Sickness review and attendance management planning is being done with staff. • 5 new staff have been recruited, awaiting employment checks and start date • Supervision is currently being done by the ward manager and 1 Band 6. • Issues regarding ward repairs and damages have been escalated to senior management and there are plans in place of dealing with the problems • The ward was highly acute due to patients mix, risk and presentation • One staff member is undergoing an investigation LEO Ward (June) • Due to sickness and RMN vacancies , NHSP/agencies provided staff , however in July 2018 one RMN started and another started at the beginning of August 2018.Two more are starting in the middle of September 2018.Two more RMN are in acting role as band 6 and RMN is secondment. • Due to absence of manager, band 6 did not have supervision or appraisals as expected - plan to complete all staff appraisals in July- 14th August 2018. • There were 5 x complaints in June 2018. Team Leader and Band 6's addressed them and patient complaints were discussed in Business Meeting with lessons learnt and future actions discussed. Individual clients were spoken by the team leader and did not want to proceed with their complaints. • The airlock door has not been replaced – the ward is awaiting a date from senior management when these doors will be replace. The new mattresses and beds are yet to be delivered. • There has been on-going investigation with 3 x members of staff that has not resolved as yet. A plan is place to performance manage the affected individuals. • The ward has not had stable leadership for months. An interim team leader is in place since end of May 2018 and structures are in place to support them in their new role • Two formal complaints were received in a month. Clients who were still on the ward were spoken to and this was addressed in the business meeting as well. • Interim leader has started the appraisal and supervision process and it well underway. • This has been a longer term issue that had not been addressed due to unstable leadership. Plans have been put in place by senior management to resolve all these issues. 4.10 Compliance Indicators – Risk Assessment and Care Plan Audits

Fig. 57: Trust audit scores Fig. 58: Percentage of care plans devised

collaboratively with service users (inpatient)

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4.11 Compliance Indicators – NICE Guidance

Fig. 59: NICE Guidance and Quality Standards Gap Analysis lead by Operations

Directorates (completed and outstanding)

4.12 Compliance Indicators – Policies

Policies In progress Overdue

Acute 3

Addictions 1

CAMHS 1 1

Croydon & BDP 1

Lambeth 1

PMOA 2 1

Southwark 4

Fig. 60: Number of policies under review by Operations Directorates

NICE Guidance 2015 2016 2017 2018

Addictions 1 1

Acute 1

BDP 1 2

CAMHS 1 2 2 4

MHOA 4 2 2

PMIC 1 1 4 1

Psychosis 1 1 1

Quality Standards 2015 2016 2017 2018

Addictions

Acute 2

BDP 1 2

CAMHS 2 1 2

MHOA 2 2

PMIC 1 2 1

PsychosisCompleted gap

analysis

Outstanding gap

analysis

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Fig. 61: List of policies under review by Operations Directorates

This month has highlighted the improved response times for complaints and completion of investigations for serious incidents. All annual ligature audits have been completed within the timeframe. Of the four wards who had a RED score in the QUESTT indicator tool, three of these were from Lambeth. The Quality Governance Compliance Meetings have explored these areas in more detail and have asked for further feedback in September.

5. Directorate Performance Reviews Summary The Performance Management Framework is comprised of Key Performance Indicators across:

Finance (including cost improvements and cost reductions)

Operations (workforce, activity and quality indicators)

Patient and commissioner measures

Learning and growth The update and design work to the Performance Management Framework to reflect the change to a borough delivery model is undergoing further modification while the development of the new performance report (in Power BI) is being tested with the intention to complete the redesign and transfer reporting over at the end of Q2, The new director of Performance & Contracts and PMO has initiated an interim plan and process to produce interim borough-based reports to support PACMAN meetings. The new process will: • Align with the monthly finance report schedule • Provide an opportunity to review reports with Directorates 5 days before the Pacman meetings • Support the Governance WorkStream in having a PMF process that delivers one monthly performance report that has undergone a robust assurance process with all relevant teams. At the September meetings (reviewing August performance), the key issues and associated actions remain consistent:

Adult inpatient pathway pressures; external overspill and Delayed Transfers of Care (DToC)

Placements (Southwark and Lewisham)

18/19 CIP and QIPP schemes

Agency expenditure and achieving the NHSI reduction trajectory

Mandatory training compliance

Community waiting times

Operational Directorate/Borough (as outlined by Policy Lead) Policy

Addictions Needle Exchange Guidelines (CDAT & Pharmacy

Croydon & BDPProtocol for Working with People with a Diagnosis of Mental and Learning

Disabilities within the Mental Health in Learning Disabilities Services (MHiLD)

CAMHSCAMHS Policies and Procedures for the Restriction of Liberty of Under 18

Patients within the Trust

CAMHS Young Refugees or Asylum Seekers and Their Families

Lambeth Clinical Risk Assessment and Management of Harm

Lewisham Discharge and Transfer Policy

PMOA End of Life Guidelines

PMOA Clinical Handover Policy

Southwark PICU Operational Policy

Southwark AWOL Policy

Southwark Engagement and Observation Policy

Southwark Hospital Response Teams

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5.1 Training

5.1.1 Mandatory Training Compliance Compliance has plateaued over the past two months with the overall figure as at 24 September 2018 being 87.35%. Within each of the core subjects there has been a steady, incremental rise in compliance, particularly in areas previously highlighted as concerns resulting in action. There has been an overall increase of 1.53% in core subjects this month.

5.1.2 Current Compliance Rates

Current compliance rates by directorate and by subject matter are shown in the tables below. The trend over the past six months is shown by subject and shows a consistent improvement during the last 6 months. Due to the Trust restructure, data by directorate is limited but we shall be able to demonstrate a trend as the months progress.

Directorate August

2018 September

2018

Child & Adolescent Services 88.35% 88.74%

Corporate Directorate 82.82% 83.28%

Lambeth Directorate 84.46% 84.29%

Croydon Directorate 89.85% 90.37%

Southwark Directorate 87.39% 87.39%

PMOA 89.03% 88.79%

Lewisham Directorate 89.86% 88.74%

Grand Total 87.31% 87.35% Fig. 62 – Mandatory training compliance rate by directorate

Core Subjects (Target 85%)

March 2018

April June 2018

September 2018

Basic Life Support –Group 1 91.07% 92.93% 95.19%

Basic Life Support - Group 2 72.30% 76.59% 84.18%

Equality, Diversity and Human Rights 85.91% 91.33% 91.99%

Fire Safety Awareness 80.07% 84.96% 87.27%

Health, Safety and Welfare 84.53% 90.04% 88.30%

Immediate Life Support [1 Year] 70.55% 77.45% 79.82%

Infection Control Level 1 89.01% 92.63% 92.17%

Infection Control Level 2 67.34% 76.04% 83.13%

Information Governance 77.74% 81.33% 85.97%

Moving and Handling - Loads - Group 1 92.75% 88.97% 98.47%



Moving and Handling - Patients - Group 1 82.58% 79.53% 85.22%



Prevent Awareness 88.64% 92.75% 93.43%

Prevent Workshop 84.39% 89.06% 91.56%

PSTS Awareness/Conflict Resolution 78.04% 84.28% 86.50%

PSTS Disengagement 67.04% 73.17% 75.51%

PSTS Team Work 83.12% 86.47% 87.15%

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Safeguarding Adults Alerters 84.77% 89.82% 90.28%

Safeguarding Adults Alerters Plus 84.85% 88.42% 87.71%

Safeguarding Children Level 1 87.85% 91.28% 91.20%

Safeguarding Children Level 1 and 2 93.07% 97.01% 97.31%

Safeguarding Children Level 3 77.89% 87.15% 88.69%

Grand Total 81.16% 85.82% 87.35%

Non-core – Mental Health Specific Subjects March 2018

June 2018

September 2018

Deprivation of Liberty Safeguards (DoLS) [3 Years] 82.35% 88.45% 87.90%

Mental Capacity Act (MCA) [3 Years] 84.31% 89.22% 87.07%

Mental Health Act Training [3 Years] 82.83% 87.42% 85.13% Fig. 63: Mandatory training compliance rates by subjects

5.1.3 Specific Actions in Relation to Current Areas of Concern

5.1.3.1 PSTS teamwork With the ongoing efforts of the trust’s initiative to reduce patient violence on ward by at least 25% within 2 years, the focus on PSTS Teamwork training for SLaM staff continues. The compliance figure has improved significantly since the beginning of 2018 to 87.15%. However new starters are now not included in reporting for the first two months so a true figure of all staff required to complete this training is not fully reflected. E&D now run a minimum of one 5 day course each week with additional runs of twice per week to ensure the intake of newly qualified inpatient nurses are trained in team skills. Demand for 5 days courses is increased by established staff allowing their compliance to expire before attending the PSTS 3 day teamwork (refresher). It is recommended that managers give a strong steer to staff to ensure they book well in advance of expiry. The trust has both venue and staff capacity issues in providing PSTS training. Most trusts have a dedicated venue for PSTS due to specific requirements of the training format where SLaM does not. There is ongoing work in sourcing suitable internal and external venues, however these are limited reducing the options to run additional 3 and 5 day courses. There is also limited numbers of suitably trained staff to delivery PSTS teamwork and a wider discussion with the E&D’s education Delivery and Quality Assurance team is needed to look at actions to build capacity. The reasons above contribute to higher waitlist numbers for staff requiring PSTS 3 day teamwork (refresher). Between now and the end of January 2019 the waitlist is at 57. If compliant members of staff are unable to attend a 3 day refresher before expiry, they then have to attend a 5 day PSTS teamwork course which further increases demand for 5 day courses.

5.1.3.2 PSTS Disengagement With the compliance figure showing at 75.51% this is flagged as an area for improvement. E&D continue to run disengagement training at the Ortus as it can accommodate larger groups but the number is limited to having sufficient trainers available to deliver. In response to the issues of limited places E&D are offering trust-wide places one Saturday per month where take-up has been good. Wherever possible, E&D are offering Saturday sessions to voluntary staff and students. This cohort is an un-quantified delegate group of non-substantive staff whose needs had not been anticipated in training planning. Giving access to Saturday training to non-substantive staff allows weekday training places to continue to be available for substantive staff and lessens pressure on waitlists. The waitlist for PSTS disengagement is high, numbering 38 staff. Location of training appears an issue for staff booking themselves on training. Places at Lambeth are in particular demand due to less take-up of training at Bishopsgate. It is recommended that managers encourage staff to take up available places regardless of location where possible.

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The review of PSTS training by the Director of Nursing is welcome and it is envisioned actions will be taken across the full PSTS portfolio of training in response to findings and recommendations within the review. Work has begun on blended learning for PSTS with the online component focussing on the theory elements of PSTS. It is envisaged that the ongoing review of PSTS will inform changes to the learning plan for this work, therefore developments are on hold until the outcome of the review and agreed changes.

5.1.3.3 ILS Two of E&D’s ILS trainers are also PSTS trainers. This impacts the department’s ability to increase training offerings across these courses. An increase in PSTS training will mean less ILS delivery. The issue further emphasises the need to build capacity for suitable trainers as well as have access to suitable venues. There are also additional costs if additional ALS trainers need to be hired. Contributing to the slower improvement on ILS compliance rates has been the manual administrative processes that sit behind ILS bookings via LEAP. Participant mailing addresses need to be gathered in order to post out pre-course materials provided by the Resus Council. A change-over of staff in the E&D training administration team and a historical need to document processes has meant a slower administration of bookings during this transition. The process is currently being reviewed to identify areas of improvement and streamlining, however until the Resus Council provide digital manuals the ability to fully automate bookings and pre-course learning is limited. There is an issue with staff committing to the bookings once made. Each booking allocated to one member of staff reduces the numbers for other. During September, 4 courses were run with 51 participants initially booking. However, out of those only 32 fully attended, with the rest being 8 DNAs, 10 cancellations/declined and 1 partial attendance. This results in lower compliance figures and is wastage of cost on venue hire and buying in additional trainers to ensure participant/trainer ratio is met with the anticipated higher numbers. It is recommended that a more rigorous follow through with staff and managers for those that book and do not fully attend. We will also link in with the Comms team to raise staff awareness of the impact their DNAs and cancellations have on trust compliance.

6. Commissioning All QIPP and investment schemes are now being managed using the Programme Management Office (PMO) principles. Service Development and Improvement Plans (SDIPs) have been drawn up and shared with each commissioner setting out the borough status for Five Year Forward View transformation initiatives and cross-referencing current performance, investment, challenges and change plans. Engagement from commissioners has been variable although over time the SDIP process should become embedded as it is the only way to ensure disinvestment and investment decisions aren’t made in isolation. Adult acute inpatient service capacity continues to be a major discussion point given the ongoing heat in the system. Commissioners have confirmed their commitment to maintain the bed base in 2018/19 and to plan to commission at 85% bed capacity utilisation. The ICare programme to reduce length of stay (with flat admissions) continues to be a major focus in 2018 for commissioners as current plans indicate the potential for a ward closure early in 2019/20 which is based on SLaM activity trajectories and ICare plan. The current operational performance indicates that significant improvements must be achieved rapidly if the March 2019 targets are to be met. There is on-going discussion with both Southwark Local Authority and CCG to evaluate the impact of changes regarding section 75 and to align CAMHS services to the outcome of the recent review. Whilst not formally signed off, there has been agreement from the review to communicate to CAMHS staff that whilst service developments are anticipated, there will not be a reduction to the CAMHS budget. Planning for the developments is now commencing.

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However, Southwark local authority have reduced their adult placement budget in 2018/19 by £700k to £2.4 million, putting the Trust at risk of non-payment of invoices once this level of expenditure is exceeded. The Trust is now reviewing this late decision to withdraw funding with Southwark local authority and Southwark CCG.

6.1 Lambeth and Croydon Alliances The Lambeth Alliance commenced in July 2018 and the Trust is working with Alliance partners in delivering the new model via the Lambeth Borough Team.

The PMOA Operational Directorate are currently undergoing recruitment to the CPN posts confirmed as part of the Croydon Alliance.

6.2 Ann Moss Unit / Older Adult Specialist Care Following a period of engagement and a joint review of the outcomes by SLaM and Southwark CCG, there was an agreement to proceed with the closure of Ann Moss Unit by August 31st 2018. As part of the ongoing engagement each patient had a health needs assessment and options for alternative care facilities were developed with their family and advocates on an individual basis. The last patient left the unit on 16th July and there has been a period of transition where the patients have been followed up by the Ann Moss team and in the community Care Home Intervention Team. Initially, from the eleven patients resident in Ann Moss, it was predicted five would need to come to move to the sister unit, Greenvale, in Lambeth. Following the reviews and work with relatives and carers only one person moved to Greenvale. The others went to nursing homes that specialised in dementia which was the preference of the families or identified in best needs meetings. This was to mitigate concerns raised that relatives will have further to travel to visit their loved ones after the closure and so there is a risk that relatives will lose regular contact with them. In terms of staff, most have been redeployed to vacant posts in other facilities with support and trials on-going for other members of the team. A small redundancy programme is likely. Greenvale Specialist Care Unit, located in Streatham, has now been designated the Older Adult Specialist Care Unit. It will be serving the 3 Boroughs of Southwark, Lambeth and Lewisham. This will be for older patients 65+ with a comorbidity of challenging behaviour due to mental health (organic and functional), learning disabilities and / or acquired brain injury and physical health. This provision has a new emphasis on shorter stays and care plans that will enable patients to be transferred to other facilities within Southwark and other Boroughs.

6.3 Commissioner-related Quality Impact Assessments (QIAs) The Programme Management Office (PMO) undertakes the assurance and governance processes for QIAs. QIAs have been developed for most CIP schemes and are either approved or in draft for approval. There are currently no schemes in delivery that do not have an approved QIA. As new schemes are developed, they will be put through the rigour of the QIA process.

6.4 Commissioning Programmes 2017-18 2018-19 QIPP and CQUIN schemes are being managed using the PMO principles.

6.4.1 Quality, Innovation, Productivity and Prevention (QIPP) programme QIPP has been rated into four categories:

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Rating Definition £’000s

Red Requires significant work 1,926

Amber Requires some work 1,264

Green Requires little work 5,314

Total 8,504

The QIPP risk dashboard is below:

QIPP Ref CCG QIPP plan Progress Value (£)

RAG YTD Variance (£)

LAM-1819-005-Q

Lambeth Lambeth Adult inpatient - baseline as per 17/18

QIPP offset by investment. 835

348

STH-1819-003-Q

Southwark Swk Adult inpatient - baseline as per 17/18

QIPP offset by investment. 532

222

STH-1819-004-Q

Southwark QIPP gap - initiatives to be identified

Initiatives to be identified 559 93

LEW-1819-012-Q

Lewisham FYE - Lewisham Community Teams - A&L Team

Community teams budget (£42k) is in the baseline budget. Budgets will be monitored to track spend

42 21

LEW-1819-013-Q

Lewisham Placements reduction

New scheme, from former ERT £150k scheme.

50 0

LEW-1819-014-Q

Lewisham

Primary care New scheme, from former ERT £150k scheme.

50 21

LEW-1819-015-Q

Lewisham Homelessness New scheme, from former ERT £150k scheme.

50 21

LAM-1819-004-Q

Lambeth SHARP M1 variance of £33k 400

69

STH-1819-002-Q

Southwark Southwark Placements - CCG

Action plans being drafted 472

0

LEW-1819-005-Q

Lewisham QIPP Triage savings

Implementation in June 18 200

33

LAM-1819-006-Q

Lambeth ASD & ADHD C&V expenditure

QIPP being achieved subject to CCG confirmation.

150

0

PMOA-1819-011-Q

Lambeth Greenvale - reduction in beds

QIPP being achieved 666

0

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PMOA-1819-010-Q

Southwark Ann Moss Way Service improvement 893 0

LEW-1819-007-Q

Lewisham FYE - IAPT (15% reduction)


0

LEW-1819-011-Q

Lewisham FYE - LITT Team - move from Psychosis to primary (PMIC link)


0

CRY-1819-010-Q

Croydon Croydon Adult inpatient - baseline as per 17/18

OBD are within the plan and QIPP should be achieved (based M1 performance)

2,333

0

CEN-1819-017- Q

NHSE NHSE Specialist Contracts

QIPP offset by investment - 17/18 baseline has therefore been retained

1,136

TOTAL 8,504 954

Fig. 64: QIPP dashboard The QIPP position at month 5 is as follows;

All QIPPs that have not been delivered in 18/19 and where there is no agreement to reduce the

baseline have been captured in the 18/19 business planning cycle with ongoing discussions in

monthly performance management meetings to address the gap.

Majority of the QIPPs identified for 18/19 have robust plans that will be monitored in the monthly

performance management meetings. All QIPPs are mapped to the new organisational structure.

QIPP Red risks

Southwark Adult inpatient (baseline as per 17/18) - Value £532k. QIPP offset by investment.

This QIPP is red as although the baseline is reinstated, the Trust is over performing (more activity

than income) against occupied bed day (OBD) baseline. Please note this is not a direct financial

risk to the plan of £532k as the baseline funding reflects over performance and has been offset by

additional CCG investment. However, the QIPP is noted as red given the requirement to achieve

85% bed occupancy and the potential financial impact on cost overall due to high bed occupancy.

Lambeth Adult inpatient (baseline as per 17/18) - Value £835k. QIPP has been offset by

investment. This QIPP is red as although the baseline is reinstated, the Trust is over performing

(more activity than income) against the occupied bed day (OBD) baseline. Please note this is not

a direct financial risk to the plan of £835k as the baseline funding reflects over performance and

has been offset by additional CCG investment. However, the QIPP is noted as red given the

requirement to achieve 85% bed occupancy and the potential financial impact on cost overall due

to high bed occupancy.

Southwark QIPP gap - initiatives to be identified. Value £559k. Southwark CCG has not identified

any initiative for this value. New initiatives have been proposed by the Trust, to the CCG in May, and

the Trust is still awaiting a response.

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Amber Risks

SHARP. Value £400k. £400k QIPP & £133k CIP removed from annual budget. However, M5

budget confirms variance of £69k. This will be managed via PACMAN and recovery action plan is

being drafted by the new Service Director for Southwark.

Lewisham Community Teams - A&L Team. Value £42k. This is a QIPP based on service

improvement. There is a lack of clarity of a plan to deliver savings. Lewisham team are in the

process of drafting a plan to recover the QIPP savings in year.

Southwark Placements. Value £472k. This is being managed via Southwark PACMAN where

performance is tracked and remedial initiatives are being identified. This QIPP is amber due to

overspent budget and high spend placements trend from 17/18, and it is still unclear where

Southwark Council sees its role in paying for its share of the agreement. Action plan is being drafted

by the new Service Director for Southwark.

FYE - Lewisham Community Teams - A&L Team. Value £42k. This is an outstanding issue that

will be picked up as part of the borough restructure programme. This remains amber due to an

overspend of £21k at M5

QIPP Triage savings. Value £200k. This QIPP is amber because Implementation of this initiative

is in delay, which is due to delay in seeking QIA approval.

6.4.2 Commissioning for Quality and Innovation (CQUIN) Schemes The national CQUINs for 18/19 are consistent with 17/18, being the second year of implementation in the two year contract cycle signed for 17/19. The final agreement to the new local CQUINs for 18/19 are still outstanding, and conversations are still ongoing with commissioners, particularly Croydon. The Physical Health CQUIN 3A has had the internal audit completed to provide assurance that Physical health data is being recorded appropriately. Although the national audit is yet to happen, there are no issues envisaged. There is still a risk around the SMI QoF alignment and CPA registers for CQUIN 3B which is due to be reported at the end of Q2. Clinical leads are still working hard to gain primary care engagement to abate this risk and have asked Performance and Contracts colleagues to raise this with commissioners at core contract meetings. The preparation for the Flu Scheme 1C is nearing completion and a local flu plan is nearing completion. There is a big risk around the A&E Frequent Attenders CQUIN Scheme 4. Following the borough restructure, the leadership for this scheme needed to be devolved to individual boroughs and there is no clarity on who the leads are for the individual boroughs or how the work is being monitored. The new Director for Performance & Contracts and PMO has agreed to coordinate this with a plan for PMO to hold this centrally whilst the boroughs identify individual clinical leads who will attend meetings with the ED teams. NHSE CQUIN schemes are progressing with Trust preparing to submit milestone requirements for Q2 in partnership with SLP colleagues to ensure 2018/19 schemes deliver full achievement. We are on track to submit Q2 requirements for all other CQUIN schemes.

7. Programme Management Office (PMO)

7.1 Cost Improvement Programme (CIP)

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Fig. 65: Trust M5 CIP position The chart above shows the summary of the Trust CIP schemes broken down by Operational Delivery Unit (ODU) and by risk as at M5. The table shows that of the 66 schemes at £16.4m in the Trust plan, £3.7m are at high risk. This is driven primarily by bed costs (overspill). £6.8m is rated medium for risk, driven primarily by overspends in inpatient nursing. The remaining £6.8m is rated as low risk.

8. Emergency Planning In response to the 2017 ransomware/cyber security incident that affected a substantial proportion of NHS organisations, a SLaM Information and Communication Technology (ICT) ‘task and finish’ group has been set up and the inaugural meeting of this group will take place in August 2018, chaired by the Chief Operating Officer. Working groups and a project board have been set up to address the areas of non-compliance as highlighted in the NHSE (London) annual EPRR assurance process from November 2017. These complement existing performance review meetings across the Trust. Key areas are as follows:

The Trust has created a new EPRR Specialist Manager post, to be recruited to imminently. The post will lead on delivering specialised EPRR objectives for the organisation.

The Trust is in the process of formalising its lockdown plan (to be included in the Secure Environments policy).

The Trust is updating Business Continuity plans to reflect the recent move to Borough based operational directorates. A training needs analysis will be undertaken for both on-call directors and the wider organisation in relation to EPRR, focusing on specific aspects of risk.

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The Trust has its latest Disaster Recovery (DR) plan in draft, awaiting ratification and submission to NHSE (London). It is anticipated that this plan will be ratified imminently.

The Trust is continuing with Business Continuity exercises and the on-going work with NHSE (London), and the LAS (London Ambulance Service) to develop a Hazardous Materials (HazMat) and Chemical Biological Radiological Nuclear and explosives (CBRNe) 'train the trainer' course, specifically aimed at Mental Health Trusts. A pilot training session took place in May, which was attended by both departmental representatives from SLaM, and representation from NHSE (London).

A core EPRR team is currently preparing an updated version of the Emergency and Major Incident Plan (EMIP), to be presented to the September meeting of the Board.

The Trust has moved the risk associated with EPRR from the Executive Risk Register to the COO Delivery Risk Register.

9. Conclusion The Trust continues to meet the NHS Improvement Single Oversight Framework indicators covered by this report. Pressure across the adult acute pathway (inpatient and community) has increased and is resulting in continued usage of external overspill inpatient beds. The first multi-agency discharge event (MADE) was held in Southwark in July and the next one is planned in September for Croydon. The Programme Management Office is now supporting the 18/19 oversight process for CIP, QIPP and CQUIN. £3.8 million of the CIP programme is currently rated as high risk. There is an agreed approach with commissioners to evaluate their investment plans and the Five Year Forward View transformation trajectories. We continue to work with both Southwark Local Authority and CCG to evaluate the impact of the proposed changes regarding section 75 and to align CAMHS services to the outcome of the recent review; the risk from the reduction in placements budget by Southwark Local Authority is being assessed. The Performance Management Framework is being reviewed as part of the development of the borough operational delivery model. Continued progress is evident with our emergency preparedness.

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Appendix 1 - Glossary

Abbreviation Description

AEP Accountable Emergency Officer

AfC Agenda for Change

Ascom Alarm / communications system supplied by Ascom UK, a telecommunications company

ASD / LD Autism Spectrum Disorder / Learning Disability

CAG Clinical Academic Group – bringing together clinical services, research and education and training into a single management grouping e.g. Psychosis

CAMHS Child and Adolescent Mental Health Services

CBT Cognitive Behavioural Therapy {CBTp is CBT of psychosis}

CCG Clinical Commissioning Group – an NHS body responsible for the planning and commissioning of health services for their local area

CHS Croydon Health Services NHS Trust

CIP Cost Improvement Programme

CPA Care Programme Approach

CQUIN Commissioning for Quality and Innovation: A fund where payment is contingent on delivery on quality improvements and meeting milestones agreed with commissioners.

CYP Children & Young People

DBT Dialectical Behaviour Therapy

DTOC Delayed Transfers of Care

E&D Education & Development Department

EI Early Intervention: First Episode Psychosis

ePJS Electronic Patient Journey System: Clinical records system

EPM Emergency Planning Manager

EPRR Emergency Preparedness, Resilience and Response

GSTT Guys & ST Thomas’ NHS Foundation Trust

HTT Home Treatment Team

IAPT Improving Access to Psychological Therapies

ICD10 Diagnosis coding: International Classification of Diseases (World Health Organisation). Currently iteration ICD10

JOSC Joint Overview and Scrutiny Committee

LoS Length of Stay. The duration of an inpatient stay, usually measured in days. Can include or exclude leave and can focus on a stay on a particular ward or the full hospital admission.

LSLC Lambeth, Southwark, Lewisham & Croydon (CCGs)

MHOAD Mental Health of Older Adults and Dementia

MHSDS Mental Health Services Data Set: National dataset submitted to NHS Digital (formerly known as the Health & Social Care Information Centre)

NHSE NHS England

NHSE(L) NHS England (London)

NHSI NHS Improvement: the new regulatory body overseeing all NHS providers as well as independent providers that provide NHS funded care

NHSP NHS Professionals

NICE National Institute for Health and Care Excellence: provides national guidance and advice to improve health and social care

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OAP Out of Area Placement

OBD Occupied Bed Day – is a unit of currency used to measure the use made of a bed (e.g. 1 obd = 1 bed occupied for 1 day by a patient)

PACMAN Performance and Contract Management (meeting)

PICU Psychiatric Intensive Care Unit

PMF Performance Management Framework

PMO Programme Management Office

QIA Quality Impact Assessment

QIPP Quality, Innovation, Productivity and Prevention programme is a series of schemes required by the CCGs and developed with SLaM to help enhance services and improve their cost effectiveness

QuESTT Quality, Effectiveness and Safety Trigger Tool. An inpatient self-audit which enables pressures in inpatient wards to be quantified. In 2018 a simple community equivalent is being developed and introduced at SLaM.

SEL South East London

SLP South London Mental Health and Community Partnership. A partnership of SLaM, Oxleas and SWLStG formed in 2015

SOF Single Oversight Framework: NHSI assurance and performance mechanism

SPC Statistical Process Control

STP Sustainability and Transformation Partnership

SWL South West London

SWLStG South West London and St George’s Mental Health NHS Trust

YTD Year to Date

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Appendix 2 - Pilot Community QuESTT Report September 18

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30 October 2018

Title

Freedom to Speak Up Guardian (FTSUG) report – no.1 & 2 for Year 2018/19

Author Zoë Reed, Director of Organisation and Community & Freedom to Speak Up Guardian

Accountable Director Matthew Patrick, Chief Executive


This paper updates the Board on Freedom to Speak Up (FTSU) in the Trust. It describes how we have been delivering the function within the organisation and what next steps we have identified.

The content of this paper was discussed at the Equalities and Workforce Committee (EWC) on 13th September and ideas suggested at that meeting have been incorporated. It has also been updated with additional information gathered since that meeting.

Executive summary

The Board has agreed that it will receive 3 Reports per year from the Freedom to Speak Up Guardian, Zoë Reed. The intention is that a report will be presented in July and October each year, with the Annual Report the following March. It was not possible to produce the July report this year due to the Trust Guardian, Zoë Reed having to undergo emergency surgery. This report therefore covers the whole period since the Annual Report in March 2018.

The National Guardian’s Office (NGO) and NHS Improvement (NHSI) have recently issued ‘Guidance for Boards on Freedom to Speak Up’ which was published in May 2018. This is the subject of another paper which will be presented at this meeting, as a separate agenda item, by the Chief Executive.

The National Guardian’s Office has also issued a revised ‘Freedom to Speak Up Guardian Job Description’ which was published in March 2018, and it states that the aim of the FTSU function is to:

Protect patient safety and the quality of care

Improve the experience of staff

Promote learning and improvement

One of the recommendations in the guidance document is on the form and content of the FTSUG reports to their Board. This report seeks to follow that guidance and is therefore organised under the following headings

1. Assessment of Issues 2. Potential patient safety or workers experience issues 3. Action taken to improve FTSU culture 4. Learning and Improvement 5. Recommendations

Recommendations In our 20th March 2018 Board report some recommendations for action were outlined, some of which are underway and some of which need further development:

Ongoing communication and awareness raising – we have done this more over the last 6 months and plan to consistently deliver on regular communication with SLaM staff

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Focus on ‘Being Heard’ as much as ‘Speaking Up’, supporting managers to react positively and proactively respond to staff speaking up – discussion to take place with the Training and Development Department and the commissioning of a skills package might be required. The Inclusive Leadership Programme will also be supporting the development of necessary awareness

Case studies and sharing positive experiences – during staff presentations about FTSU, Advocates talk openly about their personal experience of using the service themselves and taking on an Advocate role to support others; some of these stories will be captured and used to further promote the service

Data triangulation: speaking up takes place in many other places and processes – as listed in the ‘Who can I talk to?’ poster – as well, of course, as directly within line management structures. The specific issue of triangulation, to identify areas where more speaking up would be beneficial, and our approach to its development is included as part of the FTSU Improvement Action Plan (see separate Review report).

Following an analysis of the last nine months of activity (in Q4 2017/18, Q1 2018/19 and Q2 2018/19), we have identified further recommendations including:

- Raising the profile of the FTSU Advocate role and recruit more colleagues to join the FTSU network - Continue to hold regular Steering Committee and FTSU Network meetings - Develop an Advocate Information Pack and associated Training Programme - Deliver more FTSU presentations to staff teams - Develop communications, including a new poster to sit alongside existing FTSU material - Gain the support of Operational Directorates to promote FTSU amongst their staff - Increase the profile of the FTSU communication campaign so that all staff know they are welcome

to apply to be Advocates AND to reassure all staff that the FTSU service is completely confidential focused on helping them to Speak Up and Be Heard and the Trust to learn and improve.

- Steering Group relevant leads to analyse the 3 National Case Reviews to identify the learning points relevant to the Trust

- The Themes analysis section points to the need to o continue the Trust’s focus on Inclusive Leadership training and development o Offer support and coaching to managers so that they remain connected and engaged with

staff particularly when things are becoming difficult o To have a particular focus on managers staying connected and engaged during times of

reconfiguration and restructuring o Develop the capacity of the trade unions to fully support staff even in the most complex

cases so that the Trust’s formal processes are trusted to be used in all circumstances - Devise a survey to test the Themes with staff more broadly to get an assessment of how widely

they are experienced across the Trust. This could also be used as a way of promoting FTSU widely amongst staff and identify areas where further promotional work is required.

In addition, there are recommendations for significant work arising from the review carried out by the Chair

and Chief Executive because of the new ‘FTSU Self Review Tool’ published in May 2018.


BAF Risk 1 - Workforce

Committees where this item has been considered Date Committee / Meeting

13 September 2018 Equalities and Workforce Committee

30 October 2018 Trust Board Meeting

Background The last report to the Board from the Freedom to Speak Up Guardian was in March 2018. It was the Annual Report and summarised the activities and progress over the preceding year. It was not possible to produce

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the July 2018 report due to the Trust Guardian, Zoë Reed, having to undergo emergency surgery. As a result, this report covers the period April – October 2018. The next report will be the Annual Report in March 2019. In May 2018, the National Guardian’s Office (NGO) and NHS Improvement (NHSI) issued ‘Guidance for Boards on Freedom to Speak Up’. The Chief Executive will update on this document as a separate item on this Agenda. One of the recommendations in this document is around the suggested content to be included in the FTSUG report for the Board. This report follows the recommended template and is set out under the following headings which have been addressed in the main body of this report in turn:

1. Assessment of Issues 2. Potential patient safety or workers experience issues 3. Action taken to improve FTSU culture 4. Learning and Improvement 5. Recommendations

1. Assessment of issues In Q4 2017/18 we had 5 cases reported to the NGO; in Q1 2018/19 we had 8 and in Q2 2018/19 we had a further 9 FTSU cases. It is of note that in Q4 all the cases were from the FTSUG, however 5 of the cases in Q1 were from Advocates and 5 cases in Q2. This demonstrates that the Advocates are becoming better known as a helpful resource for SLaM colleagues. The issue remains that we need to (a) recruit more Advocates and (b) continue work to raise their profile amongst staff in their allocated geographic area. N.B. The above figures refer to cases that have been initiated in Q4 2017/18, Q1 2018/19 and Q2 2018/19 and do not include cases that continue to be live from previous quarters. Over the past 6 months, a number of important developmental steps that have been achieved:

The profile of FTSU is rising within the Trust with the help of the communication plan

FTSU has taken up opportunities to be more visible (e.g. liaising with the communications team to send out promotional materials along with another internal mail outs to all teams across the Trust)

Word of mouth promotion has taken place, both from those that have used the service themselves and from those that are part of the FTSU network as Advocates and Ambassadors

The appointment of the FTSU Coordinator in April 2018 has helped drive forward the FTSU function, particularly in the areas of promotion, building the FTSU Network and supporting Advocates with resources for promotional work

Being proactive about visiting staff teams during handovers and team meetings and spreading visual promotional material has enabled colleagues to know who they could talk to, has opened discussion about the function of FTSU and raised awareness in a more personable way.

The most significant Trust-wide improvement that has been made because of colleagues speaking up through FTSU, is the development of the Trust wide ‘Valuing and empowering staff – tackling abuse of power and discrimination’ statement – which is attached to this Report. This came out of a FTSU issue that was brought forward to the Trust Guardian. A draft statement was developed by Nicola Byrne, Zoë Reed and members of the FTSU Network. It was discussed at the Trust Board on 20th March as part of the FTSUG Annual Report. The statement was further refined involving Mike Franklin, Altaf Kara, Rachel Evans and Julia Park, the final version was signed off at the Equalities and Workforce Committee and published via SLaM internal e-news on April 24th April – see the article here.

In Appendix 1 you will see FTSU data returns for the NGO. This information from our Trust, and that of other Trusts nationally, is made public by the NGO and can be accessed via their Care Quality Commission (CQC) hosted webpage here. A summary of the data follows. Categorisation is carried out by FTSU Advocates and FTSUG when they report on the cases they have undertaken. We gather this data and submit it to the NGO via their online form. Over the last nine months we have reported to the NGO that:

3 / 22 cases were raised anonymously

9 / 22 cases have an element of patient safety/quality

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http://slam.newsweaver.com/InternalWeekly/ai6ika3l3zis1k75vyylub?email=true&a=1&p=53262206&t=23544355

https://www.cqc.org.uk/national-guardians-office/content/speaking-data

17 / 22 cases related to behaviours, including bullying and harassment

9 / 22 cases indicated that the person is suffering detriment because of speaking up (this refers to staff attempts to talk to their line manager about a concern and suffering detriment for taking that action i.e. it does not refer to speaking up through the FTSU service).

The NGO strongly recommends that comparisons are NOT drawn between Trusts as each are at different stages of development and spread. Each Trust also has different cultures, opportunities and context within which staff can raise issues at work. For example, SLaM has many opportunities where staff can raise issues of concern (see attached Information Sheet) and this may not be the case in other Trusts. There may also be differential interpretations between FTSUGs as to how to count cases [e.g. when a whole Team is involved in raising a case]. Nevertheless, for the purpose of this report we have analysed Q1 2018/19 data published by the NGO to show SLaM and other NHS Trusts that report themselves as small pure mental health NHS Trusts in London and across the country (small is defined as those that have less than 5,000 staff). For interest, the table does highlight in green our neighbouring Trusts because we three comprise the South London Mental Health and Community Partnership. Q1 2018/19 FTSU data published by the NGO – ‘small’ mental health Trusts, national and London

Trust name Region Total number

of cases Anonymous

cases

Element of patient safety/ quality

Element of bullying or harassment

Suffering detriment

as result of speaking up

South London and Maudsley NHS FT

London 8 3 4 8 6

**Oxleas NHS FT London 3 3 2 0 0

South West London and St George's MH NHS Trust

London 32 1 5 6 4

Barnet, Enfield and Haringey MH NHS

Trust London 7 0 3 3 0

Tavistock and Portman NHS FT

London 11 0 10 2 2

Hertfordshire Partnership

University NHS FT

East of England

4 1 3 0 0

Greater Manchester MH

NHS FT

North West

3 1 2 2 0

Avon and Wiltshire MH Partnership

NHS Trust

South West

12 2 6 5 1

Birmingham and Solihull MH NHS

FT

West Midlands

5 1 1 4 0

Dudley and Walsall MH Partnership

NHS Trust

West Midlands

4 1 1 3 1

N.B.

Shaded in green are member Trusts in the ‘South London Partnership’ which includes ** Oxleas NHS FT – this is not directly comparable as it is a combined mental health / learning disability / community NHS FT, small in size

All other Trusts identified themselves as pure mental health trusts with up to 5,000 staff (small)

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This data set has excluded mental health Trusts that are combined with other functions and acute Trusts

Camden and Islington NHS Foundation Trust did not submit any data to the NGO in Q1 2018/19 and are therefore not displayed in this table

Barnet, Enfield and Haringey mental health NHS Trust has been included in this table - please note that they have changed their categorisation from combined to pure mental health on a number of occasions over the last year

Total number of cases received and published by NGO in Q2, Q3, Q4 2017/18 and Q1 2018/19 from ‘small’ mental health Trusts in London:

Trust name

Q2 July-Sept 2017/18

Q3 Jul-Sept 2017/18

Q4 Jan-Mar 2017/18

Q1 Apr-Jun 2018/19

Q2 Jul-Sept 2018/19

South London & Maudsley NHS FT

4

7

5

8

9

**Oxleas NHS FT

1

0

No data received

3

Not yet published

South West London & St George’s MH NHS Trust

14

19

30

32

Not yet published

Barnet, Enfield and Haringey MH NHS Trust

12

9

8

7

Not yet published

Camden & Islington NHS Foundation Trust

2

2

1

No data received

Not yet published

Tavistock & Portman NHS Foundation Trust

9

10

9

11

Not yet published

N.B.

Shaded in green are member Trusts in the ‘South London Partnership’ which includes **Oxleas NHS FT which is a combined mental health / learning disability / community NHS FT, small in size

All other Trusts identified themselves as small with up to 5,000 staff

This data set has excluded combined mental health Trusts and acute Trusts

Barnet, Enfield and Haringey mental health NHS Trust has been included in this table, please note that they have changed their categorisation from combined to mental health on a number of occasions over the last year

Q2 2018/19 data from other Trusts are not included in this table as this report was written before that data was published by the NGO.

It is worth reiterating that the role of the FTSU service is to:

Be supportive; offering a listening ear that enables the person to order their thoughts

Recognise that sometimes just offering a confidential, impartial, non-judgmental space for someone to reflect on what has been going on and how they are feeling, is highly valued by the individual

Keep the focus on “Speaking Up and Being Heard” [i.e. to believe the person and be supportive in their distress; not to get involved in judging the rights and wrongs but to keep exploring ways that the person might be able to speak up and be heard]

Help the person develop options for next steps

Ensure they are aware of the formal routes they can take if they wish to

If necessary and wanted, to offer to support the person in implementing the next steps.

The themes emerging from the 17 Q1 + Q2 cases are set out below. It is important to note that while the numbers may seem low, the cases are often complex and require on-going support from FTSU Advocates/Guardian over several months.

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The Themes of course could be just pertaining to the few staff that we have dealt with through the FTSU service, or they could be symptomatic of wider cultural issues affecting more staff. We have tried to offer some suggestions as to causes of these themes and possible solutions. The dynamics being revealed in these themes could be seem as common place in teams and organisations. However, that does not mean that they are acceptable and thought needs to be given as to what steps could be taken to make what could be considered as normal no longer normal here at our Trust. All themes have occurred in more than one case:-

Staff were Speaking Up but were felt they were not Being Heard; managers need to ensure they feed back to staff the actions they take following staff raising issues with them

Bullying and Harassment from management, in the form of micromanagement, not understanding and mismanagement. Can also be the culture in team. Lack of staff support. Poor union response, no mediation, no investigation. Managers need to continue to develop their Inclusive Leadership skills, fully engaging with all staff in the team; trade union capacity needs enhancing

Voicing opinions is seen as challenging with an in-crowd and out-crowd existing within the staff group; managers need to continue to develop their Inclusive Leadership skills – everyone in the Team needs to feel they can speak their opinion and not be treated as challenging; it is the purpose of Multi-Disciplinary Teams to gather a variety of different perspectives.

As relationships become strained, the regularity of supervision sessions drops; managers need to be supported to see the need to particularly maintain regular contact when things are getting difficult

People in more senior positions but outside line management, assume the worst of an individual’s actions as relationships deteriorate; again points to need to maintain and increase contact when relationships become strained to understand the actions and motivations of the individual and not jump to conclusions; there maybe a training need for managers to become skilled in this

Sense that staff are not treated even-handedly within disciplinary processes usually linked to where trade union support poor/not evident; need to develop capacity of trade unions to work effectively with all staff and in all circumstances

Fear that following formal routes could result in retribution and also that they ‘take on a life of their own’ which is in-humane for the individual being investigated; need to develop a stronger trade union identity in the Trust so that staff know they will be protected through formal processes

Staff feeling disempowered, devalued and bullied – often through the way they are treated in meetings including the dismissive treatment they receive; need to promote the Board’s Statement on Abuse of Power as this sense could just be the unintended consequences of manager’s/leader’s behaviour

Reflect and Review Checklist still not being properly implemented – individuals subject to informal investigation not clear about what they are being accused of and told that they are to be the subject of informal investigation by a senior manager, not their line manager [who has gone direct to the senior manager asking them to notify the person]; need to spread the understanding of how to implement the new Checklist and managers may need training and support to enable them to have the ‘difficult conversations’ rather than refer the staff member to someone else for action.

Statements intended to be humorous are experienced as racist; continue Inclusive Leadership training programme and also promote FTSU so that people Speak Up immediately if they experience remarks as racist [note that the statements were probably not intended to be racist but power differentials make them perceived as such and hard to challenge]

A site which was the subject of a FTSU case last year is still experiencing communication difficulties; need to emphasise the importance of keeping staff informed of progress on works

Recent reconfiguration and restructuring has not been carried out in a way which respects the contribution which staff have given to the Trust nor was it mindful of their wellbeing. The speed and timing has given staff the feeling that the exercise was a foregone conclusion; Particular concerns have been raised about the At Risk Process, which felt uncaring, lacking in empathy and was not conducted by Trust senior staff as if to distance themselves from the process and outcomes; need to review process and take on board lessons learnt from the good examples in the Trust as well as those negatively affected [a positive experience was described as where senior managers were actively involved throughout the process; provided spaces for staff to air their views and listened empathetically and responded to the points raised; kept staff informed at all times about what was happening; full HR, psychological and counselling support available]

It was suggested at the EWC that the possibility of testing these Themes more widely might be explored. For example, they could be circulated as a survey via eNews and staff invited to indicate whether they have resonance with them or not. This would help with the assessment as to whether they are a systemic problem

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or the unfortunate experience of a few members of staff. It could also be used as an opportunity to promote FTSU and to identify areas where further promotional work is required.

2. Potential patient safety or workers experience issues The need for systematic triangulation of data from other relevant systems across the Trust is something recommended in the new National Guidance and has been agreed as part of the development plan. This is described in the ‘Freedom to Speak Up Guidance for Boards – Development of Improvement Action Plan’ paper presented by the Chief Executive as a separate Agenda item at this meeting. The purpose of the triangulation would be to identify areas where patient safety and quality issues or worker experience issues are showing up across several systems. The aim would be to see if it is possible to ascertain a broader picture of FTSU culture, identify barriers to speaking up as well as potential patient safety/quality risks, damaging staff experience and opportunities to learn and improve. The results of this triangulation exercise could then be built upon to improve the overall cultural environment of the Trust.

3. Action taken to improve FTSU culture

The FTSU Steering Committee and Network have taken steps to improve the FTSU culture in the Trust through a multi-pronged approach to increase communication flow to improve awareness. Over the last 6 months we have increased the visibility of FTSU through:

- 7 presentations to staff teams booked in (3 presentations delivered in Southwark, 2 in Lewisham and 2 were cancelled at short notice between April – August 2018) with a combined attendance of 71 members of staff

- 6 stalls held at Trust Values day event where on average around 50 new members of staff attend - FTSU Posters sent to all staff teams in an internal communications mail out reaching around 230

teams - 4 Steering Committee and FTSU Network meetings where promotion is a standing item of discussion - 2 e-news items sent out through internal communications, 1) launching the ‘valuing and empowering

staff – tacking abuse of power and discrimination’ statement (read the article here) and 2) celebrating a FTSU presentation to Southwark IAPT service and encouraging other team leaders to book a presentation for their team (read the article here)

- 2 Tweets with the FTSU network learning about Teams and a FTSU presentation to Southwark IAPT - 1 Screensaver on Trust computers.

We have acted to identify and support any workers who are unaware of the speaking up process or who find it difficult to speak up by:

- Continuing to visit staff teams and talk with colleagues directly about the service - Developing an accessible ‘Information Sheet’ about the FTSU services to ensure that all roles and

levels across the Trust will understand the information, please see Appendix 2 - Setting up a generic freedomtospeakup@ email account for colleagues to email the FTSU

Coordinator for contact details of Advocates and Trust Guardian - Encouraging Advocates who have used the FTSU service to talk from their own experiences of

engaging with the service to encourage others to utilise the service and promote applications to become a FTSU Advocate

- Continue to recruit new Advocates from a variety of roles and levels across the Trust to enable colleagues from a variety of backgrounds to utilise the service.

We are assessing the effectiveness of the speaking up process and the handling of individual cases by:

- Creating a confidential space on Microsoft Teams for Advocates to talk with the Trust Guardian about cases to gain support on how to best advise colleagues

- Discussing the effectiveness of the service regularly at Steering Committee and FTSU Network meetings

- Developing a ‘Advocate Pack’ which will support new Advocates to learn from case studies that have been developed with the help of NGO information and examples

- Developing a training programme for new and existing Advocates so that they can continue to develop their skills, knowledge and understanding

- Creating and disseminating a feedback survey for colleagues that have gone through the process of FTSU anonymously

- Requesting the Advocates and the Trust Guardian to share learning about their experience of supporting colleagues on a quarterly basis which is in line with the NGO’s request of all Trusts.

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http://slam.newsweaver.com/InternalWeekly/ai6ika3l3zis1k75vyylub?email=true&a=2&p=53262206&t=23544355

http://slam.newsweaver.com/InternalWeekly/1xuedd74itw1jyjogybakn?email=true&a=2&p=53738337&t=23544355

We have acted to improve the skills, knowledge and capability of workers to speak up and to support others to speak up and respond to the issues they raise effectively by:

- Developing a Trust wide ‘Valuing and empowering staff – tackling abuse of power and discrimination’ statement

- Promoting FTSU through various means - Promoting other support services available to staff which are described on the ‘Who can I talk to?’

poster. The NGO has launched its campaign resources for October to be National Freedom to Speak Up month. They urge close working with Trusts communication teams and to prepare plans that include active use of social media including the hashtag SpeakUptoMe. To sit alongside this, we have also launched a new poster, banner, table cloth and pens. The FTSU page on Maud has also gone live. We have worked with the FTSU Network to identify promotional opportunities locally. Many activities are underway during this FTSU month and will be reported to the October Board as part of this report. As part of this campaign we have invited members of the FTSU Network to attend the Board on 30th October to see this Report being presented. 4. Learning and improvement We have gathered feedback from colleagues that have used the FTSU service, staff that are involved in a FTSU role and staff that have attended a FTSU presentation in their team meeting / handover. Below is some of the feedback we have been given:

Comments colleagues have given after they have used the FTSU services have been gathered through an anonymous online survey and from Advocates and Trust Guardian receiving verbal and written feedback from colleagues they have supported:

10 people gave positive feedback, comments include - ‘I found it very helpful to have the opportunity to discuss issues… I felt less isolated and more

empowered’ - ‘Very pleased at speed of response to email’ - ‘very helpful to be listened to by experienced colleague’ - ‘It was great just to be able to talk to someone in complete confidence so you are doing a great

job’ - ‘felt let down by the Trust and found FTSU helpful in addressing this’ - ‘the [FTSU] service is more organised now’ - ‘it’s important that people are more aware of it’ - FTSU made ‘lots of enquiries’ to support them with their concern - FTSU is more recognised in the Trust

1 person gave neutral feedback, comments include - ‘my issue came up as the FTSU service was just forming… the introduction of timelines would

have improved my experience’

1 person gave a negative comment - ‘How does this service help staff?’

1 person added that more guidance was needed on how quickly an issue could be resolved

1 person was leaving the Trust and was pleased to have spoken to an Advocate within a week of contacting the service via email.

Comments from staff teams that have attended FTSU presentations which give an opportunity for colleagues to ask questions directly with their respective borough Ambassador and Advocates. Some of the queries that have been asked include:

1 staff member commented that safety on wards was an issue in terms of Promoting Safe and Therapeutic Services (PSTS) – challenging work environments that are not well supported mean that staff move on to other roles, it was discussed that FTSU could be a space to discuss these concerns among other routes

1 staff member wanted to get more of an idea of the kind of issues they can talk to an Advocate about (without us disclosing previous case issues) – we are developing case studies to help describe the kind of issues that can be brought to FTSU

1 staff member wanted clarity around understanding how FTSU differs from other Trust policies such as whistleblowing, mediation and making a complaint – this was discussed and is now helped through the new Trust wide ‘Who can I talk to?’ poster for staff

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Some staff members are still sceptical about how confidential the service is – it was explained how FTSU information case information is kept confidential to the Advocate with general, summarised data within Microsoft Teams and any sharing of information for learning purposes are discussed and authorised with the person raising the issue

Some staff members wanted clarity on what information is shared with the NGO as there is a concern that case information is shared – the staff presentation now includes information that clarifies what the NGO asks from each Trust to reassure people that no identifiable case details are shared

1 staff member raised an issue around SLaM offering opportunities and resources for teams to address ‘dysfunctional’ work cultures without it impacting on their team budget – it was discussed that this would be shared with the Trust Board in this report

1 staff member wanted clarity about raising concerns to the Trust about issues with their physical work environment – it was discussed and they thought they could log the concerns over a period of time to build a case for a change in their physical work environment.

Broader developments in FTSU, learning from case reviews and guidance and best practice includes:

- Sharing learning at FTSU conferences which the FTSUG and at times Advocates attend – this was explained in more detail in the 20th March 2018 Trust Board report where there was a national presence, a regional network and connection to Kings Health Partners

- Communication from the NGO about national FTSU data and learning which could be adopted by SLaM

- Connecting with other Trusts and learning from the way they have organised their FTSU service, communications and approaches to embedding a culture change in their organisation

Learning from the National Case Reviews is strongly recommended by the NGO and it is intended to ask the relevant service leads on the Steering Group to analyse them and advise how we might incorporate the recommendations and learning from them into our organisation.

5. Recommendations

In our 20th March 2018 Board report some recommendations for action were outlined, some of which are underway and some of which need further development:

Ongoing communication and awareness raising – we have done this more over the last 6 months and plan to consistently deliver on regular communication with SLaM staff

Focus on ‘Being Heard’ as much as ‘Speaking Up’, supporting managers to react positively and proactively to staff speaking up – discussion to take place with the Training and Development Department and the commissioning of a skills package for use might be required. The Inclusive Leadership Programme will also be supporting the development of necessary awareness

Case studies and sharing positive experiences – during staff presentations about FTSU, Advocates talk openly about their personal experience of using the service themselves and taking on an Advocate role to support others; we will capture some of these stories for wider promotion of the positive benefit of using the FTSU service.

Data triangulation: noted there is speaking up in many other places and processes – as listed in the ‘Who can I talk to?’ poster. The specific issue of triangulation and our approach to its development is included as part of the FTSU Improvement Action Plan [see separate Review report].

Following an analysis of the last nine months of activity (in Q4 2017/18, Q1 2018/19 and Q2 2018/19), we have identified further recommendations including:

- Raising the profile of the FTSU Advocate role and recruit more colleagues to join the FTSU network - Continue to hold regular Steering Committee and FTSU Network meetings - Develop an Advocate Information Pack and associated Training Programme - Deliver more FTSU presentations to staff teams - Develop communications, including a new poster to sit alongside existing FTSU material - Gain the support of Operational Directorates to promote FTSU amongst their staff - Increase the profile of the FTSU communication campaign so that all staff know they are welcome to

apply to be Advocates AND to reassure all staff that the FTSU service is completely confidential focused on helping them to Speak Up and Be Heard and the Trust to learn and improve.

- Steering Group relevant leads to analyse the 3 National Case Reviews to identify the learning points relevant to the Trust

- The Themes analysis section points to the need to o continue the Trust’s focus on Inclusive Leadership training and development

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o Offer support and coaching to managers so that they remain connected and engaged with staff particularly when things are becoming difficult

o To have a particular focus on managers staying connected and engaged during times of reconfiguration and restructuring

o Develop the capacity of the trade unions to fully support staff even in the most complex cases so that the Trust’s formal processes are trusted to be used in all circumstances

- Devise a survey to test the Themes with staff more broadly to get an assessment of how widely they are experienced across the Trust. This could also be used as a way of promoting FTSU widely amongst staff and identify areas where further promotional work is required.

In addition, there are recommendations for significant work arising from the review carried out by the Chair

and Chief Executive because of the new ‘FTSU Self Review Tool’ published in May 2018. Appendix 1 - Freedom to Speak Up data submitted for Q4 17/18, Q1 18/19 and Q2 18/19

Freedom to Speak up data Q4

1Jan-31Mar 2017/18

Q1 1Apr-30Jun

2018/19

Q2 1Jul-30Sept

2018/19

Total number of cases brought to Freedom to Speak Up Guardian and Advocates in our Trust

5 8 9

Number of cases raised anonymously 0 3 0

Number of cases with an element of patient safety/quality 3 4 2

Number of cases related to behaviours, including bullying/harassment 5 8 5

Number of cases where people indicate that they are suffering detriment as a result of speaking up 2 6 2

Please give details of the number of cases raised to you by particular professional groups. Your return for this section should equal the total number of cases raised.

Doctors 1 0 1

Nurses 2 4 3

Healthcare Assistants 0 1 0

Allied Healthcare Professionals 1 0 0

Administrative/Clerical staff 0 1 2

Corporate service staff 1 2 2

Other 0 0 1

Feedback* Q4

1Jan-31Mar 2017/18

Q1 1Apr-30Jun

2018/19

Q2 1Jul-30Sept

2018/19

Number of responses reported to NGO this quarter 3 1 3

Given your experience, would you speak up again?

The number of these that responded 'Yes' 2 1 3

The number of these that responded 'No' 1 0 0

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The number of these that responded 'Maybe' 0 0 0

The number of these that responded, 'I don't know' 0 0 0

*N.B.

The ‘Feedback’ data does not necessarily relate to the cases initiated in the period outlined. Responses could have referred to feedback on cases reported in previous quarters

A fuller description of feedback received can be seen in section 4. Learning and Improvement.

Appendix 2 – FTSU at SLaM Information Sheet, Aug 18

Freedom To Speak Up (FTSU) at SLaM for staff

The FTSU story

The Francis report found that patients could be at risk from harm because NHS staff were not speaking up or raising concerns if they saw or felt something was wrong in their work environment. A recommendation of the report was to create ‘Freedom to Speak Up’ Guardians in the NHS to encourage the adoption of a more open and transparent culture. Its aim is to:

- Protect patient safety and the quality of care - Improve the experience of staff - Promote learning and improvement

Nationally: There is the ‘National Guardian’s Office’, they are independent, non- statutory and exist to lead this culture change in the NHS.

Locally: At SLaM we have a team of staff from a variety of roles and levels based across the Trust that have taken on a FTSU role. We help staff speak up and raise concerns, especially if they feel unable to with their line manager. Expect a friendly listening ear, ideas to help enable you to Speak Up and Be Heard, a source of information and help to escalate issues if you want us to – this is always with your agreement.

Be aware of

The Trust has an ‘Abuse of Power Statement’ which sets out the expectations the Trust has on its staff to tackle abuse and discrimination. Do familiarise yourself with this statement which is reproduced at the end of this note, it also relates to our FTSU role and was developed as a result of someone raising an issue with the FTSU Guardian. SLaM has many policies and services that support staff listed in the attached poster – for more information you can ask your line manager or look on the intranet.

How it works

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1) Speak to your line manager or senior manager first 2) If you can’t, consider FTSU 3) Email / phone to arrange to meet a FTSU Advocate or the Trust Guardian 4) Meet to talk about your concern, explore options for speaking up and next steps 5) If the concern is not resolved and you are not being heard, an investigation maybe appropriate 6) If still not resolved, concern can be escalated to the Chief Executive via the Trust Guardian – Zoë Reed 7) Time will be given to review the investigation 8) If the concern is still not resolved and the concern is of public interest around wrongdoing – Whistleblowing is an option.

FTSU roles and responsibilities

Role What they do

Advocates

Advocates are colleagues you can raise a concern with. They are members of staff from a variety of roles and levels located across all parts of the Trust.

Our Advocates are allocated to boroughs and are often nominated by senior staff because they are approachable, a good listener and are committed to helping others.

Advocates meet colleagues with a concern, explore informal ways to deal with this, take notes on the conversations, provide information and guidance to help resolve the situation so that you can Speak Up and Be Heard. This includes signposting to other Trust resources and policies if that is more appropriate. If necessary they can take advice from the Trust Guardian. In turn, the Trust Guardian can take advice from the National Guardian if necessary.

Trust Guardian

Zoë Reed is SLaM’s Freedom to Speak Up Guardian.

Her role is to support staff to speak up, address barriers that stop staff from being able to do this, oversee the delivery of FTSU and feed up concerns and learning at a strategic level. She also provides independent and impartial advice for Advocates and acts as a link to the Chief Executive and the Board.

Zoë can initiate independent investigations into concerns where appropriate and can be contacted, just as you would an Advocate.

Coordinator

Chip De Silva coordinates the FTSU Network of Advocates and the Steering Committee part time. She reports FTSU data (not cases) to the National Guardian’s Office and works closely with the Advocates and the Trust Guardian. She is a helpful resource who can provide you with information and materials and manages the

[email protected] email address.

Staff can contact her to get the most current list of Advocates. You are free to approach anyone on the list

Borough Ambassadors

We have Borough Ambassadors Lambeth: Dennis Dobbin Southwark: Christy Wellings Lewisham: Hilary Williams Croydon: Beatrice Komieter and Sabrina Phillips

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mailto:[email protected]

Ambassadors ensure that their allocated Borough is well covered by Advocates, work to raise the profile of FTSU and are a part of the Steering Committee. Theirs is a supportive and enabling role for Advocates and they do not get involved in casework.

Steering Committee

The Steering Committee is made up the Trust Guardian, Borough Ambassadors, FTSU Coordinator and of representatives from relevant functions in the Trust e.g. Chaplaincy, Human Resources, Complaints and Serious Incidents, Communications, Joint Staff Committee Trade Union Rep.

The Steering Committee make decisions about how best to deliver FTSU within SLaM, promote its service and ensure it is embedded in all Trust policies and procedures.

For more information contact FTSU: [email protected]

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SLaM Changing Lives

Valuing and empowering staff - tackling abuse of power and discrimination

South London and Maudsley NHS FT is clear that it rejects any form of abuse of power or discrimination.

Any abuse of power is a wrong to the individual and a challenge to our shared purpose. The skills, dedication and

teamwork displayed by our staff are at the heart of our ability to provide compassionate care. We want to show

leadership in our NHS environment by both raising our shared awareness of the risk and impact of abuse within

SLaM and improving our systems to address it, including how we talk about it e.g. more open sharing on reported

numbers of incidents. This is a key part of our Changing Lives strategy.

Abuse can take different forms e.g. discrimination, bullying, harassment, humiliation, intimidation or

inappropriate sexual attitudes and behaviour. Unhealthy staff dynamics are then potentially mirrored, even

amplified, in our relationships with patients and carers.

Any relationship with a power imbalance contains a risk of abuse. Within SLaM this applies where anyone has any

control over the job security or advancement of others, and / or the dignity and experience of patients. Vulnerability

to abuse increases wherever there is a bias against certain groups. That said, abusive situations can be complex,

carried out by any one of us, or affect any one of us. None of us are immune.

Starting with ourselves

Very few of us set out to be abusive or discriminatory. Such behaviour varies by degree, may be subtle, unconscious

and more likely when we’re under stress. It’s essential then we all consider how we work in and across our teams:

1. Do we treat others in a way we would want to be treated? Is our behaviour towards others open, respectful

and fair, regardless of our power in a situation? When we’re under stress do we still meet these standards, or

might others be experiencing us as bullying for example, even if that’s never our intention?

2. Is there any discrimination, bullying or abuse happening in the teams we work in, and if so, what will we do

about it? It’s not up to the victim. If we stand by and do nothing we’re part of the problem.

3. If we have leadership responsibility, have we established a team culture that encourages people to ‘speak

truth to power’? When we’re the most senior person in a room, what tone do we set, how do we exercise our

power, and how might others experience it? Can everyone in the team, regardless of status, raise questions or

say when someone’s behaviour makes them feel uncomfortable? Can our patients and carers say the same?

Taking action

We recognise raising concerns can be difficult. If we’ve experienced abuse or discrimination we may struggle to

address it, especially if we have felt silenced or have good reason to fear the consequences. If we want to support a

colleague we may feel helpless if they’ve told us to do nothing, but we remain concerned an injustice may have

occurred and others may be at similar risk from the same person in future. Whilst speaking up takes courage you

need not be alone, and we will listen. Guidance is available in the Harassment and Bullying, Whistleblowing and

Grievance policies and information about available support can be found on the Staff Support intranet pages.

If following Trust policies seems impossible in a situation, or you lack trust or confidence in our systems to address

these problems for any reason, you can access the confidential advice of our Trust Freedom to Speak Up service,

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which includes local Advocates and the Trust’s Freedom to Speak Up Guardian, Zoe Reed. There is a notice about

the service in each Team or you can email [email protected] for more details. Alternatively, the

independent advice of professional bodies or Trade union representatives can be sought.

SLaM is determined to address abuse and discrimination in our organisation. We’re committed to changing lives,

including by valuing and empowering each other as colleagues. Together we can establish a more mentally

healthy work environment for the benefit of everyone, including ultimately the patients and carers we serve.

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Who_Can_I_Talk_To.indd 1 08/06/2018 11:58Page 141 of 224


30 OCTOBER 2018

Title

Freedom to Speak Up (FTSU) Guidance for Boards – Development of

Improvement Action Plan

Authors

Matthew Patrick, Chief Executive

Roger Paffard, Chair

Zoë Reed, Freedom to Speak Up Guardian (FTSUG)


To enable the Board to consider the review carried out by the Chair and Chief Executive against two documents published by the National Guardian’s Office (NGO) and NHS Improvement (NHSI):

1) Guidance for Boards on Freedom to Speak Up ( 2) Freedom to Speak Up self-review tool for NHS Trusts and Foundation Trusts (Appendix 2)

Both documents can be found here: https://improvement.nhs.uk/resources/freedom-speak-guidance-nhs-trust-and-nhs-foundation-trust-boards/ The guidance recommends a way forward to enable all members of the Board to fulfil the expectations of them set out in the Guidance through undertaking the self-review and developing the Improvement Action Plan group during a ‘Board Deep Dive’ session. The paper was considered by the Equalities and Workforce Committee in September.

Executive summary

NHSI and the NGO have issued Guidance for Boards on FTSU in NHS Trusts and Foundation Trusts, which can be found here: https://improvement.nhs.uk/resources/freedom-speak-guidance-nhs-trust-and-nhs-foundation-trust-boards/. The guidance document sets out their expectations of Boards in relation to FTSU and asserts that meeting the expectations set out in the guide will help a Board to create a culture responsive to feedback and focused on learning and continual improvement. Having a healthy speaking up culture, it says, is an indicator of a well-led Trust and the Care Quality Commission (CQC) assesses a Trust’s speaking up culture during inspections. The intention is that Boards treat the guide as a benchmark of good practice. That they review where they are against it and reflect what they need to do to improve. The expectation is that the Board, and the executive and non-executive leads for FTSU, will complete the review with proportionate support from the Trust’s FTSU Guardian (FTSUG). In this Trust the Chair and the Chief Executive, as the non-executive and executive leads for FTSU, have undertaken an initial review against the guidance with support from the FTSUG, Zoë Reed. The review, including recommended areas for improvement, is presented here for consideration together with a proposed way forward that will enable all members of the Board to fulfil the expectations of them set out in the Guidance. The proposal is that the self-review and development of the Improvement Action Plan takes place as part of a Board Deep Dive session.

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https://improvement.nhs.uk/resources/freedom-speak-guidance-nhs-trust-and-nhs-foundation-trust-boards/




http://sites.intranet.slam.nhs.uk/commteam/Picture Library2/1/SouthLond Maudsley FT Col A.jpg


BAF Risk 1 - Workforce BAF Risk 7 – Quality & statutory compliance

1. Context

In line with best practice, the Chair and the Chief Executive have carried out an initial review of

Freedom to Speak Up (FTSU) arrangements within the Trust against the ‘Guidance for Boards on

Freedom to Speak Up in NHS Trusts and foundation Trusts’ and their findings are set out later in this

report. The purpose of this section is to set the context for the Chair and Chief Executive’s Review.

Following the publication of the Francis Report in 2015 the Trust, at its January 2016 Board meeting,

decided to establish a pilot FTSU project to run for one year starting from April 2016. Zoë Reed was

appointed as the Trust’s Freedom to Speak Up Guardian (FTSUG). A Steering Group of senior

representatives from Clinical Academic Groups (CAGs) and corporate services was established

together with a small amount of support running the FTSU Network. Great effort was made by the CAG

Ambassadors to identify staff from the full diversity of the Trust, in terms of gender, ethnicity, grade and

profession, to join the network and support the development and spread of the FTSU word.

In October 2016, the National Guardian Dr Henrietta Hughes was appointed, together with her Office

(the NGO) and the developments within the Trust were then shaped by national guidelines and

approaches. The Trust’s FTSU Guardian became part of the national and London regional networks as

well as the mental health and community services one. These are used by the NGO to promote the way

they wish to see FTSU developing and for FTSUGs to network and clarify points of concern as well as

learn from one another. A FTSUG model job description was issued in October 2016 and helped clarify

the role. Reporting requirements were also established so that the NGO could collate the picture of

FTSU activity across the NHS. From the pattern of reporting it became clear that most cases being

raised were about staff experience with only about a quarter of issues being about patient safety (which

has been the focus of the Francis Report). The NGO aligned itself with NHS Improvement (NHSI) and

the CQC and FTSU became part of the Well-Led CQC Inspection framework. A new job description

was issued for FTSU Guardians in May 2018 which made explicit that the role encompasses both

patient safety and quality of care AND staff experience.

FTSUG reports were made regularly to the Board – in November 2016, July 2017 and November 2017

with the first Annual Report in March 2018. This documented progress in establishing the FTSU

network and promoting Speaking Up and Being Heard across the Trust. The Trust’s approach was to

see FTSU as just one of many mechanisms and ways that staff can speak to someone outside their line

management if they have concerns at work. The national guidance was that all approaches from staff to

the FTSUG were to be welcomed and nothing was to be considered inappropriate – i.e. a widening from

the focus on patient safety to encompassing all issues of staff concern. The approach taken is to listen

empathetically and without judgement; to help the person order their thoughts so that they can decide

what steps they want to take next. The focus is to address what is stopping them Speaking Up and

Being Heard.

In April 2018, the first FTSU Coordinator (1 day per week) came into post (the other 4 days are working

on external engagement and stakeholder management) and this had greatly enhanced the capacity to

drive forward this work. Advocates now have a cental point to obtain resources and both the Steering

Committee and the FTSU Network are coordinated well. The Internal Communications Manager joined

the Steering Committee and produced a Communication Plan. As part of this, the FTSU Coordinator

has established a FTSU Microsoft TEAMS infrastructure to encourage collaboration within each of the

Borough-based groups of Advocates (each supported by one or more Ambassadors from the clinical

services); within the Steering Committee and across the FTSU Network.

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The FTSU Coordinator has developed a pack of materials including a slide set which can be used by

Advocates and Ambassadors with local staff teams to spread the word about FTSU and to make clear

to all staff that the Trust encourages Speaking Up - if it is not possible to with their line manager, then

they are encouraged to consider using the FTSU route. The [email protected] email is

maintained by the FTSU Coordinator and all enquiries are then correctly routed for handling.

A priority task now is to increase the number of Advocates. The Trust approach is that Advocates need

to be in roles where it is possible for them to make themselves visible within their allocated geographic

area and can undertaken FTSU duties along side their normal role. Specific protected time is not

provided and all Advocates get the approval of their line manager to undertake their FTSU duties. This

means that the Trust needs a large number of Advocates all with a small patch to work in to make the

model work. Various methods have been used to recruit Advocates including presentations to

Directorate Management Teams and identification by senior managers; open advertisement via eNews;

presentations at a range of forums including the BME Forum, Junior Doctors Committee and the JCC;

invitation to consider becoming an Advocate at the end of each Team presentation and events;

invitation to people who have used the FTSU service to become Advocates as they are probably best

placed to empathise with staff who are having difficulty Speaking Up and how best to support them. It is

intended to continue with all these approaches in the next phase of recruitment.

The full context for this report is contained in the FTSUG’s October 2018 Board Report as a separate

item on this agenda. it sets out the progress that is being made in implementing the Communication

Plan and is formatted under the headings contained in the latest NGO Guidance for Boards – the

subject of this Chair and Chief Executive Report. In summary, some key metrics are:

o All staff are covered by Advocates based on geographic Boroughs regardless of directorate

o Advocates are supported by 5 Ambassadors who help to create the context for FTSU to be

known and welcomed by all staff

o We currently have 11 Advocates allocated across the geography from different roles,

professions and grades, and Ambassadors are actively working to increase that number

o Over Q1 2018/19** there have been a number of staff contacts with the FTSU Network including those present at the Trust Values Day where FTSU has a stall (142 staff members attended over 3 events in Q1); during team presentations (71); and a programme is being developed to ensure a FTSU presence at all future major staff conferences and events as well as attendance at more local team meetings.

o In Q1 2018/19**, 5 cases were handled by Advocates and 3 by the Guardian – this demonstrates a growing confidence in FTSU and increasing skills amongst the Advocates

o The Communication Plan is starting to ramp up with 7 presentations to staff teams, a screen saver has been developed and a short film covering case studies is in production.

** nb For the October Board Report the Q2 2018/19 figures will be added This summary above provides the context for the review carried out by the Chair and Chief Executive of FTSU arrangements within the Trust against the ‘Guidance for Boards on Freedom to Speak Up in NHS Trusts and foundation Trusts’ and their findings and recommendations follow. 2. Background

The NHSI and NGO issued, together with the guidance document, a self-review tool and recommend completion of the self-review tool and developing an improvement action plan as helping Trusts to evidence their commitment to embedding speaking up, and oversight bodies to evaluate how healthy the Trust’s speaking up culture is. They make clear, however, that a mechanical ‘tick box’ approach to the items in the self-review is not likely to lead to better performance. The guidance asserts that the attitude of senior leaders to the review process, the connections they make between speaking up and improved patient safety and staff experience, and their judgements about what needs to be done to continually improve, are much more important. Both the documents can be found here: https://improvement.nhs.uk/resources/freedom-speak-guidance-nhs-trust-and-nhs-foundation-trust-boards/.

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This initial review has highlighted the key areas within the guidance where we need to make improvements and recommends a way forward that involves all members of the Board. 3. FTSU Vision and Strategy, Policies and Procedures

The guidance is based on the assumption that each Trust will have a clear FTSU vision, translated into a robust and realistic strategy that links speaking up with patient safety, staff experience and continuous improvement. It puts great expectations on executive and non-executive directors (referred to in the Guidance as senior leaders) taking an interest in the Trust’s speaking up culture and being proactive in developing ideas and initiatives to support speaking up. Currently the approach is that FTSU is one channel amongst many that staff can use to raise concerns

and issues to do with work. There is a ‘Communication Plan’ underway to promote FTSU amongst all

staff and to increase the number and visibility of Advocates with the ambition that FTSU will play its part

in the Trust’s plans to have an open, honest and inclusive culture. The FTSU approach, structure and

reporting mechanisms are clearly developed and communicated however they are not formalised in a

policy and procedure document.

Considering the new FTSU guidance there does seem merit in checking the current ‘Changing Lives

Strategy’ to see if the Speaking Up and Being Heard elements are sufficiently highlighted as well as

reviewing Leadership and Culture aspects. Building on this a FTSU strategy could be developed, for

inclusion within the overall ‘Changing Lives Strategy’, that specifically links speaking up with patient

safety, staff experience and continuous improvement.

Alongside the FTSU strategy development process the necessary work to develop a FTSU policy and

procedures could be undertaken. This would need to ensure that the Board is provided with a variety of

reliable, independent and integrated information that gives assurance on the range of factors contained

in the Guidance viz:

Workers in all areas know, understand and support the FTSU vision, are aware of the policy and

have confidence in the speaking up process

Steps are taken to identify and remove barriers to speaking up for those more vulnerable groups

such as BAME workers and agency workers

Speak Up issues that raise immediate patient safety concerns are quickly escalated

Action is taken to address evidence that workers have been victimised because of Speaking Up,

regardless of seniority

Lessons learnt are shared widely both within relevant service areas and across the Trust

The handling of Speaking Up issues is routinely audited to ensure that the FTSU Policy is being

implemented

FTSU policies and procedures are reviewed and improved using feedback from workers.

Action:

CE to oversee the development of the FTSU vision and strategy together with associated policies,

procedures and assurance indicators. FTSUG and Director of Strategy and Commercial to review the

Changing Lives Strategy with a view to checking alignment possibilities in the development of the FTSU

Strategy.

4. Data triangulation

As the FTSUG has reported to us in earlier Board reports, some attempt was made to consider how

data held in other Trust systems – for example Complaints and SIs; Employee disciplinaries and

grievances; Datix reports on safety matters – might be triangulated with a view to proactively spotting

potential areas of concern. In light of the guidance, these initial thoughts need to be formalised and a

report brought forward on the feasibility and resource requirements of systematically carrying out this

triangulation.

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Action:

FTSUG and Head of Employee Relations, Head of PMO and Head of Complaints/SIs consider

possibilities and benefits of triangulation to proactively identify potential areas of concern.

5. FTSUG Reports to the Board

The guidance recommends that reports are submitted to the Board frequently enough to enable the

Board to maintain a good oversight of FTSU matters. These should be issued no less than every 6

months and should be presented by the FTSUG or member of the Trust’s FTSU network in person. We

currently have a frequency of 3 reports a year, in July, October and Annual Report in March written and

presented by the FTSUG and it is proposed to continue with these arrangements and frequency.

Whilst ensuring that data and other intelligence are presented in a way that maintains the confidentiality

of individuals who Speak Up, the Guidance states that Board reports could include:

Assessment of issues

o Information on what the Trust has learnt and what improvements have been made as a

result of Trust workers Speaking Up

o Information on the numbers and types of cases being dealt with by the FTSU Guardian

and their local network

o An analysis of trends, including whether the number of cases is increasing or

decreasing; any themes in the issues being raised [such as types of concern, particular

groups of workers who Speak Up, areas in the organisation where issues are being

raised more or less frequently than might be expected]; and information on the

characteristics of people Speaking Up (professional background, protected

characteristics)

Potential patient safety or workers experience issues

o Information on how FTSU matters relate to patient safety and the experience of workers,

triangulating data as appropriate, so that a broader picture of FTSU culture, barriers to

Speaking Up, potential patient safety risks, and opportunities to learn and improve can

be built

Action taken to improve FTSU culture

o Including to increase visibility and promote process; any assessments of effectiveness of

the process and case handling; information on any instances where people who have

spoken up may have suffered detriment and recommendations for improvement; and

actions to improve skills, knowledge and capability amongst the workforce to Speak Up,

support speaking up and improve response to the issues that are raised.

Learning and Improvement

o Including feedback from people using the FTSU service and update on any broader

developments regionally and nationally. This would include learning from case reviews

undertaken by the NGO.

Recommendations

o Suggestions of any priority action needed

The FTSUG reports presented over the last couple of years have been informative and have largely

touched on these areas and it is intended in future that they will be framed around these headings.

Another good practice recommendation in the guidance is that Boards should consider inviting workers

who have Spoken Up to present their experience in person. We have already done this with two

workers who spoke of their experience at a Board meeting and who have, because of their experience

using the service, become FTSU Advocates where they help other colleagues through FTSU. It is

proposed that once a year when the Annual Report is presented that we invite a worker who has used

the FTSU service to present their issues to the Board.

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6. Roles and Responsibilities

The guidance sets out clear expectations of all Board members, Executive and Non-Executive, that

they are knowledgeable and up to date about FTSU and can readily articulate the Trust’s FTSU vision

as well as key learning and continual improvement from issues that workers have spoken up about.

The Chair and Chief Executive have specific responsibilities both as Non-Executive and Executive

leads for FTSU, and as the people ultimately accountable for ensuring the FTSU arrangements met the

needs of the workers in their Trust. There are also specific responsibilities of the Director of HR and the

Medical Director and Director of Nursing. The FTSUG is clear that these senior leaders are supportive

of FTSU and fulfil their responsibilities, nevertheless it is proposed that she have separate meetings

with them to ensure all requirements are in place.

Action:

The FTSUG to meet with those senior leaders with specific FTSU responsibilities as defined in the

Guidance to ensure all requirements are in place.

7. Leadership and Culture

As a Board, we will want to fulfil our responsibilities as defined in the ‘Guidance for Boards on Freedom

to Speak Up’ including developing a meaningful improvement action plan. We want this to lead us to an

organisational culture where everyone Speaks Up quickly and clearly whenever an issue arises, secure

in the knowledge that they will Be Heard and their concern responded and that they need have no fear

that they will suffer detriment as a result.

It is therefore recommended that the CE oversee the workstreams outlined in this report and that a

‘Board Deep Dive’ take place when some of the material is ready for our consideration. We can then

consider it as we complete the self-review tool.

Action:

CE to oversee FTSU function at SLaM with the support of the Chair as the non-executive

representative

FTSUG and others implement the workstreams outlined in this report

A ‘Board Deep Dive’ session be fixed once it his clear when the material will be ready for

consideration alongside the self-review tool.

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REPORT TO THE TRUST BOARD: PUBLIC 30 October 2018

Title

Quality Improvement Update

Author Dr Barbara Grey, Director QI and SLaM Partners

Accountable Director Dr Michael Holland, Medical Director


This paper is a regular update for the board on the QI work and provides a brief update on the Trust wide QI programmes, and the number of team QI projects. The paper focusses on progress for Icare and learning from the evaluation conducted from the foundational level training together with recommendations for the continued support for the approach to Icare and the intention to develop a revised plan for continuing to develop the capacity and capability for QI development as part of the QI strategy. This will be presented to the board in December 2018.

Executive summary

The QI and SP team have focussed their work on: - Supporting/ coaching the progression of Icare including enabling leaders and teams to develop

their readiness to change - Launching the first Trust Memory Collaborative - Evaluation of Improvement science in action projects - Delivering QI, leadership and coaching development programmes - Coaching QI projects

Recommendations Icare: The Board and wider senior leadership continue to support the QI approach and allow time for the improvements to be planned, tested and spread, in a systematic and timely way. Building capacity and capability In view of the findings of the QI foundation programme and the CQC report, we recommend that in conjunction with King’s Implementation Science (KIS), we develop a revised plan, as part of the QI strategy, for continuing to build the capacity and capability in the Trust. The strategy will be presented to the board in December 2018. This will clearly articulate the technical expertise i.e. QI knowledge and skill required for all staff, as well as leadership/management/ team development needed to achieve culture change.


BAF Risk 11 – QI delivery - There is a risk that the significant time, resource and money that the trust has invested in quality improvement will not result in the improvements in quality and efficiency of services that is anticipated.



26.09.18 Global Digital Exemplars (GDE) Governance meeting

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Trust-wide work Leadership walk arounds: There have been 125 leadership walkarounds by the SMT since January 2018. They continue to be positively reviewed by staff. The SMT is continuing to improve the capturing and follow up of actions. QI Huddles: The SMT has run their weekly QI huddle for nearly 12 months and have now commenced a safety huddle. Most directorates have now started weekly QI huddles and we are working to develop guidelines for QI and safety huddles as several clinical teams have started to introduce huddles and we want to develop a consistent approach. Reducing violence and aggression: This is part of the QI work for safety. The Quality Improvement team and Modern Matrons are currently supporting 21 acute wards with the re-testing and implementing 4 Steps to Safety interventions. Teams are also being encouraged to test other change ideas they believe might have an impact on violence and aggression. These include changes such as more on the ward activities and debriefs after restraints. Most wards have completed the contracting and planning stages and are in process of begin testing. A consultant Psychiatrist has been identified to provide more strategic clinical leadership. A sustainability plan is being developed with Modern matrons. Deming (Trust dashboard): Since it was launched in July 2018, there have been over 250 users. The QI team is demonstrating its use and there is ongoing work by the QI team to publicise and engage staff in using Deming to familiarise themselves in using data to support their decision making and improvement. Memory learning Collaborative A collaborative methodology is being employed to support the CAG workplan to reduce unwarranted variation and improve patient and staff experience and ensure that services are compliant with NICE guidelines and current best practice. The first learning event to launch the collaborative took place on 8.10.18 and practical next steps agreed. Update on number of current team QI projects, by Quality Priority The chart and table below illustrate the number of current team QI projects aligning with the quality priorities.

SLaM QI Project Summary – October 2018 (Source: QI Work Plan, MS Teams)

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Row Labels Reducing Violence

Right Care, Right Time, Appropriate Setting

Service User and Carer Involvement

Staff Satisfaction

Grand Total

Lambeth 8 12 1

21

Croydon & Forensics 7 9 2

18

Southwark & Addictions 4 11 2

17

Lewisham 7 2 1 1 11

Trust-Wide

5 2 2 9

PMOA

7 1 1 9

CAMHS

6 1 1 8

Other Corporate

3

1 4

Pharmacy

2

2

ICT

1 1

Partner Organisation

1

1

Grand Total 26 58 10 7 101

Improving Care and Outcomes This work focuses on the improvement work across general adult inpatient and community services. The aim being to provide the highest quality care in adult mental health services so that care is received in the right place at the right time and that the service is sustainably run. The outcome measures are:

10% Reduction in admissions

35% reduction in length of stay (LOS) 50% reduction in violent incidents There are three QI work streams for Icare and one workstream for SLaM Partners (SP):

QI Workstream Inpatient services Community services

Safety

4 steps to safety Use of debriefing

Testing of personal alarms – work will be integrated into care process model work Improving physical environments

Flow Experience

1. Red2 Green 2. Barriers to discharge 3. Care process model identifying

standards of best practice ( using RCP guidelines and those coproduced with patients and carers- Test site all wards in Lewisham

Care process model development Test site CMHTs in Southwark

SP work stream Working with leaders/ managers and teams to improve readiness to change so that there is a greater opportunity and motivation to shift mindsets and behaviours to achieve culture change.

Progress: Barriers to Discharge: It was agreed that the QI team would support the work to put system in place to help reduce barriers to discharge identified through the Multi-Agency Discharge Events (MADEs). Objective: to agree Standard Operating Procedures to unblock common barriers to discharges between community and inpatient services and develop a system/process for both inpatient and community teams to use and implement protocols when barriers to discharge occur.

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Meetings have been held with Croydon, Lambeth and Lewisham Clinical Service Leads and Community Service Leads and discussed Standard Operating Procedures for each borough. As believed, there were common themes between the three boroughs: Accommodation, Funding issues, Repatriation, Capacity Assessment, access to ID and Discharge issues. Issues requiring Standard Operating Procedures have now been collated and themed. The next steps are to:

Set up focus groups in each borough week of 22 October with the relevant people and expertise in each of the themes.

Agree how we implement the Standard Operating Procedures and develop a system for both inpatient and community to use e.g. flash cards, accessible on Maud, laminated escalation procedures or on ePJS. These will then be tested using QI methodology by mid-November 2018

Red to Green is a patient flow tool as a means:

1. To optimise patient flow. 2. Reduce length of stay. 3. To improve patient experience by increasing the number of ‘value adding days’ on the ward. 4. To reduce internal and external delays. 5. Ensure discharges take place as efficiently as possible.

This process requires system change and hence a shift in practices for clinical leaders and teams. Testing has started in Croydon and Lambeth, with challenges identified in some wards and some early positive indications of more green days and discharges in one ward (see charts below).

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The QI team has identified a checklist of components that need to be in place to optimise improvement in the system. These are:

Borough SMT understanding of Red 2 Green and their role in supporting this. SMT responsibilities are:

o Initiate engagement with the wards o Support QI team who provide initial training o Review progress o Unblock difficulties

Borough escalation process agreed

Consultant and team leader engagement, buy-in and explicit commitment to leading the process (key to success) agreed through dynamic contracting with Red 2 Green facilitators.

Up to date care plans for all patients (including an expected date of discharge (EDD), a clear purpose for admission and Clinical and Social criteria for discharge (CCD / SCD)

Senior, clinical, decision making presence agreed (e.g. Consultant, Team Leader, SpR, PDN - NB; this may differ per ward)

Screen or board in place for daily Red 2 Green huddles

Ward team engagement and buy in into Red 2 Green process agreed through dynamic contracting with Red 2 Green facilitators.

Agreed start dates, support provided and review dates with ward leadership team, QI team and borough SMT present. (suggested weekly, minimum fortnightly during testing phase)

SLaM Partners (SP) continues to lead on the team development work and they are providing additional support to identified teams and testing the use of a team evaluation framework and a team effectiveness tool. Operational Care Process Models (CPM) Putting in place best standards of care for access, assessment, treatment, discharge. These will be integrated into clinical care pathways for particular patient groups. Inpatient CPM: We have co-produced a draft for standards for each process of the care pathway and these will be integrated with the standards set out in the Royal College of Psychiatrists (AIMs). We are working with all wards in Lewisham to check the standards and then test improvements starting with the discharge process. Learning will be spread at pace to other boroughs. Community CPM: Learning from the inpatient CPM development work we facilitated engagement groups with staff, patients, carers and external stakeholders and using the royal college of Psychiatrist’s standards for community teams. We are integrating ideas from the engagement work and are in the process of planning the first tests for change ideas in Southwark, focussing on reducing admissions. Three change ideas are being progressed

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1. improving interface with primary care 2. reducing crisis admissions 3. creation of crisis cafe (or similar) in Southwark

Given the CQC recommendations, we are integrating the work of Icare to ensure that fundamental standards of care are complied with and improved and that it is fully integrated with the flow work. We will continue to use a QI approach to further engage staff and to improve standards. Sufficient time needs to be given to engagement and planning so that when we get to testing, this can be done rapidly with a view to spreading at pace. Recommendation: The Board and wider senior leadership continue to support the QI approach and allow time for the improvements to be planned, tested and spread, in a systematic and timely way. Evaluation of QI projects generated from Improvement Science in Action (ISIA) training programmes (January 2017 – April 2018) To foster organisational learning, we initiated an evaluation of Quality Improvement (QI) projects by staff members who received the Improvement Science in Action (ISIA) training by SLaM QI since 2016, supported by King’s Implementation Science (KIS). A generic framework was developed to overcome the difficulty of making comparisons when project-specific aims and outcomes were heterogeneous and highly localised. SLaM QI staff members were requested to identify five “successful” and five “unsuccessful” QI projects based on their own assessment. Data were accrued for a sample of 52 (out of 104) QI projects. A total of 115 staff members, typically in teams of two (60%), carried out the 52 QI projects. The most common profile of project leads was band 7 clinical staff. Among 52 QI projects, 16 (31%) achieved their aims, 14 (27%) were adopted, 3 (6%) triggered similar projects at other sites. Highlighted below are some of the key findings on a range of factors that had an impact on whether project teams achieved their aims. Organisational factors

20% less likely to achieve their aims if it was the first QI project undertaken by the team.

20% less likely to achieve their aims if staff turnover happened.

20% less likely to achieve their aims if it was an in-patient setting.

10% more likely to achieve their aims if the project lead was band 8 or above.

20% more likely to achieve their aims if the team had 3 members (vs smaller team).

30% more likely to achieve their aims if the team had 3 members (vs larger team). Engagement factors

40% more likely to achieve their aims if key stakeholders (not in project team) were involved

60% more likely to achieve their aims if service users were involved in the project Measurement and data quality factors

35% more likely to achieve their aims if target outcomes were quantified in the aims.

40% more likely to achieve their aims if balancing measures were incorporated

50% more likely to achieve their aims if PDSA had two or more cycles

50% more likely to achieve their aims if projects had baseline data prior to testing change idea or follow-up data after testing change idea

70% more likely to achieve their aims if PDSA had documentation to enable replication

90% more likely to achieve their aims if projects had evidence to show that aim was sustained Engagement, measurement and data quality generally showed a larger impact than organisational factors. In fact, when we examined commitment of SLaM resources, we found no difference in terms of meetings, site visits and email communications over the life span of completed and terminated projects. On average, completed projects had a longer life span than terminated projects (22 vs 15 weeks). In total, the 23 completed projects clocked 513 weeks, whereas the 29 terminated projects clocked 430 weeks. The latter highlights a potential dilution of SLaM QI resources and suggest a need for more strategic support for fewer but larger-scale projects.

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Our evaluation findings call for a “less-is-more” approach in SLaM QI and coaching service. By targeting more strategically, we can increase the rigour and impact of QI initiatives. To improve engagement of stakeholders, we are putting in place project registration protocols that screen for project sponsorship. To strengthen quality of data and measurement plan, we will introduce formal evaluation frameworks that have been developed in the field of implementation and improvement science. Recommendation In view of the findings of the QI foundation programme and the CQC report, we recommend that in conjunction with King’s Implementation Science (KIS), we develop a revised plan, as part of the QI strategy, for continuing to build the capacity and capability in the Trust. The strategy will be presented to the board in December 2018. This will clearly articulate the technical expertise i.e. QI knowledge and skill required for all staff, as well as leadership/management/ team development needed to achieve culture change.

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30th OCTOBER 2018

Title

Finance Report As At 30th September 2018

Author Andy Bell, Tim Greenwood & Mark Nelson Accountable Director

Gus Heafield

Purpose of the paper The Finance Report provides an update on the financial position of the Trust as at 30th September 2018 (month 6). The summary financial statement and calculation of the Use of Resource rating from the NHSI Month 6 submission is attached to the report in Table 2. Subsequent to the discussion at the FPC we have submitted a revised return to NHSI showing the gap on funding the pay award in our forecast (£1,019k net of a small other adjustment of £38k). The attached report is as submitted to NHSI with the Q2 Financial returns with the addition of the section in the summary of the benchmarking and brief summary of the planning timetable and an update on the flow plan and costings. We are working on a further update to the forecast which will seek to quantify the range of possible scenarios and quantify the mitigations available which we will discuss with Board members in Part 2 of the Board meeting. The Board is asked to approve the report including consideration of the pressures, risks and mitigations in place to meet the NHSI control total.

Executive summary Headlines

• M6 YTD - £0.1m favourable to plan • However, if costs proceed at the current rates significant forecast pressures

(£6m) will require action in order to achieve the Trust’s Control Total. • CIP still expected to deliver £16.4m but slippage on Overspill, SLP savings and

Borough reconfiguration will require replacement schemes. • Cash position remains robust at £68m YTD. • Capital spend is £4.8m YTD (£3.2m lower than plan). Forecast for the year is

£14.9m, £13.7m below plan, resulting from slippage across a number of schemes • All figures stated in key drivers and risks below represent full year forecast

impacts. Key Drivers (included in the forecast)

• Key areas driving overspend operationally YTD are: • Overspill (39% in Lambeth) - £4.9m (after impact of risk shares) • Ward Nursing Costs – mainly Bank use - £3.2m run rate pressure • Agency usage – at a 20% premium - £3.3m run rate pressure

• Key areas driving overspend corporately are:

• Medical - Junior Doctors Costs including agency use - £0.7m • Estates – ISS inflation/CIP contract dispute - £0.4m • HR – training income targets not met, apprenticeship costs & payroll

transfer - £0.6m • Reduction in R&D income - £0.35m.

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Key Risks (not included in the forecast)

• Southwark Local Authority fail to fund Complex Placements (£0.9m to £1.8m) • SLaM unable to mitigate longer term Overspill pressure (an additional £0.0m

to £1.0m) • SLaM are unable to deliver backloaded CIP requirement (SLP & Boroughs) -

£1.0m to £2.0m

Risks / issues for escalation BAF Risk 1 - Workforce - If the trust cannot attract, recruit and retain enough highly skilled staff, in the right settings with the ability to respond to organisational change the risk is that the quality of care may not be acceptable or consistent across services BAF Risk 8 – Finance contracts - If new contract values and the transitions to new contracts do not provide sufficient financial resource to deliver high quality clinical care there is a risk that the trust will not be able to provide timely access to safe high quality services across all Boroughs and care pathways. BAF Risk 9 – Estates - The trust estate strategy will be delivered over the next 5 years and is dependent on significant capital investment. During the five years services will continue to be delivered from buildings of differing age, quality and standards and there is a risk that the experience of staff and patients is adversely affected and that safety is compromised. Furthermore, there is a risk that developments will be unfit for purpose, delivery of major new buildings will be delayed or go over budget. BAF Risk 11 – QI delivery - There is a risk that the significant time, resource and money that the trust has invested in quality improvement will not result in the improvements in quality and efficiency of services that is anticipated. BAF Risk 12 Finance – cost management - If services and departments do not deliver within their budgets, do not deliver the planned cost improvements, QIPPs and CQUINs and if we do not manage within Trust capacity the risk is that costs are uncontrolled and that the financial position of the Trust is destabilised which will prompt intervention by the Regulators.

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2018/19 Month 6 Finance Return and Narrative Document and Workforce Return Overview The attached return shows YTD and FOT positions meeting the agreed control total for 2018/19. However, significant ongoing and emerging financial risks need to be mitigated and this is becoming an increasingly difficult gap to bridge. As a result, The Trust Board are keeping the financial outturn position under constant review. The Trust will continue to work with NHSI in the assessment of its position. Based on current assessment the risk to the forecast is circa £6.0m but it should be noted that this is not a worst-case scenario. Financial Context Benchmarking The graph below from the NHS benchmarking club gives the context for the investment by Borough across London by weighted population for 2017/18 and is the context for the operational and financial pressures we are experiencing. NHSE/NHSI have recently issued a timetable for the finalisation of plans and contracts for 2019/20 (pdf version attached to this report) and the benchmarking data will form the basis of the Trust’s contracting position including expectations over Mental health Investment Standards (MHIS) investment and QIPP.

The current pressures on the SLaM financial position fall broadly into 3 categories:

1. The need to ensure high quality and safe patient services This, in part, requires responding to findings from the 2018/19 CQC inspection which were not in the original business plan. This has included making additional investment in estate as well as focusing SLaM management capacity on delivering the CQC’s requirements. The current estimate of additional cost is between £0.75m

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and £1.0m. This estimate could increase depending on the ongoing development of CQC compliance schemes which could increase the risk by £0.5m to £1.0m.

2. The need to manage ongoing systemic inpatient bed pressure Demand for inpatient beds is exceeding the original plan across all boroughs and is evident in the increasingly high demand for Mental Health beds from ED presentations. This is driving significant additional cost in terms of the use of private beds and staffing our wards sufficiently with bank and agency medical and nursing staff. The current forecast spend on private beds is £2.9m but without mitigation this could increase to £5.0m. In response to this system pressure the SELSTP and NHSI have been working with SLaM to develop a plan to help ease the capacity and flow issues in the system for the benefit of all provider Trust’s in the region. Whilst significant funding has been made available by the system it is likely that there will still be a cost pressure for SLaM to deliver the full benefit of the proposed plan. Details of the flow plan and potential costings are included in a separate report on the Board agenda. The Board should note that the additional costs over and above the sources of funding already identified have not been included in this forecast at this stage as they are still to be finalised (£1.5m to £3.3m depending on model option for 2018/19). In addition to this immediate action there is also a system wide recognition that Adult Mental Health beds have been significantly under funded over the longer term and this will require a more strategic solution in the longer term.

3. Cost Pressures Outside of SLaM’s direct control

A number of issues have emerged in year that would not have been reasonable to include in the Trust plan notably:

a. Agenda for Change Pay Award Cost Pressure – currently estimated at £1.0m unfunded cost.

b. Reduction in R&D funding after the planning deadlines - £0.5m reduction in RCF (infrastructure support funding) which is fully committed.

c. New Models of Care funding challenges – currently NHSE have not confirmed that they will fund Forensic beds in line with the agreed business case. In addition, NHSE have not yet agreed to fund the new CAMHS PICU service despite its request for the service and very good early outcomes reports. Currently, the Trust CIP plan assumes full funding which would yield a £2.0m saving for the Trust.

d. Southwark Local Authority Placements – The CCG and Local Authority no longer have a Section 75 agreement in place the local authority has indicated that it will fund to a level that is £1.6m short of the expected spend. The Trust is working with partners in Southwark to mitigate the risk but this is limited at this stage.

e. Delay in Transfer of Kent CAMHS Services – The Trust plan expected this service to transfer to NELFT in Q1. However, issues between NHSE London and NHSE South have meant this has been delayed at their request until March 2019 which has created an additional £0.5m cost pressure and increased projected medical agency usage significantly.

Impact on Cost improvement There are 3 material impacts on CIP delivery based on the pressures highlighted above:

• Private Bed Usage - £2.4m CIP will not be achieved due to increased Demand pressure on inpatient beds. A significant overspend is expected if this is not reduced quickly in the immediate future.

• SLP Savings - £3.0m contribution from more efficient provision of Forensic and CAMHS services under New Models of Care is at risk if NHSE fail to meet

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requirements of agreed business cases. In addition, a range of other schemes including back office savings are being developed.

• Borough Reconfiguration – £1.0m the proposed efficiencies from the restructure have been paused in light of the focus on CQC and the significant challenges around inpatient demand and flow.

Required Mitigations To achieve the reported delivery of the full year control total the following mitigations are required:

• Agenda for Change shortfall is centrally funded or Trust control total adjusted. • NHSE fully fund the New Models of Care as per the agreed business cases • Local Authority Placements are fully funded by Southwark CCG and Local Authority

as per previous Section 75 agreement. • CQC Compliance work does not exceed existing forecast overspends. • System pressure funding is made available to support short to medium term capacity

and flow challenges. • Additional Lock In and Replacement CIP schemes are identified (current assessment

shows a potential yield of circa £3.0m) • Additional mitigations are identified through not recurrent means (e.g. balance sheet

items, disposals). It should be noted that the scope for additional disposals is limited in the current year.

• The introduction of flow and capacity plans ease the pressure on private bed usage across the remainder of the financial year.

• CQUIN is fully funded and there is no penalty to SLaM for unmet QIPP. • There is an improvement in cost per case/variable activity as projected by local

services. Further detail on the above pressures and mitigations can be found in the detailed report attached below.

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1) Financial Summary

Area 2018/19 Mth 1

Variance £000

2018/19 Mth 2

Variance £000

2018/19 Mth 3

Variance £000

2018/19 Mth 4

Variance £000

2018/19 Mth 5

Variance £000

2018/19 Mth 6

Variance £000

2018/19 Total

Variance £000

CAGs 336 391 831 (317) 2,969 1,007 5,217 Infrastructure Directorates 455 82 (127) (164) 724 311 1,281 Corp Income (48) (89) (129) 224 (244) (19) (305) Other including provisions released & central CIPs

336 760 422 221 (2,118) (868) (1,247)

Use of Reserves (1,210) (1,309) (815) 82 (1,141) (392) (4,785) Total EBITDA

(131)

(165)

182

46

190

39

161

2) Key Cost Drivers (unmitigated by alternative income, risk shares etc.)

Area 2018/19 Mth 1

Variance £000

2018/19 Mth 2

Variance £000

2018/19 Mth 3

Variance £000

2018/19 Mth 4

Variance £000

2018/19 Mth 5

Variance £000

2018/19 Mth 6

Variance £000

2018/19 Total

Variance £000

Ward Nursing* 214 151 153 156 657 245 1,576 Agency Premium @ 20% 220 285 270 254 285 332 1,646 Acute Overspill*** 265 487 679 594 867 651 3,543 Unmet CIPs** 166 307 423 870 (326) 8 1,448 Placements*** (98) (84) (111) 60 (70) (25) (328) CPC/C&V Income 330 335 401 406 326 661 2,459

Total

1,097

1,481

1,815

2,340

1,739

1,872

10,344

* includes safer staffing funding **see Section 3 *** before application of risk shares & excl Swk LA funding issue

Service Analysis

Full Year Live Budgets (£)

Current Month

Actual(£)

Variance From Live

Budgets (£)

Year To Date Actual (£)

Variance From Live

Budgets (£)

Variance Last Month (£)

01. Lambeth 22,174,500 2,184,400 449,800 12,370,200 1,335,900 886,100

02. Southw ark 29,629,600 2,244,800 (215,700) 14,702,400 261,600 477,400

03. Lew isham 23,681,200 2,324,000 302,500 13,018,300 1,222,000 919,500

04. Croydon 16,356,400 2,038,400 383,300 9,787,700 1,793,900 1,410,600

05. PMOA (760,900) (159,400) (144,200) (790,400) (256,000) (111,800)

06. Child & Adolescent Service 509,400 298,800 230,600 1,039,500 859,500 628,900

07. Clinical Support Services 8,520,600 675,500 (34,600) 4,153,400 (106,900) (72,300)

08. Infrastructure Directorates 63,333,500 5,890,800 345,700 35,253,900 1,387,300 1,041,700

09. Corporate Income (105,449,100) (8,689,400) (19,800) (52,552,300) (305,400) (285,500)

Operational Deficit 57,995,200 6,807,900 1,297,600 36,982,700 6,191,900 4,894,600

10. Corporate Other (79,106,900) (7,394,200) (866,300) (40,322,900) (1,246,500) (380,300)

11. Contingency - planned 1,800,000 0 (150,000) 0 (900,000) (750,000)

12. Other reserves/provisions 7,223,600 0 (242,100) 0 (3,884,600) (3,642,500)

Corporate Other (70,083,300) (7,394,200) (1,258,400) (40,322,900) (6,031,100) (4,772,800)

EBITDA (12,088,100) (586,300) 39,200 (3,340,200) 160,800 121,800

13. Post EBITDA Items 10,110,000 1,152,900 (196,800) 2,583,200 (204,800) (7,200)

Trust Financial Position (1,978,100) 566,600 (157,600) (757,000) (44,000) 114,600

Items Not Included In NHSI Target (480,900) (43,000) (4,000) (264,000) (24,000) (20,000)

NHSI Control Total (2,459,000) 523,600 (161,600) (1,021,000) (68,000) 94,600

Monthly Figures Year to Date Figures

Page 160 of 224

1. Explanation of YTD and FOT variances

• Acute/PICU Overspill Overall 29 overspill beds were used by the Trust in September, a similar figure to the previous 3 months and 26 beds above our original plan. However this number has increased going into October (49 as at 10/10/18) and is at levels not seen since May 2017. The use of overspill and other non local CCG beds has resulted in a cost pressure, after application of risk shares, of £2.4m after 6 months. The main drivers of this contract overperformance and hence resort to using beds outside the Trust continue to be Lambeth (ytd - 18% above contract), Southwark (ytd - 12% above contract) and Lewisham (ytd - 16% above contract). Lewisham in particular is experiencing unprecedented levels of contract overperformance as seen in the graph below –

The use of all acute/PICU beds (internal and external) by LSL&C CCGs is shown in the tables below:

Page 161 of 224

The second graph above indicates how far we are away from achieving our goal of 85% occupancy where the blue line indicates actual CCG bed usage versus the red and purple lines indicating 100% and 85% bed usage respectively. The table below highlights both the overperformance and associated CCG risk share payment attached to this. Further discussions are taking place with the local CCGs given the level of financial risk this presents to both parties.

• Use of Agency Staff

NHSI have set a ceiling to spend no more than £15.1m on all agency staff. By way of comparison, the Trust spent £17.2m on agency in 2017/18. The Trust is currently £1.8m above that ceiling at month 6 and at present rates of expenditure will be £4.7m above the ceiling at year end and in excess of its 2017/18 position. Agency cost reductions form part of the annual plan and rely upon meeting the NHSI ceiling. As at month 6 ytd the Trust had incurred an additional expense of c£1.6m above the cost of employing permanent SLaM staff, assuming a 20% agency premium.

Medical agency costs increased substantially in month 6 and now represent nearly a third of total agency costs (a disproportionately high level of spend compared to other

Last Mth Risk ShareCCG Plan Actual Variance Variance Variance Value

Beds @ 100% Beds Beds % Beds £000Lambeth 82 96 15 18.2% 15 500Southwark 75 83 9 11.5% 8 268Lewisham 65 76 11 16.3% 6 363Croydon 82 85 2 2.6% 2 61NCA/Overseas 21 17 -4 -20.2% -4 0Total 325 357 32 9.8% 26 1,192

TOTAL (YTD)

Page 162 of 224

groups of staff). A breakdown of all agency use compared to permanent/bank usage ytd is given below –

• Ward/Unit Nursing Costs

At month 6 ward nursing costs overspent by £245k (£1.6m ytd). This now takes full account of the nurse bank pay award where arrears were paid in month 6. The impact of the pay award has been less than originally indicated by NHS Professionals (who run our nurse bank) but pay costs remain very high with overspends averaging more than they have done for at least the last 5 years. In addition it remains unclear whether the NHS pay award will be applied to nurse agency rates. No additional funding is being made available by the Department of Health. Although a 3% award would not increase ward/unit nursing costs materially (ward/units make relatively small use of agency staff), it would make a material difference to community nursing costs. The Trust is seeking clarity on this issue with the NHS London Procurement Partnership. The main areas of concern remain with the Lambeth, Lewisham and Croydon adult wards which represent 74% of the total ward/unit nurse overspend. Included within this are Eden PICU (Lambeth), Johnson Unit PICU and Clare (Lewisham) and Fitzmary 1 (Croydon) which are all +20% above their funded nurse establishments.

• Cost per Case/Cost and Volume Income (variable income aligned to activity)

The position has deteriorated from 2017/18, with 3 Directorates standing out –

Directorate All Staff Agency Usage Agency UsageEstimated Cost Above Funding

£000 £000 % £000

Lambeth 15,478 1,464 9% 244Southwark 18,522 1,386 7% 231Lewisham 13,449 1,279 10% 213Croydon 26,447 2,675 10% 446PMOA 18,071 547 3% 91CAMHS 18,055 1,117 6% 186Other 32,279 1,407 4% 234

Total 142,301 9,873 7% 1,646

Page 163 of 224

Ø Croydon (£0.5m adverse) – income below target on Forensic Ward In The Community (additional beds above block funding not occupied), Psychosis Unit (currently 75% occupancy following agreed bed closures) and NAU (reduction in beds/income due to continuing building works). In addition the ADHD clinics continue to only break even whereas last year they were overperforming against reduced income targets.

Ø PMOA (£0.8m adverse) – part of this year’s CIP programme was to retain the 17/18 income targets but make progress towards meeting them. This is yet to occur uniformly with some of those services that underperformed last year - in particular, neuro psychiatry and eating disorders inpatients & outpatients – continuing to underperform. In addition Chronic Fatigue and Affective Disorders are not currently meeting activity targets.

Ø CAMHS (£1.3m adverse) – the underperformance largely relates to outpatient services, in particular the Conduct Adoption and Fostering service and the Childrens Forensic Team where insufficient activity is taking place to fully meet costs. The latter service has now effectively closed which should result in a reduction in costs. There is also likely to be some catch up in terms of activity being recorded on the systems or timing of income due such that some improvement is expected in the second half of the year in line with previous years. However there are also income shortfalls on inpatient services where activity remains below target in Kent and on Snowsfields whilst delays in converting beds at Acorn Lodge into high dependency beds means income targets are also not being met. The new PICU Unit is expected to be fully open later in the year but meeting its income target will rely upon the outcome of continuing contract negotiations with NHSE (both the tariff value and type of contract – block or cost and volume – are still under discussion).

CAG Income Target Actual

Invoiced Surplus/

Deficit(-) At Month 6 At Month 6 At Month 6

£'000 £'000 £’000

Lambeth

1,296 1,409 (112)

Southwark

790 820 (30)

Lewisham Croydon

303

14,707

341

14,224

(38)

483

PMOA CAMHS

9,356

11,898

8,547

10,550

809

1,348

TOTAL 38,350 35,891 2,459

Some of these shortfalls (43% by value) are being offset by corresponding net pay underspends but it is important that follow up action is taken to mitigate these income positions wherever possible.

• Complex Placements

Placements are currently in balance largely achieved through a combination of additional income (Southwark CCG) and changes to budget as allowed for in the Annual Plan. However there remains a high risk on Southwark local authority placements where funding is no longer being routed through the CCG contract under a Section 75 agreement. Previously this provided the Trust with some certainty as the CCG effectively underwrote any issues that the CCG had with the Local Authority as regards recovery of funding. The Trust must now invoice the Local Authority direct in order to recover costs which last year overspent by £0.8m against a baseline budget of £3.1m. As at month 6

Page 164 of 224

the LA element of placements has cost £1.94m with zero recovery as yet from Southwark Council. The Council have indicated they are only willing to purchase activity up to a value of £2.4m leaving a potential forecast gap of £1.5m. This situation is being taken up with the Council/CCG and whilst progress is being made, the funding gap still exists.

2. Underlying position

• The current underlying position is under pressure mainly due to CIP slippage – notably in Overspill, Agency spend and SLP collaboration savings. Non-recurrent alternatives have been identified and these will be developed to see if they can be made recurrent. However, at this stage they are increasing the underlying position pressure.

• SLaM remains committed to eliminating its underlying position over the next 3 years and this is a feature of the Trust’s LTFM.

3. Run rates

• See above

4. High Risk CIPs

Name Risk

Level YTD Plan

YTD Actual

YTD VAR FY Plan FY

Actual FY VAR Narrative

£000s £000s £000s £000s £000s £000s

Overspill Reduction High 1,206 1,206 -1,206 2,403 417 -1,986

Overspill remains High Risk due to ongoing bed pressures in SE London

Direct engagement of staff High 42 7 -35 80 7 -73 Scheme delayed

Estates Reduction 1 High 0 217 217 358 337 -21

This is still expected to largely deliver but pressure on estates due to CQC related programmes means this remains a high risk.

Lambeth & Lew PICUs High 44 0 -44 156 29 -127 This remains high risk due to demand pressures on beds

Borough Restructure Target - 2nd Tranche High 0 0 0 300 0 -300

Savings have been identified but on hold following focus on CQC issues and inpatient pressures

SLP Collaboration High 0 0 0 500 0 -500

Credible plans to deliver this level of savings through SLP have been identified but are dependant on NHSE honouring previous agreements around settlements on CAMHS tier 4 and Forensics

Promoting Recovery Teams High 0 0 0 486 486 0

Was expected to deliver but will remain high risk until Borough reconfigurations are finalised

CPC Outpatients income High 96 0 -96 201 21 -180 Activity driven – remains high risk CAMHS Inpatient income High 96 0 -96 191 0 -191 Delay in converting beds to HDU Southwark Estates savings tied into service redesign High 36 59 23 76 76 0

This relates to the exit of a Trust site that is off track - alternative schemes are being identified

Nursing Management Unidentified CIP 18/19 High 18 0 -18 38 0 -38

Nursing management budgets are underspending but this CIP is yet to be finalised.

Site Manager Post redundant

High 36 0 -36 68 0 -68

Post removed but non rec redundancy payment offsetting saving

Agency Spend High 168 0 -168 500 0 -500

Pressure on inpatient beds and ongoing recruitment challenges means agency is running above the agreed ceiling. This is expected to improve through the year but will be dependent on SLaMs exit from Kent CAMHS which is under review with NHSI.

Page 165 of 224

Total 1,742 276 -1,466 5,357 1,373 -3,984

5. Use of Contingencies & Risk Reserves • Due to the pressures detailed in the YTD and Forecast position all contingencies

and reserves are fully committed. • In its plan the Trust had an initial £1.8m general reserve which has been utilised

to support in year pressures (e.g. Overspill and Ward costs) and Service developments (e.g. CQC related support schemes)

6. Cash & Working Capital Position

• BPPC, Debtor and Creditor Positions and Days remain accurate and are subject

to robust processes that are regularly reviewed and audited. • The Trust continues to have a robust cash position which will remain across the

financial year.

7. Balance Sheet • No issues of note at this point in the year other than timing. • Capex YTD M06 is £3.2m behind plan due to slippage including;

- £0.8m Norbury Ward - £0.4m Clinical room environment - £0.4m estates backlog maintenance schemes - £0.4m AL3 Ward refurbishment - £0.4m ICT projects - £0.3m Snowsfield replacement windows

8. Revenue Support Drawdown

• The Trust does not expect to draw down any revenue support in 2018/19.

9. Schedule of risks and opportunities against FOT

• Acute overspill averaged 29 beds in the month – a similar position to August – but since the 2nd half of September the position has been deteriorating (49 as at 10/10/18). This number excludes local CCG patients overspilling into Trust beds that were planned to be funded by NCA activity (non contracted activity – primarily overseas and cross boundary flow patients). The net financial impact of overspill and loss of NCA income is £2.4m ytd after the impact of risk shares. Clearly this is a major risk to our financial plan if it continues at levels well above the 3 beds included in the plan. The main area of concern continues to be Lambeth (18% above contract ytd) but Lewisham has seen a significant increase in bed activity over the last 2 months (31% above contract in August and 34% above contract in September). The Trust is in discussion with NHSI, the STP and SLP regarding the demand pressures being experienced and what mitigations can be put in place including the use of any winter pressure funding.

• Ward nursing costs have remained high with associated overspends at their

highest levels since 2012/13. Although budgets are set at safer staffing levels, some wards are not able to keep within these establishments. The position is being compounded by the Agenda For Change (AfC) pay award where our nurse bank staff are paid on an increment point that attracts a higher level of pay award than other staff on the same band but on a different increment point. This fact has not been recognised in the pay award uplift from the Department of Health.

Page 166 of 224

• Complex placements are reporting a balanced position but this relies upon reaching a satisfactory agreement with Southwark Local Authority regarding its purchase of placement activity. The Trust has no contract with the LA and the LA have indicated they will only purchase £2.4m of activity when activity is forecast to cost £3.9m. Discussions with both the CCG and LA are taking place to resolve this issue.

• The Trust had planned for a reduction in agency costs, in line with the new NHSI

ceiling. However agency usage over the first 6 months is £1.8m above this ceiling (a £0.7m movement in the month). Although the new ceiling is £2.3m lower than last year, the position is being exacerbated by our agency costs also increasing. They are £1.4m higher than at this point last year and on current run rates will exceed the new ceiling by £4.7m at year end. This would also mean exceeding the NHSI ceiling by more than 25% triggering an increase on the agency element of our NHSI use of resources risk rating (from a 2 to a 3). Medical agency costs remain disproportionally high (a third of total agency costs) with overall agency usage highest in the adult boroughs at 9% of pay costs.

• Last year the Trust, overall, met its cost and volume income targets (higher risk

income that relates directly to increases/decreases in activity). However the overall performance masked areas where income was not on plan. Some of these areas have continued to underperform going into 2018/19, whilst others have moved from a surplus into a deficit and are now driving a bottom line income deficit of £2.4m at month 6. Corresponding pay underspends will mitigate 43% of this variance but a number of services are required to improve their performance over the remaining 6 months.

• The month 6 assessment of the impact of the AfC pay award decreased from

£5.0m to £4.6m, and the unfunded amount from £1.4m to £1.0m. This decrease results from an analysis of paid arrears for bank staff in month 6 extrapolated for the year plus a small increase (£100k) in the funding now being provided by the Department of Health. It seems unlikely that any further funding will be made available and this £1m cost pressure will need to be taken account of in our forecast position.

Based on the above the Trust has identified financial risks though totalling c£6m by year end (excluding the Southwark LA placements issue described above). These can be mitigated as described on page 2 above

10. Income Assumptions & Commissioner Challenges

• All CCG core contracts have been agreed and cross referenced at STP level. • Risk shares around bed days are being calculated based on agreed contract

terms. • There are ongoing negotiations around deployment of Mental Health Investment

Standard (MHIS) funding through agreed SDIPs with CCGs. These discussions are moving forward positively.

• Any emerging commissioner issues are dealt with at regular core contract meetings with all key CCGs.

• Discussions with NHSE around funding settlements for SLP related schemes (Forensics and CAMHS tier 4) are ongoing.

• The Trust has seen a £0.5m reduction in its RCF R&D funding from the DH which it was not notified of until May 2018.

• Southwark CCG and Local authority do not currently have an agreed section 75 which means that a funding risk around complex placements has emerged for SLaM. The local authority has stated their intention to limit funding to £2.4m which is projected to be £1.5m below the funding required. This remains a risk to the current forecast which will be reassessed over the next few months.

Page 167 of 224

Glossary AMH Adult Mental Health – used in this report to cover a programme of investment in

community schemes that aim to reduce the usage of acute/triage beds in the Trust

CCG Clinical Commissioning Group – an NHS body responsible for the planning and commissioning of health services for their local area

CIPs Cost Improvement Programme CPC/C&V Cost per Case and Cost and Volume income varies depending upon the

amount of clinical activity being undertaken EBITDA Earnings before interest, tax, depreciation and amortisation is an accounting

measure used as a proxy for an organisations current operating profitability ICT Information and Communications Technology NCA Non Contracted Activity - a patient treated by SLaM where no contract exists

between the Trust and the Commissioner (e.g. a Lewisham resident who has a Bromley GP will not be charged against the Lewisham contract but will be invoiced as an NCA to Bromley CCG)

NHSI NHS Improvement – the new regulatory body overseeing all NHS providers as well as independent providers that provide NHS funded care

OBD Occupied Bed Day – is a unit of currency used to measure the use made of a bed (e.g. 1 obd = 1 bed occupied for 1 day by a patient)

O/P Outpatient PICU Psychiatric Intensive Care Unit - provide mental health care and treatment for

people whose acute distress, absconding risk and suicidal or challenging behaviour needs a secure environment beyond that which can normally be provided on an open psychiatric ward

PoS Place of Safety – under section 136 of the Mental Health Act, the police have the power to take an apparently mentally disordered person who is in a public place and is apparently a danger to himself or to other people, to a "place of safety" where they may be assessed by a doctor

QIPP The Quality, Innovation, Productivity and Prevention programme is a series of schemes required by the CCGs and developed with SLaM to help reduce the cost of services to the CCG

STF Sustainability & Transformation Fund that is intended to support providers to move to a sustainable financial footing

STP Sustainability and Transformation Partnership. These are 44 areas covering all of England, where local NHS organisations and councils have drawn up proposals to improve health and care in the areas they serve.

Triage Triage ward – used to admit patients for a short period of time where their needs are assessed before being either discharged to the care of community teams or transferred to an acute ward

WTE Whole Time Equivalent – is a concept used to convert the hours worked by several part-time employees into the hours worked by full-time employees e.g. 1 wte = 1 full time employee

YTD Year To Date

Page 168 of 224

YTD YTD Plan Forecast/Actual FY Plan ! SummaryEBITDA £3.8m £4m £11.2m £13.2m "

I&E (deficit) surplus £0.8m £0.7m £2m £2m " # 1) At Month 6 ytd the Trust made a surplus of £0.75m, a favourable variance of £0.1m against the NHSI surplus control total

EBITDA margin 1.9% 2.1% 2.9% 3.4% "Debt service cover 1.21 1.25 1.85 2.02 " 2) Acute overspill averaged 29 beds in the month – a similar position to August. This number excludes local CCG patients overspilling

" into Trust beds that were planned to be funded by NCA activity (non contracted activity – primarily overseas and cross boundary flow

patients). The net financial impact of overspill and loss of NCA income is £2.4m ytd after the impact of risk shares. Clearly this is a

major risk to our financial plan if it continues at levels well above the 3 beds included in the plan. The main areas of concern

continue to be Lambeth (18% above contract) and Southwark (11% above contract) and Lewisham (13% above contract)

3) Ward nursing costs remain high particularly the Lambeth, Lewisham and Croydon adult wards which represent 74% of the total

ward/unit nurse overspend. Although budgets are set at safer staffing levels, some wards are not able to keep within these

The position is being compounded by the Agenda For Change (AfC) pay award where our nurse bank staff are paid on an increment

point that attracts a higher level of pay award than other staff on the same band but on a different increment point. This fact

has not been recognised in the pay award uplift from the Department of Health.

$4) As at month 6, the Trust had generated CIP savings of £4.3m. The current adverse variance from the CIP plan of £1.4m is largely

driven by our failure to meet acute overspill targets as indicated above. The Trust is largely meeting its CCG QIPP targets although

it is not keeping to its baseline acute obd positions and there have been delays in restructuring SHARP in Lambeth

5) Complex placements are reporting a balanced position. However there remains a key risk in Southwark where the Local

" Authority are no longer in a Section 75 arrangement with the CCG. This means the Trust is more exposed on securing the funding

required to meet those placement costs

6) The Trust had planned for a reduction in agency costs, in line with the new NHSI ceiling. However agency usage over the first

6 months is £1.8m above this ceiling. Although the new ceiling is £2.3m lower than last year, the position is being compounded

by our agency costs also increasing. They are £1.4m higher than at this point last year and on current run rates will exceed the

new ceiling by £4.7m at year end. Medical agency costs are disproportionally high and agency usage is highest in the adult boroughs

%7) Last year the Trust, overall, met its cost and volume income targets (higher risk income that relates directly to increases/decreases

in activity). However the performance overall, masked areas where income was not on plan. Some of these areas have continued

to underperform going into 2018/19, whilst others have moved from a surplus into a deficit and are now driving a bottom line

income deficit of £2.4m at month 6 (43% of which will be offset by associated net pay underspends)

8) Although established pay budgets have been uplifted in line with the award, sufficient funding has not been provided by the DoH

to cover this increase in cost. We have estimated a shortfall of £1m

9) The Trust is currently rated by NHSI as a 3 against use of resources (where 1 is best out of a 1-4 range). The rating was

" originally scored at 2 but due to an override against the Trust's capital service cover has been downgraded to a 3. This score is in

line with the ytd Plan and will improve by year end provided the Plan is met. However the score on use of agency staff is likely

to deteriorate

Key Financial Drivers

$ Performance v CIP - £1.5m below the NHSI Plan - 25% < target "

Ward Nursing - £1.6m overspent " Acute Overspill - £3.5m overspent excluding impact of risk share " Complex/Non Secure Placements - £0.3m underspent excluding impact of risk shares " Cost per Case/Cost & Volume - £2.4m ytd < target excl offsetting pay costs "

Other Metrics Forecast FSRR less than 2 in next 12 months Yes "

Better payment practice code (non-NHS by value) 89% "

Cash at bank and in hand £68.5m "

"

%

Use of Resources Risk Rating

SLaM - Financial Overview as at 30th September (Month 06 / Q2) Income and Expenditure Financial Position Commentary

(2)

(1)

-

1

2

3

4

M1 M2 M3 M4 M5 M6 M7 M8 M9 M10 M11 M12

£m's NHSI I&E control total surplus (deficit)

actual forecast plan NHSI target straightline

-

3

6

9

12

15

18

M1 M2 M3 M4 M5 M6 M7 M8 M9 M10 M11 M12

£m'sCost Improvement Programme

actual forecast plan

-

4

8

12

16

20

24

28

M1 M2 M3 M4 M5 M6 M7 M8 M9 M10 M11 M12

£m's Capital spend against plan


-

10

20

30

40

50

60

70

80

M12 M1 M2 M3 M4 M5 M6 M7 M8 M9 M10 M11 M12

£m's Working Capital

receivables payables plan cash cash Net assets

-

2

4

6

8

10

12

14

M1 M2 M3 M4 M5 M6 M7 M8 M9 M10 M11 M12

£m's Cumulative EBITDA


-0.5

0.0

0.5

1.0

1.5

2.0

2.5

3.0

3.5

M12 M1 M2 M3 M4 M5 M6 M7 M8 M9 M10 M11 M12

cover x Balance sheet sustainability - Debt service cover YTD

actual forecast plan Rating 1 Rating 2 Rating 3 Rating 4

(15) (10)

(5) - 5

10 15 20 25 30 35 40 45

M12 M1 M2 M3 M4 M5 M6 M7 M8 M9 M10 M11 M12

Days Liquidity rating YTD


-3.0

-2.0

-1.0

0.0

1.0

2.0

3.0

4.0

5.0

6.0

M12 M1 M2 M3 M4 M5 M6 M7 M8 M9 M10 M11 M12

% Operational performance - I&E control total margin


-3.0-2.0-1.00.01.02.03.04.05.06.07.08.09.0

M12 M1 M2 M3 M4 M5 M6 M7 M8 M9 M10 M11 M12

% variance Performance against plan - I&E control total margin

actual % forecast % plan % Rating 1 Rating 2 Rating 3 Rating 4

-20

-10

0

10

20

30

40

50

M12 M1 M2 M3 M4 M5 M6 M7 M8 M9 M10 M11 M12

% variance Agency ceiling target £17.4m

actual % forecast % plan Rating 1 Rating 2 Rating 3 Rating 4

Page 169 of 224

Table 1

The South London and Maudsley NHS Foundation Trust - Operating Budgets

As At Mth 6 Change As At Mth 5

Service Analysis

Full Year Live Budgets (£)

Current Month Actual(£)

Variance From Live Budgets

(£)



(£)


Forecast Variance (£)

Movement From Previous

Forecast (£)

Forecast Last Month

Variance (£)

Notes Re Mth 6

01. Lambeth 22,174,500 2,184,400 449,800 12,370,200 1,335,900 886,100 2,146,000 496,000 1,650,000£150k lock in has impacted on position this mth. Position also continues to be driven by use of acute beds above contract (£828k over ytd inc risk share). Wards are overspending particularly Eden PICU (£177k) and Luther King (£60k). Delayed QIPP delivery on SHARP. Home Treatment Team pay overspend continues (£59k over ytd)

02. Southwark 29,629,600 2,244,800 (215,700) 14,702,400 261,600 477,400 141,000 (184,000) 325,000Adverse acute overspill variance of £487 ytd inc risk share. Ward expenditure has remained largely under control despite bank pay arrears this month. Additional CCG income re placements this year BUT concern over the Local Authority element where the LA have stated they are reducting their funding of an already overspending budget (current assumption is b/e but could be £1.3m over at year end)

03. Lewisham 23,681,200 2,324,000 302,500 13,018,300 1,222,000 919,500 1,850,000 350,000 1,500,000

Position driven by a combination of ward expend, overspill & high communtiy team pay costs. All 5 wards are overspending (in total £469k ytd). Scale of overspend is out of line compared to Swk & Croydon boroughs. Adverse acute overspill variance of £522 ytd inc risk share - the significant deterioration seen in mth 5 has continued (34% above contract in the month). 17/18 QIPP not made in community teams and review of primary care team required. £200k overspend on A&L teams (pay costs).

04. Croydon 16,356,400 2,038,400 383,300 9,787,700 1,793,900 1,410,600 2,718,000 326,000 2,392,000 Overspill at £243k ytd inc risk share plus significant acute/PICU ward & Psychosis Unit overspends (£0.7mk ytd) & 0), forensic services (£343k ytd) PRT overspends (£192k ytd), unmet historical CIPs in B&D (SUBSF) & income in developmental disorders below 17/18 levels.

05. PMOA (760,900) (159,400) (144,200) (790,400) (256,000) (111,800) (350,000) 0 (350,000) General underspends in older adult services helped by good control of ward/unit budgets. Largely income related issues on adult services with activity below target mitigated by pay underspends

06. Child & Adolescent Service 509,400 298,800 230,600 1,039,500 859,500 628,900 771,000 375,000 396,000 Low Kent bed occupancy but high costs (med agency) set to continue with transfer of service delayed (£298k ytd), variance of £213k on new PICU due to delays & low occupancy, delay in opening HD beds (estate issue) and O/P activity lower than Plan in some services but expected to improve.

07. Clinical Support Services 8,520,600 675,500 (34,600) 4,153,400 (106,900) (72,300) 108,000 (248,000) 356,000 Drugs remain in budget ytd but impact of new starters on paliperidone must be factored into forecast - review to be undertaken for mth 7

08. Infrastructure Directorates 63,333,500 5,890,800 345,700 35,253,900 1,387,300 1,041,700 2,921,000 (412,000) 3,333,000 includes various cost pressures in Estates (maint teams, hotel services) HR (training income, cost of payroll transfer & apprenticeship scheme), Medical (junior doctors), Nursing (legal fees - inquests) & R&D (£0.5m reduction in RCF funding)

09. Corporate Income (105,449,100) (8,689,400) (19,800) (52,552,300) (305,400) (285,500) (250,000) (200,000) (50,000) Impact of NHSE C&V income tolerances Operational Deficit 57,995,200 6,807,900 1,297,600 36,982,700 6,191,900 4,894,600 10,055,000 503,000 9,552,000

10. Corporate Other (79,106,900) (7,394,200) (866,300) (40,322,900) (1,246,500) (380,300) 3,392,000 768,000 2,624,000 release of provision for bank pay award this month as now incl in Directorate positions. Forecast includes an increase in the overspill risk 11. Contingency - planned 1,800,000 0 (150,000) 0 (900,000) (750,000) (1,800,000) 0 (1,800,000)12. Other reserves/provisions 7,223,600 0 (242,100) 0 (3,884,600) (3,642,500) (4,941,000) (761,000) (4,180,000) includes non rec transfer of Q1 lock ins (£2.1m) to reservesCorporate Other (70,083,300) (7,394,200) (1,258,400) (40,322,900) (6,031,100) (4,772,800) (3,349,000) 7,000 (3,356,000)

EBITDA (12,088,100) (586,300) 39,200 (3,340,200) 160,800 121,800 6,706,000 510,000 6,196,000

13. Post EBITDA Items 10,110,000 1,152,900 (196,800) 2,583,200 (204,800) (7,200) (600,000) (450,000) (150,000)

Trust Financial Position (1,978,100) 566,600 (157,600) (757,000) (44,000) 114,600 6,106,000 60,000 6,046,000

Items Not Included In NHSI Target (480,900) (43,000) (4,000) (264,000) (24,000) (20,000) 0 0 0 target excludes impairments, donated depreciation & gains/losses.

NHSI Control Total (2,459,000) 523,600 (161,600) (1,021,000) (68,000) 94,600 6,106,000 60,000 6,046,000 distance from NHSI Target

As At Mth 6 Change As At Mth 5

Corporate AnalysisFull Year Live Budgets (£)

Current Month Actual(£)


(£)



(£)



Movement From Previous

Forecast (£)


Notes Re Mth 6

A) Estates & Facilities 30,036,300 2,391,800 (141,600) 15,248,100 254,500 396,100 361,000 (328,000) 689,000 energy inflation budget uplift has improved the position this mth. However, maint team costs still too high, hotel services inflation dispute not resolved, high capital planning agency costs above budget and car park income delayed

B) Nursing & Quality 5,929,000 476,000 (17,200) 3,435,200 14,800 32,000 90,000 25,000 65,000 legal fees re inquests (£154 adverse ytd)C) Digital Services 8,215,600 655,200 (54,200) 4,056,200 53,900 108,200 0 0 0 unpredictable expenditure pattern - forecast to b/e at year endD) Finance 3,916,500 336,800 (10,100) 2,008,900 (42,400) (32,300) 0 0 0 CIPs expected to impact in 2nd half of the yearE) Human Resources 4,973,600 391,900 (54,700) 2,816,300 401,400 456,100 571,000 (55,000) 626,000 ongoing low training income, apprenticeship costs, payroll dept redundancy provision, OH contract overperformance and CIP savings not being metF) Strategy & Business Development 1,509,300 67,300 (67,000) 669,900 (63,300) 3,700 (11,000) 0 (11,000) favourable impact of UAE contract this mthG) Chief Executive 4,759,000 380,500 (16,700) 2,321,100 (54,700) (38,000) (30,000) (30,000) 0

H) Medical & Clinical Governance 12,829,400 1,210,600 122,300 6,803,900 432,600 310,400 800,000 118,000 682,000 cost of junior doctors above budget including use of locums and unmet CIPsI) Chief Operating Officer (3,947,400) 500 197,400 232,700 285,000 87,600 712,000 (129,000) 841,000 In month variance due to ongoing budget changes relating to the Borough management restructureJ) South London MH Partnership 5,200 319,500 319,100 (93,800) (96,400) (415,500) 0 0 0 net surplus being generated in SLP but will transfer to COO where the savings target sits

K) R&D (4,893,000) (339,300) 68,400 (2,244,600) 201,900 133,400 428,000 (13,000) 441,000 £0.5m reduction in RCF fundingInfrastructure Directorates 63,333,500 5,890,800 345,700 35,253,900 1,387,300 1,041,700 2,921,000 (412,000) 3,333,000

L) Corporate Other (79,106,900) (7,394,200) (866,300) (40,322,900) (1,246,500) (380,300) 3,392,000 768,000 2,624,000 release of provisions ahead of plan offset by unmet centrally held CIPs. Forecast includes an enhanced provision for acute overspillM) Trust Reserves 9,023,600 0 (392,100) 0 (4,784,600) (4,392,500) (6,741,000) (761,000) (5,980,000)Corporate Other (70,083,300) (7,394,200) (1,258,400) (40,322,900) (6,031,100) (4,772,800) (3,349,000) 7,000 (3,356,000)

F o r e c a s t


September 2018


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Table 2 NHSI Summary For South London & Maudsley NHS Foundation Trust

Page 171 of 224

Table 3 Summary CIP Performance

Income/Cost Type FY Plan 18/19FY Forecast

18/19FY Variance

18/19

FYP £ - Total CIPs 70 Pay 8,726 10,711 (1,985)

CYP £ 16,401 No of CYP Forecast % Plan Non Pay 6,428 4,442 1,986

Forecast Outturn 16,400 Schemes £'000s £'000s Income 1,247 1,247 -

YTD Plan 5,794 Low 36 8,873 10,651 54% Total 16,401 16,400 1

YTD Actuals 4,346 Medium 20 4,263 2,442 26%

YTD Variance (1,448) High 14 3,265 3,307 20% Recurrent 15,021 13,229 1,792

YTD Achieved % 75% Unidentified 0% Non Recurrent 1,380 3,171 (1,791)

Summary of Progress

There are some potential risk areas within the forecast which requires consideration:

a) within the forecast there is £3.3m of schemes which are Red Rated - this includes savings relating to the restructure, Estates , SLP collaboration and the additional risk associated with Overspill

c) Notable areas where there are potential risks to the projected forecast includes:

LEWISHAM -Lewisham Triage and PICU (£106K) ESTATES - Reduction in Maintnenace Costs (£118k) PATHOLOGY & PHARMACY - Prescribing Policy (£211k)

Significant movements in M6

Overspill on beds -1.99m

Trustwide - the lock in position is expected to be more favourable than planned 1.79m

Medical- ahead of target on training review 0.13m

Nursing & Clinical Governance- slightly ahead of target on staffing reviews in Health and Safety and Chaplaincy 0.07m

0.0m

Boroughs -1.99m

Trustwide 1.79m

Corporate 0.20m

0.0m

The position at Month 6 is in line with the in month target of £1m and £1.4m behind the YTD target of £5.8m.

TRUST CIP POSITION AMBER

RAG Ratings & Risks

OVERALL RAG RATING

The key movements contributing to the forecast variance are :

The full year forecast is expected to deliver to the planned £16.4m CIP which includes non recurrent values of £3.5m in relation to lock ins.

Financial Position M6

b) the CIP phasing requires significant delivery in the 2nd half of the year with 73.5% of the target expected to be delivered from M7-12 , therefore much resilience and scrutiny is required around the planning and management of the projects to ensure that delivery does not deviate in the later part of the year.

The primary driver behind the YTD position is acute overspill which accounts for all of £1.4m YTD underachievement.

Summary

-

500

1,000

1,500

2,000

2,500

Apr-18 Jun-18 Aug-18 Oct-18 Dec-18 Feb-19

SLaM Plan Vs Actual at M6

Plan NHSI Phasing Forecast/Actual -

500

1,000

1,500

2,000

2,500

Apr-18 May-18 Jun-18 Jul-18 Aug-18 Sep-18 Oct-18 Nov-18 Dec-18 Jan-19 Feb-19 Mar-19

NHSI Plan Vs Actual M6

NHSI Phasing Forecast/Actual

Page 172 of 224

To: CCG AO Trust CE CC: NHS Improvement and England Regional Directors NHS Improvement and England Regional Finance Directors Publications Gateway Reference 08559 16 October 2018

Approach to planning

The Government has announced a five-year revenue budget settlement for the NHS from 2019/20 to 2023/24 - an annual real-term growth rate over five years of 3.4% - and so we now have enough certainty to develop credible long term plans. In return for this commitment, the Government has asked the NHS to develop a Long Term Plan which will be published in late November or early December 2018.

To secure the best outcomes from this investment, we are overhauling the policy framework for the service. For example, we are conducting a clinically-led review of standards, developing a new financial architecture and a more effective approach to workforce and physical capacity planning. This will equip us to develop plans that also:

x improve productivity and efficiency; x eliminate provider deficits; x reduce unwarranted variation in quality of care; x incentivise systems to work together to redesign patient care; x improve how we manage demand effectively; and x make better use of capital investment.

This letter outlines the approach we will take to operational and strategic planning to ensure organisations can make the necessary preparations for implementing the NHS Long Term Plan.

Collectively, we must also deliver safe, high quality care and sector wide financial balance this year. Pre-planning work for 2019/20 is vitally important, but cannot distract from operational and financial delivery in 2018/19.

NHS Improvement and NHS England Wellington House

133-155 Waterloo Road London SE1 8UG

020 3747 0000

www.england.nhs.uk www.improvement.nhs.uk

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Planning timetable

We have attached an outline timetable for operational and strategic planning; at a high-level. During the first half of 2019-20 we will expect all Sustainability and Transformation Partnerships (STPs) and Integrated Care Systems (ICSs) to develop and agree their strategic plan for improving quality, achieving sustainable balance and delivering the Long Term Plan. This will give you and your teams sufficient time to consider the outputs of the NHS Long Term Plan in late autumn and the Spending Review 2019 capital settlement; and to engage with patients, the public and local stakeholders before finalising your strategic plans.

Nonetheless, it is a challenging task. We are asking you to tell us, within a set of parameters that we will outline with your help, how you will run your local NHS system using the resources available to you. It will be extremely important that you develop your plans with the proper engagement of all parts of your local systems and that they provide robust and credible solutions for the challenges you will face in caring for your local populations over the next five years. Individual organisations will submit one-year operational plans for 2019/20, which will also be aggregated by STPs and accompanied by a local system operational plan narrative. Organisations, and their boards / governing bodies, will need to ensure that plans are stretching but deliverable and will need to collaborate with local partners to develop well-thought-out risk mitigation strategies. These will also create the year 1 baseline for the system strategic plans, helping forge a strong link between strategic and operational planning. We will also be publishing 5-year commissioner allocations in December 2018, giving systems a high degree of financial certainty on which to plan.

We are currently developing the tools and materials that organisations will need to respond to this, and the timetable sets out when these will be available.

Payment reform

A revised financial framework for the NHS will be set out in the Long Term Plan, with detail in the planning guidance which we will publish in early December 2018. A number of principles underpinning the financial architecture have been agreed to date, and we wanted to take this opportunity to share these with you.

Last week we published a document on ‘NHS payment system reform proposals’ which sets out the options we are considering for the 2019/20 National Tariff.

In particular, we are seeking your engagement on proposals to move to a blended payment approach for urgent and emergency care from 2019/20. The revised approach will remove, on a cost neutral basis, two national variations to the tariff: the marginal rate for emergency tariff and the emergency readmissions rule, which will not form part of the new payment model. The document will also ask for your views on other areas, including price relativities, proposed changes to the Market Forces Factor and a proposed approach to resourcing of centralised procurement. As in

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https://improvement.nhs.uk/resources/201920-payment-reform-proposals/

previous years, these proposals would change the natural ’default’ payment models; local systems can of course continue to evolve their own payment systems faster, by local agreement.

We believe that individual control totals are no longer the best way to manage provider finances. Our medium-term aim is to return to a position where breaking even is the norm for all organisations. This will negate the need for individual control totals and, in turn, will allow us to phase out the provider and commissioner sustainability funds; instead, these funds will be rolled into baseline resources. We intend to begin this process in 2019/20.

However, we will not be able to move completely away from current mechanisms until we can be confident that local systems will deliver financial balance. Therefore, 2019/20 will form a transitional year, in which we will set one year, rebased, control totals. These will be communicated alongside the planning guidance and will take into account the impact of distributional effects from any policy changes agreed post engagement in areas such as price relativities, the Market Forces Factor and national variations to the tariff.

In addition to this, we will start the process of transferring significant resources from the provider sustainability fund into urgent and emergency care prices. The planning guidance will include further details on the provider and commissioner sustainability funds for 2019/20.

Incentives and Sanctions

From 1 April 2019, the current CQUIN scheme will be significantly reduced in value with an offsetting increase in core prices. It will also be simplified, focussing on a small number of indicators aligned to key policy objectives drawn from the emerging Long Term Plan.

The approach to quality premium for 2019/20 is also under review to ensure that it aligns to our strategic priorities; further details will be available in the December 2018 planning guidance.

Alignment of commissioner and provider plans

You have made significant progress this year in improving alignment between commissioner and provider plans in terms of both finance and activity. This has reduced the level of misalignment risk across the NHS. We will need you to do even more in 2019/20 to ensure that plans and contracts within their local systems are both realistic and fully aligned between commissioner and provider; and our new combined regional teams will help you with this. We would urge you to begin thinking through how best to achieve this, particularly in the context of the proposed move to blended payment model for urgent and emergency care.

Good governance

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We are asking all local systems and organisations to respond to the information set out in this letter with a shared, open-book approach to planning. We expect boards and governing bodies to oversee the development of financial and operational plans, against which they will hold themselves to account for delivery, and which will be a key element of NHS England’s and NHS Improvement’s performance oversight. Early engagement with board and governing bodies is critical, and we would ask you to ensure that board / governing body timetables allow adequate time for review and sign-off to meet the overall timetable.

The planning guidance, with confirmation of the detailed expectations, will follow in December 2018. In the meantime, commissioners and providers should work together during the autumn on aligned, profiled demand and capacity planning. Please focus, with your local partners, on making rapid progress on detailed, quality impact-assessed efficiency plans. These early actions are essential building blocks for robust planning, and to gauge progress we will be asking for an initial plan submission in mid-January that will be focussed on activity and efficiency (CIP / QIPP) planning with headlines collected for other areas.

Thank you in advance for your work on this.

Yours sincerely

Simon Stevens Chief Executive NHS England

Ian Dalton Chief Executive NHS Improvement

Page 176 of 224

Annex

Outline timetable for planning Date

NHS Long Term Plan published Late November / early December 2018

Publication of 2019/20 operational planning guidance including the revised financial framework Early December 2018

Operational planning

Publication of x CCG allocations for 5 years x Near final 2019/20 prices x Technical guidance and templates x 2019/20 standard contract consultation and dispute resolution

guidance x 2019/20 CQUIN guidance x Control totals for 2019/20

Mid December 2018

2019/20 Initial plan submission – activity and efficiency focussed with headlines in other areas 14 January 2019

2019/20 National Tariff section 118 consultation starts 17 January 2019

Draft 2019/20 organisation operating plans 12 February 2019 Aggregate system 2019/20 operating plan submissions and system operational plan narrative 19 February 2019

2019/20 NHS standard contract published 22 February 2019

2019/20 contract / plan alignment submission 5 March 2019

2019/20 national tariff published 11 March 2019

Deadline for 2019/20 contract signature 21 March 2019

Organisation Board / Governing body approval of 2019/20 budgets By 29 March

Final 2019/20 organisation operating plan submission 4 April 2019 Aggregated 2019/20 system operating plan submissions and system operational plan narrative 11 April 2019

Strategic planning

Capital funding announcements Spending Review 2019

Systems to submit 5-year plans signed off by all organisations Summer 2019

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OCTOBER 2018

Title

CHIEF EXECUTIVE’S REPORT

Author

Dr Matthew Patrick


To inform the Board about significant issues affecting the Trust.

A – CQC Inspection report

On Tuesday, the CQC published its report arising from the recent inspection of the Trust. The Trust

has achieved an overall rating of ‘good’ and we are also rated as ‘good’ for the well-led domain. In

the caring domain, the Trust is now rated either ‘good’ or ‘outstanding’ for every single

pathway. This reflects considerable hard work across the breadth of the Trust and I would like to

extend my warm thanks to staff for all they do to provide high-quality care to our service users.

We do, however, also have some important improvements to deliver. As has been discussed

previously at the Board, the inspectors identified a number of areas of concern and these were

highlighted in their governance improvement notice relating to the acute care pathway. These

concerns have affected the ‘responsive’ and ‘well-led’ domains in the adult inpatient wards pathway,

with the result that this pathway is now rated ‘inadequate’ overall. Following receipt of the notice,

staff have been very focused on the development of an improvement plan and we now have a

detailed programme of interventions - designed by our senior service, clinical and nursing leaders -

to ensure that the necessary improvements and a consistently high quality of care are delivered

quickly and effectively.

We are confident that the new Borough-focused Directorate structures will help to improve the

consistency of performance in our acute pathway. But we also know that the pressures in the

system, relating to patient flow and emergency admissions, put severe strain on our services and

directly impact the quality of our care. Our proposals to improve patient flow are set out in the paper

coming to the Board this month. Subject to the Board’s agreement this month, we will be submitting

our improvement plans to the CQC, which will cover patient flow as well as a range of other detailed

improvements to improve leadership, governance and the consistent delivery of fundamental

standards of care. These have been set out on both a Directorate by Directorate and a Trust-wide

basis. The Board will be kept fully informed about our progress.

Given our current focused efforts on improvement, we must not forget to celebrate the numerous

areas in which the CQC identified not only good, but also outstanding, practice across the Trust.

For example:

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Our community-based services for older people demonstrated consistent improvements

since the 2015 inspection and have been given a good rating overall. In the well-led domain,

they have attracted an outstanding rating.

At our Bethlem Hospital site, the Lishman Unit (unannounced inspection) and our Eating

Disorders services were rated good across all five domains.

The Home Treatment Team and Health Based Place of Safety have also done a great deal

to improve and are rated good across the board.

Inspectors were impressed with our forensic services and their consistent improvement over

time. They were given a good for their overall rating.

Inspectors said that the trust had a skilled and ‘high calibre’ board that is determined to make

changes to provide high quality care to local communities, including participating in local

systems to drive progress to achieve integrated care. The high-quality role of our Governors

was also highlighted.

These, and other positive findings, are a testament to the care and dedication of our staff in those

teams and our senior leaders. I would like to extend my sincere thanks to these teams on behalf of

our Board.

B – South London Mental Health and Community Partnership Portfolio Board

Across South London, community mental health services are in real need of additional investment.

The South London Partnership met earlier this month to agree plans relating to the acute care

pathway and to complex care placements. We know that there is a substantial opportunity to

improve the quality of care being provided for complex care placements across our Boroughs and

also for this to deliver better value. The Partnership has now submitted a proposal to our two STPs

that we believe would allow for significant resources to be freed up for re-investment in mental health

services.

C – Maudsley Charity

On 17th October, the Board of the new independent Maudsley Charity met for a Strategy Away Day.

The Board is chaired by Alan Downey, previously a SLaM Non-Executive Director, and members of

the Board include Nicola Byrne, June Mulroy and myself, together with a number of talented and

enthusiastic new independent trustees from a range of backgrounds and disciplines. It is a strong

and developing Board which fully recognises the mutual importance of the relationship between the

independent Maudsley Charity and the Trust.

D – Pastures new

The Charity Away Day was an opportunity to extend the sincere thanks of the Trust to Alan Downey

for all his hard work and contribution as a Non-Executive Director over a period of more than four

years.

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We also marked the departure of two longstanding and much-loved members of staff this last month

who are taking up exciting new positions. Professor Tony David is leaving to join University College

London as Director and Sackler Chair of the UCL Institute for Mental Health. Amanda Pithouse,

who has worked in the Trust for many years and contributed to all our major CQC inspections

amongst many other contributions, is joining Barnet Enfield and Haringey Mental Health Trust as

their new Director of Nursing. We wish them both all the very best in their new roles.

E – Royal Foundation

On Tuesday 16th October, I attended the Steering Group working with the Royal Foundation to help

shape the Duchess of Cornwall’s campaign on early years and mental health. The group is working

towards a prioritised set of recommendations and is making good progress.

F – Maudsley Health Conference

The Annual Maudsley Health Conference took place in Abu Dhabi on the 11th October. I have had

the honour of both opening and closing this successful event over each of the past three years. The

conference brings together some great minds in the fields of psychiatry and wellbeing and provides

updates on cutting edge advances in child, adolescent and adult mental health services.

I also took the opportunity to carry out a Leadership Walkaround of our Al-Amal hospital. It was a

very informative visit and I came away impressed with the quality of care being provided.

G – Nursing Times Award for learning and development – South London Partnership

I am delighted to report that the South London Partnership (SLP) has won the prestigious national

Nursing Times Workforce Award for Best Workplace for Learning and Development (over 1,500

staff) - for the work of the SLP Nursing Development Programme.

My congratulations and thanks to all the Nursing Development Team and most of all to the

thousands of nursing staff across the South London Partnership who have helped to make the

improvements. These range from the introduction of new shared job descriptions and competency

frameworks to the launch of a successful new Band 4 Nursing Associate/Assistant Practitioner

Development Programme.

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30 October 2018

Title

Council of Governors’ report

Author Charlotte Hudson, Deputy Director of Corporate Affairs

Accountable Director Rachel Evans, Director of Corporate Affairs


To update the Board on the recent activity of the Council of Governors

Extraordinary meeting of the Quality Working Group – 10 September An extraordinary meeting of the Quality Working Group was called for 10 September, designed to give Governors an opportunity to learn more – and ask questions about – Trust projects to reduce length of stay, how quality of care is maintained post-discharge, preventing re-admission and about current demand for inpatient beds. There was an emphasis on flow, and Governors learned more about the Multi-Agency Discharge Events (MADEs) taking place across Lambeth, Lewisham, Southwark and Croydon. Visit to Aubrey Lewis 3, Eileen Skellern 1 and John Dickson wards – 11 September A group of Governors joined four Non-Executive Directors on a visit to Maudsley-based wards on 11 September. The group visiting AL3 were invited to attend a safety huddle, so they could see how they operate. Flow issues were raised on ES1 and AL3. A visit to a Southwark community team (part of the acute pathway) has been arranged for 11 December. Council of Governors’ meeting – 13 September The full Council met on 13 September, and there was a good turn out from both Governors and prospective candidates for election who came to observe. Governors received the auditors’ limited assurance report on the Quality Accounts as well as the annual report from the Audit Committee. The Chair updated Governors on the recent CQC inspection and outlined the improvement plan put in place because of the CQC warning notice in respect of the acute pathway. Governors also received a presentation on plans for the Centre for Young People. Annual Members’ Meeting and Staff Awards – 25 September The AMM took place on 25 September at the KIA Oval. Feedback from Governors has included a request that attendance at the AMM should be one of the “core” events that Governors should really try to attend.

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Members’ Seminar – 12 October

As part of the ongoing programme of SLaM Members’ Seminars, Professor Khalida Ismail, Professor of Psychiatry and Medicine at the Institute of Psychiatry, Psychology and Neuroscience at King’s College Hospital, presented a well-attended talk entitled “Double, Double, Toil and Trouble: Diabetes in Psychosis”. She told attendees about current practice in diabetes management, the relationship between diabetes and psychiatry, and local examples of integrated working e.g. between SLaM and KCH. She discussed the impact of medication on type 2 diabetes, and what clinicians can do to ensure that a service user’s mental and physical health needs are met in one clinical environment.

Nominations Committee appointment Simon Darnley (Staff Governor) has been appointed to the Nominations Committee further to a vacancy arising. Governor Away-Day - 23 October The Governors’ Away-Day will take place on 23 October. CCG representatives have been invited to attend and outline the challenges and priorities for them with regards to the provision of mental health services in the four boroughs. Governor elections The election process is currently underway, with two public and three service user vacancies. There were two staff vacancies, but only one member of staff stood and has been duly elected. The Membership and Involvement Working Group plans to look at how to engage more staff members in the work of the Governors and thereby encourage more staff to stand for election. Results in the remaining categories will be declared on 5 November and new Governors will take up post from 1 December. Lobbying A letter, signed by 20 Governors and nine South London MPs, was sent to the Secretary of State for Health and Social Care on 8 October. The letter called for

1. Increased investment in CAMHS services in south east London; 2. Funding to assist with recruiting and retaining staff to work in mental health, including

support for staff accommodation and the reinstatement of bursaries; 3. Investment in new and improved digital platforms; 4. Capital funding to enable investment in fit-for-purpose buildings.

Meeting with NEDs Governors are due to meet with the NEDS ahead of the Board meeting and have raised questions about patient flow, bed capacity and the Trust’s financial position.

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COMMITTEE REPORT TO THE TRUST BOARD: PUBLIC

30 October 2018

Title

EQUALITIES AND WORKFORCE COMMITTEE UPDATE

Non-Executive Director

Roger Paffard, Chairman


This is a regular report to the Board which sets out:

the key issues discussed at the Committee meeting and the actions proposed;

the key points of assurance;

the key risks that the Chair or the Committee wish to flag; and

any issues to flag to other Committees. The Board is asked to note the report which is presented for information and discussion.

Board Assurance Framework

BAF Risk 1 - Workforce BAF Risk 13 – Mandatory training

KEY ISSUES SUMMARY

Actions proposed to address key issues

Board to ward KPIs covering all aspects of workforce are taking longer than hoped to deliver

SMT to consider whether this should be raised as a risk on the BAF

It was noted that leadership engagement plans discussed by this committee have been overtaken by the Leadership & Culture workstream action plan within the Trust’s CQC improvement plan

Workstream action plan to be brought to this committee to note

Under-estimates of the volume of Occupational Health activity in our new contract are impacting on turnaround times

Discussions are in progress with our OH service provider

Our WRES targets remain a challenge Work with Yvonne Coghill to improve our ability to deliver these targets

Freedom to Speak Up Guidance for Boards requires an improvement action plan

Requirements to be presented to the Board

Staff survey response for the 2017 survey was lower than peer group and needs improving in 2018

Detailed action plan presented and agreed

Talent management strategy to be refreshed

Presentation to SMT in November

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Support required for the Lived Experience (Staff) Network

Now agreed by SMT

Key points of assurance

A new style workforce report providing KPIs and supporting narrative as at Q1 was presented.

Equalities and workforce action plan progress as at Q2 was noted.

There are two workforce risks on the BAF – recruitment and retention, and mandatory training. The causes, controls, gaps in assurance and actions to close the gaps were discussed. It was expected that the rating of BAF 13 relating to mandatory training could be reduced at the next meeting provided compliance levels continue to rise.

Freedom to Speak Up Guardian’s October Board report was presented.

WRES plan for year 2 presented.

Key risks to flag

Risks that OH performance may impact on time to hire. Continued risks in relation to delivering the WRES targets.

Issues to be brought to the attention of other Committees

Workforce report including KPIs to be presented to the Quality Committee.

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30 October 2018

Title

BUSINESS DEVELOPMENT AND INVESTMENT COMMITTEE UPDATE


June Mulroy






any issues to flag to other Committees. The Board is asked to note the report which is presented for information and discussion. This report provides an update for the October BDIC meeting, held on 9th October 2018.


BAF Risk 1 - Workforce BAF Risk 2 – Operational Delivery Structure BAF Risk 5 – Partnership working with service users. BAF Risk 7 – Quality & statutory compliance BAF Risk 8 – Finance (contracts) BAF Risk 9 – Estates BAF Risk 12 Finance (cost management)

KEY ISSUES SUMMARY


Commercial strategy – a first version of the commercial strategy was presented to BDIC, several next steps and actions were agreed.

Write up paper to develop private practice case within timeline of Commercial Strategy

Develop the Commercial Estates elements to present at the January 2019 BDIC meeting

Scoped out and defined within timeline of Commercial Strategy the digital workstream

The management and governance of commercial activities update paper was presented, BDIC members commented that alongside research from areas which had had success with wholly owned subsidiaries those which has failed also needed to be investigated.

Agreed to contact North Bristol and other selected other Trusts to gain insight and continue with agreed next steps

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Need to incorporate past learnings from previous contracts to inform approach to HMP Wandsworth & Brixton tender

Contact previous clinical leads for input and previous issues and ensure these are not taken forward with the current opportunity


Progress being made on performance data for international activities and this will come back to BDIC in December. NEDs will get exposure to Commercial Strategy at the next Board Away Day.

Key risks to flag

No key risks to flag


None

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30 OCTOBER 2018

Title

FINANCE AND PERFORMANCE COMMITTEE (‘FPC’) UPDATE


June Mulroy, FPC Chair


From FPC meeting of 09 October 2018 This is a regular report to the Board which sets out:




any issues to flag to other Committees. The Board is asked to note the report which is presented for information and discussion.


BAF Risk 3 Informatics

BAF Risk 8 Finance (contracts)

BAF Risk 9 Estates

BAF Risk 12 Finance (cost management)

KEY ISSUES SUMMARY


(1). Lambeth Living Well Alliance activities: update. The report provided an update on the progress of the transformational, strategic and operational dimensions of the Living Well Network Alliance and explored: (a) transformation plans, finance and activity; (b) a forward view of the Alliance programme; and (c) identification of management and risk issues. The Trust’s risk share has, by negotiation, remained unchanged by the formation of the Alliance, and the FPC noted that:

the paper’s narrative style did not highlight matters such as financial risk, contract performance, and risk sharing (total risk and the Trust’s share). The FPC also noted that the report’s format could be usefully amended to include information in graphical or tabular form, with increased use of projections of future performance, run rates, comparatives with prior periods and benchmarking; and

reports from Alliances added another layer of reporting and may be difficult to consolidate with the Trust’s finance reporting. It may assist if all

The Director of Finance will discuss the FPC’s comments with the Interim Alliance Director so that future reports to the FPC are more finance-orientated and include the type of information requested by the FPC (Dec.2018).

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KEY ISSUES SUMMARY


Alliances adopted a consistent form and content for their reports.

(2). Procurement Department. The paper sought (and after discussion obtained, subject to the comments raised) the FPC’s approval to progress discussions as to a shared service arrangement with Guy’s and St Thomas’ NHS Foundation Trust (‘GSTT’). The meeting recapitulated the benefits of such an arrangement. The FPC heard that GSTT has to date been very flexible in negotiations. The FPC noted that both parties will have ‘red lines’, noted that these should be identified and discussed as soon as possible and noted that such red lines might include: the timescale to set up the contract; the duration of the contract; fees and in particular any performance-related element for any fee to GSTT; arrangements with other shared service partners; and productivity – price and quality KPIs. Benchmark information from ‘The Model Hospital’ may be useful in this regard. The FPC discussed how and where the contract will be managed, reported and subject to scrutiny.

The CFO and Head of Procurement will reflect on the comments raised by the FPC, will circulate a revised proposals paper in the next 30 days, and will submit a final decisions paper to the BDIC in December 2018 (Nov.2018, Dec.2018). The COO will present a paper to the next FPC meeting about possible use of the benchmarking information available in The Model Hospital (Dec.2018).

(3). SLP: 2018/19 financial plan and month 4 position. The month 4 finance report was produced using the budget plan shared at the Portfolio board in July 2018. This presented a potential net surplus of £5.68m, reducing to £1.88m surplus once a number of risks (contingencies) had been factored into the plan. The overall position was a year to date deficit of £0.23m. This represented a shortfall of £0.70m against the planned target of £0.47m surplus. This position included two year to date contingencies of £1.07m which are described in more detail in the paper. Adult Secure service users (Forensics) is one key area of departure from the plan, there being a gap of some 16 service users. Often beds are available but cannot be accessed for funding reasons. The agreement under which the SLP operates was signed off before NHS England introduced (in April 2017 for Forensic) the New Models of Care (‘NMoC’) regime. Arguably this had resulted in an unfair operating agreement which the SLP might refer for arbitration; The contract for Child and Adolescent Mental Health Services (‘CAMHS’) was not currently signed off, as the tariff had yet to be agreed; and Under the current contracts there was there was little incentive for adoption of best practice. NHS England had requested SLaM to provide the services covered by the SLP (Forensics, CAMHS and complex care).

The FPC noted the paper and agreed that the issues discussed should be flagged to the Board in the FPC’s ‘key issues’ report.

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KEY ISSUES SUMMARY


(4). BAF update. The FPC noted that the BAF now covers key risks in the Executive Risk Register (‘ERR’), and that BAF risk 2 (operational performance) is now recommended as to be transferred to the remit of the Quality Committee.The FPC again discussed which committee should be responsible for review of BAF risk 3 (health informatics) – currently still shown as the FPC despite comments raised in previous FPC discussions. The FPC noted that other Trusts have technology committees which discuss health informatics issues and noted that SLaM’s technology group (which is not a Board committee) could review technical aspects of matters covered in BAF risk 3, and could report to the FPC which would review informational aspects.

Post meeting note: the SMT subsequently decided that BAF risk 2 (operational performance) should remain under the joint remit of both the FPC and the Quality Committee. The Head of Risk and Assurance will liaise with the Director of Nursing and the Director of Corporate Affairs about the FPC’s proposal for the Technology Group to review technical aspects of BAF risk 3 and report to the FPC thereon. The Director of Nursing will report back to the next FPC meeting (Dec.2018)

(5). Finance and Performance reports. The key issue is an increase in bed days due both to an increase in demand (A&E attendances increased) and decrease in discharge rates. The increase in demand is across all sources. Winter pressures funding of some £1.3m (covering both SLaM and Oxleas) has been announced. This is an increase compared with prior years, but is a relatively small sum compared with SLaM’s control total. SLaM has kept NHS Improvement informed about the pressures and risks around achievement of the control total, and to date NHSI’s response has been to continue to encourage SLaM to achieve the control total. Key to resolving these issues is a change of behaviours. Trust management is preparing an improvement plan for review by the COO and Medical Director. This would probably require 6 months for set up, the benefits being realised over the following 12 months. The meeting discussed in some detail the increase in risks of SLaM’s delivery of its 2018/19 control total, NHS Improvement’s stance having been informed thereof and how SLaM should best proceed.

The COO and Medical Director will prepare a paper on bed pressures for review at the next Board meeting outlining the causes thereof and SLaM’s improvement plans in response – perhaps structured around ‘Base, Aggressive, Relaxed’ scenarios (Nov.2018). The Director of Finance will shortly email to FPC members the text of a suggested note to NHS Improvement about achievement of SLaM’s 2018/19 control total (Oct.2018)


All the above points provide assurance

Key risks to flag

The FPC concluded that no matters required escalation for the attention of the Board. However the FPC considered that the Board should be made aware of certain key issues covered at the meeting namely:

issues around the SLP’s operations (item 3 above); and

issues around achievement of SLaM’s control total (item 5 above).

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Issues to be brought to the attention of Committees

BDIC – item (2) regarding proposed changes to SLaM’s procurement arrangements Technology Group – item 4 regarding review of BAF risk 3 (health informatics) The Audit Committee will receive a copy of this key issues report as a matter of course.

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30 OCTOBER 2018

Title

AUDIT COMMITTEE UPDATE


Duncan Hames


(A). Key issues report: issues arising from the September 2018 Audit Committee meeting This is a regular report to the Board which sets out: the key issues discussed at the Committee meeting and the actions proposed; the key points of assurance; the key risks that the Chair or the Committee wish to flag; and any issues to flag to other Committees. The Board is asked to note the report which is presented for information and discussion. Available upon request – the Audit Committee minutes on which this key issues summary is based. (B). Signed and sealed report Also presented is the signed and sealed report. SLaM management is required to report to Audit Committee meetings on documents signed and sealed on behalf of the Trust, and the Audit Committee is required subsequently to present that report to the Board. The Board is asked to note the report which is presented for information and discussion.


BAF Risk 7 - quality and statutory compliance

KEY ISSUES SUMMARY


(1). Capital Projects internal audit report (TIAA): closing agreed actions. The Director of Capital, Estates and Facilities (‘CEF’) advised that: (a) the previous Committee meeting had discussed the recommendations in the internal audit report ‘Capital Projects’ issued in November 2017 by the Trust’s previous internal audit provider (TIAA), which had expressed a ‘limited assurance’ internal audit opinion; and (b) the current paper outlined how Trust management had now closed all the agreed actions from TIAA’s report.

The Director of CEF confirmed that the improvements introduced would be embedded into practice. The current Head of Internal Audit confirmed that he and his team had discussed the paper with the Director of CEF and, based on that, was satisfied that the management actions if implemented as described in the paper would address the recommendations made.

(2). Operational matters. The COO advised the severe challenges resulting from intense bed pressures, already (in September 2018) moving towards winter working methods, noting that a regime of daily escalation phone calls was in place.

The COO noted the drive to reduce length of stay, in particular for the Croydon cohort, also noting that resolution of this issue lies in a systems/partnership approach. However the COO advised that partnership working with St George’s Hospital has been proving very difficult

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KEY ISSUES SUMMARY


The Committee noted that the Trust is at risk of moving from its statutory role as a provider of mental health services to provision of ‘sanctuary’. The COO agreed, noting that there had been a step change in levels of distress in the local population (perhaps due to Universal Credit or Brexit) and that this risk also derived from complex care issues arising from issues in the Housing sector.

The Committee noted that alliances and partnership working were ‘two-way streets’ and hence all parties should be aware that the Trust is entitled to receive support as well as providing support to other bodies

(3). Finance matters. The CFO advised that the Trust is currently in the right place as at month 5 with its financial plan, but has used all currently available non-recurring schemes to do this and the year end position currently projected is a potential gap of some £5m to £6m. This is being driven by operational pressures, the most significant of which are overspill beds and agency costs and some pressures that were not known at the time of the Trust’s planning and which exceed available contingency. The CFO advised that NHS Improvement has signalled its intention to review the financial regime of Control Totals and Provider Sustainability Funding (‘PSF’).

Noted for Board information only

(4). Board Assurance Framework (‘BAF’). The meeting discussed BAF risk 7 (Quality and statutory compliance) in the light of the findings from the CQC’s recent visit. The COO advised that Trust management had been aware of the type of issues reported by the CQC, but had not appreciated their full scale. The Committee queried how/why Trust management was not thus aware and was advised that the Trust may have concentrated on addressing the CQC’s concerns from their previous visit, which had focused more on review of staffing, care plans and existence of policies and procedures. The Committee Chair noted that the Trust needed to ensure that it had the capacity to deliver mitigation plans regarding quality and statutory compliance, especially given the work required on Human Resources and Estates.

Committee members stressed the need for the Trust to set its own priorities and to avoid any tendency simply to respond to issues identified by the CQC. The COO flagged the need for the Trust to obtain evidence of achieving desired outcomes, not just to produce policies or embed processes. Committee members and the COO flagged the need to improve use of available systems (clinical audit, peer review and Business Intelligence) to identify and close issues. The COO advised that Business Intelligence dashboards had not been flagging the gaps that the CQC had found. The CFO confirmed that the Trust would be addressing these issues in the forthcoming Governance review.

(5). Internal audit report: ‘IT support and maintenance contract management’ (limited assurance). The Head of Internal Audit advised that the overarching issue was an inconsistent approach to contract management, but that audit work had not indicated that Trust staff were using software out of contract or with missing licences. Committee members considered that a key implication was the likely negative effect on the ability of staff to perform their duties and to use the balanced scorecard appropriately. The Committee Chair flagged the

The Chief Information Officer will prepare a note on how the Trust is implementing the recommendations in the internal audit report and will attend the next Committee meeting to discuss this with the Committee (Dec.2018)

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KEY ISSUES SUMMARY


recommendation on ‘procurement processes’ (high priority, June 2018 implementation date).


Points 1 and 3 provide assurance.

Key risks to flag

See above


None

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South London and Maudsley NHS Foundation Trust 24/05/2018 -11/09/2018 Report to September 17th 2018 Audit Committee

Summary of Documents signed on behalf of the South London & Maudsley NHSFT where sealing is required

Number Date Description Value

Length of

Time

involved Between And Signature Signature

173 26/06/2018

Engrossed

Lease relating to the premises at the Munro Centre,

Snowfields, London SE1

Peppercorn rent

SLaM

The Bloomfield

Learning Centre for

Children Ltd

Matthew Patrick Gus Heafield

CFO Report to Audit Committee Meeting 17th September 2018 Appendix 1

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South London and Maudsley NHS Foundation Trust 24/05/2018 -11/09/2018 Report to September 17th 2018 Audit Committee

Summary of Documents on behalf of the South London & Maudsley NHSFT where signing is required.

Number Date Description Value

Length of

Time

involved Between And Signature Signature

581 26/06/2018

Lambeth Living Well Alliance Agreement

£48,000,000 7 year SLaM

NHS Lambeth CCG

LBL

Thames Reach

Southside Partnership

Gus Heafield Kris Dominy

581 a 26/06/2018 NHS Standard Contract in relation to entry 581 above £3m balance for MHOA & CAMHs 7 year SLaM Lambeth CCG Gus Heafield Kris Dominy

581 b 26/06/2018NHS Standard Variation Contract in relation to entry 581

above £3m balance for MHOA & CAMHs7 year SLaM Lambeth CCG Gus Heafield Kris Dominy

582 09/07/2018NHS Standard Contract ( 1 copy)

£130,000 14 months SLaMBromley, Lewisham, &

Greenwich MINDGus Heafield Altaf Kara

583 09/07/2018

NHS England Standard Contract Variation ( 2 copies)

No financial changes, to bring into line

with National Standard Contract May

2018 edition

1 year SLaM NHS England Gus Heafield Altaf Kara

584 09/07/2018 NHS Standard Contract £446,776.00 1 year SLaM Bexley CCG Gus Heafield Altaf Kara

585 09/07/2018Service Contract (1 copy)

£50,000 1 year SLaMGibraltar Health

AuthorityGus Heafield Altaf Kara

586 02/08/2018

Deed of Contract extension for the provision of "Healthy

Weight Management Programme" for a further 12 months to

end March 2019 £102,000.00 1 year

SLaM

Lambeth Council Matthew Patrick Altaf Kara

587 NOT USED NOT USED NOT USED

588 02/08/2018

NHS Standard Contract for the provision of Traumatic Stress

Service (2 copies) Cost per case basis 2 years SLaM

Surrey & Borders NHS

FT Matthew Patrick Altaf Kara

CFO Report to Audit Committee Meeting 17th September 2018 Appendix 1

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30 October 2018

Title Quality Committee update

Non-Executive Director Anna Walker, Chair of the Quality Committee






any issues to flag to other Committees. The Board is asked to note the report which is presented for information and discussion. This report covers meetings of the Quality Committee which took place on 11 September and 17 October. The latter was an Extraordinary meeting, called to provide assurance to the Board on Our Improvement Plan.

KEY ISSUES SUMMARY


Our Improvement Plan At its September meeting, the Committee received terms of reference for the groups convened to manage and oversee progress against Our Improvement Plan and to ensure appropriate governance, including the Delivery Board and Oversight and Scrutiny Committee. The latter will report to the Board through the Quality Committee. At an extraordinary meeting convened for 17 October, the Committee received the improvement plans for Lambeth, Lewisham, Southwark, PMOA and Croydon for scrutiny. Each plan includes Trust-wide Must and Should Dos arising from the CQC inspection. The Trust wide Improvement Plan was also considered. NED members congratulated the teams on the amount of work that had gone into the plans. The teams were asked to make their plans more outcome focussed so the QC, Oversight and Scrutiny Committee and Delivery Board could see, and discuss, where more support was needed. NED members also asked for more clarity around proposed floor-to-Board governance including a clear governance organogram and what the flow of information would be with a view to ensuring that all levels of the organisation receive consistent and proportionate

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performance information. Proposals are due to go before the Delivery Board wc 22 October and would be reported to the QC/Board. . The Committee stressed the importance of the organogram and information/metrics including community teams and pressed for roll-out of the Community Quality and Effectiveness Trigger Tool (QuESTT) to assist with monitoring team performance. Assurance was received that the Delivery Board is working to finalise the 20 metrics that will be specifically reported on as performance measures going forward. The Committee stressed that outcomes and improvements must be quantitative. It was agreed that the QC would see, and seek assurance on, the metrics which were to be reported. The general view was that the CQC requirements were not difficult in themselves. The challenge would be solving the flow issues and cultural change. It was very important that the centre was clear about what it expected of all staff. It is recognised that different boroughs had different challenges (e.g. recruitment and retention in Lewisham and Croydon; Southwark does not have a male PICU and deals with a busy Emergency Department at Kings College Hospital). Support from the centre will need to meet these specific challenges. Directorates were asked to consider the amount of resources, capacity and capability to deliver the improvement plans. These issues should not slow down action plans but need to be recognised.

Flow The Committee received updates at both meetings in respect of plans to improve flow, including progress at Multi-Agency Discharge Events (MADEs). The performance aims for measurement are:

No 12 hr breaches in Emergency Departments

No s136 breaches

No cancelled MHA assessments in the community

No inpatients sleeping anywhere other than a bed. It was agreed that clinical information was needed on the flow issues ( e.g. percentage of service users with psychosis) It was also agreed that the Trust needed to collect waiting time information systematically to ensure solutions to flow issues are not achieved by increasing waiting times. Waiting time information collected should include the wait for psychological therapies.

Community QuESTT As indicated in discussions around our Improvement Plan, the Quality Committee urges the speedy development of a Community QuESTT to ensure that there is the same oversight of community risks as there are inpatient risks.

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Statutory / mandatory training

The Committee noted the improvements in compliance with statutory / mandatory compliance and will receive a report at its November meeting with proposals for streamlining / rationalising the suite of training that staff must undertake.

Care plans Data shows that the number of care plans being designed collaboratively with service users (inpatients) has steadily increased. Matrons in acute services are auditing the quality of care plans and early feedback from the CQC suggests that quality has improved. This is a very positive development. It was recognised that information was also needed the number of care plans involving carers.

Lessons Learned Q1 It was reported that Q1 was unusual insofar as the Trust received two preventing future deaths reports, one in CAMHS in respect of additional learning around care planning and crisis support, and one about improving observations and nursing further to an inpatient suicide on an older adults’ ward. In each case, the inquests were challenging, and the learning has been identified and acted upon. It was agreed that, in future, the QC would be given more timely and detailed information on any preventing future deaths reports. The Committee discussed the flow of information regarding serious incidents (including deaths) to ensure floor to Board oversight. It was recognised that more clarity needed to be agreed on what comes to the QC. Safety huddles provide week-on-week reviews of all incidents and track learning, taking place on teams and up to the Trust Senior Management Team. An independent review of themes from Serious Incidents Requiring Investigation (SIRIs) was commissioned by the Trust from Dr Jane Carthey, Human Factors and Patient Safety Consultant. Workshops will take place for the directorates to reflect on the learning and will be open to Board members and Governors .It was agreed that the QC should receive reports on how actions identified in Jane Carthey’s report were being acted on across the Trust.

Quality BAF risks The Quality Committee made recommendations at its September meeting that:

The score for BAF Risk 7 (Quality and Statutory Compliance) is increased to 16 and is red-rated;

The narrative of BAF Risk 7 is revised to widen the definition of “quality” beyond statutory and mandatory requirements;

The mitigations against the risk are articulated more widely

Work on the BAF has been undertaken at pace and many revisions made ahead of Board-wide consideration of BAF

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Risk 7 on 30 October, so the Committee has necessarily been receiving drafts subject to change.

Physical Healthcare Strategy

The Quality Committee has commissioned an update on challenges to implementing the strategy, including cultural change and resources.

Research and Development Strategy

At its September meeting, the Committee received an update on the R&D strategy and sought to encourage closer links between directorates and the R&D team and better communication with all staff about the results of the R&D programme so they could see how it benefited service users.


Governance and oversight The Quality Committee had considered meeting monthly until at least April 2019 in light of the warning notice. Having consulted members and looked at the governance of Our Improvement Plan, it was instead decided to keep meetings bi-monthly and call extraordinary meetings if required. It is recognised that directorate management time is best focused on the improvement meetings in place. Quality Committee has a clear place in that governance structure to ensure that it has an appropriate role as part of the Trust’s Improvement Plan, the right flow of information across the Trust and enough time to discuss key risks so it can out its assurance role for the Board fully. The QC endorsed the directorate Improvement Plans but asked for clear outcome measures to be included. It also asked for a clear organogram of Board to floor relationships and an agreed flow of information from Board to floor to be put in place as soon as possible. Board Assurance Framework: Quality risks The Committee revisited BAF Risk 7 in light of the CQC inspection and warning notice and has made recommendations as above, namely:

The score for BAF Risk 7 (Quality and Statutory Compliance) is increased to 16 and is rated red;

The narrative of BAF Risk 7 is revised to widen the definition of “quality” beyond statutory and mandatory requirements;

The mitigations against the risk are articulated more widely

Key risks to flag

BAF Risk 7: Quality and Statutory compliance The outcomes from the recent CQC inspection of services and Well Led inspection have an impact on the current ratings for BAF Risk 7 and will be reviewed at the Board on 30 October.

Issues to be brought to the attention of other committees

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BAF Risk 7: Quality and Statutory compliance The outcomes from the recent CQC inspection of services and Well Led inspection have an impact on the current ratings for BAF Risk 7 and will be reviewed at the Board on 30 October. Staff support – Equalities and Workforce Committee Quality Committee has asked to see the paper going to the Equalities and Workforce Committee in respect of the offer to staff where they require support, particularly where they may have been subject to assault. Statutory / Mandatory Training – Equalities and Workforce Committee Quality Committee will receive at its November meeting with proposals for streamlining / rationalising the suite of training that staff must undertake.

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30 October 2018

Title

Changing Lives – SLaM’s strategy refresh

Authors Sarah Thomas, Head of Communications

Accountable Director Altaf Kara, Director of Strategy and Commercial


SLaM’s strategy, called Changing Lives has been published in a long-form and a short-form strategic narrative. The documents have been published in a digital format on www.slam.nhs.uk. The Board reviewed a final draft of the long narrative at the September board meeting. Members are now asked to note the publication of these documents.

Executive summary

The strategy, Changing Lives, was launched to coincide with World Mental Health Day on October 10th.

The documents were published in a long-form and short-form narrative on the Trust’s website www.slam.nhs.uk. We have also produced a summary printed document and additional poster setting out our strategic aims in an easy-read format, both of which are appended below.


N/A

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http://www.slam.nhs.uk/

http://www.slam.nhs.uk/

QualityWe will get the basics right in every contact and keep improving what matters to service users

PartnershipWe will work together with service users, their support networks and whole populations to realise their potential

A great place to workWe will value, support and develop our managers and staff

InnovationWe will strive to be at the forefront of what is possible, exploiting our unique strengths in research and development, with everyone involved and learning

ValueWe will make the best use of our assets, resources, relationships and reputation to support the best quality outcomes

Our strategic aims

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A summary:Our strategy to improve the lives of the

people and communities we serve

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Changing Lives

2Changing Lives – our strategy

Contents

Our strategy 3

Our vision and mission 5

Our strategic aims - quality 6

Our strategic aims - partnership 7

Our strategic aims - a great place to work 9

Our strategic aims - innovation 10

Our strategic aims - value 12

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Our strategy

Our strategy is named ‘Changing Lives’ because everything we do is to help people improve their lives. We know this is what matters to our service users, carers, families, local communities and our passionate staff.

To achieve this we are focused on the quality of our services, but we cannot do this alone. We need to work in partnership with people and communities, make the trust a great place to work to attract and retain the very best people, maximise our ability to innovate, and deliver best value from all of our assets and resources.

Overview As a large, diverse mental health trust providing local and national services, we aim to make a difference to lives by seeking excellence in all areas of mental health and wellbeing: prevention, care, recovery, education and research.

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Changing Lives


Our Changing Lives strategy sets out five strategic aims to steer our work:

1. Quality: we will get the basics right in every contact and keep improving what matters to service users

2. Partnership: we will work together with service users, their support networks and whole populations to realise their potential

3. A great place to work: we will value, support and develop our managers and staff

4. Innovation: we will strive to be at the forefront of what is possible, exploiting our unique strengths in research and development, with everyone involved and learning

5. Value: we will make the best use of our assets, resources, relationships and reputation to support the best quality outcomes

One fundamental shift that we want to make is to change the relationship with service users, carers and families at all levels. We have already made strong progress but we need to support both professionals and service users to take different roles and approaches that will help people change their lives. Our well-established five commitments to build trusting, mutual relationships set us on good course for this.

The Changing Lives strategy builds on our direction of travel, evolving from our previous strategy, but with stronger emphasis on consistent quality, continuous improvement and partnership in its different forms.

The strategy is aligned with a wide range of partners including:

n clinical commissioning groups

n local authorities

n sustainability and transformation partnerships (STPs)

n South London Mental Health and Community Partnership (SLP)

n Healthy London Partnership

n Maudsley Charity

n Institute of Psychiatry, Psychology and Neuroscience (IoPPN), King’s College London

and will engage an increasingly wide range of partners such as schools, the housing sector, employers, the police, voluntary sector, community and faith groups.

Next steps

We will work with service users, staff and partners to consider the strategy, what it means for them and their contribution to implementing the strategy.

Implementation will have a strong emphasis on quality as our lead aim. Our Improvement Plan from autumn 2018 to spring 2019 will bring together multiple strands and kick-start progress. We will align our strategy with our operating plan for financial year 2019/2020 and 2020/2021 by working closely with our clinical teams, borough and community partners and the IoPPN.

We are immensely grateful to our staff, service users and stakeholders for their insights in steering the direction of the trust.

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Changing Lives


Our mission Seeking excellence in all mental health and wellbeing: prevention, care, recovery, education and research

Our strategic aims1. Quality: we will get the basics right in

every contact and keep improving what matters to service users

2. Partnership: we will work together with service users, their support networks and whole populations to realise their potential

3. A great place to work: we will value, support and develop our managers and staff

4. Innovation: we will strive to be at the forefront of what is possible, exploiting our unique strengths in research and development, with everyone involved and learning

5. Value: we will make the best use of our assets, resources, relationships and reputation to support the best quality outcomes

Our quality priorities1. All patients will have access to the right

care at the right time in the most appropriate setting

2. Within three years, we will routinely involve service users and carers in all aspects of service design, improvement and governance; and all aspects of planning and delivery of each individual’s care

3. Over the next three years, we will enable staff to experience improved satisfaction and joy at work

4. We will reduce violence by 50% over three years with the aim of reducing all types of restrictive practices

Our five commitmentsWe are committed to building trusting, mutual relationships with each other and with service users. Our commitments were developed with staff and checked with service users. They are:

1. I will be caring, kind and polite

2. I will be prompt and value your time

3. I will take time to listen to you

4. I will be honest and direct with you

5. I will do what I say I am going to do

Our visionEverything we do is to improve the lives of the people and communities we serve and to promote mental health and wellbeing for all - locally, nationally and internationally

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Changing Lives


Our ambitions

As an organisation, our focus has to be on delivering the best possible care for everyone who comes into contact with our services, on every day and on every site – safe, caring and effective. We must provide consistency in the quality of care.

We will achieve the best possible outcomes and experience for service users through a focus on leadership, the fundamental standards of care, continuous quality improvement and developing new models of care. We are developing a culture with quality at its heart, where everyone has a mind set for continuous improvement and focuses on outcomes that matter to people who use our services and their carers, families and friends.

We are improving our acute care pathway. In particular, we are working to reduce the level of unwarranted variation in the quality of care across our acute wards and psychiatric intensive care (PICU) services. A key success factor will be improving and sustaining better management of flow through the acute care pathway from community right through to in-patients.

Two years ago, we committed to becoming an organisation where quality improvement (QI) is what we are about and at the heart of everything we do through our partnership with the Institute for Healthcare Improvement (IHI). QI is about working continuously to improve the care and treatment we offer by supporting a culture of constant curiosity about how to improve and the development of skills at all levels to think differently, be innovative and take a systematic approach to improving quality using the IHI ‘model for improvement’ to make changes, spread best practice and measure how we are doing. Now, QI is becoming strongly embedded across the trust as core to how we work and executive and board leadership is highly visible.

Our strategic aims - qualityWe will get the basics right in every contact and keep improving what matters to service users.

Our initiatives

n Leadership for quality

n Fundamental standards of care – priority areas for improvement across the organisation

n Fundamental standards of care – acute care pathway services

n Quality improvement

n New models of care

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Changing Lives


Our ambitions

We want to make a step change in working collaboratively with service users, carers and families. We will work together with people to plan care, to understand them and their carers, to maximise their control, and bring together services to achieve the outcomes important to them.

We will support people to develop the knowledge, skills and confidence they need to more effectively look after themselves and make informed decisions about their own health and well-being.

We recognise adopting person-centred care as ‘business as usual’ requires fundamental changes to how services are delivered and to roles - not only those of health care professionals, but of service users too - and the relationships between service users, professionals and teams. Staff, service users and carers need to recognise that each play a vital role in the wellbeing of the person needing our help and the power imbalance between the three parties needs to be acknowledged and addressed. Genuine co-production will mean that people’s cultural needs will be recognised and met because their assets, needs and wants will be at the heart of what we develop to support them when they have mental health difficulties.

We are working with other organisations to deliver joined up care pathways, for example through the South London Mental Health and Community Partnership, the Lambeth Alliance and work with other boroughs.

Our combined clinical and academic expertise and strength of partnership working means we are in an excellent position to develop leading edge approaches to population health management. We will make better use of routine information to understand our populations and their mental health, so that working with our commissioners, we can plan and design services more effectively and efficiently.

We will identify those groups of people who are at risk of adverse health and well-being outcomes and use advanced analytics to predict which individuals are most likely to benefit from different interventions, and then ensure that they are offered services that best meet their needs – constantly looking to lower risk. We will routinely identify missed elements of evidence based care in our pathways of care and ensure that commissioners and partners are informed and work together so gaps are filled. We will enable service users to contribute extra information to allow for more holistic solutions to their needs. These solutions will be co-produced with service users and local partners such as education, community safety, police, leisure, transport, employers, housing and primary care. We will use anonymised information to ensure that we are consistently addressing the inequalities that are faced by many groups.

Our strategic aims - partnershipWe will work together with service users, their support networks and whole populations to realise their potential.

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Changing Lives


Through this, working collaboratively with our local partners, we will better focus on prevention, access, early intervention and recovery to improve our reach and impact on people’s lives. To drive primary prevention, we will work with a wide range of partners - schools, the police, local government and housing – developing and sharing the evidence about what works and helping educate people about mental health. We will provide joined up care, close to home and focus on key outcomes that matter to local people.

Embracing partnership working and forging local connections, relationships and partnerships will help develop a collaborative movement to improve life opportunities.

This will build on our existing work in Lambeth where resources have been pooled to prevent long in-patient stays and for older adults in Croydon.

The foundation for all our work is our commitment and success in developing productive strategic partnerships - with our four boroughs, CCGs, South London Partnership, Lambeth Alliance, King’s Health Partners (AHSC), Health Innovation Network (AHSN), Institute of Psychiatry, Psychology and Neuroscience (IoPPN) at King’s College London, Maudsley Charity and others.

Our initiatives

n Work in partnership with people who use our services, their carers, families and friends, and members of local communities

n Partnerships to help local communities realise their potential, including using leading edge population health management approaches

n A joined-up approach to mind and body and physical healthcare

n Strategic partnerships

Our strategic aims - partnership

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Changing Lives


Our strategic aims - a great place to workWe will value, support and develop our managers and staff.

Our ambitions

The quality of care that service users receive depends first and foremost on the skill and dedication of our staff. We know that staff who are engaged, happy and supported at work provide the best care. Our passionate staff do a difficult job, often in challenging circumstances and there is more we can do to improve their experience, satisfaction and joy at work and equip them to deliver quality care. This will come from listening to their views and valuing their contribution as well as offering opportunities to develop new skills and career progression as part of their continuous development, and investing in staff wellbeing. Making the trust a great place to work will help us continue to attract, recruit and retain the very best people.

Our initiatives

n A new recruitment and retention strategy with increased investment

n Step change in training, education and development opportunities

n Leadership development and organisational development, including investment in quality improvement

n A comprehensive nursing development programme

n Improve change management

n Enhance our health and well-being strategy

n Develop our Freedom to Speak Up structure

n Develop our equalities strategy, with a particular focus on black and minority ethnic (BME) staff

n Staff communications and recognition

“Acute care is an area I am truly passionate about and I love

coming to work every day.”

Victoria Fawcett, ward manager Jim Birley Unit

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Changing Lives


Our ambitions

We will maximise benefit to service users and the local community from our research and development by making it a routine, core part of clinical activities across the organisation - in all professional groups and teams across our geography. We will build on our unique breadth and depth of research and clinical care; many clinical areas already have strong research programmes which inform local, national and international practice. Leading edge big data and digital approaches will allow us to better identify people at risk, spot potential problems, develop new interventions, deliver support and improve care.

We will answer key questions in clinical practice and population health, informing our work in the trust and that of mental health practitioners across the globe. We will continue to undertake research and generate evidence that will lead to ground-breaking discoveries. We will introduce new practices, refined and evaluated through our close clinical academic partnerships to establish evidence-based practice. Our care pathways will be underpinned by research and evidence supporting the highest possible standards of care. We will increase the number of staff involved in research by encouraging and supporting all staff to get involved and take more active roles in leading research and take pride in being part of a research active organisation.

Our strategic aims - innovationStriving to be at the forefront of what is possible, exploiting our unique strengths in research and development, with everyone involved and learning

Eileen Skellern 1 (ES1) Psychiatric Intensive Care Unit (PICU) has pushed the boundaries with their innovative practice.

“We aim for the best and are involved in a number of QI projects to enhance what we do to provide the best service for patients. The sensory

room is one of several innovations that helps to give patients the best opportunities to cope with the environment they are in.”

Onyekachi Nwankwo, ward manager, ES1

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Changing Lives


Quality improvement approaches will be used to put evidence-based practice into wider use and to become a true learning organisation and system. Our approach to education and training will support staff to get involved in both research and quality improvement which will help to further develop an ethos of innovation as we develop our workforce and our clinical services.

The Maudsley Charity is one of the larger hospital charities and able to make a significant difference to innovation in the trust. It works closely with our staff to generate ideas that will make a difference to care, treatment and service innovation.

As a trust, our relationship with academic mental health and the world leading reputation of the Maudsley brand in research and innovation is perhaps what we are most known for. As such leaders for mental health, we will use the insight and our voice to improve care nationally and internationally and tackle stigma and discrimination.

Our initiatives

n Progress our research and development strategy - involve more teams and service users and carers, support staff to be research active, improve recruitment of research participants and research communication, ensure the highest scientific and ethical standards and shape national best practice guidance

n Embed quality improvement

n Develop the SLaM-IoPPN Centre for Translational Informatics

n Create a new Centre for Young People’s Mental Health

n Develop our education and training strategy and launch Maudsley Learning

Our strategic aims - innovation

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Changing Lives


Our strategic aims - valueMaking the best use of our assets, resources, relationships and reputation to support the best quality outcomes.

Our ambitions

We will ensure our care services and support services provide the best possible value by focusing on the outcomes we achieve for the resources invested. Being financially sustainable and governed to the highest possible standards is a core focus with a strong interface between performance, finance and quality. We will manage our costs effectively so we can re-invest in our people, innovation, research and training. Reducing clinical variation will provide better value. Commercial ventures will allow us to reinvest in staff development, innovation and local services at a time when these budgets are under pressure. Staff will be able to make the best use of information with reliable IT infrastructure and applications and data to support quality improvement and innovation. Our staff and service users will benefit from being in places we are proud of.

Our initiatives

n Continue to develop our leadership and governance

n Take forward our five-year financial strategy

n Commercial development

n Deliver improvements to the quality of our estates and facilities

n Progress on getting the IT basics in place and implementing our digital strategy, working towards becoming a global digital exemplar

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South London and Maudsley NHS Foundation Trust, Trust Headquarters, Maudsley Hospital, Denmark Hill, London SE5 8AZ

T. 020 3228 2830F. 020 3228 2021E. [email protected]. www.slam.nhs.uk

Switchboard: 020 3228 6000

Published October 2018

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30 October 2018

Title

South London Mental Health and Community Partnership Board Minutes

Author N/A

Accountable Director N/A


For the Board to note the minutes of the South London Mental Health and Community Partnership Board

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Summary of Partnership Board Meeting 20180726 v1.1 Page 1 of 5

Partnership Board Meeting Notes

09:30 – 11:30 26 July 2018

Health Innovation Network, Ground Floor Minerva House

5 Montague Close London SE1 9BB

Present Roger Paffard, Chair (RP) Chair, SLaM Stephen Dilworth (SD) NED, Oxleas Jean Daintith (JD) NED, SWLStG Helen Smith (HS) Acting CEO Oxleas David Bradley (DB) CEO SWLStG In Attendance Ranjeet Kaile (RK) Director of Communications and Stakeholder Engagement, SWLStG Jeremy Walsh (JWa) Director, SLP Jonathan Wood (JWo) Programme Manager, SLP Apologies: Duncan Hames (DH) NED, SLaM Matthew Patrick (MP) CEO SLaM

Item Business Item

1. Apologies – noted above.

2. Minutes of the last meeting, matters arising and actions

Minutes of the Partnership Board on 24 May 2018 were agreed with minor amendments. All actions are recorded in a separate tracker and all previous actions have been completed.

3. Operational Board Updates

3.1 Productivity

A meeting has been held with NHS Digital to review the Global Digital Exemplar (GDE) Fast Followers submissions (Oxleas and SWLStG). Funding is available but this

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is the first instance of an exemplar having two fast followers. NHSD provided positive feedback and offered support to address outstanding queries. An update on the NHSD response will be provided at the next meeting.

A list of all the contracts across the partnership is being drawn up to understand the current spend and renewal dates so that collaborative procurement can be effected such as legal, waste and transport services.

Options to comply with the recommendations of the NHSI Carter review on unwarranted variations in mental health and community health services included joining the North East London FT led Mental Health or the Guys and St Thomas Trust procurement partnerships as there was concern that the SLP procurement project would not deliver a solution by the deadline of December 2018.

3.3 Clinical Programmes 3.3.1 CAMHS

Recruitment continues to be difficult in a challenging market and a Recruitment Open Day has been arranged for Saturday, 8 September. This includes the opportunity to obtain continuing professional development points from the planned presentations and training as well applying and arranging interviews for the available roles across the partnership. This is being marketed across all social media, including Instagram, which nurses use.

The chair has met with Peter John, Southwark Council Leader and recently elected chair of London Councils, who is very supportive of expanding accessibility of CAMHS for early intervention in schools across London. The three priority areas for local authorities are: reducing violent crime, improving housing and potentially CAMHS.

It was noted that the recent Government Green Paper on Transforming children and young people's mental health provision aims to have a designated lead in mental health in every school and college by 2025; trained mental health support teams linked to groups of schools and colleges and a shorter waiting time of four weeks. There is £200m funding available and an opportunity for the partnership to reduce admissions further.

The centralised SLP Bed Management function has moved into the next phase of expansion and is now operating 8am to 9pm Monday to Friday.

There has been excellent success in reducing out of partnership bed days and distance from home, both of which are ahead of the trajectory. However, there have now been 12 admissions into the private sector as at 26 July. This is a demand and capacity issue for complex cases.

There has been a complex case workshop on 18 July with clinicians from the three trusts and directors of children’s services from most of the 12 local authorities. Another workshop has been scheduled for October to understand how health and

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social care can work better together by developing a risk management structure for integrated care.

An Eating Disorders workshop with clinicians was held on 20 July to explore the value of expanding intensive treatments.

3.3.2 Forensic

A demand and capacity review has been commissioned to support the long-term requirements and the increased capacity of the Bridge House and CDU business cases. A paper will be presented to the Forensics Programme Board on 10 August.

The new care model (NCM) service has been evaluated this week by NHSI with stakeholder interviews and site visits by the assessor, Sue Salas.

3.3.3 Complex Care

Due diligence is continuing to confirm the scope of the programme and identify all the patients and budget. Not all the data has been received but assessments are being initiated for the high-cost placements in locked rehab as a priority. However, it is frustrating having to go through the CCGs to arrange these assessments.

A meeting with Tonia Michaelides, the South West London lead commissioner for SWLStG, has been arranged to escalate the issue.

The poor data on complex care cases has been raised as an unacceptable issue by the CQC.

There is the possibility of a new partnership opportunity; an integrated care system bid. The SLAM chief executive has had a useful meeting with NHSE/I to discuss an urgent care pathway based on the new care model (NCM) approach used for Forensics and CAMHS. The SLP has been recognised as an effective commissioner and provider to help address the ongoing difficulties that the CCG have for urgent care.

4. Work Programme 4.1. Women’s PICU

The Portfolio Board had approved the women’s PICU project to progress to the full business case stage, to be completed by the August Board meeting. There are two leading options: Middle House at the Maudsley and Cator Ward on the Princess Royal University Hospital site. The Portfolio Board also asked that a new modular build is explored.

There have been four meetings of the Clinical Reference Group which agreed at the last meeting that visits are required to each site to understand their suitability.

It was noted that SWLStG and Oxleas use the Huntercombe Roehampton PICU which has just been rated as inadequate by the CQC. This is an operational issue but raises the urgency of implementing the PICU. There is a possibility of using the PICU in Camden and Islington.

It was noted that the women’s PICU at ES1 is an exemplar and Faisal Sethi is a

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national lead on PICUs. JD suggested that having one team to oversee the 20 beds on one site could be more effective.

4.3. Transforming Care Programme – Learning Disabilities

The transforming care programme (TCP) is due to close by the end of March. This is not a NCM but the success of SLP has been recognised and was asked to support Oxleas and the south east London STP. Greenwich CCG is leading in the development of pathways. There is an outline proposal for the Sutton LD crisis model from the south west London STP.

4.4. Adults Eating Disorders Service

There has been a meeting with NHSE to look at a more effective commissioning and providing a model to improve the quality of the adult eating disorders service and provide alternative treatments to admissions.

5. 2018/19 SLP Source and Application of Funds

The 2018/19 source and allocation of funds report that was submitted to the Portfolio Board was presented. A detailed report will be submitted to the Portfolio Board in August that will be seen by the Partnership Board in September.

The source funds included the 17/18 full year effect which is recurrent. Investments are prioritised on patients’ needs.

6. Trust updates

6.1 Oxleas: (HS)

The trust has successfully bid to provide perinatal services and is currently preparing for the autumn CQC inspection.

Staff attended the SLaM summit on the acute and emergency pathway and a multi-agency discharge event (MADE) has been planned; the first in the country.

The Trust is pleading guilty regarding the HSE case that may be heard in the crown court as there is a possible conflict of interest for the Woolwich judges; the factors taken into account are being negotiated.

An issue with the Serco service at Thameside Prison that was resolved a year ago has been raised in the media with a BBC programme due to be broadcast.

6.2 SLaM (RP)

Bed capacity continues to be a challenge with over 30 out of area placements due to high demand and occupancy. There has been a 25% increase in A&E demand.

The re-organisation consultation is progressing from 7 clinical academic groups to 4 borough based directorates plus older and children’s services.

The first week of the CQC inspection went well but there were issues with the

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second week, especially around the acute care pathway. The well-led assessment takes place between 14 and 16 August.

The Lambeth Alliance went live this month but there are some concerns with GP engagement. The Southwark Alliance could go live in April.

The £450m estate modernisation programme is progressing to ensure all rooms are en suite; currently only 21% of the rooms have en suite facilities. This includes a new inpatient unit project at the Maudsley (£70m); fund-raising for this will launch in January. The strategic outline case (SOC) for the Centre for Young People is scheduled to be opened in 2022. Additional funding will come from King’s Health Partners and the SLaM charity.

6.3 SWLStG (DB)

The joint HR Director (Mary Foulkes ) for SWLStG and SLaM has been appointed.

Emergency department assessments have increased. There are patients at the Roehampton Huntercombe unit rated inadequate by the CQC.

Interviews for the Chair completed last week and the Trust is waiting for the decision from NHSI.

7. Any Other Business

RK provided an update on communications campaigns: o The annual review has been printed and sent out to key stakeholders as well as

being made available across all sites and social media sources. o JWa and Mari Harty have written blogs to support recruitment. o The next SLP event for senior leaders is being arranged. o The Nursing Development Programme has been shortlisted for the Nursing

Times “Best workplace for learning and development – over 1500 staff” award but this announcement is embargoed until the official launch on 31 July.

o There is a benchmarking event at Cavendish Square.

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30 October 2018

Title

Report from previous month’s Part II meeting

Author

Charlotte Hudson, Deputy Director of Corporate Affairs

Accountable Director

Rachel Evans, Director of Corporate Affairs


To produce a summary report for consideration in the part of the Board meeting held in public which lists the items which were discussed in the Part II (private) meeting the previous month.

Executive summary

The detail below refers to the Part II meeting held in September 2018.

Ref Item discussed Summary of discussion Lead

Director

Reason for taking

in PII

BODPTII 28/18

SOUTH

LONDON

MENTAL

HEALTH AND

COMMUNITY

PARTNERSHIP

BOARD

MINUTES

To review the minutes of the

Board meeting of the South

London Mental Health

Community Partnership held in

March 2018.

Matthew

Patrick

Includes financial

information for each

member of the

partnership not yet in

the public domain

BOD PTII 29/18

CENTRE FOR

YOUNG PEOPLE

(CYP) AND

DOUGLAS

BENNETT

HOUSE (DBH)

SCHEME

AFFORDABILITY

AND

PROPOSED

NEXT STEPS

To consider the Strategic Outline

Case for each project.

Matthew

Patrick

Commercial in

confidence

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Please note that minutes from this meeting are a public document and will be published on the Internet and may be requested under the Freedom of Information Act (2000). Any attendee that would like their name omitted from the minutes should discuss this with the minute taker. Note that it may not always be possible to oblige as this is dependent on the persons role and the business being discussed.

web site: www.slam.nhs.uk

Board of Directors Meeting

To be held 27th November 2018 2:30pm - 5:00pm ORTUS, Maudsley Hospital

PROPOSED AGENDA: Part 1

Quality Improvement Focus Presentation by teams about their QI Projects (located at the back of the room)

2:30pm

Opening Matters

/18 Welcome, apologies for absence & declarations of interest

/18 Minutes, Action log review 2:40pm Page

Quality

/18 Board Level Review of Serious Incident Beverley 2:45pm Page

/18 Risk Focus: BAF Risk – 2 tbc Page

/18 Safety Report Beverley Page

/18 Serious Incident Focus Amanda/Beverley Page

/18 Quality & Performance Report Kris Page

/18 CQC Improvement Plan Stocktake Beverley Page

/18 Capital Planning, Estates and Facilities Altaf/Matthew N Page

/18 Briefing from the FPC October Meeting Stephen Page

Innovation

/18 Research & Development Strategy (action Nov 17) Gill/Fiona Page

Value /18 Finance Report Gus Page

Updates

/18 Chief Executive’s Report Rachel Page

/18 Council of Governors Update Charlotte Page

/18 Finance & Performance Committee Update Steven Page

/18 Mental Health Law Committee Update Kay Page For Noting

/18 Report from previous month’s Part II Charlotte Page

/18 Wrap-up and Next Meeting Page

/18 Meeting Evaluation tbc Verbal

The next Board of Directors Meeting will be held on 18th December 2018 2:30pm, at the ORTUS, Learning Centre, 82-96 Grove Lane, SE5 8SN.

Maudsley Hospital

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