1. Council of Governors Performance Report
Summary
Committees
NHS Improvement
Quality
Finance
Council of Governors Performance Report
10 May 2018 meeting
2017/18 Quarter 4 / March 2018 Data
1.2 NHS Improvement
Segment
1.3 NHS Improvement
Use of Resources
1.1 CQC Rating
Requires
Improvement 2 1
Agenda Item: 10
Lead Director: Non-Executive Directors
Presented For: Discussion 1
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2. NHS Improvement Indicators Summary and Recommendations
Committees
NHS Improvement
Quality
Finance
The purpose of this Performance Report is to assist the Council of Governors in seeking assurance against the Trust’s performance and progress in delivery of a broad range of key targets and indicators.
Key Highlights
Slides
NHS Improvement Indicators
Information
Exception
The Care Quality Commission (CQC) rating reflects the CQC report published in February 2018, following the 2017 inspection.
Under the Single Oversight Framework, NHS Improvement segments providers based on the level of support each provider needs across the five themes of quality of care, finance and use of resources, operational performance, strategic change and leadership and improvement capability. NHS Improvement has moved the Trust from segment 1 to segment 2 (providers offered targeted support), due to the change in the Care Quality Commission rating from ‘Good’ to ‘Requires Improvement’.
In January 2018, we did not meet the waiting time target for people with a first episode of psychosis, as a resulted of planned and unplanned staff absence in December Waiting time performance improved in February and March 2018 and the target has been met for quarter 4 of 2017/18. 1 10
Quality
Assurance
The information governance training compliance 95% target has been met in March 2018.
Appraisal compliance is slightly below target in March Underlying reasons vary across business units, with performance impacted by labour turnover, team leadership changes, sickness absence and workload. Discussions are occurring within corporate and service business units to mitigate risks when several of these factors occur simultaneously.
Following feedback from the December Council of Governors meeting, recruitment rate shows the number of posts being actively recruited to (227 posts) and the number of staff in post, as well as the percentage performance.
There were two duty of candour incidents in the period January to March The first related to a palliative care patient who was discharged from the district nursing service after several attempts at visiting the home address without success. The second related to an inpatient who took an overdose and required acute hospital treatment. 13
Finance
Control Total Performance – 2017/18 Performance: Surplus/(Deficit) Position: The end of year annual accounts (draft) position is a surplus of £3,268k. This includes including technical impairment reversals of £872k. Excluding impairment reversals the position is a surplus of £2,396k. This exceeds the planned £1,578k surplus by £818k, comprising £409k favourable performance (£192k gain on asset disposal and £217k favourable movement in month 12 risks) matched by anticipated £1 for £1 Sustainability and Transformation Fund incentive income of £409k. 14
Summary and Recommendations
Overall the report shows continued strong performance in January, February and March 2018, despite some challenges.
Correlation of quality information (including patient experience and safety related measures), performance, finance, workforce and health and safety information has taken place at the Board Committees (see highlights at slides 3 to 6). 2
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3. Summary Committees NHS Improvement Quality Finance
Finance, Business and Investment Committee (FBIC) – 19 March 2018 and 25 April 2018
Assurances
A summary of informatics issues was received from the newly appointed Associate Director. The Committee discussed areas of immediate focus, positive actions to eliminate telephony cost pressures and also longer term issues over the Trust’s expectations and approach to informatics. 
Learning from the recent Care Quality Commission (CQC) inspection had been incorporated into the annual health and safety policy review.  
The Committee noted continuing challenges relating to smoke free and separate discussions at the Executive Team in relation to the Trust’s responsibilities to volunteers. 
Substantial progress has been made by the i-Care programme over its first 12 months, and further prospects may be opened up by crowd sourcing. 
The Committee noted relevant assurances for internal audit work over the past year and agreed to consider a focused approach to talent management (one element of the internal audit of the Workforce Strategy that had received a limited assurance) later in the year. 
A refreshed approach to corporate benchmarking will be considered in June, on the basis of an updated national analysis.  
Programme and financial management reports continued to suggest that the Trust will deliver its control total at the end of 2017/18. It reviewed the remaining risks and their mitigations. 
The Trust has been successful in tenders to provide School Aged ‘Flu Immunisation and a Strategic Breastfeeding Service for Bradford.
Exceptions
Issue:
A number of Cost Improvement Programmes are still being considered through the Quality Impact Assessment process: assessments of their deliverability will be required before the Trust submits its Annual Plan at the end of April. Currently the most significant uncertainty is attached to inpatient occupancy reductions and to managing inpatient staffing cost pressures.
Status:
Ongoing.
Population health needs and demands - the context emerging from integrated care system planning, and NHS England’s future approach to financial allocations will affect planning beyond 2018/19.
The Committee has suggested that the Board considers these issues in the first half of the new financial year.
Discussions over the way forward relating to the future procurement of community dental services are scheduled with regional NHS England Commissioners for late March. The Trust must remain alert to potential re-allocations of resources between contract ‘lots’. 3

4. Finance, Business and Investment Committee - continued
Summary
Committees
NHS Improvement
Quality
Finance
Finance, Business and Investment Committee - continued
Exceptions
carried forward
Issue:
Delivery of the Trust’s 2018/19 Annual Plan – the last report highlighted the Annual plan may be impacted by a number of factors including the negotiated 2018 pay award for staff and national funding for this and the implications on Trust contracts of the Bradford Council’s budget and Early Year’s Consultation. Detailed planning requirements and guidance is awaited from NHS Improvement.
Status:
Bradford City Council’s approach to contracting children and young people services, including oral health promotion, is expected to become clearer shortly, with market engagement underway and service specifications / timelines due to be clarified in early 2018/19.
2018/19 Control Total – the last report highlighted the Trust did not anticipate achieving the £1652k surplus Control Total and that planning guidance was awaited from NHS Improvement.
Awaiting feedback from NHS Improvement regarding the control total position.
Workforce Challenges – the last report highlighted the workforce challenges in place and reported further work was planned to assess the risk scores included in the Board Assurance Framework (BAF) and Corporate Risk Register (CRR).
Paper submitted to Audit Committee in April and the Executive Management Team are now reviewing the BAF and CRR risks on a monthly basis. 4

5. Mental Health Legislation Committee – 19 April 2018
Summary
Committees
NHS Improvement
Quality
Finance
Mental Health Legislation Committee – 19 April 2018
Assurances
Care Quality Commission (CQC) Action Plan – the Committee was provided with the actions arising from the CQC inspection and was assured these were either in development or on track.
Internal Audit Reports provided assurance that the Mental Health Act team administrative systems were working effectively.
Mental Health Act Action Plan - the Committee was assured that the CQC Mental Health Act Reviewer did not identify any issues on the Bracken Ward. However, the development of care plans that demonstrate involvement and inclusivity of the service user was a theme running through a number of other CQC Mental Health Act review visits and the Committee asked for further details on the care plan review process for consideration at the October meeting.
Care Programme Approach (CPA) Audit provided assurance that audit compliance had improved and was now at 82%. The way future audits will be conducted will change with the migration to SystmOne.
Review of Blanket Restrictions – the Committee was assured that a new procedure had been developed to ensure front-line clinical staff on wards understood what constituted a restriction and how to assess and apply/not apply as appropriate.
The Committee was assured the Trust had approached Bradford University about training requirements relating to Mental Health Legislation. There had been recognition there was a knowledge gap in relation to the understanding of the legislation by newly qualified nurses.
Exceptions
Issue:
Section 17 Leave – the Committee heard from a Consultant Psychiatrist in Low Secure about a number of practice and system development issues in relation to the recording of leave.
Status:
These will be explored and addressed prior to migration of records to SystmOne.
Committee Dashboard – the Committee asked for further analysis of the ethnicity data relating to adults of working age from an Indian, Pakistani and Bangladeshi background as detention rates were higher than the population of Bradford would suggest.
Ongoing.
Exceptions carried forward
Advocacy Service Provision – the last report highlighted the Committee had requested further information about the impact on service users during their transition from Bradford and Airedale Mental Health Advocacy Service (BAMHAG) to Voiceability.
Status
The Trust had not been informed of any issues. 5

6. Quality and Safety Committee – 9 February 2018 and 23 March 2018
Summary
Committees
NHS Improvement
Quality
Finance
Quality and Safety Committee – 9 February 2018 and 23 March 2018
Assurances
Children’s services strategy: the Committee was assured that the strategy engaged extensively with service users to design a model of care with the child at the centre of the service network, recognising that others may be appropriately involved in the decision about what is best for a child. In light of the uncertainties surrounding the children’s service model going forward, including severe financial pressures, the Committee asked to receive an update on implementation of the strategy later in the year.
Serious Incident policy: the policy was approved by the Committee. The Committee welcomed the review of the network of clinical policies within which this policy sits.
Safeguarding children - Wakefield: the risks present at the point of transfer of the service have been mitigated with a safeguarding team and supervision in place and a significant improvement in proportion of staff with in date safeguarding training, operating to a single set of standards across the Trust.
Business Units: there is an ongoing robust approach to quality and safety assurance and improvement in Adult Mental Health and Specialist Inpatient, Administration and Dental Services.
The Trust currently has the highest achievement nationally on the CQUIN Physical Review of the health of Mental Health service users.
There has been an external review of the Forensic Mental Health service with 7 of 14 standards met and areas of good practice noted, 3 partly met and 4 not met.
Out of Hospital Care: the Committee received an assurance report on the development of an integrated approach across the Bradford Integrated Care System including the establishment of Primary Care Homes to include GPs, BDCFT, acute Trust, local authority community services and voluntary services
All call monitoring key performance indicators for the Single Point of Access were rated green in December for the first time (data is collected monthly).
The Committee approved the three new Quality Goals for the whole organisation together with nine priorities for 2018/19. These have been derived from the Care Quality Commission (CQC) action plan and will be included in the Quality Report. Each will be monitored by a Board sub-committee.
CQC Assurance – the Committee approved timescales for implementation of the `Must Do’ actions that had been allocated to the Committee, having been assured that these were sufficient to allow embedding of the actions and accepted its role in the CQC governance framework. The Committee will also receive reports on the `Should Do’ actions at a future meeting.
It was agreed that the Committee Dashboard would, in future, incorporate a narrative on each slide (to be provided by the Clinical lead as appropriate). The Research and Development slide will be removed, with monitoring undertaken through a bi-annual report with an emphasis on projects in progress and their potential impact. Mandatory training will only be monitored at Board to remove duplication of effort. Required training and supervision will be monitored by the Committee.
Safeguarding training will become mandatory throughout the organisation.
Library and Health Promotion Resources Strategy was reviewed and the Committee supported its ratification by the Board. 6

7. Quality and Safety Committee – continued
Summary
Committees
NHS Improvement
Quality
Finance
Quality and Safety Committee – continued
Assurances
A policy is to be produced to support the use of e-cigarettes by inpatients, in outdoor areas. It is anticipated this will reduce risks associated with illicit smoking and the use of staff time to deal with incidents associated with cigarette smoking.
Safety Huddles and associated patient safety tools have been associated with some reduction in safety incidents. Virtual Safety Huddles for Community teams and a huddle for the Estates team are being explored.
A reduced list of questions to support Board Quality and Safety walkabouts has been produced.
Exceptions
Issue:
Vacancies in psychological therapies for service users with Learning Disabilities has been rated as a red risk.
Status:
Two of the posts are expected to be filled shortly.
The time taken to transfer calls from the SPA to First Response has been rated as a red risk:
Two of four tele-coach posts have been filled, there are now only isolated instances of long waiting times for calls to be answered and the number of unsuccessful transfers has fallen.
Staffing on the Dementia Assessment Unit continues to be challenging despite a range of actions in place.
Ongoing.
Waiting lists for community mental health psychology services continue to grow, despite action taken to reduce this.
The number of clinical policies in date has deteriorated with a quarter of policies out of date and no smart plan for approval in place.
A strengthened monitoring process has been agreed.
The committee agreed to the development of a new provider Serious Incident Assurance report, incorporating the work of the refreshed Serious Incident and Complaints forum as well as the relevant elements of the CQC action plan, to give assurance of appropriate and sustained learning from serious incidents.
Ongoing
Exceptions carried forward
Move to 7 Day Working of the Trust’s Medicine Management Team – the last report highlighted the Medical Director had written to Bradford Teaching Hospitals Foundation Trust regarding the resultant impact of 7 day working on the quality of service provision to the Trust. A response is awaited. 7

8. Audit Committee - 19 February 2018 and 16 April 2018
Summary
Committees
NHS Improvement
Quality
Finance
Audit Committee - 19 February 2018 and 16 April 2018
Assurances
There have been no "limited assurance" or "no assurance" reports from Internal Audit. The Committee received "significant assurance" reports, covering: budgetary control; administration of the Mental Health Act; the workforce strategy, risk management, recruitment and retention, Financial Forecasting and General Data Protection Regulation (GDPR) preparedness. However, the Committee recognised the limited scope of the work undertaken by Internal Audit on retention and recruitment and noted that further work in this area is contained in the revised Internal Audit plan for 2018/19;
Assurances were also received in relation to: Progress towards preparation and audit of the 2017/18 Report and Accounts and Quality Accounts, including a satisfactory outcome to interim audit work by the External Auditors; Audit planning for the 2017/18 Report and Accounts and Quality Accounts; work undertaken to reduce the Trust’s risk of cyber attack; counter-fraud activity; losses and special payments and the waiver of standing orders;
The Committee agreed a revised internal audit plan for 2018/19, which takes into account the implications of the Care Quality Commission (CQC) report.
Exceptions
Issue:
Board Assurance Framework (BAF) Risk 1981: fostering a culture of innovation - This will be discussed by the Director of Corporate Affairs with the Director of Human Resources and a report given at the next Audit Committee meeting.
Status:
Paper submitted to Audit Committee in April and the Executive Management Team (EMT) are now reviewing the BAF and Corporate Risk Register risks on a monthly basis.
It was agreed that the Quality and Safety Committee should be asked to do a deep dive into ward audits.
Action to be progressed during quarter 2.
Issues highlighted in internal audit reports will, in future, be shared with the relevant committee for information and potential action.
Internal audit agreed to facilitate this.
The Trust’s policies and procedures are being reviewed, with a view to streamlining these.
Initial paper discussed at Audit Committee in February and a further paper is planned for May 2018.
Through triangulation of information provided by various reports, the Committee noted the significant risks existing around workforce issues.
Whilst it was agreed that the risks are being monitored/managed by the Board, Finance, Business & Investment Committee and the Human Resources department, the Committee agreed that it should be kept on the Committee’s “radar” and reviewed again for potential escalation. 8

9. Audit Committee - continued
Summary
Committees
NHS Improvement
Quality
Finance
Audit Committee - continued
Exceptions
Issue:
Following further consideration of the CQC report, the Committee requested that the Board review its risk appetite, having identified certain areas where it seems that CQC are more risk averse than the Trust.
Status:
Risk Management Strategy to be reviewed by the Board once new Chief Executive is in post.
The Committee agreed that the Committee Chair will liaise with the Chair of the Quality & Safety Committee to confirm that all aspects of clinical audit, and assurances and learning arising therefrom, are covered by one or other of the committees.
To be arranged through the Non Executive Directors meeting.
The Committee proposed that post-implementation audits should be undertaken on all major projects and cost improvement plans (CIPs), not just those involving significant capital expenditure. There will be liaison with the Programme Management Office to determine how this can best be approached.
To be considered at a future EMT meeting. 9

10. Single Oversight Framework Operational Performance Metrics
Summary
Committees
NHS Improvement
Quality
Finance
Single Oversight Framework Operational Performance Metrics
Indicators M7, M10, M11: Reporting shows the 3 month rolling position, rather than traditional quarters, in order to match how NHS Improvement now monitors these metrics under the Single Oversight Framework (updated November 2017).
Indicator M7: Data is provisional provided in relation to the waiting time element of the new standard for Early Intervention in Psychosis (EIP). This shows patients who started treatment in March 2018 within two weeks of referral. The number of incomplete pathways (patients waiting) at the end of March 2018 was 39; 27 of these patients have been waiting for more than two weeks. 10
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11. Single Oversight Framework Operational Performance Metrics
Summary
Committees
NHS Improvement
Quality
Finance
Single Oversight Framework Operational Performance Metrics
Indicator M21: As forecast, Improving Access to Psychological Therapies (IAPT) recovery rate has improved in quarter 4. Provisional data for February 2018 indicates recovery rates above 50% for two of the three Clinical Commissioning Groups and for the Trust overall.
The Trust has commenced innovative work within the City IAPT Team to consider and develop appropriate service responses to cultural issues. This work is supported by Hari Sewell, a national expert in the specialist field of equalities in mental health, and is due to complete in June We expect that this will support improvements in both access and recovery in City CCG and also BME populations across the district, by introducing culturally adapted promotion and interventions based on BME service user experience.
Indicator M23: The Trust has relatively few inappropriate out of area bed days, relating to the Psychiatric Intensive Care
Unit only. The Trust’s local data for out of area bed days are included in the Board integrated performance report, rather
than using the NHS Digital published data that suppresses small numbers. 11

12. Serious Incident Numbers This month's performance
Summary
Committees
NHS Improvement
Quality
Finance
Serious Incident Numbers
Indicator No.
16/17 Out-turn
This month's performance
17/18
Out-turn Q3 96 2 28
In the period January to March 2018, there were three ‘Serious Incidents other’. These related to:
the death of a detained patient;
an allegation of abuse by staff member on service user;
an allegation of inappropriate use of physical intervention.
This data is monitored in more detail via the Quality and Safety Committee on a quarterly basis. 12

13. Workforce – Appraisal & Mandatory Training
Summary
Committees
NHS Improvement
Quality
Finance
Workforce – Appraisal & Mandatory Training
Indicator No.
Indicator
16/17 Outturn
17/18 Target
Current Performance
17/18 Outturn
Graph
Q17
% Mandatory training (excluding Information Governance Compliance)
88.96%
80%
88.53%
Q17c
% Information Governance Training - All Staff Combined
98.28%
95%
95.68%
Q18
% Staff Receiving
Appraisal
83.77%
79.01%
Q19
% Labour Turnover
11.62%
10%
11.30%
Q20
% Sickness absence rate
5.12%
4.00%
4.96%
5.54%
Indicator No.
Indicator
16/17 outturn
17/18 Target
Numerator
Denominator
Current Performance
17/18 outturn
Graph
Q21
% Recruitment rate (Number of posts being actively recruited to as a percentage of staff in post)
10.0%
227
3033
7.48% 13

14. Summary
Committees
NHS Improvement
Quality
Finance
Finance Key Measures
Note for red/amber/green for Cost Improvement Plans (CIPs) – 10% variance is Amber, over 10% is Red
Before taking into account the high risk CIP reserve performance is £121k behind plan. A key focus remains recurrent scheme delivery and/or substitution and is subject to Finance, Business and Investment Committee scrutiny. 14