MEETING OF THE BOARD OF AGENDA DIRECTORS … of Directors...RES1101, Shire Hall Cambridge CB3 0AP...

MEETING OF THE BOARD OF DIRECTORS IN PUBLIC

AGENDA PART 2

Date: 30th March 2016 Time: 13:00 – 17:00 Venue: Boardroom, Elizabeth House, Fulbourn, CB21 5EF

Time Item Lead

1. 13.00 Welcome Julie Spence

2. 13.05 My Story Mary Mumvari

3. 13.35 Apologies for absence Julie Spence

4. 13.40 Declarations of Interest Julie Spence

5. 13.45 Minutes of the meeting held on 27th January 2016 Enclosed Julie Spence

6. 13.55 Matters Arising Enclosed Julie Spence

7. 14.05

Chair’s Report

Register of Interests

Enclosed Enclosed

Julie Spence

8.

14.15

Chief Executive’s Report

Vanguard Presentation

Library Strategy

Enclosed Enclosed Enclosed

Aidan Thomas

9. 14:35 Research and Development Verbal Ed Bullmore

Questions from members of the public relating to above items

14:45 Break

Strategy

10. 14:55

Business Plan

(10a) Trust Annual Business Plan 16 / 17

(10b) Operational Plan

Enclosed Enclosed

Scott Haldane

Quality, Workforce, Performance & Finance

11. 15:15

Quality, Safety and Governance

(11a) Quality, Safety and Governance Committee Summary

(11b) Safety and Quality Exception Report

(11c) Safer Staffing

(11d) Nurses Revalidation

Enclosed Enclosed Enclosed Enclosed

Jo Lucas & Mary Mumvari

12. 15:30 Eliminating Mixed Sex Accommodation Enclosed

Mary Mumvari

13. 15:35

Emergency Preparedness, Statement of Readiness

Enclosed

Mary Mumvari

14. 15:40

Business, Performance and Finance

(14a) Business and Performance Committee Summary

(14bi) Monthly Finance Report

(14bii) Month 11 Finance Report

(14c) Integrated Performance Report, Feb

Enclosed Enclosed Enclosed Enclosed

Julian Baust & Scott Haldane

15. 15:55 Charitable Funds Committee Update Enclosed Simon Burrows & Scott Haldane


Governance

16. 16:05 Cycle of Business Enclosed Lauren MacIntyre


Other Business / For Information

17. 16:15 Any Other Business

Close

The next scheduled meeting of the Board to be held in public is on Wednesday, 25th May 2016 in the Boardroom at Elizabeth House.

Board Work Agreement

It will be assumed that you have read the papers

Use pre positioning to avoid ambush

Be engaged, present and participate in the meeting

Be respectful – ask questions to enquire not challenge

Ensure concise, high quality and timely information

Celebrate and value diversity of thinking

It’s OK to disagree

It’s OK to give feedback e.g. ‘You are talking too much!’, ‘You are playing with the instruments’

Brief attendees on what is required/to expect.

Keep presentations short to allow time for discussion

Pay attention to process of the meeting – call ‘stop the Board’ to check in on process

Review our meetings using an appreciation and encouragement frame

Commit to spending informal time together – getting to know each other.

Agenda Item: 7

BOARD OF DIRECTORS MEETING

REPORT

Subject: Chair’s Report Date: 30th March 2016

Author: Julie Spence, Chair

Lead Director: Julie Spence, Chair

Executive Summary: This report contains the following items:

WAVET AND GET joint meeting

Joint Chairs letter to the leader of the County Council

Terms of Reference for the review of UnitingCare

Governor Elections

Board Governance Review

Declarations of Interest

Recommendations:

The Council is asked to note the contents of this report.

The Nominations Committee recommends that the Council of Governors formally ratifies Sarah

Hamilton as new Non Executive Director.

The Council is asked to approve the cycle of business

Relevant Strategic Priorities (please mark in bold)

A local provider of patient and carer centred integrated community, mental health and social care

Our mission is to put people in control of their care. We will maximise opportunities for individuals and their families by enabling them to look beyond their limitations to achieve their goals and aspirations, ‘To offer people the best help to do the best for themselves’.

One of the UK’s premier providers of key specialist mental health services

An organisation whose services are enabled by world leading research and education

Links to BAF / Corporate Risk Register N/A

Details of additional risks associated with this paper (may include CQC Essential standards, NHSLA, NHS Constitution)

N/A

Financial implications / impact N/A

Legal implications / impact N/A

Partnership working and public engagement implications / impact

N/A

Committees / groups where this item has been presented before

N/A

Has a QIA been completed? If yes provide brief details

No

Chair’s Report

WAVET (Work, Advice, Volunteering, Education and Training) and GET (Guidance, Employment and Training) joint meeting I was invited to speak at this meeting on 3 February 2016. This secured their best attendance yet which indicated the number of organisations that want to work with CPFT. Both WAVET and GET are similar networking groups for organisations. In particular WAVET is a networking group for Voluntary and Community Sector organisations and Mental Health Trust teams who all support people with mental health issues. The chair rotates between CPFT and one of the member groups. WAVET also organises training opportunities for its members and holds regular networking events which aim to improve communication and ultimately provide a more effective service for service users. Many of the organisations signed up for information on becoming a member of CPFT and all the signatories are being followed up by the Trust Secretariat. Joint Chairs letter to the leader of the County Council - Steve Count A letter was sent by the chairs of all the constituent bodies in our health economy to the leader of the Council expressing our concern about the pressures on the social care budget (appendix 1). The letter we sent was circulated to all councillors and hopefully encouraged the favourable vote for the 2% precept which occurred during a very long council debate on next year’s budget in early February. The leaders’ response is attached (appendix 2). Terms of Reference for the review of UnitingCare The revised Terms of Reference were noted at the Council of Governor’s meeting and the Chief Executive and Lead Governor were meeting with Judge Business School and Anglia Ruskin University in the week commencing 21st March 2016, as they were the only two responders after initial interest was shown by four organisations. Judge Business School was chosen to complete the review and they have accepted. Governor Elections The Trust Secretariat has been working in collaboration with the Electoral Reform Services to run the governor election process. The remaining stages of the election process are listed below.

Election stage

Notice of Poll published Monday, 4 Apr 2016

Voting packs despatched Tuesday, 5 Apr 2016

Close of election Thursday, 28 Apr 2016

Declaration of results Friday, 29 Apr 2016

The uncontested report below has been published on our website. Staff constituency was contested so ballot papers will be distributed.

Further to the deadline for nominations for the above election at Noon on Thursday 10th March 2016, the following constituencies are uncontested: Public: Cambridgeshire 6 to elect The following candidates are elected unopposed: MIKE COLLIER BERNIE GOLD

CHARLOTTE PADDISON 3 vacancies remain Public: Peterborough 2 to elect The following candidate is elected unopposed: HELEN BLYTHE 1 vacancy remains Public: Service users living within the electoral areas of Cambridgeshire County Council 2 to elect The following candidate is elected unopposed: ELIZABETH NICOLA BANNISTER 1 vacancy remains All term lengths are for three years . Board Governance Review In line with Monitor’s publication ‘The Well- led Framework for Governance Reviews: Guidance for NHS Foundation Trusts’, the Trust is starting the process for its external governance review. After a helpful Board Development session looking at the governance review process, the Board decided to complete the self-assessment stage before tendering. The Interim Trust Secretary has amended the timeline to incorporate this change. The Director of Nursing will be the Executive Lead, and she will work with the Trust Secretary. Both will report to me as Board lead. The Trust is recruiting an individual for a temporary period, to help with the governance review process. Declaration of Interests The Board of Directors has a legal duty to act in the best interest of that organisation and to avoid

situations where there may be potential conflict of interest. NHS boards should promote transparency

and accountability by ensuring clear and robust systems are in place. In line with Trust policies, senior

management above a certain level should complete a declaration of interests form. The Trust

Secretary is working with management to ensure that the Trust has a full register (Appendix 3

attached).

Lockton House

Clarendon Road

Cambridge

CB2 8FH

Tel: 01223 725400

Direct: 01223 725585

Fax: 01223 725401

Email: [email protected]

Web: www.cambridgeshireandpeterboroughccg.nhs.uk

Our ref: MD/SKS/5feb2016 Your ref: 5 February 2016 Cllr Steve Count Leader Cambridgeshire County Council Leader’s Office RES1101, Shire Hall Cambridge CB3 0AP Dear Steve Cambridgeshire County Council Budget Position and Strategy We are writing this joint letter on behalf of the local NHS to express our grave concern about the proposed Council budget strategy for 2016/17 and associated cuts to social care budgets. We believe that it will have significant and negative consequences for provision of health services for Cambridgeshire patients at a time when local NHS organisations are facing unprecedented financial difficulty. We would urge the Council to agree the 2% precept for social care in order to mitigate these impacts. You will recall that the Chairs of all local health organisations wrote to Cambridgeshire County Council on 10 November 2015 expressing concern regarding the proposed budget reductions and the potential detrimental effect on health services. We are grateful for the impact analysis work which was carried out as a result and shared with NHS colleagues on 2 February 2016, but we are concerned that there has not been an opportunity for wider consideration of the issues raised amongst the NHS organisations affected. We note that the total savings requirement for 2016/17 for Children, Family and Adult services is £31m and that the proposals most relevant to the health system relate to the reductions proposed for the care budgets for older people, people with mental health needs and people with learning and physical disabilities (total £12m in 2016/17 and c£45m over the 5 years of the plan). We understand the strategic approach to focus on preventative and early help services and thereby contain expenditure on other forms of care, such as residential and nursing home placements. This fits well with the NHS emphasis on proactive care and prevention. We welcome the intention to protect the reablement service budget, continued investment in community navigators and protection for front-line staffing levels in social work teams. We understand that the Council will shortly be deciding on the budget for 2016/17 and the level of council tax to be charged. We would urge the Council to consider every possible means of mitigating the impact of budget cuts on the local NHS and the patients we serve. We are concerned by overall reductions in care budgets (older people, disabilities and mental health) which will put further pressure on the independent sector care providers, which will in turn worsen the already acute shortages in supply of care and make it more difficult to arrange prompt care following a stay in hospital.

In particular, the proposed reduction of £2m in meeting the needs of older people requiring care in 2016/17 is likely to result in unnecessarily extending time in hospital and we know that this will have a negative effect on their health and ability to regain independence. We are also concerned by the proposed £841k reduction in spend on care for adults with mental health needs – at a time when we are endeavouring to deliver parity of esteem between physical and mental health needs. There is a risk that patients may relapse due to reduced social care support, resulting in increased reliance on NHS services and delays in placements due to additional scrutiny of care packages. In addition, we note the intention to review funding responsibility for continuing healthcare and joint funded placements, resulting in a net reduction in Local Authority funding and a corresponding increase in NHS funding. The proposed ‘saving’ to the Council is stated as £450k for 2016/17. We are concerned that this will be counter productive at a time when we need to work in partnership to transform services and that patients will get caught in arguments over funding responsibility. Whilst we recognise there are opportunities to improve care for people with learning disabilities through the Transforming Care programme, we remain concerned that there are risks associated with the proposed reduction of £5.2m for 2016-18 for this group of people. We understand that the impact assessment workshop on 2 February 2016 and supporting materials focused on adults, but we are also aware of proposals which are likely to have a negative impact on health services for children, about which we are equally concerned. As you know, the local NHS must deliver short and long term financial savings through efficiency measures and transformation. We remain committed to working with Local Authority partners to ensure there is a shared approach to the Sustainability and Transformation Programme. We believe it is essential to maximise income to the local health and social care system as well as ensuring every pound is spent effectively. In summary, we appreciate the work carried out to assess the impact of the Council’s budget proposals on the local health service, but we remain deeply concerned that the effect will be damaging without further mitigating measures. We would welcome the opportunity to discuss this with you as a matter of urgency. Yours sincerely

Maureen Donnelly Jane Ramsey Chair Chair Cambridgeshire and Peterborough CCG Cambridge University Hospitals NHS Foundation Trust

Nicola Scrivings Julie Spence Chair Chair Cambridgeshire Community Services Cambridgeshire and Peterborough NHS NHS Trust Foundation Trust

Alan Burns Rob Hughes Chair Chair Hinchingbrooke Health Care NHS Trust Peterborough and Stamford Hospitals NHS Foundation Trust

Prof John Wallwork Chair Papworth Hospitals NHS Foundation Trust cc Dr Neil Modha, Chief Clinical Officer, Cambridgeshire and Peterborough CCG Roland Sinker, Chief Executive, Cambridge University Hospitals NHS FT Matthew Winn, Chief Executive, Cambridgeshire Community Services NHS Trust Aidan Thomas, Chief Executive, Cambridgeshire and Peterborough NHS FT Lance McCarthy, Chief Executive, Hinchingbrooke Health Care NHS Trust Stephen Graves, Chief Executive, Peterborough and Stamford Hospitals NHS FT Stephen Bridge, Chief Executive, Papworth Hospitals NHS FT

Cllr Tony Orgee, Chair, Cambridgeshire Health and Wellbeing Board Cllr David Jenkins, Chair, Cambridgeshire Health Committee Gillian Beasley, Chief Executive, Cambridgeshire County Council

Adrian Loades, Executive Director: Children, Families and Adults Services, Cambridgeshire County Council

Dear Maureen As your joint letter of 5th February 2016 recognises, the County Council faces enormous

financial challenges. I would firstly like to set the general context for my response in that

I agree completely with the urgent need for effective partnership working so that across

the health and social care system, we are confident that we are securing the best

outcomes with the resources we have collectively available to us.

The decision on the 2% Council Tax Adult Social Care Precept will be made by the

County Council at its meeting on 16th February. I feel it is also worth noting that the

debate is within the context of a Council in no overall control. I am sure that a wide

range of views will be considered during the debate on the Council’s Business Plan and

the debate will consider concerns for services and concerns for the impact on council

taxpayers. Your letter has been shared widely and will no doubt inform those views. In

my position of Leader of the Council, I am sure that you will understand that I can only

commit to considering the concerns that you have raised, the decision on the precept is

for the Council meeting to make. Whilst you have specifically raised the issue of the

Adult Social Care precept, there is the wider issue of how the Council deploys the

quantum of resources that it has available in response to the demands and pressures it

faces.

I would like respond to some of the concerns you have raised, whilst not in any way

downplaying the seriousness of the financial position facing the Council.

Firstly, I can reassure you that the Council’s eligibility criteria for accessing care will not

change. The criteria are set in law and we cannot generally vary access to support in

relation to the resources available. Therefore, the Council’s focus has to be on how

savings are made through meeting needs in different ways. Most people will only see a

change in their care following a formal review of their needs and care plans will still

specify how needs will be met. In meeting needs we will be placing greater focus on the

support that can be provided from families and communities. We will be changing our

From: Councillor Steve Count

Please reply to: Shire Hall, SH1102, Castle Hill, Cambridge, CB3 0AP

Telephone:

07989 032456 (mobile) 01223 699173 (office)

Date: 15th February 2016

Ms Maureen Donnelly Chair, NHS Cambridgeshire and Peterborough CCG [email protected]

mailto:[email protected]

policy framework in some areas which will reduce the support available to some people,

but this will be on a risk based basis. The personal experiences of the changes that we

will make will vary considerably, depending on the circumstances of the service users

concerned. However, the Council will meet its statutory duties.

There are risks attached to this strategy and one is the potential impact on other partner

organisations. I can assure you that the Council is very mindful of this and will work with

partners to seek to ensure that the risk is managed effectively.

The potential impact on independent sector providers of the budget strategy has been

openly acknowledged. The Council is seeking to manage these risks, for example

through funding both inflationary costs and the costs of the National Living Wage for

providers. We are also engaging in dialogues with providers to explore different service

models and approaches that will mitigate some of the impact of the reduced funding

situation. It remains a key priority of the Council, and indeed it is a statutory duty, to

ensure there is a strong market for care provision in Cambridgeshire.

We have sought to engage partners in our plans, for example our planned reduction in

mental health spend have been discussed for some months with CPFT and again we

will ensure that eligible needs are met. I do understand the concern about the impact on

the CCG of the Council securing savings through ensuring that those people eligible for

Continuing Health Care receive it, but it is the case that some very vulnerable people in

Cambridgeshire are currently paying for care that they are potentially entitled to receive

for free.

There is a pressing need for a more integrated approach to service planning and the

delivery of services. I am sure that the Council is not alone in its frustration at the

significant amount of work that went into the Uniting Care programme and the time that

has been lost in making operational progress toward integrated services. However, it is

important that many of the ideas and proposals that were developed with Uniting Care

are not lost.

The need more for more joined up planning is also illustrated by a number of recent

CCG decisions impacting adversely on the Council. For example, the decision to close

waiting lists for children and young people with ASC and ADHD has had a significant

impact on the demand that Council services are managing. The proposed withdrawal of

s256 funding from partnership agreements will also impact financially, as will the current

ongoing reduction in community beds funded by the CCG. I raise these examples to

stress the need for a more integrated approach to the planning of services. I am aware

that your officers have agreed to share budget proposals with the County Council, in the

same way the Council’s proposals were shared at the recent impact assessment

workshop. This will be helpful and for the future I suggest that we commit to sharing our

emerging thinking and proposals much earlier in our respective planning cycles. I am

confident that our officers collectively could design such a process.

I would also like to take the opportunity to raise the issue of the Better Care Fund. I am

aware that the contribution from the Better Care Fund to Cambridgeshire County Council

is already significantly proportionately lower than that received by neighbouring local

authorities. Therefore, the apparent proposal from the CCG that none of the uplift to the

2016/17 Better Care Fund is shared with the County Council will not be acceptable. We

will be seeking greater parity of resourcing through the Better Care Fund, particularly in

the light of the concerns that you have raised on your letter.

I would be happy to meet with you to discuss these matters further

Yours sincerely

Councillor Steve Count Leader – Cambridgeshire County Council cc: Dr Neil Modha, Chief Clinical Officer, Cambridgeshire and Peterborough CCG Roland Sinker, Chief Executive, Cambridge University Hospitals NHS FT Matthew Winn, Chief Executive, Cambridgeshire Community Services NHS Trust Aidan Thomas, Chief Executive, Cambridgeshire and Peterborough NHS FT Lance McCarthy, Chief Executive, Hinchingbrooke Health Care NHS Trust Stephen Graves, Chief Executive, Peterborough and Stamford Hospitals NHS FT Stephen Bridge, Chief Executive, Papworth Hospitals NHS FT Cllr Tony Orgee, Chair, Cambridgeshire Health and Wellbeing Board Cllr David Jenkins, Chair, Cambridgeshire Health Committee Gillian Beasley, Chief Executive, Cambridgeshire County Council Adrian Loades, Executive Director: Children, Families and Adults Services, Cambridgeshire County Council

REGISTER OF INTERESTS

NON EXECUTIVE DIRECTORS

Name Designation Other employment Relevant and material interests in business firms, partnerships, limited companies

Membership of voluntary and charitable organisations

Other Dated

Julie Spence

Chair / Non Executive Director

Chair – Police Mutual Society

Julie Spence Ltd Consultancy for Police and Crime Commissioners, Northgate Business Solutions, Cambridge University

Trustee Ormiston Children & Families Trust Governor Anglia Ruskin University

None 17.03.2016

Julian Baust

Non Executive Director

Warwick University Lecture (1 per year)

Owner JPFB Consulting Board Member, UnitingCare Partnership LLP Vice Chair Diabetes UK

Vice Chair Diabetes UK None 23.03.2016

Prof Sir Patrick Sissons

Non Executive Director

None Consultant for GlaxoSmithKline

Arthritis Research UK – Trustee Public Health Genetics Foundation – Trustee

National Medical Research Council of Singapore – Board Member International Scientific Advisory Board Member:

Lady Davis Institute, McGill University, Montreal, Canada

A* Graduate Programme, Singapore

22.03.2016

Simon Burrows Non Executive Director

None SJB Management and Consultancy

National Animal Welfare Trust Mane Chance Sanctuary

None 23.03.2016

Jo Lucas Non Executive

Self employed psychotherapist,

None MIND Board Member (Cambridgeshire and

None 22.03.2016



Other Dated

Director freelance consultant and carry out evaluations for EU funded organisations

Huntingdon)

Mike Hindmarch Non Executive Director

Vice Chair Joint Audit Committee Police & Crime Commissioners / Chief Constable of Cambridgeshire and Peterborough

Personal consultancy practice offering services to charities seeking contracts in health & social care

Volunteer for SENSE – a charity for deaf/blind people

None 17.03.2016

Sarah Hamilton Non Executive Director

Weightmans LLP (Partner) Cilex Law School Non-Executive Director

Weightmans LLP (Partner) Cilex Law School Non-Executive Director

Director Mental Health Act Manager HPFT

None 17.03.2016

EXECUTIVE DIRECTORS



Other Dated

Aidan Thomas Voting

CEO None Board Member UnitingCare Partnership LLP

Member Braintree Rugby Club

None 17.03.2016

Chess Denman Voting

Medical Director

None None Trustee: The Denman Charity Trust & The Talisman Trust

Partner works as unpaid volunteer for CPFT

17.03.2016

Mel Coombes Voting

Director of Nursing

None None None None 23.03.2016

Scott Haldane Voting

Director of Finance

None University Technical College Cambridge - Governor

Edinburgh Leisure – NED University of Stirling – Member of Court Heritage Care (National Charity) - Trustee

None 17.03.2016

Stephen Legood Voting

Director of Business

None

Governor of Cambridge University Hospital NHS FT

None Partner is an employee of CUH

17.03.2016

Development & Workforce

Sarah Warner Voting

Chief Operating Officer


Deborah Cohen (Joint Appt with LAs) Non Voting

Director of Service Integration


OTHER SENIOR STAFF



Other Dated

Elaine Bailey Associate Director People Services

None Governor of a primary school which is an academy and therefore governors are registered as directors

None None 17.03.2016

Nicola Brookes-Jones

Associate Director

None None None Son works as an apprentice in the HR department and occasionally provides adhoc cover for reception at Elizabeth House

17.03.2016

Lauren MacIntyre Trust Secretary

None None None Mother works for CPFT – Brookside receptionist

17.03.2016

Jonathon Artingstall Associate Director

None Partner runs Communication Cambridge, who offer skills groups, training for children in need

None None 22.03.2016

Kit Connick Associate Director

None None School Governor – St Louis Catholic Academy, Newmarket

None 22.03.2016

Neil Winstone Associate Director


John Hawkins Locality Manager


Julie Frake-Harris Associate Director


Manaan Kar-Ray Clinical Director

Private practice privileges at Fitzwilliam Private Hospital.

Director in MKR Consultancy Ltd

Involved in a number of community and social projects through Bengali Cultural Association, Peterborough and Cambourne Cultural Society

None 23.03.2016

Agenda Item: 8

TRUST BOARD MEETING IN PUBLIC

REPORT

Subject: Chief Executives Report Date: 30th March 2016

Author: Aidan Thomas

Lead Director: Aidan Thomas

Executive Summary:

Informs and updates the Board about a range of matters affecting the Trust

Recommendations:

The Board of Directors is asked to note the content of this report.






Links to BAF/Corporate Risk Register several


N/A

Financial implications/impact N/A

Legal implications/impact N/A

Partnership working and public engagement implications/impact

N/A

Committees/groups where this item has been presented before

N/A


No

1. Contracting

The contracting round has been difficult because of the CCG deficit. The Trust is committed to

ensuring services are safe and deliver what the contract requires. The current offers make neither

requirement possible at present.

Integrated Older People’s Services Contracting

The Trust is negotiating the contract for these services with the CCG for 2016/17.

Some progress has been made to close the gap which now stands at about £3.5m Work

continues to negotiate the closure of this.

Mental Health Services Contracting

The Trust is negotiating the contract for these services with the CCG for 2016/17.

As a result of the new requirements for Mental Health set out in the Carter report and the need

to comply with the CQC report, Safer staffing requirements for inpatients, and the cost

pressures around emergency care in Personality Disorder services and the new targets

around Early Intervention services there is a significant financial gap (c£5m) between the

service requirements and the commissioners initial offer.

Negotiations continue and in parallel the Trust and CCG are preparing for the arbitration

process.

2. UnitingCare and Reviews and Investigations into the collapse of the UnitingCare

Contract

UC is working to close the organisation down before the end of the financial year, paying off all

proven creditors, and settling accounts. The majority of UC staff have either left or found

alternative roles, although the Trust and its partner CUH are still working with individuals.

The Trust and UCP have had sight of and commented on a draft report setting out findings of the

review of the contract collapse and procurement undertaken by NHS England who used an

Independent reviewer.

NHS England and Monitor attended a Joint Councils Overview and Scrutiny meeting which

examined their roles in the contract collapse.

The CCG’s Internal Audit Report has been published. CUH has also undertaken an internal

review which will be shared. Monitor are reviewing their role too.

The Trust review has been commissioned from the Judge Business School, and will report by the

end of June.

3. Monitor Financial Investigation

Monitor have ended their investigation into the Trusts financial stability which was linked to the

acquisition of the Community services, and have returned the official status of the Trust to its

standard FRR reporting status. This is good news for the Trust and local services.

4. Transformation Programme

Monitor and NHS England continue to take a strong lead in this programme as a result of the UC

contract closure and the difficulties across the local health economy.

The programme has been re-launched with the structure reported to the last Board meeting.

The Trusts Services are affected by all of the workstreams, and we are engaged in all of them. In

particular we have a significant leadership role in the Proactive care and prevention stream which

picks up much of the work started by UnitingCare, and in the “Vanguard” Urgent and Emergency

Care stream where JET, Case Management, Long Term Conditions and Mental Health are

addressed.

The Proactive Care and Prevention stream is defining pathways for all LTCs commencing with

those which have the biggest impact on acute admissions or spend across the economy. The

workstream is also intending to bring together the various Mental Health Strategies for adults that

are current in the health economy.

There will be separate presentations made to the Board about the work of the Vanguard Urgent

and Emergency Care stream.

Also important is the Children’s workstream, and we are closely involved although it is focussing

initially on acute care.

All the workstreams have parent and carer representation either planned or already engaged.

5. Five year Forward View - Farmer report on Mental Health

A copy of the recommendations is attached.

The Trust would strongly support the aims of the paper but is concerned that the funding has in

fact already been allocated as reported in the media. Discussions are taking place with the CCG

over the extension of Early Intervention services for Young people both in terms of capacity for

age extension and capacity for delivery of a NICE guidance compliant service(our service is one

year only) for 2016/17 to comply with the governments requirements on this. The CCG has not so

far offered enough funding to do this, but negotiations are ongoing.

The Trust is also negotiating changes to children’s Mental Health services to assist, in the

management of urgent care. This is dependent on the CCG and specialist commissioning working

together.

6. Children’s Services

The Trust is meeting its waiting list targets. We are starting to prepare for the likely forthcoming

competitive tendering exercise for children’s services across Cambridgeshire and Peterborough

which is likely to happen in the next eighteen months.

7. Learning Disability Services

In the absence of a credible commissioning strategy and in view of the difficulties around staffing

in the service the Trust has decided to temporarily close one of the two units for safety reasons

and concentrate services at the Hollies. The two remaining Individual clients on IASS are being

discharged as planned to appropriate placements, and the Trust is arranging for temporary

appointments for all staff elsewhere in our services. When this work is complete the IASS unit will

close temporarily. We are working with commissioners as far as possible to resolve the LD

pathway, and meet the national targets, which it should be noted do require a permanent

reduction in inpatient beds.

8. Welney Ward

The Trust has closed Welney ward temporarily due to a shortage of qualified staff which was

exacerbated by the unavoidable absence of the ward manager.

9. Adult ADHD services

The Adult ADHD Service remains closed to referrals having exceeded the commissioned number

by more than treble this year. The CCG have agreed new pathway arrangements which are being

put in place, and the trust is working with commissioners to deal with the waiting list.

10. Qatar

The Trust is waiting to hear about the possible award of a potential contract for Qatar as

previously described.

11. Other Business

The Trust is considering bidding for GP Health care across the South East of England. We

already have some expertise in this area and depending on the service specification yet to be

released the Trust may tender with relevant partners for this contract.

The Trust supported by the DTI and Health England received a visit from Ministers form the UAE.

The visit was an exploratory one looking at a potential Mental Health Contract.

12. Adult Mental Health Services Directorate Structures

The Trust is considering the structures it has for Mental Health Services in the light of changes to

emergency care and the need for better coordination, and the need for closer cross directorate

working to deliver the CIP next year. A consultation with key staff is likely to take place in the next

few weeks.

13. Service Visits and Work in the Service

I visited the Fens Unit at Whitemoor Prison which is a Ministry of Justice commissioned service for

Personality disordered violent and disruptive prisoners, which runs along the lines of a therapeutic

community“ in so far as is possible inside a Category A prison. The outcome measures and

research programme are very impressive but even more impressive was the testimony I got about

the programme from prisoners themselves.

14. The Independent Commission report on Acute Mental Health Care led by Lord Nigel

Crisp

This report is not a government sponsored report and so its recommendations are unlikely to be

adopted in commissioning requirements.

The Trust currently has a very low level of adult patients placed outside the county compared to

most other Trusts. This is largely because of the 3:3:3 bed system employed in our inpatient

service which ensures throughput of patients, and increases bed availability. The only exceptions

are specialist placements which the Crisp report recognizes might still be required.

At the same time the Trust does need to implement safer staffing levels as agreed in the CQC

report. Funding for this is being discussed with the CCG. If funding for this cannot be delivered

then the Trust will need to consider closing wards and returning the Out of Area treatment budget

delegated to us, to the CCG. If this happened the number of patients receiving care at a distance

would increase, which is a poor outcome from a quality perspective, but would be safer than the

alternative. Hopefully this will not happen.

From the perspective of children the Trust is net receiver of outplaced children. This is a result of

poorly developed crisis services here and across the country.

15. Staff survey

The results of the 2015/16 staff Survey are now published. The Trust is roughly average in most

areas with a few responses in the top twenty. It should be recognised however that this is the

result of a very significant improvement in our scores. We must plan for further improvement, but

we can also be pleased with the comparative results against last year. There are a small number

of areas where the Trust does need to focus, and is planning its response.

16. Volunteering Strategy

The Quality and Safety Governance Committee approved a new trust Volunteering Strategy,

which seeks to increase the use of volunteers in the Trust and strengthens the links of

volunteering as a an element of Recovery.

17. Compact

The Trust has signed formal agreement to the Compact which is the formal agreement with third

sector partners setting out how we would work with them as a fellow provider.

18. Operational productivity and performance in English NHS acute hospitals

This looks primarily at Acute hospitals. It does however have relevance to the Trust. Three

specific areas include;

Estates where the Trust is building improved efficiency as part of our CIP program.

Sickness absence, where the Trust is not the worst but where improvement is certainly possible

and a number of improvements are planned such as the introduction of common information

systems across the Trust, and the adoption of successful policy and practice in following up

sickness. Wellbeing is also an issues and the Trusts attempts to address workload issues are

important.

Procurement, where the Trust is working with SERCO and staff to improve practice in a number of

areas.

General productivity, where the Trust is identifying clear capacity tools for monitoring its

community teams. These initially focus on Mental Health, and have been developed primarily for

safety reasons but will also enable us to compare the relative efficiency of teams as well helping

to protect patient’s staff and the Trust.

19. Communications Update

We are in the process of restructuring the communications team to reflect the evolving needs of

the Trust. Andréa Grosbois has been in post as Interim Head of Communications and Marketing

since January 2016, following a year and a half secondment at UnitingCare as Head of

Communications. We will shortly be advertising the permanent position.

For the period of 1 February – 21 March

External communications The focus recently has been increasing our social media presence and on 7 March we launched a CPFT LinkedIn account – this will help us with recruitment. We are also working on a GP engagement strategy to improve patient care and experience; build a stronger working relationship with GPs; set out CPFT’s offer; and ensure their feedback informs our service design and decision making.

Media activity Total media hits: 17 (broadcast: 5, print: 12) Top 5 positive stories:

- Mental health Vanguard project to improve urgent mental health - Heart FM, Peterborough

Telegraph, Cambridge News. - Feature on JET - Emergency Nurse Magazine - What Minor Injury Units do and don’t treat -

Cambridge TV

- Promise: Mental health programme at centre of attention - Cambridge News

- Article on self harm by Dr Jorge Zimbron from Springbank - Cambridge News

There has been media coverage regarding the publication of the CCG internal review on UnitingCare. We anticipate more with the publication of the NHS England report. There are a number of press releases lined up for April including the staff awards, ovarian cancer project with CUH and the staff nurse who is running a food bank to ensure patients have food when leaving the ward.

Facebook New likes: 78 to 166 Total posts: 112 Audience reach: 16,296

Twitter New likes: 1,584 to 1,660 Total Tweets: 141 Total interactions: 650 Audience reach: 55,161

LinkedIn Launched on 7 March Total likes so far: 641 Total posts: 12 Total interactions: 110 Audience reach: 4,279

Internal communications The communications team has continued to support and advise on many internal projects, including; mental health Vanguard programme; marketing of Springbank ward; patient engagement strategy; development of neighbourhood teams; Triangle of Care project etc. We are preparing for the annual staff awards ceremony on 8 April, which will be attended by over 200 staff.

Media hits Total value of print and radio

coverage (excluding TV) : £27,278

Positive

Neutral

Negative

20. Chaplain’s Update

As the newly, and first, appointed Muslim Chaplain for CPFT, I have found that Trust values spiritual and pastoral support and this is already evident through the well-established Chaplaincy Team, who work effectively in a joined-up and embedded manner. My initial focus has been to enable staff, patients and carers to understand specifics relating to the management and care of Muslim patients, and we have already seen a significant number of delegates attend the ‘Introduction to Islam’ presentations across the Trust. I have been working very closely with Ward Managers and inpatient services, and helping with the support, care and after care of patients through liaising directly with families and carers. There has been a fast realisation from local community organisations and local Mosques regarding the real impact of mental health challenges and we continue to address this through seminars and lectures, as well as meeting with Muslim doctors in order to widen the bridge for enabling Muslims to access mental health services. We send out weekly news bulletins which include information about our upcoming events as well as addressing current and saddening events being reported by the media, and how this affects all of humanity, regardless of creed, colour or culture. Whilst we continue with our active work within the community, the template for Muslim Chaplaincy is still very fresh and much more great work can be done. I, personally, am grateful for the opportunity and am looking forward to continuing to enhance the good work of the Chaplaincy Team. We hope to provide a more in depth update in May 2016. Mohammed Quadeer Rashid Muslim Chaplain

AT 21/03/16

Urgent and Emergency Care (UEC)

Vanguard Programme

Appendix 1 to CEO Report (8)

Corporate services Title goes here 00.00.00

What are the Vanguard sites?

2

To deliver national New Care Models programme, which underpins the NHS Five Year Forward View

50 Vanguard sites across England

Five types of Vanguard sites:

- Urgent and emergency care; - Integrated primary and acute care systems; - Enhanced health in care homes; - Multispecialty community providers; - Acute care collaborations. National non-recurrent funding to facilitate system-wide change.

Cambridgeshire and Peterborough CCG is one of eight Urgent and Emergency Care Vanguard sites.


Urgent and Emergency Care Vanguard sites – Aims:

3

To implement the Keogh recommendations :

• To provide better support for self-care

• To help people with urgent care needs get the right advice in the right place, first time

• To provide highly responsive urgent care services outside of hospital

• To ensure that those people with serious or life-threatening emergency care needs receive treatment in centres with the right facilities and expertise in order to maximise chances of survival and a good recovery

Corporate services Title goes here 00.00.00 4


Cambridgeshire and Peterborough UEC Vanguard Programme – Workstreams

5

Urgent children’s care is a subset of each of the above


System transformation

6

Fig 1 System Governance

Proactive care & prevention (LTCs / Primary care

UEC Vanguard (5 x work streams) / SSRG

Elective care/ referral management

Maternity & Neo natal

Children & young people

Clinical Advisory Group Service standards/configuration/care models

Health Executive

CCG Chair

Regional Tripartite

FDs Forum

Modelling/contract design/new

payment models/system

control total

System Modelling

Demand/capacity/forecasting/activity

shifts

Programme Directors Office

Out of Hospital Estates

Communications & engagement/telling the story to staff/patients/public

HR/Support services

PSHFT/HHCT Project Board

6 work streams

Health Child Joint Commissioning

Unit

System sustainability planning / Benefits realisation

Stakeholder Group(s)

Individual boards/GBs


Mental health Vanguard model

7


Mental health Vanguard

8

Phase 1 – May 2016

• System-wide co-ordinator for out-of-hours

referrals and advice for professionals including

gatekeeping the Sanctuary.

• First response service in Cambridge locality

only for out-of-hour assessments in the

community linking with the existing crisis teams.

• Increased hours of mental health liaison at

Addenbrooke’s Hospital.

• Sanctuary, a safe place for people in crisis run

by third sector in Cambridge between 6 pm and

1am. Three evenings in Huntingdon (MIND).

• Integrated working with new mental health

teams in Police control room between 8am and

10pm.

Phase 2 - September

Subject to sufficient funding and recruitment

• Increase hours and coverage of system-wide co-ordinator.

• Open to self-referrals via NHS111

• Tele-triage available.

• Increased first responder capacity across the county 24/7.

• Increase number of safe places across the county (Peterborough and Fenland)

Evaluate with a view to recurrent commissioning


Admission avoidance Vanguard

9

• Link emergency department front-of-house schemes with JET

• Case management

• Standardise stroke pathway

• Review end-of-life pathway

• Dementia crisis response service

• Care homes

• Voluntary sector

• Falls


Post hospital discharge - Vanguard

10

- Community bed review

- Intermediate care ( ICWs in Neighbourhood teams , and intensive rehabilitation). Work with LA reablement teams

- Discharge planning; trusted assessors

- Managing flow through the system


In hospital emergency care- Vanguard

11

• Re-designation of A&E departments within the county in-line with national standards

• Review of Minor Injuries Units in-line with national standards for urgent care centres

• Discharge of frail elderly from hospital

• Ambulatory pathways


CPFT involvement in Vanguard work streams

12

2016-2018 Knowledge, Library, and Information Services Strategy

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KNOWLEDGE, LIBRARY, AND INFORMATION SERVICES

STRATEGY

Author Ian Rennie

Knowledge, Library, and Information Manager

Sponsor

Responsible committee Board of Directors

Ratified by

Date ratified

Date issued

Review date

Version 2.1

If developed in partnership with

another agency, ratification

details of the relevant agency

N/A

Supersedes Knowledge, Library, and Information Strategy

v1.0

Signed on behalf of the Trust: ………………………………………………….. Aidan Thomas, Chief Executive

Elizabeth House, Fulbourn Hospital, Fulbourn, Cambs, CB21 5EF Phone: 01223 726789

Version Control

Version Date Author Comments

1.0 19/12/2012 IR Submitted to board.

2.0 1/5/2015 IR Revised and substantially replaced to reflect 2015-2017 goals and

objectives.

2.1 1/2/2016 IR Minor revisions and updates to account for changes to the Trust.


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CONTENTS

1. Executive Summary .................................................................................................... 3

2. Authorisation ............................................................................................................... 6

3. Organisational Description ......................................................................................... 7

4. Mission Statement ....................................................................................................... 9

5. Goals and Strategies – Identification of Themes .................................................... 10

5.1. Horizon Scan .............................................................................................................. 10

5.2. Emergent strategic themes....................................................................................... 10

6. Integration with Knowledge for Healthcare framework .......................................... 12

6.1. National Priorities ...................................................................................................... 12

6.2. National Strategic Themes........................................................................................ 12

6.3. Actions to carry forward ........................................................................................... 13

7. Overall Vision ............................................................................................................. 14

8. Strategic goals ........................................................................................................... 16

8.1. Document supply ...................................................................................................... 16

8.2. Collection Development ............................................................................................ 17

8.3. Partnership and Strategic Working .......................................................................... 18

8.4. Service Integration and Quality ................................................................................ 19

8.5. Infrastructure ............................................................................................................. 20

8.6. Education, Training, and Outreach .......................................................................... 21

8.7. Service Promotion and Marketing ............................................................................ 22

9. Conclusion ................................................................................................................. 23


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1. Executive Summary Plan On A Page

Vision • A provider of library services to integrated community, mental health, and social care services across Cambridgeshire, Peterborough, and beyond.

• Providing library services, resources, and customer experience at a national standard • Informing and informed by world-leading research and education

Mission Our mission is to put library users in control of library services. We will maximise access opportunities to existing library services and resources, and provide the chance to input into every aspect of service from title selection to opening hours. In other words:

“To provide the support so every library user can satisfy every information need.”

Values Professionalism Respect Innovation Dignity Empowerment

Strengths We provide services to a distributed community-based organization, so we are ahead of the game in our thinking about remote access, outreach training, and electronic service delivery.

We have formed partnerships with public libraries to bring library access to inpatient service users.

As a small library service we can operate in a lean and responsive way and incorporate horizon scanning into our service model.

Our Goals

Expand collection, services, & delivery to reflect CPFT’s position as an integrated provider of community, mental health, & social care services.

Enhance CPFT specialist mental health services with up to date, responsive materials.

Invest in and secure the future of the library service by securing grants and recognition for innovations and new ways of working.

Work in partnership with other NHS libraries and other public organisations to deliver the best healthcare information to staff and service users.

Develop the workforce of the future through education opportunities and resources for continuing professional development. Utilize cutting edge IT solutions to overcome barriers of distance, time, and resource availability. Put library users in charge of library purchases through Patron Driven Acquisition

Themes Document Supply Collection Partnership Integration Infrastructure Education Promotion

Actions Maintain transaction numbers

Revitalize website

Create “library in a

box” collections

Reform library service standards

Streamline purchase cycles

Empower staff in

purchasing decisions

Implement patron driven acquisition

Create library of

borrowable technology

Increase NHS representation at

the CLA

Increase support to Recovery College .

Make collaborative regional purchases

Bid for Health

Education England library services

Expand regional partnerships

Responsive, integrated collection

Ensure appropriate skill mix in library

staff

Maintain & ensure service quality

Increase library points of access

Improve mobile working for staff

and users

Improve existing facilities

Increase Athens

usage

Expand online training

Online clinical

procedures training

Increase library presence at

professional groups

Greater focus on and access to

outreach training

Streamline electronic presence

Create publicity

refresh cycle

Send publicity packs to wards and

teams

Promote knowledge

management


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The Knowledge, Library, and Information Services strategy identifies the scope and direction of library services for the period 2016 to 2018. This document was developed in consultation with Trust staff from multiple service areas, including Nursing, Psychology, Psychiatry, Learning & Development, and Medical Education. The content of this strategy has also been informed by daily contact with the Trust’s clinical and nonclinical staff within the library. This strategy follows and expands version 1.0 of the Knowledge, Library, and Information Services strategy, which covered the period 2013-2015. The successful implementation of this strategy, and the changed environment the library was faced with at the conclusion of the first implementation plan, led to the drafting of version 2.0 of the strategy. In the year following this second draft, changes to the Trust’s organisation necessitated further revision and the current version (2.1) was created. The strategy is underpinned by the library’s vision, mission statement, and values: Vision:

A provider of library services to integrated community, mental health, and social care services across Cambridgeshire, Peterborough and beyond.

Providing library services, resources, and customer experience at a national standard

Informing and informed by world-leading research and education Mission:

Our mission is to put library users in control of library services. We will maximise access opportunities to existing library services and resources, and provide the chance to input into every aspect of service from title selection to opening hours. In other words:

“To provide the support so every library user can satisfy every information need.” Values:

Professionalism – We maintain the highest standards in the service we deliver and help our users to develop as professionals

Respect – We put library users and service users at the heart of our thinking, building positive relationships by delivering on our promises and going beyond what we are asked for.

Innovation – We are constantly finding new ways to connect library users with the information and knowledge they need. We are proud to support world class research and innovation.

Dignity – We treat our library users not just with the dignity we would want for ourselves but with the dignity they display to service users, carers, and the public.

Empowerment – We go beyond answering the questions library users ask and give them the tools to satisfy their information needs.

The strategy has seven underlying themes, which also serve as our strategic aims.

Document Supply

Collection

Partnership

Integration

Infrastructure

Education

Promotion


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For each of these aims, the strategy examines our current efforts against a strategic hierarchy, establishes a vision of library services, and identifies tasks that will need to be performed in order to achieve this vision. The major initiatives identified include:

Develop “library in a box” collections for outreach to distance staff.

Implement Patron Driven Acquisition for eBooks

Increase support of Recovery College East

Enable clinical skills training and assessments online.

Improve mobile working for library staff and library users

Create a library of borrowable learning technology

Promote and increase outreach training

Working with Organisational Development and other teams to promote knowledge management activities.

These tasks and their timetables are detailed in this document and its accompanying two year implementation plan, which is contained in the Appendix document to this strategy. The strategy and plan will form the backbone of the library’s Annual Review, which will determine how the library is progressing in reaching its strategic aims, and also identify any new challenges that the strategy might need to be revised in order to meet. To support this strategy, the appendix also contains Collection Development and Marketing strategies, drafted as part of the strategic revision process. The implementation goals from these strategies are included in the overall implementation plan.


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2. Authorisation This document was produced by the Knowledge, Library, and Information Manager, Ian Rennie. It was produced in consultation with the Library Strategy Steering Committee, which consisted of the following members from a variety of disciplines and locations within the Trust: Emma Bayliss – Library and Information Services Paul Collin – Social Care Judy Dean – Nursing Karen Foody – Nursing – Community Sharon Gilfoyle – Recovery College East Alec Grimshaw – Nursing – Acute Sepehr Hafizi – Psychiatry – Acute Rowena Harvey – Health Visiting Ehab Hegazi – Psychiatry – Cavell Centre Vanya Johnson – Psychiatry – Older People’s Mental Health Vanessa Moore – Learning & Development Clare Mundell – Pharmacy Alexandra Leech-Faragher – Research & Development Wendy Scott-Earl – Nursing – Older People’s Mental Health Rachel Wakefield – Allied Health Professionals Neil Winstone – Nursing and administration. Young Elaine – Nursing – Adult Services


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3. Organisational Description

3.1. Brief description

Cambridgeshire and Peterborough NHS Foundation Trust library services provide a multidisciplinary knowledge, library, and information service to the staff and students of Cambridgeshire and Peterborough NHS Foundation Trust, an integrated mental health and community services Foundation Trust. CPFT Libraries also provide library services to the employees of Health Education East of England.

The library currently operates two locations: Fulbourn Library in Block 14 of Ida Darwin in Fulbourn, and the Cavell Centre library in Peterborough. Across these locations we offer a range of knowledge, library, and information services to staff and students, including books on all aspects of health and social care, access to a wide range of electronic and print journals, and point of care and instructional tools for clinicians.

In the last five years, CPFT’s library services have expanded from a single point of access with a single member of staff to three FTE equivalent roles providing service across two in-person library locations, with an additional increased emphasis on online and distance services including electronic resources and training outreach.

3.2. Facilities and Holdings

The library service currently operates two facilities: Fulbourn library, and the Cavell Centre library, while providing support to the Recovery College East’s libraries at the Gloucester Centre in Peterborough and Ida Darwin in Fulbourn.

Fulbourn library is the larger of CPFT’s two facilities, housing a collection of around 2000 books, along with an extensive print journal archive and around 25 journal subscriptions. Fulbourn also hosts an extensive e-learning suite, suitable for up to 18 simultaneous learners. Fulbourn library is open for 40 hours per week, Monday to Friday from 9AM to 5PM.

Cavell Centre library is a compact modern facility within the Cavell Centre in Peterborough. It currently houses a collection of over 500 recent books across a range of disciplines, with plans to increase this collection substantially. Additionally, the library currently receives the latest issues of 28 high impact journal titles across a wide range of health and social care topics, from psychiatry to safer communities. Cavell Centre library is open to staff through mediated access 24 hours a day, and is staffed Monday to Friday from 9AM to 5PM.

The library service as a whole holds around 2700 circulating items including books, CDs, and DVDs, with a continually updated collection. In addition, the library subscribes to around 60 e-Book titles and is in the process of expanding its holdings in this area. The library service subscribes to over fifty journals in print across its two locations, and has print holdings of decades of back issues. In addition to this, the library offers electronic access to over four thousand journals mediated through Athens, many of which include access up to the latest issue.

3.3. Staff and organizational structure

Library services are managed by the Trust’s Knowledge, Library, and Information Manager (band 7), and delivered by the library staff, which currently consists of the Library Manager, an Assistant Librarian (band 5), and a Library Apprentice. The Library Manager reports to the Head of Learning and Development.

3.4. Library Funding


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The library service is jointly funded by Health Education East of England and Cambridgeshire and Peterborough NHS Foundation Trust. In previous years, CPFT would invoice Health Education East of England quarterly for library funding. Due to changes in the funding model, money for library services is now included in the Learning and Development Agreement as part of the overall medical and non-medical education tariffs. The agreed formula for library funding from Health Education East of England is as follows:

8% of the Placement Fee listed in Part C (funding for Medical Posts)

5% of the Non Medical Placement Tariff listed in Part B

5% of the Undergraduate Medical Placements funding listed in Part E The library also receives funding directly from Cambridgeshire and Peterborough NHS Foundation Trust.

3.5. Library Organizational Chart Chief Executive

Director of Business Development and Workforce

Associate Director of People Services

Head of Learning and Development

Knowledge, Library, and Information Manager (Band 7)

Assistant Librarian (Band 5)

Library Apprentice


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4. Mission Statement The library service is guided by CPFT’s overall Vision, Mission, and Values. However, as the library offers a distinct service, it also has a distinct vision and mission. Informed by the Trust’s Vision, Mission, and Values, the library has developed its own:

Vision:

A provider of library services to integrated community, mental health, and social care services across Cambridgeshire and beyond.

Providing library services, resources, and customer experience at a national standard

Informing and informed by world-leading research and education Mission:

Our mission is to put library users in control of library services. We will maximise access opportunities to existing library services and resources, and provide the chance to input into every aspect of service from title selection to opening hours. In other words: “To provide the support so every library user can satisfy every information need.”

Values:

Professionalism – We maintain the highest standards in the service we deliver and help our users to develop as professionals

Respect – We put library users and service users at the heart of our thinking, building positive relationships by delivering on our promises and going beyond what we are asked for.

Innovation – We are constantly finding new ways to connect library users with the information and knowledge they need. We are proud to support world class research and innovation.

Dignity – We treat our library users not just with the dignity we would want for ourselves but with the dignity they display to service users, carers, and the public.

Empowerment – We go beyond answering the questions library users ask and give them the tools to satisfy their information needs.

The vision expressed here will be expanded upon in the Overall Vision in section 7 of the strategy.


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5. Goals and Strategies – Identification of Themes

5.1. Horizon Scan

The first step in identifying the library’s future course of actions is to look at what we currently do well, what we could do better, opportunities to improve services in future, and potential barriers or threats to these service improvements. This is done through a SWOT/ SWOB analysis. A SWOT/SWOB questionnaire was sent to all members of the library’s stakeholder group, as well as being filled out by the library manager and assistant librarian. The details of these results can be found in the appendix to this document.

5.2. Emergent strategic themes. The SWOT analysis, combined with the review of the previous strategy, identified a number of strategic themes to the library’s service, both in terms of what we do and in terms of what we could improve. These are:

5.2.1. Document supply The provision of print and electronic books, articles, and other resources to staff and students within the groups we serve.

Processing requests and locating resources from own stock or partner libraries.

Delivering resources to end users.

Directing library users to available self-service resources.

5.2.2. Collection development The growth and maintenance of the library’s print and electronic resources.

Identifying gaps within the collection for development and identifying collection needs for new community staff by expanding the stakeholder group

Working with stakeholders to improve the collection

Sourcing new titles and journals for the collection cost-effectively

Processing received titles and promoting new resources in person and electronically

Maintaining and promoting the existing collection

Weeding old or unwanted resources

Identifying new ways to connect the collection with library users

5.2.3. Partnership and strategic working Collaborating within and beyond the Trust to deliver the greatest benefit from library services.

Forming partnerships and networks with other libraries and library cooperative schemes, including LIHNN Mental Health Libraries Group, PLCS, and the Copyright Licensing Agency.

Sharing best practice and pooling resources

Networking with leadership within own organisation to identify underserved staff

Reaching formal agreements with other organisations to improve overall service.

Supporting library services for Recovery College East

Partnering with local educational institutions to support staff and placement learners.


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5.2.4. Service integration

Recognising the continued efforts needed to expand service from mental health library provision to integrated mental health and community library provision.

Outreach to community based staff through promotion, induction, and training.

Instilling library ownership in community staff with community input into purchasing and strategic decision making.

Ensuring continuity of existing relationships between community staff and other NHS libraries.

Expanding and improving existing community library resources.

Innovation in resources for and delivery to community staff.

5.2.5. Infrastructure and facilities The provision and maintenance of adequate physical facilities for the library to offer its services.

Pushing for suitable facilities in the north part of our service area

Becoming involved in any and all discussions about the Ida Darwin site

Tailoring service availability to not miss the needs of distance staff

Ensuring facilities have adequate resources and infrastructure to offer the best service.

5.2.6. Education, training, and outreach The sharing of knowledge, expertise, and resources with library users no matter where they are located within or beyond our service area.

Delivering training in the use of our resources in a wide variety of locations, class sizes, and forms, including online and outreach delivery

Delivering out-of hours access to expertise through library clinics and outreach visits.

Developing multimedia electronic ways of delivering our training

Extending distance access to resources through mail and the use of “Library boxes”.

5.2.7. Service Promotion and Marketing The raising of awareness of library services in all their forms.

Promotion of resources and services in person, through displays, and through publicity

Maintaining library presence at professional group meetings to promote the service

Marketing the collection and service through library events, induction, and team events.

Spotlighting under-used but useful resources for staff.

Demonstrating the benefits of the library at distance learning events. Two of these areas, collection development and marketing, will have dedicated strategies that will be part of the strategy’s implementation plan. The overriding strategic aim of the library service is the maintenance of these seven key areas.


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6. Integration with Knowledge for Healthcare framework As library services conform to national as well as regional and local standards for service, this strategy has been developed in accordance with. Health Education England’s five year development plan “Knowledge for healthcare: a development framework for NHS library and knowledge services in England”. CPFT’s library strategy acts as a synthesis of national and local standards for library services.

6.1. National Priorities Health Education England list the following as the purpose of library services:

The purpose of healthcare library and knowledge services is to:

Provide knowledge and evidence to enable excellent healthcare and health improvement.

Use the expertise of their staff to ensure that NHS bodies, staff, learners, patients and the public have the right knowledge and evidence, when and where they need it.

They also give the following as an overall vision of library services:

NHS bodies, their staff, learners, patients and the public use the right knowledge and evidence, at the right time, in the right place, enabling high quality decision-making, learning, research and innovation to achieve excellent healthcare and health improvement.

This emphasis on supporting and informing high quality research and learning aligns with CPFT Libraries’ own vision as outlined in Section 4. Health Education England also identify four key areas of work:

The importance of information

Evidence-based Practice

Patient Expectations

The Future Workforce. The key areas of evidence based practice and patient expectation map to the library’s own identified vision of patient care being at the heart of our services, and our duty to provide the best service possible. The commitment to the future workforce maps to our vision of world-leading research and education. The importance of information is embodied in our mission statement: “To provide the support so every library user can satisfy every information need”.

6.2. National Strategic Themes The Knowledge for Healthcare framework consists of four strategic themes, which map onto the tasks that CPFT Libraries have identified as priorities for the coming two years.

6.2.1. Transforming the service – proactive customer-focussed services The commitment to customer focus is embedded in our seven key strategic areas. Our collection development initiatives will develop targeted service offers. Our education and training work will promote information and digital literacy, and improvements to our document supply service will ensure services are available at the point of need.


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6.2.2. Transforming the service – quick and easy access

CPFT libraries have long been innovators in the area of improving access, as we serve such a broad service area. The addition of new community staff to the Trust make this even more of a priority. Our document supply services will enable easy multi-platform access to resources. Our collection development efforts will involve engaging with and influencing publishers and suppliers. We will work with our IT staff to make sure that our IT infrastructure is robust enough to support the demands on our service.

6.2.3. Effective leadership, planning and development of the healthcare library and knowledge services workforce

While much of this theme revolves around actions that are taken at a national leadership level, a necessary part of CPFT Libraries’ Education, Training, and Outreach has to include the development of our own staff. Opportunities for staff to develop and deliver better services must be part of our strategic approach.

6.2.4. Optimising funding for best value CPFT Libraries will optimise our funding by partnership and strategic working with other local libraries serving intersecting and overlapping communities. This will be especially important with serving our new community staff, many of whom have existing relationships with other library services. By working with these libraries we can avoid unnecessary duplication of resources and spend local library funding more wisely.

6.3. Actions to carry forward The following priorities were identified in our analysis of the Knowledge for Healthcare framework and should act as objectives for the library strategy:

6.3.1. Document Supply – Ensure services are available at the point of need, Provide simplified sign-on to resources, Ensure access via multiple platforms and mobile devices

6.3.2. Collection Development – Develop targeted service offers, Ensure that policy and funding support eligibility for all, Engage with and influence publishers and suppliers

6.3.3. Partnership and Strategic Working – Promote cross-sector LKS collaboration, Promote collaboration between LKS and other functions, Engage with national stakeholder organisations

6.3.4. Service Integration – Produce more national products and services for local delivery

6.3.5. Infrastructure – Further automation of internal functions to increase time for customer facing service, Influence and inform national and local IT strategy & policy, Influence the development of a robust IT infrastructure

6.3.6. Education, Training, and Outreach – Promote information and digital literacy amongst NHS staff and learners

6.3.7. Service Promotion and Marketing – Improve marketing and promotion of services

These actions will inform the library’s detailed vision and become part of our strategic goals.


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7. Overall Vision As a guiding principle of how to improve library services by 2018, it is worth giving a vision of library services as they should exist by that point. In this next section we will give that vision, and follow it with the steps needed to make it a reality. Vision of 2018 By 2018, CPFT Libraries will offer equality of access to all its users regardless of geographical location, job role, home organisation, or method of access. Library users will expect and receive high quality, instantly available information and knowledge services at their fingertips. All library users will have immediate access to a responsive, tailored health and social care collection covering multiple access methods, subjects, and formats. These will include recent, relevant print books available in our libraries and by post, instantly accessible e-Books usable from computers or tablet devices, and a vast collection of journal articles accessible electronically and in print. Users will be guided by extensive bibliographies and curated subject collections. All resources will be searchable through a single, easily accessible point of access. The collection will be both proactive and responsive, anticipating demand and serving all its users information needs. All library users will have input in the library’s collection, with purchase requests being a simple one-click function on the library’s website. The library’s partner organisations will give library users swift access to millions of book and journal articles and share their facilities with CPFT library users for reference and study. The library’s high profile within and beyond the Trust, in concert with their publicity and marketing efforts, will keep library users aware of the resources available to them. These efforts will include a responsive, easy to use website that offers simple access to all library services on any platform, as well as broadly distributed current awareness newsletters and publicity. The library will support free and equal access to libraries for service users by working closely with public libraries in Cambridgeshire and Peterborough. Inpatient users of CPFT’s services will have easy and regular access to public library services through mobile library visits, and will be signposted to other library services and locations. To support service users in their recovery, the library will assist in collection development and training for the staff, students, and library services of Recovery College East. The library will meet the needs of a diverse and distributed Trust by delivering a diverse and distributed service. Resources within CPFT’s libraries will be as available to staff at their desk as they would in the library itself, from books to journals to library expertise. Document supply through email and internal mail will mean that the library’s collection is swiftly available to all staff. Curated “library-in-a-box” and e-Book subject collections will assist users in resource discovery. The library’s knowledge services will be instantly available by phone, email, and instant message whenever the library is open. Site visits and attendance at professional meetings will ensure the library has a presence in every discipline and area of the Trust. Training in the use of library services and electronic resources will be available in person in the library or at the user’s workplace, electronically via e-learning courses, or in any other more convenient venue. The library will advocate for its users regionally and nationally through partnerships with other East of England libraries, national NHS library organisations, and regional and national groups such as the Reading Agency. The library’s excellent service quality will be recognised though consistently high scores from the Library Quality Assurance Framework and the sharing of best


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practice and innovation nationally. Within its home organisation, the library will be recognised as a first stop for knowledge and information, with over 25% of staff having Athens accounts and a similar number having library membership. Library facilities will be responsive to the needs of a changing distributed Trust. The library’s several locations will all be sufficient – in terms of time and resources – to meet the needs of their service area as well as strongly supporting distance staff. The library will work closely with Trust IT to support mobile and distance working so the library can be as mobile as its staff. Community services will form a large and growing part of the library’s clientele. The library will have resources and staffing suitable to their unique needs and will deliver outreach training to these staff at their places of work. Services to community staff will be carefully monitored, and specific outreach and promotion efforts will aid their integration into the library’s service area. The library will work in close partnership with other libraries who deliver services to these staff to make sure that we are working towards the same clear objectives. The library will act as a focal point for training in the Trust, serving as both a venue for and provider of training. A wide array of training – both in person and electronic – will run on library computers, and library staff will author and present in person and online training opportunities to staff and students within CPFT and to the wider library and learning communities.


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8. Strategic goals

In the development of this strategy the library service has identified seven strategic themes through which improvements to library services can be identified and implemented. This section of the strategy expands on these themes and the library’s vision to give quantifiable goals necessary to implement this vision. The “timetable” section of these strategic actions gives an estimate of the amount of time each action will take. For details of the dates of implementation for each action, please see the implementation plan in Appendix 1 of this document.

8.1. Document supply

Vision: By 2018, CPFT Libraries will offer equality of access to all its users regardless of geographical location, job role, home organisation, or method of access. Library users will expect and receive high quality, instantly available information and knowledge services at their fingertips. Document supply through email and internal mail will mean that the library’s collection is swiftly available to all staff. Curated “library-in-a-box” and e-Book subject collections will assist users in resource discovery.

8.1.1. Keep library transactions above 6000 per year by 2018

8.1.2. Develop library website as “one stop shop”

8.1.3. Create “Library-in-a-box” collections

8.1.4. Reform library service standards

Aim: Conduct 6000 transactions in 2016 with library users, and a similar number in 2018. Transactions are defined as: supplied documents, a completed literature searches, delivery of education or training.

Aim: Create a single point of contact for all requestable materials on the library’s website. If possible through a single request form.

Aim: Increase use of library materials in distance teams by the use of frequently replenished local collections.

Aim: Improve library performance and data retention by benchmarking and restructuring document supply standards.

How: Raise and maintain profile of the library within the Trust. Promote lesser used library services such as literature searches, and reach out to less served groups, such as student nurses and social care staff.

How: Liaise with IT about adding email forms to the website. Develop and promote form. Ensure that the form is mobile-accessible and simple to use (choice of what they’re requesting, space for name and email address, large text box to paste in request details).

How: Create “library in a box” lists for multiple subject areas. Contact ward and service managers about hosting small collections (~20 books) for a 6 month period. Create protocol and pilot with enthusiastic or unserved distance teams (MST in Kettering, new community teams). If successful, roll out Trust-wide.

How: Conduct retrospective benchmark on time taken to deliver key metrics of document supply service. Draw up service standards to reflect and improve on existing service. Conduct review after one year to compare results.

Measurement of achievement: Monthly and annual library statistics.

Measurement of achievement: Form used by 2 or more library users a week.

Measure of achievement: Successful pilot. Usage of boxes by 3 or more teams in the first six months and the successful and complete return of the boxes in the second six. Usage of contained materials.

Measure of achievement: Net improvement on time from response to delivery on key metrics of document supply service at one year review.

Timetable: 2 years, reviewed annually. Timetable: 6 months for development of the form, 6 months for promotion. Measure usage in April of 2016.

Timetable: 6 months to design protocol and book lists. 6 months to pilot with first site. 12 months to extend to the rest of the Trust.

Timetable: 3 months to arrange and conduct benchmarking, 1 month to write service standard, 1 year to review.


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8.2. Collection Development

Vision: All library users will have immediate access to a responsive, tailored health and social care collection covering multiple access methods, subjects, and formats. These will include recent, relevant print books available in our libraries and by post, instantly accessible e-Books usable from computers or tablet devices, and a vast collection of journal articles accessible electronically and in print. Users will be guided by extensive bibliographies and curated subject collections. All resources will be searchable through a single, easily accessible point of access. The collection will be both proactive and responsive, anticipating demand and serving all its users information needs. All library users will have input in the library’s collection, with purchase requests being a simple one-click function on the library’s website.

These items will be discussed in greater detail in the Collection Development Strategy

8.2.1. Streamline collection development and purchase cycles

8.2.2. Empower library staff in purchasing decisions

8.2.3. Implement Patron Driven Acquisition of eBooks

8.2.4. Create equipment library for learning-related technology

Aim: Reduce processing time from purchase request to received item by increasing smaller purchases between the stages of the purchase cycle.

Aim: Transform purchasing into an organic process where materials are tailored and decisions made at a local level

Aim: Put electronic purchase decisions into the hands of library users with a Patron Driven Acquisition collection

Aim: In partnership with CPFT’s Technology Enhanced learning team, implement a repository of lendable library related technology.

How: Develop and detail workflow for purchasing. Delegate to assistant librarian (see 8.2.2). Introduce monthly smaller “express” purchases.

How: Get access to purchasing systems for assistant librarian. Empower assistant librarian to own and develop Peterborough collection. Change purchasing workflow from top-down model for Peterborough purchases.

How: Negotiate a PDA collection with Ebsco or another eBook provider. Implement a small pilot fund (£2000 to begin with) and advertise heavily. When titles are accessed more than once by library users they will be purchased and added to the collection

How: Pilot a programme where communal technology in the Learning and Development team (cameras, training laptops, tablets, etc) are catalogued and checked out to trainers. If successful, extend to borrowable technology for wider staff.

Measurement of achievement: All requested items to go from request to shelf in 6 weeks or less. This standard to be present in the library’s service standards.

Measurement of achievement: Peterborough collection is responsive to Peterborough needs, as reflected by checkout statistics.

Measurement of achievement: Increase in eBook usage. Post-purchase title usage.

Measurement of achievement: Successful pilot programme with all technology usage properly recorded and no missing equipment.

Timetable: 3 months to develop process workflow. 6-12 months to pilot.

Timetable: 6 months to develop workflow.

Timetable: 3 months to draw up initial PDA collection. 6 months to promote and pilot usage, then make decision as to whether to expand.

Timetable: 3 months to develop protocols, 6 month pilot before any wider rollout.


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8.3. Partnership and Strategic Working

Vision: The library’s partner organisations will give library users swift access to millions of book and journal articles and share their facilities with CPFT library users for reference and study. The library will support free and equal access to libraries for service users by working closely with public libraries in Cambridgeshire and Peterborough. Inpatient users of CPFT’s services will have easy and regular access to public library services through mobile library visits, and will be signposted to other library services and locations. To support service users in their recovery, the library will assist in collection development and training for Recovery College East. The library will advocate for its users regionally and nationally through partnerships with other East of England libraries, national NHS library organisations, and regional and national groups such as the Reading Agency.

8.3.1. National representation with the Copyright Licensing Agency

8.3.2. Explore expansion of facilities for Recovery College East

8.3.3. Collaborative Purchase

8.3.4. Bid for extended library services

Aim: Represent the local interests of the Trust and the broader interests of mental and community health with the Copyright Licensing Agency

Aim: Explore funding options for opening CPFT library services to all delegates of Recovery College East

Aim: Reduce overall cost of library resources and services by entering into collaborative purchase options for e-journals and e-books.

Aim: Increase library profile and income by bidding to deliver library services to Health Education England.

How: Attend meetings of the CLA Royalties Data Collection Working Group. Give input to the design of usage protocols. Champion appropriate use of copyright within the Trust and to the NHS at large while pushing the interests of healthcare libraries and healthcare information use to the CLA.

How: Speak to Health Education East of England’s professional adviser for libraries about expanding services to include service user students of Recovery College East. Speak to the director of Recovery College East about potential for funding from other sources. If a recurring funding source can be found, implement service expansion.

How: Review current and desired subscriptions, holdings, and platforms. Compare with others in the East of England to find opportunities for collective purchase. Make purchases if opportunities exist.

How: Draft formal tender, take part in bidding process. If successful, deliver high quality library services to Health Education England.

Measurement of achievement: Mental health and community health interests represented in any CLA copyright usage standards.

Measurement of achievement: Prospect fully explored. If funding available, services expanded.

Measurement of achievement: Collective purchases identified and made.

Measurement of achievement: Success in bidding process.

Timetable: Ongoing, depending on meeting schedule of Copyright Licensing Agency.

Timetable: 6 months to examine expansion options, 1 year to pilot.

Timetable: 12 months to examine and identify collaborative options and make initial purchases.

Timetable: 3 months to bid, 12 months to implement services.


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8.4. Service Integration and Quality

Vision: Community services will form a large and growing part of the library’s clientele. The library will have resources and staffing suitable to their unique needs and will deliver outreach training to these staff at their places of work. Services to community staff will be carefully monitored, and specific outreach and promotion efforts will aid their integration into the library’s service area. The library will work in close partnership with other libraries who deliver services to these staff to make sure that we are working towards the same clear objectives. The library’s excellent service quality will be recognised though consistently high scores from the Library Quality Assurance Framework and the sharing of best practice and innovation nationally.

8.4.1. Regional Partnership 8.4.2. Responsive Collection for an Integrated Service

8.4.3. Appropriate staffing and skill mix for an expanded Trust

8.4.4. Maintain and ensure service quality

Aim: Partner with other East of England libraries to promote the idea of “One NHS, One Library”

Aim: Transform existing library collection from a mental health collection to an integrated mental health and community services collection.

Aim: Ensure that the library service is responsive and resilient by reviewing current staffing levels and skill mix against national standards.

Aim: Receive a Library Quality Assurance Framework score of 95% or more by 2018.

How: Work with other NHS libraries in the East of England to raise awareness of the value library services deliver at local, regional, and national levels. Gain library representation on national NHS library groups. Explore greater collective purchasing and action.

How: Invite representatives from community staff groups to join the library stakeholder group. Make significant purchases in community care subject areas. Create publicity to market new resources to new staff (bibliographies etc)

How: Benchmark current staffing against national averages and standards. If appropriate, review banding and number of current library staffing. If suggested by benchmarking, reband or hire as appropriate within existing library budget.

How: Determine courses of action to correct existing areas of noncompliance or partial compliance with LQAF. Budget time for evidence gathering and service development. Involve all library staff in completing the LQAF to ensure no blind spots in the process.

Measurement of achievement: Higher profile for libraries within and beyond the Trust.

Measurement of achievement: Library usage by community staff. Usage of materials purchased as part of community collection.

Measurement of achievement: Consistent staffing of library service points, increase in performance by library service standards

Measurement of achievement: Score in the annual Library Quality Assurance Framework.

Timetable: Ongoing promotion and partnership efforts.

Timetable: 3 months to expand stakeholder group. 6 months for new publicity.

Timetable: 2 months to benchmark current staffing. 6 months to make case for any necessary rebanding or hiring.

Timetable: LQAF submissions due in July of 2016 and July of 2017.


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8.5. Infrastructure

Vision: Library facilities will be responsive to the needs of a changing distributed Trust. The library’s several locations will all be sufficient – in terms of time and resources – to meet the needs of their service area as well as strongly supporting distance staff. The library will work closely with Trust IT to support mobile and distance working so the library can be as mobile as its staff. The library will be recognised as a first stop for knowledge and information, with over 25% of staff having Athens accounts and a similar number having library membership.

8.5.1. Prepare library for potential move

8.5.2. Improve mobile working 8.5.3. Improve existing facilities 8.5.4. Increase Athens usage

Aim: Improve library readiness for an eventual move from the Fulbourn site.

Aim: Using mobile technologies, find ways to bring library services to distance staff.

Aim: Increase service availability and quality by making our existing facilities the best they can be.

Aim: By 2018, give 25% or more of staff access to Athens.

How: Review library assets and holdings to streamline a move. Conduct any necessary weeding or purchasing of library holdings and furnishings. Review proposed facilities for suitability. Investigate options for expanded hours or services at new facility including patron driven checkout. Publicise move with leaflets notifying users of the change of address.

How: Develop or discover mobile-accessible ways of conducting major library functions (including circulation, document supply, Athens administration, and other vital functions). With these in place, arrange “library clinics” in underserved parts of the community. Work with Health Education East of England’s Mobile Development Group to find innovative mobile device uses.

How: Within 2 years, double the number of available library computers in the north part of our service area, through expanding the Cavell Centre library or creating capacity elsewhere.

How: Heavily promote Athens, develop procedures to make Athens signup as simple and easy as possible, provide aftercare to make sure expiring Athens accounts are removed or renewed as quickly as possible.

Measurement of achievement: No loss of service in move to new location.

Measurement of achievement: Increase in circulation from less served areas of the community.

Measurement of achievement: Improved perception of our facilities, as measured in the library survey.

Measurement of achievement: 25% of staff have an Athens account by April 2018.

Timetable: Variable depending on move timetable.

Timetable: 6-12 months to identify ways of delivering services through mobile technology. 12 months to pilot distance delivery.

Timetable: 2 years Timetable: 2 years.


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8.6. Education, Training, and Outreach

Vision: Resources within CPFT’s libraries will be as available to staff at their desk as they would in the library itself, from books to journals to library expertise. Document supply through email and internal mail will mean that the library’s collection is swiftly available to all staff. Curated “library-in-a-box” and e-Book subject collections will assist users in resource discovery. The library’s knowledge services will be instantly available by phone, email, and instant message whenever the library is open. Site visits and attendance at professional meetings will ensure the library has a presence in every discipline and area of the Trust. Training in the use of library services and electronic resources will be available in person in the library or at the user’s workplace, electronically via e-learning courses, or in any other more convenient venue.

8.6.1. Expand online training 8.6.2. Implement online clinical procedures training

8.6.3. Increase library presence at professional group meetings

8.6.4. Increase and simplify outreach training

Aim: Increase the accessibility of library training with short and long online training courses.

Aim: Improve staff clinical abilities with a range of online guidance and assessments.

Aim: Make library presence a regular part of inductions or professional meetings for every staff group within the Trust.

Aim: Make booking outreach training to your place of work as easy as requesting n item or booking onto a training session.

How: Develop short online courses in the use of simple online functions like ELMS. Consider a “welcome to the library” course folder with ELMS, Athens, and other simple introductions. Develop online critical appraisal training and promote to junior doctors and clinicians.

How: Using tools such as the Royal Marsden Manual Online and Clinical Skills, promote online procedures training and assessments. Work with Learning and Development to embed this training in areas such as Preceptorship and the Care Certificate.

How: Liaise with leads or other education staff for medicine, nursing, psychology, allied health professionals, social workers, support workers, R&D, pharmacology, and other identifiable professional groups. Determine the best way for the library to meet their information needs and promote library service. Offer library presence at inductions, team meetings, away days, and so forth.

How: Promote outreach training as a concept to teams throughout the Trust and especially to those at a distance from library locations. Create simple one-page outreach booking form that can be filled out in print or electronically. Liaise with Technology Enhanced Learning team to create a simple and easy session request form. Have Athens Outreach sessions listed in the CPFT prospectus.

Measurement of achievement: 50 people taking a “welcome” course in the first year after its release. 25 people taking and passing the critical appraisal course.

Measurement of achievement: Sign ups to and usage of Clinicalskills.net, access statistics from the Royal Marsden Manual.

Measurement of achievement: Increased library usage from currently underserved groups.

Measurement of achievement: 4 or more Athens outreach courses in the next two years.

Timetable: 12 months to develop courses, 12 months to pilot.

Timetable: 6 months to implement. Clinical Skills procedures an embedded part of the Care Certificate and preceptorship portfolios by April 2017

Timetable: 12 months to make approaches and increase meeting attendance.

Timetable: 6 months to promote outreach and create booking form. Athens Outreach included in 2017 prospectus.


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8.7. Service Promotion and Marketing

Vision: The library’s high profile within and beyond the Trust, in concert with their publicity and marketing efforts, will keep library users aware of the resources available to them. These efforts will include a responsive, easy to use website that offers simple access to all library services on any platform, as well as broadly distributed current awareness newsletters and publicity.

These items will be discussed in greater detail in the Marketing Strategy

8.7.1. Streamline the library’s electronic presence

8.7.2. Implement publicity refresh cycle

8.7.3. Send library publicity packs to every team

8.7.4. Promote organisational knowledge management

Aim: Create a single point of externally accessible web contact for the library, rather than separate Intranet and website pages.

Aim: Every piece of library publicity to be reviewed and renewed at least every six months.

Aim: On a 6 or 12 month cycle, send every team within the Trust a printed pack of library publicity including training dates, leaflets, and posters advertising new materials.

Aim: Increase the library’s role in organisational knowledge management by innovating in knowledge management provision and promoting knowledge management services.

How: Save a copy of all Intranet pages. Remove pages as they currently exist and replace with simple link/landing page directing people to the library’s website or Learning Management System pages. Update webpages with content from former Intranet pages. Look into subdomain or separate domain for library website. Consider use of Totara learning Management System as base for library web presence.

How: Build publicity refreshment into work schedule. Date every piece of library publicity (on the file and on the document) and timetable refreshment dates for each.

How: Develop a team list and a distribution schedule. Inform team managers that materials will be sent out. Liaise with communications to see if distribution can be done through partnership with them. Send out packs across the calendar year so nobody is overwhelmed or missed out.

How: Work with organisational development to codify and promote library knowledge management services. Work with the Trust Secretariat to clarify library role in policy development. Pilot Q and A form knowledge repository within teams with an eye to organisational usage. Increase training offered in critical appraisal and reference interviewing.

Measurement of achievement: Increased usage of library website.

Measurement of achievement: All publicity distributed has been checked and updated within the last 6 months.

Measurement of achievement: Increased library awareness and program attendance.

Measurement of achievement: Higher profile for the library in KM provision, better management of organisational knowledge.

Timetable: 6 months for prep and revision.

Timetable: 3 months to implement cycle.

Timetable: 6 months to develop, 12 months for distribution cycle.

Timetable: Various across the life of the strategy.


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9. Conclusion Cambridgeshire and Peterborough NHS Foundation Trust is an organisation that has considerably changed since the first draft of this strategy was written. When version 1.0 of the library strategy began its implementation process in 2013, this was an organisation in turnaround, with a focus fixing immediate problems and quick results. A lot of this focus is evident in version 1.0 of the strategy, which looked at short term metrics and small scale implementation. The strategy was a success, but part of its success was that it enabled the library to look at broader aims. Since the first strategy was written, the Trust has changed, both in terms of adopting new leadership and in terms of expanding as an organisation. An integrated Trust has different needs from its library service than a mental health Trust, and delivering library service to an organisation with 3500 members proposes different challenges to delivering those services to an organisation with 2200. This new strategy reflects those challenges but also treats them as opportunities to make better use of public money and deliver better service to public employees. What has not changed from the previous version of the strategy is the library’s commitment to providing excellent service and supporting excellent care. In the last year the Trust has changed the wording of its vision and values, but their central message still resonates with the mission of library services. The last library strategy helped the library service to turn around and begin its growth and improvement. This revised version will help the library flourish as a high quality service that CPFT can be proud of.

Agenda Item: 10a


REPORT

Subject: Trust Annual Business Plan – 2016 / 17

Date: 30th March 2016

Author: Kit Connick, Associate Director

Lead Director: Stephen Legood, Director of People and Business Development

Executive Summary: Each year, NHS Foundation Trusts are required to submit operational plans to NHS Improvement. For

FY16/17 a one year operational plan is required, within the context of the Trust’s overarching strategy. The

timescales set by NHS Improvement require the Trust to submit a full draft plan on 8th February 2016,

against which they will provide feedback ahead of the final plan submission on 11th April 2016.

In the 14/15 planning round the Trust developed a long term (five year) strategic plan for achieving

sustainability centred on four key areas; service integration, workforce development, IT and estates

development and commercial development.

NHS Improvement expects the operational plan to be aligned to the Trusts long-term plan and to the local

health and care systems Sustainability and Transformation Plan (STP), covering the period October 2016 to

March 2021

Recommendations:

That the board members are assured that there has been a robust process to ensure the plan is in line with

the guidance produced by NHS Improvement.

That the plan is driven by the Strategic Direction as set by the Board and the healthcare system’s

Sustainability and Transformation Plan.

That committee members note the final plan submission that will be submitted on 11th April 2016 (subject to

some changes to the financial and activity data, following discussions with the CCG).

That in the event of no agreement being reached with the CCG, the Trust Development Authority Dispute

Resolution process will be applied.

That the board consents to delegate its authority to the Chair and Finance Director when signing off the final plan, in order to meet the submission deadline of 11th April.

Development of CPFT One Year Operational Plan – 2016/17

1. Purpose The purpose of this paper is to present to the Board the requirements Foundation Trust plans as required by NHS Improvement and to give assurance that the process and timeline for the production of these within the Trust has been adhered to. This work is undertaken in conjunction with the development of the Trust’s financial plan including activity assumptions, cost pressures, cost improvement programmes, workforce plan and capital planning. This is supported by contracts with commissioners that reflect reasonable assumptions on activity that balances risk appropriately. 2. Background NHS Improvement’s overarching objectives for the 16/17 planning round is that all providers will have in place robust, integrated operating plans for 16/17 - that demonstrate the delivery of safe, high quality services; and achievement of, or delivery of recovery milestones for, access standards. Through a combination of provider actions to improve efficiency, the expected tariff arrangements, and the deployment of the Sustainability and Transformation Fund (STF): there will be an improved financial position compared to 2015/16 for all providers and an aggregate break-even position for the provider sector.

2.1. NHS Foundation Trusts are required to submit an operational plan to NHS Improvement. In the 2014/15 planning round the Trust was asked to develop a long term (5 year) strategic plan for achieving sustainability. NHS Improvement has confirmed for 16/17 that they require a one year operational plan only, sitting within the context of the overarching strategy aligned to the local health and care systems Sustainability and Transformation Plan (STP).

2.2. NHS Improvement have indicated that this new requirement is driven by a need for all NHS

organisations to develop their strategic position, engage with health system partners in the process, in order to address issues of poor performance. There is also a clear requirement to meet the operational and financial requirements set out in the Trust’s provider licence; and to ensure flexibility and capacity to overcome unexpected short-term difficulties along the way.

2.3. Though the planning cycle is for one year, it clear that the Trust must continue with its long

term strategy which should remain live, evolving and responding to changes in internal performance and external factors over the long term.

3. Process for Development of Operational Plans – 2016/17

3.1. To support FT boards and executive teams in discharging their responsibility for assessing the quality of business planning NHS Improvement has developed a ‘Strategy Development Toolkit’ in order to identify any gaps in planning processes and weaknesses in plans produced for 16/17.

3.2. In line with NHS Improvement’s ‘Strategy Development Toolkit’ the Trust Board held a

Strategy Away-Day in October 2015, in part to review the strategic objectives within the Trust’s 5 Year Plan and to support the development of additional supporting strategies. The Board reaffirmed its overarching vision to be:

• a local provider of patient and carer centred integrated community, mental health and

social care • one of the UK’s premier providers of key specialist mental health services • an organisation whose services are enabled by world leading research and education

3.3. The process timeline followed for the operational plan has ensured that submission dates

have been met and that full opportunity has been given to the Business and Performance Committee and Board of Directors to consider the operational plan, along with a presentation to the Council of Governors on Wednesday 16th March.

3.4. In November 2015 the Directorates started to develop their Operational Plans which were

reviewed in December 2015 with final sign off at an Operational Planning Review Workshop in February 2016. Underpinning this process, detailed work on determining budgets, activity assumptions, costs pressures, business developments, CIPs, workforce and capital plans has been undertaken.

The Business Planning Lead has worked closely with Finance, Contracting, Workforce and Performance colleagues to ensure a joint approach to the development of the plan.

3.5. The draft plan was signed off by the Chair and the Chief Executive with the Executive Team support and review. Formal submission of the draft plan was 8th February 2016 and included (a maximum of) 20 pages of narrative covering:

• approach to activity planning • approach to quality planning • approach to quality improvement • delivery of seven day services • quality impact process • triangulation of indicators • approach to workforce planning • approach to financial planning • Link to the emerging Sustainability and Transformation Plan • Membership and elections

There was no adverse feedback from Monitor on the content of the draft plan. Any outstanding areas in the draft submission have now been completed for the final attached submission (a maximum of 25 pages). There are two areas that require further refinement; finance and activity planning. These are dependent on the ongoing contracting discussions and will be further developed in March prior to the submission in April.

3.6. In the event of no agreement being reached with the CCG, the TDA Dispute Resolution process will be applied:

• The dispute resolution process applies to disputes arising in relation to agreement of

terms for a new contract, as part of the 2016/17 planning round:

between commissioners and providers, and which typically have material financial implications;

where the scope of the dispute relates to contractual payment, services and obligations; and

where another means of resolution is not otherwise stated in national guidance

NHS England, NHS TDA and Monitor are able to offer advice and assistance to support the process, and where possible avoid arbitration

3.7. The final submission for the detailed 1 year 2016/17 Operational Plan will be submitted to NHS Improvement on 11th April 2016. It is composed of a detailed set of financial forecasts covering 1 year, an operational plan with detailed assumptions, mitigations, health system analysis, workforce implications, quality plans, CIP narrative etc. A redacted summary of the operational plan narrative, in a format suitable for external publication is also required (attached as Appendix 1).

3.8. NHS Improvement will conduct a high-level review of providers’ final operational plans

following the 11th April submission. This review will largely entail corroboration of the material movements; with the expectation that providers final plans will have been based on the discussions and feedback provided after the draft plan submissions. The process will also involve identifying and following up on unexpected movements. NHS Improvement will consider the implications for providers of their final operational plans and monitor their delivery during 2016/17 through the routine oversight and assurance processes.

4. Conclusions The Trust is required to deliver a one year operational plan aligned with its Five Year Strategy and system-wide Sustainability and Transformation Plan. NHS Improvement has set deadlines for Foundation Trusts to submit the final version of their one year plan by 11th April 2016. The Board is asked to: • Note and approve the final plan submission that will be submitted on 11th April 2016 (subject to

some changes to the financial and activity data, following discussions with the CCG).

• Note and approve that in the event of no agreement being reached with the CCG, the Trust Development Authority Dispute Resolution process will be applied.

• Consent to delegate its authority to the Chair and Finance Director when signing off the final plan, in order to meet the submission deadline of 11th April.

1

Agenda Item: 10b

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1. STRATEGIC CONTEXT

The Trust Cambridgeshire and Peterborough NHS Foundation Trust (CPFT) is a health and social care organisation, providing integrated community, mental health and learning disability services across Cambridgeshire and Peterborough, and children’s community services in Peterborough. CPFT supports around 100,000 people each year and employs more than 3,400 staff. It’s largest bases are at the Cavell Centre, Peterborough and Fulbourn Hospital, Cambridge, but staff are based in over 90 locations. The Trust is a designated Cambridge University Teaching Trust and a member of Cambridge University Health Partners; one of only eight Academic Health Science Centres in the UK. Our mission To offer people the best help to do the best for themselves. To put people in control of their care, we will maximise opportunities for individuals and their families by enabling them to look beyond their limitations to achieve their goals and aspirations. CPFT vision We want to give those people who need our services the best possible chance to live a full and happy life, despite their condition or circumstances.

Recovery – we will adopt the principle in all our services of empowering patients to achieve independence and the best possible life changes removing dependence and giving them and their families (in the case of children) control over their care.

Integration – we will work closely with providers along pathways to deliver integrated person-centred care and support to local people close to their homes, principally in non-institutional settings. We will integrate with key partners to improve efficiency and effectiveness and simplify access.

Specialist services – we are one of England’s leading providers of key specialist mental health services, with particular expertise in eating disorders, children and young people’s mental health, autistic spectrum disorders and female personality disorders.

Values - PRIDE

Professionalism - We will maintain the highest standards and develop ourselves and others by demonstrating compassion and showing care, honesty and flexibility

Respect - We will create positive relationships by being kind, open and collaborative

Innovation - We are forward thinking, research focused and effective by using evidence to shape the way we work

Dignity - We will treat you as an individual by taking the time to hear, listen and understand

Empowerment - We will support you by enabling you to make effective, informed decisions and to build your resilience and independence

Changing healthcare landscape The Trust operates within the Cambridgeshire and Peterborough local health and social care economy with Cambridgeshire and Peterborough Clinical Commissioning Group (CCG) as the main commissioner. Other commissioners include NHS England and two Local Authorities. The Trust serves a fast-growing, ageing and diverse population with significant inequalities. At the start of 2015, the population registered with GP practices within the region was 913,000 and continues to increase. Demographic analysis shows a growth in population of 5.3% over the next five years, with the greatest absolute increase in adults of working age. In relative terms, the population aged over 65 is growing fastest, with the most significant increases being recognised in the over 85’s. Information from the Office of National Statistics illustrates the following changes:

Cambridgeshire population is forecast to increase by 4.4% between 2014 and 2019 (28,000 people in total), with most of the increase in South Cambridgeshire.

Peterborough population is forecast to increase by 5.7% between 2014 and 2019 (10,900 people in total).

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There are also other factors that are creating rapid changes in the population growth and health demographics, including:

The student population of Cambridge City (approx. 25,000) equates to nearly a quarter of the City’s resident adult population.

Changes in the migrant population add to the complexity of commissioning services. The region has a high international migrant population from different socio-economic backgrounds. In the last ten years, there has been a particular influx from Romania, the Baltic States and the USA (mainly armed forces).

There are significant areas of deprivation in areas of Cambridgeshire and Peterborough. The latter is predominantly urban, with 26% of the population living in areas that are amongst the 20% most deprived in the country.

Life expectancy figures illustrate significant differences across the region for both men and women.

Over the duration of the last five year plan, the acuity of the population’s health need increased by 2.5% per annum and is now forecast to increase to 3% in 2016/17. This in part reflects the increase in growth of our elderly population.

In 2014 the Health system alone was identified as one of eleven ‘challenged Health economies’ nationally, with an estimated £250m f i n a n c i a l ‘ gap’ i d e n t i f i e d over the next five years. The root cause of this is identified to be a mismatch between capacity and demand, which affects all parts of the system and is significantly affecting all providers. The CCG reports that by 2018/19 if there has been no change within the Health system they will face a deficit of at least £250 million. In addition, the budgets for adult social care for both Councils are under considerable pressure. This manifests itself not just in a reduction in funding for care packages, but in contracting care home and home care markets – a common issue within ‘Shire’ areas of the country and where reductions are forecast in funding for the voluntary sector. Discussions with the CCG have commenced although these are not yet finalised. The demand for mental health services continues to increase, particularly the number of people presenting with dementia. The focus on community-based ‘recovery’ services to alleviate the pressure on acute provision places significant pressures on community services and the voluntary sector (referred to above). Work is underway with Cambridgeshire County Council (CCC) to develop an overarching strategy to protect and invest in preventative and early-intervention services and to focus on building independence and resilience, via a number of actions under the umbrella of a Health Impact Assessment plan. At present, the Trust anticipates a cost improvement (CIP) requirement of £8.5 million in 2016/17. The twin challenges of growing demand and financial constraint has led the local health and social care system over a number of years to move towards an integrated health and social care model, primarily in mental health services. More recently, the CCG tendered the Older People’s and Adults Community Health Services, which was won by UnitingCare Partnership (a Limited Liability Partnership established by CPFT and Cambridge University Hospitals). This led to approximately 1,300 staff transferring to the Trust on 1 April 2015 to deliver integrated physical and mental health care for older people and adults with long term conditions. The contract between the CCG and UnitingCare was terminated by the Partnership on 2 December 2015, although the Trust continues to deliver the services to patients within their scope under a direct commission from the CCG. As a result of this expansion, the Trust’s annual turnover increased from £127m in 2014/15 to £190m in 2015/16. As a Trust, we remain committed to the integration of services with our partners to alleviate pressure on the system, facilitating better patient care and making the best use of available resources. This includes working with the CCG and our local Councils to lead on the Vanguard programme to remodel urgent and emergency mental health services. The programme seeks to provide a universal, 24/7, mental health crisis care pathway, which can be accessed directly by patients and carers. 2015/16 Performance Review The Trust has invested significantly in infrastructure improvements in-year, with Capital expenditure of £4.3m in 2015-16; all of which has been internally funded. Improvements in the year have included investment in technology to improve IT resilience and performance, investment in mobile working to support clinical staff in the community, and a comprehensive review and reorganisation of the facilities and estate to enhance and ensure a continued safe clinical and working environment. Over the course of 2015/16 the Trust has continued to experience demand and capacity issues, with ongoing challenges for inpatient service capacity and a significant increase in referrals in some service areas. Additional investment will be sought as part of the 2016/17 commissioning round to secure the sustainability of these services.

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The Board has been satisfied during the year that sufficient plans have been in place to ensure on-going compliance with all existing national targets. Strategic Delivery – Progress During 2015, there have been many changes in the system and the services provided by the Trust. The Board has used this opportunity to review its core values and sense of strategic direction. It has realigned its objectives based on the challenges and opportunities ahead, successfully establishing the Trust as an integrated services provider of both physical and mental health services for the patient and user population that it serves. This transition will help the organisation to build on its successes and ensure a sustainable future going forward. Four strategic work streams form the basis of the five year strategy, each with an Executive Lead, Clinical Sponsor and Project Management support from the Change Team. These work streams will continue into 2016/17.

a) The development, commissioning and implementation of a new Integrated Service

The Trust has worked in partnership with key stakeholders to deliver this component of the strategy and linked this to the system-wide transformation programme being led by the local CCG. The local health economy-wide redesign programme is consistent with the NHS Five Year Forward View principles, with success being measured by the breaking down of barriers between mental and physical care; how the care is provided across the system; and greater use of technology and the provision of care closer to home. In 2015, 1,300 staff transferred to the Trust as part of the Integrated Care for Adults and Older People work stream. Following a detailed mobilisation and transformation plan, services safely transferred to the Trust’s responsibility and, since then, the gradual service integration and culture change has made good progress. Adult Mental Health has worked extensively with the third sector and Primary Care to bridge the gap between primary and secondary care to create a seamless service for patients. In 2016/17, the Trust will continue to support the redesign of Integrated Care for Children and Families work being led by Local Authorities as part of the system-wide transformation process, which will include co-location of some Trust services in Peterborough with the resident Social Care Teams, as a precursor to potential vertical integration. There remains the potential that CPFT could run these integrated services in the future on the basis that we build strong partnerships with third sector organisations e.g. Barnardo’s. The Trust will continue to work with its commissioners, Cambridgeshire Community Services (CCS) – another local provider of Children’s services across a large part of the CCG’s geography - and third sector providers to support a new care delivery model and ensure that we are central to the development.

b) The design, development and implementation of the future CPFT workforce

There has been a significant amount of work undertaken to redesign the clinical and corporate workforce to support the delivery of a service model based on the wider principles of recovery. The model ensures sustainability of a service provision that is affordable and delivers high quality care that meets the needs of patients. An agile working strategy is being implemented, which includes the use of mobile working to drive productivity gains, along with an ongoing review of skill mix. The Trust continues to engage with both private and third sector partners in delivery of specific services as part of the redesign of the clinical workforce. Other key work streams include:

The Apprenticeship Scheme

Safer Staffing Review – Inpatient ward focussed on and following national guidance on appropriate model

Enhanced ‘Grow Your Own’ Programme, working with Anglian Ruskin University (ARU)

Internal leadership and development programmes for corporate and clinical staff

c) Maximising the contribution of IT and the Trust estate This work stream focuses on the development of highly innovative and effective ways to use technology and the Trust estate in support of person-centred care, whilst maximising the financial benefit for CPFT. A five-year Estates Strategy was approved by the Board in 2015, setting out a number of long term programmes to support the development of the Trust e.g. agile working programme, delivery of the integrated care strategy and redevelopment of the Fulbourn site.

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The Trust has undertaken an extensive review of its sites to ensure that, wherever possible, care is provided close to patients’ homes and communities. An agile working project is in place to support staff to deliver care in those communities. The transfer of CCS services has opened up opportunities to make better use of the estate, support co-location of services and closer working as part of the health and social care system. Information Technology is also an essential enabler to delivering care close to patients’ homes and communities and in reducing administrative costs, improving efficiency and supporting agile working. We have now commenced a number of pilots supporting the mobile working for community clinical staff and these will be extended to cover a broader range of services and staff groups in the coming year.

d) A commercial and financial sustainability strategy

The Trust will seek to deliver financial stability and sustainability over the lifetime of our strategic plan through a mixture of organic growth, selected acquisition and tender success (subject to option appraisal). Following the Integrated Care for Adults and Older People bid, the Trust’s annual turnover has increased by 33% over the past year, to £190m in 2015/16. Building on its Commercial Strategy, the Trust is supporting a number of key priorities:

Working with Cambridge University to (i) develop a Clinical Neurosciences Private Patient Centre in Cambridge and (ii) develop specialised ‘Apps’ for use with mobile technology

The ongoing development of an International Commercial Directorate to actively seek opportunities abroad via the provision of management consultancy advice and support focused on the design of mental health services.

The investigation of potential new service lines in emerging markets that are consistent with the Trust’s five year strategy and successful development of integrated older adult community health services. This includes developments for the Integrated Care Directorate and the forthcoming Children’s Services tender.

Responding to existing services that are subject to procurement in order to maintain existing core services e.g. CAMH Tier 4 Services, Eating Disorder Inpatient Services, Peterborough Prison Services, GP Mental Health and Wellbeing Service and the Children’s Community Eating Disorder Services.

To explore the opportunities around the development of new services e.g. a Female PICU Service to provide both a local and regional service and a perinatal unit as part of the system-wide redesign work.

2. ACTIVITY PLANNING

The Trust takes a robust approach to activity plans being driven by operational services, ensuring that there is sufficient capacity to deliver the required services, whilst aligning this with our commissioners’ plans. Monthly contract meetings are held with commissioners to review performance, demand and capacity and to ensure that performance is aligned with the agreed plan. As part of this ongoing work, the Trust will obviously respect the forthcoming Monitor guidance on activity planning and mental health outcome focussed commissioning models.

3. QUALITY PLANNING The Quality and Safety strategy is led by the Director of Nursing and is founded on the ‘Three Pillars of Quality’ approach, each of which has its own strategic objectives, priorities and work programmes. The quality priorities for 2016/17 are in line with both Local and National commissioning priorities and fall under the following three categories:

Patient safety

Patient experience

Clinical effectiveness In developing these indicators the Association of Medical Royal College guidance on the ‘Responsible Consultant’ has been taken into account. The indicators under each of these headings is set out below and includes any unachieved objectives from 2015/16:

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Patient Safety 1. To reduce avoidable harm through:

Improved falls prevention and reduction in harm from falls

Reduction in the number of avoidable pressure ulcers acquired in CPFT

Reduction in the number/proportion of self harm (moderate to severe) incidents

2. To improve practice and Trust processes relating to the management of violence and aggression:

Use of restraint

Physical assaults

Seclusion and long-term segregation

3. To improve processes for embedding learning in the Trust from:

Incidents and complaints

Audits and service improvement projects

Service reviews (accreditations, etc) Patient Experience

1. To ensure that our patients are treated in the best possible clinical environments: 2. Improvement in PLACE scores

Note: overall Trust wide 2015/16 scores for mental health wards met the target of scores equal to or higher than national average, but individual wards had scores lower than national average. Also, integrated care directorate (ICD) community wards were excluded from the target. Target for 2016/17:

o Mental health – all wards to have scores equal to or higher than national average o ICD – to show an improvement in 2015/16 scores

Therapeutic environments – relevant scores in patient experience surveys to be no less than 95%

Improving our physical environments:

o Improving signage, especially in ICD wards o Full compliance with Mixed Sex Accommodation Standards in all our wards – privacy and dignity,

safety ligature etc

3. Friends and Family Test – address specific areas that show consistent low scores in the patient experience survey:

Food

Weekend activities

Medication side effects

Clinical effectiveness

1. To implement the Clinical Effectiveness Strategy across the Trust:

All services will be using a Trust-approved Patient Reported Outcome Measure (PROM) that is recorded and reported upon by the end of the year

To strengthen evidenced-based intervention (EBI) processes in CPFT

To strengthen the culture of research among frontline staff

To improve physical health monitoring processes in our mental health services

2. To improve processes for identifying learning and embedding change from:

Incidents, near misses and complaints

Audits, service improvement and research projects

External service reviews

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CPFT achieved a ‘Green’ rating overall when it was assessed by the CQC in May 2015 against the ‘Well-Led’ domain, and is committed to sustaining this rating for 2016/17. In particular, the CQC commended the following areas:

The Trust Board had developed a vision statement and values for the Trust; most staff were aware of these

Good governance arrangements were in place, which supported the quality, performance and risk management of the services

Key performance indicators were used to gauge performance

The Trust had undertaken positive engagement action with service users and carers

Team managers had sufficient authority to manage the service effectively

There was effective team working and staff felt supported by this

Staff knew how to use the ‘whistleblowing’ process and could submit items to the risk register

There was a commitment to quality improvement and innovation. CPFT achieved a ‘Green’ rating overall when it was assessed by the CQC in May 2015 against the ‘Well-Led’ domain, and is committed to sustaining this rating for 2016/17 as well as the five ‘Sign up to Safety’ pledges. In particular, the CQC commended the following areas:

The Trust Board had developed a vision statement and values for the Trust; most staff were aware of these

Good governance arrangements were in place, which supported the quality, performance and risk management of the services

Key performance indicators were used to gauge performance

The Trust had undertaken positive engagement action with service users and carers

Team managers had sufficient authority to manage the service effectively

There was effective team working and staff felt supported by this

Staff knew how to use the ‘whistleblowing’ process and could submit items to the risk register

There was a commitment to quality improvement and innovation.

Quality review of 2015/16

a) Patient experience

A total of 30 wards/units were assessed in the 2015 PLACE assessment, which included those transferred from Cambridgeshire Community Services. The Trust’s overall organisational scores for PLACE for 2015 were above the national average for all five assessment domains, which was an improvement on the previous year. However, local improvements are needed for some wards/units e.g. those that relate to the age and condition of some of the general buildings. The Trust has made good progress in identifying and developing improved support for carers, including the launch of the ‘Triangle of Care Assessments’ for the mental health services in the Trust; setting up of a Carers’ Board within the Trust; and the launch of the carers’ experience survey.

b) Patient safety

The Trust has made excellent progress in 2015/16 in meeting the objectives of ‘Positive & Proactive Care’ (PPC), which is overseen by the PPC group and chaired by the Director of Nursing. We have significantly reduced the incidents of prone restraint and are confident of completely eliminating this practice by April 2016. During 2015 we have strengthened our incident recording to enable the capture of more detailed information on restrictive practice incidents and include this data on ward monthly dashboards for staff to see progress. In 2015 the Trust also introduced a more robust process for post-incident debriefing for both service users and staff, which will be evaluated in 2016. Our ward managers continue to lead their teams in adopting innovative and proactive care approaches to reduce the need for restrictive practice and have presented their respective ward initiatives at both regional and national events during 2015. These initiatives continue to be mapped through the Trust’s ‘Promise Project’, which has gone from strength to strength during the year.

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c) Clinical effectiveness

Improving documentation around diagnosis remained a quality priority for the Trust in 2015/16, with an incremental target of 65% from 47% at the end of 2014/15. At December 2015, performance was recorded at 58%. Other key achievements include maintaining accreditation status in National Quality Improvement Programmes for our services, with a number of our services achieving ‘excellent’. For 2015/16, the Trust committed itself to the development of a Trust-wide Clinical Effectiveness Strategy, taking account of our new services, with the aim of embedding a quality improvement culture in the Trust to support our vision of providing the best possible outcomes for the people who use our services. As part of the strategy, we identified four key priorities for the next three years: research and development, evidence-based interventions, outcome measures and physical health.

Quality Improvement The Trust will map its indicators against national requirements, including CQC standards, Monitor targets, commissioning requirements, CQUINs and other national quality standards such as NICE. In addition, the Trust will have its own local (internal) indicators, which will be based on the Strategic Plan. There will be a governance framework in place to ensure we monitor our progress and performance, including dashboards that are fit for purpose and processes for reporting and monitoring these, as well as a range of monitoring activities e.g. audit, regular team-based monitoring activities such as the Integrated Compliance Assessment Tool (inCA), monthly checks, service reviews, staff and patient surveys, research, and service improvement/development projects. Improvements identified for 2016/17 will include:

strengthening engagement with the Directorates

improving the monitoring processes

ensuring there are adequate resources to support the plan. Seven-day services Seven-day services are a fundamental foundation that underpins the Urgent and Emergency Care Vanguard programme that the Trust is engaged in. The Trust already offers a range of services under the banner of Seven-Day Services (see Table 1 below); through redesign of our services we now provide Crisis Resolution & Home Treatment, Liaison Psychiatry, Personal Wellbeing Services (IAPT); and an enhanced medical rota covering the County. The Trust is seeking to extend and enhance these services in 2016/17.

The Trust is engaged in the delivery of the system-wide Vanguard programmes, which are of fundamental importance to the Trust’s business plans for 2016/17. The work streams will help transform urgent and emergency care requiring a fundamental shift in the way services are provided to all ages; improving in-hospital and out-of-hospital services so that the Directorate and system partners deliver better care, closer to home. Further detail of the programmes is set out in Table 3.

Table 1: Seven-Day Services

24/7 MH Crisis Response: Schemes

Comments Compliance

Tele-coach Patients calling NHS 111 in mental health crisis will be accessed by a tele-coach to understand the issue(s) and attempt to de-escalate the crisis or make a referral via the DOS

Yes 24/7 (subject to funds)

First responder To respond to patients accessed via the tele-coach as vulnerable and needing face-to-face support

Yes 24/7 (subject to funds)

Safe Place A safe place, called the Sanctuary, for people experiencing a mental health crisis to take time out, provided by the voluntary sector (MIND)

Yes 7/7 1800 - 0100

Psychiatric Liaison

Increased provision at Cambridge University Hospitals and Peterborough and Stamford Hospital.

Yes 7/7 0800 – 0100

Integrated Mental Health Team

Mental health staff in the Police control room advising and assisting the Police to support people in a mental health crisis.

Yes 7/7 0800 – 2200

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Quality Impact Assessment (QIA) process All Cost Improvement Programmes (CIPS) are identified through the annual business planning process via a bottom-up approach, led by each Directorate. This information is gathered and triangulated to inform the Trust-wide Business Plan. The QIA is an integral part of the overall planning process. Standardised QIA templates include a range of categories e.g. patient safety, patient experience, impact on staff etc. These are completed by Service Managers and clinicians with support from the Trust’s Programme Management Office (PMO). All data is captured centrally by the PMO and ownership for each QIA is held with the Clinical Directors. QIAs are discussed and ratified by Director of Nursing and Medical Director at the start of each financial year. The Trust’s System Change Committee (SCC) has dual responsibility with the Performance and Risk Executive (PRE) for managing the overall CIP programme. Discussions on quality related issues are escalated from these fora to the Quality, Safety and Governance Committee (QSG - a Board sub-committee). The Board is informed of any outstanding risks and mitigations via a report from the QSG. In-year monitoring of QIA is co-ordinated by the PMO and all CIP projects are regularly reviewed for performance against target and, where appropriate, the QIA is reviewed and updated as necessary. There is an exception reporting process to the SCC and PRE for in-year changes. Directorates have responsibility for reporting all above threshold risks (including clinical risks) to the Corporate Risk Register, via the Directorate risk registers. Outstanding quality concerns The Trust received its final CQC report in October 2015 and was praised for the significant improvements made since the last inspection. As a result of the inspection there are three key areas that require improvement at Directorate level and Requirement Notices:

Reg 13: MHA & MCA compliance around section 58 - Consent to Treatment and Seclusion

Reg 15: Ligature risks and observations

Reg 18: Staffing

There were also recommended actions in two other areas, one of which remains outstanding:

Availability of psychological therapies There are a number of action points that require commissioner support, particularly those in relation to staffing and resource requirements. To mitigate the risk, there are a number of steps already in place:

Each Directorate has a specific action plan that feeds into the strategic action plan

A CQC Oversight Group has been established to oversee the implementation of the action plan, with clear lines of reporting to the Performance Risk Executive, the Quality, Safety & Governance Committee and ultimately the Trust Board

Long-term monitoring will be integrated into the performance review processes

Action points around funding requirements will be monitored at agreed intervals through quality, contracts and performance meetings with the commissioners

Monitor has offered to support the Trust in its discussions and negotiations with the commissioners around funding issues to bring the relevant Trust services in line with the CQC recommendations to deliver safe, effective and responsive services.

The Trust has put in place detailed plans to address these concerns and robust governance arrangements to monitor progress, check completion of the actions and the desired outcomes.

Triangulation of indicators The Trust adopts a Directorate-based approach to performance reporting, triangulating indicators, breaking these down by services and engaging clinical and corporate functions in the analysis and review of the data. The data forms part of a monthly reporting cycle to inform the Board of performance in the period. Exceptions and areas of under-performance are scrutinised further, as required.

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The Trust is a member of the NHS Benchmarking Network and participates in various national benchmarking initiatives throughout the year. This data is used to inform areas for development within the Trust e.g. quality of care and productivity. We also triangulate with the HSCIC published data which is extracted from our mandatory and statutory returns.

4. WORKFORCE PLANNING The overarching Workforce Strategy is underpinned by a suite of supporting strategies:

Organisational Development (OD) Strategy

Health and Wellbeing Strategy

Recruitment and Retention Strategy These suite of strategies will support the Trust in achieving the key aims of the Workforce Strategy by delivering on the following six key workforce objectives across 2016/17:

Integration To develop the workforce to be fully integrated to support future Trust strategies and enhance the skills, knowledge and experience across all staff groups and disciplines, developing new integrated roles

Resourcing and recruitment To attract, recruit and retain high calibre, appropriately skilled and experienced staff who share our values and demonstrate supporting behaviours to ensure the provision of safe integrated care of high quality.

Organisational development To strengthen the leadership and management development ensuring values are role modelled for all staff and appropriate plans are in place to support talent management and succession planning

Workforce planning, education, training and development To develop a robust workforce plan to support the Trust strategy. To support the Trust through the learning and development process, in achieving a competent and confident workforce able to deliver a responsive, equitable, safe and compassionate service that meets all required standards.

Supporting staff To strengthen staff engagement, reward and recognising achievements, and maximising the value of our workforce whilst supporting and improving our staff well-being

Quality and safety To improve patient experience by ensuring staff are appropriately trained, equipped, supported and can perform at their optimum level improving efficiency and productivity.

The Trust already measures a range of key workforce performance indicators via a monthly Workforce Dashboard

and the Trust Board receives quarterly workforce reports which will include progress against the workforce strategy.

The following table details the Key Performance Indicators (KPIs) that will be used to measure the outcomes of the

strategy

Table 2: Workforce Strategy Key Performance Indicators (KPI’s)

KPI’s FY17 FY18 FY19 FY20 FY21

Turnover <10.5% <10.5% <10% <10% <10%

Vacancy levels <5% <5% <5% <5% <5%

Recruitment time to fill 10wks 9wks 9wks 9wks 9wks

Reduction in Bank & Agency spend from FY16 figures

by:

5% 7% 10% 15% 15%

Number of apprenticeships 60 60 65 70 80

National staff survey engagement Scores 3.81 3.85 4.00 4.25 4.5

Sickness absence rates <4.35% <4.35% <4.35% <4% <4%

% of staff to recommend CPFT to family and friends as

a place to work

60% 65% 70% 75% 80%

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% of staff to recommend CPFT as a place to care for

family and friends

60% 65% 70% 75% 80%

Mandatory training xompliance 95% 95% 95% 95% 95%

Appraisal compliance 95% 95% 95% 95% 95%

Appraisal Quality as per staff survey scoring 3.05 3.15 3.25 3.30 3.45

Reporting of bullying and harassment as per Staff

Survey

20% 18% 16% 12% 10%

The suite of strategies, actions, risks and workforce plans are all overseen by the Workforce Executive; a sub-committee of the QSG. The Trust is focused on supporting staff to deliver excellent care and high quality leadership, whilst maintaining a healthy and highly satisfied workforce. This programme of work is set out in the Health and Wellbeing strategy (to be ratified in March 2106) that identifies the key actions to support staff well-being.

In 2015/16, the Trust put in place a robust action plan in response to the 2014 Staff Survey results. This centred on five core themes; staff safety, work pressures, management support, culture and values and general communications. The results of the 2015 survey show that 34 of the 35 key findings were improved or the same, when compared to 2014. The survey also shows that our top five improvements include more staff who would recommend the Trust as a place to work and would be happy for a friend or relative to be treated here. A comprehensive action plan is being drawn together to ensure that there is ongoing improvement.

The Trust’s approach to workforce planning is aligned to the business planning process, which involves the opportunity for input from all clinical and corporate leaders in line with Health Education England - East’s recommendations. The Trust is aligning its workforce plans with the Sustainability and Transformation Plan via its engagement with the East of England-wide Planning and Transformation Committee work streams. The Trust is part of the local Workforce Partnership Group (WPG), which leads on system-wide planning and transformation. As part of this the Trust is committed to working with its local and Health and Social Care partners to ensure that there is a positive impact on identified staff groups. The Trust also works with the Local Education & Training Board (LETB) to identify priorities and risks for training and workforce supply. The Trust actively engages in system-wide workforce initiatives e.g. recruitment and retention campaigns. It is also leading with the CCG on the mental health Vanguard, as part of the Five Year Forward View. The Trust has an e-rostering system in place that supports most inpatient units (excluding the physical health element of the Integrated Care Directorate) in effective management of rosters. This supports the Trust plan to reduce the use of Agency staffing to a minimum and aids the skill-mix review work being undertaken. It is the intention for all services to use the e-rostering system within the next 18 months. The Trust is also working to ensure it falls within the Agency usage cap set by Monitor, whilst ensuring that services remain safely staffed. The monthly Trust performance dashboard provides detailed information on workforce information that is triangulated with financial and quality metrics. This data is reviewed and analysed as part of the monthly Performance Review Executive meetings.

5. FINANCIAL PLANNING Financial summary The key strategic financial focus of the Trust continues to be the development of the Integrated Older People’s Services following the success in securing the adult and older people’s services tendered by the Cambridgeshire and Peterborough CCG during FY16. The financial year FY16 was a significant transitional year for the Trust, with the transfer of staff and services from Cambridgeshire Community Services and the implementation of the new Integrated Care Service Models taking place over the course of the year. The FY17 focus will be on consolidating our financial position, embedding new service provision, ensuring that income is sustained and seeking conservative growth within existing or related service areas.

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In line with published Planning Guidance, the Trust is negotiating a base Tariff Inflator of 1.1% with key commissioners, recognising the 2% national deflator and the national inflation uplift of 3.1%. This is reflected in the Financial Plan. The plan also includes recognition of unavoidable cost pressures and agreed elements of service change. The Trust’s key contracts in FY17 will be with NHS Cambridgeshire and Peterborough CCG, for local mental health and community services and adult and older people’s integrated care services, and with NHS England for Specialist Services. The FY17 plan includes a limited number of service developments, as well as a focus on cost reductions throughout the Trust. The Trust continues to explore international opportunities, with continued engagement regarding the provision of specialist support for the development of mental health services overseas. Income NHS Cambridgeshire and Peterborough CCG, which covers the Trust’s core geographic area, is the main Commissioner of Trust services. The Trust’s other main commissioner is NHS England, who commission a range of specialist services. The Trust has a range of smaller commissioning agreements with bordering CCG’s and with Local Authority commissioners under Clinical Partnership arrangements. The Trust’s non-NHS income is primarily from research and development, and education and training activities. The table below highlights the Summary Income and Expenditure position for the Trust for 2016-17: Table 3: Income and Expenditure

Efficiency savings for 2016/17 In developing the 2016/17 Financial Plan the Trust continues to address significant financial challenges within the local Health system, whilst at the same time continuing to provide a range of safe and effective services with restricted funding. The Trust’s financial planning assumptions for the period include responding to the national efficiency requirement for 2016/17 of 2%; addressing the undelivered elements of 2015/16 savings plans and unavoidable pressures within the Trust’s financial cost base.

INCOME STATEMENT SUMMARY

FY16

Forecast

Outturn

FY17

Plan

Income £m £m

Healthcare Income 175.409 175.883

Other Income 14.400 14.781

Total Income 189.809 190.664

Expenditure

Pay Costs (134.058) (133.176)

Other Operating Costs (47.105) (48.878)

Total Operating Expenditure (181.163) (182.054)

EBITDA 8.646 8.610

Non-Operating Costs (8.211) (8.610)

Operational Surplus / Deficit 0.435 0.000

Gain / (Loss) on Joint Ventures (4.135) 0.000

Surplus / Deficit (3.700) 0.000

13

The Cost Improvement Programme (CIP) for the year has been developed by Directorate Leads, with support from Corporate Services, and includes a range of both transformational and traditional savings plans. Plans have been developed through Executive-led Directorate business planning meetings, chaired by the Chief Operating Officer, with support from the Project Management Office (PMO). The development of detailed CIP project plans has been supported by the Trust’s PMO to ensure each CIP is deliverable and has had a Quality Impact Assessment (QIA) undertaken. There is a robust governance structure in place to manage the delivery of the CIP, with the System Change Committee (SCC), chaired by the Director of Finance, having oversight and scrutiny of the collective development of business plans. The Trust has a number of activities planned for 2016/17 to ensure future sustainability of our services. These include:

Recognising that in the community setting, there is a focus on using data in real-time to support the effective and efficient delivery and design of services. This allows localities to be more responsive and localise the way in which services are delivered to meet local need. This approach will drive out inefficiencies, improve patient care and ensure that staffing is aligned to the need of the local population. It will also highlight any future demands that the Trust is not resourced to meet to inform discussions with commissioners and service redesign

A review of the Trust’s Advice and Referral Centre (ARC), to align this with a Single Point of Access for Integrated Care services. This will focus on how referrals should be managed in the medium-term and links with the Mental Health Vanguard to improve access to emergency care for mental health. This review will include a revised workforce model, including skill mix and a potential estate saving

Continuing to work with commissioners, CCS and social care to support the system-wide redesign of children’s and physical and mental health services in the community. This will facilitate a revised model of care that supports greater integration with the third sector and other providers around Tier 2 Services

Completing the integration of the older adult’s community and mental health services. This will continue to ensure that the model will help to support the system pressures, as well as improving patient care and delivering savings

A comprehensive review of recovery, clinical roles and skill-mix to improve productivity, patient experience and facilitate the smooth transition of patients from inpatient and community settings into Primary Care

The pilot of an enhanced Primary Care service to better meet the needs of people with a serious mental health illness and prevent referrals into secondary mental health services

Accepting a joint lead with the CCG for the mental health Vanguard, which seeks to improve access and response for urgent mental health needs in the system. This will be linked to ‘111’ services and is anticipated to reduce A&E admissions and referrals into secondary mental health services, thereby making financial savings as well as improving services for patients

Reducing agency spend through adoption of the new Agency Rules and focusing on targeted recruitment and enhancing staff bank function.

Capital planning The Capital Plan has been developed via the Trust’s Finance and Capital Infrastructure Group and supports the Directorate business plans for FY17. Membership of this group includes Executive Directors as well as Clinical and Corporate Directorate representation. The Trust intends to continue to finance its Capital Expenditure plans from internally generated funds. The funding available to support Capital Expenditure in FY17, based on forecast Depreciation levels, is £5m. Expenditure at this level will therefore have a net impact of zero on the Trust’s liquidity position in FY17. The outline Capital Plan includes a range of schemes aimed at improving the Trust’s Estate and Infrastructure. This work builds on the Capital Programme in FY16 in ensuring our in-patient, community and corporate facilities are fit for purpose, and that our IT systems provide support to clinical staff in delivering safe and effective patient care. The capital investment is aligned to, and underpins, the Trust Clinical Strategy supporting the sustainability of services. The Trust has a five year Estates Strategy that sets out the plan for improved utilisation of current sites, working with partners to co-locate and to exit sites that are no longer deemed ‘fit for purpose’. An agile working project is in place to support this strategy and facilitate better patient care provided closer to home and the community.

14

Lord Carter’s provider productivity programme The Trust has taken into account the Lord Carter review and has built these recommendations into the development of its CIP plans, identifying areas where savings can be realised and further efficiencies can be driven out. This work is supported by the NHS Benchmarking Network that the Trust is a member of, which enables the Trust to identify other areas of potential development. There are also long-term strategies in place to assist the Trust in making best use of its resources e.g. in Estates and Workforce. Agency Rules The Trust has fully engaged with the new Agency Rules issued by NHS Improvement. This includes working only with recommended suppliers; monitoring usage and spend; and adhering to the hourly cap on rates. The Trust has had variable use of Agency expenditure throughout 2015/16. To mitigate this for 2016/17 a number of actions have been put in place:

Weekly report on Agency spend by ward to be provided to the COO

All consultancy costs to be reviewed by the Executive board

Review of Trust bed usage to ensure that the Agency Rules are adhered to and that services are delivered in a safe and managed way

Implementation of e-rostering in the Integrated Care Directorate It is anticipated that these control measures will contribute to a significant reduction in 2016/17 on Agency spend. Procurement The Trust outsources its procurement function to specialist providers and works closely with them to review procurement activity and prices/benefits achieved. The Trust adheres to nationally agreed procurement frameworks and spend is monitored via a monthly procurement report, which is reviewed centrally. Additional measures are planned for 2016/17 to provider further focus and control expenditure. These include:

Review of the top 100 most common non-pay items

Clinical focus group established to review and reduce the range of clinical supplies throughout the Trust, in order to reduce spend and deliver consistency

The Trust has an online ordering system and will seek to extend utilisation of this system to cover a wider range of procurement activity, thereby enhancing control

Procurement spend to be reviewed by the Business and Performance Committee (a Board sub-committee) to ensure that adequate governance controls and scrutiny is in place.

Costs

The Plan recognises the impact of specific cost inflation factors on the cost base of the Trust over the planning period. The assumptions include the following for key cost categories, recognising the challenging economic environment:

Pay costs – assumes pay uplift of 1% in FY17, additional pension costs, and an allowance for Incremental drift

Other costs – inflationary increase of 1.1% on specific costs e.g. Third Party contracts etc.

PFI – assumption that the RPI uplift will be 1.1%

The other main changes to the cost base are related to the cost saving plans for the year. The key components of the Cost Improvement Programme are outlined in the CIP scheme table above.

Liquidity

The plan for FY17 is to maintain the liquidity position, with an affordable Capital Plan as outlined above.

Financial Sustainability Risk Rating (FSRR) The Trust delivered a FSRR of 2 in FY16 due to the non-recurrent costs of the settlement agreement for UnitingCare Partnership. The Financial Plan for FY17 sets out plans to return the Trust to an FSRR of 3 for the year.

15

Key financial priorities and investments The Trust’s key financial priority is to deliver the Financial Plan as presented for FY17. This will require ongoing review of the financial assumptions, continuing review of the implementation of the new integrated service models, and ensuring the CIP plan is delivered. The Strategic Change Committee (SCC) will take on an overall CIP monitoring role during the year to ensure that the plan is delivered, or mitigations are put in place to address any shortfalls. The monthly Performance and Risk Executive Meetings will also have a clear focus on CIP delivery and mitigation for any shortfall. The Trust will continue to work with the local CCG to take forward the implementation of a more ‘sensitive’ contracting currency model for mental health services and the potential to move away from a Block Contract. This will result in a more acceptable form of contract, reflecting work undertaken. A key element of this will be to improve the activity data recording and clustering, and linking this to financial systems to develop improved Service Line Reporting and Management. This work will enable the Trust to determine the appropriate funding level for current and any agreed future activity levels from FY17 onwards. Initial discussions with the CCG indicate a preference for a non-Block contract for FY17. The Trust is therefore currently working with the CCG to understand the implications of such an approach.

The Trust will also continue to support the development of the Vanguard Programme in the local Health Economy during the year. At this stage the proposals are under development and the financial impact on the Trust is not yet known. The Trust is also continuing to explore international business development opportunities in Qatar and associated areas. The financial plan does not currently reflect any income or expenditure related to these proposals for Vanguard or international developments; both of which are likely to have positive impact.

Risks and mitigation The Trust has identified a range of risks to the financial plan for FY17, which include the following:

Variable income is not recovered at planned levels

Failure to deliver CIP savings

Change in demographics continuing to impact on service demand

Weak liquidity level

Level of contingencies available to mitigate any in-year changes

Resource and capacity to deliver the identified programmes of work.

The Trust has a number of mitigation options to offset the risks which include:

Qatar Bid – the Trust is bidding to provide support to the Qatar Government in developing Mental Health services. The Trust is in the final shortlist and the award of tender is anticipated in Spring 2016

Additional efficiency savings through greater integration opportunities, as well as exploring further estate rationalisation possibilities

The Enabling Fund of £1million and CIP risk reserve of £0.8m

A comprehensive staffing and skill-mix review

Implementation of the Estates Strategy Review and rationalisation of the estates portfolio. Sustainability and Transformation Plan There is a comprehensive Sustainability and Transformation Plan (STFP) that Health and Social Care have signed up to across the system. The plan sets out the working groups, along with timescales and governance arrangements for delivery of the plan. The areas of focus and the impact on the Trust’s 2016/17 plan are set out below: Table 4: Sustainability and Transformation Plan

Summary objectives & scope Affects CPFT plan for 2016/17?

Clinical Advisory Group

To recommend a sustainable clinical five year vision for health and care, including the transformation required to deliver it.

To recommend short term opportunities to improve the effectiveness and efficiency of care, and medium term options for service configuration (including primary, community, mental health, acute, specialised and social care delivered in Cambridgeshire and

Yes

16

Peterborough.)

To assure clinically a) Consultation documentation b) a C&P Mental Health strategy and c) a Five Year Sustainability and Transformation Plan.

Proactive care and prevention (including LTCs, Mental Health & Primary Care at Scale)

To develop the long-term vision for proactive community based care (including the sustainability of primary care, mental health, social care and community services) and care for people with LTCs

To identify, quantify and deliver a set of short term opportunities to reduce admissions amongst rising-risk LTC and SMI patients, including the delivery of priority public health schemes that will have short term (1-3 years) and longer-term impact (5+ years)

To propose localised delivery plan(s) for executing against the proactive care and LTC care model over a 3-5 year period (covering self-care, primary care, SMI, community pharmacy, UnitingCare Wellbeing service, hospice care and population health management).

Yes

Urgent and Emergency Care Vanguard

To develop the long-term vision for sustainable urgent and emergency care that will reduce preventable A&E attendances and admissions by implementing physical and mental health services that implement the national urgent and emergency care vision (covering 111, ambulance, MH crisis, JET, ICTs, neighbourhood teams, acute care, supporting IT platform/ Directory of Services)

To identify, quantify and deliver a set of short term opportunities to improve the cost-effectiveness of urgent and emergency care

To propose and evaluate a set of reconfiguration options for urgent and emergency care, taking into account national standards, key clinical standards and delivery of 7 day services across all settings.

Yes

Elective Care Design Programme (including specialty specific sub-groups)

To develop the long-term vision for elective care (including all cancer care), with further detailed specifications on a vision for elective pathways including orthopaedics, cardiology, ENT and ophthalmology (including care models, standards and pathways)

To identify, quantify and deliver a set of short term opportunities to improve the cost-effectiveness of elective care

To propose and evaluate a set of reconfiguration options for elective care, as well as detailed options for orthopaedics, cardiology, ENT and ophthalmology.

No

Maternity and Neo-natal CWG

To develop the long-term vision for sustainable maternity and neonatal care, in line with the National Review’s recommendations

To identify, quantify and deliver a set of short-term opportunities to improve the cost-effectiveness of maternity and neonatal care

To propose and evaluate a set of reconfiguration options for maternity and neonatal services.

No

Children and Young People CWG

To propose a care model and service specifications for acutely unwell children and young people, children and young people with Long Term Conditions (LTCs) and children and young people with life limiting conditions

To identify, quantify and deliver a set of short term opportunities to improve the cost-effectiveness of children and young people’s services

To propose and evaluate a set of long-term reconfiguration options for paediatric and children’s health services in primary, secondary and community, linking in to the joint commissioning strategy.

Yes

There is a collective commitment to deliver these work streams via shared demand, capacity and cost assumptions and forecasts, (facilitated via a System Modelling Group), whilst engaging in a system-wide communications and engagement strategy and benefits realisation programme.

17

Key outputs for the plan include:

Incremental organisational form changes at Hinchingbrooke and Peterborough hospitals to reduce duplication

System-wide cross-organisational efforts to optimise efficiency

End-to-end pathway redesign

Demand management and delivery of preventative schemes

To progress system-wide financial incentives alignment

Accelerating in-hospital service changes

System-wide cross-organisational efforts to optimise efficiency. Membership and elections

Cambridgeshire and Peterborough NHS Foundation Trust (CPFT) holds Governor elections on an annual basis. In

collaboration with the Electoral Reform Service, a timetable is collated in January each year with final Governor

ratification occurring at the May Council of Governors meeting.

Information regarding the election process is communicated to all Trust Members in a members’ newsletter and

Governor nominations are encouraged. Once elected/appointed, each Governor is invited to an internal Trust

induction day where they receive a comprehensive resource pack and presentations from staff about the Trust and

their role. They are also required to attend the NHS Providers Core Skills course. Their development progresses with

a bi-monthly internal training programme, as well as invitations to attend external courses.

Table 5: Governor Elections

Year Number of seats in

election

Number of seats

filled by election

Number of seats

remaining vacant

Total number of

elected seats

2016 12 TBC TBC 25

2015 10 6 4* 25

2014 15 11 4** 25

*Public Peterborough: 1 vacancy; Staff: 1 vacancy; Service User - Cambridgeshire: 1 vacancy; Service User - Rest

of England: 1 vacancy.

**Public Peterborough: 2 vacancies; Service User - Cambridgeshire: 1 vacancy; Staff: 1 vacancy.

In 2014 the Trust produced a three year strategy to recruit and sustain an engaged membership. The programme

was split into three phases, with some immediate actions identified as well as longer term goals. The first phase of

the strategy consisted of a data cleanse (an ongoing task) and membership analysis. A recruitment and engagement

plan was then developed and working papers were, and continue to be, submitted to the Council of Governors on a

twice yearly basis.

The Trust successfully recruits to, and actively engages with, its membership. Members are invited to attend

quarterly Member talks from Trust experts, Council of Governor meetings, mindfulness sessions, training courses,

charity/awareness events as well as participating in consultations and surveys. Governors are asked to attend these

events to enable regular communication between the Trust’s Council of Governors and membership. They also

receive a newsletter every six months and regular emails.

To maintain a diverse membership, the Trust communicates with, and promotes events to, its local constituencies

through libraries, GP surgeries, Community Centres, ethnic minority groups and colleges etc. Staff leaving the Trust

are contacted with the intention of retaining them as Public Members, and volunteers joining the Trust are asked if

they would like to join the membership.

Agenda Item: 11a


REPORT

Subject: Quality, Safety and Governance Committee meeting dated 27

th February 2016


Author: Jo Lucas, Interim Chair

Lead Director: Mel Coombes, Director of Nursing and Quality

Executive Summary: The agenda was packed for this meeting and my sense is that authors / presenters need to be

absolutely clear what they want to get from their paper coming to this committee and that

background information should be presented as appendices rather than in the body of the paper.

This can be reviewed when the new cycle of business has embedded. It was also noted that the

opportunity for governors to contribute is limited by massive agendas and limited time. This could

be resolved either by brief meetings with governors or by integrating time for this element of the

meeting into the meeting planning.

Director of Public Health presentation This has been long awaited. It was an opportunity to raise questions of concern and identify areas for future cooperation especially around suicide prevention and dual diagnosis services.

Integrated performance report Noted and agreed that housing and carers figures will be integrated into future reports.

Volunteers strategy The increased capacity was noted and welcomed. It was agreed to look at how volunteer supervision on wards could be integrated into the teams responsibilities

Compact This new agreement for working with third sector organisations was welcomed with a discussion about the importance of supporting joint working and respecting confidentiality.

Carers programme Board It was noted that the culture towards carers has changed and this was welcomed

Risks Register

Potential for risk around Welney Ward closure and impact of Vanguard programme on vacancies were noted

Staff survey The outcomes of this survey were noted briefly

Recommendations:

To note this report and the quality and safety issues raised in the committee papers

The agendas and papers are reviewed carefully. JL / SH and MC

Time for governors is integrated into the agenda. JL / SH and MC








N/A




N/A


N/A

Has a QIA been completed? If yes provide brief details No

1

Agenda Item: 11bi


REPORT

Subject: Quality, Safety & Clinical Governance -Exception Report


Author: Mary Mumvuri (Deputy Director of Nursing and Quality)

Lead Director: Melanie Coombes ( Director of Nursing and Quality)

Executive Summary: This integrated quality and safety exception report provides an overview of the Trust performance on key measures up to end of February 2016. Specifically, it includes areas related to patients and carers experience, complaints, PALS, patient safety, serious incidents, RIDDORs, Claims, safeguarding children and adults, infection prevention and control, Safety Thermometer and Positive and Proactive Care. This summary should be read in conjunction with the attached slide deck where additional information is provided in the form of tables and graphs. Patient Experience

Friends and Family Test - showed that 92.41% out of 1186 people surveyed would recommend the Trust if they needed similar care or treatment. This is a slight increase from 89.16% in January.

The Children’s Directorate had a 2% decrease in the positive recommend score during the reporting period. The areas requiring improvement are ensuring young people know how to contact the team and helping them to make choices about their care and treatment in two of the community based teams. This was however, a significant improvement of 8% from December to January scores where respondents indicated that they would not recommend the service due to long waiting lists. The Directorate has continued to work on reducing waiting list and this is showing month on month improvements. Other improvements were also noted in Specialist directorate inpatient FFT where scores rose by 30% from 26% to 56%

Meridian satisfaction survey - there has been a 2% decrease in the overall score to 88.14% in February compared to 90.14% in January. This is the lowest Trust score in the last twelve months. Main decreases were noted in Adult community mental health (2%) and Integrated Care Community 4% and were in response to knowing who and how to contact services to get support out of hours, explanation of medication side effects, weekly reviews of care, explanation of care plan and inadequate evening and weekend activities. Due to the changes in the cycle of business, the detailed analysis at Sub-Board groups and Directorate Governance Meetings that usually inform actions required has not taken place. This will be reported in the next Board report.

2

Food rating average score remains static at 69% for January and February however reduced scores were reported across most adult acute wards with a significant decline on Darwin, GMH and Phoenix. Improvements were noted on all Integrated Care Wards. Review and analysis of the recent changes will be undertaken at the next PLACE oversight forum. Recent improvements to the menu on Springbank and on S3 have contributed to the positive and increased satisfaction scores in February and reflected in some of the qualitative feedback.

Evening/weekend activities - the score has increased from 59% in January to 64% in February however, it remains relatively low when compared with the year figures. Significant decline was noted on Maple, Oak 1 and GMH and slightly on Mulberry 3, Oak 3 and Phoenix, some of which correlates to poor staffing fill rates.

Possible medication side effects inpatients and community – the scores this month indicate a continuing downturn to 62% for inpatients which is the lowest score over the past year. Wards with poor scores include ICD inpatient wards and four of the six Specialist Directorate wards. Community survey showed 81% satisfaction which is a continuing decline from 91% in September 2015. The most affected areas are community based ICD services and some Adult mental health teams. ICD only started seeking feedback on this measure from January 2016, prior to this, the Directorate only asked the Patients Friends and Family Test question. The Interim Chief Pharmacist has been tasked with working with the clinical directorates to understand the issues impacting on practice and to support them with identifying and implementing some improvement actions. This will be followed up in the coming months through Quality, Safety and Governance Committee (QSG). On the contrary, the Specialist Directorate community teams have improved significantly, achieving 100% satisfaction from all the patients surveyed.

PALS – there was a slight decrease in enquiries from 49 to 46 in February, 37% of which (n = 17) were concerns related to delays in accessing Psychological and Well Being service, accessing continence products for residents in care homes, concerns from primary school about accessing Speech and language Therapy and dissatisfaction with the assessment and diagnosis from Adult Locality Teams. Feedback has been provided to the services for further action and progress on this will be reported via QSG.

Complaints

There has been a continued decrease in the number of complaints registered – 14 in February, 16 in January and 20 in December. Of the 14, 6 were received from the Adult Mental Health Directorate, 5 Integrated Care Directorate, 2 Specialist and 1 Corporate.

100% of the complaints were acknowledged within 3 working days. The average response time in February was 43 working days which was an increase from the 36 days in January. Following the restructure and reorganisation of the Nursing and Quality Directorate, an extra resource has been identified to support the Complaints administrative processes. This should free the Complaints Officer to be able to offer training and additional support to Investigating Officers in order to improve the timeliness and quality of complaint investigations.

A third of the complaints received this month related to staff attitude, in particular nursing staff in the community and inpatients. The other theme was access to Community services, including issues with discharge arrangements and access to psychological therapies. Communication continues to be a theme throughout the majority of complaints received.

A total of 16 complaints were closed in February. Of these 3 were upheld, 7 were partially upheld, 3 were not upheld, and 3 were withdrawn. Where complaints have been upheld or partially upheld, action plans are developed and monitored to demonstrate improvements.

3

Patient safety and Serious Incidents

969 patient safety incidents were reported in February. 633 (65.4%) resulted in no harm, 250 (25.8%) low harm, 69 (7.1%) moderate harm, 5 (0.5%) severe, 2 (0.2%) deaths related to patient safety and 10 (1%) unrelated to patient safety.

There were 137 (14.1%) patient self-harm incidents, and 114 (11.7%) patients developed pressure ulcers.

There were 10 SIs reported in January and 11 in February. The majority continues to come from the Adult Mental Health Directorate and are as a result of unexpected deaths. There have been 4 Information Governance incidents, 3 of which originated from the Children’s Directorate and 1 from ICD. They are all currently under investigation.

SI report submissions –The timeliness of SI report submissions to Commissioners reduced from 85% in January to 81% in February. This was in part due to internal quality scrutiny which required the reports to be further revised and sickness and absence of the Investigating Manager which made it difficult to re-start the investigation because all interviews had already been undertaken and it was thought to be inappropriate to re-allocate and repeat interviews all over again. . Inquests – there were 3 new cases opened, 2 of which involved District Nurse teams. The 3 closed inquests returned verdicts of drug related overdose. Harm-free care – Safety Thermometer survey of 1163 patients across older people inpatients and community service and inpatient learning disability shows a Harm Free care of 94% against a target of 95%. There has been a significant reduction in the reported number of new pressure ulcers in February. The survey of the remaining 3 harms reports no change. Infection Prevention and Control – no cases of MRSA bacteraemia or Clostridiums Difficile reported which is the same as the previous month. Children safeguarding training - Safeguarding children compliance figures across the Trust have risen from 84% in Q3 to 91% end of February and this is reflective of the intensive monitoring of performance and additional training offered by the Safeguarding children team. There continues to be an increase in contacts with the safeguarding children team across the Trust. In February this was particularly evident with increases in enquiries from the Children and Adult Directorates across the Trust. Prone position “Face Down” restraint – Only 1.61% of the incidents involved prone restraint. There

were 9 prone restraints reported in February, from 4 wards. This is an increase from 5 in January. 6 of

the prone restraints were in relation to administering IM injections. Staff continue to be trained to

administer IM injections in a supine position.

Claims – there were 2 new claims issued against the Trust in February which are being reviewed. RIDDOR incidents – there were no RIDDOR incidents confirmed during February. There are 3 outstanding RIDDOR issues all related to the Adult Directorate. Learning from Mistakes League – The Department of Health has published a “learning from mistakes league” ranking Trusts on their openness and honesty. The league table has been drawn together by scoring providers based on the fairness and effectiveness of procedures for reporting errors; near misses and incidents; staff confidence and security in reporting unsafe clinical practice; and the percentage of staff who feel able to contribute towards improvements at their Trust. The data for 2015/16 is drawn from the 2015 NHS staff survey and from the National Reporting and Learning System. Providers can be measured as outstanding, good, cause for significant concern or has a poor reporting culture.

4

CPFT is rated Good – levels of openness and transparency and are ranked 73 out of 230 providers. Recommendations:

To discuss the contents of the report

Note the significant reduction in SI reportable Pressure Ulcers

5






Links to BAF/Corporate Risk Register Yes


Some of the safety and quality risks contained in this report are reflected in the CQC intelligence Monitoring tool. Staffing has been identifies as a safety issue requiring improvement following the CQC inspection

Financial implications/impact N/A



N/A


Clinical Governance and Patient Safety


N/A

Board Integrated Quality and Safety Exception Report

30 March 2016

Agenda Item: 11bii

Contents Slide #

Key Quality & Safety Indicators Summary 3 - 6

Patients Friends and Family Test 7 - 10

Meridian survey- overall satisfaction & High and Low scores 11 - 12

Overall scores – Food, evening/weekend activities, told meds side effects, vocational activities, out of

hours contact

13 - 19

PALS and Compliments 20

Complaints 21

Incidents 22 - 23

Closed & Open Serious Incidents 24 - 25

Timeliness of reporting 26

Inquests 27

Claims & RIDDOR 28

Infection Prevention and Control 29 - 30

Positive and Proactive Care 31 – 33

Safety Thermometer (Overall Trust)

34

2

Indicator Performance Narrative Overall

RAG

Action

Target Actual

Mental Capacity and

DOLs training

90% 91% Integrated Care Directorate 89%

Corporate 89%

Adult 96%

Specialist 96%

Children 93%

Maintain or improve target

Safeguarding Children

(Mandatory Training)

95% 91% 91% clinical staff working with Children

91% Clinical staff working with Adults

95% non clinical staff

The Directorates continue to

focus on this area.

Safeguarding team now

provides four additional

training days a month to

support capacity

Safeguarding Adults

(Mandatory Training)

95% 96% Integrated Care Directorate 95%

Corporate 96%

Adult 98%

Specialist 97%

Children 97%

Maintain or improve target

RIDDORS There were no confirmed RIDDORs during February

2016.

Two incidents are currently being reviewed by the

Serco ASP Safety Team, with one incident having

the potential to be reported under RIDDOR.

There are three outstanding RIDDOR issues all

related to the Adult Directorate.

Key Quality and Safety Indicators Summary

3

Key Quality and Safety Indicators


RAG

Action

Target Actual

SIs meeting 60 Day

Target (changed from

45 days in August

2015)

100% 67% 13 completed incident reports were submitted in February 2016.

10 of the reports were submitted within the specified timeframe.

3 of the reports were submitted late.

2 further reports remain late and, although due, have not yet

been submitted.

Executive Director of Nursing

to receive weekly updates on

the management of serious

incidents.

Complaints

Compliments

PALS

Patients FFT

Meridian survey

14 complaints were registered

in February 2016:

6 – Adult Services

5 – Integrated Care

2 – Specialist

1 – Corporate

100% were acknowledged

within 3 working days.

636 compliments were received

in February.

46 PALs enquiries in February,

of which 17 were concerns.

1186 responses received in

February (888 in January)

88% in February (90% in

January)

Average response time in February was 43 working days

against a target of 30 working days. This was an increase from

January (36).

The main theme this month related to staff attitude, in particular

nursing staff. The other theme was access to Community

Services, including issues with discharge arrangements and

access to psychological therapies. Communication continues to

be a theme throughout the majority of complaints received.

The Trust received the final report for a complaint about the

Advice and Referral Centre which was found to be upheld. The

Directorate are currently in the process of drafting the action

plan.

This high figure reflects compliments and positive comments

received via the Trust patient experience surveys (‘what's been

good about the service you’ve received ?’) .

Main concerns were issues relating to accessing the new

Psychological Wellbeing Service, accessing continence products

for residents in a care home, concerns about patients unhappy

with their assessment and diagnosis from Adult Locality Teams,

and concerns from a primary school relating to delays in

accessing Speech and Language Therapy Service.

92% recommend/2% don’t recommend. The % of

recommended has increased from 89%/not recommended

remains static. The Children’s Directorate had a decrease in the

positive recommend score since last month of 1%.

There has been a 2% decrease in the score , the lowest

recorded in the last 12 months. However there has been a

substantial increase in the responses from the Integrated Care

Directorate which has impacted on the overall score.

Remind investigators of

response target timeframe.

As part of the consultation in

the Nursing & Quality

Directorate, an additional

resource has been identified

to support the administration

in the Complaints Team. The

focus will be on training

Teams in the Trust in

complaints management.

Remind services to report

compliments

4



RAG

Action

Target Actual

Safety Thermometer

Delivery of harm free care at

94% against target of 95%

(92% January)

A point prevalence survey of 1163 patients. This data

reflects the Trust’s inpatient wards and Neighbourhood

Teams in the Integrated Care Directorate, and the 2

Learning Disability inpatient wards from the Specialist

Directorate.

Continue implementing

actions form the Pressure

Ulcers ambition group and

Falls reduction strategy

group

CQC Intelligence

Monitoring – Band 2

(recently inspected)

Target is to not have Red

rated risks

The report was published on 26 February 2016.

The Trust has challenged the red risk – whistleblowing –

which has subsequently been removed. There are 5

amber risks remaining.

Safer Staffing for

inpatients

Above 80%

Fill rate

RNs day =

101%

RNs night =

94%

HCAS day

= 109%

HCAs night

= 120%

Average fill rates across all wards for night and day shifts

has been above 94%.

Exceptions for low fill rates were on Mulberry 1, Mulberry

2, The Croft, Hollies, Maples and Oak 4.

These are as a result of vacancies and short term

absence.

All gaps were filled with staff from the opposite Band and

other MDT members

Contract negotiations are

ongoing in response to the

establishment review.

The Trust is exploring

alternative recruitment

strategies as part of the

Band 5 and 6 work.

5



RAG

Action

Target Actual

Prone “ Face down “

restraint

Zero by

April 2016

9 prone restraints

reported for the

Trust in February

(5 January). X4

Oak1 (4 different

patients, 3 of

whom put

themselves in the

prone position), x2

Oak4 (1 for IM

and 1 risk to staff),

x1 PICU (5-8

seconds), x1

Mulberry and x1

Maple (both IM

administration).

There has been an increase from 5 in

January to 9 in February.

Ongoing implementation of work

plan through the Positive and

Proactive Care steering group and

improvement on data recording and

staff and patient debriefing.

Baseline audit to be undertaken in

July.

MRSA Bacteraemia &

Clostridium difficile

0% 0% Maintaining no cases reported, screening

has remained at 100%

Elimination of avoidable

Grade 3 & 4 pressure ulcers

0 cases 0 cases

The Trust is member of the

SHA ‘Stop the Pressure’ campaign.

6

Patients Friends and Family Test – February 2016

Response total =1186 Response total =1186

• The graph above shows the overall percentage recommend/not

recommend responses to the Patient Friends and Family Test

Question ‘How likely are you to recommend our ward/team to

friends and family if they needed similar care or treatment?’

(Data includes Integrated Care Directorate from October 2015).

• % recommended has increased from 89%/not recommended

scores remain static

• Directorates with decreases in positive recommend score since

last month: Children’s Community 1%

• The Specialist Directorate has reported an increase in positive

recommend score of 5% for both inpatient and community.

• The breakdown of replies to each question to the Patient

Friends and Family Test is highlighted above.( Data

includes Integrated Care Directorate from Oct 15).

• Overall % responses to Extremely Likely increased by

4%.

• FFT response numbers as a whole continue to increase

significantly, due to the introduction of new survey targets

for the Integrated Care Directorate in January.

Response numbers Dec Jan Feb

Extremely Likely 450 589 827

Likely 172 202 269

Neither Likely or Unlikely 23 29 23

Unlikely 7 12 16

Extremely Unlikely 7 8 10

Don't Know 41 48 41

Total response numbers 700 888 1186

7

Patient Friends and Family National Data – December 2015

Response Numbers =13593 Response Numbers = 72552

• Data is based on NHS England December 2015 figures

• Figures for December 2015 show lowest scoring Trust scores and highest scoring Trust scores. Number of submissions per Trust varies

considerably for December, from a low of 9 response to a high of 4822 (community groupings) 6 – 1264 (mental health groupings).

• A 2% increase in positive recommend score is noted for CPFT within the Mental Health Groupings. Community Groupings remains

static.

• National data is not directly comparable due to flexibility in FFT collection methods/variation in local populations.

• Data is submitted nationally under broad service categories – within the mental health and community groupings.

• Services can be configured differently on a national basis and therefore this should be taken into consideration when reviewing the figures.

8

Patient Friends and Family National Data by Trust – December 2015

• Figures show national data from neighbouring Trusts based on December 2015 figures.

• % recommend scores are based on positive responses to the Patient Friends and Family Test question.

• Data is not directly comparable due to flexibility in FFT collection methods, and localised Trust agreement on Mental

Health/Community Groupings.

• Data should as such be viewed as an overview, rather than as a direct comparison.

All Trust Response Numbers = 13593 Response Numbers =72552

9

Patient Friends and Family Test

Comments

.

The support I have had from here has been amazing a lot of places down south don't have any services like they have here all the staff have been understanding supportive and patient with helping me I owe them my life and a big thank you

I found most of the staff very cold and rarely smiling. There was no real support here other than medication, I was not even spoke to a psychologist one on one to discuss what treatments Would help me when I left. The whole process seemed to be to get you out As quick as possible

I have found the CBT sessions that I had extremely

useful. This was great, especially as I have had other

therapy in the past (at other places) which has not

helped so much

I was impressed by the skill

and professionalism of the

service, the assessment of my

progress and continuing needs,

and provision of useful

equipment

Long waiting list

Well I'd hope that I wouldn't have to

'recommend' it to anyone because

frankly who wants to be in hospital!

It's such a laid back unit support is

awful !! They care more about bed

times then how much you eat

I really hate this place at time.. Well all the time!! Although some staff here are very good at their job

Support is individual, non judging and genuine. As much or as little help. Good experience

Kind and helpful

My mother was extremely ill on admission

what a difference to her now after the care

from dedicated staff

10

Meridian Surveys – Overall Satisfaction

Response total = 1208

• Scores shown are based on the overall responses to all questions for all Directorate-wide surveys. Survey

data now includes the Integrated Care Directorate, following the launch of the realigned surveys from the

11/1/16.

• Scores denote a 2% decrease in score, which represents the lowest score in the past twelve months.

However a substantial increase in responses from the IC Directorate is included this month, which has

impacted on the overall score.

The following report decreased scores:

• Adult Community = 2%

• Integrated care community = 4%

• All other services indicate a static or increase in satisfaction score for overall survey question responses.

11

Meridian – Low and high ranking score in community and inpatients

Response total = 168 Response total =1040

• The graph above highlights the lowest four scoring questions and

the highest four ranking questions for the inpatient surveys –

Acute, Specialist, Integrated Care.

• Weekly care meetings drops into the bottom four ranked questions

this month replacing understanding care plans - due to low scores to

this question from inpatient wards in the Integrated Care Directorate.

• The graph above highlights the lowest four scoring questions and

the highest four ranking questions for the community surveys –

Acute, Specialist, Children’s, Integrated Care.

.

• Knowing who care co-ordinator/key worker is drops into the

bottom four ranked questions replacing having an out of hours

contact number. Lower scores for have a plan of

care/treatment/therapy are primarily due to low scores within

Integrated Care Community teams.

12

Food rating

Scores are based on responses within inpatient wards to the question ‘How

would you rate the food on the ward?’

Overall figures indicate a static score in positive responses to food.

Extracted heat map data highlights those wards with lower scores (ie 74% and

below) over past three month period.

• Adult Directorate: A number of teams have lower scores this month, despite

less negative comments

• Specialist Directorate: The majority of teams have low scores

• Integrated Care Directorate: Most wards indicate some improved scores.

ICD new survey was launched 11/1/16 with equivalent trust wide questions,

therefore no comparable data for these wards is available for December.

How would you rate the food on the ward? Selection of comments (February 2016)

Croft Good compared to most hospitals, it helps that they have a housekeeper to cook it!

Darwin Centre Cook chill is pure sxxx but Debbie cooking nice

Mulberry 2 Okay overall but sandwich selection not so good

Oak 4

Food cooked on ward is amazing. Canteen food is a lot better, more variety due to 4

weekly rotation. More flavour in food.

P'bor Int Care Unit Enjoyed the food like being in a restaurant

P'bor Int Care Unit Some hot meals arrived cold Hot meals not very appetising

P'bor Int Care Unit Fantastic

Phoenix Centre Very disgusting! Bland no flavour unappetising

Phoenix Centre

I like some of the food and then others are not of a nice consistency and don't taste of

much.

S3 Definitely could be better. It would be 100 times better even if it was just hotter

S3

The new menu choices have made such a difference - thank you! I love the veggie

curry!

Trafford excellent

Welney Very very good

No

Dec

% No

Jan

% No

Feb

%

Mulberry 1 5 80 9 58 14 69

Mulberry 2 8 57 9 83 8 50

Mulberry 3 5 25 6 75 16 67

Oak 1 12 80 13 90 9 78

Oak 2 7 93 7 93 9 69

Oak 3 17 77 11 56 22 63

Oak 4 5 100 5 100 5 67

Poplar PICU 3 100 3 50 2 100

Springbank 3 0 6 20 2 50

Croft 0 n/s 0 n/s 5 90

Darwin 5 38 8 0 3 17

GMH 5 63 8 57 4 38

Hollies 0 n/s 2 50 1 100

IASS 1 n/s 1 n/s n/a n/a

Phoenix 6 33 7 75 6 20

S3 3 33 4 25 4 50

Integrated Care Directorate

Denbigh 6 n/s 5 n/s 6 n/s

Lord Byron A 1 100 2 100

Lord Byron B 0 n/s 0 n/s

Maple 11 85 5 90 12 79

P'boro Intermediate Care 8 79 21 81

Trafford 7 100 7 88

Welney 3 83 2 100

Willow 4 50 7 50 8 83

Specialist Directorate

Adult Directorate

no comparable

data

no comparable

data

13

Evening/Weekend Activities

Scores are based on responses within inpatient ward to the question Are

there activities, groups or things to do during the evening and

weekend?

Scores show signs of improvements this period, although these remain

relatively low when compared with the year.

Extracted heat map data highlights those wards with lower scores (ie 74%

and below) over past three month period.

Adult Directorate: Oak 1/Oak 3, have decreasing scores over the past three

month period.

Specialist Directorate GMH remains low, although showing signs of

improvement.

Integrated Care Directorate: Maple scores continue to drop.

Adult Directorate

Mulberry 1 5 80 9 20 14 50

Mulberry 2 8 43 9 75 8 83

Mulberry 3 5 100 6 100 16 50

Oak 1 12 100 13 90 9 44

Oak 2 7 86 7 57 9 86

Oak 3 17 92 11 89 22 54

Oak 4 5 100 5 100 5 100

Poplar PICU 3 100 3 100 2 100

Springbank In-Patients 3 0 6 20 2 100

Int. Care Directorate


Maple 11 80 5 60 12 27

Willow 4 0 7 75 8 100

Specialist Directorate

Croft Child and Family Unit 0 n/s 0 n/s 5 100

Darwin Centre 5 25 8 25 3 100

GMH 5 50 8 0 4 25

Hollies In-Patients 0 n/s 2 0 1 100

IASS In-Patients 1 n/s 1 n/s n/a n/a

Phoenix Centre 6 0 8 100 6 67

S3 In-patients 3 67 4 33 4 50

Total responses 106 117 136

No

Feb

%No

Jan

%No

Dec

%

GMH The weekends are boring and sometimes drag because the is nothing to do.

Maple I would like some more please

Maple No I just sit here (lounge chair)

I would like to go to church

Mulberry 2 Yes but not many

Oak 1 There is less on the weekend I think, they leave you to get on with it

Oak 1 I am not aware of them

Oak 3 Not as much going on

Phoenix Centre

I am usually in my room or on leave but I think they do activities for people who

don't do those things.

Are there activities, groups or things to do during the evening and weekend? Selection of comments (February 2016)

14

Possible Medication Side Effects

Inpatients

Scores are based on responses within inpatient wards to the question

‘Were you told about possible side effects of medication by this ward?

Scores this month indicate a continuing downturn, resulting in the lowest

score over the past year.

Extracted heat map data highlights those wards with lower scores (ie 74%

and below) over past three month period.

Adult Inpatients: Mulberry 3, Oak 1 display low scores. Oak 1 suggests

ongoing dissatisfaction with responses to this question.

Specialist Services: A number of wards have low responses.

Integrated Care Inpatients Several wards exhibit low scores. The new

ICD survey was launched 11/1/16 with equivalent trust wide questions,

therefore no previous comparable data available for December.

Darwin Not all the time

Maple I've worked it out myself

They weren't told to me but I have read them

Oak 1

I was given written information on the medication

that I am taking, however I have not yet spent the

time to fully read this information and understand all

the side effects.

Poplar At ward round

Were you told about possible side effects of medication/treatment

prescribed by this ward? Selection of comments (February 2016)

Adult Inpatients Mulberry 1 5 80 9 60 14 100

Mulberry 2 8 33 9 56 8 100

Mulberry 3 5 0 6 100 16 50

Oak 1 12 70 13 67 9 56

Oak 2 7 100 7 86 9 75

Oak 3 MOD 17 75 11 80 22 73

Oak 4 5 100 5 100 5 100

Poplar PICU 3 100 3 100 2 100


Integrated Care Inpatients Denbigh 6 n/s 5 n/s 6 n/s

Lord Byron A 1 0 2 100

Lord Byron B 0 n/s 0 n/s

Maple 11 70 5 33 12 45

P'boro Intermediate Care 8 40 21 41

Trafford 7 33 7 50

Welney 3 50 2 100

Willow 4 0 7 50 8 17

Specialist InpatientsCroft Child and Family Unit 0 n/s 0 n/s 5 100

Darwin Centre 5 100 8 100 3 100

GMH 5 100 8 67 4 0

Hollies In-Patients 0 n/s 2 100 1 0

IASS In-Patients 1 n/s 1 n/s n/a n/a

Phoenix Centre 6 100 7 100 6 40

S3 In-patients 3 67 4 50 4 0


No

Feb

%No

Jan

%

no comparable

data

no comparable

data

No

Dec

%

15

Possible Medication/Treatment Side Effects

Community

Scores are based on responses in Community teams to the question Were

you told about possible side effects of medication/treatment prescribed

by this team?

Scores indicate a 2% decrease in response to this question. – the lowest

score over the past year. Extracted heat map data highlights those community

teams with lower scores (ie 74% and below) over past three month period.

Adult Community : Personality Disorders remains low, along with

Peterborough/Borders locality

Specialist Community: All teams have improved scores

Integrated Care Community: A number of teams have low scores in response

to this question. The new ICD survey was launched 11/1/16 with equivalent

trust wide questions, therefore no comparable data for December.

Data excludes Children’s Community teams who are not asked this question in

their directorate survey.

Adult Community

Adult Cambridge South Locality 12 100 10 78 19 73

Adult Cameo North 5 80 5 80 0 n/s

Adult Huntingdon Locality 4 33 15 82 2 100

Adult Personality Disorders 10 80 11 33 7 50

Adult Peterborough/Borders Locality 10 75 11 71 11 44

Integrated Care Community Continence Pilot 0 n/s 80 73

Dietetics 20 67 9 80

MIU Princess of Wales 10 50 78 81

NT Cambridge East 13 n/s 19 50

NT Huntingdon Central 43 50 20 83

NT Isle of Ely 11 100 30 71

NT North Villages 5 n/s 18 0

NT Wisbech 17 100 63 74

Neuro Rehabilitation 5 100 3 0

TB Service 2 100 1 0

OP CRHT North 4 100 3 50

OP CRHT South 0 n/s 2 50

X-ray Doddington 5 100 15 0

X-ray North Cambs Hospital 23 50 26 0

X-ray Princess of Wales 22 50 19 60

Specialist Community

Adult Eating Disorders Norfolk

Outpatients 6 100 7 50 6 100

Liaison Psychiatry Outpatients 16 80 16 50 16 100

HMP Peterborough 4 67 4 100 4 100

Cambridge Forensic Community

Services 0 n/s 4 67 4 100


No

Feb

%

no comparable

data

No

Jan

%No

Dec

%

Adult Cambridge South Locality Yes, very informative.

Adult Crisis Resolution Huntingdon

I was aware of the side effects with have been

discussed when I saw the team in the past.

MIU Princess of Wales I did ask though and was reassured and guided.

Continence Aware of risk of infection

Diabetes

And was told what to do if I experienced any side

effect

NT- Fenland

told about how i could expect to feel after 1st

session. advised to work within my own boundaries

Were you told about possible side effects of medication/treatment

prescribed by this team ? Selection of comments (February 2016)

16

Information On Vocational

Opportunities

Scores are based on responses within inpatient wards to the

question:

‘If you required support, have you been informed of vocational

opportunities such as education, leisure, volunteering or paid

employment in your local community?’

Scores have decreased by 1%

Extracted heat map data highlights those wards with lower scores

(ie 74% and below) over past three month period.

Adult Inpatients: Mulberry 3, Oak 1/2 have decreased scores this

month.

Integrated Care Inpatients: The majority of scores (n/s) indicate

question is not applicable.

Excludes Specialist Services– question not included in directorate

inpatient survey.

Oak 1

Yes the occupational therapist helped me with university and work. Also

with thinking about how to manage this with being unwell

Oak 1 I did not need advice

Mulberry 2 OT helping me find out about courses at the Recovery College

If you required support, have you been informed of vocational opportunities such as

education, leisure, volunteering or paid employment in your local community? Selection of comments (February 2016)

Adult Inpatients

Mulberry 1 5 50 9 50 14 83

Mulberry 2 8 67 9 100 8 100

Mulberry 3 5 100 6 100 16 50

Oak 1 12 100 13 100 9 67

Oak 2 7 100 7 100 9 67

Oak 3 17 80 11 60 22 78

Oak 4 5 100 5 100 5 100

Poplar PICU 3 n/s 3 n/s 2 n/s


Integrated Care Inpatients


Maple 11 100 5 n/s 12 n/s

Willow 4 n/s 7 0 8 n/s


No

Feb

% No

Jan

%No

Dec

%

17

Out of Hours Contact Number

Scores are based on responses within Community teams to the

question ‘Have you been provided with an out of hours contact

number/know who to contact?

Scores have decreased by 5% this period.

Extracted heat map data on those community teams with lower

scores (ie 74% and below) over past three month period, shows:

• Adult Community– Personality Disorders score remains low

this period.

• Specialist Community Adult Eating Disorders Norfolk has

significantly lower score.

• Integrated Care Community Several teams are indicating low

scores. New survey was launched 11/1/16 with equivalent Trust-

wide questions, therefore no previous data for December.

Excludes Children’s services – question not included in directorate

community survey

Adult Peterborough/Borders

Locality

Though if I now have any issues I can call 111 or my

GP due to discharge

NT - Fenland Not sure

NT - Wisbech I have a phone number.

Continence

No, not at anytime. This has given me a lot of worry

especially as I have and a lot of injections & cannot

always get in to see my GP.

Dietetics Discussed calling GP/Out of hours if urgent concern

MIU Princess of Wales I was given a leaflet

Out of Hours Contact Number Selection of comments (February2016)

Adult Community

Adult Huntingdon Locality 4 50 15 86 2 100

Adult Personality Disorders 10 63 11 60 7 60

Adult Crisis Resolution Cambridge 3 67 12 100 8 100

Integrated Care Community

Adult Speech and Language Therapy 1 n/s 10 33Chronic Fatigue Syndrome 1 n/s 5 50Continence 15 n/s 50 60Continence Pilot 0 n/s 80 73

Dietetics 20 91 9 67

NT Fenland 3 100 13 40

Neuro Rehabilitation 5 50 3 0

Tissue Viability 0 n/s 5 50

OP Memory Assess Gtr Cambridge 8 60 1 100

X-ray Princess of Wales 22 89 19 60

Specialist Community

Adult Eating Disorders Norfolk

Outpatients 6 50 7 100 6 40

Liaison Psychiatry Outpatients 16 50 16 33 16 100


No

Feb

%

no comparable

data

No

Jan

%No

Dec

%

18

Trust Wide Carer Survey – Overall Satisfaction

Scores shown are based on the overall responses to questions asked in the Trust

wide Carer Survey introduced in September 2015.

Scores show a 3% decrease since January.

February response total = 18

19

PALS & Compliments 37%

63%

0%

10%

20%

30%

40%

50%

60%

70%

Concern/Issue Enquiry Information/signposting

PALS by Type for February 2016

Of the 46 PALs enquires, 37% (n= 17) were concerns. Among

these were a concern about delays in accessing the Psychological

well-being service following referral to single point of access,

accessing continence products for residents in a care home, 3

concerns about patients feeling unhappy with their assessment and

diagnosis from Adult Locality Teams and concerns from primary

school relating to delays in accessing Speech and Language

Therapy service.

20

Complaints – February 2016

Themes

The main theme for complaints received this month related staff attitude in particular nursing staff. The other theme was access to

community services including issues with discharge arrangements, and access to psychological therapies.

Communication continues to be a theme throughout the majority of complaints received.

Opened complaints

The Complaints Team registered 14 complaints during

February:

• 6 – Adult

• 5 – Integrated Care

• 2 – Specialist

• 1 – Corporate

100% (14 out of 14) were acknowledged within 3

working days.

Parliamentary Health Service Ombudsman (PHSO)

The Trust received the final report for a complaint

about the Advice and Referral Centre which was found

to be upheld. The Directorate are currently in the

process of drafting the action plan.

21

Apr May Jun Jul Aug Sep Oct Nov Dec Jan Feb Mar

2014/15 16 14 17 20 8 8 14 14 11 11 11 17

2015/16 12 16 14 25 15 9 18 13 20 16 14

0

5

10

15

20

25

2014/15 2015/16

Issue/Risk Action to Take/Taken Who by When by

None noted

Incidents – Reporting February 2016

22

354 346 358

10 20 22 7 9 9

407 413 387

1

149

201 192

0

50

100

150

200

250

300

350

400

450Number of Incidents Reported by Directorate

Adult MentalHealthDirectorate

ChildrensDirectorate

CorporateDirectorate

IntegratedCareDirectorate /Adult andOlder Peoples

IntegratedGovernance

SpecialistDirectorate

Incidents – Reporting February 2016

23

Incidents reported for February 2016

Total number of incidents reported by number and percentage: 969

Degree of Harm February

No Harm 633 (65.4%)

Low (Minimal harm) 250 (25.8%)

Moderate (Harm) 69 (7.1%)

Severe (Permanent or Long Term Harm) 5 (0.5%)

Death (is related to patient safety incident) 2 (0.2%)

Death (Unrelated to patient safety incident) 10 (1%)

“Top 5” Type February

Patient Self Harm 137 (14.1%)

Developed Pressure Ulcer 114 (11.8%)

Service User Issue Other 67 (6.9%)

Physical Outburst 61 (6.3%)

Slip/trip/fall 61 (6.3%)

Serious Incidents (SI’s) Closed – February 2016


Learning

from

Incidents

Continue with Quarterly Lessons in

Practice Bulletin

Patient Safety Lead Completed and remains ongoing

13 completed incident reports were submitted in February

2016. Ten of the reports were submitted within the specified

timeframe. However, 3 reports remain late and, although due,

have not been submitted.

Adult Directorate 2 serious injuries

2 unexpected death/suspected suicides

1 unexpected death/suspected suicide (L)

1 Unexpected death - Shot by Police

3 unexpected deaths

Outstanding

1 safeguarding

Specialist Directorate 1 serious injury

1 unexpected death

Integrated Care Directorate 2 Pressure ulcer incidents (x2 L)

Outstanding

1 fall

0

10

20

30

40

50

60

70

80

90

100

Jan Feb Mar April May June July Aug Sept Oct Nov Dec

% SI Reports completed within 60 Days

2014

2015

2016

24

Serious Incidents (SI’s) Open - Reporting Period February 2016 In February 11 new SIs were reported to either CCG/CQC/SCG

0

2

4

6

8

10

12

14

16

18

20

Number of SIs reported by month

2012/13 2013/14 2014/15 2015/16

Adult Directorate Reporting Category Team

W 59645/2016 Unexpected Death HALT

W 59863/2016

Safeguarding – Adult Mulberry 2

W 60028/2016

Serious Injury -Self Harm CSALT

W 60453/2016

Unexpected death/Suspected

Suicide

CSALT

W 60630/2016

Under 18 Admission to Adult

Ward

Mulberry 1

Children's

Directorate

Reporting Category Team

W 59906 /2016 IG CAMH Central Core

Team - Cambs

W 56245/2016 IG Admin & Clerical -

community South 2

W 60542/2016 IG CAMH Central Core

Team - Cambs

ICD Reporting Category Team

W 59971/2016 Unexpected Death NT Peterborough

City 1/ NT

Borderline Central

team

W 59994/2016 IG NT Cambs North

Villages

W 60439/2016 Serious Injury-Fall Maple 1 25


Failure to submit any of the three required

reports within the timeframe results in non

adherence to the agreed KPI and a contract

query with the CCG.

Continue to work with directorates to ensure that

the timeframes are adhered to. The changes to

the national reporting timeframe from 45 to 60

days will help the Trust to meet this target in the

future. An analysis of the length of delayed

reports tend to be within this timeframe.

Patient Safety Team Ongoing

CCG uses a cumulative total when calculating the

timeliness of reporting.

The three areas are

Initial reports –These are the initial

escalation reports that need to be

completed within 48 hours of identifying the

incident

final reports –These relate to the

completed SI reports

Responses to final reports –These are

queries sent to us by the CCG following

submission of the final SI report. 0

20

40

60

80

100

120

Pe

rce

nta

ge

Timeliness of SI Data reporting by Month

2014/15

2015/16

2016/17

26


Issue Action Taken Who by When by

Inquests – Reporting February 2016

There were 3 new cases opened in February 2016.

Notes on closed cases

(S) NS (Si with Inclusion) Inquest held 18.2.16- Read only

inquest Cause of death 1a Alcohol toxicity in combination with

methadone. Conclusion drug related death

(S) AM Inquest held 2,2,16. Read only inquest 1a Opiate

toxicity with the use of pregabalin and Amitriptyline.

Conclusion drug related death

(S) GH inquest held 2.2.16. Read only inquest 1 A Morphine

toxicity. Conclusion drug related death

Planned Inquests for March 2016

There are five inquests planned in March

0

2

4

6

8

10

12

Jan Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec

Closed Inquests

2014

2015

2016

0

2

4

6

8

10

Jan Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec

Open Inquests

2014

2015

2016

27

28

Claims & RIDDOR - Reporting Period February 2016

There were two new claims issued against the Trust for the

reporting period 1 to 29 February 2016.

Notes on claims: We have received notification of one new

clinical negligence claims against the Trust in the reporting

period 1 - 29 February 2016.

[A]16/757 (AL) – Pre-action letter received in reference to a

breach in duty of care arising from a claim for damages from

a Claimant in May 2013. M&R Solicitors were instructed in

this respect.

[ICD]6/768 (BJ) - The Claimant developed a grade 3

pressure ulcer to her left heel which is alleged to have

resulted due to a breach of duty of care involving failure to

properly assess, particularly in relation to the Claimant’s high

Waterlow levels.

0

1

2

3

4

5

6

7

Jan Feb Mar Apr May Jun Jul Aug Sept Oct Nov Dec

Open Claims

2014 2015 2016

RIDDOR Headlines

1. There were no confirmed RIDDORS in February

2. Zero confirmed RIDDORs during February 2016.

3. Outstanding Issues:

There are three outstanding RIDDOR issues all related to the Adult Directorate and are being reviewed

28

29

Infection Prevention & Control

Context

• MRSA screening is a requirement of the Health and Social Care Act and allows for adequate precautions and treatment to take place. Data is percentage of wards who have completed a screening return, not percentage of patient screened (as per requirement from NHS Cambridgeshire).

• National requirements for mental health trusts reflect the lower level of risk, so there is targeted screening of high risk patients only.

Context

• Essential Steps is the audit too used to demonstrate good

practice within infection prevention and control.

• It monitors compliance with hand hygiene, aseptic technique,

sharps and personal protective equipment.

Risk/Issue Action taken/to be taken Who by By When

Non compliance with

the Health and Social

Care Act 2010: MRSA

screening and Essential

Steps audit.

Information has been provided to all in-patient units and training given to IPaC link workers to

ensure 100% of patients are screened for MRSA and those who fit the criteria are swabbed.

100% returns continue to be obtained.

All units have had instruction on Essential Steps auditing.

Head of

Infection

Prevention

and

Control

Monthly

29

30

Area Results for February 2016

MRSA

bacteraemia

No cases

Clostridium

difficile

No cases

Context for cleaning standards

• Low risk is the National Standard for our out-patient areas

• Significant risk is the National Standard for our in-patient areas.

• We consistently exceed minimum standards.

Risk/Issue Action taken / to be taken Who by By when

Breach of targets for MRSA bacteraemia, Clostridium

difficile and pressure ulcers.

Investigation for any cases of MRSA BSI,

or C.diff, this may include an SI investigation

As determined by

IPaCT in liaison

with SI team

As

determined by

RCA/SI

processes

Infection Prevention & Control


Positive and Proactive Care: Reducing restrictive interventions

31

Background

• Guidance to reduce restrictive practice launched by DoH in April 2014

• Restrictive practice in the context of physical, mechanical, chemical, seclusion and long term segregation

• Guidance aims are to reduce restrictive practice over 2 years

• End prone “face down” restraint by April 2016

• Board leadership and oversight

Current position

• Positive & Proactive Care Steering Group continues to meet monthly.

• PMVA: Trajectory for all staff to be trained in new techniques (via 1 day refresher) was January 2016.

L & D Report 97% trained.

• Administering IM medication to avoid prone positioning: L&D developed training that covers IM in supine position.

Bespoke IM skills training plan has been developed and is being rolled out

• Evaluation of use of post-incident debriefing for service users and staff completed. Revisions to document for

recording will be amended

• Datix output extended - rapid tranquilisation (RT), ‘full PI’ and ‘safe holding’ now included in ward dashboards

• CQC Action: Trust to review use of seclusion: Task & Finish Group led by Adult DHoN and MHA Manager

continues. Reviewed Seclusion Policy currently with Trust solicitors. Recommendation from T & F Group is for

seclusion rooms on PICU, Mulberry 2, Denbigh and possibly Darwin.

• 9 prone restraints reported for the Trust in February (n=5 in January); x4 Oak 1 (4 different patients, 3 of whom put

themselves in the prone position), x2 Oak 4 (1 for IM, 1 risk to staff), x1 PICU (5-8 seconds), x1 Mulberry 1 (IM

administration), x1 Maple 1 (IM administration).

• 4th NHS Benchmarking Data collection submitted in February.


0

20

40

60

80

100

Apr May Jun Jul Aug Sep Oct Nov Dec Jan Feb

Number Of P.I. Incidents

0

2

4

6

8

10

12

14

16

18


Number Of Prone Incidents

84.64%

13.21%

0.54% 1.61%

CPFT

Incidents NoP.I. Used

Incidentswhere P.I.(Not Full)Used

Incidentswhere FullP.I. (NotProne) Used

Incidentswhere ProneUsed

0

50

100

150

200

250

300

350

400

450

500

CPFT

Incidents No P.I. Used

Incidents where P.I. (Not Full) Used

Incidents where Full P.I. (Not Prone) Used

Incidents where Prone Used

0

5

10

15

20

25

30

35

40


Number Of Full P.I. Incidents


Datix reporting (Type of Restraint) March 2016 (Reporting on February Data)

Unit/Type Of Restraint

Searching Breakaway Techniques

Safe Holding

Safe Holding (Patient sitting)

Full Physical Intervention Three Person

Supine

Full Physical Intervention

Prone Position (Face down)


(Patients sitting)


(Patient Kneeling)

Flexion

Oak Ward 1 1 14 18 11 2 4 0 0 2

Oak Ward 4 1 5 6 4 1 2 1 0 0

Poplar Ward (PICU) 0 0 2 1 0 1 0 0 0

136 Suite 1 0 1 1 1 0 0 0 0

Mulberry 1 0 0 2 1 0 1 0 0 0

Mulberry 2 0 0 2 0 0 0 0 0 1

Mulberry 3 0 0 1 1 0 0 0 0 0

Maple 1 0 2 2 1 0 1 0 0 0

Maple 2 1 1 0 0 0 0 0 0 0

Denbigh Ward 0 1 1 1 0 0 0 0 0

Willow Ward 0 0 2 1 0 0 0 0 0

Ward S3 0 0 2 2 0 0 0 0 0

The Hollies 0 0 1 0 0 0 0 0 0

Eating Disorder Service 0 0 1 1 1 0 1 0 0

GMH 0 2 2 1 0 0 0 0 0

The Darwin Centre 20 0 10 2 1 0 1 0 0

The Phoenix Centre 0 0 3 2 0 0 0 0 0

Totals 24 25 56 30 6 9 3 0 3

Safety Thermometer – February 2016 – Overall Trust The NHS Safety Thermometer involves the collection of data on patient harm. It provides a “snapshot” survey of the 4 harms -

pressure ulcers, falls, urinary tract infections (UTIs)/catheters, and venous thromboembolism (VTE).

This data reflects the Trust’s inpatient Wards and Neighbourhood Teams in the Integrated Care Directorate, and the two Learning

Disability inpatient Wards from the Specialist Directorate.

The results collected on 17 February had a response rate of 27 teams out of a total of 30.

Harm Free Care measure: target 95% Types of harm (by number): February 2016

Types of harm

(by number)

District Nurse

TeamsTrafford Ward Pboro ICU

Maple

Unit

Pressure ulcers - new 6 0 0 0

Falls - with harm 6 0 0 1

Catheter & UTI 8 1 1 0

New VTEs 10 0 0 0

No of patients 1022 19 30 21

The “types of harm” data collected in February and illustrated

on the graph shows a decrease in the number of new pressure

ulcers compared to December and January.

The table below illustrates that these harms occurred mainly in

the Community. 0

2

4

6

8

10

12

14

16

Dec-15 Jan-16 Feb-16

Pressureulcers - new

11 16 6

Falls - withharm

9 9 7

Catheter & UTI 7 10 10

New VTEs 6 9 10

No of patients 1189 1164 1163

Dec-15 Jan-16 Feb-16

% Harm Free Care 94% 92% 94%

% New Harm Free Care 98% 97% 98%

Number of patients 1189 1164 1163

34

1

Agenda Item: 11c


REPORT

Subject: “Hard Truths” Safer Staffing – Inpatient Exceptions


Author: Mary Mumvuri (Deputy Director of Nursing and Quality)

Lead Director: Melanie Coombes (Director of Nursing and Quality)

Executive Summary: This is the fifteenth in the series of exception reports to the Board in respect of the national inpatient safer staffing publication. The report provides figures and an analysis of the Registered Nurses (RNs) and Health Care Assistants (HCAs) monthly average fill rates for day and night shifts for January and February 2016. The fill rates are analysed against quality, safety and workforce measures. Exceptions are reported on average fill rates below 80% and above 130%. Each ward’s average RN and HCA fill rates for day and night shifts are uploaded on Unify on a monthly basis and the data is accessible to members of the public through Choices. The key highlights are: RNs average fill rates less than 80% - in January and February, Mulberry 1 & 2, Oak 4 and Maples had low RN fill rates at night. In addition, Hollies and the Croft were noted to have a low fill rate during the day during February. RN average fill rates above 130% - these were noted during the day on Croft and on IASS in January and on night shifts on Trafford and S3 throughout February. Complaints – Of the 20 complaints received by the Trust in January and 16 in February, 3 and 4 of these related to inpatient areas but none were concerned with unsafe staffing. Datix Staffing incidents - There were 19 reported incidents of inadequate staffing or poor skill in January and 17 in February. The Datix incidents indicate that no harm to patients was caused as a result. Vacancies and recruitment - Band 5 & 6 RNs vacancies are gradually declining and are 24.18 % and 6.34% respectively as of end of February. Four areas have been agreed as a focus in the recruitment and retention plan for the next six months and they are aligned to the recruitment and retention strategy. Establishment review outcome - there are ongoing contracting discussions and negotiations in respect of the required increase in staffing in response to the November 2015 establishment review and outstanding compliance actions following the CQC inspection last year.

2

Recommendations:

To discuss and note content of the report including the Board actions at the end f the report

3






Links to BAF/Corporate Risk Register Nursing vacancies are included in the Board Assurance Framework


CQC’s new Inspection regime will assess the safety and availability of nursing staff to respond to service users needs in line with NQB expectations.

Financial implications/impact Some of the higher fill rates have resulted in cost pressures for those services



N/A


Clinical Governance and Patient Safety and Nursing Leadership Group


N/A

4

Hard Truths – Safer Staffing Inpatient services 1. Purpose

This report provides the Board with exceptions in respect of Safer Staffing for all inpatient wards. 2. Background

The background to this report is well documented. The exceptions in this report continue to be based on levels below 80% and above 130%, the latter which tends to be related to increased levels of dependency and reflect the funding gap following an establishment review in 2014. The exceptions are analysed alongside internal online safer staff reports, workforce metrics, patient safety and complaints as it relates to inadequate staffing in order to provide assurance about quality of care. 3. Average staffing fill rates

Graph 1 below shows the average RNs fill rates for the last four months as being mainly over 90% apart from December when it dropped to 89%. The reasons for this decline were indicated in the January exception report to Board. The pattern seems to be one of difficulties in filling night shifts compared to day shifts, typically as a result of short notice cancellation of shifts due to sickness and temporary staff not reporting for duty.

Graph 1

Exceptions - fill rates less than 80% In January and February, Mulberry 1 & 2, Oak 4 and Maples had low RN fill rates. In addition, Hollies was noted to have a low fill rate in January and the Croft in February. As new career development opportunities in services within the Trust have emerged, this has attracted staff movement from inpatient to community based services; such has been the case in some adult acute wards and CAMHS. There are ongoing reviews of career development opportunities to enable a flexible training pathway for RNs and to make inpatient care just as attractive. An analysis of the reasons for lower fill rates showed that this was a result of short term sickness and absence and removal from clinical duties, which impacted on ability to find replacement cover at short notice. In some of the more specialist services such as the Croft, it is difficult to find temporary staff with

103% 100% 103% 101%

123%

89% 95% 94%

0%

20%

40%

60%

80%

100%

120%

140%

Nov-15 Dec-15 Jan-16 Feb-16

Average RN fill rates

RN day

RN night

5

the relevant skills and knowledge to work with the client group, therefore the short fall has been mitigated by support from Ward Manager and HCAs who know the children well. Other reasons for the staffing gap have been Agency staff not reporting for duty and a sudden increase in acuity or dependency on the ward which requires immediate arrangements for additional staff, such is the case where formal observations are initiated during the course of a shift. In the event of inadequate staffing particularly at night, the DNOs undertake risk assessments of the whole site and redeploy resources accordingly. An analysis of Datix related incidents indicate that the Nurses in Charge of shifts always use professional judgement to prioritise tasks to ensure safety is maintained and fundamental care needs are met. Impact of staffing gaps has been noticed on facilitation of activities particularly during evenings and weekends and escorted leave for detained patients. Welney ward – fill rates have been in the lower 80% for RNs. The ward continues to successfully recruit to RN vacancies. There is a planned incremental approach to re-opening the beds with a view to fully operating up to 16 beds by end of April. Fill rate over 130% The Matrons and Heads of Nursing are requested to provide rationale for higher than planned staffing cover. This is to ensure effective use of resources, by checking that formal observations are reviewed in a timely manner and that there is an appropriate spread of skill mix. This scrutiny confirmed that the increase in staff was required in response to enhanced observations as a result of increased dependency on the wards. In the case of S3 and IASS, this is also reflective of the funding gap following an establishment review in 2014 which showed that the wards require additional RNs to cover their shifts. A decision is pending on the recommendations made from the most recent establishment review to formally strengthen the skill mix and increase the nursing establishment. Internal Safer Staffing tool The wards with more uncovered shifts are consistent with those reporting higher incidents of inadequate staffing. Due to the staffing shortages on some wards, the night shifts have only had one RN instead of two. In such cases, the risk has been mitigated by support from DNO, adjacent wards and by covering with HCAs who know the wards well. Impact on patient experience While there was no harm associated with inadequate staffing however the impact has been on patient experience as captured via the Meridian surveys. When staff report incidents on Datix and on the online staffing tool, they also indicate the actions taken to remedy the situation and the activities and care they are unable to provide as a result. Tasks such as facilitation of escorted leave for detained patients, facilitation of therapeutic 1:1 engagement time and provision of activities tend to be the ones most affected and yet they make a significant impact on the experience of inpatient stay. This was noted on the Meridian survey results for mental health wards in January. The Ward Managers are exploring options of increasing provision of activities at weekends and out of hours through use of Volunteers and working differently with Occupational Therapists. Analysis of staffing on patient safety incidents and complaints Of the 20 complaints received by the Trust in January and 16 in February, 3 and 4 of these originated from inpatient areas. An analysis of the reasons for the complaints revealed that they were unrelated to lack of staff or inability to receive appropriate and timely care on the wards.

6

All clinical teams are encouraged to report situations of inadequate staffing as patient safety incidents on Datix and this information is communicated to Heads of Nursing on a weekly basis for action. There were 19 reported incidents of inadequate staffing or poor skill in January and 17 in February. An analysis of the Datix incidents indicates that no harm was caused to as a result however there was in some cases, an impact to their experience as already alluded to. Band 5 & 6 RNs recruitment Task and Finish group The Band 5 & 6 Trust recruitment and retention action plan has been reviewed recently by the group to refocus its attention on areas assessed as potentially resulting in high impact. The four areas identified are improving the marketing of services to demonstrate the unique specialist and integrated services provided by the Trust, reviewing the effectiveness of the recruitment and retention initiatives, exploring transport and accommodation options. These new focused areas are aligned to the recruitment and retention strategy however the success of it require additional resources to support the developments. Due consideration is being given to progress these actions. Two recruitment events aimed at third year students have been organised and the first was held at Anglia Ruskin University (ARU) on 12 March and a second one is scheduled for 2 April. Majority of the students who attended the event have been offered staff nurse positions. Learning and feedback from the event on 12 March has been gathered and will be used to improve and shape the 2nd April event. There are additional plans to attend other Universities job fairs. At the recent Trust wide Induction, it was noted that the majority of the new nursing staff in attendance had been trained from outside ARU. This means that efforts to target staff nationally have yielded some results. Feedback about reasons for choosing the Trust was an attraction to work in some of the innovative service and the support offered to Preceptees by the Trust. The success of the preceptorship programme followed a review that led to the development of a bespoke programme and provision of protected time to work on the programme objectives, something which has been welcomed by the staff. Workforce metrics Vacancies in some wards remain a concern in respect of fill rates. The Band 5 & 6 Recruitment and retention group has been monitoring vacancies for this staff group since October 2014 to identify hot spot areas and to inform actions for improving the position. Over the course of a year, vacancies for Band 5 RN have ranged between 32.96% and 14.74% but with a current rate of 24.18% as of end of February. The rate has been declining since September 2015 which has been encouraging in light of the focused recruitment for Band 5 RNs. For Band 6 Nurses, the highest rate since October 2014 was 13.48% and a most recent rate of 6.34% end of February 2016. This is not a surprise given that after a period of working as a Band 5 RN, some staff will be looking for promotion and a step up; hence the Band 6 vacancies tend to be lower overall. Sickness and absence rates for all ward based staff were between 4% and 50% in January and 10% and 43% in February. Although Willow and Maples had high sickness rates in January, however they were able to find replacement cover. On Hollies where there was 50% sickness absence, this impacted on their ability to find replacement cover for RNs resulting in a 72.4% RN fill rate during the day. The gap was mitigated by additional HCAs and support from other members of the MDT who work during office hours. Lord Byron, PICU, Darwin and S3 had sickness rates above 30% in February and for January this was on Oak 3, Maple, Willow and Hollies, however most of these wards had good average fill rates. Establishment review –There are ongoing discussions about the recommendations from the last establishment review completed in November 2015. The CCG requested and has been provided with additional information containing raw data that was collected by wards as part of this establishment review

7

as well as information on how the previous investment was used. It is hoped that this additional information will aid decision making. 4. Board Action

The Board is asked to note the exceptions, the changes to the focus of the recruitment action plan, recent successful recruitment campaigns and the fact that a decision is waited on the recommendations of the establishment review and the CQC Inspection “must do” actions in respect of staffing on Springbank and PICU.

1

Agenda Item: 11d


REPORT

Subject: Nursing Revalidation


Author: Rebecca Thorogood, Nurse Lead for Revalidation

Lead Director: Mel Coombes Director of Nursing

Executive Summary Revalidation is the process that all registered nurses will need to engage with to demonstrate that they practise safely and effectively throughout their career. Registrants will need to revalidate with the Nursing & Midwifery Council (NMC) every three years, at the point of their renewal of registration. In practice every registered nurse working within the Trust will need to demonstrate the following:

Practise a minimum of 450 hours over the three years prior to the renewal of registration

Undertake 35 hours of continuing professional development (CPD)

Obtain five pieces of practise-related feedback

Record a minimum of five written reflections on the NMC Code

Engage in a Reflective Discussion with another NMC registrant

Provide a health and character declaration

Declare appropriate cover under an indemnity arrangement

Gain confirmation, from a third party, that revalidation requirements have been met

Registered nurse to submit application for revalidation on NMC online

During 2015 the NMC worked with 19 organisations across the UK to pilot the new system. Learning from these pilots has been used to refine the revalidation model that the NMC announced on the on 8th October 2015. Purpose This brief paper updates the Board on our state of readiness and follows on from the previous paper to Board on 27th January 2016 and the report to QSG on 20th October 2015. Current Situation The NMC have confirmed the new model of revalidation will commence in April 2016. The application process will be undertaken online and any evidence required for audit verification must be submitted electronically to the NMC within 14 days of their request. The NMC have stated they will notify nurses 60 days before their revalidation online application is due.

2

The NMC have provided training resources and materials for employers to use within their organisations to prepare nurses for revalidation This guidance has been used within CPFT to:

inform launch sessions with key leaders,

deliver workshops with registered nurses in both clinical and non clinical roles

develop an E-learning package, accessible to all, as a point of reference. Workshops and training sessions have been positively evaluated with staff feeling, supported, prepared and confident. CPFT’s Revalidation Project Group, chaired by the DoN, continues to promotes a nursing empowerment ethos through the provision of education and support which emphasises nursing professionalism and accountability alongside monitoring uptake of the organisational resources being made available Current Position: The Implementation Plan and Key Milestones for the project remain largely unchanged. and the monitoring system is bedded in with the Revalidation Lead Nurse and DHoN’s fully aware of the timely steps to be taken to support nurses revalidating. Communication between parties is fluid and reactive if/when required. Implementation Plan and Key Milestones

Revalidation Project Steering convened and has met six times. A decision was made to meet bi-monthly from April

High level project plan signed off in January.

Communications Plan developed and CPFT Revalidation Newsletter produced monthly and disseminated via staff news with hard copies being circulated within Directorates. (Feedback will be sought in February from registered staff to review the newsletter content and consider suggestions and improvements).

E-Learning package launched from the 1st December 2015.Statistics of use are awaited from L & D. This package provides an overview of the revalidation process, the requirements and the NMC revalidation tools and templates

Revalidation Nurse Lead attended each Directorate meeting alongside the Directorate Heads of Nursing to ensure leadership team are aware of revalidation and responsibilities.

11 Launch sessions have been delivered to key leaders within services between 29th October and 13th November 2015. Leaders have since been undertaking training sessions locally within their services to ensure resources are spread.

40 workshops for clinical nurses completed.

4 workshops for nurses in non-clinical roles completed in January

8 Reflective Discussion and Confirmer sessions completed in January.

By end of April current figures show at least 540 CPFT registered nurses will have completed the workshops training. (approx. 50% of our registered staff) This figure increases daily as workshops remain open for bookings.

HR Lead distributes revalidation data (approximately)monthly to each Directorate Head of Nursing. Individual’s Revalidation dates are drawn from ESR

Data on ESR is being cleansed, where necessary through review by team leaders and managers, reporting back any missing or incorrect data for amendment

3

Revalidation Lead holds ‘Department walks’ – these are being well received by teams and offer further opportunity for practical support and guidance

Revalidation Lead Nurses Drop in clinics commenced in March are well received - staff book in slots to review their portfolios prior to submission.

Targeted emails are being sent by the Revalidation Lead Nurse to individuals 3 months before their revalidation to those who have not engaged with the workshops provided.

Workforce Development have confirmed that there is a system we can use to prompt and further alert registered staff of forthcoming revalidation dates alongside the registration reminder sent directly from the NMC.

Workshop sessions will continue in April and their need and frequency will be reviewed by the Revalidation Project Steering Group and delivered accordingly.

Milestones on Delivery:

August 2015

Revalidation dates drawn from ESR showing 1261 nurses employed by CPFT at this time need to revalidate

Submitted Trust Self assessment tool to Monitor

September 2015

Revalidation Nurse Lead appointment

Initial meeting of Revalidation Project Steering Group. TOR agreed

Communication Plan developed and commenced

October 2015

First CPFT Revalidation Newsletter published

NMC announced decision about Revalidation model and toolkit

CPFT E-Learning package developed using new NMC guidance

Presentation on Nursing Revalidation and Trust plans at Wider Leadership Team

Revalidation Nurse Lead attendance at Directorate Management Team Meetings

November 2015 Launch Sessions with key leaders

November 2015 - January 2016 Workshop Sessions for registered nurses delivered

December 2015 Revalidation E-learning launched

January 2016

Workshop sessions for nurses in non clinical roles delivered

Revalidation Data review and targeted email sent to 1st cohort of nurses to revalidate in April who have not engaged in workshops

January 2016 – February 2016 Workshop sessions for Reflective Discussion and Confirmation Roles

February 2016 – April 2016 Continued workshops for nurses in clinical or non clinical roles

February 2016 Data review and targeted email sent to nurses revalidating in May who have not engaged in workshops

March 2016 Individual drop in clinic appointments with Revalidation Lead targeted at first cohort

April 2016 First 36 nurses revalidate

4

Risk Register The main risks from the Revalidation Project are outlined below:

Risk Mitigation

Risk of nurses failing to understand the revalidation process

Direct communication from NMC has taken place with all registrants

Launch Sessions for key leaders to share the information/key message within their teams

Workshops for revalidating nurses and confirmers

E-Learning package available

Monthly Revalidation Newsletter

Revalidation Lead nurse available to clarify

Revalidation resources developed for dissemination within teams

Large proportion of the workforce does not revalidate on time

Communication plan developed and commenced

Review of linked HR policies: Supervision, Appraisal and Maintaining Professional Registration

Clear role for DHoNs in ensuring dissemination of information and monitoring engagement

Availability of electronic system monitoring process (ESR)

Nurses not having enough time to achieve revalidation requirements

Revalidation Project Group has agreed a position for protected time 3 months prior to revalidation

Attendance at workshops within work time if staff employed directly by CPFT. Bank staff can access materials within their own time, unpaid.

Early engagement with Directorate Heads of Nursing

NMC revalidation requirements and evidence are not overly prescriptive or time consuming. Individual learning styles are accommodated

Board Action To note the contents of this update paper






Links to BAF/Corporate Risk Register N/A

5


Revalidation ensures nurses compliance with the NMC Code: professional standards of practice and behaviour for nurses and midwives (March 2015)


Legal implications / impact

Nurses must revalidate with the NMC to provide assurance of their fitness to practice as a registered nurse.


N/A


Nursing Strategy Launch Event Oct 2014 Trust Nursing Leadership Group monthly Trustwide Nurses Event May 2015 Monthly Revalidation Project Steering Group Trust Board May 2015, Sept 2015, January 2016


No

Agenda Item: 12


REPORT

Subject: Eliminating Mixed Sex Accommodation


Author: Judy Dean, Head of Nursing

Lead Director: Melanie Coombes, Director of Nursing and Quality

Executive Summary: It is a statutory requirement to declare and publish our compliance against the delivery of same sex accommodation standards on an annual basis and to inform commissioners of our compliance status. This paper provides:

A summary of our Trust’s compliance against the standards

A draft statement of compliance for 2016/17 for Board approval

Summary of the actions which the Trust and wards took in 2015/16 to ensure we have all the measures in place to demonstrate good practice and robust risk management in relation to the standards, including strengthening the Eliminating Mixed Sex Accommodation Policy

Recommendations:

The Board is asked to note:

the outcome of the Eliminating Mixed Sex Accommodation audit

the improvement actions taken in 2015/16

approve the draft statement of compliance for 2016/17 and advise Trust Communications to publish on Trust public website without delay








Failure to meet the ‘Eliminating Mixed Sex Accommodation standards’ impacts on Trust CQC compliance

Financial implications / impact Financial penalties apply for non compliance

Legal implications / impact As above


N/A


N/A


Eliminating Mixed Sex Accommodation

1. Purpose

It is a statutory requirement to declare and publish our Trust’s compliance against the delivery

of same sex accommodation standards on an annual basis and to inform commissioners of our

compliance status.

This paper provides:

A summary of our Trust’s compliance against the standards

Summary of the actions wards have taken to ensure we have all the measures in place to demonstrate good practice and robust risk management in relation to the standards

A draft Declaration of Compliance for Board consideration and publication on our Trust website

2. Background & Context

Cambridgeshire and Peterborough NHS Foundation Trust is committed to a

person-centred approach to care through the provision of environments that

both promote and safeguard the privacy and dignity of patients. The standards expected are

stipulated in ‘Delivering Same Sex Accommodation’ (DoH, 2009) and summarised thus:

The Trust is required to ensure that sleeping areas, toilets and washing areas are designated

and clearly identified as either women or men only and can be provided in:

Same sex wards or units, where the whole ward is occupied by men or women only

Mixed sex wards or units where patients are cared for in single rooms with en-suite or adjacent same sex washing and toileting facilities. In mixed sex environments each ward will provide a clearly signed ‘ladies only’ sitting room

Mixed sex wards or units where patients are cared for in same sex bays with adjacent same sex toilet and washing facilities. In mixed sex environments each ward will provide a clearly signed ‘ladies only’ sitting room

Moreover, in ‘With Safety in Mind: Mental Health Services and Patient Safety. Patient Safety

Observatory Report (NPSA, July 2006), findings on sexual assaults within inpatient settings

suggested that both women and men are vulnerable, for example men also report unwanted

sexual pressure. This comes mainly from other men but occasionally from women. Therefore, it

is also very important that staff teams are aware and are vigilant of individual risk issues,

whatever the gender make-up of the ward.

3. Changes since the 2015/16 Statement of Compliance

The Eliminating Mixed Sex Accommodation Policy was reviewed in September 2015 and revised to reflect transferred services from Cambridgeshire Community Services and to also clarify the provision of same sex lounges across the Trust (the provision of female lounges is a requirement in mental health settings though not in physical healthcare settings). The new policy reflects the MHA Code of Practice (2015) and includes strengthened guidance on how front-line staff manage breaches, including escalation to ensure Directorate and Trust oversight.

Changes have also been made to the Datix incident notification list to ensure that Directorate Heads of Nursing and Corporate Nursing have timely oversight and are alerted to breaches. All incident reports relating to breaches of same sex accommodation must have the breach and resulting management plan signed off by the Directorate Heads of Nursing and for Corporate Assurance the Head of Nursing or Deputy Director of Nursing.

4. Methodology

As in previous years, the Head of Nursing requested the ‘Eliminating Mixed Sex

Accommodation Checklist’ be completed by the Ward Managers of all our mixed sex wards.

Returns were received from all wards and these were verified by either ward visits or telephone

contact to Ward Managers. The checklist includes guidance on definitions and acceptable and

unacceptable breaches and is included in Trust policy (Appendix 1)

Ward Managers were asked to identify any additional actions they would need to undertake to

provide assurance that mixed sex accommodation standards are being met on their wards.

4. Trust Summary The following summary sets out our overall Trust position:

All mixed sex wards are included with the exception of the Croft which caters for young

children and their families.

Trust Mixed Sex Wards Total

(Directorate Breakdown)

Adult Directorate:

Cavell Centre: AAU (aka Oak 3), Oak 4

Fulbourn Hospital: Mulberry 1, Mulberry 2, Mulberry 3

Integrated Care:

Peterborough City Care Centre: Intermediate Care Unit

Brookfields Hospital: Lord Byron A, Lord Byron B

Princess of Wales Hospital, Ely: Welney Ward

North Cambs Hospital, Wisbech: Trafford Ward

19

5

8

Cavell Centre: Maple Unit

Fulbourn Hospital: Denbigh, Willow

Specialist Services:

Cavell Centre: Hollies,

Fulbourn Hospital: George McKenzie House

Ida Darwin: Phoenix Centre, Darwin Centre, IASS

Addenbrookes Hospital: S3

6

Breaches

A breach occurred in IASS in May 2015. A female was sleeping

in a single room on the male corridor. As she was sharing a

male designated gender area with two men (even though they

all had their own rooms), the Trust was required to register 3

breaches.

There have been no further reported breaches for the remainder

of 2015/16

3

Ward Checklist returns: Issues for Board to be aware of

Specialist Directorate: S3, Phoenix and Darwin.

In the unusual circumstances of male(s) being admitted, they

are allocated bedrooms with access to toilet/bathrooms for their

sole use. Provision of a single sex sitting room/lounge is also

accommodated

There is a single sitting room/lounge on S3. Due to the ratio of

male to female patients (at most 12 females to 2 males), should

a male be admitted a small room off the main ward area is

designated.

On Phoenix the male bathroom and bedroom facilities that

become designated should a male(s) be admitted are located in

the same area of the ward as the female bathroom facilities.

There is a local risk management protocol in place on the

Phoenix and a ward plan for bed allocation

On Welney Ward, the team are awaiting works to be completed

to ensure permanent gender toilet signage. We have written

assurance that this work will be completed by the 28th March or

sooner if possible.

Adult Directorate: Mulberry 3, Fulbourn.

Female patients on Mulberry 3 who want to have a bath (rather

than a shower in their en-suite facilities), currently access an

assisted bathroom (DDA compliant) that is located at the

beginning of the male bedroom corridor, where they are

escorted by staff at all times.

5. Trust Action in 2015/16 During 2015/16 a number of actions have taken to place to improve environments for patients

and ensure robust governance and practice standards including:

Maple Unit refurbishment which introduced enhanced gender segregation facilities. In addition to the single sex bedrooms, the bedroom corridor has been sub-divided into female and male only areas. Access to the female area is accessed via a swipe card (issued to female patients) and exit is via an electronic press plate. The designated female only lounge is located within the female only area. Assisted bathing facilities are available in both the male and female areas.

Mulberry 3. Redevelopments in 2015 facilitated the provision of male and female designated lounge areas

IASS: a fully designated female lounge was created from the conversion of a laundry store, as previously a multi-activity room for the ward was also serving as a female lounge. This arrangement was not providing the desired function of a designated female-only space.

6. Statement of Compliance

The Trust is in a position to declare and publish compliance on this basis. A draft statement for

Board Approval is included in this report.

7. Monitoring Ward Managers are responsible for ensuring that their staff are aware and have an understanding of this policy and take the necessary actions to ensure that patients admitted are accommodated appropriately. Ward managers will ensure that with regard to delivering same sex accommodation the allocation of bedrooms ensures that men and women are, as far as is clinical appropriate accommodated in separate areas/corridors of the wards. Ward/unit managers will ensure that bathrooms and toilets are appropriately marked with signage that is clear and that service users are orientated to facilities. Where gender specific lounges are required, the ward will ensure that this area is restricted to

single gender and not used for visitors.

Data on Same Sex breaches is collected every month as part of our statutory responsibilities of reporting and included in the Trust’s and CCGs performance dashboards. The Trust dashboard is reviewed with Directorates at the monthly Performance Review Executive (PRE) with any actions/shared learning being fed back to the Quality, Safety and Governance Committee

8. Recommended Next Steps

The Board is asked to note the contents of this report and approve the draft statement of

compliance for 2016/17.

The Board is further requested to advise Trust Communications of the need to publish this

declaration on the Trust’s public website without delay.

(DRAFT) Statement of Compliance: Eliminating Mixed Sex Accommodation 2016/17

CPFT is pleased to confirm that we are compliant with the Government’s requirement to eliminate

mixed-sex accommodation.

We have the necessary facilities, resources and culture to ensure that patients who are admitted to

wards on our sites will either have their own bedroom or only share the room/bay where they sleep with

members of the same sex, and same-sex toilets and bathrooms are close to their bed area. If our care

should fall short of the required standard, we will report it and act on it. CPFT monitors privacy and

dignity through incident reports, through PALS and complaints and through patient experience visits

and feedback. We will undertake an annual audit to ensure compliance with this standard, and we will

publish our statement of compliance on our website.

What does this mean for our patients?

Same-sex accommodation means that patients admitted to wards on our sites at CPFT can expect to

find the following:

The room/bay where your bed is will either be a single room or, if shared, have only patients of the

same gender as yourself

Your toilet and bathroom will be just for your gender, and will be close to your bed area

It is possible that there will be both males and female patients on the ward and you may have to

cross a ward corridor to reach your bathroom, but you will not have to walk through opposite-sex

areas

You may share some communal living spaces, such as lounges or dining rooms, and it is very likely

that you will see both male and female patients as you move around the ward.

In wards where there are both males and females, you will have a quiet room for use by your own

gender

Unless accompanied by nursing staff, visitors are expected to make use of communal day areas,

lounges or other visiting facilities rather than patient bedrooms

If you need additional help to use the toilet or take a bath (eg, you need a hoist or special bath) then

you may be taken to a “unisex” bathroom used by both males and females, but a member of staff

will be with you, and other patients will not be in the bathroom at the same time.

Our commitment to privacy and dignity

Every patient has the right to receive high-quality care that is safe, effective and respects their privacy

and dignity. CPFT is committed to providing every patient with same-sex accommodation, because it

helps to safeguard their privacy and dignity when they are often at their most vulnerable.

CPFT also ensures that our staff are supported and trained to understand what privacy and dignity

means in practice.

How will we measure how we are doing?

CPFT undertakes the national annual patient survey for the Care Quality Commission and uses the

results of this to inform our service development work. In addition, we undertake our own surveys that

include specific questions on same-sex accommodation and privacy and dignity issues, and have

developed a patient experience system so that patients and carers can give us feedback about privacy

and dignity issues and other care issues. This feedback system is available directly to patients pre- or

post-discharge, and also available through our website. We also make use of feedback through our

PALs and complaints service to improve patient experience. Reports on all patient experience

feedback and developments are made to our Quality, Safety and Governance Committee and to the

Board, and made available to our commissioners.

Privacy and dignity concerns - PALS

We want to know about your experiences. Please contact CPFT's Patient Advice and Liaison Service

(PALS) if you have any comments or concerns. The contact number is:

Freephone 0800 376 0775

T 01223 726774 (during office hours)

A confidential e-mail service is also available at [email protected]

mailto:[email protected]

Appendix 1: Eliminating Mixed Sex Accommodation – Ward Checklist

The following outlines our ward arrangements to ensure we are compliant with the requirement to

eliminate mixed sex accommodation within our services and ensure the ward has processes in place to

manage potential breaches

Ward Name Site Date

Guidance Notes Definitions:

Same Sex Accommodation is where male and female patients sleep in separate areas and have access to toilets and washing facilities used only by their own sex.

Same Sex Accommodation can be provided in single-sex and mixed-sex wards.

In a same sex ward, the ward is occupied by either men or women and has its own dedicated toilet and washing facilities

In mixed-sex wards, same sex accommodation can be provided either as:

single rooms with same-sex toilet and washing facilities and Multi-bed bays or rooms occupied solely by either men or women with their own same-sex toilet

and washing facilities.

Criteria Y N Action Required Patients do not share a bedroom with a member of the opposite sex

Patients do not share toilets and bathrooms with members of the opposite sex

Patients do not need to walk through another patients bedroom to access their own bedroom

Patients do not need to walk through another toilet or bathroom to access their own toilet or bathroom

Posters Displayed stating compliance with Eliminating Mixed Sex Accommodation guidance

Ward plan indicating bedroom allocation displayed in the ward/unit office

Signage on Toilets and Bathrooms that are gender designated in pictorial form

DDA Toilets/Bathrooms have signage which can show either male or female

The ward has a women only lounge with signage (mental health and learning disability units only)

There is a process in place for allocating bedrooms for patients

Process and documentation in place for risk management in respect of potential mixed sex accommodation breaches

http://www.datadictionary.nhs.uk/data_dictionary/nhs_business_definitions/s/same_sex_accommodation_de.asp?shownav=0



http://www.datadictionary.nhs.uk/data_dictionary/nhs_business_definitions/m/multi-bed_bay_de.asp?shownav=0

Additionally, patients should not need to pass through mixed communal areas or sleeping areas, toilet

or washing facilities used by the opposite gender in order to get to their own facilities

Guidance on Breaches

Acceptable justification (Not Breach)

In the event of a life threatening emergency, either on admission or due to a sudden deterioration in

a patient’s condition

Where a critically ill patient requires constant 1:1 nursing care e.g. in ICU (Within CPFT this would

relate to PICU environments)

Where a nurse must be physically present in the room/bay at all times (the nurse may have

responsibility for more than one patient. This would be unacceptable if staff shortages or skill mix

were the rationale

Where a short period of close patient observation is needed e.g. immediate post-anaesthetic

recovery, or where there is a high risk of adverse drug reactions

On the joint admission of couples or family groups

Unacceptable justification (Breach)

Placing a patient in mixed-sex accommodation for the convenience of medical, nursing or other

staff, or from a desire to group patients within a clinical specialty

Placing a patient in mixed -sex accommodation because of a shortage of staff or poor skill mix

Placing a patient in mixed- sex accommodation because of restrictions imposed by old or difficult

estate/buildings

Placing a patient in mixed-sex accommodation because of a shortage of beds

Placing a patient in mixed-sex accommodation because of predictable fluctuations in activity or

seasonal pressures

Placing a patient in mixed-sex accommodation because of a predictable non-clinical incident e.g. a

ward closure

Placing or leaving a patient in mixed-sex accommodation whilst waiting for assessment, treatment

or a clinical decision

Placing a patient in mixed-sex accommodation for regular but not constant observation

Agenda Item: 13


REPORT

Subject: Emergency Preparedness: NHS Major Incident Statement of Readiness


Author: Emergency Planning Lead

Lead Director: Director of Nursing and Quality

Executive Summary: NHS England has requested that all health care providers provide a statement of readiness in relation to preparations to manage an incidents similar to the recent tragic events in Paris. Whilst primarily aimed at the acute sector all health care providers have been asked to review the relevant areas and provide assurance that they have taken the steps necessary to provide an appropriate level of support. Recommendations: The Board is asked to agree the Trust’s Statement of Readiness.








CQC Essential Standard Compliance NHSLA Compliance


Legal implications / impact

Civil Contingencies Act 2004 Health and Social Care Act 2012


CPLHRP


Emergency Planning Forum


Emergency Preparedness: NHS Major Incident Statement of Readiness

1. Purpose

The purpose of this paper is to seek Board agreement of the Trust’s Major Incident Statement of Readiness as requested by NHS England in Publications Gateway Reference No.04494 dated 09 December 2015.

2. Background

In light of the tragic events in Paris, NHS England together with the Department of Health and other agencies are reviewing and learning from the incidents to ensure that Emergency Preparedness Resilience and Response procedures are appropriate. NHS England have request our support in ensuring CPFT remains in a position to respond appropriately to any threat. This request comes against the backdrop on a threat level that remains unchanged since August 2014. The threat assessment to the UK from international terrorism in the UK remains SEVERE. SEVERE means an attack is highly likely. We have completed the annual Emergency Preparedness Resilience and Response assurance process, and have incorporated the relevant elements from the refreshed NHS England Assurance Framework into our Critical Incident Plan and Corporate Business Continuity Plan. NHS England has asked for assurance from health providers on a number of points; those specifically relevant to CPFT are that:

• We review and test our cascade systems to ensure we can activate support from all staff groups in the event of a loss of the primary communications system.

• We have arrangements in place to ensure that staff can gain access to sites in circumstances where there may be disruption to the transport infrastructure, including public transport where appropriate, in an emergency.

• We have plans are in place to significantly increase support to our acute provider partners over a protracted period of time in response to an incident, including where patients may need to be supported for a period of time prior to transfer for definitive care; and

• We have considered how we can access specialist advice in relation to the management of patients with traumatic blast and ballistic injuries.

• Our responses to the above form part of a statement of readiness at a public board meeting in the very near future as part of the normal assurance process.

3. Statement of Readiness

CPFT undertook a full review of its compliance with the Emergency Preparedness Resilience and Response Core Standards and was awarded a ‘fully compliant’ grade at peer review in September 2015. We have a multi-tier robust call out system that all staff access. The dispersed nature of the CPFT estate is conducive with ‘alternate site working’ and the requirement to identify alternative work locations forms an integral part of Operational Business Continuity Planning completed at service delivery level and incorporated into the Trust’s Critical Incident Plan and Corporate Business Continuity Plan. The integrated way in which CPFT delivers care and works alongside our acute service providers maximises our ability to increase support in accepting patients from hospital for ongoing treatment in the community. Working so closely with our acute partners we are able to access specialist advice that enables our committed staff to provide the spectrum of community based physical and mental health care.

4. Action

The Board is requested to review and agree the Statement of Readiness.

Agenda Item: 14a


REPORT

Subject: Business & Performance Committee Report


Author: Julian Baust

Lead Director: Julian Baust, Non Executive Director

Executive Summary:

This report presents the key issues discussed by the Business & Performance Committee at its meeting on

25th of February 2016. The areas covered included:

Business Planning 16/17

Commissioning and Contracting update

Business development update

UCP update

Capital and Infrastructure update

System Change Committee update

Financial Performance Report

Integrated Performance Report

Estates Statutory Compliance

Charitable Funds Report

Information Governance Report

Cycle of Business

Recommendations:

Note this report and any recommendations highlighted.








N/A

Financial implications / impact Note review of the Financial Report and Forecast



N/A


Business & Performance Committee


BUSINESS & PERFORMANCE COMMITTEE REPORT – 25th February 2015

1. Purpose The purpose of this report is to highlight issues discussed at the February meeting of the Committee which it is felt should be drawn to the Board’s attention.

2. Summary of Issues Discussed

Business Planning 16/17 The committee received assurance that there is a process in place to meet the filing requirements for the 2016/17 plan. The draft operational plan submitted to Monitor on the 8th of February was shared with the Committee. The plan calls for a breakeven outturn, assuming a satisfactory outcome to commissioner negotiations and achievement of some tough CIP goals, of which £1.6M are still to be identified. Commissioning and Contracting update Negotiations are underway whilst standard contract templates are awaited from NHSE. The national proposal is expected to deliver a price uplift of 1.8% net of a 2% efficiency gain. Business cases have been submitted for increased funding for Adult Mental health services and for Children’s services. Discussions are at an early stage regarding Older People’s and how to retain the gains made through UCP. Commissioners are working towards resolution of negotiations by the end of March. Business Development update A number of BD initiatives were shared. The threat that CCS potentially may pose with regard to the tendering of Children’s services was identified. However, it was noted that plans to mitigate this possible risk/threat are under development. There was also disappointing news from the Far East that we did not win the smaller of two bids to provide consultancy for L&D and MH promotion, apparently because our response submitted did not meet requirements. Further feedback on the core reasons for the decision is still being pursued. This was a £9M contract. We await a final decision regarding the bigger contract by end of March amid changes in the HMC leadership. Other bids are under consideration but represent relatively low value. UCP Update The Trust will contribute to the payment of the commitment to suppliers as part of the UCP closure. This will impact on the cash position of the Trust (see Finance report). Some costs are still surfacing which is clearly a concern. Front line services continue to be delivered, funded now by the CCG. Capital and Infrastructure update The Committee were updated on capital spend which YTD stands at £977K below plan. The full year outlook is to spend £4.3M against an original budget of £6.0M Overspend in IT was offset by underspending in Estates. System change committee update The minutes of the recent committee were shared with the B&P Committee. A number of issues were highlighted in the Minutes including the shortfall on CIP’s of £900K which continues to be a major concern especially as only 50% of those delivered are recurrent, putting further pressure on next year’s plan. Work continues to find further savings.

Finance report Month 10 showed an £84K deficit vs a planned surplus of £17K. Revenue was £81K above plan in the month. Pay costs were £20K and Other Operating Expenses were £141K overspent, resulting in an £80K unfavourable position. Movements in depreciation, non-operating costs and finance costs moved the deficit to £101K overall in the month. Trust spend on Agency and Bank staff was £704K over budget for the month offset by under spends on permanent staffing of £684K. Recruitment remains an issue, along with higher levels of sickness. Year to date the deficit sits at £471K which is £433K adverse to plan. The Executive Team remain confident that a year-end breakeven position is still achievable despite the current shortfall and difficulty in delivering CIP’s. The impact of the UCP termination costs appears below the line at £3.7M. There is some concern that costs are continuing to be identified against UCP where we have little headroom if we are to avoid a FSRR of 1. Cash ended the month at £11.1M; below plan by £1.0M. This relates to the removal of some of the proceeds of the sale of Vinery Road that were included in the original plan but which will not now go ahead. Payment of some outstanding property costs following resolution with other NHS bodies has reduced the surplus previously recorded. Month 11 will see a further fall in cash as UCP costs are settled. Debt moved up in the month, particularly in the past 90 days category. This needs to be closely monitored. Payment is expected imminently from UCP and from the CCG to clear 50% of the amount. FSRR ended the month on plan at a rating of 3. There is little room to manoeuvre after the UCP costs to ensure that we achieve a 2 at year-end. Integrated Performance Report The IPR came complete with a breakdown of the variances, which gave the committee a clear view of the challenges by area. The measures were discussed. Frustration was expressed that January data was not available for the meeting. Estates Statutory Compliance Frustration was shared by the Executive at the hitherto failure of SERCO to fulfil their contractual obligation to provide a full survey, report and management of Estates statutory requirements. However, after some strong follow up with SERCO, Alison Manton (AD Estates) has managed to secure a report which was shared with the committee. There is clearly work to be done in the coming year to ensure that all standards are met. This programme will be managed with SERCO by the Estates team. The issue of Estates non-compliance by SERCO will be added to the contractual escalation discussions underway with them. Charitable Funds report This report was presented by Simon Burrows, NED, following some detailed investigation work by him into the relative underperformance of fundraising for the Trust. It concluded that CPFT are currently raising less than one third of the average raised by other NHS charities (£42K vs £127K). Clearly there are some ‘star performers’ who have well established brands and fundraising infrastructure. However, the gap with CPFT is too large to be explained other than through a lack of focus and resource. The Committee supported the move to look for resource to move fundraising for the charity forward, but were not convinced that recruitment of a CEO at an estimated cost of £80K/annum was warranted at this stage. It was agreed that an internal resource would be identified along with a plan to move things forward, which would be brought back to the Committee for further review.

Information Governance Quality Assurance report The Committee received the report and are assured that work is on track to deliver the required result on the Toolkit. The issue of information being sent to the wrong address/service user is being worked on to reduce it further through process improvement. Training continues, especially in the Integrated Care Directorate. Cycle of business Discussed and approved.

4. Board Action The Board is asked to note this report.

Julian Baust Non Executive Director

Agenda Item: 14ci


REPORT

Subject: Finance Report, 29th February 2016


Author: Derek McNally, Deputy Director of Finance

Lead Director: Scott Haldane, Director of Finance

Executive Summary: [Arial 12] The Trust is reporting a deficit of £90k in February against a planned surplus of £25k for the month;

The year to date position is a deficit of £561k against a planned deficit of £13k;

The month 11 adverse variance includes the settlement costs of the MARS scheme.

The Trusts Financial Sustainability Risk Rating (FSRR) is a 3 as planned;

Forecast outturn is to achieve the planned breakeven operational position with an overall deficit of £3.7m,

and a FSRR of 2, once exceptional items have been taken into account.

Recommendations:

Members of the Board are asked to note the contents of this paper.








N/A

Financial implications / impact

This paper outlines the financial performance to the Trust at 29 February 2016.



N/A


N/A


Finance Report to 29 February 2016

(Month 11)

Corporate services Finance Report M11

Finance Report to 29 February 2016

2

Contents:

Key Messages

Appendices – Detailed Financial Statements

Scott Haldane

Director of Finance

Corporate services Finance Report M11 3

AREA PLAN ACT FCAST NARRATIVE

Overall Financial Position

- Month 11

- Year to Date

£25k

(£13k)

(£90k)

(£561k)

(£3.70m)

February deficit of £90k represents a negative variance of £115k against the

plan for Month 11. This deficit includes the repatriation into the Trust of staff that

had been working in UnitingCare, Qatar bid costs, and also the cost of the

MARS agreements.

The year to date overspend for the Trust is £561k, which represents an

adverse variance of £548k against plan.

Cost Improvement Plan

(CIP) YTD Position

£5.68m £4.61m £5.20m CIP savings are behind target by £1.07m year to date. See Appendix 2 for

details.

Liquidity £11.1m £11.4m £8.1m Cash balance is in line with plan at the end of Month 11. See Appendix 5 for

details.

Capital - Expenditure £5.15m £3.83m £4.3m Capital expenditure is below plan by £1.32m at the end of Month 11, due to

planned revision of the spend profile in some schemes. See Appendix 7 for

details.

Financial Sustainability

Risk Rating (FSRR)

3 3 2

Financial Sustainability Risk Rating was introduced in the updated Risk

Assessment Framework in August. Performance is as per plan at the end of

M11. Details of this are provided in Appendix 8. The forecast included at

Appendix 1.3 identifies the FSRR impact.

Summary

of Key

Risks and

Issues

The overall financial position is behind plan by £548k at the end of Month 11. See Appendix 1 for further details.

The Trust is continuing to assess the financial implications for the year of the termination of the UnitingCare contract with the CCG in early

December. The Month 11 position recognises the costs of staff employed by CPFT who were seconded to UnitingCare who have now returned to

the Trust.

The forecast position identifies the range of issues included in the Settlement Agreement on the UnitingCare contract and the potential financial

impact of these. The work to fully quantify the financial impact of each element is nearing completion and it is still hoped that this will be

successfully concluded by the year end. A verbal update will be provided at the Board Meeting.

Excluding the impact of the UnitingCare contract issues, the Trust is continuing to forecast that an operational breakeven position for FY16 will be

delivered. The impact of the UnitingCare contract is considered in the high level forecast outturn included in Appendix 1.3. The most likely case is

a £3.70m deficit for the year. The impact on both the liquidity and I&E positions of the Trust as a result of this settlement just maintains a Financial

Sustainability Risk Rating for the year of 2. Monitor have been kept fully informed of this impact.

Key Messages

The Trust remains on monthly reporting to Monitor. The Monthly Monitoring Report consists of an extract of the information provided in the Income Statement and Cash

flow plus the FSRR.


Section 1: Appendices

4

1. Income & Expenditure Statement

1 Revenue Analysis 2 Operating Expenses 3 Forecast Outturn 2. Cost Improvement Plan Analysis

3. Directorate Analysis

4. Temporary Staffing

5. Statement of Position and Cash Flow

6. Debtor Report

7. Capital Expenditure

8. Financial Sustainability Risk Rating (FSRR)


Appendix 1 - Income & Expenditure

Month 11 position for the Trust is a deficit of £90k, which is an adverse variance of £115k compared to the plan for the month. The in-month deficit includes the costs of the staff who had been working in UnitingCare but have returned back to the Trust on the termination of the UnitingCare contract with the CCG in early December. In addition the Month 11 position includes £280k of non-recurring costs related to agreed redundancies and the MARS scheme. This gives the Trust a deficit of £561k year to date.

Annual Ytd FY15

Month 11 & Year to date Plan Plan Actual

Plan to

Date

Actual to

Date Actual

£m £m £m £m % £m £m £m % £m

Operating Revenue for EBITDA 190.664 15.852 16.246 0.394 2.5% 174.891 174.514 (0.377) (0.2%) 115.384

Pay Costs (133.176) (11.259) (11.456) (0.197) (1.8%) (121.987) (123.069) (1.082) (0.9%) (79.120)

Other operating expenses (49.451) (3.902) (4.191) (0.288) (7.4%) (45.547) (44.576) 0.971 2.1% (29.503)

EBITDA 8.036 0.691 0.600 (0.091) (13.2%) 7.357 6.870 (0.487) (6.6%) 6.761

Profit/Loss on Asset Disposal 1.600 0.000 0.000 0.000 0.0% 0.000 0.000 0.000 0.0% 0.004

Depreciation (4.514) (0.372) (0.400) (0.028) (7.5%) (4.142) (4.268) (0.126) (3.0%) (4.173)

Finance Costs (1.404) (0.117) (0.108) 0.009 7.8% (1.287) (1.187) 0.100 7.8% (1.191)

PDC Dividend (2.217) (0.185) (0.185) (0.000) (0.0%) (2.032) (2.033) (0.000) (0.0%) (2.023)

Other non-operating items 0.100 0.008 0.003 (0.005) (60.1%) 0.092 0.056 (0.035) (38.4%) 0.017

Net Surplus/(deficit) 1.600 0.025 (0.090) (0.115) (459.0%) (0.013) (0.561) (0.548) (4282.9%) (0.605)

Impairment 0.000 0.000 0.000 0.000 0.0% 0.000 0.000 0.000 0.0% 0.000

Net Surplus/(deficit) after impairments 1.600 0.025 (0.090) (0.115) (459.0%) (0.013) (0.561) (0.548) (4282.9%) (0.605)

EBITDA % 4.21% 4.36% 3.69% -0.67% 4.21% 3.94% -0.27% 5.86%

I&E Surplus Margin % 0.84% 0.16% -0.55% -0.71% -0.01% -0.32% -0.31% -0.52%

Month 11 Year to Date

Variance Favourable /

(Adverse)


(Adverse)


Appendix 1.1 – Revenue Analysis

Community Services Income – this category includes the Community Services element of the ex-UnitingCare contract, other third party revenue associated with these services and the funding from C&P CCG for Community Children's Services in Peterborough. These arrangements are, by and large, based on Block Contracts. The positive variance in month reflects the continued positive contribution from physical health contracts with Acute NHS Trusts, which have been agreed for amounts higher than budgeted.

High Cost/Low Volume Cost & Volume Income – this category includes the variable income from Specialist Services commissioned by NHSE. Underperformance in M11 is related mainly to under occupancy in the CAMH Tier 4 In-patient Units (£23k) and Springbank Unit (£16k), and the Adults Eating Disorder unit (£3K).

Other Cost & Volume Income – this category includes income from Non Contract Activity which has an over recovery of £74k in M11 and income from the MoD contract which is above target by £36k in the month.

Block contract – C&P CCG –the in-month favourable variance is due to reducing the provision for underperformance against the PWS contract, based on the activity being delivered against this.

Other Clinical Income – the in-month adverse variance is due to the under recovery of two cost dependent services, Fens OPD Unit (£25k) and Liaison Psychiatry (£41k). As these are cost dependent, this is offset by underspends in related expenditure.

Education and Training – The adverse variance in the month includes under-recovery in Junior Doctor income (£47k), albeit this is offset by underspends in related pay costs, and reduction in SIFT income to reflect revised funding arrangements (£13k).

Other Income – The main favourable variance in the period is the release of previously deferred learning and development funding from HEE to offset costs (£120k).

Annual Ytd FY15


Plan to

Date

Actual to

Date Actual

£m £m £m £m % £m £m £m % £m

Community services income 68.369 5.610 5.715 0.105 1.9% 62.839 63.319 0.480 0.8% 7.973

High Cost Low Volume C&V Income 9.389 0.782 0.741 (0.042) (5.3%) 8.607 8.278 (0.329) (3.8%) 8.709

Other cost & volume income 0.615 0.051 0.163 0.112 218.7% 0.564 0.755 0.191 33.9% 0.392

Block contract (MH) - C&P CCG / UCP 71.095 5.960 6.095 0.135 2.3% 65.136 65.477 0.342 0.5% 62.699

Block contract - NHS England (SCG) 3.701 0.313 0.315 0.002 0.8% 3.389 3.415 0.027 0.8% 4.181

Block contract - Other CCG's 3.592 0.299 0.336 0.036 12.1% 3.293 2.933 (0.360) (10.9%) 3.337

Clinical partnership income (incl. s75) 13.187 1.087 1.066 (0.021) (1.9%) 12.100 11.624 (0.475) (3.9%) 10.255

Private patient income 0.014 0.001 0.000 (0.001) (97.9%) 0.013 0.001 (0.012) (96.0%) 0.026

Other clinical income 6.018 0.511 0.445 (0.066) (13.0%) 5.506 5.036 (0.471) (8.5%) 4.222

Total clinical revenue 175.982 14.615 14.876 0.261 1.8% 161.446 160.839 (0.607) (0.4%) 101.793

Research & Development 4.152 0.346 0.351 0.005 1.5% 3.806 3.573 (0.233) (6.1%) 3.507

Education and Training 6.862 0.592 0.540 (0.052) (8.8%) 6.270 5.569 (0.701) (11.2%) 5.722

Other Income 3.667 0.298 0.479 0.180 60.5% 3.369 4.533 1.165 34.6% 4.362

Total non clinical income 14.682 1.237 1.370 0.133 10.8% 13.445 13.675 0.230 1.7% 13.591

Total Operating Revenue 190.664 15.852 16.246 0.394 2.5% 174.891 174.514 (0.377) (0.2%) 115.384



(Adverse)


(Adverse)


Appendix 1.2 – Operating Expenses

Pay costs – Pay costs in Month 11 include additional costs of £280k related to agreed redundancies and the cost of the MARS scheme. Without these exceptional costs, overall pay costs would have been well within plan for the month. Notwithstanding, Agency costs continue at a level significantly above the Monitor cap and have increased by £180k from the spend in the previous month. The project in place reviewing the TSS processes to minimise the dependence on Agency staff across the Trust is continuing to address this issue.

Other Costs – the overspend includes the continuing overspend on Minor Works (£44k), Windows Licences (£27k) and telephony costs (£32k). Further spend on promotion of the Personal Wellbeing Service has been incurred in month (£16k). The Month 11 position also includes additional Vehicle Insurance costs for Lease Cars (£150k) and additional charges from CUHFT for catering in ward S3 (£26k).

Reserves – This includes the proportionate share of the CIP Risk Reserve and Earmarked Reserves for the year to date, in line with the Financial Plan submission to Monitor. The costs allocated to Reserves are non-recurring and this month relates to agency costs in Business Development.

Annual Ytd FY15


Plan to

Date

Actual to

Date Actual

£m £m £m £m % £m £m £m % £m

Pay - employees (131.022) (11.076) (10.403) 0.673 6.1% (120.013) (112.982) 7.031 5.9% (72.476)

Pay - contract and agency staff (2.155) (0.182) (1.053) (0.870) (477.9%) (1.974) (10.086) (8.113) (411.1%) (6.644)

Pay expenses (133.176) (11.259) (11.456) (0.197) (1.8%) (121.987) (123.069) (1.082) (0.9%) (79.120)

Drug costs (1.230) (0.098) (0.110) (0.011) (11.7%) (1.132) (1.057) 0.075 6.6% (1.037)

Clinical supplies (3.166) (0.260) (0.216) 0.044 16.9% (2.905) (2.952) (0.047) (1.6%) (0.380)

Non-clinical supplies (0.498) (0.042) (0.035) 0.006 14.9% (0.457) (0.436) 0.021 4.5% (0.408)

Secondary commissioning costs (0.813) (0.068) (0.065) 0.003 4.8% (0.745) (0.636) 0.109 14.6% (0.959)

Research & Devpt costs (4.299) (0.358) (0.363) (0.005) (1.4%) (3.941) (3.700) 0.242 6.1% (3.578)

Education & training costs (3.937) (0.348) (0.362) (0.014) (4.0%) (3.590) (3.586) 0.003 0.1% (3.257)

Other Costs (30.061) (2.430) (2.813) (0.383) (15.8%) (27.630) (29.189) (1.559) (5.6%) (17.908)

PFI Unitary Payment (2.262) (0.188) (0.194) (0.005) (2.9%) (2.073) (2.125) (0.052) (2.5%) (1.976)

Reserves (3.185) (0.111) (0.033) 0.078 69.9% (3.074) (0.894) 2.180 70.9% 0.000

Non-pay expenses (49.451) (3.902) (4.191) (0.288) (7.4%) (45.547) (44.576) 0.971 2.1% (29.503)

Total operating expenses for EBITDA (182.628) (15.161) (15.646) (0.485) -3.20% (167.534) (167.645) (0.110) -0.07% (108.623)


(Adverse)


(Adverse)



Appendix 1.3 - Forecast Outturn

8

Forecast Outturn

The forecast outturn identifies the

range of issues which will impact on

the operational financial position

during the remainder of the year, and

the most likely estimate of the impact.

The non-recurring impact of the

Termination Agreement on the

UnitingCare contract and the potential

financial impact of these is

highlighted as Exceptional Items.

The work to fully quantify the financial

impact of each element of the

agreement is ongoing,

Most

Likely

Case Comments

£000's

Surplus (Deficit) as at M11 (excluding UC

Termination Costs) (561)

Run Rate estimate M12 (90) Monthly Run Rate estimate - based on M11

Forecast Based on Current Run rate (651)

Further Issues impacting on Forecast

Agency Cost Planned Reduction 65 Required to deliver Monitor Agency Target

MARS Scheme - Costs 0 Based on MARS Panel Outcome & Agreements reached (paid in M11)

MARS Scheme - In-Year Benefit 6 Based on MARS Panel Outcome & Agreements reached (M12 saving)

VR Net Costs - Discussed at VR Panel 0

VR Payments agreed in FY16 of £292k - funded as part of the UC settlement

below.

Additional Funding - Vanguard Project 0 Contribution from Vanguard Project in-year (in M11 position)

Release of IAPT Provision for Under Performance 58 Likely to hit IAPT target in-year (50% released in M11)

Funding of Qatar Bid Costs (following agreement of

Contract) 0

No income recognised against set up costs incurred in the year as agreements

not yet signed.

Review of spend and held contingencies 247

Reflects actions that can be taken to minimise discretionary spend and review of

contingencies currently included in the financial position. would reduce the

severity of the cuts required.

Staff Costs of CPFT Seconded Staff to UC 0

Based on monthly payroll costs, reduced for those individuals who can be slotted

into vacancies in CPFT allowing Temporary staff costs to be released. Included

in Monthly Run rate estimate M12.

Additional Income - CLDP (Specialling) 290 Contract Uplift agreed for FY16

666

Adjusted Forecast (Deficit) - Operations 15

Exceptional Items Related To UnitingCare Contract

Most Likely

Case

CPFT Share of UC Settlement (3,500)

UnitingCare transactions are currently being finalised which will determine the

final CPFT liability for the Trust's share of the settlement agreement.

Proportion of Input VAT related to UC not reclaimable (310)

Liability under discussion with HMRC and DoH. There is the potential that a

reduced charge, or a liability exemption could be given.

Additional Legal Advice on UC 0 To Be Confirmed

HEE Funding 246 Funding due from UC for Research Study on Integrated Care in the Community

Agreed Repayment to CCG (650)

Potential Capital to Revenue Transfer 500 Capital to Revenue Transfer agreed at £500k

Total - Exceptional Items (3,714)

Forecast Surplus / (Deficit) (3,700)

Financial Sustainability Risk Rating (FSRR) 2

Appendix 2 – Cost Improvement Plan Analysis

9

Month 11 Plan CIP risk

reserve

released

Plan mitigated by CIP risk

reserve

Achieved

Recurrently

(% of Plan)

Achieved

non

recurrently

(% of Plan)

Total

Achieved

(% of Plan)

Variance

against plan

(% of Plan)

In month £659k (£42k) £618k £302k 49%

£145k 24%

£446k 73%

(£172k) 27%

YTD £6.134m (£458k) £5.675m £2.905m 51%

£1.701m 30%

£4.605m 81%

(£1.070m) 19%

Work stream Scheme

Annual

Planned

Savings Value

Planned

Savings

M11

Actual

savings

M11

Variance

M11

Planned

Savings

YtD

Actual

savings

YtD

Variance

YtD Comments

New CIP Plans FY16

Workforce CIP Adult Directorate Plans 454 51 21 (29) 403 247 (156) Range of Projects Underway to deliver savings.

Workforce CIP Older Peoples Directorate Plans 220 37 21 (16) 183 104 (79)

Scheme to combine Ward Teams into a Single team.

Changes implemented from 1st Oct.

Workforce CIP Children's Directorate Plans 240 31 0 (31) 209 0 (209)

Further plans under development as original plans not

being progressed. Directorate making significant

mitigating savings.

Workforce CIP Specialist Directorate Plans 79 8 3 (6) 70 28 (43) Range of Projects Underway to deliver savings.

Workforce CIP AOP Services Plans 1,072 98 65 (33) 974 715 (259) Range of Projects Underway to deliver savings.

Workforce CIP Exec Portfolio Plans 760 63 6 (57) 697 101 (596)

Savings behind plan at M11. MARS scheme completed

with little impact on savings target.

Sub-total - Workforce Savings 2,824 287 116 (171) 2,537 1,195 (1,342)

Non-Pay CIPs Adult Directorate Plans 10 0 0 0 0 0 0 Non-pay Savings from introduction of Mobile Working.

Non-Pay CIPs Older Peoples Directorate Plans 330 32 21 (11) 298 229 (69) Non-pay reductions from revised contracts.

Non-Pay CIPs Children's Directorate Plans 241 20 55 35 221 426 205 Use of Reserves and non-pay reductions.

Non-Pay CIPs Specialist Directorate Plans 19 1 2 0 14 21 8 Non-pay Savings from introduction of Mobile Working.

Non-Pay CIPs AOP Services Plans 732 81 65 (16) 651 469 (182) Estates and Procurement savings

Non-Pay CIPs Exec Portfolio Plans 760 80 43 (37) 680 476 (204) Telecomms, Estates and Procurement savings.

Sub-total - Non-pay Savings 2,092 215 186 (29) 1,863 1,621 (242)

Business Development CIPs Adult Directorate Plans 354 30 0 (30) 325 89 (236) Increased income from Springbank ward

Sub-total - Business Development 354 30 0 (30) 325 89 (236)

Total Identified CIP Savings Plans 5,270 531 302 (230) 4,725 2,905 (1,820)

Schemes under developmentTrust wide 1,537 128 0 (128) 1,409 0 (1,409)

This relates to the CIP balance not yet identified,

however this has been profiled evenly throughout the

year to maintain visibility of the target to ensure work

is progressed on identifying this balance.

Non-recurrent Mitigation Adult Directorate Plans 0 0 59 59 0 381 381 Non recurrent vacancies within the services

Non-recurrent Mitigation Older Peoples Directorate Plans 0 0 0 0 0 55 55 Non recurrent vacancies within the services

Non-recurrent Mitigation Children's Directorate Plans 0 0 10 10 0 499 499 Non recurrent vacancies within the services

Non-recurrent Mitigation Specialist Directorate Plans 0 0 22 22 0 325 325 Non recurrent vacancies within the services

Non-recurrent Mitigation AOP Services Plans 0 0 0 0 0 0 0

Non-recurrent Mitigation Exec Portfolio Plans 0 0 54 54 0 441 441 Non recurrent vacancies within the exec portfolio

Sub-total - Mitigating Savings 0 0 145 145 0 1,701 1,701

TOTAL OF NEW CIP PLANS for FY16 6,807 659 446 (213) 6,134 4,605 (1,528)

TOTAL OF CIP PLANS 6,807 659 446 (213) 6,134 4,605 (1,528)

NEW SCHEMES - Risk Adjustment

@10% -500 -42 0 42 -458 0 458

RISK ADJUSTED SAVINGS PLAN 6,307 618 446 (172) 5,675 4,605 (1,070)


Appendix 3 - Directorate Analysis

In-Month Variations

The clinical directorates are reporting a £103k favourable

variance against plan:

- Adult Directorate is showing an overspend of £25k in month.

This is due to the continuing use of Agency nursing costs in the

month in the inpatient wards, Agency Medical costs (£30k) and

increased costs in PWS to deliver targets (£28k). Continuing

savings from CRHT’s and Community team vacancies and

additional income from MoD beds partially offset this overspend.

- Children’s Directorate underspend continues, as a result of

incremental savings within the Health Visiting service. The rate of

the underspend is slowing due to the recruitment to posts funded

by the £600k additional investment given to the service in-year,

including Locum Medical costs.

- Specialist Directorate has a £16k underspend in the month.

This includes under-recovery of income of £44k against Specialist

Commissioning contracts, which is offsetting savings from

vacancies across a range of services.

- Integrated Care Directorate is reporting an underspend of

£103k. Continuing overspends against inpatient budgets (£120k)

due to the high levels of Agency staff being used to cover

vacancies and sickness is being offset by savings from vacancies

in the Community Teams (£170k). A reduction in SLA charges

(£60k) and non-pay costs for continence products (£30k) is also

helping to mitigate the inpatient cost pressures.

The Executive Portfolios are reporting an overspend of £418k in

the month. The Director of Finance overspend includes the

monthly impact of the previously reported cost pressure for

Microsoft licences (£27k) and Minor Works expenditure (£44k).

Following a detailed review of Lease car accruals and

prepayments this month it also includes additional related costs for

Lease Cars of £150k.

The Director of People Services underspend of £78k in month

includes the release of income from HEE previously deferred

(£151k). This is mitigating continuing overspends on Agency staff,

the costs of Bank staff within TSS and unachieved CIP. The

Medical Director overspend of £49k is due to the cost of Agency

Pharmacy staff, and an agreed increase in the SLA for the

provision of Pharmacy support from PSHFT. The Director of Social

Care & Integration underspend is related to the recharge of the

costs of the designated Social Care lead in Peterborough

previously charged here to the S75 Agreement.

The costs allocated to Reserves are non-recurring and, in-month,

are mainly related to Agency costs in Business Development.

Directorate / ServiceAnnual

PlanPlan Actual

Plan to

Date

Actual to

Date

£m £m £m £m % £m £m £m %

Clinical Directorates

Adult Directorate (31.205) (2.593) (2.618) (0.025) (1.0%) (28.629) (28.544) 0.086 0.3%

Childrens Directorate (14.171) (1.193) (1.183) 0.010 0.8% (12.965) (12.434) 0.531 4.1%

Specialist Directorate (2.819) (0.245) (0.230) 0.016 6.4% (2.568) (2.278) 0.290 11.3%

Integrated Care Directorate (59.683) (5.002) (4.900) 0.103 2.1% (54.679) (54.713) (0.034) (0.1%)

Total Clinical Directorates (107.878) (9.034) (8.931) 0.103 1.1% (98.841) (97.968) 0.873 0.9%

Executive Portfolios

Chief Executive Office (0.763) (0.063) (0.057) 0.007 10.9% (0.700) (0.762) (0.062) (8.8%)

Chief Operating Officer (0.253) (0.021) (0.043) (0.022) (102.0%) (0.232) (0.325) (0.093) (40.2%)

Director of Finance (30.290) (2.604) (3.072) (0.468) (18.0%) (27.665) (28.758) (1.092) (3.9%)

Director of Nursing (2.389) (0.158) (0.164) (0.005) (3.4%) (2.231) (2.495) (0.265) (11.9%)

Director of People Services (4.177) (0.339) (0.261) 0.078 22.9% (3.838) (4.654) (0.815) (21.2%)

Medical Director (1.852) (0.167) (0.216) (0.049) (29.3%) (1.698) (1.722) (0.024) (1.4%)

Social Care & Integration (0.362) (0.030) 0.011 0.041 138.2% (0.332) (0.424) (0.092) (27.7%)

Total Executive Portfolios (40.087) (3.383) (3.801) (0.418) (12.4%) (36.697) (39.139) (2.442) (6.7%)

Trust Financing 1.149 0.096 0.091 (0.005) (5.2%) 1.053 1.017 (0.035) (3.4%)

Research & Development (0.147) (0.012) (0.012) 0.000 (1.3%) (0.135) (0.137) (0.002) 1.2%

Reserves (2.881) (0.077) (0.032) 0.045 (58.2%) (2.803) (0.899) 1.905 (67.9%)

CIP Target Unidentified 1.429 0.124 0.000 (0.124) (100.0%) 1.305 0.000 (1.305) (100.0%)

Total Net Expenditure (148.416) (12.286) (12.685) (0.399) -3.2% (136.118) (137.125) (1.007) -0.7%

Block Contract Income 148.416 12.311 12.594 0.283 2.3% 136.105 136.563 0.458 0.3%

Net Surplus / (Deficit) (0.000) 0.025 (0.091) (0.116) (0.013) (0.562) (0.549)

Variance

Favourable /

(Adverse)

Variance

Favourable /

(Adverse)

Month 11 YTD Month 11


Appendix 4 - Temporary Staffing Costs

The Temporary Staff Costs run rate highlights the spend on Bank and Agency across the Trust in both Clinical and Corporate areas. The Report includes the

performance against the Monitor set Target for Qualified Nurses Agency costs, which is 6% over the final 6 months. Actual in M11 was 9.8%, which is an increase

of 1% on the previous month. Usage remains higher than the planned trajectory. However, every effort continues to be made to deliver the Monitor Target.

Within the clinical services, there are several areas of non-recurrent service provision where

Agency is the preferred method of delivery and where funding from commissioners is based on

this assumption. The overall amount spent on Temporary staffing in month 11 represents 11.7%

of the Trust’s total Pay Costs.

Agency costs include costs of Agency staff within R&D which are reported against

R&D Expenditure in the Operating Costs analysis in App1.2.

Feb-15 Mar-15 Apr-15 May-15 Jun-15 Jul-15 Aug-15 Sep-15 Oct-15 Nov-15 Dec-15 Jan-16 Feb-16

Bank 53 (37) 93 (56) 50 37 11 33 31 37 25 38 37

Agency 110 117 138 104 153 140 100 101 73 74 89 95 35

(100)

(50)

50

100

150

200

250

Spe

nd

£

Temporary Staffing - Corporate

Feb-15 Mar-15 Apr-15 May-15 Jun-15 Jul-15 Aug-15 Sep-15 Oct-15 Nov-15 Dec-15 Jan-16 Feb-16

Bank 233 236 449 228 241 321 365 298 299 363 362 298 311

Agency 283 402 642 628 449 707 1133 829 804 715 1026 724 962

200

400

600

800

1000

1200

1400

1600

Spe

nd

£

Temporary Staffing - Clinical

Period Agency £'000 Bank £'000 Grand Total

Mar-15 519 199 718

Apr-15 780 542 1323

May-15 733 172 905

Jun-15 601 291 892

Jul-15 848 358 1206

Aug-15 1233 376 1609

Sep-15 793 331 1125

Oct-15 877 330 1207

Nov-15 789 400 1189

Dec-15 1166 336 1502

Jan-16 819 336 1156

Feb-16 997 347 1345

Grand Total 10155 4020 14175

6.7% 6.7% 6.5%6.1%

5.0%

9.3%

6.6%

2.8%

5.1%

14.9%

13.6%

8.4%

7.3%

10.2%

8.8%

9.8%

0.0%

2.0%

4.0%

6.0%

8.0%

10.0%

12.0%

14.0%

16.0%

Apr-15 May-15 Jun-15 Jul-15 Aug-15 Sep-15 Oct-15 Nov-15 Dec-15 Jan-16 Feb-16

%

Month FY16

Agency Nursing % Vs Monitor Target Trajectory

Monitor target Actual


Appendix 5 – Summarised Statement of

Financial Position and Cash Flow

Cash performance is in line with plan at Month 11. This is after making a net cash payment to UnitingCare of £2.7m as the initial payment under the

settlement agreement.

The Trusts overall Debtor balance has reduced by £1.9m in Month 11 which has helped offset the initial UnitingCare payment.

The plan continues to include sale proceeds of £2.6m from Vinery Road, which will no longer be realised this year. The necessary amendment to

the plan is currently in the process of being agreed with Monitor. The capital plan has been reduced to offset this impact in year.

Statement of Financial Position - Month 11

As per Final

Accounts

2014/15

Plan

This Month

Actual

This Month

Variance

from Plan

£'m £'m £'m £'m

101.8 Property, Plant and Equipment 103.3 101.4 (1.9)

20.8 Assets Current 20.3 23.9 3.6

(22.7) Liabilties, Current (23.6) (27.2) (3.6)

(28.3) Liabilities, Non-Current (27.7) (27.5) 0.2

71.7 TOTAL ASSETS EMPLOYED 72.4 70.6 (1.7)

71.7 TOTAL TAXPAYERS EQUITY 72.4 70.6 (1.7)

Cashflow Statement - Month 11

As per Final

Accounts

2014/15

Plan YTD

Month 11

Actual YTD

Month 11

Variance from

Plan

£'m £'m £'m £'m

7.6 EBITDA 8.0 6.9 (1.1)

5.4 Movement in working capital (3.0) 0.2 3.2

13.0 CF from Operations 5.0 7.1 2.1

(2.3) Net capital Expenditure (2.6) (3.8) (1.2)

10.7 CF before Financing 2.4 3.3 0.9

(4.3) Financing (2.9) (3.4) (0.5)

6.4 Net cash outflow/inflow (0.5) (0.2) 0.4

5.2 Opening Cash Balance 11.6 11.6 (0.0)

11.6 Closing Cash Balance 11.1 11.4 0.3


Appendix 6 – Debtor Reporting

5,000

6,000

7,000

8,000

9,000

10,000

11,000

12,000

13,000

14,000

£'0

00

s

Overall Debt level

3,066 3,584 3,430 4,122

348

3,669 3,381992

6,539547 1,774

2,628

543,467

3791,151

1,304

1,0813,959

2,091

0

2,000

4,000

6,000

8,000

10,000

12,000

14,000

Nov-15 Dec-15 Jan-16 Feb-16

£'0

00

s

Aged Debt Analysis

Past due after 90 Days

Past due 60-90 Days

Past due 30-60 Days

Past due less than 30 days

Current

Debtors over 90 days have decreased by 47% in month 11.

Debtors > 90 DAYSFeb

£'000

Jan

£'000Change Comment Action Taken

Cambridgeshire County

Council720 645 (75)

Invoice of £273k for additional

observation cost at IASS unit in

2014/15. This may be resolved by the

agreement on funding Specialiing

Costs in FY16. Q1 & Q2 OPMH Social

care teams outsatnding (£202k).

Section 75 agreement for

Occupational Therapy : £123k.

Contracting discussion have

progressed regarding Specialling Costs.

Delay on other invoices is due to the

requirement of a Purchase order

number from the Council before they

w ill process them for payment - these

have been requested.

PSHFT 561 561 0

All 15/16 Nomination Agreement

invoices : £286k and Psychiatric

Liaison Q2 invoices : £185k invoices

remain outstanding at the end of

February but have been paid in March.

Staff recharges totalling £100k are

being disputed.

All invoices over 90 days for the

nomination agreement and psychiatric

liaison invoices have been paid in

March.

CUHFT 268 308 40

Psychiatric liaison service Q1 & Q2

are outstanding £180K and salary

recharges.

Being progressed as part of the

Agreement of Balances process. Serco

Debtors (w ho are responsible for the

CPFT credit control function) have been

instructed to re-double efforts to

understand and help resolve reasons

for non-payment of over 90 days

invoices.

Cambs and

Peterborough CCG191 1,112 921

Disputed SLA amount for last year of

£66k regarding Otters Retreat. Four

initial assessment and rehab

packages at £10k each.

The disputed SLA amount is being

raised for resolution at commissioning

meeting, and has now been escalated

to the Director of Finance to take further

action.

Peterborough City

Council138 92 (46)

School Nursing SLA : £58k and SLT

additional funding £40k

Serco are chasing payment the school

Nursing invoice has a purchase order.

Other 351 1,242 891

West Norfolk CCG : £116k, South

Lincolnshire £32k and other smaller

amounts for NCAs. The over 90 day

Uniting Care invoice from last month

has been paid .

Backing data supplied to CCG's to allow

them to validate these invoices for

payment.

Total 2,229 3,960 1,731

TOP 5 DEBTORS Balance Last MonthChange in

month% of Total Recovery Action

Cambridgeshire County Council £1.942m £1.976m £0.034m 30.6%

February LD invoice of £433k (now paid). Remaining

balance predomiantly relates to over 90 day invoices -

see table above for commentary.

Peterborough and Stamford Hospital £1.257m £0.931m (£0.325m) 19.8%5/16 Nomination Agreement invoices and Psychiatric

Liaison Q2 invoices. £698k paid in March.

Peterborough City Council £1.084m £1.756m £0.672m 17.1%

Three ASC invoices : £310k. School Nursing : £287k.

February Health Visitor: £255k (now paid) All have

purchase order so should not be a delay in payments.

Cambs & Peterborough CCG £1.040m £1.063m £0.024m 16.4%

£684k are current invoices. Older invoices include

disputed March 2015 SLA of £66k . Dressing recharge

: £62k and Recovery Coach : £72k

Health Education England £1.026m £0.372m (£0.654m) 16.2% All invoices outstanding were raised in February 2016

Total £6.348m £6.098m (£0.250m) 100%


Appendix 7 - Capital Expenditure

At the end of Month 11 the Capital Plan is underspent by

£1.316m.

The Capital Plan is monitored in detail by the Capital and

Infrastructure Committee to ensure the overall spend

forecast is managed within the level of funding available.

The Capital Plan in FY16 was based on utilising an

element of the disposal proceeds from the sale of Vinery

Road to fund the spend. The Trust has now decided that

Vinery Road will not be disposed of this year. As a result,

the capital spend for the year has been revised to ensure

that it fits within the revised funding envelope. This is

reflected in the forecast figure which has been reviewed

and agreed at the Capital & Infrastructure Group, to ensure

there is no significant impact on staff, patients and services

as a result of the agreed reduction in spend.

Additionally, Monitor has approved and actioned a £0.5m

transfer from capital to revenue to help mitigate the impact

of the UnitingCare settlement. This means that the capital

spend for the year can not exceed £4.3m. Capital spend is

being closely monitored to ensure that only essential spend

is being undertaken until the end of March.

Annual

Budget

Budget

to Date

Actual to

date Variance Forecast

£'000 £'000 £'000 £'000 £'000

IT 1,725 1,425 1,647 (222) 1,790

Estates 4,350 3,724 2,186 1,538 2,510

Total Capital Plan 6,075 5,149 3,833 1,316 4,300

Material Variances

Annual

Budget

Budget

to Date

Actual to

date Variance Forecast

£'000 £'000 £'000 £'000 £'000

Windows 7 upgrade 50 50 384 (334) 452

Assets transferred from AOP 0 0 171 (171) 171

Telephony Upgrade 150 125 254 (129) 260

Remedial work 14/15 0 0 54 (54) 60

Equipment replacement 100 91 199 (108) 190

IDH Fulbourn OBC Fees 100 91 160 (69) 180

Laptops from CCS 0 0 157 (157) 157

Data Warehousing 0 0 110 (110) 110

Newtown Centre security system 0 0 61 (61) 61

Mulberry 1 interior improvements 0 0 83 (83) 83

Mulberry 1 & 2 Red attack system 0 0 51 (51) 52

DDA Compliance 160 124 8 116 10

Intergrated Medicines Management 600 550 185 365 200

IDH Heating instruction 670 670 89 581 95

Other IT works 825 609 358 251 249

Other Estates Works 3,420 2,839 1,509 1,330 1,970

Total Material Variances 6,075 5,149 3,833 1,316 4,300


Appendix 9 - Monitor – Financial Sustainability Risk Rating

Monitor have now published an updated Risk Assessment Framework incorporating the new Financial Sustainability Risk Rating. This is calculated by combining the existing COSRR elements (i.e. liquidity, capital service capacity), with a re-introduced I&E margin and variance from plan measure, moderated with a fixed weighting for each component. Calculating the financial sustainability risk rating for

NHS foundation trusts

Financial sustainability risk ratings and their regulatory

implications


Appendix 9 - Monitor – Financial Sustainability Risk Rating

At the end of Month 11 the Trust has a Financial Sustainability Risk Rating of 3. The planned FSRR (derived

from the Financial Plan submitted to Monitor in May) is also a 3.

Thresholds 4 3 2 1

Capital Service Cover 2.5 1.75 1.25 < 1.25

Liquidity 0 -7 -14 < -14

I&E Margin 1% 0% -1% <=-1%

I&E Margin Variance 0% -1% -2% <=-2%

Plan For

YTD

ending

29-Feb-

16

Actual

For

YTD

ending

29-Feb-

16

Variance

For

YTD

ending

29-Feb-16

Financial Sustainability Risk Rating CPFT CPFT

Capital Service Cover

Material Adjustments to:

Revenue Available for Capital Service £m 7.471 6.925 (0.546)

Capital Service £m (3.968) (3.872) 0.096

Capital Service Cover metric 0.0x 1.88 1.79 (0.090)

Capital Service Cover rating Score 3 3

Liquidity

Material Adjustments to:

Working Capital for FSRR £m (1.851) (3.739) (1.888)

Operating Expenses within EBITDA, Total £m (166.675) (167.682) (1.007)

Liquidity metric Days (3.665) (7.358) (3.693)

Liquidity rating Score 3 2

I&E Margin

Normalised Surplus/(Deficit) £m (0.019) (0.563) (0.544)

Total Income £m 174.146 174.607 0.461

I&E Margin % (0.01%) (0.32%) (0.31%)

I&E Margin rating Score 3 2

I&E Margin Variance

I&E Margin % (0.01%) (0.32%) (0.31%)

I&E Margin Variance From Plan % 0.09% -0.31%

I&E Margin Variance From Plan rating Score 4 3

Financial Sustainability Risk Rating before overrides Score 3 3

Rating Trigger for FSRR Text No Trigger No Trigger

Overall Financial Sustainability Risk Rating Score 3 3

Agenda Item: 14ci

BOARD OF DIRECTORS MEETING IN PUBLIC

REPORT

Subject: Integrated Performance Report – Feb 2016


Author: Jonathon Artingstall, Head of Information and Performance


Executive Summary: The CPFT Integrated Performance Report details a wide variety of performance metrics. This paper outlines notable areas of performance for these metrics, as reported in the February 2015 data. This paper attempts to provide the Board with insight into reported performance issues. Furthermore, the paper aims to offer assurance that where performance problems exist, the Trust has plans in place to address and resolve the issues.

Recommendations:

The Board are asked to note the content of this report.








N/A




N/A


PRE meetings, only not B&P Committee (due to timing)

Has a QIA been completed? If yes provide brief details N/A

Integrated Performance Report – Feb 2016

1. Purpose This paper summarises the CPFT performance information, as present on the Trust Integrated Performance Report. Data is reported from February 2016, which has passed through the internal Performance Review Executive (PRE) meetings with the clinical services, but due to timing of meeting has not yet been presented to the Business and Performance and Quality, Safety and Governance Committees. Using February data is hoped to provide the Board with recent relevant performance information, as December data was the latest data presented to the committees. The purpose of this report is to contextualise some of the key performance issues reported in for February 2016.

2. Background The Integrated Performance Report, which accompanies this paper, is the mechanism that the Trust uses to monitor and manage directorates on various key performance indicators during the monthly reporting cycle. Directorate data, aggregated up to the Trust wide position is reported widely, with the information outlined below used to highlight any areas of concern within the consolidated Trust data.

3. Quality – Clinical Effectiveness Indicator 3.1 CAMHS Choice Waiting List

Indicators Dec 15 Jan 16 Feb 16 Target

CAMHS Choice Waiting List >18 weeks 23.5% (54)

0.0% 0.8% (1)

0%

The measure reporting CAMHS Choice Waiting List shows the proportion of children waiting over 18

weeks for an assessment. Due to a discrepancy in capacity and demand in 2015, the performance

against measure peaked in August for those on the list waiting over 18 weeks (44%(n=131)). Since

this time, commissioner funding has increased, and with the extra capacity, the proportion of waiters

over 18 weeks has dropped to only one patient. Additionally, the total on the waiting list has also

dropped from 358 in August to 166 at the end of February. Of these remaining waiters, 74% have

waited within 0-6 weeks and of the 11 waiters over 12 weeks, appointments are scheduled for all.

The planning and performance by the clinical services has addressed this issue within the timescale

communicated with commissioners.

3.2 % Patient with a HoNOS Score


% Patients with a HoNOS Score 95.4% 94.7% 94.3%

=>95%

This metric monitors the proportion of active caseload within in scope services that have a

completed Mental Health Clustering Assessment recorded. This measure is important due to the

onset of Monitor guidance based on payment by cluster which will be introduced as the contractual

payment mechanism from FY17/18. Performance has decreased during January and February,

following a sustained achievement of target for preceding 3 months. Similar trends are reported for

cluster assessments within review period, with a small decrease in performance in February.

Through the PRE performance cycle, and with the launch of the Clinical Dashboard which

demonstrates to each clinician who on their caseload is missing a cluster assessment, it is expected

that performance will return to above target in March.

3.3 Diagnosis Recording


Diagnosis recorded (% of Current referrals where Diagnosis recorded)

58.2% 58.4% 57.9%

=>95%

Diagnosis continues to prove a challenging area for some directorates in CPFT mental health

services. Areas of better performance does exist such as within the Specialist (84.8%) and the

Integrated Care directorate (77.8%).

Guidance, training and restating the requirement continues to be reiterated to the clinical services.

The Clinical Dashboard mentioned above also includes the Diagnosis completion rates for each

individual mental health clinician, which is hoped will then enable clinical service managers to

address this ongoing problem.

From March, the Clinical Dashboard now reports both unconfirmed and confirmed diagnoses, to

assist clinicians in meeting this target, by simplifying the processes within the RiO clinical system.

4. Quality – Patient Safety Indicators

4.1 CPA 7 Day Follow Up


CPA 7 Day Follow Up 94.9% 95.3% 94.4% >95%

This patient safety measure is to support people through the transition from inpatient care back into

community settings. This national Monitor target reports the number of people discharged from an

inpatient setting, who were then subsequently followed up by the Trust within seven days of

discharge.

The performance in February relating to this target has deteriorated. Despite numerous attempts 6

discharges from inpatient spells were unable to be followed up within the required period. These

discharges were from a range of Adult wards, suggesting isolated incidents rather than systemic

problems. This performance and the process will be reviewed in the coming months, and the

performance in March to date has seen an increase in performance. The combined Quarter 4 return

to Monitor is expected to be above the target.

4.2 Safety Thermometer


Safety Thermometer 93.6% 92.1% 94.0% >95%

Performance relating to harm free care has been below target for the third month in succession. The

reduction in performance for February relates to the four physical health services wards at Trafford,

Welney, Lord Byron and Peterborough ICU wards and the Integrated Care district nurse services.

The Safety Thermometer assessments check whether patients have pressure ulcers, old or new

UTIs, catheters, VTEs or any harmful or non-harmful falls for any inpatient or district nursing

services. Each collection day samples around 1000 patients, and the drop in performance presented

above reflects the increased physical health patients the Trust now cares for.

4.3 % Vacancy rate


% Vacancy Rate 11.3% 10.6% 11.3% <10%

Trustwide vacancy rates have exceeded target again in February.

There are a high volume of vacancies for Integrated Care directorate but a recruitment specialist is

being brought in to deal with these posts. 53 candidates have been appointed and sent conditional

offers, and once these candidates have started the vacancy rate will reduce. All vacancies for this

directorate including Neighbourhood Teams are now being fed through the Vacancy control Process

this will allow managers to manage their vacancies and to highlight to HR where additional support

is required.

Other initiatives that are expected to have a positive result regarding vacancies include an open day

on the 21st December with a number of Band 5 and 6 nursing posts within the mental health older

people teams being recruited to. Within Adults directorate, the Vanguard recruitment process is now

underway.

4.4 % Sickness rate


% Sickness Rate 6.2% 5.8% 6.0%

<4.35%

February reports an increase in CPFT sickness rate, as is expected seasonally. Through the PRE

process, the sickness rate of each directorate is monitored, with a wide range of compliance

reported. Alll directorates exceeded the target this month, with the Integrated Care directorate faring

worse, with sickness rates for February is 6.9%.

Seasonally, this pattern repeated last financial year, with February 2015 sickness rate reported

slightly lower at 5.1%.

4.5 % Spend Temporary Staffing – Agency

Indicators

Dec 15 Jan 16 Feb 16

Target

% Spend Temporary Staffing- Agency 7.6% 7.5% 8.1%

<=6%

Agency spend across the trust remains above the target set by Monitor of 6%. During the December

cycle of PREs, the first directorate breakdowns of this information was provided, with all directorates

except Specialist being challenged by this target.

A series of team based reports are being developed to enable the effective performance

management of this issue. More detail can be found within the Finance report to the Board.

4.6 Overall Mandatory Training Compliance


% Compliance Overall Mandatory Training 91.8% 92.8% 93.6%

=>95%

Existing issues remain relating to mandatory training compliance. Through PREs, the themes for

non compliance continue to relate to timeliness and accuracy of data, cancellations of classroom

based training, and lack of transparency about training requirements. Within the data, compliance

around Fire Safety and Infection Control training suggests areas of concerns, which are being

addressed via the PRE cycle.

Services are supported with monthly named reports of people out of compliance, and people who

are approaching non-compliance. However, clearly these reports are not effectively assisting and a

review needs to be undertaken to streamline and simplify information processing.

With the pending launch of the Totara Learning Management System in April, the management of

mandatory training compliance is expected to become a much more streamlined and therefore

effective process.

5. Board Action The Board are asked to note the content of this report.

Dashboard: Integrated Performance Report

Organisational level: Trust

Reporting Period: February 2016

Reviewing committee/meeting: Business and Performance & Quality, Safety

& Governance

Review lead: Sarah Warner, Chief Operating Officer

Date of review: 26th November 2014.

Indicators Tru

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Metric

2014-2015

Outturn Apr 15 May 15 Jun 15 Jul 15 Aug 15 Sep 15 Oct 15 Nov 15 Dec 15 Jan 16 Feb 16 Mar 16 Target YTD Actual

Year End

Fcst Monitor

Quality- Clinical Effectiveness Indicators

CRHT Gate Keeping Monitor SW SW % 96.3% 97.7% 94.7% 93.9% 95.4% 96.5% 99.3% 98.3% 99.1% 100.0% 100.0% 99.0% >95% 97.8% Yr

% Delayed Transfers of Care Mental Health Monitor SW SW % 4.9% 3.4% 2.6% 2.9% 2.4% 1.6% 2.2% 1.7% 1.5% 2.7% 3.7% 1.6% <7.5% 2.4% Yr

% Delayed Transfers of Care Community Services 17.7% 19.5% 20.8% 18.8% 15.6% 16.1% 17.3% 9.5% 10.8% 10.5% TBC 10.5%

Delayed Service Discharge (Open Referrals no contact 7 months) Trust SW SW % 1447 1378 1431 1453 1458 1379 1467 1402 1415 1480 1410 1416 TBA 1416 Mth

Psychosis Early Intervention Services- New Cases (Cumulative) Monitor SW SW No 156 17 32 58 65 84 107 137 153 169 179 208 190 208 Mth

EIP Access Target - % waiting > 2 weeks (from April 2016) TBC TBC

18 Weeks (PCC only) Trust SW SW % 54.8% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% =>95% 100.0% Mth

CAMHS Choice Waiting List >18 weeks

CCG SW SW %,n DNP 22% (85) 27.4% (111) 33.9% (110) 44.86% (131) 44.52% (130) 30.97% (83) 29.13% (67) 23.48% (54) 0.0% 0.81% (1) 0% 0.8% Mth

% Patients with a Honos Score Trust CD CD % 94.5% 94.1% 94.2% 93.2% 93.7% 93.2% 94.9% 95.4% 95.3% 95.4% 94.7% 94.3% =>95% 94.3% Mth

% Patients with a HoNOS with Cluster Review Period ` Trust CD CD % 68.7% 70.2% 67.9% 75.5% 73.9% 76.1% 76.3% 76.1% 75.3% =>95% 75.3% Mth

Diagnosis recorded (% of Current referrals where Diagnosis recorded) Trust CD CD % 47.0% 51.8% 53.5% 54.5% 55.3% 55.3% 56.8% 58.4% 61.7% 58.2% 58.4% 57.9% =>95% 57.9% Mth

Psychological Wellbeing Service (PWS - previously known as IAPT) - Number of referrals

CCG SW SW No 805 716 731 795 756 945 1103 1118 1034 1200 1232977 per

month10435 Mth

Psychological Wellbeing Service (PWS - previously known as IAPT)– patients entering treatment

CCG SW SW No 925 681 814 820 649 962 1039 1072 992 1116 1154977 per

month10224 Mth

Proportion of Mental Health Patients in touch with secondary care in employment. Monitor DC DC % 13.71% 11.80% 12.70% 11.90% 11.70% 12.40% 12.50% 12.30% 12.30% 13.70% 13.20% 12.70% 12.70% Mth

Proportion of Mental Health Patients in touch with secondary care living independently Monitor DC DC % 78.45% 79.13% 79.17% 79.96% 79.70% 80.17% 80.54% 80.93% 80.88% 79.81% 80.40% 79.64% 74.7% 79.64% Mth

Quality- Patient Experience indicators

Access to Health care for people with LD Monitor SW SW Met Met Met Met Met Met Met Met Met Met Met Met Met Met Mth

Number of New Complaints registered in period Trust MC MC No 152 12 17 14 25 15 9 18 13 20 16 14 TBA 173 Mth

Patient food Trust MC MC % 65.4% 67.7% 67.0% 64.7% 63.1% 64.8% 63.0% 65.7% 61.3% 68.4% 64.8% 61.5% 75.0% 64.7% Mth

Patient Experience - Friends and Family Question (% that would Recommend trust) Trust MC MC % 85.4% 82.7% 83.8% 81.5% 88.0% 86.4% 83.3% 88.7% 89.3% 88.8% 89.1% 92.5% >60% 87.8% Mth

Mixed Sex Breaches (Number of effected people) DoH MC MC No 0 0 3 0 0 0 0 0 0 0 0 0 0 3 Mth

% INCA Score Trust MC MC % 96.0% 96.0% 96.0% 98.2% 97.7% 98.6% 95.4% 98.0% 96.1% 96.7% 97.3% >95% 97.3% Mth

Quality- Patient Safety indicators

Number of Serious Incidents Recorded Trust MC MC No 90 10 7 8 10 7 9 13 8 10 10 11 TBA 103 Mth

Trust wide % Serious Incidents (reported to CCG) resolved within National timescales (Grade 2 - 60 days)

Trust MC MC No 83.4% 20.0% 60.0% 90.9% 87.5% 100.0% 100.0% 75.0% 90.0% 75.0% 63.6% 66.7% 100.0% 75.0% Mth

CPA 7 Day Follow Up Monitor CD CD % 96.3% 96.3% 99.1% 94.5% 96.2% 96.8% 97.6% 97.6% 94.0% 94.9% 95.3% 94.4% >95% 96.0% Mth

Service User CPA review 12 months Monitor CD CD % 91.1% 97.1% 96.7% 96.7% 96.4% 95.9% 94.6% 95.6% 97.2% 98.2% 97.0% 96.2% >95% 96.2% Mth

% of Inpatient with a Risk Assessment Trust CD CD % 90.1% 95.7% 98.2% 96.6% 94.4% 96.9% 96.4% 96.6% 99.4% 97.8% 96.9% 98.7% >95% 97.0% Mth

% of Inpatients Physical Health check within 24 hrs admissions

Trust CD CD % 86.0% 76.9% 85.2% 85.8% 91.0% 96.1% 94.7% 93.8% 92.4% 95.5% 96.9% 98.0% >95% 91.3% Mth

Staff trained in Children Safeguarding CCG SL SL % 91.1% 95.4% 93.4% 93.8% 92.7% 93.7% 93.4% 89.3% 94.7% 93.6% 94.3% 95.1% >90% 95.1% Mth

Staff trained in Adults Safeguarding CCG SL SL % 97.1% 97.5% 97.3% 97.4% 96.7% 95.9% 95.0% 93.9% 96.4% 95.2% 95.6% 96.0% >90% 96.0% Mth

Safety thermometer CCG MC MC % 98.7% 100.0% 98.6% 96.5% 100.0% 95.3% 96.6% 96.6% 94.4% 93.6% 92.1% 94.0% >95% 93.7% Mth

Never events Trust MC MC No 0 0 0 0 0 0 0 0 0 0 0 0 0 0 Mth

Coroner Schedule 5 Notices Trust MC MC No 0 0 0 0 0 0 0 0 0 0 0 0 TBA 0 Mth

Number of new legal claims Trust MC MC No 15 0 0 0 2 1 0 1 0 1 1 2 TBA 8 Mth

Avoidable Grade 3/4 Pressure Ulcers Trust MC MC No 0 0 0 0 0 2 1 1 0 0 1 0 TBA 5 Mth

MRSA confirmed needs to be MRSA bacteraemia confirmed CCG MC MC No 0 0 0 0 0 0 0 0 0 0 0 0 0 0 Yr

c.Diff confirmed needs to be avoidable C.diff infection confirmed Monitor MC MC No 0 0 0 0 0 0 0 0 0 0 0 0 1 0 Yr

HCAI Essential Steps Trust MC MC % 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 92.3% 100.0% 100.0% 100.0% 100.0% 100.0% 99.3% Mth

Safe Staffing Levels (Registered and Unregistered) Trust MC MC Ratio 109.0% 110.2% 113.0% 111.0% 111.0% 109.0% 108.0% 105.0% 111.0% 104.0% 108.0% 106.0% 80.0% 106.0% Mth

Safe Staffing Levels (Registered) Trust MC MC Ratio 100.8% 102.0% 102.0% 102.0% 99.0% 99.0% 102.0% 108.0% 103.0% 101.0% 99.0% 80.0% 99.0% Mth

Safe Staffing Levels (Unregistered) Trust MC MC Ratio 118.5% 122.0% 119.0% 120.0% 117.0% 116.0% 107.0% 113.0% 105.0% 114.0% 112.0% 80.0% 112.0% Mth

CAS Safety Alerts Implemented Within Required Timescale Trust MC MC % 100.0% DNP 100.0% DNP 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% Qtr

% Vacancy Rate Trust SL SL % 5.6% 7.3% 5.3% 3.9% 3.6% 4.2% DNP 4.0% 10.6% 11.3% 11.3% 11.3% <10% 11.3% Mth

% Sickness Rate Trust SL SL % 4.2% 4.8% 4.1% 4.6% 4.2% 5.0% 5.0% 4.8% 5.3% 6.2% 5.8% 6.0% <4.35% 5.1% Mth

% Spend Temporary Staffing- Agency Trust SL SL % 4.1% 7.1% 6.7% 6.4% 6.8% 7.6% 7.5% 7.6% 7.5% 8.1% 8.1% 8.2% <=6% 8.2% Mth

% Spend Temporary Staffing- Bank Trust SL SL % 4.2% 4.9% 3.2% 3.0% 3.1% 3.1% 3.1% 3.1% 3.1% 2.8% 2.8% 2.4% <=4.6% 2.4% Mth

% Compliance Overall Mandatory Training Trust SL SL % 92.1% 94.8% 94.99% 94.77% 93.23% 92.77% 92.20% 91.18% 93.66% 91.79% 92.75% 93.61% =>95% 93.61% Mth

Workforce Indicators

Staff Net Promoter Score (recommend Trust to Friends and Family as a place to work) reported Quarterly Trust SL SL % 50.1% Quarterly Figure 54.5% 53.3% DNP >60% 53.3% Mth

Staff Net Promoter Score (recommend Trust to Care for Friends and Family ) reported Quarterly Trust SL SL % 60.6% Quarterly Figure 65.3% 68.4% DNP >60% 68.4% Mth

Cumulative turnover rate (12 month rolling) Trust SL SL % 13.4% 9.5% 10.2% 10.0% 10.8% 11.4% 11.6% 11.5% 12.2% 12.9% 13.4% 13.7% <=12% 13.7% Mth

Average Number of Weeks to fill a vacancy (in Weeks) Trust SL SL No 8.73 11.26 10.77 11.86 11.40 11.97 12.96 13.34 10.42 9.52 10.35 10.44 <16 10.44 Mth

Financial- income and expenditure related

Financial Efficiency - Deficit (Cumulative) Monitor SH SH % £154k £111k £333k £228k £505k £373k £431K £299k £387k £471k £561k -1.6% £471k Mth

Financial Efficiency - Adverse variance (position against where we expected to be) Monitor SH SH % £87k £103k £165k £88k £396K £295K £360K £234k £332k £443k £548k -1.6% £443k Mth

Cash position versus plan

Trust SH SH % 193.3% 103.2% 137.0% 130.0% 116.7% 100.0% 140.0% 83.9% 107.0% 104.0% 91.2% 103.3%=>90% =<

110%91.2% YTD

Capital Spend v plan ratings Trust SH SH % 47.7% 81.5% 102.0% 138.0% 118.2% 84.9% 72.6% 84.9% 80.1% 92.2% 86.3% 74.4% <100% 86.3% YTD

SERCO Contract Compliance with KPI's (SERCO dependant) Trust SH SH % DNP DNP DNP DNP DNP DNP DNP DNP DNP DNP DNP DNP =>95% DNP Mth

External Assessment Indicators

CQC Registration Requirements CQC MC MC Met Met Met Met Met Met Met Met Met Met Met Met Met Met Mth

FT Monitor- Financial Risk Rating (Continuity of Service- new) Monitor SH SH No 2 3 3 3 3 3 3 3 3 3 3 3 >=3 3 Mth

FT Monitor- Governance Risk Rating

Monitor MC MCUnder

review

Under

Review

Under

Review

Under

Review

Under

Review

Under

Review

Under

Review

Under

Review

Under

Review

Under

Review

Under

Review

Under

Review<1

Under

ReviewMth

FT Delivery of FT membership

Monitor NBJ NBJ on Target Met on Target on Target on Target on Target on Target on Target on Target on Target on Target on Target Met on Target Mth

NHS Performance Framework DoH MC MC Met DNP DNP DNP DNP DNP DNP DNP DNP DNP DNP DNP Met DNP Mth

Intelligent Monitoring Report Risk band CQC MC MC No 2 2 2 2 2 2 2 2 2 2 2 5 0 5 Mth

Intelligent Monitoring Report Red rated risk CQC MC MC No 1 1 1 0 0 0 0 0 0 0 0 0 0 0 Mth

Information Assurance

Data completeness: identifies MHLDDS (Exc CAMHs) Monitor SW SW % 98.3% 98.7% 98.7% 98.7% 98.7% 99.1% 99.2% 98.9% 98.9% 98.9% 98.9% 99.0% >97% 99.0% Mth

Data completeness MHLDDS:Outcomes for Pts on CPA Monitor SW SW % 84.5% 84.1% 85.6% 86.6% 83.1% 89.6% 90.2% 91.1% 87.4% 86.0% 88.9% 90.1% >50% 87.4% Mth

Compliance with IGT v13 (starts in June at 1 working to attain 2+ going forward) CQC SH SH % 2 2 1 1 (57%) 1 (69%) 1 (70%) 1 (70%) 1 (70%) 2 (70%) 2 (71%) 2 (78%) 2 (78%) =>2 2 Mth

Aidan Thomas

Scott Haldane

Chess Denman

Deborah Cohen

Keith Spencer

Melanie Coombes

Nicola Brookes-Jones

Jonathon Artingstall

Sarah Warner

Stephen Legood

DNP = data not provided

PI = Proposed KPI

Information assurance

Indicator has been audited within required cycle no issues found

Indicator has been audited within required cycle - minor issues found that do not impact

confidence in KPI

Indicator has been audited within required cycle - significant issues found that do impact

confidence in KPI

Indicator to be audited.

NBJ

JA

SW

SL

AT

SH

CD

DC

KS

MC

Agenda Item: 15


REPORT

Subject: Charitable Funds Committee Summary


Author: Simon Burrows, Chair and Non Executive Director


Executive Summary: This report presents key items discussed at the Charitable Funds Committee held 10th March 2016.

Items the Committee wish to bring to the attention of the Board include:

Investment funds

Bids for funding

Future direction

Recommendations:

The Board is asked to note items highlighted and review and approve one request for funding (Long Service

Awards).

CHARITABLE FUNDS COMMITTEE REPORT - MARCH 2016

1.0 INTRODUCTION

Key items to be drawn to the Board's attention, and as discussed at the Committees March meeting,

are summarised below.

2.0 ITEMS DISCUSSED

Investment Funds

The Committee received a summary report of the charity's financial performance to January 2016.

Investment yield - actual versus potential - was an area discussed requiring review given reported

(under) performance.

The Director of Finance undertook to update the Committee on progress with this review subject to

finalisation of an overall Investment Strategy.

Bids for Funding

Three proposals requesting funding were reviewed and discussed.

The Committee approved total funding of £10.1k covering two proposals; Nurses Day Conference

(refreshments) and Recovery college (peer employment training).

A third proposal from the Workforce Development Team (Long Service Awards as attached) was

discussed in further detail. Key issues for the Committee in discussion:

(I) Appropriate for charitable funding (?)

(II) Funds would finance a past event

(III) Lack of clarity on whether verbal approval was previously given

The Committee agreed the proposal should be issued to the full CPFT board, as corporate trustee

for the charity, for final approval.

Future Direction

The Committee devoted the second half of the meeting to discussing future development of the

charity, particularly relating to fundraising and administrative support.

The Director Finance undertook to investigate with colleagues through the System Change

Committee and other routes and report back to the committee on options to secure fund-raising

resource.

3.0 SUMMARY AND CONCLUSIONS

The Board is asked to note the contents of this report and approve the Workforce Development Teams

Long Service Awards proposal.

APPENDIX 1 – Long Service Awards Application

Application for CPFT Charitable Funds

1. Project Summary (maximum 50 words)

Long Service Awards

The Trust recognises the Long Service of staff, who’ve worked for the NHS for 25 years, 30 years, 35 years and 40

years.

The 30 and 40 years service awards are for those staff who TUPE’d from CCS for the Integrated Care directorate,

they are therefore on a different Policy than other staff. This will be harmonised in future.

2. Why is there a need for your project?

To recognise and say thank you to staff for their contribution and loyalty to the NHS.

3. Who will benefit from your project?

Staff who meet the criteria.

4. How many people will benefit from your project?

114 Staff Members who meet the criteria.

5. Describe your project and show how it will address the need identified above.

This will be a celebration event held at Burgess Hall, St Ives, where staff will be awarded with a certificate and

vouchers to say thank you. They are invited to bring a guest to share this experience with them. The Chief Executive

and Chair will host the event and lunch will enable all recipients the opportunity to share stories and catch up with

colleagues possibly not seen for years. The costs associated with the event are:

Event Cost (inc. venue and certificates) £ 3,216

Award Cost (Vouchers for 114 people) £ 10,973

Total £ 14,189

This is the sum which we are requesting from the Charitable Funds Committee.

6. What are the main outcomes expected from your project?

Increased Staff Engagement

Staff Retention

Improved Service User Experience

Improved Networking

7. How does your project link with national, regional or local priorities?

Awarding and recognising staff is something which forms part of the Organisational Development Strategy. The Long

Service Awards is the longest running staff reward that the Trust has given out. The Trust did not run the event in

2014, and so this awards ceremony is capturing all those due an award for 2014 and 2015, including the staff using

the CCS policy. By running the event as soon as possibly under the two current schemes, the Trust can then develop

a new harmonised policy for long service / loyalty awards which will form part of the Trust’s Rewards Strategy.

8. How will the work of your project be a catalyst for change?

This is an annual event, with guidelines for attainment that staff can work towards.

9. How will the work initiated by your project be sustained after the end of the funding period? (If the funding

requested is for one-off activity, will it have any lasting effects?)

This is an annual event and will form part of the Trust’s Rewards Strategy which is currently being developed as part

of the new Workforce Strategy.

10. How have you involved people who use mental health services in the development of your project and how

will they contribute to its delivery?

n/a

11. What support do you have for your project from senior management within your organisation and/or, where

appropriate, other organisations with an interest in the proposed activity?

The Senior Management fully support the Long Service Awards. The plan for this event has been signed off by the

Workforce Executive.

12. Describe the governance and project-management arrangements proposed for your project.

The HR Team are responsible for the project management of the event. Continuous Service is taken from the

Electronic Staff Record (ESR), some employee records do not have their full NHS Service on the ESR, so are able to

be nominated and provide evidence of service to their manager, who completes the nomination. All individuals are

checked against previous recipients to ensure they have not already received an award. A project plan has been

followed to ensure the event runs on budget. The budget has been monitored by the Workforce Executive.

13. How will you monitor the progress of your project towards achieving its proposed outcomes? Indicate the

main milestones and stages at which they should be reached.

This will form part of the OD Strategy outcomes. The Pulse Survey and Staff Survey enable us to monitor Staff

Engagement.

14. How will you evaluate the success of your project in achieving its proposed outcomes?

Feedback from the event.

15. How will you share the learning from your project?

Any learning will support in developing the next Long Service Awards.

16. What other sources of funding (including in-kind contributions) will help to meet the costs of your project?

None

Declarations

As far as I am aware everything on this application form is correct.

Applicant Signature

Emma Byrom, Workforce Development Manager

Date 02/02/16

Agenda Item: 16


REPORT

Subject: Cycle of Business

Date: 30 March 2016

Author: Lauren MacIntyre, Interim Trust Secretary

Lead Director: Aidan Thomas, Chief Executive

Executive Summary:

Attached is the proposed FY17 Board of Directors Cycle of Business for both the public and private meetings.

Recommendations:

The Board is asked to review the cycle of businesses and discuss the frequency of items, whether they are correctly identified as public/ private and whether any items are missing.

The Board is asked to approve the cycle of business, subject to any amendments that may be suggested.








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Cambridgeshire and Peterborough NHS Foundation Trust Board of Directors Private Cycle of Business FY17

MEETING PLANNING SUBMITTED BY

May July Sept Nov Jan MarDate of Meeting Secretariat 25th 28th 28th 30th 25th 29th

Circulation of Agenda Secretariat 11th 14th 14th 16th 11th 15th

Date for Submission of Papers (noon) All 16th 19th 19th 21st 16th 20th

STANDING AGENDA ITEMS

Introductions, apologies, declarations of interest Chair x x x x x x

Minutes from the last meeting Chair x x x x x x

Matters arising and action update Chair x x x x x x

Chief Executive Report Chief Executive x x x x x x

Chairs Report (as and when required) Chair x x x x x x

STRATEGY

Commissioning and Contracting Update Dir. People+ BD x x x x x x

Operational Plan update / Trust progress against Strategy Dir. People+ BD x x

Review one year Operational Plan submission to Monitor Dir. People+ BD x

System Transformation CEO x x x

Business Development Dir. People+ BD x x x x x xBusiness Case Review CEO x x

QUALITY, FINANCE, WORKFORCE AND PERFORMANCE

Remuneration Committee Summary Chair x x

- Director/ Senior Manager remuneration Chair x

- Succession planning Chair x

Serious incidents summaryPatient Safety &

Complaints Leadx x x x x x

Revenue Budget Dep. Dir. Finance x

Capital Budget Dep. Dir. Finance x

GOVERNANCE

Review quarterly compliance returns to Monitor Dep. Dir. Finance Q4 Q2

Sign off Annual Report and Accounts Trust Sec/ Dep. Dir.

Financex

Sign off Quality AccountsHead of Compliance/

Clinical Effectiveness x

20172016

Cambridgeshire and Peterborough NHS Foundation Trust Board of Directors Public Cycle of Business FY17

MEETING PLANNING SUBMITTED BY

May July Sept Nov Jan Mar

Date of Meeting Secretariat 25th 28th 28th 30th 25th 29th

Circulation of Agenda Secretariat 11th 14th 14th 16th 11th 15th

Date for Submission of Papers (noon) All 16th 19th 19th 21st 16th 20th

STANDING AGENDA ITEMS

Introductions, apologies, declarations of interest Chair x x x x x x

Minutes from the last meeting Chair x x x x x x

Matters arising and action update Chair x x x x x x

My Story - patient/ staff story Patient Experience Lead x x x x x x

Chairman Report Chair x x x x x x

Chief Executive Report inc communications Chief Executive x x x x x x

STRATEGY

Commissioning and Contracting Update Dir. People and BD x x x x x x

Operational Plan Update/ Trust progress against Strategy Dir. People and BD x x

Review one year Operational Plan submission to Monitor (public) Dir. People and BD x

System Transformation CEO x x x

Board Assurance Framework annual agreement (strategic risks) Risk Manager x

Board Assurance Framework 6 monthly review (strategic risks) Risk Manager x

QUALITY, WORKFORCE, PERFORMANCE AND FINANCE

Quality, Safety and Governance

- Quality, Safety and Governance Committee Summary Committee Chair x x x x x x

- Safer Staffing Report Dep Dir. Nursing x x x x x x

- Single Sex Accommodation Head of Nursing x x x x x x

- EPRR Core Standards Emergency Planning x

Business, Performance and Finance

- Business and Performance Committee Summary Committee Chair x x x x x x

- Performance ReportHead of Information and

Performance x x x x x x

- Monthly Finance Report Dep Dir. Finance x x x x x x

- Review quarterly compliance returns to Monitor Dep Dir. Finance Q1 Q3

Audit and Assurance Committee Chair x x x x

Nomination Committee Update - Board skills mix Chair/ Trust Secretary x

Charitable Funds Committee Summary Committee Chair x x x x

20172016

GOVERNANCE

Cycle of Business Trust Secretary x

Review of Terms of Reference Trust Secretary x x

Board self-evaluation results/ actions/ effectiveness Trust Secretary x

Scheme of Delegation Trust Secretary x

Constitution update Trust Secretary x

Fit and Proper Person declaration Chair/ Trust Secretary x

Register of Interests Trust Secretary x

Agenda Item: 17

BOARD OF DIRECTORS MEETING IN PUBLIC

REPORT

Subject: Risk Assurance Framework FY17

Date: 30 March 2016

Author: Caroline Macpherson, Head of Risk

Lead Director: Mel Coombes, Director of Nursing

Executive Summary:

As part of the ongoing risk assurance framework and annual review of organisational risk appetite, the risk management procedure has been considered and the proposed framework is outlined in the attached paper. To further strengthen the risk management framework, the Datix risk module has been developed and is used to manage and escalate all organisational risks from ward to Board.

Recommendations:

The Board of Directors are asked to:

Review and approve the contents of this report;

Agree escalation levels outlined;

Agree frequency of reporting.








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Risk Assurance Framework

1. Introduction The following procedure details proposed arrangements for managing risk and will be used in conjunction with the wider Risk Management Strategy.

2. Risk Definition

Strategic Risks:

The ‘Top 6’ organisational risks which have the greatest impact on the achievement of the organisational strategic objectives.

Known as the Board Assurance Framework (BAF).

Agreed by the Trust Board on an annual basis.

Reviewed by the Trust Board on a bi-monthly rolling cycle.

Reviewed by The Executive, as part of the wider Corporate Risk Register review, on a monthly basis.

The BAF is maintained by the Head of Risk.

Corporate Risks:

Risks that threaten delivery of the Trusts strategic objectives.

Known as the Corporate Risk Register (CRR).

Apply to the organisation as a whole.

Reside on Directorate risk registers and have a residual risk score of 15+.

Reviewed and updated on a monthly basis by the Executive Team.

Reviewed by Audit and Assurance at each quarterly meeting

Top 10 quality risks pulled from corporate risk register go to QSG bi-monthly

Top 10 business pulled from corporate risk register go to B+P bi-monthly

The Corporate Risk Register is maintained by the Head of Risk.

Directorate Risks:

Risks that threaten delivery of the Directorate and operational objectives.

Are applicable to the Directorate.

Reside on Directorate Risk Registers and have a residual risk score of 12+.

Reviewed and updated on a monthly basis by the General Manager, Clinical Director and Head of Nursing.

Scrutinised at PRE.

Service Risks:

Risks that threaten operational delivery and are applicable to a particular service.

Reside on Service Risk Registers and have a residual risk score of 8+.

Reviewed and updated on a monthly basis by the Service Manager.

Local Team Risks:

Risks that threaten operational delivery and are applicable to a specific team.

Reside on local Team Risk Registers and have a residual risk score of up to 8.

Reviews and updated on a monthly basis by the Team Manager.

3. Roles and Responsibilities

There are three main roles for managing risk:

Risk Assessor / Identifier:

The person who identifies a risk and completes the ‘Risk Assessment Form’ in Datix.

Risk Owner:

The person who is ultimately responsible for managing and mitigating the risk.

For Corporate Risks, this is typically an Executive Director.

For Directorate Risks, the risk owner will be the General Manager, Clinical Director

and/or Head of Nursing.

For Operational Risks, the risk owner will be the Service Manager.

For Local Team Risks, the risk owner will be the Ward/Team Manager.

Action Owner:

The person who has delegated responsibility to complete actions that will reduce

the consequence and/or likelihood of risk occurring.

4. Applying the Risk Appetite The organisational risk appetite will determine the extent to which the risk is acceptable or unacceptable, and should be applied to:

The top 6 Strategic Risks (Board Assurance Framework); All risks with a net score of 15+; Risk which apply to the whole organisation.

The ‘Risk Appetite’ will be based on a sliding scale from ‘None’ to ‘Significant’ appetite and will be set by the Trust Board on at the beginning of each financial year.

None

Low

Moderate

High

Significant

Avoidance of risk is a key objective

Not willing to accept, except in very exceptional circumstances

Willing to accept risks in certain circumstances

Willing to accept risks

Accepts potential risks when embarking on opportunities

Five categories of risk will be explored as part of the appetite review process, to

determine the Trust’s appetite for each type of risk the organisation may face:

Quality and Safety

Workforce

Technology and Estate

Financial Strategy: Profit and Loss / Commercial

Business / Reputation.

Given that risk levels vary and therefore risk tolerances differ across each clinical Directorate, Senior Management Teams have been asked to discuss the risk appetite and indicate their individual threshold of acceptability specific to their client group/s. The agreed risk appetite will then be applied at Directorate level during the risk review and escalation process.

5. Risk Review

The organisational risk appetite will determine the extent to which the risk is acceptable. Trust Board The Board will view the top 6 strategic risks (also known as the Board Assurance Framework) at each meeting.

The Executive Team The Corporate Risk Register (15+), including the top 6 Strategic Risks, and any other risk which applies to the whole organisation, will be managed on behalf of the Trust Board by the Executive Team and reviewed by the Executive on a monthly basis.

Audit and Assurance Committee The Audit and Assurance Committee will receive a report on the entire Corporate Risk Register at each meeting (quarterly). Quality, Safety and Governance Committee The Quality, Safety and Governance Committee will receive a movement report on the top ten quality and safety risks at each meeting.

Business and Performance Committee The Business and Performance Committee will receive a movement report on the top ten business risks at each meeting.

Directorate Management Team (DMT) The DMT will review and update the Directorate Risk Register on a monthly basis, escalating any risk with a residual risk score of 12 or above for review at Performance, Risk and Executive (PRE) meetings.

Sub-Committees (Clinical Governance and Patient Safety, Infrastructure Committee etc) Each sub-committee / working group will receive a report of all relevant risks at each meeting.

The Chair of the Committee must ensure the risk register is a standing agenda item and allocated time is held for review and discussion at each meeting.

Each Committee Administrator is responsible for running a Datix risk report of respective risks and submitting as part of the meeting papers.

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