AGENDA Time Item no. Item Board action Lead Paper PRELIMINARY BUSINESS (16) (17) (18) (19a) (19b)

Transcription

1 Leeds Community Healthcare NHS Trust Public Board Meeting Agenda Thursday 4 June am 10.30am Boardroom, Stockdale House, Victoria Road, Leeds Please note: agenda timings are approximate BOARD ACTION KEY For Approval For Noting For Information For Discussion Strategies, plans, policies and minutes External reports and statutory requirements Internal reports and updates Challenging and forming opinions AGENDA Time Item no. Item Board action Lead Paper PRELIMINARY BUSINESS (16) (17) (18) (19a) (19b) (19ci) (19cii) Introductions and apologies Declarations of interest Questions from members of the public Minutes of previous meetings and matters arising: a. Minutes of the meeting held on 1 May 2015 b. Action log c. Key issues from: i Quality Committee 20 May 2015 ii Business Committee 1 June 2015 Neil Franklin For noting Neil Franklin N For discussion Neil Franklin N For approval For information For information For information Neil Franklin Neil Franklin Tony Dearden Brodie Clark N Y Y Y N (20) (21) (22) (23) QUALITY AND DELIVERY Chief Executive s report For information Thea Stein N Care Quality Commission: outcome of inspection Quality Account GOVERNANCE Annual report and accounts 2014/15 a. Annual report b. Annual accounts and Trust certificates c. Letter of representation d. ISA 260 external auditor s opinion For information Thea Stein Y To approve Helen Thomson For approval Bryan Machin Y Y (24) (25) Audit Committee annual report 2014/15 NHS Trust Development Authority: Board compliance statements and Monitor s licence conditions For approval Jane Madeley Y For approval Emma Fraser Y (26) REPORTS Close of the public section of the Board Neil Franklin N Date of next public meeting Friday 3 July 2015, 9.00am 11am Boardroom, Stockdale House, Leeds

2 Leeds Community Healthcare NHS Trust Trust Board meeting PUBLIC MEETING AGENDA ITEM (19a) Boardroom, Stockdale House, Victoria Road, Leeds Friday 1 May 2015, 9.00am 11.00am Present: Apologies: In attendance: Minute taker: Observers: Members of the public: Neil Franklin Thea Stein Brodie Clark Dr Tony Dearden Robert Lloyd Jane Madeley Bryan Machin Sam Prince Dr Amanda Thomas Helen Thomson Sue Ellis Emma Fraser Paul Morrin Professor Ieuan Ellis Vanessa Manning Tricia Hannon Richard Chillery None present Trust Chair Chief Executive Non-Executive Director Non-Executive Director Non-Executive Director Non-Executive Director Executive Director of Finance and Resources Executive Director of Operations Executive Medical Director Interim Executive Director of Nursing Director of Workforce Director of Strategy and Planning Director of Integration Non-Executive Director Interim Company Secretary Interim Assistant Board Secretary Clinical Lead for Specialist Services and Vulnerable Groups Item Discussion points Action (01) Welcome and introductions The Chair welcomed members and opened the meeting. Richard Chillery attended in the capacity of an observer for his own personal development. Apologies were noted from Professor Ieuan Ellis (02) Patient s story Asylum seeker couple s experience of York Street Health Practice The Chair welcomed and introduced the patients to the meeting. Barbara Nkosana, Specialist Practice Nurse at York Street Health Practice attended the meeting in support of the patients. Em Brown of the Membership Involvement Team, Leeds Community Healthcare NHS Trust also attended for this item and she set out the background to the patient s story. 1

3 The patient stated that his initial experiences with his GP had been poor. The patient had explained to his GP his health related problems but was declined the necessary treatment despite having a letter from his country of origin stating that an operation would be required. Since moving to the care of York Street health practice, the patient had been referred to hospital and was undergoing treatment for his health problems. As the couple have also been trying for a family for some time, the couple had made enquiries regarding fertility treatments and had obtained an appointment for possible treatment. The patient said that he had seen the same GP for his care and feels that he has experienced good continuity of care. He had since recommended York Street to his friends who were experiencing GP and interpreter access problems. The patient concluded by saying that York Street is unique and special and he is very happy with the care and service received. The Chair said that the Trust is very proud of the York Street practice and the good clinical service and patient experience it provides. The Chair thanked the patients and Barbara Nkosana for their time in attending the meeting and sharing their story with the Board (03) (04) (05) (05a) Declarations of interest A Non-Executive Director (JM) declared an interest in items regarding the University of Leeds and the Academic Health Network. Questions from the members of the public No members of the public attended the meeting. Minutes of the previous meeting held on 27 March 2015, matters arising and action log The minutes were reviewed for accuracy and two amendments noted. Item 171(i) Quality Committee 16 March 2015 The minutes stated that the Research and Development Forum had been suspended in order to review its purpose and function. The Executive Medical Director said that it was the Innovation and Research Forum that had been suspended temporarily but that the Board should note that considerable research and development work across the Trust is continuing. Item 171(ii) Business Committee 25 March 2015 The Chair proposed that the minute related to recruitment be amended to read: The Chair noted the progress being made to tackle recruitment issues but indicated that short term challenges remained and there were considerable further improvements to be made. (05b) Action log There were no outstanding actions on the action log overdue for completion as at 1 May

4 (05c) Key issues from committees Item 05c(i) Quality Committee: 20 April 2015 A Non-Executive Director (TD) presented the report and the two main items arising. Outcome measures Some good positive discussions had taken place at both the Quality and Business Committees where it had been noted that outcomes data is being utilised to direct quality enhancements in front line services. Whilst outcome measures were not to be used as key performance indicators at present, the means by which outcome measures could be used to drive performance in the future were to be considered. A work plan is to be devised and a group set up to take forward this work. Future reports are to be received by the Quality Committee. Research and development strategy The Quality Committee received a research and development strategy for the Trust, the Board was recommended to ratify adoption of the strategy. As a result of the strategy, the Trust will focus on several main areas. With reference to the research funding, 0.5m has been identified for research with a focus on partnerships and working with academics and universities. Outcome: The Board noted the key issues highlighted in the report. Item 05c(ii) Business Committee: 22 April 2015 A Non-Executive Director (BC) presented the report and highlighted the main items. The main issues being related to areas of under-performance and the development of future performance measures. Key performance Indicators (KPIs) Key performance indicators (KPIs) are to be signed off at the next Business Committee meeting. Action: The KPIs used to populate the integrated performance report (IPR) to be reviewed at the Business Committee meeting on 1 June Service line reporting A report, with focus on particular areas, providing performance updates by service line with a heat map, will be considered at the Business Committee. Action: Further report on service line reporting and heat map to progress to the 24 June 2015 Business Committee and for subsequent inclusion in the IPR. Cost improvement programme reporting A significant amount of work had been carried out and a business as usual approach is to be adopted for the delivery and monitoring of cost improvement plans (CIPs). Executive Director of Finance and Resources Executive Director of Finance and Resources It was proposed that there should be a change to the reporting of CIPs with future reports included in the financial reports within the IPR; the Business Committee retaining primary responsibility for challenging and testing. CIPs for 2016/17 will be considered in the later part of the calendar year

5 Recruitment A report had been developed which looked at core areas of concern including recruitment to band 5 posts and staff availability for work. A recruitment and retention dashboard is being developed based on software developed by Leeds Teaching Hospitals NHS Trust, with funding provided by the Clinical Commissioning Group (CCG). The database to support the dashboard will be further developed in-house. In reply to a Non-Executive Director (BC), the Director of Workforce said information is being obtained from staff leavers through exit questionnaires with a third of leavers completing forms. It is hoped this number can be increased in future in an effort to address staff retention. The Director of Workforce said she was serving on a national group looking at supply issues in the NHS workforce. Outcome: The Board noted the matters brought to its attention and approved the change to future CIP reporting. Item 05c(iii) Audit Committee: 24 April 2015 The Chair of the Audit Committee/Non-Executive Director (JM) provided a verbal update. She noted the appointment of TIAA Limited as the Trust s new internal auditors. There had been some challenges in finalising internal audit reports in the latter part of the year. Several draft internal audit reports had been reviewed at the Audit Committee meeting where it was recommended that future internal audit reports were to be presented to the Board s sub-committees for review, to oversee actions and to take ownership of the reports. The Internal Audit Manager had presented the draft internal audit annual report for 2014/15 which included the Head of Internal Audit opinion. The draft internal audit plan 2015/16 was to be presented to the senior management team and then to the Audit Committee meeting scheduled for 24 July Action: The draft internal audit plan 2015/16 to be progressed through senior management team and the July 2015 Audit Committee meeting. The senior management team had reviewed the draft annual accounts and following the page turner meeting on 15 May 2015, these were due for approval and sign off at the 2 June 2015 Audit Committee meeting and the Board on 4 June Executive Director of Finance and Resources The Board s sub-committee annual reports for 2014/15 had been received at the Audit Committee meeting. Statements of compliance related to adherence to terms of reference will be included in future sub-committee annual reports. The draft annual statement of governance 2014/15 had been received and following amendment was to be sent to external auditors KPMG. Outcome: The Board noted the matters highlighted. 4

6 (06) Chief Executive s report The Chief Executive made specific reference to the winter review item contained in her report and referred to the stresses in the system across the city relating to the availability and demand for acute and integrated care bed capacity. She stressed that the pressures are not just being experienced during the winter period but at other peak times during the year such as Easter and bank holiday weekends. The challenges for the Trust are significant with the Chief Executive and Executive Director of Operations working collaboratively with partner organisations. The clinical commissioning groups will begin pre-winter planning from August A Non-Executive Director (TD) asked about any observations from the Department of Health in relation to year round demand and capacity. The Executive Director of Operations said that the Department of Health had recognised that increased pressures existed at all times and now referred to year round resilience and was looking at funding service pressures accordingly. A Non-Executive Director (BC) asked for an update on the staff engagement sessions and the arrangements to provide feedback to staff. The Chief Executive said that feedback had been collated and issues and actions had been discussed at the senior management team meeting; a full report was to be released soon. She confirmed that a focus on staff engagement is included in the operational plan 2015/16. The Chief Executive advised the Board that she and the Executive Medical Director had attended the initial event of the Academic Health Partnership in Leeds, of which Leeds Community Healthcare NHS Trust is a key member. Health organisations are working in partnership with the council and universities with the aim of bringing funding and resources to Leeds for research and development. A Non-Executive Director (RL) referred to the concerns expressed by some integrated community team (ICT) staff about the reorganisation of neighbourhood teams and asked about the changes taking place. The Chief Executive said that this represented a further tranche of integration. The Trust is listening to staff views and visiting each team to ensure change occurs smoothly. The Interim Executive Director of Nursing confirmed that achieving integration is a key priority for the Trust. In reply to a Non-Executive Director (TD), the Chief Executive confirmed that there is currently a pause, financially and in project terms, on the review of the integrated service for children with additional needs (ICAN). Additional time is required to consider the pace and nature of change before progressing further. Action: The reports on changes in ICT and ICAN services to be kept under review by the senior management team. Executive Director of Operations Outcome: The Board noted the contents of the report. 5

7 (07) National NHS staff survey 2014 action planning The report was introduced by the Director of Workforce. The report updated the Board on the review of the 2014/15 NHS national staff survey action plan as had been requested at the March 2015 meeting. The Director of Workforce drew attention to the review of the 2014/15 plan and made specific reference to appraisal processes, communications between senior managers and staff, support from managers, work related stress and staff understanding of the organisational development strategy. In addition to the staff survey results, additional feedback was being gained from the Chief Executive s staff engagement work and the results from staff, friends and family test. A Non-Executive Director (BC) asked about lessons learnt and what the organisation is doing differently compared to the previous year. He agreed that the organisational development strategy should remain the driving force, and as such is amongst the organisation s priorities for The quality of interaction with staff and managers and confidence in carrying out appraisals were discussed. The Executive Director of Operations said that whilst there is a need to improve the paperwork, the appraisal process itself should not be overly concentrated on documentation. A Non-Executive Director (JM) asked about the training for line managers. Appropriate training for managers to carry out appraisals was discussed and it was confirmed that managers receive the necessary training. A Non-Executive Director (BC) asked about mandatory management training. The Executive Director of Operations confirmed that the training and development needs of managers are identified individually based on their leadership experience and skills as part of induction or appraisal; training needs then inform an individual development plan. The Chief Executive concurred with the Executive Director of Operations and said that the competences of new appointees were considered carefully and that training initiatives and support needed to be sensitive to the needs of individuals based on prior experience. The Chief Executive made reference to levels of sickness absence and efforts to limit staff absence in the interests of high quality patient care; she confirmed that further assurances would continue to be brought to the Board. A Non-Executive Director (RL) drew attention to the summary review of 2014/15 and asked if the organisation felt progress with the organisational development strategy and plan was satisfactory and asked about the level of confidence in meeting planned improvements in 2015/16. The Director of Workforce responded that the organisational development strategy was a considerable piece of work and change would take a number of years. In 2014/15, service reviews had had a significant impact on progress. Long term benefits would only be felt in part in 2015/16. Staff side interests supported the approach being taken and had indicated that the Trust had demonstrated good practice in staff engagement. 6

8 Action: The approach to management development and the extent to which management training is considered as mandatory to be reviewed by the Business Committee on 22 July 2015; and incorporated into the Board paper on the organisational development plan for 7 August Director of Workforce Outcome: The Board received the information regarding the review of the plan for 2014/15 and noted the progress with work undertaken through the organisation development plan (08) Quality governance assurance framework (QGAF) The report was presented by the Executive Medical Director who highlighted the actions which have taken place since the review by the Quality Committee in March An internal sense check had taken place and comments are being incorporated into the QGAF action plan. A QGAF peer review had taken place in April 2015 by Bridgwater Community Healthcare Foundation Trust and Derbyshire Community Health Services Foundation Trust. It was noted that a joint publication by the NHS Trust Development Authority, Care Quality Commission and Monitor had introduced the Well-Led Framework which would replace the QGAF and the Board Governance Assurance Framework (BGAF). Non-Executive Directors (TD and IE) queried the future timescales for progression of the QGAF documentation through the Quality Committee, and the Board. It was agreed the QGAF and the improvement trajectory would progress through the June 2015 Quality Committee meeting and onto the July 2015 Board. Action: A QGAF self-assessment update, including conclusions drawn from the sense check and peer review, to be reported to the Quality Committee on 22 June 2015; and the Board on 3 July Incorporation into the wellled framework would be considered as part of a workshop during September Executive Medical Director Outcome: The Board received and noted the report and the revised timeframe for reporting the QGAF self-assessment to the Quality Committee and then Board (09) Integrated performance report The report was presented by the Executive Director of Finance and Resources who highlighted the main performance points within the report. The finance report represented the year end pre-audit position. The Chair asked that, in future, the covering paper should reflect prior discussions at Quality and Business Committees. In reply to a Non-Executive Director (JM), the Executive Director of Finance and Resources confirmed that the Trust continues to perform less well than comparator trusts in relation to sickness absence for 2013/14 and 2014/15. 7

9 A Non-Executive Director (RL) queried the March 2015 patients contacts figure which was below target at year end with a reported position of 4% below target. The Executive Director of Finance and Resources clarified that this was not the final position and that further data would be included in a finalised year end position. The Executive Director of Operations explained that the shortfall in the activity figures may result from under-recording and non-outcoming of appointments in pressurised teams; additional administrative support was being brought in to assist. Action: The integrated performance report covering paper to incorporate conclusions from discussions at both the Quality and Business Committees in future months. Action: Fuller review of activity recording, reporting and activity for 2015/16 to be undertaken by the Business Committee on 1 June The Executive Director of Finance and Resources provided an update on the year-end financial processes. The pre-audit position was as previously forecast with the majority of the financial targets having been met or exceeded. The surplus for the year is 2m or 1.36%. Executive Director of Finance and Resources Executive Director of Finance and Resources The Chair congratulated the Executive Director of Finance and Resources and his team for all their work on the year end processes. Outcome: The Board received and noted the report and the Trust s performance against its performance objectives and supported the recovery actions being taken (10) Programme management board report The Executive Director of Operations provided the report and said that there had been some concerns and challenges over the last month relating to delivery of financial plans. She reported on the current initiatives taking place including the Choose and Book project and the corporate review project which had been recently initiated following approval by the senior management team. A Non-Executive Director (JM) commented on the 2014/15 programme status and the red rating shown on the graphs both for the in year variance actual and the in year forecast outturn. This was clarified by the Executive Director of Operations as relating to an in year shortfall from 1 April 2015; she offered to discuss this item further outside the meeting with the Non- Executive Director (JM). The Executive Director of Finance and Resources said that in future this report would be part of the financial report included in the IPR. Action: CIP reporting to be incorporated into the IPR from May Outcome: The Board noted and received the report from the Programme Management Board. Executive Director of Finance and Resources 8

10 (11) Corporate risk register The Director of Integration presented the report. In line with recent agreements as to the level of risks reported to the Board, the corporate risks scoring 15 or below no longer appear on the risk register. As a result of this, the risk numbers have reduced in number from 11 to four; the status of those risks being summarised in the report. The Chief Executive clarified that mitigated risks with a scoring of 15 and above will be continued to be looked at in detail by the senior management team in line with the risk management strategy. This was further reinforced by the Chair. A Non-Executive Director (JM) queried the first three risks on the register relating to recruitment and suggested that these amounted to the same risk. Clarification was provided that the first three risks are around the risk of reduced level of care due to staff recruitment issues amongst three distinct staff groups. The fourth risk related to sickness absence and was trust-wide. A Non-Executive Director (JM) suggested that the Trust s risk management strategy be kept under review to ensure robust processes are in place and that all risks are revisited. A Non-Executive Director (RL) commented on mitigation and risks, safer staffing levels and the need to focus on levels of care; all of which may be compromised by the ability to recruit and levels of staff sickness. The use of agency/bank staff was discussed. The Chair commented on the risks around not having sufficient permanent staff in place and the consequent greater use of agency staffing. The Chair said that recruitment remains a major risk for the Trust with less than optimum levels of permanent staff to meet correct staffing levels and to match demand. Further work is required on the corporate risk register and to revisit risks scoring 15 and below; the Board endorsed a number of identified actions. The Chief Executive advised that the corporate risk register responsibility will come under her remit in future. Action: A report on safer staffing and the usage of agency staff to be developed for the Quality Committee meeting on 22 June Action: Covering papers with future reports to provide more detail on actions to address risks Action: Risk management processes to be enhanced to provide a greater role for the senior management team and the establishment of a risk review panel. Outcome: The Board noted the report and risk register. Interim Director of Nursing Interim Company Secretary Interim Company Secretary 9

11 (12) NHS Trust Development Authority (TDA) monthly report on Board compliance statements and Monitor s licence conditions The Director of Strategy and Planning introduced the NHS TDA monthly report and advised of the Trust s unchanged position from last month. She also advised that as part of the stakeholder engagement strategy, the Trust is committed to improving service information to patients. This will be progressed on websites in future and as part of the forthcoming Leeds Community Healthcare NHS Trust s website review. Outcome: The Board approved the assessment of full compliance with the TDA Board Statements, the assessment of non-compliance with Monitor Condition G8, and noted that this will be progressed (13) Corporate governance update The report and draft annual governance statement was presented by the Chief Executive. Action: Amendments, as raised in the Audit Committee, to be incorporated into the annual governance statement. The Chair provided clarification on the proposal to create two associate non-executive director (NED) positions. Following the Nominations and Remuneration Committee meeting held in March 2015, the committee had proposed the appointment of two new associate non-executive directors with both roles having specific responsibility for equality and diversity and community links. Interim Company Secretary The Board discussed how effective the new roles would be to the Trust and the contribution they would make to future succession planning. The Director of Workforce said the roles would be appointed on the basis of 0.5 non-executive director allocation and the expectation of the roles would be to develop equality and diversity and community links. The Chief Executive proposed that the Board did not agree a position on the proposed two associate non-executive director posts until a further review is undertaken. The Chair proposed, and it was agreed by the Board, that the Nominations and Remuneration Committee review the roles and requirements for the two associate non-executive director posts at the meeting in June 2015, and report back with further proposals to the Board in July Action: The Nominations and Remuneration Committee to review the requirements for the two new associate non-executive director posts at their meeting on 26 June 2015 for reporting to the Board on 3 July Director of Workforce The frequency of Board and committee meetings was an item for discussion with a proposal to reduce the number of meetings following a review of the frequency of Board and committee meetings. Outcome: The Board received and noted the contents of the report. 10

12 (14) (14a) (14b) (14c) (15) Minutes of Board committees The Board noted the following final approved committee meeting minutes and formally accepted the minutes. Business Committee: 25 February 2015 Business Committee: 25 March 2015 Quality Committee: 16 March 2015 Close of the public section of the Board The Chair concluded the public section of the Board meeting. Date and time of next meeting Thursday 4 June 2015, 08.30am 10.30am Stockdale House, LS6 1PF 11

13 Leeds Community Healthcare NHS Trust Trust Board meeting (public) action log: 4 June 2015 AGENDA ITEM (19b) Agenda Action agreed Lead Timescale Status number Meeting held on 5 December (121) Winter preparedness plan Development of a quarterly report to the Board entitled bringing care closer to home incorporating development of sustainable services which manage winter pressures as normal business. Proposal to be considered by senior management team and Board briefed on the outcome. Meeting held on 6 February 2015 Director of Strategy and Planning New timescale: (updated from Feb 2015) May 2015 Closed Approach to monitoring and reporting against strategic objectives to be developed and discussed at future workshop (148) OD strategy implementation Consideration to be given to KPIs to be scrutinised through Board committees to demonstrate progress against OD implementation plan. Director of Workforce Jun 2015 Closed Scheduled for Board August 2015 Meeting held on 6 March (157c) Complaints Further analysis to be undertaken of not upheld complaints with a greater emphasis on thematic analysis to be reported to Quality Committee through six monthly thematic report. Interim Executive Director of Nursing Aug 2015 Closed Scheduled for Quality Committee discussion (159) Integrated performance report: sickness absence, appraisal and statutory and mandatory training In line with agreement of KPIs for 2015/16, realistic improvement trajectories to be developed and monitoring established through performance panels and Business Committee Director of Workforce June (161) NHS staff survey 2014 Senior management team to evaluate progress against 2013 survey s action plan. Further analysis of 2014 results to include benchmarking against other trusts. Actions, timescales and key performance indicators to organisational development plan for Board monitoring. Director of Workforce May 2015 Completed Meeting held on 27 March (172) Operational plan (2015/16) The operational plans to be reviewed and linked into the broader board assurance framework. Director of Strategy and Planning New timescale: August 2015 (updated from April 2015) Update To be included in next iteration of BAF 1

14 Meeting held on 1 May (05cii) Business Committee: Key performance indicators (KPIs) KPIs used to populate Integrated Performance Report (IPR) to be reviewed by Business Committee 1 June Executive Director of Finance and Resources June (05cii) Business Committee: Service line reporting Further SLR report and heat map ; to be taken to Business Committee on 24 June 2015 then included in the IPR for committee and Board review. Executive Director of Finance and Resources July (05ciii) Audit Committee: Internal audit plan 2015/16 Internal audit plan to be received by SMT and Audit Committee meeting (scheduled 24 July 2015). Executive Director of Finance and Resources July (06) Chief Executive s report: service visits Reports on changes in ICT and ICAN to be kept under review by SMT. Director of Operations July (07) National NHS staff survey 2014 Approach to management development and mandatory requirements to be reviewed by Business Committee on 22 July 2015; then incorporated into Board paper on OD plan for Board meeting on 7 August Director of Workforce August (08) Quality Governance Assurance Framework (QGAF) QGAF self-assessment to Quality Committee on 22 June 2015 and Board on 3 July Incorporation into the well-led framework workshop September Executive Medical Director September (09) Integrated performance report Future covering papers to incorporate conclusions from discussions at Quality and Business Committees. Executive Director of Finance and Resources July (09) Integrated performance report: IPR activity data Review of activity recording, reporting and activity plan for 2015/16 to be undertaken by Business Committee on 1 June Executive Director of Finance and Resources June (10) Programme management report CIP reporting to be incorporated into the IPR from May 2015 (using April 2015 data). Executive Director of Finance and Resources June 2015 Completed 2

15 (11) Corporate risk register: safer staffing Report on safer staffing and agency staff usage (in excess of safer staffing reporting requirements) to Quality Committee on 22 June Director of Workforce June (11) Corporate risk register Further detail on actions to be included in future covering papers. Interim Company Secretary August (11) Corporate risk register: risk process Processes to be enhanced; greater role for SMT and establishment of a risk review panel. Interim Company Secretary August (13) Corporate governance: annual governance statement Amendments to be made from the April 2015 Audit Committee. Interim Company Secretary May 2015 Completed (13) Corporate governance: associate NED role Requirements to be reviewed by Nominations and Remuneration Committee on 26 June 2015 and Board on 3 July Director of Workforce July 2015 Key Total actions on action log Total actions on log completed since last Board meeting 1 May 2015 Total actions not due for completion before 4 June 2015: progressing to timescale Total actions not due for completion before 4 June 2015: achieving agreed timescales and/or requirements is at risk or has delayed Total actions outstanding as at 4 June 2015: not meeting agreed timescales and/or requirements

16 AGENDA ITEM (19c) Report to: Trust Board Date of meeting: 4 June 2015 Report title: Key issues from Quality Committee 20 May 2015 Responsible Director: Chair of Quality Committee Report author: Executive Medical Director Previously considered by: n/a EXECUTIVE SUMMARY Issues for the Board arising from the Quality Committee 20 May 2015 The Quality Committee met for a shortened meeting to consider four key areas: Quality Account CQC Inspection: Quality Improvement Plan Savile Report: response to the NHS Trust Development Authority Risk register: clinical risks scoring 8+ The following matters are to be highlighted to the Trust Board: 1. Quality Account The Professional Lead for AHPs presented the final draft of the Quality Account and the Quality Committee is recommending the document to the Board for approval following the inclusion of stakeholder comments. 2. CQC Inspection: Quality Improvement Plan The Foundation Trust Programme Manager presented the progress report on the CQC actions contained within the Quality Improvement Plan. The Quality Committee received significant assurance on the approach and progress made to date, and agreed to receive bimonthly reports with exception reporting in the intervening months. The Board will receive the progress report on 4 June Clinical risks 8 and above on the risk register The Company Secretary presented a report providing clinical risk registers for the three business units scoring 8 and above (28 risks). The Quality Committee noted the improvement of the register and the closed, consolidated and de-escalated risks. The Committee discussed the escalated risk (ID 644) relating to increased demand for child and adolescent mental health services in the context of limited capacity due to staffing issues that has been escalated from 12 (high) to 16 (extreme) and would wish to highlight this risk to the Board. Page 1 of 2

17 4. Savile Report: recommendations and action plan The Director of Workforce presented the action plan and progress to date with regard to the Savile report. The NHS Trust Development Authority (TDA) has requested the action plan by the end of May 2015 and are also seeking assurance that the Board has received the action plan. In addition to the report received by the Quality Committee, the action plan has been considered by SMT on 1 April 2015 and the Safeguarding Committee on 14 April The Director of Workforce highlighted that the TDA timeline of completed actions by 31 May 2015 would be challenging due to some outstanding work including policies and procedures. One recommendation regarding disclosure and barring service checks for all staff and volunteers every three years may be subject to further change and the Committee has considered and recommended that the Trust will await legislative change given the resource implications and following the advice of the Head of Safeguarding for the clinical commissioning groups. The action plan has made progress in all eight other recommendations. Quality Committee on behalf of the Board gave oversight of this matter in principle and felt that this constituted sufficient governance for he Chief Executive to sign off the action plan and make a statement to the TDA. The action plan is available for any Board member who wishes to receive the full detailed plan. RECOMMENDATION The Board is asked to note the matters highlighted Links to strategic objectives: Links to principal risks: NHS Constitution: CQC Outcomes: Equality and diversity: Sustainability Implications: Publication Under Freedom of Information Act: The work of the Committee relates to all the strategic objectives. The Quality Committee is responsible for reviewing the adequacy and effectiveness of the Trust s approach to quality. The work of the Quality Committee supports all of the principles and values in the NHS Constitution. The Quality Committee provides assurance to the Board that the Trust is meeting its regulatory duties with regard to fundamental standards of care. An Equality Analysis screening form has not been completed because the report does not relate to a new or revised policy, strategy, project or service. None This paper has been made available under the Freedom of Information Act. Page 2 of 2

18 AGENDA ITEM (21) Report to: Trust Board Date of meeting: 4 June 2015 Report title: Response to Care Quality Commission (CQC) Inspection Findings Responsible Director: Executive Medical Director Report author: Foundation Trust Programme Manager Previously considered by: Quality Committee EXECUTIVE SUMMARY This paper provides a progress report to the Board on development and delivery of a robust organisational response to the CQC inspection findings set out in the final reports published on 22 April The Trust was required to submit an action plan addressing the two compliance actions by 15 May 2015 (complete) and the improvement actions by 29 May 2015 (on track). The Trust has a two-stage approach to development and delivery of a Quality Improvement Plan to address the CQC s findings and wider quality improvement initiatives. The CQC and partners acknowledged at the CQC Summit that a limited number of improvement actions can only be fully addressed in a longer time-frame and / or are not fully within the Trust s control e.g. strengthening morale, recruiting to establishment, reducing child and adolescent mental health services (CAMHS) waiting times and moving from Little Woodhouse Hall to suitable alternative premises. The report indicates the key focuses of the CQC s improvement actions and provides assurance about progress made in progressing nearly all improvements in the plan. One compliance action and five other actions have been completed. A number of actions require further time to undertake the repeat audits / spot-checks to provide assurance of the impact and embeddedness of improvements before being considered complete. RECOMMENDATIONS The Board is recommended to: Receive significant assurance on the approach and progress made to date with development and implementation of the Stage 1 Quality Improvement Plan Note the plan for development of an organisation-wide Quality Improvement Plan (Stage 2) Approve the proposed monitoring and reporting arrangements through the SMT and Quality Committee to Board 1

19 Links to strategic objectives: Links to principal risks: NHS Constitution: CQC Outcomes: This report supports the following strategic objectives: To provide high quality, safe services, continuously improving patient experience and measuring our success in outcomes To work in partnership with service users, communities and stakeholders to deliver service solutions, particularly around integrated care and care closer to home To engage and empower our workforce, ensuring we recruit, retain and develop the best staff To become a viable and sustainable organisation with the ability to invest in the community & with a relentless focus on value for money Risk: ineffective systems and processes for assessing the quality of service delivery and compliance with regulatory standards Risk: failure to implement and embed lessons learned from internal and external recommendations Risk: failure to achieve Foundation Trust status Risk: lack of internal capacity to secure quality and drive transformational change This report supports all of the principles, values, rights and pledges detailed within the NHS Constitution. The principle ones relate to: Working together for patients Commitment to quality of care This paper supports all CQC outcomes Equality and diversity: Sustainability Implications: Publication Under Freedom of Information Act: An Equality Analysis screening form has not been completed because the report does not relate to a new or revised policy, strategy, project or service. There are no sustainability implications that the Committee needs to take into account This paper has been made available under the Freedom of Information Act 2

20 1.0 PURPOSE OF THIS REPORT 1.1 The purpose of this report is to provide a progress report to the Trust Board on development and delivery of a robust organisational response to the CQC s inspection findings and reporting requirements. 2.0 BACKGROUND 2.1 CQC Requirements The CQC published the final reports on its inspection of Leeds Community Healthcare (LCH) on 22 April The CQC overall rating for the Trust was requires improvement. The individual ratings are shown in the table below The CQC required the Trust to submit action plans in relation to the two compliance actions four weeks after the CQC Summit (Friday 15 May 2015) and an action plan in relation to improvement actions six weeks after the CQC Summit (Friday 29 May 2015) It is then for the Trust, with the support of the NHS Trust Development Authority (TDA), to decide when to invite the CQC to re-inspect i.e. when the Board is confident of achieving a good overall rating. At the CQC Summit, the CQC acknowledged that the time-scale for fully addressing some actions will be quite long and / or some actions are not fully within the Trust s control e.g. strengthening morale, recruiting to establishment and moving from Little Woodhouse Hall to suitable alternative premises. The CQC indicated that achieving a good rating would not be dependent on having fully addressed such actions, but the CQC would need evidence of good progress underpinned by a robust plan and effective operational systems and procedures. 3

21 2.1.4 Following submission of the action plan in relation to improvement actions on 29 May 2015 the Executive Medical Director and the Foundation Trust Programme Manager will contact the CQC to set up regular engagement meetings. The Trust is unlikely to receive any feedback from the CQC about the action plans prior to re-inspection. The team will continue to engage with other trusts to learn from their experience. 2.2 Trust Approach The Senior Management Team (SMT) agreed a two-stage approach: Stage 1: o Development, implementation and monitoring of a comprehensive Quality Improvement Plan that addresses the CQC s service specific compliance actions ( must-do s ), improvement actions ( should do s ) and concerns ( could do s ) flagged in the body of the reports. o The action plan submitted to the CQC in relation to improvement actions does not include actions relating to CQC concerns ( could do s ) that do not relate directly to an improvement action ( should do s ). Stage 2: development of an organisation wide Quality Improvement Plan encompassing key quality improvement initiatives e.g. Quality Challenge key improvement themes, Sign up to Safety and organisation-wide assessment of CQC improvement actions and concerns. This will be developed in June A lead Director and lead manager is accountable for each Quality Improvement Plan action. A key principle underpinning the Quality Improvement Plan is the requirement to evidence the impact and embeddedness of improvement actions. For many actions this is achieved by the requirement to evidence 3-5 consecutive clean spot checks / audits. Wherever appropriate, this is being incorporated into existing audit activities e.g. environmental audit, documentation audit The NHS Trust Development Authority (TDA) has reviewed and provided advice about the LCH approach, drawing on their experience in supporting other Trusts, which has been incorporated into the plan SMT has had close oversight of development and implementation of the plan. Going forward, updating and reviewing progress will be incorporated into the Business Unit monthly performance review and reported monthly to SMT. A report was presented to Quality Committee on 20 May 2015 who requested bi-monthly progress reporting with exception reporting in the intervening months. 4

22 3.0 CURRENT POSITION The Trust has made significant progress in progressing nearly all improvements in the plan. Six actions have been completed. A number of actions require further time to undertake repeat audits / spot-checks to provide assurance of the impact and embeddedness of improvements before being considered complete. 3.2 Key Areas for Improvement and Progress to Date COMPLIANCE ACTIONS The Trust has made good progress in addressing both compliance actions. The action plan was submitted on the 15 May 2015 as required. The action relating to the recording of risk assessments on CAMHS electronic patient records was reported as complete. This contributed to the CAMHS requires improvement rating for the safe domain. Good progress has been made in addressing patient safety risks associated with Little Woodhouse Hall. The work to remove the ligature risk from windows and taps is expected to be complete in June SMT will review an options appraisal of suitable alternative premises and the potential for making improvements to Little Woodhouse Hall, in early June. This action was the reason the CQC gave CAMHS in-patients a requires improvement rating for the safe domain. IMPROVEMENT ACTIONS Safe As indicated in the CQC ratings table at para above, safe is the domain which presents the greatest challenge as four of the six service clusters were assessed as requires improvement. In addition to the compliance actions, a key issue causing the requires improvement rating for the safe domain was the CQC s assessment of the potential impact of staffing levels on care in CAMHS outpatients, adult neighbourhood teams and South Leeds Independence Centre (SLIC). Recruitment is one of the organisation s top priorities for 2015/16 and is well sighted on the Trust s recruitment and retention approach, receiving regular progress reports through Business Committee. As discussed at the Quality Summit on 20 April 2015, due to local and national workforce supply constraints, there is a real risk of the Trust not being able to fully recruit to establishment. The Board is also sighted on the pro-active approach the Trust has taken to ensure safe and effective staffing levels at SLIC, holding the financial risk of funding to the required level of nursing pending the outcome of the multi agency review of the service, and using bank / agency staff pending recruitment to vacancies. 5

23 The Trust has also had a concerted focus on strengthening monitoring and reporting of staffing levels e.g. the development of daily sitrep reporting to the service and business unit for adult neighbourhood teams and further development of safe staffing reporting for in-patient units, including use of agency staff and strengthening review with escalation from business unit to senior management team. Development of quality impact assessment reporting and service level reporting will also provide further assurance about service delivery The Trust is making satisfactory progress in addressing the other CQC improvement actions for the safe domain which relate to: Adults services: transcription of medicines SLIC: strengthening assessment and care planning processes, resuscitation procedures and practice, equipment maintenance and access to emergency drugs CAMHS in-patient unit: analysing occasions when restraint is used to reduce risk to patients, and ensuring Leeds General Infirmary security guards assisting with restraint are suitably trained Effective The requires improvement rating for the effective domain relates to SLIC. The principal improvement action relates to ensuring initial assessments and discharge plans are promptly undertaken and care plans sufficiently patient centred. Care planning, including discharge planning processes have been strengthened and are being audited to ensure compliance There were also improvement actions for the effective domain relating to: reviewing how health visiting and school nursing work together; this will be progressed through the service review of the health visiting service, currently underway ensuring school nurses are aware of how to access archived health records: protocols amended and communicated to staff, practice being audited ensuring training and supervision is recorded on electronic systems Responsive The requires improvement rating for the responsive domain reflects CQC s assessment that: SLIC should strengthen assessment of patient dependency to ensure patients needs can be met. A care needs tool was being piloted at the time of the CQC inspection and has now been implemented. Electronic reporting is being developed 6

24 waiting times for some CAMHS out patient clinics were excessive. The Trust is addressing this through several initiatives: continuation of the waiting list reduction initiative; 15/16 CQIN to reduce waiting times for consultation clinics to 12 weeks; a service review which should identify more transformational opportunities to improve the efficiency and effectiveness of the service, including reducing waiting times. Reducing CAMHS waiting times will also depend on the outcome of the forthcoming commissioner review of emotional health and well-being Well Led Trust received a good rating for the well-led domain. The reports included recommendations relating to: ensuring investigations of clinical incidents are timely: being addressed through revision of the SI Policy and associated training and communication to staff improving reporting on outcome measures both organisation-wide and specifically at SLIC. The Board is well sighted on work underway to develop outcome reporting The CQC indicated concerns ( could do s ) in relation to the Trust audit approach, risk management and staff morale. The Board is sighted on actions being taken to strengthen risk management organisation-wide and staff morale. The 15/16 audit work plan is being submitted to June 2015 Quality Committee for approval. 4.0 IMPACT 4.1 Financial/Resource Additional capacity implications have been identified from the following CQC improvement actions / concerns: increasing and improving clinical audit developing outcome monitoring and reporting SMT are considering these as part of the wider review of corporate services. 4.2 Risk A robust and effective approach to addressing the compliance and improvement actions set out in the CQC s inspection report will support mitigation of the following board assurance framework risks: ineffective systems and processes for assessing the quality of service delivery and compliance with regulatory standards failure to implement and embed lessons learned from internal and external recommendations failure to achieve foundation trust status lack of internal capacity to secure quality and drive transformational change 7

25 4.3 Legal/Regulatory There are no legal implications that the Board needs to take into account. 5.0 NEXT STEPS 5.1 SMT will sign off the action plan for improvement actions on 27 May 2015 prior to submission to the CQC also on 27 May SMT will receive monthly progress reports which will inform bi-monthly progress reporting to Quality Committee and exception reporting in the intervening months. The Board will receive assurance from Quality Committee on progress with implementation of the plan. 5.3 The Trust will link with the CQC to establish regular engagement meetings. 5.4 The Stage two organisation-wide Quality Improvement Plan will be developed in June for review by the SMT prior to submission to the Quality Committee for approval. 6.0 RECOMMENDATIONS 6.1 The Committee is recommended to: receive significant assurance on the approach and progress made to date with development and implementation of the Stage 1 Quality Improvement Plan note the plan for development of an organisation-wide Quality Improvement Plan in June 2015 (Stage 2) approve the proposed monitoring and reporting arrangements through the SMT and Quality Committee to Board 8

26 AGENDA ITEM (22) Report to: Trust Board Date of meeting: 4 June 2015 Report title: Quality Account Responsible Director: Interim Director of Nursing/Executive Medical Director Report author: Professional Lead for AHP Previously considered by: Quality committee 20 May 2015, EXECUTIVE SUMMARY Attached is the quality account for Leeds Community Healthcare NHS Trust for 2014/15. The quality committee is recommending the quality account to the Board for approval. The quality account has been developed in line with guidance given in the Department of Health Quality Account tool kit and the quality account regulations. The priorities for quality improvement have been identified through a review of performance data, consideration of feedback from CQC, TDA and CCGs, engagement with stakeholders and learning form incidents and complaints. Projected outcomes and indicators have been agreed with relevant operational and corporate leads. The priorities will be monitored through a number of routes including the integrated performance report and the development of the quality improvement plan. Progress against the priorities will be overseen by the quality committee through quarterly reporting to the clinical effectiveness group. A draft version of the quality account has been sent to partner organisations for comment. They have found the account to be an honest reflection of the quality of services provided and are supportive of the priorities identified. Healthwatch have commended our stakeholder engagement. The final document will be submitted to Department of Health via NHS Choices by 30 June RECOMMENDATIONS The Board is recommended to: Approve the quality account Page 1 of 2

27 Links to strategic objectives: Links to principal risks: NHS Constitution: CQC Outcomes: Equality and diversity: Sustainability Implications: Publication Under Freedom of Information Act: This report supports the following strategic objectives: To provide high quality, safe services, continuously improving patient experience and measuring our success in outcomes Risk to achieving the strategic objective: To provide high quality, safe services, continuously improving patient experience and measuring our success in outcomes This report supports the following principles, values, rights and pledges in the NHS Constitution: The provision of high quality care that is safe, effective and focused on patient experience Commitment to quality of care Outcome 4. Care and welfare of people who use services Outcome16. Assessing and monitoring the quality of service provision An Equality Analysis screening form has not been completed because the report does not relate to a new or revised policy, strategy, project or service. This paper supports sustainability by reducing the number of subgroups and the frequency of written reports whilst improving the quality of the governance arrangements. This paper is available for publication under the Freedom of Information Act. Page 2 of 2

28 Leeds Community Healthcare NHS Trust Quality account 2014/15 Contents Introduction... 3 Statement of directors responsibilities in respect of the Quality Account... 3 Section 1 A review of quality in LCH... 5 Safety... 5 Safeguarding... 6 Incident management... 6 Sign up to safety... 7 Pressure Ulcers... 8 Falls... 9 Infection prevention and control... 9 Effective Appraisals Clinical supervision Outcome measures Caring Patient satisfaction Responsive Serious incident look back Complaints Equality and diversity Well led Leadership and Staff engagement Members priorities Section 2 Statements on quality as mandated in the regulations Review of services Transformation: Service Reviews and Developing Improvement Capability National clinical audits Local Clinical Audit Clinical research Commissioning for quality and innovation (CQUIN) CQC registration Secondary uses and hospital episode data Information governance Payment by Results Staff satisfaction Page 1 of 43

29 Patient experience of community mental health services Patient safety incidents Section 3 Quality improvements for the coming year Safety Effectiveness Caring Responsiveness Well led How quality will be monitored throughout the year Section 4 Statements from others on the quality of LCH services Acknowledgements Glossary How to comment on the Quality Account Page 2 of 43

30 Introduction Welcome to the 2014/15 Quality Account for Leeds Community Healthcare NHS Trust (LCH). This account sets out our achievements and challenges in relation to quality in the last year and the areas we have identified as quality priorities for the coming year. LCH has seen a number of changes in the executive and non-executive team this year. We welcome our new Chief Executive, Thea Stien and a new non-executive director, Brodie Clark. Our Executive (Nurse) Director of Quality has retired and we are currently in the process of recruiting an Executive Director of nursing and therapies. The overall performance of LCH in 2014/15 has been strong and we have continued to deliver against the majority of quality targets. LCH has a strong incident reporting culture and continues to be in the top three community organisations for reporting incidents. We have increased the percentage of staff that have received an appraisal and staff have continued to ensure they have relevant training for their role. Twenty services have been through a service review and have identified the measures we will monitor to ensure the changes do not impact on quality. We have co-located community nursing and adult social care establishing 13 neighbourhood teams to work closely with GP practices. We have introduced the patient friends and family test and patient satisfaction remains above 95%. We know that we still have improvements to make in some areas of quality. We have had a high incidence of falls within the inpatient units and a high incidence of pressure ulcers across our community nursing services. We have also seen an increase in the number of serious incidents in our inpatient units. Staff morale is low and staff engagement is poorwe continue to have higher than average staff off sick. We have also faced the same challenges as other organisations with regards to nurse recruitment. As a result of this some services have been under considerable pressure. We have managed this risk through the year by using agency staff. This year we have had our first full inspection from the Care Quality Commission (CQC). They found our staff to be very caring and the services that we provide to be effective. They noted that patient feedback was good and that patients were treated with dignity and respect. The CQC felt that we need to improve our responsiveness, leadership and safety. They particularly want us to look at how quickly we are able to see and assess children in the community children s and adolescent mental health service and how we make sure that any risks we have identified in the inpatient unit are recorded where everyone can see them. The CQC agreed with us that staff morale at the moment is low even though most people feel well supported by their immediate line manager. They noted that the culture of the organisation is open and supportive of learning from incidents however staff are weary of change. They would like us to look at how we share the learning from incidents across the services. This is something that we have included in the priorities for quality improvement for next year. Statement of directors responsibilities in respect of the Quality Account The directors are required under the Health Act 2009 to prepare a Quality Account for each financial year. The Department of Health has issued guidance on the form and content of annual Quality Accounts (which incorporates the legal requirements in the Health Act 2009 and the National Health Service (Quality Accounts) Regulations 2010 (as amended by the National Health Service (Quality Accounts) Amendment Regulations 2011). Page 3 of 43

31 In preparing the Quality Account, directors are required to take steps to satisfy themselves that: The Quality Account presents a balanced picture of the trust s performance over the period covered The performance information reported in the Quality Account is reliable and accurate There are proper internal controls over the collection and reporting of the measures of performance included in the Quality Account, and these controls are subject to review to confirm that they are working effectively in practice The data underpinning the measures of performance reported in the Quality Account is robust and reliable, conforms to specified data quality standards and prescribed definitions, and is subject to appropriate scrutiny and review, and The Quality Account has been prepared in accordance with Department of Health guidance. The directors confirm to the best of their knowledge and belief they have complied with the above requirements in preparing the Quality Account. By order of the Board...Date...Chair...Date...Chief Executive Page 4 of 43

32 Section 1 A review of quality in LCH Leeds Community Healthcare NHS Trust (LCH) published a quality strategy in 2012 setting out our vision for quality improvement until The definition of quality in that document described quality as effectiveness, safety and experience. In last year s quality account we expanded that definition to reflect the Care Quality Commission (CQC) domains of quality (safe, effective, caring, responsive and well led). This section of the quality account will review the priorities we set for ourselves under each of the CQC domains as well as describing some of the achievements and challenges over the last year. Safety The table below shows the priorities relating to safety that we set last year, the progress we have made against each target and what we will now do in relation to each priority. Quality area for action Safeguard ing adults and children: 90% of staff to have received training Protect people from harm: 90% of staff trained in infection prevention and control Achievements to date / / / / / /15 Percentage staff trained- adults Percentage staff trained - Childrens Percentage staff trained MCA Target Percentage staff trained Target Comments we have increased the number of staff who have been trained in safeguarding children compared to 3 years ago and this year we have made progress with increasing the number of staff who are trained in safeguarding adults. Next year we would like to focus on the quality of our services in relation to the areas that have been identified in safeguarding referrals. We will continue to monitor safeguarding training as part of individual service performance reviews. Over the last 3 years we have consistently improved the percentage of staff that have been trained in infection prevention and control. This will remain a priority for staff training and will be monitored through the service performance review process. Page 5 of 43

33 Reporting incidents: 70% of incidents reported will have resulted in no harm / / /15 Percentage no harm Target The percentage of incidents that occur in our care that result in no harm is consistently better than similar organisations. We will continue to monitor this through the performance process and next year replace it with a priority that looks at learning from incidents rather than the process of reporting. Safeguarding Improving uptake of safeguarding training has been a priority for us in each of our quality accounts for the last 3 years. Staff are supported in fulfilling their responsibilities by the trusts safeguarding team. Over the past year the safeguarding team has focused on learning from best practice, incidents, complaints, serious case reviews and domestic homicide reviews to safeguard those who are least able to protect themselves. Learning has contributed to the development of guidance and policies for our staff and those working in other agencies. This includes advice on how to manage bruises in non-ambulant children, and how to identify possible Child Sexual Exploitation in young people. Learning is also shared through Lunch and Learn sessions, team meetings and briefings to staff. In March 2014 the Supreme Court made a ruling that anyone over the age of eighteen, who lacks mental capacity to make decisions about care and treatment and is under continuous care and control and not free to leave cannot lawfully be detained without a Deprivation of Liberty Safeguard (DoLS) authorisation. This has resulted in a rise in the number of DoLS assessments our in-patient units need to make. Bespoke training and regular support visits to the units have been introduced to equip staff with the knowledge and skills to safeguard individuals in our care, to ensure staff always act in the best interests of our patients and to ensure staff consider what solution is the least restrictive. Furthermore the LCH Restraint Policy has been developed to ensure we consider all aspects of restraint and employ the least restrictive measures. In the past twelve months a tremendous amount of work has been done to increase awareness around dementia with the introduction of dementia friends with customer service staff and practitioners. The Trust has recently become a member of the Dementia Action Alliance. This year we have completed the safeguarding action plan for the Community Intermediate Care Unit (CICU). The safeguarding board commended the work that the CICU team had undertaken to address the issues raised. We have had further safeguarding issues this year in the South Leeds Independence Centre (SLIC) and we are currently working with commissioners and the safeguarding board to address this. Incident management We have a good incident reporting culture within LCH and the number of reported incidents benchmark well with other similarly profiled organisations. A good level of incident reporting is Page 6 of 43

34 considered positive in creating a robust reporting culture where staff recognise and learn from patient safety incidents. Last year we said we would improve our incident management by: Continuing to require staff to report incidents Continuing to train staff in how to report incidents Continuing to investigate every patient safety incident to find out why and how the incident occurred and what can be done to prevent it happening again Continuing to ensure we learn from incidents through the development and implementation of action plans and learning for patient safety memos Developing processes to ensure the appropriate escalation of incidents We have supported staff to report incidents through: a poster campaign to remind staff how to report concerns and incidents; providing information about reporting incidents at the monthly Trust Induction event; providing dedicated support with incident reporting and visiting staff and teams on a request basis to provide refresher training and advice. Our incident reporting has increased this year showing a good reporting culture across the organisation. The incident management process ensures that all patient safety incidents are assigned to an appropriate manager for investigation as quickly as possible. Specialist reviewers work with the managers for specified categories of incidents, such as pressure ulcers. The specialist reviewer will monitor any trends and identify any actions required to address gaps in the standard of service or areas for improvement. A monthly report to the senior management team identifies themes and trends from all reported incidents and examines major harm and serious incidents in detail. Any areas of concern are identified and required actions detailed. The senior management team are responsible for sharing this information with the relevant committees and Board. All of the information gathered, including concerns and action required, is shared with the business unit managers. The business unit managers and clinical leads are responsible for seeing that teams receive feedback about incidents, lessons learnt and actions to be taken. Safety memos are used to widely communicate learning from incidents across services. We are currently looking at new ways of sharing and communicating learning with services such as encouraging services to access the Datix dashboards, exploring setting up an incident and experience group, and developing a newsletter for staff sharing quality matters. Details of incidents reported this year and how we compare with other organisations is included with the statements that we are mandated to make further on in the quality account under patient safety incidents. Sign up to safety This year we joined the sign up to safety campaign. This is a national campaign launched by NHS England that aims to deliver harm free care to every patient, every time, everywhere. The campaign challenges every organisation that signs up to identify what actions they will take to reduce harm over the next 3 years. Organisations are expected to develop an action plan and publish this on their website. There are 5 pledges for which each organisation has to agree actions. These, along with our pledge are summarised in the table below. Pledge Putting safety first. Commit to reduce avoidable harm in Our actions We will continue to be a high reporter of incidents with a high percentage of low or no harm incidents reported Page 7 of 43

35 the NHS by half and make public our locally developed goals and plans We will develop and implement safety improvement plans for the main causes of avoidable patient harm identified through our incident reporting falls and pressure ulcers. We will reduce by 75% over 3 years the number of reported falls on LCH in-patient units. We will reduce by 30% over 3 years the number of reported falls resulting in avoidable harm on LCH in-patient units We will reduce by 50% over 3 years the number of reported falls in our Neighbourhood teams. Continually learn. Make our organisation more resilient to risks, by acting on the feedback from patients and staff and by constantly measuring and monitoring how safe our services are We will reduce by 50% the number of category 2 and 3 pressure ulcers acquired by patients in LCH care and have no category 4 pressure ulcers. Triangulate data from patient feedback including Friends and Family, patient survey, compliments, comments and complaints to ensure that patient experience in relation to safety influences safety improvement plans. Complete root cause analysis investigations for all major harm incidents that are assessed as avoidable or as a direct result of LCH care. Establish safety notices that are visible in our inpatient units to publish incident figures, days free from harm and learning from incidents Ensure learning from incidents are a standard agenda item on all clinical forum and team meetings Being honest. Be transparent with people about our progress to tackle patient safety issues and support staff to be candid with patients and their families if something goes wrong Collaborating. Take a lead role in supporting local collaborative learning, so that improvements are made across all of the local services that patients use Being supportive. Help people understand why things go wrong and how to put them right. Give staff the time and support to improve and celebrate progress Explore new media for sharing the learning from incidents and LCH quality data. Embed duty of candour within the organisation and develop staff to feel comfortable saying sorry when harm has been caused. Encourage open and honest reporting of when mistakes occur by providing feedback and support to teams and services. Develop the integrated performance report to identify where improvements are required and monitor progress. LCH will work with key stakeholders in both the neighbourhood teams and community bed bases in order to share knowledge and reduce avoidable patient harm as a result of falls. LCH will share learning with key stakeholders who were involved in the patient s care where major or moderate harm occurred. LCH will work with other key stakeholders on the city wide pressure ulcer action plan. Increase shared learning when mistakes are made through service/team level feedback. Support teams by providing service specific incident/complaints feedback to improve motivation to report and share learning. Develop service specific Clinical Supervision Models. Explore use of the LCH intranet to share learning and good news stories. Develop staff to use improvement science (Improvement Academy) as a means of reducing incidents resulting in harm. We have included some of the targets identified in this campaign in our quality priorities for this year in section 3. We are currently working with services to agree what actions we need to take and agree the action plans. Pressure Ulcers The national institute for clinical excellence (NICE) describes a pressure ulcer as damaged caused to the skin and the tissue below when it is placed under enough pressure to stop the blood flowing. Page 8 of 43

36 This can occur when a person spends a lot of time in a chair or a bed because of illness. The damage caused is categorised into one of 4 categories with 4 being the worst. We ask staff to report all pressure ulcers as safety incidents. This year we had agreed a quality improvement plan with our commissioners aimed at reducing the prevalence of pressure ulcers happening in our organisation and to work with the teaching hospital to reduce the prevalence of pressure ulcers altogether. We did not meet the target for reducing pressure ulcer prevalence agreed with commissioners and we have reported 59 pressure ulcers as serious incidents. Four of these were category 4 pressure ulcers. We recognise that this is high and we have a plan in place to reduce this to zero for next year. We have introduced a standardised assessment tool that has been developed with university partners and we have ensured that all our nursing staff are up to date with their training. We have also developed and introduced a training programme for allied health professionals and support workers so that they are trained in spotting the signs and symptoms of a pressure ulcer developing. Falls Falls continue to be a major healthcare concern. Falls have accounted for up to 19% per quarter of all reported incidents in the last year within the Trust. This is a reduction on the 22% we reported in last year s quality account. The consequences of a fall can impact on quality of life and wellbeing of both patients and their carers/families, therefore it is important to have effective falls risk assessment and management strategies in place to address this. The Trust has developed a work plan identifying actions required to address, monitor and manage falls within LCH. The following are key areas being implemented and monitored to ensure that falls risk is being effectively managed within the Trust: Falls education sessions to key LCH services to promote greater awareness of falls risk, and encourage a more standardised approach to falls risk assessment and management across these services Development of Standard Operating Procedures for reducing the risk of falls among patients in their own homes, and within the bed bases and inpatient units Update of the LCH Prevention of Patient Slips, Trips and Falls Policy Ongoing review of the LCH falls pathway in line with NICE guidance and in light of the health and social care integration Partnership working with other organisations such as Age UK and Public Health to pilot evidence-based community group falls prevention exercise programmes Sign up to Safety campaign with focus on falls reduction Infection prevention and control LCH does not accept that healthcare associated infections (HCAIs) are an inevitable part of, or acceptable risk related to care delivery. In the pursuit of a zero tolerance for avoidable HCAI the Infection Prevention Team have worked closely with all LCH care delivery teams and will continue to systematically review practice and performance against locally and nationally established targets. Effective hand hygiene is the single most important way to reduce the spread of infection. Within LCH all staff have to Page 9 of 43

37 attend specific infection prevention and control training, where the importance of correct hand washing and being bare below the elbows is emphasised. Compliance with hand hygiene requirements is monitored throughout the organisation using peer assessments and also ad hoc reviews from the Infection Prevention Team. Over the past year new technology has been introduced to scientifically identify how clean staff members hands really are. Use of ATP machine to assess hand cleanliness Although there are no specific government targets for infections caused by germs such as Meticillin resistant Staphylococcus aureus (MRSA) and Clostridium difficile (CDI), the organisation has a locally agreed target of no more than 2 cases of MRSA blood stream infection and 3 cases of CDI, directly attributed to LCH within the year. Graph 1 shows the year on year comparison for MRSA bacteraemia within LCH For the year 2014/15 one case of MRSA bacteraemia was attributed to LCH involvement during June A full review of the circumstances relating to this incident was undertaken and learning around the management of urinary MRSA Bacteraemia Cases Attributed to LCH Page 10 of 43 catheters, clinical documentation and antibiotic prescribing was identified and shared both locally and throughout the organisation. The implementation of this learning within the respective clinical teams has been monitored, with progress being reported to the Infection Prevention Group and Senior Management Team. Graph 1 MRSA bacteraemia cases attributed to LCH 0 During the report period 2014/15 three 2009/ / / /3 2013/ /15 cases of CDI have been identified on LCH in-patient areas. All three of the cases have been subject to a review process as recommended by NHS England and deemed to be unavoidable, with no lapse in care from LCH teams being identified.. The 3 cases are not attributable to LCH care and we therefore CDI Cases Attributed to LCH did not reach our locally agreed target Awaiting discounting of cases Graph 2 Clostridium difficile cases attributed to LCH 2 The Infection Prevention Team has continued to foster relationships with the 0 Trust membership and involved a number 2009/ / / /3 2013/ /15 of members in the assessment of infection prevention activities within both in-patient areas and health centres. The Safe Clean Care Project, which forms the framework for the patient assessment has received a runner up prize at the recent Nursing Times awards. Work has been done with the Trust Development Authority (TDA) to review and progress the infection prevention agenda within the organisation. An educational event, facilitated by the TDA

38 was held in February. This workshop explored the processes involved in reviewing untoward incidents and provided staff with an enhanced understanding of the Root Cause Analysis (RCA) method of investigating these situations. LCH members assessing infection prevention practices at an LCH health centre Further work is being done to enhance the surveillance of specific infections within the wider community healthcare economy. LCH, as part of a programme called the Safety Thermometer monitors the infection status of patients receiving care from LCH services to provide assurances as to the standards of safe practice being provided by care teams. The graph below shows the monthly prevalence figures for infections experienced by patients with indwelling urinary catheters. 1 Percentage of Patients with a CAUTI Percentage Leeds Community Healthcare (excl. SLIC) National Average (Community Services)** 0 Feb-14 Apr-14 Jun-14 Aug-14 Oct-14 Dec-14 As demonstrated in the graph, the average rate of infection within the LCH patient cohort is significantly lower than the national average for all months except August Each case identified is reviewed, with any learning shared throughout the organisation. The prevention of HCAI remains a key organisational priority for LCH. The effective prevention and control of HCAI will continue to remain at the forefront of LCH strategy and form an important part of the delivery of quality healthcare within Leeds. Effective The table below shows the priorities relating to effectiveness that we set last year, the progress we have made against each target and what we will do in relation to each priority. Quality area for action Continue to develop the robustness of outcome measures. Services will have agreed individual outcome measure targets. Achievements to date We have not made as much progress with this area of quality improvement as we would have liked to. Service Reviews have posed a challenge to some services in progressing this work. Services have been classified as being in one of three different positions with regard to their progress in embedding outcome measures in practice. These are: Position 1: the service has outcome measures in use and is able to collect, analyse and report on the data. (30% of services) Position 2: the service has identified relevant outcome measures, ways to collect data and is collecting data. They are not yet fully analysing or reporting on the data collected. (35% of services) Position 3: services are currently reporting their outcomes as outputs. (31.5% of services) Comments Work is being undertaken within the business units, with support from the clinical leads, to positively improve the position at which services currently sit. This work will continue next year with some specific targets being agreed for identified services. Page 11 of 43

39 Continue to embed clinical supervision for clinical staff: 75% of clinical staff engaging in supervision / / /15 Percentage staff receiving clinical supervision Target We aim to ensure our clinical staff are supported through clinical supervision. We have set a target of 75% for the last 3 years. We have not yet achieved this target so we are keeping this as a priority for quality improvement next year. Ensure all staff receive an appraisal: 90% of staff have had an appraisal in the last year / / /15 Percentage staff with appraisal Target This year we have increased appraisal activity by 5% moving towards our target of 90% of staff having an appraisal. We will continue to monitor this through service performance reviews and focus next year on benchmarking wellstructured appraisals. Contribute to transformation of services for the people in Leeds: Relevant services to have taken part in a service review Patient records: 75% of all audited notes will show the following criteria as complete: 20 service reviews have been undertaken this year. Staff and service users have been actively involved in the service re-design process through attendance at workshops, newsletters and active involvement in working groups. Over 50 staff have been involved in active learning programmes around developing their improvement and innovation knowledge and skills. Criteria 3; Assessment of patient needs Criteria 4; An action/treatment plan in relation to the identified needs including any risks and; Criteria 5; Interventions being implemented according to the action/treatment plan as fully met. LCH met its target for all 3 of the criteria with performance well exceeding 75%. Performance for all 3 criteria has also significantly improved from 2013/14. Page 12 of 43 We have successfully undertaken a number of service reviews. We will continue to monitor the impact of these changes through individual service performance panels. Action plans are in place to monitor those services that are not fully compliant with record keeping standards. Regular audits are undertaken to monitor performance and ensure that the quality of record keeping is improving across the Trust. Staff have been issued with documentation prompt cards and record keeping is included in all relevant appraisals. We will continue to focus on improving patient records next year.

40 80% 60% 40% 2013/ /15 20% 0% Criterion 3Criterion 4Criterion 5 Appraisals Over the past 12 months there has been significant progress with the appraisal system as a whole. The 5% increase in appraisal activity has been supported by the development and introduction of a toolkit, refocused training content and the feedback received from the qualitative review. The toolkit highlights the core appraisal documentation that managers and staff are required to use which supports the appraisal conversation, provides consistency and gives a benchmark for the qualitative review. The training content has had renewed focus on feedback skills which provides managers with a framework to support their conversations. In 2015/16 the Trust will be rolling out a behavioural framework which will refocus our appraisal arrangements and training. Our priority in 2015/16 is to aspire to improve and meet the Community Trust benchmark for a well-structured appraisal. Clinical supervision Clinical supervision provides an opportunity for staff to: Reflect on and review their practice. Discuss individual cases in depth. Change or modify their practice and identify training and continuing development needs. (CQC 2013). Over 2014/15 LCH has actively engaged with clinical staff to develop a culture that supports practitioners to seek supervision and value it has part of their practice. We established a Clinical Supervision Working Group to review, develop and implement a new trust wide Clinical Supervision Policy. The development process involved practitioners from every service. All clinical services now have an agreed model that describes how they will deliver the new policy s standards and principles from April Taking this approach reflects the diversity of services provided to communities in Leeds and the differing needs of practitioners delivering clinical care. Already the change in culture has seen services: Changing and increasing the number practitioners requiring clinical supervision. Dental / medical staff and unregistered practitioners providing direct care to patients along with registered nurses and AHPs are now required to have supervision The development of service improvement programme within Health And Justice in partnership with Leeds University meeting the complexity of clinical situations within prison and custody healthcare settings The development of an introduction to clinical supervision incorporated into service inductions programmes Page 13 of 43

41 Improved recording of supervision using the electronic staff record and linking to staff appraisal and objectives Making these changes has identified the lack of a robust means for all services to collate information on clinical supervision uptake. The Trust has moved to using the Electronic Staff Record [ESR], which provides both practitioners and managers with rapid access to information. Where services are fully using the ESR system 96% of practitioners are having clinical supervision according to guidance, compared to 54% for the trust as a whole. This recognises that there is more work to do. 2015/16 will see: All services using the ESR reporting process A database of supervisors across the organisation Development of developmental and support for supervisors Development of processes to demonstrate the quality of supervision Outcome measures Clinical outcome measures are Measures that demonstrate the impact of clinical intervention over time for the patient and/or carers. Services have been asked to identify at least one clinical outcome measure as an indicator of the effectiveness of the care they have given. As shown in the table above, the progress that services have made with identifying and using clinical outcome measures have been grouped into 3 different positions. The aim is that all services are able to attain position 1 (where they have outcome measures in use and are able to collect, analyse and report on the data). Thirty percent of our services have achieved this. The clinical leads and the Quality and Professional Development Department are supporting the remaining services to achieve this. Developing clinical outcome measures has been a priority for LCH for the last 3 years. It is disappointing that we have not yet got outcome measures in every service. Despite this there has been some innovative work and our dietetics service have lead on the development of a clinical outcome measure that has been adopted in many other organisations. The dietetics service developed a set of Therapy Outcome Measures (TOMs) which can be used to enable the service to: identify the effectiveness of dietetic interventions; improve reflection on practice and job satisfaction; support service development and improvement; and, provide evidence that services are clinically and cost effective. A 6 month pilot involved TOMs being developed for the following 6 areas: obesity, under nutrition, home enteral feeding (HEF), diabetes, irritable bowel syndrome (IBS) and cardiovascular disease (CVD). After piloting, analysis was carried out based on the findings from the patient sample and focus groups were undertaken with the staff to understand how TOMs could contribute to their work, professional practice and job satisfaction. The focus groups identified that developing TOMs has meant a cultural change in how dieticians perceive their practice and reflect on both practitioner and intervention effectiveness. TOMs have led to change in practice discussions.. The evaluation of the first six months of dietetic TOM s has demonstrated that TOMs can enable us to assess our effectiveness, make improvements, demonstrate to our customers the effectiveness of what we do, to ensure we continue to improve and deliver the best possible care to the community of Leeds. Further work and greater numbers are required to embed TOMs, and understand how to develop and improve practice further. Page 14 of 43

42 Caring The table below shows the priorities relating to caring and experience that we set last year, the progress we have made against each target and what we will do in relation to each priority. Quality area for action Involving people and partners; 90% report that they are involved in the planning of their care. Achievements to date / / /15 Percentage involved in care Target Comments The percentage of people who feel invoved in the planning of their care has dropped. The drop has happened in the last 3 months of the year and we are still working with services to understand why this is. We will continue to monitor this through patient satisfaction surveys and service performance panels. Friends and family test (FFT) for patients: the test will be implement ed in all services Uptake of friends and family test We have met the requirements set out by NHS England and achieved our target to impliment FFT in all services. Our focus for next year will be on the qulaity of services people receive so they continue to recommend our services to others. 0 April May June July Aug Sept Oct Nov Dec Jan Feb Mar Patient satisfaction For the past three years LCH has gained the views from patients/service users through the organisational Patient Satisfaction Survey (PSS) which asks a total of 6 questions and provides the opportunity for free text responses to three questions; What do we do well? What can we do better? Is there anything else you want to tell us? The Friends and Family Test (FFT) was introduced for some NHS providers in 2013 to ask patients whether they would recommend services to their friends and family if they needed similar care or treatment. The FFT was expanded to mental health and community services on 1 January LCH has incorporated the nationally required Friends and Family Test (FFT) into the local Patient Satisfaction Survey (PSS). We have been collecting FFT data for the majority of services since April 2014, and all services since January Page 15 of 43

43 % satisfaction Average Patient Satisfaction Across all LCH Services Target 95% The table above shows that patient satisfaction declined between October and January and is now beginning to improve again. The deline in patient satisfaction happened at the same time as the majority of our services were going through the service review process. Staff moral has been affected and this has clearly had an impact on how satisfied patients are with the care they received. As services are settling into new structures and changes, patient satisfaction is beginning to rise again. Services have been working to understand the reasons for the decline and actions needed to reverse this. This work will continue throughout 2015/16. While satisfaction with the services has decreased, patients would still recommend our services to family and friends. The overall FFT score for the organisation has remained above 90% since April FFT results: I would recommend this service to friends and family April May June July Aug Sept Oct Nov Dec Jan Feb Mar 6Cs = Care, compassion, competence, communication, courage, commitment In December 2012 the NHS England Chief Nursing Officer Jane Cummings launched the 6Cs. Care, compassion, courage, communication, commitment and competence form the bedrock of the national nursing strategy and apply to all staff and services in LCH. Work is ongoing to ensure that the values and standards required to create the right culture to provide really excellent care are consistently delivered by staff. South Leeds Independence Centre (SLCI) staff have a detailed improvement plan which includes: ensuring patients have the opportunity to discuss their wishes, goals and aims for planning their discharge from admission and assessing care. Page 16 of 43

44 developing further the way information is shared with patients with compassion, with the team being open and honest improving their communication to each other, handing over care from shift to shift the commitment of staff always listening to patients, discussing their experiences and stay, gaining an objective view. An activity co-ordinator is currently working alongside staff to provide stimulating sessions which patients have requested. The environment is also being improved for patients diagnosed with dementia. an updated training programme for new staff on their induction is supporting staff in their development and gaining competencies so that the right staff have the right skills for the job to be done Staff are encouraged and supported to speak up and having courage to do so when they have a concern about any part of their job and service so that actions can be taken to improve staff and patient experiences Rachel Barber and Katherine Davies, Therapists say that we are committed to providing high quality care, which is the best possible care for our patients, through valuing patient experiences and by seeking feedback from them and their visitors in a number of ways. We are continuously listening to views of our patients and visitors to learn and improve our service. Responsive The table below shows the priorities relating to responsiveness that we set last year, the progress we have made against each target and what we will do in relation to each priority. Quality area for action Learning from major harm incidents: 100% of major harm incidents will have a completed Root Cause Analysis. Continuously improve our learning from patient feedback: regularly collect feedback from our inpatient units and share this on our website. Achievements to date All major harm incidents were reviewed as per the Trust criteria to see if we needed to carry out a Root Cause Analysis (RCA). Out of the 16 major harm incidents, four were deemed not to require an RCA, as the patient fell within their own home. The preliminary investigation found, they had been appropriately assessed and the correct action plan was in place. Five of the incidents have completed RCA investigation. Seven remain under investigation. A detailed audit of the process has not been undertaken. A look back at Serious Incident management was prioritised as an alternative following recommendations made by the Trust Development Authority. An audit will be planned for the forthcoming year. 11 LPS memos were sent out to share learning from incidents across the organisation. This year we began to hold regular feedback sessions on 2 of our inpatient units. Tea parties have been held on CICU since May 2014 and SLIC since August 2014 to provide both social activity and facilitate feedback. All feedback is responded to and learning and improvement identified. This is shared through you said we did displays and publiscised on the Members Zone of the website embership_/members_zone1/feedback_and_reports_20 14/ We have not done as well as we would have liked with Page 17 of 43 Comments We are consistently good at completing RCAs were necessary and ensuring that the findings are shared in patient safety memos. We need to audit how effectively we learn from incidents and we will continue this as a priority for next year. We will continue to hold tea parties on our inpatient unit to collect feedback. We will monitor the action plans developed from complaints and publish action we have taken as a result on our website.

45 sharing learning from complaints beyond the service in which they occurred. We have refreshed the complaints procedure and process at the beginning of January 2015 to address this. Serious incident look back This year the Trust Development Authority suggested that we look back at the incidents from the previous year to identify if any of those that cause harm would this year have been classified as a serious incident as the criteria had changed. This study concluded that LCH would have reported an additional 41 incidents to the commissioners if the new criteria was applied to 2013/14 incidents. Each of the 41 incidents identified had a completed investigation that would not have been carried out differently had the new criteria applied. The change in reporting requirements has led to an increase in the reporting of Serious Incidents (SIs); these incidents being category 3 pressure ulcer and fractured neck of femur incidents. Excluding those additional incidents reported this year in response to the change in criteria: 7 SIs have been reported so far this year in comparison to a total of 13 for 2013/14. This indicates no significant change in the number of other SIs reported. Complaints In January 2015 LCH introduced a revised compliments and complaints process which aims to ensure all concerns and complaints are handled timely to meet statutory requirements and public expectations. 300 Complaints received Complaints received / / /15 This year LCH logged 338 complaints. 238 complaints related to services that we provide. The remaining complaints were passed to other organisations for investigation. The total number complaints we have received this year is slightly less than last year (261) but still more than in 2012/13 (171). Most of the complaints that we receive were about clinical treatment, delayed or cancelled appointment or the attitude of staff. So far we have resolved 131 complaints. Eighty five of these were either fully or partially upheld and we have written to the complainant to apologise and explain what we will now do differently. To ensure that we are not making the same mistakes again we will Page 18 of 43

46 share the learning from complaints along with good practice through a newly created organisational Patient Experience Group. Equality and diversity In 2015, LCH achieved the NHS Equality Delivery System 2 overall grade of achieving. In working towards this we have also been recognised in the national setting with: An improved ranking with the Stonewall Workplace Equality Index from 244 to 154 An improvement to 3rd in the Stonewall Healthcare Equality Index from 7 th last year an Employers Network for Equality and Inclusion (ENEI) silver award Jobcentre Plus Positive about Disability re accreditation. LCH continues to work with Black Health Initiative Leeds (BHI) in the delivery of the Who am I? BME lesbian, gay and bisexual (LGB) awareness conference. The aim of this conference was to support people in declaring their sexuality and feeling comfortable in accessing appropriate support and services. With other partners in the city, as the Leeds Equality Network, we have been working in partnership to improve access and experiences of lesbian, gay, bisexual and transgender (LGBT) people in the city. We supported the Leeds LGBT Challenge event held at Leeds Civic Centre in July. At this event members of the public feedback that there was a lack of information from health visitors suitable for same sex couples. As a result of this we raised awareness amongst staff about language and support available from other agencies. Well led The table below shows the priorities relating to well led that we set last year, the progress we have made against each target and what we will do in relation to each priority. Quality area for action Develop leadership within the organisation Communication and staff engagement: 70% of staff report that they would fell happy for a relative to be treated by our organisation Achievements to date Leadership development work has been maintained with participants continuing to complete courses in ILM at levels 4, 5 and 7. Bespoke leadership events have taken place to support the introduction of revised leadership structures / / /15 Average satisfaction Comments We will continue to develop leadership as a priority next year. We are pleased that the percentage of staff that would fell happy for a relative to be treated in our services has increased since last year. We recognise that this is still not as high as the national average and we have plans in place to increase this for next year. Leadership and Staff engagement This year we have continued to develop leadership within the organisation and ensured that we have retained clinical leadership through the service reviews. For example, the neighbourhood teams that we have created in the adult services have a clinical and an operational leader to reflect the clinical and managerial leadership of the business unit. Page 19 of 43

47 The CQC noted that leadership in the organisation is improving and that staff felt supported by their immediate line managers. They also noted that at the time of their inspection, many services were going through a service review and there was low staff morale. This was also reflected in the low response rate from staff to the annual staff survey. Our overall response rate for the national staff survey was lower than anticipated at 34%. In addition to the national survey LCH also introduced the staff friends and family test as part of the national commissioning for quality and innovation guidance. As part of this survey, staff were asked each quarter if they would be happy for a friend or relative to be treated in the services we provide The results are shown in the box below. Quarter 1 Quarter 2 Quarter 3 Quarter % 77% National Staff Survey 76.5% 64% The average staff satisfaction over the year is over 70%. We recognise that there is still work to be done to improve staff engagement and leadership in the organisation. The new Organisational Development strategy, which encompasses our approach to leadership development, was adopted by the board in June 2014 and a detailed action plan agreed in October A coordinated programme of staff engagement, led by the Chief Executive, has started this year and will continue in 2015/16 with the aim of people feeling connected and aligned to our vision and values. This includes organisation wide engagement events and a continued focus on how we ensure better engagement and visibility between senior leadership and staff. We have commissioned various strands of work which includes continued work on developing a behavioural framework and investment in individual and team coaching. Members priorities Last year we invited members to identify priorities for quality improvement and we included these in our quality account. There were 3 specific areas that we said we would look at. We said we would demonstrate how we have listened to and acted upon the feedback given by those that use our services: We have held 7 focus groups in the form of tea parties at Community Intermediate Care Unit (CICU) and South Leeds Independence Centre (SLIC). These are held quarterly and provide an opportunity for patients at those units to feedback to LCH members who are not involved in delivering care. The views gathered direct from patients and carers, with observations made by LCH members, are collated and fed back to the units with action as a result shared on you said we did displays on the units and made publicly available on the Members Zone of the website A key change being made as a result of feedback is to increase social activity through the development of volunteer roles and individually engage patients not able to attend the tea-party itself. Were very happy, everyone was chatting. The theme seemed to draw people in. We said we would create visible markers for people to know and be reassured that the practitioner treating/caring for them is competent: Page 20 of 43

48 We set up a Quality Steering Group for patients, carers and public members to design tools and markers for different areas of competence. The group developed a tool based on mystery shopper principles, called my LCH experience and prioritised safety as the first area they wished to consider. 35 health centres and clinics were invited to take part and there were 139 respondents from 17 different health centres covering 11 different LCH services. 98.6% respondents were satisfied or very satisfied with the visible markers for safety by staff delivering their care. An annual programme of markers has been developed by the Quality Steering Group. The next marker being developed is around caring. All the staff wore badges. They were very helpful and polite The staff did provide a lot of useful information about the diseases. We said we would use mystery shopper principles to evaluate the communication of non-clinical staff e.g. receptionists, to provide reassurance that clinical and non-clinical staff communicate effectively and treat people as individuals: Patients, carers and public members in the Quality Steering Group designed a tool called my LCH experience which was used to gather people s views on their experience of front of house. 92.9% respondents to date were either satisfied or very satisfied with their experience of reception. The markers identified for this included whether staff identified themselves, communicated clearly, had a positive attitude (were helpful), created a welcoming atmosphere (smiled). Everything was professional and comfortable. Staff made me feel welcome and at ease. Page 21 of 43

49 Section 2 Statements on quality as mandated in the regulations This section of the quality accounts contains all the statements that we are required to make. These statements enable our services to be compared directly with other services submitting a quality account. Review of services During 2014 / 15 LCH provided and / or sub-contracted 65 NHS services. LCH has reviewed all the data available to it on the quality of care in all of these NHS services. The income generated by the NHS services reviewed in 2014 / 15 represents 100 per cent of the total income generated from the provision of NHS services by the LCH for 2014 / 15. Transformation: Service Reviews and Developing Improvement Capability Staff drive transformation and innovation through: Contributing to the organisation-wide service review and redesign project for their service Developing their improvement and innovation capability expertise through taking part in the Improvement Learning Programme or ILM improvement and innovation module LCH is midway through a significant transformation programme, which has included the initiation of twenty service reviews during The service reviews have focussed on designing and delivering improvements in service quality and outcomes for service users whilst utilising resources more efficiently. Examples of improvements in quality include: Integrated Children s Additional Needs Service (ICAN): The service review has centred on integrating a number of separate Children s nursing, therapy and medical services into a single coordinated and joined-up child and family orientated service focused on outcomes, using goalsetting to direct care planning. This will promote coordination of care, ensure quality of service provision, reduce duplication and allow for discharge planning. Aspects of service provision will be redesigned by April 2015 to most effectively deliver this care, including: Management and leadership reorganised to support inter-disciplinary working and to provide operational management closer to the teams. Improving access to and coordination of services through, for example, a single point of access; ensuring that all appointments are in the right service first time, have a clear purpose, allow choice and thereby adding value to children and their families. Clinical pathways will be reorganized to ensure children are seen by the most appropriate professional and given the right support as early as possible in their care Development of robust service user involvement in ongoing service design and delivery. Integrated Health and Social Care services for Adults: In a similar way to the changes described above, there is a major programme of work to join up services for (older) adults in a more effective way. This includes services within LCH but also services provided by adult social care and GPs. The aim will be to create neighbourhood teams that work with identified GP practices. The quality improvements this will deliver to service users include: Better planned and coordinated care between professionals with less duplication and repetition for service users Delivery of standardised care across the city through 13 integrated neighbourhood teams More efficient referral and information management systems supported by an electronic patient record, enabling information to be shared more effectively and thus leading to safer, more effective care Greater access and more responsive care delivered at local level More people enabled to remain in their own home or community with fewer admissions into long term care placements Page 22 of 43

50 More opportunities for people to have greater say and control over their care, supported by professionals as appropriate Fewer people admitted to hospital inappropriately alongside less people staying in hospital when they do not need to be there School Nursing and Immunisation service: This service review has focussed on maximising the capacity of frontline school nurses and support workers to provide pro-active support and care for school age children. This will be achieved through: Centralising referrals and administration within a single point of access to the service. This will ensure a faster, more effective response to service users / referrers, and will be supported by improved web-based access to information, enabling more self-management, in response to feedback from children and families Reducing overhead costs by streamlining from 6 teams to 3 teams, to be based across the city. Standardising the school nursing and immunisations service offer to children and families across the city and ensuring the 3 teams are staffed with the appropriate staffing levels and skills / experience to deliver this offer effectively Improving the sharing of information and other communications through an electronic patient record Transformation: Involvement in city wide service improvement This year we have worked with other organisations in Leeds as part of the Leeds Institute for Quality Improvement (LIQH). The aim of the LIQH is to create a culture of best quality clinical care across Leeds. It has supported organisations in doing this by developing skills and abilities in understanding data and variation; developing a shared understanding of quality improvement: facilitating system wide leadership and championing co-production. As well as having staff represented on the steering groups developing the LIQH, we have supported 4 members of staff in undertaking the Advanced Leaders programme and approximately 15 staff in undertaking the Professional Leaders Programme. The programmes we have worked on across Leeds include the COPD, Cardiac and Fractured Neck of Femur pathways. Staff have been able to take the learning from this work and apply it in other areas. National clinical audits During 2014/15 five national clinical audits and 1 national confidential inquiry covered the NHS services that LCH provides. During that period LCH participated in 80% of national clinical audits and 100 % of national confidential enquiries, of the national clinical audits and national confidential enquiries which it was eligible to participate in. The national clinical audits and national confidential enquiries that LCH was eligible to participate in during 2014 / 15 are as follows: Eligible National Clinical Audits Chronic Pain (National Pain Audit) Epilepsy 12 (RCPH National Childhood Epilepsy Audit) Parkinson s Disease (National Parkinson s Audit) Page 23 of 43

51 National Diabetic Foot Care Audit National Audit of Intermediate Care Eligible National Confidential Enquiries National Confidential Inquiry (NCI) into Suicide and Homicide by People with Mental Illness (NCI/NCISH) The national clinical audits and national confidential enquiries that LCH participated in during 2014/15 are as follows: National Clinical Audits Participated in Chronic Pain (National Pain Audit) Epilepsy 12 (RCPH National Childhood Epilepsy Audit) Parkinson s Disease (National Parkinson s Audit) National Audit of Intermediate Care National Confidential Enquiries Participated in National Confidential Inquiry (NCI) into Suicide and Homicide by People with Mental Illness (NCI/NCISH) The national clinical audits and national confidential enquiries that LCH participated in, and for which data collection was completed during 2014/15 are listed below alongside the number of cases submitted to each audit or enquiry as a percentage of the number of registered cases required by the terms of that audit or enquiry. National Audit Number of cases submitted Percentage National Audit of Intermediate The audit was not looking at the N/A Care quality of care but was looking Epilepsy 12 (RCPH National Childhood Epilepsy Audit) at service configuration. This is a city wide audit across 2 Trusts therefore number of cases per Trust is not available Not available National Confidential Enquiries National Confidential Inquiry into Suicide and Homicide by People with Mental Illness (NCI/NCISH) Number of cases submitted Percentage 3 Not available Data was submitted for one of the four audits. The other three audits were not in the data collection phase during 2014/15 so no cases were submitted for these audits. The Trust agreed that it would not participate in the National Diabetic foot care audit during 2014/15 but that it would alternatively audit foot ulcer care during 2015/16. The reports of 4 national clinical audits were reviewed by the provider in 2014/15 and LCH intends to take the following actions to improve the quality of healthcare provided: National Audit LCH action 2014/15 Chronic Pain The Trust continues to be involved in the Leeds Chronic Pain (National Pain Steering Group. There is now a revised pathway and the revised Page 24 of 43

52 Audit) Epilepsy 12 (RCPH National Childhood Epilepsy Audit) Parkinson s Disease (National Parkinson s Audit) Falls and non-hip fractures (National Falls and Bone Health Audit) National Audit of Intermediate Care service specification/model of delivery has been tendered. New contracts will be awarded mid-march with a view to service provision commencing in April The Trust is planning to bid for the service with a view to continuing to provide a high quality evidence based pain management service that meets the recommendations regarding Multidisciplinary working and patient centred care. The Epilepsy 12 audit is a city wide audit across two Trusts; it is therefore not possible to separate the dataset for analysis per Trust. LCH has participated in the Re-audit process and is compliant with access to patient information with availability of leaflets and web based information from appropriate organisations. Whilst there are no Epilepsy Nurse Practitioners in LCH, there is a trained nurse to provide training for parents and other inter-agency staff for administration of rescue medication. LCH paediatricians work closely with Tertiary Paediatric Neurology services and have access to LTHT Epilepsy Nurse Practitioners in shared care patients and is exploring the possibility of an extended nurse practitioner role within CDCs which will further improve counselling and training for patients, families and professionals.' The 3.5 wte Parkinson s Disease Nurse Specialists are now in post. There was no audit in 2014 but LCH will be participating in the 2015 audit in conjunction with LTHT. The service redesign is ongoing since this is a two-year project. Community teams continue to screen patients for their risk of falls using the Tier 1 falls risk screening questions, which determines if a more in-depth falls risk assessment is required (Tier 2). Tiers 1 and 2 falls risk assessments are being developed onto Electronic Patient Record (EPR) templates. Community LCH services that complete the Tier 2 falls risk assessment have access to community geriatricians and the Falls Clinic at the local acute hospital for further medical assessment and support if required. Falls education sessions are currently being run for registered staff in the neighbourhood teams. Standard Operating Procedures have been developed for falls occurring in the community and in inpatient/community Intermediate Care bed bases. The Prevention of Patient Slips, Trips and Falls Policy is currently being reviewed. A falls work plan has been developed to reflect the ongoing work being undertaken in the Trust which in turn will identify any areas of further work required. The audit was not required during 2014/15. The National Audit of Intermediate Care (NAIC), now it its third year, provides a unique, bird s eye view of intermediate care commissioning and provision in England. The organisational level aspects of the audit covered four service categories (crisis response, home based intermediate care, bed based intermediate care and reablement services) for the second year running. This demonstrates a comprehensive picture of services that support people after leaving hospital, or at risk of being sent to hospital, and allows changes between the years to be reviewed. The audit highlighted a wide variation in service configuration, scale and performance between services in different areas of the country. For Leeds, this is the first time that the Trust, CCG and Adult Social Page 25 of 43

53 Care colleagues have participated in this national audit. The local and national results for providers and commissioners will assist in shaping the future community and a bed based model for the community of Leeds. Local Clinical Audit The reports of 35 local clinical audits were reviewed by the provider in 2014 / 15 and LCH intends to take the following actions to improve the quality of healthcare provided: It is planned to develop a pathway and prescribing checklist for young people on ADHD medication at the time of detention; young people where ADHD medication has lapsed; and young people with ADHD symptoms without a diagnosis. The check list will include important past medical history and physical monitoring. An audit of missed and delayed doses of medication at the adult inpatient units at SLIC and CICU identified an area for improvement when there was a missed dose with an approved missed dose code recorded (good practice), the full details for the reason(s) for omission were not always documented on the appropriate section of the prescription chart. The requirement for the detail to be recorded has been reinforced to staff and it is planned to re-audit this at both inpatient centres during 2015/16. An audit of Controlled Drugs (CDs) was carried out at LCH inpatient settings and the overall results demonstrated safe and secure use and handling of CDs. There were some further good practice points identified where record keeping of dosage forms could be improved to ensure clarity. Two further standard operating procedures (SOPS) were developed around the supply of CD s and clinical monitoring of prescribed CD s to ensure that LCH meets regulatory requirements in this area. A re-audit of prescribing standards within SLIC demonstrated a high level of compliance overall. One area requiring improvement identified was that medicine names must be recorded on the medication chart in capital letters as per the Trust Medicines Code, which was not always adhered to. A further developmental area focussed on cancellations of medicines and ensuring these are signed and dated to ensure that all staff are aware when medicines have been stopped, and by whom. These two areas for improvement were discussed with prescribers on the unit. A further re-audit will be undertaken in 2015/16. An audit of the use of Therapy Outcome Measures within the Childrens Physiotherapy Service An audit of compliance of the use of the 6 month plan in West CDC During 2014/15 all services were required to participate in the annual documentation audit and produce an action plan to identify required improvements. 92% of services completed their annual documentation audit and the remainder (4 services) were deemed as exceptions due to the impact of service reviews. A revised audit tool was developed for staff to use to undertake their annual documentation audit. In addition a documentation prompt card was developed and disseminated to clinical staff to remind them of the expected standards for record keeping. All audits undertaken are recorded on the Trust s registration database. 2014/15 has seen a reduced number of clinical audits being undertaken due to the impact of the work involved in completing the service reviews. Audits are being prioritised to focus on outcomes of serious and major harm incidents, which include updating relevant policies and procedures and ensuring staff are supported with their clinical competencies. Local Clinical audits Prescribing Standards Audit on inpatient units Audit of Controlled Drugs on inpatient units Medicines Reconciliation Children s Physiotherapy Treatment Handling Risk Assessment Audit on Assessment and Treatment of Page 26 of 43

54 Missed and Delayed Doses of Medication on adult inpatient units Infection Prevention and Control Environmental Audit South Leeds Independence Centre (SLIC) General Cleaning Audit in South Leeds Independence Centre (SLIC) Review of completed Part C Health Plans on the BAAF Form (British Association for Adoption and Fostering) Paracetamol Prescribing Practice Within (Inpatient Unit)Little Woodhouse Hall (LWH) Audit of patients with ulceration having care plan E applied and wound forms completed within the patient record (Podiatry) Audit of physical health monitoring of patients on antipsychotics and Opioid Substitution Therapy (OST) Compliance with Standard Operating Procedures (SOPS) Safeguarding Adults Audit of assessment and management of pain for inpatients on the Community Intermediate Care Unit (CICU) Measuring compliance with Nice Guidelines - Management of Spasticity with children Children's Occupational Therapy Routine Outcome Measurement (ROM) Audit Project Audit of Use of Therapy Outcome Measures (TOMS) within the children s physiotherapy service Appropriate use of referral pathways within the podiatry service for nondiabetic and diabetic feet Audit of standards of care provided to women who request emergency contraception- completion of audit loop Audit on outcomes for all patients referred from the new entrant TB screening clinic to Leeds Chest Clinic Quit Manager compliance audit cases with ADHD in Wetherby Youth Prison Falls Audit in LCH Inpatient Units Monitoring of physical health in young people with intellectual disabilities who are prescribed antipsychotic medication for challenging behaviour Fire Safety Re-audit SUDIC Process Medical Devices Inventory Review of practice for time interval between pessary changes between different types of pessary, different clinicians and establishing standard practice. Evaluating the Implementation of the Leeds Child and Adolescent Mental Health Service Eating Disorders Assessment Pathway Re-Audit of personal evacuation plans - process for wheelchair users attending podiatry clinic at Yeadon HC Quick starting and bridging prior to implant insertion Assess use of the Visual Analogue [pain] Scale (VAS), or other subjective/objective record entry, to record efficacy of insole provision within generic LCH Podiatry clinics Infection Prevention and Control Health Centre Environmental Audits IBS Prospective - Community Dietetics Measuring the efficacy of prescription orthotic devices issued by LCH Podiatry Leg ulcer- Any Qualified Provider (AQP) Outcomes Audit of the Pressure Ulcer Action Plan Out of Hours Admissions Patients who lack capacity to consent to care and treatment DNA Appointments Audit of Delayed Discharges in the Adolescent Inpatient Service Clinical research The number of patients receiving NHS services provided or subcontracted by LCH in 2014 / 15 that were recruited during that period to participate in research approved by a research ethics committee was 550. Research activity in LCH continues to grow and new teams are becoming involved in the research agenda. Locally and nationally, there is a drive to initiate and deliver clinical research that increases Page 27 of 43

55 the opportunity for patients to participate. Teams such as the Musculoskeletal Service and the Stroke Rehabilitation and Neurology services are keen to ensure they have support both financially and from the Research and Development (R & D) team to achieve this. One service which has shown the impact of research is seen within the prison setting. The research team developed a risk assessment tool for prisoners to better assess risk of self-harm to facilitate closing of the Assessment, Care in Custody and Teamwork (suicide monitoring) document. They also published a paper on an 8 year dataset of methadone prescribing in HMP Leeds. The key message was that despite rapid increase in prescribing, there were no methadone related deaths over the 8 year period. The paper highlighted the competency and clinical governance framework to ensure patient safety. Commissioning for quality and innovation (CQUIN) A proportion of LCH income in 2014 / 15 was conditional on achieving quality improvement and innovation goals agreed between LCH and any person or body they entered into a contract, agreement or arrangement with for the provision of NHS services, through the Commissioning for Quality and Innovation payment framework. Further details of the agreed goals for 2014 / 15 and for the following 12 month period are available on request from lorraine.chapman4@nhs.net CQUIN Goal Target Actual Comment Friends and Family Test Implementation of staff FFT Demonstrate indicator has been achieved Achieved Friends and Family Test Early Implementation and phased expansion of patient FFT To implement in some services by April 2014 and all by March Achieved Safety Thermometer - Improvement Goal Reduction to 4.5% prevalence or lower calculated based on the median of five consecutive monthly data points up to 31 March Not achieved We did not achieve 4.5% for 5 consecutive months. We were below of close to the national average for the last 4 months of the year. Pressure Ulcer Reduction Plan 100% of admitted patients should be screened for pressure ulcers and those at risk should have management plan in place Achieved We worked closely with partner organisations in the city to develop an action plan to achieve this Dementia Find, assess refer - Community Matrons 90% patients are: asked dementia case finding question; have diagnostic assessment; are referred for diagnostic advice Achieved Dementia Find, assess refer Community Intermediate Care Beds 90% of admitted patients should be screened for dementia and referred for specialist diagnosis where required Achieved Best Start - Children with Complex Needs Joint development and delivery of a whole pathway service for children with Page 28 of 43 Achieved

56 complex needs. Development of neighbourhood teams Development of neighbourhood plans detailing how integrated neighbourhood teams will work with GP practices. Achieved Joint Review of Discharge Incidents Improve discharge for patients thorough joint review of discharge incidents Achieved Prison Healthcare - Escort and Bed Watch (EBW) Reduction Plan 10% reduction in escort and bed watch activity Achieved CAMHS Inpatient - Cardiometabolic assessment for patients with Schizophrenia Completion of national audit of schizophrenia demonstrating 90% of patients assessed in relation to 6 key cardio metabolic indicators. Achieved CAMHS Inpatient - Communication with General Practitioners Number of patients who s GP has been provided with an up to date care plan. Achieved CAMHS Inpatient - Assuring the appropriateness of unplanned admissions 60% improvement in reviews carried out within 5 days. Achieved CAMHS Inpatient - Specialised services quality dashboard Develop a clinical dashboard Achieved Pain - Clinic Letters >95% of clinical letters sent to GP within 2 days of appointment Achieved By then end of the year we were achieving 100% consistently Pain - Clinic Cancellation Reduction in cancellation of clinics to no more than 1% of total appointments Not achieved We did not achieve the 1% target. Pain - Inappropriate referrals >80% of inappropriate referrals returned to GP with reason for rejection and advise on appropriate treatment given Achieved Pain - Patient Experience Development of patient satisfaction questionnaire and achievement of >50% return rate Achieved We achieved an average return rate of 61% CQC registration LCH is required to register with the Care Quality Commission and its current registration status is full registration without condition. LCH has the following Compliance notices on registration Page 29 of 43

57 We must make sure that we protect patients at Little Woodhouse Hall against the risks associated with unsafe or unsuitable premises We must make sure that we record on the computer systems as well as on paper any risks we have identified for individual patients in the Child and Adolescent Mental Health services Secondary uses and hospital episode data LCH submitted records during 2014 /15 to the Secondary Uses Service for inclusion in the Hospital Episode Statistics which are included in the latest published data. The percentage of records in the published data: Which included the patients valid NHS Number was 100% for admitted care and was 99.97% for outpatient care Which included the patient s valid General Medical Practice Code was 99.76% for outpatient care General Medical Practice code was an optional field in version 6.1 of the Commissioning Dataset that the trust was using but this is now mandatory in version 6.2 and is included in submissions from January Information governance Leeds Community Healthcare NHS Trust will achieve level 2 compliance in 2014/15 and be graded green as part of the Information Governance Toolkit assessment conducted annually. This ensures that LCH has the relevant policies, procedures and working practices in place to comply with the requirements of the Data Protection Act and mitigate risk across the organisation. LCH also deal with large volumes of requests for personal data and consistently meets statutory deadlines in compliance with the Data Protection Act 1998 and Access to Health Records Act 1990 legislation. Deadlines are also consistently met in compliance with the Freedom of Information Act Payment by Results LCH was not subject to the Payments by Results clinical coding audit during 2014 / 15 by the audit commission. Staff satisfaction The table below shows the percentage of staff employed by, or under contract to, the Trust during the reporting period who would recommend the Trust as a provider of care to their family or friends as reported on the staff satisfaction survey. Year Number of staff employed % of those staff employed who recommend the trust to family or friends National Average Highest/Lowest 2013/ % 67% 76%/60% 2014/ % 70% 83%/62% The LCH considers that this percentage are as described for the following reasons: There has been a degree of change across all services and management arrangements that may have impact on perceptions of quality 83% of staff feel positive about their role making a difference to patients in response to questions on the national staff survey 81% of staff feel they get support from their work colleagues Page 30 of 43

58 The LCH intends to take/has taken the following actions to improve this percentage and so the quality of its services by: The executive team have engaged with staff through listening events. Local newsletters update staff on changes happening in their teams and area of work The health and wellbeing team are continuing to organise events to promote staff health such as the pedometer challenge. The organisation is celebrating the contribution of staff through the innovation and research forum and staff awards. Patient experience of community mental health services The table below summarises service user satisfaction with Specialist Child and Adolescent Mental Health Service (CAMHS) interventions during this reporting period and the last reporting period: Reporting Year Community CAMHS Young Persons' Satisfaction Parents & Carers' Satisfaction Inpatients CAMHS Young Persons' Satisfaction Parents & Carers' Satisfaction 80.81% 88.98% 49.51% 73.21% 78.24% 88.50% 38.54% 40% Source: CHI-ESQ, a CAMHS-specific satisfaction questionnaire used nationwide LCH considers that this data is as described for the following reasons: The notable drop in satisfaction within CAMHS in patient s services can be accounted for by a change in data collection method to include an increased range of satisfaction indicators. This will be tracked in future years. LCH intends to take the following actions to improve this indicator score, and so the quality of its services, by: Reviewing all user feedback on a regular basis, sharing learning across the service and using feedback to guide service developments, for example changing time of appointments. Involving young people in recruitment and selection processes for practitioners working in CAMHS. Using our new staff training DVDs, developed with young people and their parents/carers willing to share their experiences. Facilitating a young persons self-harm focus group to explore young people s experiences of attending Emergency Department and receiving CAMHS assessment and follow-up after an episode of self-harm. Developing and extending the range of ways we measure the effectiveness of our interventions, for example session rating scales and goal-based outcome measures. Continuing to co-ordinate a support group for parents/carers of young people with eating disorders providing an opportunity for carers to meet others in the same situation and share experiences. Supporting our user involvement champions within the service to identify different ways to involve young people and families in the service design and development. Page 31 of 43

59 More information regarding these developments is available upon request by ing: or Satisfaction within the Increasing Access to Psychological Services (IAPT) is collected and recorded as part of a national data set. The trust s patient experience of community mental health services indicator score with regard to a patient s experience of contact with a health or social care worker during the reporting period is given in the table below Reporting year Percentage satisfaction all of the time 2012/13 78% 2013/14 77% 2014/ % LCH considers that this data is as described for the following reasons: Patient Experience data collection is a national requirement of all IAPT Services, with satisfaction measured post screening and at the end of treatment. Audits are carried out once a year by the service The Primary Care Mental Health and IAPT Partnership at LCH intends to take the following actions to improve this indicator score, and so the quality of its services by: Reviewing all patient feedback on a regular basis and sharing learning across the service. This process will include patient representation. Working collaboratively with GP practices to help patients be better informed about the services when discussing possible referral Using our patient leaflets, developed with patients, which describe the range of services offered Continuing to organise and learn from events with patients about aspects of our service for example consultations times and venues Continuing to improve access to the service by reducing waiting times which has seen a significant number of patients now being offered treatment within 3-4 weeks More information regarding these developments is available upon request by contacting Bernie Bell, Head of Service bernie.bell@nhs.net Patient safety incidents The table below shows the number and percentage of patient safety incidents reported within the Trust during the reporting period, and the number and percentage of such patient safety incidents that resulted in severe harm or death is shown in the table below: Reporting year Number of all patient safety incidents Number of patient safety incidents that resulted in severe harm or death Number as a percentage of all patient safety incidents 2011 / % 2012 / % 2013 / (30 severe harm + 5 deaths) 1.09% 2014 / (25 severe harms + 2 deaths) 0.69% LCH considers that this number is as described for the following reasons:- Staff are encouraged to acknowledge and be open when something has gone wrong through the reporting and learning from incidents Page 32 of 43

60 We are continually developing the incident reporting processes to improve the quality of the data produced We have raised the profile of reporting all falls that result in a fractured neck of femur as a severe (major) harm incident Leeds Community Healthcare NHS Trust intends to take the following actions to improve this number and / or rate, and so the quality of its services, by:- Continue with the established pressure ulcer panels to review all category 3 pressure ulcers Develop panels for incidents resulting in a fracture neck of femur Introduce a quarterly newsletter for staff identifying quality matters Continue to promote incident reporting Continue to provide training at all levels within the organisation Since September 2014 we have been able to differentiate between incidents that occur whilst patients are under our care and those that do not. Of the 25 severe harm incidents that were reported, 18 occurred whilst the patient was being cared for by us. The 2 incidents that resulted in death occurred while patients were under our care. One is still under investigation and the other was as a result of an MRSA infection. We have completed the investigation into this incident and have been working with the Trust Development Authority (TDA) on implementing our action plan. This has included the TDA supporting our services with a training session. Page 33 of 43

61 Section 3 Quality improvements for the coming year We are currently in the process of reviewing our quality strategy. The new strategy will consider quality in relation to the five Care Quality Commission (CQC) domains of quality and will explain our model for continuous quality improvement. This year we have organised our priorities for the quality account under each of the CQC domains. To identify what actions we need to take to improve quality this year we have: Invested resource in developing and undertaking a Quality Challenge tool that enabled services to self and peer assess their services in relation to the five CQC domains. Engaged with stakeholders through membership events Reviewed the performance data that is regularly reported to the Board Considered the feedback received from CQC, Trust Development Authority and Clinical Commissioning Groups Reflected on the learning from incidents and complaints Patient and carer priorities for 2015/6 come from the common themes identified through involvement and patient experience. Feedback from patients and carers has identified the frustration of being asked the same questions again without the issues raised previously being addressed. Improving patient experience of the following issues are therefore member s quality priorities: Access to services Dignity, choice and respect Carers needs and involvement Communication interpersonal skills, documentation and sharing information Safety This year our priorities for improving safety are: Quality area for action Protecting Patients from harm that happens in our care Safeguarding Suggested projected outcome 2015/16 Reduce the number of patients who develop a pressure ulcer or have a fall while in our care. Implementation of the Think family, Work family protocol across children s and adult services Suggested indicators 5% reduction in category 2 and 3 pressure ulcers, aspire to no category 4 pressure ulcers and 5% reduction in falls resulting in avoidable harm in our inpatient units. Briefing sessions for all staff Process in place to endure learning is shared Over the last 3 years in our quality accounts we have focused our improvement on ensuring that there are appropriate processes in place and that staff are trained to be able to deliver safe care. We have been successful in creating a good reporting culture that we want to build upon. This year we have chosen safety improvement priorities that reduce harm caused to patients that could be avoided. Some of these priorities link with the Sign up to Safety Campaign. In September 2014, Leeds safeguarding children s and safeguarding adults boards published a Think Family, Work Family protocol. The protocol guides staff working with a child or an adult to be aware of the individuals in the household; assess any needs those household members may have; consider potential impact of any identified needs on the child or adult; and respond to needs appropriately. We support this protocol and have chosen the implementation of the protocol as an Page 34 of 43

62 area for quality improvement in our services. We will work this year on embedding the protocol by firstly raising awareness through briefing sessions and ensuring that our processes support learning across organisations. Effectiveness This year our priorities for improving effectiveness are: Quality area for action Outcome measures Suggested projected outcome 2015/16 Therapy Outcome Measures (TOMs) are embedded in all relevant services. Services are able to demonstrate the difference they have made to patients health and well being Audits Patient care is effective and regularly reviewed to ensure practice is up to date, meets standards and addresses areas of concern Supervision for clinical staff All services will have agreed model of supervision and demonstrate that staff are actively engaging in quality supervision. Suggested indicators TOMs data is collected and analysed for all relevant services. Baseline performance is agreed. Clinical audit plan will be agreed and published. Supervision audit showing compliance with service model. Patient records All patients have an accurate and complete record of their care facilitated by the Trust. Increase in the percentage of patients with complete care records as measured by the annual documentation audit. We have been working on introducing outcome measures in our services over a number of years. Progress has been slower than we would have liked so it is important that we continue with this priority for the coming year. This year we have chosen to focus on one particular outcome measure, the Therapy Outcome Measure (TOMs). This is a measure designed to capture the improvement in a patient s health and wellbeing. It is suitable for all staff to use not just therapists and can be used with both children and adults. This year we would like to embed the measure in our services and collect baseline data on which we can identify areas for improvement. Supervision for clinical staff is important for patient care to make sure that our staff are continually reflecting and learning from the care they have given. There have been many changes within services as a result of the service reviews so this year we will be looking to embed models of supervision suitable for the individual services. We have had difficulty in consistently recording when staff have had supervision. We will address this as we implement the new models and measure the compliance against this. Caring This year our priorities for improving experience are outlined as follows Quality area for action Staff health and well being Patient satisfaction Suggested projected outcome 2015/16 Reduce the percentage of staff that report work related stress Patients are satisfied with the care they have received and would recommend LCH as a place to be treated Suggested indicators Reduce to 41% staff that report they have experienced work related stress as measured by the staff survey. 95% of patients report that they would recommend LCH as a place to receive treatment. We know from the staff survey and the changes that services have been through this year that there is low staff morale and high levels of sickness. We have a dedicated health and wellbeing team that are supporting managers and staff to reduce the level of staff sickness. We would like to Page 35 of 43

63 reduce to the number of staff who report experience work related stress to the national average of 41%. We have been collecting patient satisfaction rates for 3 years now. This year we introduced the patient s friends and family test (FFT). We have always had high levels of patient satisfaction and we want to continue to be assured that we are providing services that meet the expectations of our patients. Our patient FFT scores have been slightly lower that the patient satisfaction scores so this year we would like to bring the FFT score up to 95%. Responsiveness This year our priorities for improving responsiveness are: Quality area for action Learning from incidents and complaints Publication of complaints Access to services Suggested projected outcome 2015/16 All incidents and complaints have a completed action plan at the time of closure We are open and transparent about complaints and the learning from them. People are seen at the right time and are not kept waiting any longer than is reasonable within the given resources Suggested indicators 100% of incidents and complaints with completed action plans at the time they are closed Number and themes of complaints along with learning will be published quarterly on the LCH website starting in September 2015 We will meet 18 week targets for mandated services. We will identify, baseline and agree reduction targets for secondary waiting lists. We have reviewed and embedded processes to manage incidents and complaints. We now need to ensure that we are learning effectively from this and that the learning is shared wider than the service where it occurred. The first stage in achieving this is to ensure that all complaints and incidents have action plans completed when they are closed. We will audit action plans at the end of the year to measure this. One of the values of the organisation is to be open and transparent and do what we say we will do. To demonstrate that we are doing this we will publish on our website a summary of the complaints that we have received, what we have learnt from this and the action that we are taking as a result. Our members have identified that access to services is important. We already manage our waiting list to ensure that we see people within the nationally set 18 week targets. We have recognised that some people come into our care through one service and are then referred onto another. We do not think that people should wait longer than is reasonable within the given resources when this happens. To make sure that people do not have excessive waiting times we will identify when this happen, baseline how long people are waiting and agree a target to reduce this. Well led This year our priorities for improving leadership are: Quality area for action Appraisal Leadership Suggested projected outcome 2015/16 Increase the percentage of staff reporting that they have had a well-structured appraisal Behaviours expected of leaders are identified and shared with all staff. Page 36 of 43 Suggested indicators Increase to 38% the number of staff who report that they have had a well-structured appraisal as reported by the staff satisfaction survey. Publication of an agreed behavioural framework.

64 Staff engagement All staff will feel more engaged in the organisation and its work. Baseline behaviours in appraisal. Increase the percentage of staff as reported in the staff survey and the staff friends and family test who feel engaged in the organisation and its work. We have increased the percentage of staff within the organisation having an appraisal within the year by 15%. The percentage of staff who reported on the staff survey that they felt this was a wellstructured appraisal was below the national average. For appraisals to be meaningful and staff to feel supported in delivering the best care to patients we need to ensure appraisals are wellstructured. We want to achieve at least the national average (which currently stands at 38%) for this. Next year we will incorporate the behavioural framework we are developing for leaders into the appraisal process. We will baseline the behaviours we expect to see in the leaders of our organisation and hold them to account through the appraisal process. Morale in the organisation is low. If staff do not feel engaged in the organisation or its work, they are not able to provide good care. We have started a coordinated programme of staff engagement, led by the Chief Executive with the aim of people feeling connected and aligned to our vision and values. We will continue this into 2015/16 with the hope of improving the percentage of staff who complete the staff survey that report they feel engaged in the organisation and its work. How quality will be monitored throughout the year Key indicators from the quality account priorities will be included in the organisations Integrated Performance report (IPR). The IPR is reviewed monthly by the senior management team and shared with the business and quality committees before being reported to Board. This will make sure that senior managers are aware of how we are doing with our quality priorities. A more detailed review of the indicators are included in the information shared with services as part of their regular performance reviews and on the quality impact assessment dashboards published monthly. This will make sure that the services are aware of how they are doing in relation to meeting the quality priorities. Progress against all of the priorities in the quality account will be monitored through the Clinical Effectiveness group and the Quality committee. The clinical effectiveness group will receive a report each quarter on the progress we have made with all the priorities in the quality account. This will enable us to ensure that we are on track to make the progress we want by the end of the year. The clinical effectiveness group will report the progress to the quality committee at least twice in the year. Section 4 Statements from others on the quality of LCH services Comments from Leeds South and East CCG (on behalf of Leeds CCGs) Thank you for the opportunity to review and provide a response to your Quality Account for 2014/15. We have sought views from a range of stakeholders and clinicians, and our response is as follows: Leeds South and East Clinical Commissioning Group (CCG) welcome the opportunity to comment on Leeds Community Healthcare Trust s quality account for 2014/15. Leeds South & East Clinical Commissioning group is providing this narrative on behalf of all three Leeds Commissioning Groups including Leeds West CCG and Leeds North CCG. Page 37 of 43

65 We have reviewed the account and we believe that the information published, that is also provided as part of the contractual agreement, is accurate. We are supportive of the priorities that have been proposed for the forthcoming year, and pleased to note the specification of standards and thresholds. In November 2013 the Government published its response to Sir Robert Francis s report into the events at Mid-Staffordshire hospital. This report, entitled Hard Truths, accepted the vast majority of Sir Robert s recommendations and confirmed the need to focus on high quality health care. It is crucial that commissioners and providers work together to ensure this continues. We are therefore pleased to see that the Trust s priorities focus on the three main elements of quality outlined in the Francis report and the two additional elements recommended by the Care Quality Commission (CQC). We appreciate that LCH is midway through a significant transformation programme, which has included the initiation of twenty service reviews during 2014/15, which has presented the Trust with some complex challenges regarding staff engagement. We are concerned about the low staff survey return (34%) and the ongoing low morale of the workforce, staff engagement and staff not feeling involved in change. These concerns were reflected in CQC and CCG quality visits and we note the Trust s acknowledgment that improvements need to be made. We support all actions to improve morale and the consequent retention of the workforce as we recognise the impact on patient experience and reported satisfaction of the service received. It would be reassuring to see this work linked to staff appraisals, mentorship & leadership. We note that the number of patient safety incidents reported within the Trust during the reporting period, and the number of patient safety harm incidents that resulted in severe harm or death has increased in 2014/15. LCH has a strong incident reporting culture and continues to be in the top three community organisations for reporting incidents, therefore we acknowledge that this increase may be attributed to the uptake in the number of staff reporting incidents in 2014/15. It is reassuring that you have focused on patient safety as one of the key priorities for 2015/16, with particular attention on learning from incidents rather than the process of reporting. We believe that the trust should have referenced Leeds Institute for Quality Healthcare as a means to help deliver system wide improvements. The Trust experienced some safeguarding concerns in 2014/15 at South Leeds Independence Centre (SLIC), the Trust worked collaboratively with CCG, Local Authority and Health Watch to develop a detailed improvement plan to address these concerns. It would be reassuring to see a standardized approach to learning from these incidents across all 3 bed bases within the Trust, to maintain the positive changes. We welcome the audits which are being prioritised to focus on outcomes of serious and major harm incidents, which include updating relevant policies and procedures and ensuring staff are supported with their clinical competencies. It is very encouraging to see a 5% increase from last year s position in the number of staff receiving appraisals and clinical supervision. We believe that the Trust should have acknowledged their plans for nursing revalidation, which commence in December LCH have acknowledged that they have not performed as well as expected with regard to sharing learning from complaints beyond the service in which they occurred. This reflects the findings from the CQC and CCG quality visits; therefore we welcome the Trust developing a newsletter and exploring new media options for sharing LCH quality data and the learning from incidents. In 2014/15 the Trust did not meet the target for reducing pressure ulcer prevalence agreed with commissioners, reporting 59 category 3 & 4 pressure ulcers as serious incidents. We are pleased to Page 38 of 43

66 note the intention for continued scrutiny and reporting of pressure ulcers with the ambition to make improvement against the current position a priority for 2015/16. We note that numbers of staff receiving training in relation to healthcare associated infections has fallen. We are pleased to see that staff training will remain a priority for 2015/16 and will be monitored through the service performance review process. It would have been useful to acknowledge that NHS England guidance recommends that community services should be assessing avoidable cases of Clostridium Difficile against the same toolkit that acute trusts are required to use. The 3 Clostridium Difficile cases discussed in the quality account should not be described as discounted ; they will be formally classed as unavoidable, if deemed to be so, through the correct governance process. The trusts Information Governance Assessment Report Score for 2014/15 and green rating is an excellent achievement for the trust. This acknowledgment also extends to the continued year on year improvement. We would also like to congratulate the Trust for the achievement with The Safe Clean Care Project, and receiving a runner up prize at the Nursing Times awards. We found it reassuring that Leeds Community Healthcare NHS Trust participated in five (80%) of the national clinical audits and one (100%) of the national confidential enquiries which it was eligible to participate in during this period. We would value an opportunity to better understand some of the local clinical audits undertaken during 2014/15; particularly related to intermediate care beds, pressure ulcers, falls and Continuing Healthcare plans. Given the level of challenge and effort of the frontline staff this year to integrate adult services within Neighbourhood Teams and improve the consequent working relationship with primary care (a key CQUIN for the Trust); We believe that it would have been good to recognise the achievements made within the quality account. We note that the Trust has not achieved 2 of the Performance for quality and innovation (CQUIN) quality improvement and innovation goals for the Trust in 2014/15. We acknowledge that 2014/15 has been a challenging time for nursing and quality within the Trust. We hope that the Trust will continue to support the collaborative working which needs to take place with the commissioners and we look forward to working more closely with Leeds Community Healthcare Trust in 2014/15 with the aim of delivering the highest standards of community care possible. Comments from Healthwatch Leeds Introduction Healthwatch Leeds hosted a session for all the organisations providing NHS services in Leeds who are required to provide annual Quality Accounts and have invited Healthwatch Leeds to comment on them as a part of their statutory duty. Each organisation was invited to present their account with a focus on accessibility, evidence of links between patient feedback or engagement and priorities, the measures of planned improvement and progress and benchmarking. Healthwatch volunteers were also invited to identify areas of good practice. As the actual copies of the QA were not provided by everyone, a general recommendation is to produce a more accessible summary, possibly in easy read that has a focus on the issues identified as important and influenced by patients, service users or their carers. Healthwatch Leeds comments for the Quality Account Leeds Community Trust demonstrated how Quality Accounts engagement and priorities have become a part of organisation wide work to improve engagement and show where decision making has been influenced by feedback. The on-going approach to engagement is to be commended. The Trust recognises that it has challenges and provides examples on how it is working to improve Page 39 of 43

67 including measures for performance. Priorities have been influenced by both patient and staff feedback and patient specific outcomes are being developed. There is benchmarking with other similar organisations and some of the priorities have been influenced by national patient safety priorities. The Trust is committed to producing a more accessible summary of their account which we recognise as good practice. Comments from the Scrutiny committee Many thanks for sharing your draft Quality Accounts for 2014/15 and apologies for any delay in getting back to you regarding comments from the Scrutiny Board. However, please be aware that at its meeting in April 2015 the Scrutiny Board agreed not to make any formal comments on any draft Quality Accounts for 2014/15. This was largely due to the timescales for producing the QA and the Scrutiny Board s capacity to make a meaningful contribution. I trust this is helpful, but please let me know should you have any queries. Response to comments by Leeds Community Healthcare NHS Trust. Thank you to the CCGs and Healthwatch for taking time to consider and respond to our quality account. We appreciate the acknowledgment of the progress that we have made and the challenges we have faced this year. We agree with the CCG that we could have included a summary of our work with partners across the health economy to improve quality. We have added a summary of our work with Leeds Institute for Quality Healthcare to the final document. Learning form complaints and incidents is a focus of our quality improvement for next year and part of our Sign Up To Safety pledge. We welcome the suggestion form the CCGs that we could standardise our approach to learning from all incidents and feedback including the safeguarding referrals. We will look at how we integrate this as we progress. NMC will be introducing nursing revalidation in December They are currently undertaking a number of pilots and will share their findings and any changes to the proposals in October We have identified an executive lead for this piece of work within the organisation and we are currently scoping what it will mean for our staff. We have not included nursing revalidation as a priority for quality improvement this year and we have not yet clearly established how we will measure this in relation to improved quality of patient care. It may well be that this is a priority for quality improvement next year. We will keep the CCGs up to date with our plans at our regular quality meetings. We have amended the comments in relation to the 3 Clostridium difficile (CDI) cases to reflect that all 3 were reviewed in line with the guidance issued by NHS England, were found to be unavoidable and not attributable to the care provided by LCH. We thank particularly the Healthwatch approach to reviewing quality accounts this year. Having an opportunity to present our areas for quality improvement to members of the public and demonstrate where their feedback is making a difference is helpful in making this document meaningful. We are pleased that the ongoing commitment to engagement and work of our engagement team is recognised. As a result of this feedback we have: Included a paragraph about our involvement in system wide quality improvement Clarified the statements about Clostridium difficile (CDI) For the coming year we will: Share audit information with CCG thorugh the quality meetings Page 40 of 43

68 Publish an easy access version of our quality account Share with the CCG our plans for nursing revalidation as they develop. Acknowledgements We would like to thank everyone who helped to influence the content and publication of our Quality Account. This includes but is not limited to patients and representative groups, our staff, the senior management team and the board of directors. This Quality Account provides insight into how our vision, values and strategic objectives have quality at their heart. It demonstrates how quality is embedded within the organisation and, with examples from each portfolio of services; we will show how quality defines us. We have also produced an Annual Report and Accounts to outline our financial and other key performance measures during 2013 / 14. You can find the Annual Report and Accounts on our website at Glossary Appraisal a method of reviewing the performance of an employee against nationally agreed standards within the NHS. Audit a review or examination and verification of accounts and records. Audit Commission the organisation responsible for auditing public bodies. Clinical supervision a reflection process which allows clinical staff to develop their skills and solve problems or professional issues. This can take place on an individual basis or in a group. Council of Governors an elected body of people from the community who have a role in holding the organisation to account. Care Quality Commission Health and Social Care regulator for England. Child protection measures and structures used to prevent and respond to abuse, neglect, exploitation and violence affecting children. Clinical coding a coded format which describes the condition and treatment given to a patient. Commissioners organisations that agree how money should be spent on health within a community. This is currently done by primary care Trusts. The Health and Social Care Bill currently under debate aims to move this responsibility to groups of GPs. Cdiff - A Clostridium difficile infection is a type of bacterial infection that can affect the digestive system. It most commonly affects people who have been treated with antibiotics CQUIN (Commissioning for Quality and Innovation) A financial incentive encouraging Trusts to improve the quality of care provided. Department of Health (DH) the government department responsible for the health and well being of people in England. Friends and Family Test A new marker of satisfaction which asks whether staff / patients would recommend the service they received to their friends or family. Information governance the rules and guidance that organisations follow to ensure accurate record keeping and secure information storage. LINk Leeds Local Involvement network is an independent organisation set up by the government to bring local people, community groups and organisations together. They aim to improve health and social care services in their local communities. Looked After Children children who are in the care of social care. This includes children in foster care and children who have been placed with relations as a result of the birth parents being unable to provide care. Page 41 of 43

69 Medical devices inventory a list of medical equipment owned by the Trust. The list is used to ensure that we carry out maintenance at regular intervals. Medicines management processes and guidelines which ensure that medicines are managed and used appropriately and safely Membership people within the local community; users of services and staff can apply to become members of a NHS foundation trust. The membership has a role in holding the organisation to account. MHRA The MHRA is responsible for regulating all medicines and medical devices in the UK by ensuring they work and are acceptably safe. MRSA Methicillin-resistant Staphylococcus aureus (MRSA) is a bacterium responsible for several difficult-to-treat infections. National Institute for Health Research (NIHR) - The NIHR was set up by the DH to transform research in the NHS. NIHR seeks to improve the health and wealth of the nation through research and works in partnership with many sectors including other Government funders, academia, charities and industry. NHS Litigation Authority (NHSLA) the organisation responsible for overseeing the insurance scheme for NHS providers. It is part of the NHS and accountable to the Secretary of State. National Institute for Health and Care Excellence (NICE) aims to assist in the prevention and treatment of ill health and to improve population health. NICE provides guidance, sets quality standards and manages a national database. National Patient Safety Association (NPSA) an arms length body of the NHS. The NPSA aims to improve patient safety and care by informing, supporting and influencing organisations and people working in the health sector. National Service Framework (NSF) strategies that set clear quality requirements for care. These are based on the best available evidence of what treatments and services work most effectively for patients. NHS Community Foundation Trust an NHS provider organisation that has freedom from Secretary of State control. They will have a clear accountability framework and will be able to plan and direct their services to more closely meet the needs of the communities they serve. OFSTED - Office for Standards in Education, Children s Services and Skills inspect and regulate services which care for children and young people, and those providing education and skills for learners of all ages Outcome Measure - A tool used to assess change in a patient or patient s circumstances over time. They measure change in meaningful areas of a person s life in a way that informs collaborative decisions about treatment. PALS the Patient Advice and Liaison Services (PALS) provide a listening and advocacy service to ensure that patients and their relatives, carers and friends can have their questions and concerns resolved as quickly as possible. Patient, Carer and Public Involvement (PPI) activities designed to build ongoing relationships and contact with patients, carers and local communities so they can be involved in developing, designing and the planning of services. Patient experience feedback from patients on what actually happened in the course of receiving care or treatment. Some measures such as waiting times can be from routine data rather then patient feedback. Patient satisfaction a measurement of how satisfied a person felt about their care or treatment. Payment by results the system applied to some services where by NHS providers are paid for the work that they have completed. Performance Matrix a report that details the performance of LCH against key national and contractual targets Pressure ulcers a type of injury that affects areas of the skin and underlying tissue. They are caused when the affected area of skin is placed under too much pressure over long periods of time. Real time measurement tools or measurements to seek people s feedback soon or immediately after having contact with the service. Root cause analysis a method of analysing problems that aims to identify the root cause. Page 42 of 43

70 Royal College the professional body of many professions including doctors, nurses and allied health professionals. Schwartz Centre Rounds - a program to support staff that brings doctors, nurses and other caregivers together to discuss the human side of healthcare Scrutiny Board (Health) a function of the local authority with responsibility to hold decision makers to account for the services they provide. Strategy the overall plan an organisation has to achieve its goals. Trust board the team of executives and non-executives that are responsible for the day to day running of an organisation. VTE venous thromboembolism. A clot that can block arteries and lead to a number of conditions including stroke. How to comment on the Quality Account If you would like to comment on this document you may do so: By to lch.comms@nhs.net Please ensure you place the phrase Quality Account 2013 / 14 Feedback as the subject of your . In writing to: Quality Account 2013 / 14 Feedback Leeds Community Healthcare NHS Trust Quality and Professional Development Department 1st Floor, Stockdale House Headingley Office Park Victoria Road Leeds LS6 1PF Page 43 of 43

71 AGENDA ITEM (23a) Report to: Trust Board Date of meeting: 4 June 2015 Report title: Annual report 2014/15, annual accounts 2014/15 and associated documentation Responsible Director: Executive Director of Finance and Resources Report author: Executive Director of Finance and Resources Previously considered by: n/a EXECUTIVE SUMMARY This agenda item comprises: Draft annual report 2014/15 Audited annual accounts for 2014/15 Draft letter of representation that the Trust will issue to KPMG, external auditors ISA260 external audit opinion from KPMG The annual report will be made available more widely at the annual general meeting in September The ISA260 contains no matters that should preclude the adoption of the accounts. RECOMMENDATIONS The Board is asked to: Approve the annual report for 2014/15 Approve the final accounts for 2014/15 supported by the external auditor s opinion Approve the letter of representation Page 1 of 2

72 Links to strategic objectives: Links to principal risks: NHS Constitution: CQC Standards: Equality and diversity: Sustainability Implications: Publication Under Freedom of Information Act: This report particularly supports the following strategic objectives: To become a viable and sustainable organisation with the ability to invest in the community and with a relentless focus on value for money N/A This report supports all the principles, values, rights and pledges detailed within the NHS Constitution. Measures to ensure effective reporting support the Trust to meet its obligations across all the CQC s domains but with a particular emphasis on well-led. An equality analysis screening form has not been completed because the report does not relate to a new or revised policy, strategy, project or service. None. This paper has been made available under the Freedom of Information Act. Page 2 of 2

73 AGENDA ITEM (23a) Annual Report and Accounts 2014 /15 Draft 1.4 Page Welcome and introduction from the Chairman and Chief Executive 2 Strategic report 3 Financial performance 3 Performance against key indicators 4 Valuing our staff 7 Staff feedback 7 Employee consultation 9 Sickness absence 9 Appraisals 9 Statutory and mandatory training 10 Workforce profile 10 Equality and diversity 10 Health and safety 11 Fraud 12 Emergency preparedness 13 Disclosure of personal data related incidents 13 Better Payments Practice Code 14 Sustainability report 15 Remuneration report 19 Nominations and Remuneration Committee Report 19 Policy on Remuneration of Senior Managers 19 Policy on senior managers contracts 20 Payments to past senior managers 20 Senior managers performance related pay 21 Off-payroll engagements 21 Remuneration of the Board 24 Salaries and allowances 24 Pension benefits of the Board 27 Statement as to disclosure to auditors 29 A statement of the Accountable Officer s responsibilities 30 Annual Governance Statement 2014 /15 31 Director s declarations of interests for disclosure 2014 /15 39 The audit opinion and report 42 Page 1 of 42 H:\Business Meetings\1.Trust Board Meetings\ \2. 4 June 2015\Public\Final\Item 23aii Annual Report Draft REVISED docx

74 Welcome and introduction from the Chairman and Chief Executive We are delighted to present our Annual Report and Accounts for the financial year 2014 /15 I joined as Chief Executive on 1 October 2014 so was here for the latter 6 months in the year. We want to thank Bryan Machin who was our Interim Chief Executive for part of the year and has now returned to his substantive role as Director of Finance and Resources. Throughout the year we have spent time with many of our services and are very proud of everything we do, every day, for some of the most vulnerable people in our communities. We have seen first-hand the tough time that staff have been experiencing. From the challenges to adopt mobile working and other technologies; to waiting times and ever higher levels of demand on our services. These, and many more issues, mean daily life for our staff is often challenging, but they continue to serve the public with care and compassion. It has also been a challenging winter for the NHS both in Leeds and across the country. We feel this has brought the best out in our staff and services, as we have worked ever more closely with our partners to deliver high quality, joined up care for people in Leeds. Paying tribute to our partners is also important to us as part of the introduction to our report. Despite these challenges our staff have been caring, safe, responsive, focussed and hard-working which has been inspiring. We have met all our financial and performance obligations and we have invested in services as well as winning new business. We have also been inspected by the Care Quality Commission in this financial year - the report will be published in April and will be part of our focus in the 2015 / 16 financial year. On a day to day basis, we have delivered great care as well as learning when there have been problems. Every day we strive to be even better. We hope you will see progress demonstrated in our report and we look forward to the future challenges and opportunities which face us. Neil Franklin Chair Thea Stein Chief Executive Page 2 of 42 H:\Business Meetings\1.Trust Board Meetings\ \2. 4 June 2015\Public\Final\Item 23aii Annual Report Draft REVISED docx

75 Strategic report Financial performance At the end of its fourth year we are delighted to report that, once again, Leeds Community Healthcare NHS Trust achieved the statutory duties set by the NHS Trust Development Authority. We spent 144m, delivering a retained surplus of 2.0m, or 1.37%. The Trust remained within both the Capital Resource and the External Financing Limits. The cash earned from the surplus is retained by the Trust for future investment. Although the continuation of our record of achieving good financial results keeps the Trust on a sound financial footing, staff and managers have had to work very hard this year to find and deliver the efficiency savings that are required by our commissioners. This has not been without pain and our service redesign processes have had a direct impact on staff with a very small number (less than 30) having to leave the trust as we have found ways of delivering services to patients with less staff. Further to this, a small number of staff have also been required to accept posts in lower grades as alternatives to redundancy. Our overriding goal through this period of change is to ensure the continuing quality of the services we provide. The transformation of services that took place during 2014 / 15 has delivered a significant proportion of the further efficiencies required for 2015 / 16. Our focus at the start of this year has been planning for the cost reductions that will undoubtedly be required in 2016 / 17. At the moment this is the financial context for providers of NHS services and there is little prospect of a significantly improved position in the near future. We are proud that we continue to receive investment in new services. This year we have successfully bid to deliver health services into police custody suites across West, South and North Yorkshire and Humberside. Working in partnership with Leeds Teaching Hospitals NHS Trust we were successful in winning the tender to continue to provide sexual health services in a new. integrated way, with this new partnership service starting in Community services remain an area of the NHS that are subject to the forces of competition more than any other part of the NHS. Whilst this is a challenge to us to remain competitive at the level of service quality we wish to provide, it is also a great opportunity to develop the organisation in new areas, providing more patients with high quality healthcare and growing our turnover. During 2015 we will see a significant investment in community services through the Better Care Fund. These services will build on the Neighbourhood Teams we have established with our partners in Adult Social Services at Leeds City Council. Page 3 of 42 H:\Business Meetings\1.Trust Board Meetings\ \2. 4 June 2015\Public\Final\Item 23aii Annual Report Draft REVISED docx

76 Once again, during 2014 / 15 we were able to continue our programme on improving our estate, completing the refurbishments at Burmantofts and Seacroft health centres. We have invested in our information technology infrastructure, putting enhanced broadband connectivity into our health centres. We have also made significant progress in implementing an electronic patient record system with enhanced mobile functionality. The technology to support that accounts for 1.2million of our capital expenditure during the year. 0.8m of that resource resulted from a successful bid to a national Nursing Technology Fund. Performance against key indicators As we strive to deliver the best possible care in every community it is important that we measure our performance. This year we have assessed how well we have done using, as a framework, the same questions the Care Quality Commission uses in their inspections: Are our services safe, effective, caring, responsive and well-led? The Board uses key performance indicators (KPIs) in addition to other information obtained, for example, from visiting services and accompanying staff as they deliver care. We were inspected by the Care Quality Commission inspection team in November 2014 with their report published in April We also measure ourselves against national targets set by regulators by a number of factors including against contractual requirements of commissioners; quality improvement targets agreed with commissioners; and against improvements targets we set ourselves. We set ourselves challenging targets and do not always meet our own expectations. Overall though, as in previous years, we can demonstrate good performance on a wide range of indicators despite being in a challenging environment. High quality care and meeting targets is due to the sheer hard work of all our staff and they should be congratulated for all that they have achieved. Safe We have met most of our performance targets. We continue to have a good incident reporting culture as reflected in 71% of patient safety incidents being reported as no harm. We met the requirement for safe staffing levels in our in-patient facilities whilst at the same time working to be responsive in all services against the challenges of ensuring all services are suitably staffed. We achieved quality improvement targets in areas such as Best Start for children with complex needs, working with primary care colleagues in multidisciplinary teams and reviewing incidents that occur as part of the hospital discharge process. Areas for improvement in 2015 / 16 include the delivery of the 95% target for harm free care (we achieved 93%) and the percentage of staff being compliant with safeguarding training where are expectation is 100% but achievement was 94% for children s safeguarding and 93% for adults safeguarding. Page 4 of 42 H:\Business Meetings\1.Trust Board Meetings\ \2. 4 June 2015\Public\Final\Item 23aii Annual Report Draft REVISED docx

77 Effective The KPIs we use to assess our effectiveness will be expanded as we continue to develop measures of the outcomes we achieve for our patients. At the end of the school year in July 2014 we achieved the targets under the national child measurement programme. We have achieved the targets for breast feeding coverage and prevalence. We achieved the requirements of the pressure ulcer reduction plan, although the Trust retains a very significant focus in reducing the number of pressure ulcers that originate in our care, as well as across the city. The Board has focussed during the year on the difficulties we have had in achieving our contractual requirements in the Improving Access to Psychological Therapies service. This is an excellent service in which the national targets are extremely difficult to achieve. We will continue to strive to be the best we can be in this and all our services. Caring Performance in this area shows that we are a caring organisation. Where things do go wrong we welcome complaints and respond to them within legislative timescales in nearly all cases, and often much quicker. During the year we implemented and expanded our use of the Friends and Family Test, using the information gained from patients views in this and our own patient satisfaction survey to improve our services. Our overall patient satisfaction levels are high at 94% but we remain determined to improve these. Working with our commissioners we have implemented systems to screen patients in some of our services for dementia to enable earlier treatment. We have met all our targets to improve care in this way. Responsive We meet all nationally reportable targets for waiting times. In some services we know that a number of patients wait too long to access care. We are taking steps to improve this and expect a significant improvement as 2015 / 16 progresses. We have met targets for a four hour response by our Child and Adolescent Mental Health Service (CAMHS) where children have self-harmed. Over the course of the year 98% of children looked after received their health needs assessment within 20 days of referral. We have worked hard during the year to help increase the number of patients accessing the Improving Access to Psychological Therapies service. The services are available and readers of this report may recall seeing our adverts on public transport or hearing them on the radio. We have also worked with GPs to improve awareness of the service. This is one area of the health service where we are actively seeking to identify patients who may benefit from this valuable service. We recognise that there are pressures in many services, such as CAMHS, with regard to non reportable waiting lists and we are working to ensure these services remain responsive to service users. Well-led We believe that the Trust is well-led and this was assessed as part of the Care Quality Commission inspection in November 2014, the results of which will be published in April We do have challenges and this is reflected in our own assessment of our performance. Our sickness absence levels remain higher than we would like them to be. We expect all staff to have an appraisal Page 5 of 42 H:\Business Meetings\1.Trust Board Meetings\ \2. 4 June 2015\Public\Final\Item 23aii Annual Report Draft REVISED docx

78 every 12 months but have only achieved 84% and anticipate all relevant staff to be up to date with mandatory training, but only achieved 88%. Of most concern is the difficulty we have in recruiting staff in certain areas to available jobs. This is not a situation unique to us but we are concerned about the effect this has on our staff and the pressure they experience and we believe this is reflected in the measures just described. Improving this position is the priority for us in 2015 / 16 as it will benefit our patients and our staff. As you can read elsewhere in this Annual Report, the Trust once again met its statutory financial responsibilities. Page 6 of 42 H:\Business Meetings\1.Trust Board Meetings\ \2. 4 June 2015\Public\Final\Item 23aii Annual Report Draft REVISED docx

79 Valuing our staff During the 2014 / 15 financial year we undertook a review in a significant number of our services. This led to service redesign and changes to posts within structures to address internal and external challenges identified through the review process. We have worked hard to support staff through this time of change and have developed an Organisational Development strategy which aims to support our staff and their efforts to deliver high quality care that promotes recovery, well-being and quality patient outcomes. There are five strategic objectives as part of this strategy that will help us to focus on delivering service changes and improving performance in the Trust. If we can achieve these it will help us to be a sustainable, thriving community organisation within Leeds that works in partnership with health, social care and third sector partners. The five organisational development objectives are: 1. Developing a shared vision with good staff and stakeholder engagement 2. Bringing Leeds Community Healthcare NHS Trust values to life 3. Building capability for innovation and learning 4. Aligning structures, systems and processes to our vision through service reviews 5. Developing a high performance culture Each of these objectives is supported by our detailed organisational development action plan which for 2015 / 16 focuses on: Recruitment and retention Clinical and professional leadership Behavioural framework Staff engagement activities Staff feedback Each year we participate in the NHS National Staff Survey. This year the survey was made available to all staff and not just a sample as previously. The response rate for 2014 was 34% which is a reduction on the previous year, however it should be noted that whilst the percentage response rate was lower the actual figure is 940 staff compared with 298 staff the previous year (due to change from sample to all staff). The Trust s top five ranking scores in 2014 were as follows: 3.67 Fairness and effectiveness of incident reporting (benchmark 3.58) 93% Percentage staff reporting errors, near misses / incidents (benchmark 91%) Page 7 of 42 H:\Business Meetings\1.Trust Board Meetings\ \2. 4 June 2015\Public\Final\Item 23aii Annual Report Draft REVISED docx

80 86% Staff receiving training on Learning or Development (benchmark 83%) 91% Percentage of staff appraised in last 12 months (benchmark 90%) 19% Percentage of staff experiencing, harassment, bullying or abuse from staff (benchmark 19%) The Trust s bottom five ranking scores in 2014 were as follows: 3.63 Support from immediate managers (benchmark 3.75) 53% Staff suffering work related stress (benchmark 41%) 3.54 Staff job satisfaction (benchmark 3.67) 32% Staff having equality and diversity training * 69% Staff feeling satisfied with the quality of work and patient care they are able to deliver (benchmark 75%) * Our obligation for statutory and mandatory requirements are met; staff joining the Trust at induction also have e-learning access in the first 3 months. Beginning in 2014 / 15 we also participated in a national survey undertaken each quarter called The Staff Friends and Family Test which asks the following questions: I would recommend my organisation as a place to work If a friend or relative needed treatment I would be happy with the standard of care provided by this organisation These questions are also included in the annual staff survey in October. The results are follows: I would recommend my organisation as a place to work reported at: June 2014 September 2014 April % 76% 78% If a friend or relative needed treatment, I would be happy with the standard of care provided by this organisation reported at: June September April 47% 43% 44% (Note Staff Friends and Family was not conducted in October December due to the national staff survey). Page 8 of 42 H:\Business Meetings\1.Trust Board Meetings\ \2. 4 June 2015\Public\Final\Item 23aii Annual Report Draft REVISED docx

81 Employee consultation During 2014 /15 the Trust has embarked on over 20 service reviews in order to ensure delivery of safe, effective and sustainable services at the best cost for now and for the future. The Trust has worked closely in partnership with recognised trade unions to develop a robust consultation process which fulfils its legal obligation and best practice. In addition to the formal Joint Negotiating and Consultation Forum the Trust formed a joint management / trade union fortnightly meeting for the period of significant organisational change. This was supported by detailed information outlining all organisational changes directly impacting on staff, in recognition of our need and commitment to work in partnership. This partnership approach to service reviews, including embedding Staffside representatives and the Programme Management Office, has evaluated well. Sickness absence We know this has been a challenging year for staff and this is reflected in our sickness absence rate in 2014 / 15 which was 5.37%. This is a rise compared to previous years. The main reason for long term absence relates to anxiety, stress and depression and musculoskeletal issues. The main reason for short term absence relates to gastro intestinal problems. The volume of change and increased pressure on staff has surely impacted on sickness rates and we hope that we can support staff even more in the future as well as minimising the change fatigue some services are experiencing. To help our staff we have investing in a dedicated Health and Well-being Team which has been focussing on: Promoting early intervention services through the musculoskeletal and Improving Access to Psychological Therapy services Absence management training supported by additional awareness sessions and promotional events Introduction of Mindfulness Based Stress Reduction Programme Occupational Health and Counselling services reviewed and agreed Working as part of Health Education Yorkshire and Humber, NHS Employers and Leeds Mind networks so that all the support we provide is based on best practice Appraisals During the 2014 /15 financial year the Trust has seen a significant improvement of staff having an appraisal from 79.81% to 84%. Page 9 of 42 H:\Business Meetings\1.Trust Board Meetings\ \2. 4 June 2015\Public\Final\Item 23aii Annual Report Draft REVISED docx

82 Statutory and mandatory training Statutory and mandatory training has remained static at 88% against a target of 100% set for 2014/15 financial year. Workforce profile The Trust employs a workforce of 3,025 people as at 31 March The Trust has a turnover rate of 11.58% for financial year 2014 /15. Equality and diversity This year we have completed the organisation s equality objective of achieving an overall NHS Equality Delivery System 2 grade of achieving. Our continuing work in becoming an inclusive employer and provider of services has been nationally and locally recognised as follows: An improved position of 244 to 154 in the Stonewall Workplace Equality Index Achieving 3rd in the Stonewall Healthcare Equality Index, an improvement from last year s 7 th position Being awarded the Employers Network for Equality and Inclusion silver award Requalification of the Jobcentre Plus Positive about Disability Two Ticks Symbol We continue to work individually with community and voluntary groups. In partnership with Black Health Initiative Leeds the Who am I? Black and minority ethnic lesbian, gay, bisexual awareness conference was delivered. Whilst working with Leeds Involving People we evaluated and suggested improvements in how we promote and manage our complaints process. Page 10 of 42 H:\Business Meetings\1.Trust Board Meetings\ \2. 4 June 2015\Public\Final\Item 23aii Annual Report Draft REVISED docx

83 Learning from this will be incorporated into the review of the our complaints policy in 2015 / 16. Building on the citywide Lesbian Gay, Bisexual, Transgender (LGBT) challenge event in the summer, work continues with our NHS and statutory partners as the Leeds Equality Network to help reduce health inequalities and work towards making Leeds a LGBT friendly city. Health and safety The Health and Safety at Work Act (1974) and the Management of Health and Safety at Work Regulations (1999) require that we have systems in place to proactively manage and control risks for our staff in the workplace. We are committed to maintaining a working environment where the health and safety of our staff, patients, visitors, contractors and general public is assured. We will comply with the relevant legislation and continue to take positive action to prevent ill health, injury and loss and promote good health and safety practice. The Health, Safety and Experience Governance Group receives assurance from Health and Safety Officer on a quarterly basis of the progress made in overseeing the management of Health and Safety within the Trust. The Committee is also responsible for ensuring that the Trust is compliant with its statutory health and safety requirements through quarterly reports to the Quality Committee on all matters of its duties and purpose. The Health and Safety Officer, Fire Advisor, Security Officer and the Infection Prevention and Control team work collaboratively to support staff across the Trust to ensure that standards continue to improve and patient care is not compromised. We have a health and safety work plan which is devised to meet Health and Safety at Work Regulations, regulatory guidance from the Health and Safety Executive, Care Quality Commission and policy guidance from the National Health Service Litigation Authority. Page 11 of 42 H:\Business Meetings\1.Trust Board Meetings\ \2. 4 June 2015\Public\Final\Item 23aii Annual Report Draft REVISED docx

84 The following table demonstrates our compliance with the Health and Safety requirements in 2014 / 15: Health and safety component Policies and procedures Slips, trips and falls e-learning Moving and handling First aiders at work Managing incidents Safety inspections of buildings Target Compliance level Comments 100% 100% All polices were reviewed by Health, Safety, Experience and Governance Group. 90% 94.57% Health and safety training is provide for all staff through induction, face to face and electronic training 90% 81.93% The Trust has increased its awareness and training programme to improve compliance 100% 89% A plan is underway to improve compliance for first aiders 100% 100% All incidents including Reporting of injuries, Diseases and Dangerous Occurrences are reported through Datix, the Trust s integrated risk management systems, are followed up. The Health and Safety Officer works closely with managers to facilitate the implementation of appropriate actions to minimise reoccurrence of incidents. 100% 100% The Health and Safety Officer inspected all buildings and conducted a site risk assessment in accordance with the Trust s annual programme. Inspections also included 23 police custody suites Fraud There is clear strategic support for anti-fraud work in the Trust. We purchase the services of a Local Counter Fraud Specialist (LCFS) who is proactively supported by the Executive Director of Finance and Resources and the Audit Committee. As the LCFS completes proactive fraud prevention and reactive fraud investigation work, reports are compiled, recommendations made on any system weakness and actions taken. The Audit Committee oversees this work on behalf of the Board. Page 12 of 42 H:\Business Meetings\1.Trust Board Meetings\ \2. 4 June 2015\Public\Final\Item 23aii Annual Report Draft REVISED docx

85 Emergency preparedness As a provider of NHS-funded healthcare, we have a number of defined requirements under the Civil Contingencies Act 2004 in order to build and maintain operational resilience, as well as prepare for and respond to disruptive or major incidents. We have an annually-updated Major Incident Plan which details our command, control and response arrangements in the event of an incident and this, along with our identified Incident Management Team, is regularly tested through desk-top scenario based exercises. This year all services, both operational and corporate, have been developing new Business Continuity Risk Assessments, Impact Analysis and Plans to ensure that their arrangements for mitigating the effect of and dealing with the impact of disruptive events are fit for purpose. In July 2014 Leeds hosted the Grand Depart of the Tour de France and this was preceded by a significant planning period for the Trust and its services. The event had the potential to significantly disrupt service provision but with careful and detailed planning, not only with our staff and services but with the wider health and social care economy, this event was a resounding success and occurred with little or no impact on staff and service users. We work closely with the wider emergency planning health and social care economy and are a member of the Local Health Resilience Partnership and associated forums and groups, alongside local planning groups including the Leeds Pandemic Planning Group and the Leeds Health Emergency Planning Group. In 2015 / 16 our efforts will include planning for the inaugural Tour de Yorkshire and the impact on our services, rolling out our new internal escalation process and enhancing our chemical, biological, radiological and nuclear capabilities, alongside the regular annual review of our Emergency Planning and Business Continuity plans. Disclosure of personal data related incidents All health service organisations in England must now use the Information Governance Toolkit Incident Reporting Tool to report details of incidents involving data loss or confidentiality breaches. In respect of this reporting requirement an incident occurred where information was disclosed as part of subject access request, to the data subject, containing details of a third party. The information was retrieved immediately once the Trust became aware and a full investigation has taken place and lessons learnt. It was subsequently decided that this incident did meet the required benchmark for reporting and has been reported to the appropriate regulators. Page 13 of 42 H:\Business Meetings\1.Trust Board Meetings\ \2. 4 June 2015\Public\Final\Item 23aii Annual Report Draft REVISED docx

86 Better Payments Practice Code The Better Payment Practice Code requires the Trust to aim to pay all valid invoices by the due date or within 30 days of receipt of a valid invoice, whichever is the later. The target for this is 95% and during 2014 / 15 we achieved an average 94%. Details can be found in the accounts, note 11. Page 14 of 42 H:\Business Meetings\1.Trust Board Meetings\ \2. 4 June 2015\Public\Final\Item 23aii Annual Report Draft REVISED docx

87 Sustainability report As a part of the NHS, public health and social care system, it is our duty to develop a sustainable development management plan (SDMP) for our organisation. This contributes toward the ambition set in 2014 of reducing the carbon footprint of the NHS, public health and social care system by 34% (from a 1990 baseline) equivalent to a 28% reduction from a 2013 baseline by It is our aim to meet this target by reducing our carbon emissions 10% by 2015 using 2007 as the baseline year. In energy usage we have achieved this by sourcing all electricity from renewable sources. Travel has fallen by 44% over the last four years. We still do not have a way of discovering the carbon content of our supplies and materials used. The following table explains where sustainability is considered in our processes and procedures: Area Travel Procurement (environmental) Procurement (social impact) Suppliers impact Is sustainability considered? Yes No No No One of the ways in which an organisation can embed sustainability is through the use of an SDMP. We will be putting together an SDMP in the near future for consideration by the Board. We do not currently use the Good Corporate Citizenship (GCC) tool or run awareness campaigns promoting sustainability. The organisation has identified the need for the development of a board approved plan for future climate change risks affecting our area. The NHS policy framework already sets the scene for commissioners and providers to operate in a sustainable manner. Crucially for us as a provider, evidence of this commitment will need to be provided in part through contracting mechanisms and partnerships. We have not currently established any strategic partnerships. For commissioned services here is the sustainability comparator for our clinical commissioning groups (CCGs): Organisation name NHS Leeds North CCG NHS Leeds South and East CCG NHS Leeds West CCG SDMP GCC Board Lead Adaptation SD Reporting score Yes No Yes No Good Yes No Yes No Excellent Yes No Yes No Good Page 15 of 42 H:\Business Meetings\1.Trust Board Meetings\ \2. 4 June 2015\Public\Final\Item 23aii Annual Report Draft REVISED docx

88 More information on these measures is available here: The following table explains how the organisation s performance on sustainability has changed over time. Floor space (m 2 ) Number of staff 2007 / / / / ,461 53,908 53, ,536 2,528 2,497 In 2009 the Carbon Reduction Strategy outlined an ambition to reduce the carbon footprint of the NHS by 10% (from a 2007 baseline) by We have supported this ambition by changing of gas boilers for highest efficiency type and changing lighting to lower energy types. 100% of our electricity use comes from renewable sources. Energy In 2014 / 15 we spent 559,016 on energy which is a 31.9% increase on energy spend from last year. Resource 2012 / / / 15 Gas Use (kwh) tco 2 e Oil Use (kwh) tco 2 e Coal Use (kwh) tco 2 e Electricity Use (kwh) tco 2 e Total energy CO 2 e Total energy spend 624, , ,016 Page 16 of 42 H:\Business Meetings\1.Trust Board Meetings\ \2. 4 June 2015\Public\Final\Item 23aii Annual Report Draft REVISED docx

89 Waste Waste 2012 / / / 15 Recycling (tonnes) tco 2 e Re-use tco 2 e (tonnes) Compost tco 2 e (tonnes) WEEE (tonnes) tco 2 e High temp (tonnes) recovery tco 2 e High temp (tonnes) disposal tco 2 e Non-burn (tonnes) disposal tco 2 e Landfill (tonnes) tco 2 e Total waste (tonnes) % Recycled or re-used 17% 25% 25% Total waste tco 2 e Page 17 of 42 H:\Business Meetings\1.Trust Board Meetings\ \2. 4 June 2015\Public\Final\Item 23aii Annual Report Draft REVISED docx