2010-11
Annual Report including Summary Financial Statements
2010-11 Annual Report
Page 1
Contents We think you are positively different
3
How are we positively different?
6
How are we making a difference?
10
How are we valuing staff?
24
How are we investing in and growing our partnerships?
30
How are we improving our environment?
32
How are we driving quality?
34
How are we preparing for our future?
36
How is our membership different?
38
How are we checking what we do is right?
52
How are we managing the money?
70
How we want to make a difference
86
Enjoying the sunshine in Stonefield’s garden
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2010-11 Annual Report
We think you are positively different! Positively different for Members I believe that the Trust is positively different in the way it works with its Governors and Members. Governors interact with the Trust in a wide variety of ways. These include a full Membership Council every three months, a range of engagement groups that allow Governors to go into more detail on specific issues such as performance and strategy and focus groups that look at combating stigma and psychological services. A formal sub committee of the Board and Council considers service users and carers issues and reports back to both bodies.
Tony Price, Lead Governor
We asked people to tell us how they thought we were making a positive difference...
Further engagement is in regular informal meetings between Governors and the Chair and the Lead Governor and six monthly one to one development sessions for Governors. There is an annual joint meeting between the Membership Council and the Board and Governors are encouraged to attend Board meetings, which are also open to the public. Governors play a key and leading role in essential standards review visits, which are an important part of the Trust’s quality monitoring and compliance systems. The approach to reviews was piloted by Governors and has been reviewed in the last twelve months to incorporate learning from earlier visits. There is dedicated support for Governors and Members from the Membership Office which has two full time employees. New Governors receive a structured induction with training provided as needed. Governors are encouraged to attend conferences and networking events. Members receive a regular newsletter, can attend Membership Council meetings and can stand for election as Governors. We are currently piloting a series of constituency meetings that will allow dialogue between Members and Governors. All in all, a positively different approach to engagement! Tony Price Lead Governor
2010-11 Annual Report
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Positively different for service users “As a service user myself I know how important the right environment is to successful recovery. And its not the big things that matter – small details like tartare sauce for your fish and chips, or a salad rather than a sandwich can make you feel a lot better about being in hospital, and the fact that someone has listened to you and helped you get what you need is vital too. I was an inpatient many years ago but have kept close links with the Trust and was delighted to be asked, by the Chief Executive, to be a Patient Ambassador. The role was to find out what patients really thought and to that end I have been granted access all areas (within reason) and get to talk to service users, staff and managers across the Trust. We have recently set up a new programme called Ward Support and myself and the hotel services manager visit 4 wards each month, in Stafford and Shrewsbury. We ask for a wish list from patients and staff and 80% of requests are easily met, within hours usually. Bigger items take a little longer but we have access to senior management and often just communicating where the request is in the system helps a lot”. Dennis Firmstone
Positively different for carers
Dennis Firmstone
“I think I have been given the opportunity to make a positive difference in the Trust because the Chief Executive had a vision of cutting through the red tape and getting to the heart of what people at the grassroots actually want and need. And it isn’t costing any more, in fact we are cutting out waste and making better use of our resources. A positive result all round”.
“During the eight years since my husband David has been diagnosed with dementia, he has accessed many of the Trust’s services. He was allocated a support worker who helped him with household jobs, increasing his confidence and sense of self worth. The support worker also enabled David to safely continue his hobby of walking and also proved to be a good friend that my husband could confide in. I find this time to myself essential to continue caring and the support worker also proved invaluable support to me when I found caring hard”. Sue Whitcombe “My wife Rachel was diagnosed with Alzheimer’s dementia four years ago, just before her 50th birthday. The future turned into an image of an unremitting nightmare full of anguish and fear but with a great amount of individual practical and emotional support at an extremely stressful time the future started to look rather less daunting. Rachel almost always says “Well, I’ve had a good day!” before turning in for the night. Her remarkably contented state of well being is in large measure down to the excellent services mentioned above. And that leaves me in a much better state of mind too”. Alex Argyropulo Page 4
Tamlink and The Friary Day Service celebrated the Royal Wedding
2010-11 Annual Report
“Rachel joined the Ladies’ Group and still ‘remembers’ the session on Laughter Yoga, not exactly what happened but the wonderful emotional uplift it gave her”.
“Without the hard work of all the excellent staff providing the services, we could not have managed together at home for so long”.
“This type of service is a lifeline for carers”. “This service means everything to us as a family”
“In the six years since my wife Margaret (now 62 years of age) was diagnosed with Early Onset Dementia I can only be very grateful that we both have had the help and support of the wonderful staff based at the Rowans Ward at Shelton Hospital who have made a positive difference to our lives. Margaret attends the monthly ` Ladies Who Lunch` group and thoroughly enjoys herself socialising and taking part in the various activities which are organised by the very caring staff. At the same time I meet up with some of the other husbands and we have our own lunchtime social event. We have made lots of friends and it is reassuring that we are not alone in the situation we find ourselves in”. Alan Donnison “Leigh loves attending the day service which has given us a different outlook on life. It not only gives me a break and respite, but Leigh gets to socialise and meet other people. Leigh gets one to one support which gives us peace of mind, she loves the atmosphere and feels she thrives from the whole experience that day service provides. This service means everything to us as a family”. Mrs Cooper “As sole carer of an adult daughter using Tamworth Link Day Service, I really value the service. My daughter has positively bloomed over the years and the day service has given her the opportunity to experience activities and outings that she would otherwise be unable to do. The staff always try to be flexible to the needs of both the service user and the carer and I greatly appreciates the open and honest style of management”. Mrs P
Making Olympic pennants
At an Al’s Café evening
2010-11 Annual Report
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How are we positively different? We believe we are positively different through our vision and values Our vision is to be positively different through positive practice and positive partnerships and we aim to demonstrate that we provide excellent services, based on evidence of good practice, that make a positive difference. South Staffordshire and Shropshire Healthcare NHS Foundation Trust provides mental health and learning disability services in Shropshire, Telford & Wrekin and Powys and specialist children’s services across South Staffordshire. We serve a population of 1.1 million, over a geography of 2,200 square miles, with around 3,500 staff. Our turnover will be over £160 million. This report looks at the achievements performance of the Trust for the year 2010-11.
and
South Staffordshire Healthcare became a Trust in 2001 and achieved NHS Foundation Trust status in May 2006 under the Health and Social Care (Community Health and Standards) Act 2003, securing certain freedoms to develop and improve services and offer more choice to service users. The integration of services from Shropshire was approved by Monitor on 1 June 2007. We are proud to offer an extensive range of services including Children and Family services, Adult Mental Health, Specialist services, Forensic Mental Health services, and Developmental Neurosciences & Learning Disabilities. These are provided by five clinical directorates: children’s; mental health; forensic mental health; developmental neurosciences & learning disabilities and specialist services. Supporting these are four virtual directorates, allied health professions, pharmacy and medicines management, psychological services, and the medical directorate, whose staff work in teams within the clinical directorate structure. Supporting all of these are our corporate services, finance, performance development, business development, quality and professional practice, membership, service user and carer engagement, human resources and organisational development, health informatics and facilities and estates.
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2010-11 Annual Report
“We were impressed by the extent, quality and nature of innovation in this Trust, clearly facilitated by unreserved commitment, excellent communication and inspirational inclusiveness of all its managers, clinicians, users and carers. This award-winning Trust should justifiably remain proud of the innovative journey it has undertaken and for its future aspirations.” J udges of Roy al College of Psychiatrists Awards
Some positively different highlights from the past year; We are registered and therefore licensed by the Care Quality Commission to provide services and have no conditions attached to this registration. In January we were asked by the CQC to make improvements in order to ensure that we maintain compliance at one of our locations. We are in the process of doing this. We have continued to be rated four for our financial management by Monitor, the regulator for NHS foundation trusts and are currently rated amber for governance. Whilst this is indicates a sound and safe service we recognise that there are areas to improve on and will actively aspire to a green rating in future quarters. The development of a new £46 million inpatient mental health unit in Shropshire finally saw the first turf lifted. Delivering on a promise initially made in 1956, the new building will open in the Autumn of next year. It is part of a major improvement to mental health services in Shropshire, including major investment in community based services across the county. A new low secure inpatient unit for people with a learning disability was formally opened by the Lord Lieutenant of Staffordshire. Based on the St George’s site in Stafford the unit offers services to people from across the West Midlands. Further development to the unit will see a new assessment and treatment service and a new community team base.
Receiving the Royal College of Psychiatrists Mental Health Service Provider of the Year award
2010-11 Annual Report
At a Celebration Day we recognised the contribution of service users and carers, including committed volunteers,
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personal development achievements and contributions to learning. Applications were invited from across the Trust for the awards. We also held successful staff awards to recognise exceptional individuals and teams who are making a positive difference in their service area. We were delighted to be named the Royal College of Psychiatrist’s mental health service provider of the year. The judges said: “We were impressed by the extent, quality and nature of innovation in this Trust, clearly facilitated by unreserved commitment, excellent communication and inspirational inclusiveness of all its managers, clinicians, users and carers. This awardwinning Trust should justifiably remain proud of the innovative journey it has undertaken and for its future aspirations.” A service led by the Trust was also named the winner of the Mental Health category of the Military and Civilian Health Partnership Awards 2010 for improving the mental health outcomes of military personnel and their families. The team led by South Staffordshire and Shropshire Healthcare has established a network of seven NHS trusts across England and Scotland making it possible to treat serving personnel close to their home or base. The service works hard to ensure patients are in hospital for the shortest length of time possible, working together with the patient’s unit and military mental heath service to support speedy recovery. An innovative service for children and young people who are in long term care or are adopted was the winner of the Mental Health and Wellbeing category of the Health and Social Care Awards. Sustain supports both the children and young people, and their foster carers, and also works with other professionals to provide training and consultation. It was set up to address concerns that children who were in the care system were struggling to access effective and timely mental health support. This was often due to them moving placement which also meant a move between health services. Her Majesty’s Lord Lieutenant of Staffordshire, Sir James Hawley visited the Trust. Sir James was keen to find out more about the Trust’s services and had the opportunity to visit an acute admission ward and the Trust’s specialist Mother and Baby unit, both at St George’s Hospital in Stafford. Lord Lieutenant, Sir James said “Not much is known about the fantastic and inspirational work
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Chairman Steve Jones with Sir James and Lady Hawley and Neil Carr, Chief Executive
Members of the Sustain Team receive their Health and Social Care Award
Representatives of MOD Stafford present a cheque to Neil Carr, Chief Executive
2010-11 Annual Report
undertaken by the Trust in this field and I have been hugely impressed by the partnership between the NHS and the military to provide outstanding mental health care to the serving men and women of our Armed Forces”.
Ann Johnson, Queen’s Nurse is pictured with Chairman Steve Jones
Staff, service users and partners helped celebrate the ground breaking for the new inpatient unit in Shrewsbury
2010-11 Annual Report
Two of the Trust’s nurses have been made a Queen’s Nurse by the Queen’s Nursing Institute. Ann Johnson is the Outreach Sister for the Shropshire service for Younger People with Dementia. She has taken the lead in expanding the community facilities on offer to service users and carers and has set up an Al’s (short for Alzheimer’s) Café, groups for both men and women and a carer’s educational programme. Ellen Ellis is a Community Behavioural Nurse within the Trust’s learning disability services and has helped establish an innovative sensory integration clinic for adults with a learning disability. The title Queen’s Nurse is open to individual nurses who demonstrate their commitment to patientcentred values and continually improving practice. To achieve this title a nurse has to show that they are someone who is committed to providing best care to their patients. Feedback from their patients and from their managers is an important part of the application. We were delighted to receive a donation from MOD Stafford towards equipment for people using our inpatient services.
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How are we making a difference? Through engagement We want to know what the people who use our services think and value the feedback they give us. Our Service User and Carer Sub Committee of the Trust Board links together a range of groups and opportunities for service users and carers to engage with the Trust. The Say Group brings together people who use our learning disability services. They have helped to ensure patient information is accessible and understandable and also take part in staff recruitment panels. The Child and Family Council aims to bring together all those interested in services for children, including carers and colleagues from both the voluntary and statutory sector. The Service User Reference Forum, or SURF, provides a communication forum for service users and carers across South Staffordshire’s mental health services. They provide feedback on good practice and areas of concern and are consulted on a range of issues such as service developments, policies and serious untoward incident recommendations. In Shropshire the “Speak Out Forum” has a similar role and an Armchair Panel offers an opportunity to have your say from the comfort of your own home. User Involvement Group meetings are held regularly within the forensic mental health directorate and are chaired by service users. More informally, coffee and chat groups offer service users an opportunity to chat with each other and with staff. We have developed a very successful Real Time Patient Experience Survey which is available either in paper form or via direct access on the Trust internet. In total this year the Trust received over 400 inpatient survey returns and over 800 community survey returns. Staff have direct access to the results enabling them to be responsive ‘real-time’ to issues raised. During the past year we have formally consulted with services users and carers, and with the local community and stakeholders on developments in mental health. In Shropshire, led by the Primary Care Trusts, we participated in a formal consultation on proposals to strengthen community care and redesign inpatient services, and in South Staffordshire, again led by the Primary Care Trust, we were part of an engagement process around closing buildings based mental health day services.
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Ellesmere House art work
Service users played an important part in designing the interiors of the new low secure inpatient unit for people with a learning disability, Ellesmere House. They helped to choose colours and designs and also gave feedback on furnishings for bedrooms and communal areas. Working with the Arts for Health team, a group of service users also took part in a photography project, documenting the various stages of the building’s construction. A series of the images were then digitally manipulated by a graphic designer who converted them to black and white, with areas of detail such as a bright red Portakabin or yellow digger. These images are now displayed throughout the building.
2010-11 Annual Report
Individual service users contribute to the work of the Trust. James works in our clinical audit department and was delighted to tell Neil Carr about his work when the Chief Executive met him during a visit to Shelton Hospital... “I am an involvement volunteer in the Clinical Audit Department in Shelton Hospital for a few days each month. I am enjoying the work and find it very interesting, and I have been made very welcome by Dave Hill, the Clinical Audit Co-ordinator and his staff, who are very patient with my speech difficulties.”
Through involvement Our service users and carers play an important part in the life of the Trust. Green fingered staff and service users at the Hatherton Centre have been so successful in their gardening that they have been supplying the restaurant on the St George’s hospital site. From an allotment in Stafford and raised beds and a polytunnel in one of the hospital gardens, parsley, chillis, aubergines and tomatoes have been supplied to George’s Bistro, whose manager has been so pleased with the fresh produce that she has donated an orange and a lemon tree to grow in the poly tunnel, and also funds for a strimmer. A quarterly magazine which is sent out to staff and Trust members regularly features contributions by service users including articles, poetry and photographs. A group of service users on Stonefield House are responsible for mailing the magazine to staff. Service users, carers and members were encouraged to join with staff to have a say about how the Trust could tackle some of the key issues and challenges associated with delivering psychological therapies. Director of Psychological Services, Felix Davies commented “we want to involve all those with an interest in our services as we recognise we all have a role to play in making the Trust’s psychological services the best they can be”.
James (r) meets Neil Carr
2010-11 Annual Report
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Through improvement Ensuring we provide high quality, effective services is key to everything we do and there is a continual focus on improving the care we offer. These improvements can be opening new buildings such as Park House in Birmingham which provides a centre of excellence for drug and alcohol treatment. This centre offers a unique, all under one roof, approach to drug and alcohol detoxification, stabilisation and rehabilitation treatment for residential and community patients and was made possible through a collaboration between the Trust, Birmingham Drug and Alcohol Action Team, Birmingham City Council, Phoenix Futures and Midland Heart. We also opened a new 12 bed low secure unit for men with a learning disability which was carefully designed to meet the needs of this challenging group of people. The opening of the unit also created an additional 40 jobs in the fields of social work, psychology, nursing, healthcare support worker, occupational therapy and administration. And of course we have finally started work on the major building project to replace Shelton Hospital with a modern, purpose built inpatient mental health facility. A successful service, which offers support to people with a mental illness in getting back into local community life, moved into new premises in central Stafford. Quest Day Opportunities offers support to individuals who experience serious mental illness, and their carers, promoting wellbeing and offering support and encouragement towards their recovery. Quest works with around 150 service users at a time, who each have a personalised, structured programme of activities and agreed goals. There are around 40 different groups which run for 12 weeks, helping people to move on to further opportunities. The location of the new premises enables service users to feel very much part of the local community and there are plans to open a café, run by service users and providing volunteering and employment opportunities.
Park House, Birmingham
Architect drawings of new inpatient facility in Shrewsbury
Ellesmere House, Stafford
Psychological Therapy services in Shrewsbury moved to new premises at Longdon House which offers improved accommodation with more space and better access. The move also meant that all local Psychological Therapy Services, including the new IAPT (Improving Access to Psychological Therapy) service, have been brought together providing a single point of access and easier referral processes for GPs.
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2010-11 Annual Report
Looking after your physical health is important too and service users have been encouraged to do more exercise, and have fun too, at a new Sports Club. Organised by David Banks, Social Support Worker, the club offers badminton, football, volley ball and basket ball and has been very well received both by participants and the professionals involved in their care. “Sport has made me come alive after a period of depression.” J, sports club user “Everyone who goes is getting something rewarding from these sessions.” Douglas, sports club user “The sports club is working wonders for the inpatients. It is brilliant at lifting the spirit and bringing out ‘the person’. These little moments of enjoyment and involvement are the lampposts on the recovery road”. Dr Manoj Kumar, Consultant Psychiatrist
Sports Club has proved very popular
2010-11 Annual Report
Across the Trust we have been working with the primary care trusts who commission our services to modernise mental health services and reduce dependency on inpatient beds. In South Staffordshire investment of over £790,000 has been made to enhance and develop community mental health services, including crisis resolution and home treatment as an alternative to hospital admission and over the last year these teams have not only seen an increase of 7 staff, with a further 8 positions planned, but have also focused their service on supporting people with acute mental health crisis to remain at home. In Shropshire the focus is also on community services and by 2012 we expect there to be 90 additional staff working differently across the nine geographical areas covered by the existing Community Mental Health Teams. Overall the changes are intended to improve access to mental health care, and ensure that services are provided for individuals in the most appropriate setting. In the coming year it is expected that there will be further consultation with local people in South Staffordshire about how inpatient services should best be provided. In general we are seeing a reduction in the need for inpatient beds. In Shropshire we have been gradually reducing the number of beds in readiness for the transfer to the new hospital, and in South Staffordshire, in partnership with local GPs, we have been trialling the gradual closure of beds to check that community services
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are in place and robust enough to offer alternative care to people who might otherwise have had to go to hospital. In South Staffordshire we have also been working with South Staffordshire Primary Care Trust on proposals to close existing mental health day services. The aim is for the Trust to concentrate more on providing specialist mental health services to those with severe and enduring mental health needs, and to move away from buildings based day services. The commissioners of mental health services are then looking to put in place some alternative community based services, working in partnership with third sector and voluntary groups. But its not just about buildings. Other service improvements are as important, if not more so, offering innovative approaches, and specifically focused on meeting local needs and assuring quality and choice. Functionalisation is a new approach to the way adult inpatient mental health services are provided. Key to this is the introduction of a dedicated ward-based inpatient Consultant Psychiatrist who provides a very intensive, focused approach, working with the multidisciplinary team, reviewing individual care and progress on a daily basis. This has been introduced across the Trust and has helped improve continuity of care and enabled nurses to spend more time caring for patients. Life has also been improved for service users and carers with the introduction of more Arts for Health projects. People have been encouraged to join in with singing and playing instruments; photography and other creative art projects have brightened up waiting rooms and communal areas; and young people have been making a DVD.
Young person with art work
“Patients tend to talk more when they are busy and you find out more about them ... its also been helpful with settling new patients onto the ward” Jeanette, Occupational Therapist “We were able to engage with a group of service users in a new and creative way” Bobby, Art Psychotherapist
Nurses working within the clinical practice setting have been supported to pilot and set up systems to improve standards of medicines and medicines management on their wards. Systems introduced have included: handover checklists which require checking all medicines cards at each handover, training and treating any unintended omission as a medicines error. The management of medicines has significantly improved as has the recording of medicines administration. The number of unintentional omissions of medicines has fallen dramatically.
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2010-11 Annual Report
Contacts with the PALs Team Type of Enquiry
Number
Concern
542
Compliment
303
Suggestion
53
Information
188
Total
1086
Through feedback
Service users enjoying a singing for health session
2010-11 Annual Report
We value the feedback we receive from service users and their carers and aim to ensure there are many ways for people to express their opinions, both positive and negative. There are ongoing and snapshot surveys of how service users feel about their care and this year we have introduced more opportunities for real time feedback, including an online survey. Our Patient Advice and Liaison Service During 2010-11, the Patient Advice and Liaison Service (PALS) saw a 19% increase in the number of contacts received. In particular, PALS have continued to see a significant increase in the number of requests for interpretation/translations services. There was an increase of 188% compared to requests received the previous year. This was mainly due to an increase in requests for British Sign Language (78% increase) and Polish (83% increase) interpreters. There was also an increase in the variety of languages requested, which resulted in our main current provider of interpretation/ translation services experiencing difficulties in providing interpreters for Cantonese and Hungarian languages. As a result of this, PALS have engaged another provider to be used to ensure that we meet service users’ needs. During the year, the PALS Team received a total of 1086 contacts, of which 542 concerns were raised. This was a slight increase from the previous year where 507 concerns were received. The highest number of concerns raised (137), was related to clinical treatment, 70 were about hotel services and a further 49 concerns related to attitude
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of staff. The table on the previous page shows the number of contacts received during the year for each type of enquiry. The PALS Team continue to promote the service by delivering staff training to individual teams, junior doctors and through organised Trustwide training sessions. The Team also attend service users’ meetings to promote the service and to capture service users’ concerns. Following PALS intervention, changes have been made to services including:
The policies relating to the next-of-kin being informed of a service user’s self discharge and the non-prescribing of medication on self-discharge are to be reviewed.
Hotel Services agreed to provide a menu to the wards the day before, in order that patient choice can be facilitated and requirements pre-ordered.
Introduction of a special diet form for service users who have special dietary requirements.
Hotel Services has reprinted menus for elderly service users in 14 font and printed on A5, which are laminated and displayed in the dining areas on each ward.
Provision of a baby changing area in the Substance Misuse Clinic at Park House.
Service user telephone number on Stokesay Ward now displayed next to the telephone, so that service users can relay this information to relatives when they call.
Paving between the bowling club and cricket club at Shelton Hospital re-laid.
Stonefield House are now using a “traffic light signals” system, which enables service users to communicate more effectively, afford them control in different situations and improve social skills. A key ring has also been designed for service users to use in the community and at home.
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The SAY Group meet regularly to gain views from service users with learning disabilities
Staff checking that Mental Health Act Administration documentation is correct
Mum and baby on our Brockington Unit
2010-11 Annual Report
The PALS service has received 303 compliments on behalf of the organisation, which was a 17% increase from the previous year.
Compliments Facilities and Estates Department commended for the excellent work they do, especially in the winter months in maintaining the footpaths, to ensure the safety of all staff, service users and those visiting the premises. Compliment received for PALS from service users on Bromley Ward thanking them for responding to their concern so quickly and obtaining better quality tea bags for them. Service user's mum complimented the Aspen Project organised by CAMHS in Burton. “I was really glad that it was so readily available for us as a family; exactly when we needed it. The weekly meetings ran during school hours and lasted for a number of weeks. Once these regular sessions started my son's outlook on life was dramatically different. Those few weeks support have enabled him to cope much better at school but have also changed his life outside. For us I would have to say our experience is a resounding success. The support from Aspen has been immeasurable”.
Ruth, a service user (above) and Sam, Activity Coordinator (below)
Family of a service user wrote to thank the staff and the Consultant on Chestnut Ward - “We would like to say a huge thank you to all for the kindness and care you showed during the time spent with you. Familiarity and routine really helped him to settle and I know that when we look back on those days in years to come we will remember musical visits, sunshine in the conservatory and a man mostly content with an art book and a piece of cake. I am so grateful that we were able to rediscover these happy moments and for this we are indebted to you all”. “Thank you to everyone at Spring Meadow, it has been the best thing I have ever done and it has helped me change my life for the better. I am always grateful and do not know what I would have done without this service”. “I would like to express my thanks and gratitude for all your help. I am pleased to inform you that I am both physically and mentally well and settling in with everyone”. Grandchildren of service user wrote a letter thanking all the excellent staff at the Margaret Stanhope Centre for helping to get their Nan back to her happy self. “Thank you for your help; I have now qualified as a teaching assistant you have helped me come through so many problems”.
2010-11 Annual Report
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Complaints Received During 2010/11 Complaint Category
% of Total
2008/09
% of Total
2009/10
% of Total
2010/11
Access To Services
7
6.14
4
2.25
0
0
Admission Arrangements
0
0
4
2.25
0
0
Appointment (OP) Cancellation
1
0.88
2
1.12
1
0.75
Appointment (OP) Delay
1
0.88
9
5.05
7
5.30
Appt - Staff Failed To Arrive
1
0.88
0
0
0
0
24
21.05
29
16.29
24
18.00
Bed Management
0
0
1
0.56
0
0
Change Of Consultant Request
1
0.88
0
0
0
0
Clinical Treatment
26
22.81
33
18.53
29
22.96
Communication/Info to Patients
12
10.52
28
15.73
28
21.21
Confidentiality
5
4.38
7
3.90
3
2.27
Diagnosis Problems
1
0.88
4
2.25
8
6.06
Discharge Arrangements
4
3.50
8
4.49
6
4.54
Equality and Diversity
-
-
-
-
2
1.51
Failure to Follow Procedures
1
0.88
3
1.68
2
1.51
Failure To Visit Patient
1
0.88
2
1.12
0
0
13
11.40
13
7.30
2
1.51
Medication
2
1.75
15
8.42
10
7.57
Mental Health Act
-
-
-
-
5
3.78
Other
0
0
1
0.56
1
0.75
Patient's Privacy & Dignity
3
2.63
5
2.80
3
2.27
Patients Property
1
0.88
4
2.25
2
1.51
Personal Records (Health)
3
2.63
2
1.12
0
0
Policy & Commercial Decisions
1
0.88
0
0
0
0
Premises - General
1
0.88
0
0
0
0
Security
1
0.88
0
0
0
0
Staffing Levels
2
1.75
2
1.12
0
0
Transfer Arrangements
2
1.75
1
0.56
0
0
Visiting Arrangements TOTAL
0
0
1
0.56
0
0
Attitude of Staff
PCT Commissioning, including Waiting Lists
114
178
132
The above table details the main category of each complaint received during 2010/11, in comparison with the previous two years. This year the main areas of complaint have included staff attitude, communication/information and clinical treatment issues but no trend has been identified relating to any particular service, individual or area of care. It is pleasing to note that there have been reductions in the number of complaints received relating to attitude of staff, clinical treatment, confidentiality, discharge arrangements and medication. Page 18
2010-11 Annual Report
At the time of writing, the Trust closed 115 complaint cases, with the following outcomes: Not Upheld
34
Partially Upheld
44
Upheld
15
Withdrawn
15
No third party consent
5
Referred to Human Resources
2
During the year, the Trust received 132 formal complaints, which represents a decrease of 26% on last year. The Trust has always welcomed receiving complaints, as it does give the organisation opportunities to learn and improve service delivery. The Trust received the outcome of an investigation undertaken by the Parliamentary and Health Service Ombudsman. An action plan, based on the recommendations of the report, was developed and completed.
We are committed to seeking the views of service users and the public on what we do and recognise the importance of using this feedback to develop and improve our services. These are just some examples of the learning and service improvements which were made as a result of complaints received during 2010/11: The necessity to clearly document receipt of any personal belongings/letters/documents has been reiterated to staff. Funding agreed by the Commissioners for a Child and Adolescent Mental Health Service/Learning Disability Psychiatrist post. Staff have been informed of the importance of giving information to service users on the possible side-effects they may experience and how to obtain support if needed. A system has been implemented within Adult Mental Health to ensure Community Mental Health Team staff, involved in checking open referrals for potential closure, makes certain that the health record, care plan and last patient letter are all examined before closing a referral, in order that outstanding actions have been completed. Recommendation made that on the GP referral form to mental heath services, there should be provision to state whether the service user has a physical disability. Primary Care Trusts undertook to raise this suggestion at a forthcoming Practice Managers Meeting. The Care Programme Approach documentation has now been modified to include a section which documents whether the carer has been offered an assessment.
Good record keeping is essential
Ward communication book now has a prompt to inform service users, on admission, of their named nurse. Notice boards in each room are now updated on a regular basis, ensuring that the service user’s key worker is identified. New service user information packs have now been placed in each bedroom. Staff have been advised to inform all service users, on admission, of the availability of the inpatient pharmacist. Revised documentation used for the giving of Mental Health Act rights and identifying all attempts made has been introduced.
2010-11 Annual Report
Page 19
Though keeping people safe We are committed to ensuring that the people in our care are safe and protected from harm. The Trust has a proactive approach to Health and Safety. All managers and supervisors, including those at ward, department and team level, are responsible for managing health and safety as an integral part of their management and supervisory duties and for implementing Trust policy and ensuring good health and safety practice is applied locally. Health and Safety training is provided for all staff through face to face and/or electronic means. During the year 2010/11 the Trust has consolidated health and safety advice and the processing of incident reports for Shropshire services which were previously subject of a service level agreement into the Risk Management team. Work was concluded on issues from the routine Health and Safety Executive (HSE) inspection visit made in 2008 with the exception of one remaining issue around debriefing processes which is subject of further work. HSE inspected a number of services and premises to review the Trust's performance, mainly in respect of four topical areas (Sickness Absence and Return to Work Strategy, Stress at Work, Violence at Work and Manual Handling). HSE Inspectors met with managers and staff and provided very positive feedback. There were no improvement notices issued nor any other enforcement action arising from the inspection - a situation which also continues to date.
In order to continue to improve standards and maintain safe environments for patients, the Infection Control team has continued to focus infection prevention and control activity on three main areas: raising awareness and reducing the incidence of health care associated infection; the training of staff to ensure the successful management of infection and embedding all aspects of infection control through the philosophy that infection control is everyone’s responsibility. For example the Trust continues to support the cleanyourhands campaign and the Infection Control team introduced the 5 moments for hand hygiene across the Trust.
Infection control is taken very seriously
The Trust has appointed a new strategic lead for safeguarding both children and adults and aims to do all it can to keep children and vulnerable adults safe. A key priority will be to ensure that staff have the right level of training in safeguarding and that we have the evidence to show that staff are following safeguarding procedures. We also work in close partnership with local authority colleagues and other professionals on this important issue.
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2010-11 Annual Report
Spirituality means being allowed to be yourself and being able to do the things that are important to you which will help you to get well.
Through dignity and respect The Trust has been accredited with being “positive about disability” (Two Ticks). To achieve this we have demonstrated our commitment to supporting disabled people seeking employment, as well as being able to ensure, as far as we are able, that staff who become disabled continue in employment. The Trust is currently consulting on a new Spirituality Strategy which aims to support the Trust to identify a model of delivery which meets people’s spiritual, religious and pastoral needs and provides a framework to measure achievement. Understanding the importance of spirituality in an individual’s life is key in ensuring that the services delivered are person centred and equitable, leading to improved outcomes.
At our Celebration Day for Service Users and Carers we looked at how descriptions of mental illness can be
Staff receive special training in maintaining dignity and respect
2010-11 Annual Report
South Staffordshire and Shropshire Healthcare NHS Foundation Trust is committed to providing an environment where all service users, their carers and staff enjoy equality of opportunity. The Trust understands the importance of being compliant with the various pieces of equality legislation and acknowledges the benefits and contribution that managing equality and diversity makes to the achievement of our business objectives in the areas of employment, service planning and service delivery. Over the last two years the Trust has made considerable progress in raising awareness of the principles of equality, diversity and human rights and subsequently moving the equalities agenda forward in relation to both employment practices and service delivery. The Trust’s Equality and Diversity Strategy and Action Plan highlight the key achievements, challenges and action required in implementing equality, diversity and human rights across the Trust as well as meeting our equality legal requirements and compliance with the Care Quality Commission Essential Standards.
Page 21
Key Developments/Achievements
There is a Non Executive Director who is a champion and Chair for the Equality and Diversity Group. Over 33 Equality and Diversity Champions have been nominated and trained across the Trust. 13 Champions successfully completed the Equality and Diversity Module at Staffordshire University. An Equality Impact Assessment Standardisation Group has been established and a new Equality Impact Assessment Toolkit and process agreed. The Trust’s magazine, PoD and monthly briefing e-PoD have included articles to raise awareness of equality, diversity and human rights. Promoting Dignity and Respect in the workplace training has been developed and delivered by the Equality and Diversity Lead in induction, management and leadership training, governor training and senior teams across the Trust. A new workbook to support training has also been produced. All training has been aligned to the KSF requirements for Level 1-3. Workforce data is more robust and captures information across all the equality groups. The Staff Survey 2010 showed an improvement in dealing with bullying and harassment issues across the Trust. Equality and Diversity Action Plans and Directorate Operational Plans have been developed. £45K has been secured to undertake a project in partnership with Staffordshire University on ‘Why Choose Nursing’ for those currently under represented in the profession.
Key Actions Required In order to ensure the organisation can meet the requirements of equality legislation and ensure that progress in embedding equality and diversity across the Trust is maintained, comprehensive action plans have been developed for the Trust and across each directorate. The aim is to mainstream equality and diversity into all organisational activity, senior roles and responsibilities and to identify equality indicators for service areas, strengthening performance management of this vital area.
Diversity Information for Staff Staff 2009-10 Age* 0-16 17-21 22+ Ethnicity White Mixed Asian or Asian British Black or Black British Chinese Other Unknown Gender Male Female Transexual Not Stated
Staff 2010-11
%
3591
100%
0 32 3378
3150 23 139
87.7% 0.6% 3.9%
3058 26 131
89.7% 0.8% 3.8%
60
1.7%
75
2.2%
17 202
0.5% 5.6%
2 15 103
0.1% 0.4% 3.0%
934 2657
26% 74%
904 2506
73.5% 26.5%
36
0.3%
60
1.8%
Recorded Disability
0.0% 0.9% 99.1%
* age breakdown not available for previous years
Diversity Information for Members Members 2010-11
%
Age 0-16 17-21 22+ Unknown
84 447 8825 2323
0.7% 3.8% 75.6% 19.9%
Ethnicity White Mixed Asian or Asian British Black or Black British Other Unknown
8671 22 89 29 331 2537
74.2% 0.2% 0.9% 0.2% 2.8% 21.7%
Gender Male Female Unknown
4510 6879 290
38.6% 58.9% 2.5%
Recorded Disability
Page 22
%
not recorded
2010-11 Annual Report
‘Effective engagement can bring ‘value added’ to the Trust business. First and foremost it is about listening and then providing opportunities for the public, service users, our partners and our staff, to influence decision making and to help lever change through understanding’. Martin Evans, Head of Communications
Through listening, responding and engaging We are a people business and there is no doubt that effective engagement can be transformational because it enables a productive relationship between our service users, our partners and our staff, where challenges can be met and goals achieved. Engagement is a core business activity and can be directly linked to improved patient care, higher quality performance and satisfied staff. It is not just about working with the media, it is not about spin but it most certainly is a task for everyone. Engaging staff are at the heart of this organisation’s culture – they facilitate and empower, rather than control or restrict and they treat others with appreciation and respect, showing commitment to development and improvement.
At a staff briefing session
The Trust website homepage
Representatives of the Sikh Temple in Hadley, Telford, paid a visit to Shelton Hospital
2010-11 Annual Report
The small but perfectly formed expert communications team consists of Martin Evans, Head of Communications, Amanda Godfrey, Communications Manager – working 25 hours per week - and Diane Saunders a Communications Assistant. Their role is to lead on external and internal communication but they are not a lone team because engagement is not the responsibility of someone else but all of us. However, to highlight some our communication ‘products’ and successes for 2010/2011: A refreshed and consistently vibrant web site that receives 11,000 hits per month. Structured communication planning, such as for the Modernisation of Mental Health Services in Shropshire, Telford and Wrekin, to give our efforts coordination, reassurance and consistency. In partnership with Organisational Development we have provided specialist communications input to the Foundation Management Course and Certificate of Leadership and running a highly regarded in-house media awareness courses. A vast number of press releases but notable successes are forging a productive partnership with BBC Radio Shropshire which has produced three programmes on dementia (award winning) and the history of Shelton and Mental Health in Shropshire. We have also had whole page spreads in local newspaper health supplements (audiences of 350,000). Introduced the internal briefing note “6 point”, a monthly bullet-point format of Foundation Management Trust issues which has been welcomed across the workforce. Staff Awards 2010 held at the unique venue of RAF Shawbury for over 400 people. We also have a new ‘youtube’ site, featuring leadership and staff award videos. http://www.youtube.com/sssftnhs Page 23
How are we Valuing Staff? Through learning and development We cannot deliver effective supported and trained staff.
services
without
well
Learning and development opportunities are available for all staff, at all stages of their learning journey. Mandatory training is delivered in a range of formats, including elearning and workbooks, and some directorates have benefited from tailored training days aimed at ensuring all staff receive appropriate training. A comprehensive menu of formal and self-directed and innovative approaches are offered to equip individuals with the knowledge and skills they need to lead and manage effectively including the Graduate Leadership Programme which has proved very successful with the initial group of 20 participants graduating this year. One of the participants commented “I believe that completing this programme has had a massively positive impact upon both my confidence and skills as a manager. I believe that I am more effective, although I still have a lot to learn, as was fed back to me in the 360 degree evaluation!”
One of the winners receives her Flying High Award
Through celebration of achievement The Trust’s staff awards were launched to recognise and celebrate individuals and teams who have made an exceptional contribution to patient care. This was the third year of the awards which were badged the “flying high” awards in recognition of the innovative venue, an aircraft hangar, complete with planes, made possible through our partnership with RAF Shawbury. This year, amongst others, we recognised an initiative which has provided work for people with a learning disability, the training, consultancy and supervision provided by the Sexual Abuse Service; the team who ensured the Trust was one of the best in the West Midlands at protecting staff through immunisation against pandemic flu, and a project which employs mental health service users, who are on their own recovery journey, to provide support and motivation to other service users.
Members of the Joint Staff Partnership at the Trust AGM
Through communication Helping to keep staff informed about finance and performance issues, what’s on, opportunities and examples of good practice, a range of briefings and newsletters are produced regularly. The Trust also has an extensive website which is regularly updated and
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2010-11 Annual Report
“I believe that completing this programme has had a massively positive impact upon both my confidence and skills as a manager. I believe that I am more effective, although I still have a lot to learn, as was fed back to me in the 360 degree evaluation!” Jo Probyn, Clinical Lead, Occupational Therapy
maintained and an intranet which reaches the majority of staff. The Chief Executive holds bi-monthly briefings with middle managers and team leaders which have proved very popular and Chairman and Chief Executive Roadshows visit all areas of the Trust twice a year. A new initiative this year has been a “6 point” briefing which ensures that the key points arising from the monthly senior management meeting are cascaded to all staff via directorate networks.
Through effective policies and procedures Trust policies are available on the website and all staff are encouraged to participate in consultation around new and updated policies through regular updates on the intranet. Newly approved policies are publicised through a network of policy leads and also in the monthly briefing issued to staff.
Service users help to distribute the Trust’s quarterly newsletter Celebrating the Graduate Leadership Programme
2010-11 Annual Report
There are six staff governors on the Trust’s Membership Council who represent the views of colleagues from the various professional groups and the Joint Staff Partnership (JSP) meets regularly to ensure the views of employees are taken into account when making decisions. During this year’s Management of Change consultations, the JSP was and integral part of the process.
Page 25
The Trust seeks to ensure that a comprehensive anti fraud and corruption culture exists throughout the organisation as detailed in the Trust Policy for Fraud and Corruption and through the work undertaken by the Local Counter Fraud Specialist. All such policy and procedure is in accordance with the NHS Secretary of State’s Directions to NHS Bodies on Counter Fraud Measures that were re-issued in November 2004. Fraud information is available on the Trust intranet and is effectively signposted on the Trust website, including a direct link to the Trust’s Whistleblowing Policy. Regular articles appear in staff newsletters highlighting this important issue.
Through supporting attendance The well being of staff is of prime importance and as part of its commitment to providing comprehensive support services as an Exemplar Employer, the Trust launched a Staff Health and Wellbeing Pilot in November 2010. Based partly on feedback from the annual Staff Survey, this is particularly aimed at supporting staff with stress related and muscularskeletal disorders through additional physiotherapy, counselling and psychology services. The Trust has already seen some positive outcomes from the pilot, although only three months of data have been analysed so far, and the Trust Board have committed to supporting the project for a further 12 months. The Occupational Health service works hard to support absent staff and ensure they receive the support they need to return to work.
2009/10
2009/10 2010/11 2010/11 Rolling Rolling
April
4.74
5.03
4.54
5.43
May
4.93
5.07
4.94
5.41
June
5.14
5.13
5.44
5.42
July
6.13
5.23
5.51
5.35
Aug
5.47
5.36
5.29
5.32
Sept
5.43
5.40
5.55
5.32
Oct
5.88
5.48
5.56
5.32
Nov
6.06
5.48
5.86
5.32
Dec
5.49
5.44
6.27
5.38
Jan
5.41
5.42
6.31
5.47
Feb
5.19
5.41
5.72
5.52
March 5.10
5.43
5.09
5.54
Sickness Absence Monitoring The rolling figure shows the average sickness level over a rolling 12 months. This is more representative of the direction of travel of sickness absence and is less affected by seasonal variation.
Through the principles within the NHS Constitution The NHS Constitution sets out patients’ rights to services and safeguards the NHS for the future, and it also ensures that the NHS provides a high quality working environment for staff. The Trust’s strategy is aligned to the principles of the NHS Constitution through its core values and an implementation plan has been developed to ensure that the Consitution’s principles and the rights and responsibilities identified for both patients and staff are communicated throughout the Trust and embedded in our policies.
Page 26
2010-11 Annual Report
Through a positive approach to staff engagement The Trust has an over-arching engagement strategy which sets out how it engages with service users, carers, partners, and staff. The staff element of Engagement forms a Pillar of the Exemplar Employer Working Group, which reports to the Trust’s Human Resources and Organisational Development SubCommittee. Reporting through this group, colleagues from communications, hum an resources, organisational development and other professions are able to influence the Trust’s approach to staff engagement. On a practical level, the Trust has implemented many measures to improve staff engagement, including an online suggestion scheme for money-saving ideas, bimonthly briefing/Q&A sessions with the Chief Executive, and most recently an initiative to increase visibility of senior staff through ‘walking the floor’. The Trust is also reviewing its appraisal process to ensure managers’ performance around staff engagement can be assessed.
Through responding to feedback The Staff Opinion Survey is carried out each year across the NHS and is designed to collect the views of staff about how they feel about their job, their personal development and the organisation they work for. These views are used nationally and locally to help provide better care for patients and improve the working lives of those providing the care. This year more staff than ever before at South Staffordshire and Shropshire Healthcare took part in the survey. The Trust’s response rate increased to 61%, putting it in the highest 20% of mental health and learning disability trusts in England. Overall the Trust had 7 key findings in the top 20%, up from 3 last year and only 3 key findings in the bottom 20%, compared to 8 last year. There were no areas where staff felt the Trust was doing worse than last year.
Staff from across the Trust make a positive difference
2010-11 Annual Report
Page 27
Staff Opinion Survey Future Priorities and Targets The key themes identified from this year’s survey were that staff remain unsatisfied with the quality of work and patient care they are able to deliver, that staff do not agree their role makes a different to patients and increasing work pressure felt by staff. This level of dissatisfaction has remained constant from last year, and in fact is below the national average, however we recognise that this is not good enough and are committed to improving our scores in these areas.
Support staff play a vital role
Actions taken include:
Long term investment in health and well-being services to support staff. Improving staff engagement and involvement of staff in developments and changes through Chief Executive and Senior Management engagement session and site visits. Ongoing investment in leadership and management training and development Review of IT systems to improve the effectiveness of data capture and reporting and reduce pressure felt by staff.
The Staff Survey results are reported to and monitored by the Human Resources and Organisational Development (HR&OD) Sub-committee. An action plan is developed in response to the Survey results and monitored by the HR & OD Sub-committee and Performance Management Process. 2009/10 Survey Response Rates
Page 28
2010/11
Trust
National Average
Trust
National Average
44%
55%
61%
54%
Trust Improvement / Deterioration
Improvement 17%
2010-11 Annual Report
2009/10 Staff Survey Top 4 Ranking Scores
2010/11
Trust Improvement / Deterioration
Trust
National Average
Trust
National Average
KF12.% appraised in last 12 months
80%
75%
95%
82%
Improvement 15%
KF14.% appraised with personal development plans in last 12 months
73%
67%
88%
73%
Improvement 15%
KF23.% experiencing physical violence from patients/relatives in last 12 months
N/A
N/A
10%
14%
N/A (Change in questions)
KF25.% experiencing harassment, bullying or abuse from patients/ relatives in last 12 months
N/A
N/A
14%
18%
N/A (Change in questions)
2009/10
Staff Survey Bottom 4 Ranking Scores
2010/11
Trust Improvement / Deterioration
Trust
National Average
Trust
National Average
KF5. Work pressure felt by staff
3.14
3.02
3.17
3.01
Deterioration 0.03
KF21.% reporting errors, near misses or incidents witnessed in the last month
90%
97%
94%
97%
Improvement 4%
KF1.% feeling satisfied with the quality of work and patient care they are able to deliver
69%
76%
69%
75%
No change
KF2.% agreeing that their role makes a difference to patients
85%
90%
88%
90%
Improvement 3%
Staff have many opportunities to have their say
2010-11 Annual Report
Page 29
How are we investing in and growing our partnerships? Through working with a diverse range of partners Our partnerships are important to us, services which work together on common goals deliver better results. We believe that partnerships are our future, both for the way in which we deliver services and also in the way that we deliver the ‘business’. We deploy a robust framework in order to assess our current and potential partners which protects our organisation and ensures we fully understand what kind of relationship we are getting into. All formal partnerships and potential partners are tested against a core set of value based qualities and these partnerships are then detailed legally in contracts and sub contracts. An illustration of our key relationships are: Local Authorities including county and borough councils Primary Care Trusts Strategic Health Authorities Third sector (social enterprise and social firms) LINKs Health Overview and Scrutiny Committees Universities Charitable organisations Voluntary organisations Local MPs Ministry of Defence Home Office and Prisons Other trusts including NHS foundation trusts The Trust aims to work in partnership with all those engaged in promoting the health and well being of local people. This year we have worked closely with our local Primary Care Trusts to establish the best way forward for mental health services and, with them, have engaged our local communities in consultation and engagement processes about how best to provide services which meet the needs of local people.
A student nurse from Staffordshire University on placement in the Trust
Brigadier John Keeling, Head of Healthcare Joint Medical Command commented; “The Trust is held in high regard within the MoD for how it is delivering a high standard of evidence based clinical care and treatment for Armed Forces personnel in an environment that is sensitive to the military culture”.
Neil Broome, 4th Year Medical Student at Keele University commented “I feel that my placement in the Trust has given me valuable insight into the way mental health services work. I have been struck by the way pleasant surroundings can significantly improve a patient’s prognosis”.
We have worked hard to ensure we are responsive and attentive to our GP partners who will have an increasingly key role in commissioning services for their patients. We launched a GP helpline to provide an easily accessible source of support and information for any GP queries.
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2010-11 Annual Report
The Trust has always had close partnerships with local universities and we were delighted to be accepted as a formal training partner by Keele University. The Membership Team supported Stafford College’s equality and diversity day and we have welcomed Dave Gill from Telford College of Arts and Technology as a Governor Member.
Colleagues from the Fire Service attended our AGM
We continue to develop our partnership with the Ministry of Defence and with our NHS partners in the network we lead to provide inpatient mental health care for serving military personnel. Pan network objectives, quality standards, policies and procedures have been developed and shared continued professional development programmes established between the NHS and MoD. An innovative new partnership has been developed with the local fire and rescue service to support the engagement of vulnerable community members and provide advice on fire safety in the home. A joint approach to training ensures fire personnel have an understanding of the needs of the Trust’s service users, whilst health staff learn more about fire hazards and risks. A “sanctuary” garden was opened at the George Bryan Centre in Tamworth. The garden has been created to provide a peaceful environment, close to, but away from the ward, where patients and their visitors can spend quiet time together. Community groups and local primary schools were involved and support was also received from Lichfield District Council.
League of Friends volunteers run a coffee shop at St George’s Hospital
Professor Peter Nolan and Dr Peter Carter, Chief Exec and General Secretary of the Royal College of Nursing visited the Trust
2010-11 Annual Report
The Trust works in partnership with a voluntary organisation called Mental Health Matters to deliver Improving Access to Psychological Therapies (IAPT). This involves talking therapy interventions to people who are experiencing problems with common mental health issues such as depression, anxiety and/or alcohol use. Services are provided in Liverpool, Sefton and North Staffordshire. Involvement in research and development activities is significantly enhanced through partnerships. The Mental Health Research Network has provided funding and a number of new partnerships have been formed for the purpose of bidding for national research funding, for example we are working with Birmingham University; Anna Freud Centre, London; University College London; Keele University and Aston University. Funding from the Comprehensive Local Research Network has supported the engagement of clinicians across the Trust and provided increased opportunities for service users to get involved in mental health research.
Page 31
How are we improving our environment? Through being a good corporate citizen and playing our part in the sustainability agenda The Trust is committed to ensuring that the environment and services we provide are conducive to healing and fit for purpose. This involves ensuring that the condition and cleanliness of our properties and equipment, along with operational services such as catering, achieve national safety and environmental health standards as well as enhance privacy and dignity for our service users. Also we aim to make our facilities sustainable and have comprehensive plans for making sure services are provided in the best possible buildings, making them accessible and within reasonable travelling distance wherever our service users are, and maximising choice.
Ellesmere House
Some examples of our progress in 2010/11 are:New Low Secure Learning Disability Unit We have invested over £3m to extend and refurbish the Ellesmere Unit at St George’s Hospital, Stafford, providing single, ensuite bedrooms, spacious social areas and landscaped gardens. Ministry of Defence Unit We have converted part of an existing ward at St George’s Hospital to establish a six bedded unit to cater for the specific needs of the military services.
Special unit for military personnel
Shelton Modernisation We have secured approval and have commenced the build programme for a new hospital in Shrewsbury to support Shropshire, Telford and Wrekin. Furniture and Equipment We have replaced a wide range of general ward furniture such as lounge chairs, tables, wardrobes and beds plus medical equipment across our inpatient areas. Patients’ Overall Environment We have introduced new ways of working, improved property efficiency, maintained cleanliness and improved the environment. This has been confirmed by our National PEAT (Patient Environment Action Team) scores for all properties having achieved a rating of ‘GOOD’.
Page 32
Starting to build in Shrewsbury
2010-11 Annual Report
Green Achievements Recycled 80% domestic waste Recycled all our electrical waste Reduced our vehicle fleet from 40 to 26 which contributes to carbon reduction Recycled all confidential waste Recycled all skipped waste 25% of electrical energy is purchased from renewable sources
Sustainability The Trust has continued to develop and improve its position relating to the effect it has on the local and national environment. This has been particularly successful in its management of waste, with redundant electrical equipment now also being recycled. 80% of all business and domestic waste was recycled and 12 tonnes of electrical waste went to recycling. As well as this all of the Trust’s confidential waste paper is now shredded onsite by mobile contractors and recycled. Energy management continues to be an important focus with rising costs and an awareness of scarce resources. In response to this the extension of the current electrical supply contract to April 2012 includes the provision that 25% of electrical energy purchased comes from renewable sources. The Trust’s revised Energy and Water Management Policy has set targets for heating temperatures in all buildings and plans are in place to improve the efficiency of these properties in line with the requirements of the Climate Change Act.
Staff are encouraged to cycle to work
Costs
Financial data (£k) 2009-10
Financial data (£k) 2010-11
Expenditure on waste disposal Water
517,152
243,393
82,266
143,581
Gas
591,398
678,948
Electric
539,145
450,534
Area
Impact
Waste minimisation and management
Volume
2010-11 Annual Report
Procurement continues to have the largest effect on the environment with an estimated 60% of the Trust’s carbon footprint being derived from what products and services we buy. We aim to continually monitor and improve the impact our purchasing has on the environment. The Trust has continued to engage with partners throughout the year, including the Staffordshire Business Environmental Network (SBEN), providing environmental training, seminars on new technologies and network contact with other businesses and organisations across Staffordshire.
Non-Financial data 2009-10 7.67Kg/m2
Non-Financial data 2010-11 8.25Kg/m2
Clinical - high temperature disposal
Clinical - high temperature disposal
Business and domestic – reverse recycle /landfill
Business and domestic – reverse recycle /landfill
Water
0.79m3/m2
0.83m3/m2
Gas
58.35Gj/100m2
59.39Gj/100m2
Electric
0.39Gj/m2
0.33Gj/m2
Method of disposal Finite Resources
Travel is a major cost both in money and use of resources. Telephone and video conferencing technologies have been introduced and proved to be effective in reducing business mileage.
Page 33
How are we driving quality? Through responding to external regulation and monitoring Our regulatory performance over the previous year shows no areas of non compliance with our Annual Plan, shortfalls in performance, or requirement to comply with Section 52-3 Notices. Whilst not complacent, and always aware that there is room for improvement, the Trust is satisfied that we met all the regulatory requirements for the year 2010/11.
Annual plan 2009-10
Quarter 1
Quarter 2
Quarter 3
Quarter 4
Financial risk rating
4
4
5
4
Governance risk rating
Green
Green
Green
Green
Quarter 1
Quarter 2
Quarter 3
Quarter 4
Financial risk rating
4
4
4
Not published
Governance risk rating
Green
Green
Green
Not published
Annual plan 2010-11
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2010-11 Annual Report
Through effective performance monitoring Effective performance monitoring systems ensure that we are able to respond to both internal and external surveys, assessments and reviews. The Trust uses a cyclical process for performance development, to drive continuous improvements from effective performance management. The process is supported by executive and non executive directors, and by the performance teams. Sessions are held with all clinical and corporate directorates.
Staff from all disciplines contribute to the Trust’s performance management processes
Through our performance management process we track progress and achievement against a wide range of performance and quality indicators. On a twice yearly basis we undertake performance management sessions in order to identify priorities for further development and improvement. Progress against priorities is also monitored through this process. The Trust has a robust process of monthly review of performance against all the targets that we are required to deliver. Assurance of compliance is provided to the Board via regular meetings of the Finance and Performance SubCommittee. We have redesigned our web based tools to provide evidence of compliance with national requirements such as Care Quality Commission essential standards, Department of Health Information Governance toolkit and the NHS Litigation Authority risk management standards. In clinical areas we have also introduced ward based tools and are able to provide relevant performance data to wards to support improvement. We have enhanced our internal processes for checking compliance with standards and our member governors are actively involved with this. They participate in visits to clinical areas in order to check compliance with essential standards of quality and safety, and they receive reports of progress through their own assurance group. The Trust has no conditions on its registration by the Care Quality Commission (CQC). However towards the end of the year, CQC undertook a review of compliance at one of our registered locations and has identified that we are at risk of non compliance with one of the 16 standards; relating to the monitoring, management and learning from risks. We are in the process of making necessary improvements identified through this review. For more information on our approach to quality, please see our Quality Accounts.
2010-11 Annual Report
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How are we preparing for our future? Through delivering services against our three core values The Trust is committed to delivering services against our three core values; People who use our services are at the centre of everything we do We value our staff Our partnerships are important to us The NHS is entering one of the most radical times of change it has faced in over 60 years. The introduction of new models of commissioning, "Any Willing Provider" and the increase in regulation and scrutiny is designed to ensure that the service user remains at the centre of the healthcare system and nothing is done to people, without them. We recognise that we are a provider of high quality mental health and social care, first and foremost. Our service users, their carers and their families are at the centre of everything we do. They drive our decisions and direction of travel and actively form our strategy. The Trust has a range of sophisticated partnerships to deliver services that offer high quality and significant innovation. These innovations have helped the Trust in providing more specialist services for local people and have opened new ways of delivering care whilst offering value for money. These partners include Charities; Social Entrepreneurs and Community Interest Companies; Home Office; Ministry of Defence; Private providers; Other NHS providers; GP Consortia/practices; Individual practitioners Statutory bodies; Social Enterprise. These partnerships are important to us. There are many occasions where we see the benefit of care provided by a partnership rather than a single organisation. This allows us to offer greater flexibility on service delivery and price whilst maintaining a priority focus on quality. The Trust is also working in partnership to explore the development of new services based on co-production with an emphasis on supporting our local economy. Some of these initiatives include; substance misuse services; neuroscience and neurorehabilitation; child and adolescent services; dementia and elderly care; prison services.
Working on an allotment engages service users in the community
We aim to support people to develop or regain work skills
We are also committed to ensuring that services that are commissioned are led clinically and represent what the service user needs. Our relationships with local Primary Care practitioners is positive and there are a number of forums where the quality of services is discussed and shared in order to drive improvements. This next year should see a greater emphasis on local commissioning based around GP practices, the Trust will need to continue Page 36
2010-11 Annual Report
to provide information, expertise and support to the development of care packages to support vulnerable people and work with GPs to keep people out of Hospital and enhance the primary/secondary care interface.
Chief Executive Neil Carr and Director of Commercial and Business Development, Steve Grange, visited RAF Shawbury
We are very excited about the redevelopment of our mental health services across Shropshire and Telford & Wrekin. Over the coming months the build will become a reality and the plan is to open it in the autumn on 2012. We are currently consulting on names for the new unit. Alongside this the workforce modernisation plans will see a gradual reduction of inpatient beds but a corresponding increase of staff working in the community. Into the future, the Trust will need to continue to be a strong player within the NHS market. Our commercial acumen has created some unique models of delivery and supported the local economy in the delivery of the NHS operating framework and its principles. We recognise that services need to be competitive and offer value for money if they are to provide the standard of quality to the service user and their carers. Our strategy for commercial development however is not based on financial growth, it is based on development only where we feel we can make a positive difference.
Plans for the new mental health inpatient unit in Shrewsbury
2010-11 Annual Report
We are also fully committed to being a good corporate citizen. We have a Corporate Social Responsibility Strategy that aligns our values to supporting the economy, the environment and a clear focus on social inclusion and work opportunities. Our goal is to embrace responsibility for the Trust’s actions and encourage a positive impact through its activities on the environment, consumers, employees, communities, stakeholders and all other members of the public sphere.
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How is our membership different? Through a commitment to engagement and a meaningful relationship The Trust Business Plan outlines the ways in which we intend to develop and grow our core services. It recognises the need to strengthen our relationships so that they are sustained into the future and ensure that what we plan to do is inclusive of our Members. We want to develop an active, progressive and developmental Membership base which is representative of our population and geography. Therefore, we aim to expand our Membership at a rate which matches our ability and capacity to be able to meet both their expectations and the Trust’s business needs. We feel that the Membership should be able to detect meaningful benefits from their Membership from the outset. We have a proactive membership, for example:
approach
to
encouraging
Active recruitment of staff using an opt out approach Active recruitment of volunteers using an opt out approach Liaising with directorates with regards to encouraging service users to join as Members Visiting service user and carer groups Media coverage including press releases, editorial and radio coverage Mail shots to existing Members encouraging friends/ family to sign up (competitions) Encouraging existing staff to encourage friends/ family to join Liaising with voluntary sector groups Raising the profile of Membership both internally within the Trust and with external organisations Encouraging Governor Members to be responsible/ engaged with their constituents Liaison with external partners such as NHS professionals to recruit/engage Members Development of a more user friendly and informative website page Development and encouragement of Member / Governor Member engagement groups Development of public constituency meetings Use of social media including Facebook to communicate with members
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Dave Gill, Governor Member, Public/Service User/Carer constituency, Shropshire Telford and Wrekin
“My personal experience is that this Trust is really committed to its membership making a positive difference. Since becoming a Governor Member in early 2010 I've been involved in a wide range of activities. As an active member of the Combating Stigma Group I've created links between the Trust and my place of work, Telford College of Arts and Technology, and participated in community meetings and promotional events. I contribute to various Telford based meetings including mental health provider forum and strategy group. I'm particularly active in helping to develop the Trust's Equality and Diversity Strategy and how this may be translated into practice across the Trust. Its really about dignity and respect for all service users, staff and the wider community to which I hope we would all wish to subscribe. Finally, I contribute to the Trust's Strategic Direction and Membership Engagement group and have been constructive in devising a survey to obtain the views of the Membership Council. “
2010-11 Annual Report
This Membership Strategy has the following aim: The Trust’s Membership from local communities, service users and carers, and Trust staff will work with the Trust in deciding how to improve services and enhance the Trust’s patient experience. What matters most are people; the people we work to provide effective services for, the people who work for us and the people we work in partnership with.
Our Membership Strategy forms an integral part of our overall strategic direction and also our Trust wide approach to governance. It covers key themes such as our vision for Membership, Governor Member engagement and support and how we will develop relationships over the longer term. It reflects the core values of South Staffordshire and Shropshire Healthcare NHS Foundation Trust. It also represents a clear determination on the part of the Trust Board of Directors to pursue and adopt an entirely professional and wholly inclusive approach towards Members and Governor Members, whom we believe will add significant energies, skills and experience to the work of the Trust. Our overall approach to membership is one that: Identifies and membership
produces
tangible
benefits
of
Is dynamic, inclusive and representative Encourages ownership and communication within our communities Builds on mutual governance collaboration with others
relationships
and
Represents the constituencies of the Trust Encourages and educates the local community about its NHS Results in a progressive “Membership Council” Motivates existing and future staff Promotes our brand of engagement and involvement Encourages engagement from Members and Governor Members The Trust is able to closely monitor its membership through the membership database held within the Membership Office. The Membership Office undertakes detailed demographic analysis of the membership and identifies where gaps exist in recruitment. As detailed in the membership strategy, we can then focus on recruiting and engaging members from these areas which allows our membership to be representative of our communities. For the purposes of membership the constituencies boundaries are South Staffordshire; North Staffordshire; Shropshire/Telford & Wrekin; England and Wales as boundaries of the regional/ national constituency
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Membership Growth Between April 2010 and March 2011, the Trust recruited 676 new members. To ensure that our membership is representative, engaged and accurate we undertook a detailed database cleanse. This resulted in a net growth figure of 147 members for the period.
Public/Service User/Carer ONLY Membership Growth – April 2010 – March 2011 South Staffordshire Apr – 10
0
0
Regional/ National 0
May – 10 Jun – 10 Jul – 10 Aug – 10 Sep – 10 Oct – 10 Nov – 10 Dec – 10 Jan – 11 Feb – 11 Mar – 11 Total
10 6 66 133 0 15 5 6 14 0 50 305
0 0 3 9 0 1 0 0 1 0 9 23
0 1 37 48 0 7 6 1 10 0 20 130
Apr – 10 May – 10 Jun – 10 Jul – 10 Aug – 10 Sep – 10 Oct – 10 Nov – 10 Dec – 10 Jan – 11 Feb – 11 Mar – 11 Total
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Member of Public 0 10 10 136 253 1 32 15 7 33 0 147 644
North Staffordshire
Service User 0 2 4 4 1 0 1 1 0 2 0 2 17
Carer 0 0 3 3 2 0 2 0 0 1 0 3 14
Staff 29 44 46 22 40 44 41 27 11 28 15 24 371
Shropshire
Total 0
0
2 10 37 66 1 12 5 0 11 0 74 218
12 17 143 256 1 35 16 7 36 0 153 676
Total 29 56 63 165 296 45 76 43 18 64 15 175 1046
2010-11 2010-11 Annual Report Report Annual
Initiatives in place to increase membership During 2010/2011 a wide range of initiatives and activities have taken place to recruit and engage new members to ensure a representative membership across South Staffordshire, Shropshire, and Telford & Wrekin. The Combating Stigma Campaign continued to be the basis for our membership recruitment and engagement and will continue to be so for 2011/2012. The theme for the coming year: “It’s time to talk – It’s Time to Change” aims to open up more opportunities to start conversations about Mental Health. The Campaign over the last year has reported a 4% reduction in reported discrimination. The Campaign’s objectives are: To increase the ability of people with mental health problems to address discrimination. Targets of a 5% reduction in discrimination and 5% improvement in public attitudes by 2012. To raise awareness of the stigma and discrimination that millions of people with mental health problems face every day. To create on-going local partnerships with employers, education facilities, sports clubs and libraries within 12 months. The Membership Team attended a Cultural and Diversity day at Stafford College
2010-11 Annual Report
To increase the membership of the Foundation Trust by 500 members by March 2012.
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Personal experiences of stigma and discrimination The following approaches have been and continue to be rolled out to deliver the strategy: Obtain Time to Change resources and send to every team base where mental health services are provided, including primary care. Continued media contact to keep the campaign live on a monthly basis and press releases on events. The Trust will identify partner employers and approach them with a pack of information showing them what they can do to reduce stigma and discrimination in their workplace and how this will benefit both employer and employee. Web site portal linked to the national campaign but also a local area that can signpost people for help and to membership. A Trust Facebook page, under the heading of “Combating Stigma – a Social Movement against Discrimination”, which will attract younger members and allow fast and easy access for membership. Letters approaching sporting clubs for partnership, which may lead to high profile media coverage. Write to members with information about how to get involved and work with their communities, asking them to get them to help create awareness and recruit members. The Trust will ask a range of businesses to display the free materials during focussed times, also asking them for links to their websites.
“In the jobcentre, going for a job, a physically disabled advisor who saw me said not to go for a certain job as I wouldn't cope. How did he know? He said I would not get the job anyway” “I had to give my driving licence back to the DVLA while I was admitted to hospital (psychiatric)” “It affects going to the pub, making new friends, applying for a job, going on holiday, joining local groups, going to church and socialising where people are not mental health connected” “I wanted to join the Territorial Army, but because I had taken antidepressants I was told I was not able to do so” “The reaction towards my diagnosis can cause many people to step away, without taking the chance to get to know me further. People’s lack of understanding and the unfounded fears attached to my diagnosis can be just as destructive as the mental health problem itself.”
Speak to libraries about a partnership which they will already do on other public health issues, this can be explored through the partner Governors from local authority and Primary Care Trusts. Obtain the information from Time to Change on the people locally who are willing to talk about their lived experience for media work. Complete media requests such as radio when asked. Continued partnerships with local educational establishments to communicate the message and encourage membership recruitment with younger people and other “hard to reach groups”. Proactive engagement within BME communities.
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Naomi’s Story 22-year-old Naomi had been struggling with depression for three years, going through long periods where she was consumed by feelings of worthlessness. As a result, she began self-harming as a way of expressing the sadness she was feeling. Naomi went through counselling to deal with her depression and managed to find a full-time job, which made her feel happier. But when the recession hit, she was made redundant and the anxiety returned. Her feelings of depression were compounded each time she was rejected from a job and in the end she was too scared to apply any more.
Naomi has been appointed as a Prince’s Trust Ambassador
One of her friends suggested that she approach The Prince’s Trust for support. This was the turning point for Naomi. She enrolled on the Team programme which gave her the skills and confidence to turn her life around. She realised that she had talents that she never knew existed. Her new self-confidence and qualifications helped her to secure her ideal job as a full-time support worker at South Staffordshire and Shropshire Healthcare, helping other people who suffer from depression and mental health problems. She is now excited to wake up every morning and be able to make a difference to other people’s lives. Naomi said ‘The Prince’s Trust, gave me confidence to rediscover my life and I love my job with the Trust’.
Our facebook page helps the campaign to reduce stigma
2010-11 Annual Report
Naomi picked up a Flying Start Award at Celebrate Success 2011 and appeared on television talking to Phillip Schofield and Holly Willoughby about her inspirational story.
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Our Membership Council
The Membership Council is comprised of 40 Governor Members under the leadership of the Foundation Trust Chairman. The Deputy Chair and Lead Governor of the Membership Council is Tony Price, Partner Governor, South Staffordshire Housing. Governors participating in Trust events such as Board meetings, events, committees or working groups as agreed or invited by the Trust, and whose expenses are not paid by another organisation, are entitled to claim expenses including mileage or public transport costs, car parking, subsistence allowance and carer's allowance. The current rates are as outlined in the Policy for the reimbursement of expenses of governors and members.
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2010-11 2010-11 Annual Report Report Annual
Additional Roles Brokering community support: Governor Members are asked to develop strong links with the community that they represent. They are one of the links to the wider membership and help the Trust to reach further into the community to encourage and develop support, engagement and consultation on specific strategies and policies. Provide real time service user feedback: We aim to harness the skills of our Governor members to provide us with real time, meaningful and direct feedback on strategies that we have developed, implemented or are due to implement. The ability to volunteer on specific work projects, mentoring etc: We also expect our Governor Members and local membership communities to become involved in specific work projects. A number of Governor Members may be able to offer specific mentoring support to our staff, other Governor Members, service users or their carers in relation to projects or initiatives.
Roles and Responsibilities of Governors To represent the interests of the membership and partner organisations. To feedback information about the Trust to the membership and partner organisations. To appoint, and if ever appropriate, dismiss the NonExecutive Directors and the Chair. To decide the remuneration and allowances, and the other terms and conditions of office, of the NonExecutive Directors. To approve an appointment of the Chief Executive. To appoint or remove the External Auditors. To be presented with the Annual Accounts, External Auditor’s Reports and Annual Reports. To provide their views to the Board of Directors on the Trust’s forward planning. To use their best endeavours to ensure South Staffordshire and Shropshire Healthcare NHS Foundation Trust remains a leading provider of mental health, developmental neurosciences, learning disabilities, specialist and children’s services. To ensure the Membership Council meetings are held in accordance with policy and standing orders. To comply with and implement the Code of Conduct for Governor Members and abide by the Nolan Principles. To be consulted on and make recommendations to the Trust Board of Directors on the development of the membership strategy. To respond as appropriate when consulted by the Board of Directors in accordance with the constitution. To undertake such functions as the Board of Directors shall from time to time request. To consider the annual accounts, any report of the External Auditor on them and the annual report. Receive regular information as appropriate to the responsibilities of the Council. Set up committees and working groups in conjunction with the Chair, for example the Nominations Committee, Non Executive Director Remuneration Committee and others as appropriate. Attend regular Membership Council meetings, the Annual Members Meeting and special events as appropriate.
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Governor Members in their Fifth Year It has been a significant fifth year for our Governor Members who are making an excellent contribution to the work of the Trust. During the year, Governor Members have: Fulfilled their statutory function of successfully appointing three new Non-Executive Directors one of whom commenced with the Trust in April 2010 and the other two in May 2010. Been involved in the appointment of a new Executive Director. Engaged in the Trust’s Essential Standards Reviews programme which provides an opportunity for Governor Members to familiarise themselves with the patient’s environment and staff engaged in their care and act as a conduit for patients and staff comments to be documented and appropriate action. Regularly receiving and commenting upon integrated clinical and business performance information at Membership Council meetings. Attended national events including Foundation Trust Network (FTN) and Monitor events and the FTN Governors’ Development Programme.
Recruiting Members and supporting the Time to Change campaign
Attended a number of training events including sessions on Essential Standards Reviews and Conflict Resolution. Commenced a new shadowing scheme which allows Governors and senior staff / clinicians to shadow one another and learn about each other’s roles. Held local constituency engagement with members.
meetings
to
increase
Attended formal Membership Council Engagement meetings focusing on key areas such as Combating Stigma, Strategic Development and Performance and Assurance.
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2010-11 Annual Report
Visited individual clinical directorates. Attended public events promoting the work of the Trust and the Time to Change Combating Stigma Campaign. Organised, through the member and governor focus group, a public psychological services conference, held in Stafford.
Constituency meetings have been held to increase engagement with members
Advised and contributed to the development of new pages of the membership section of the Trust website. Advised, contributed to and approved the Membership Strategy 2010-2014. Been consulted upon and agreed the Full Business Case: Modernisation of Mental Health Services in Shropshire/Telford and Wrekin.
Members were invited to help shape the future of psychological services
2010-11 Annual Report
A register of interests is maintained in relation to all Governor Members on the Membership Council. This is available for viewing on the Trust website or by application to the Company Secretary.
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Elections Public/Service User/Carer and Staff Governor Members are elected by the Membership. Elections are held in accordance with the election rules, as stated in the Constitution, using a single transferable vote system. The elections are currently administered on behalf of the Foundation Trust by the Electoral Reform Services Limited. The fifth annual round of elections was held in the summer of 2010. The election turnout as a measure of engagement with members is healthy, where a turnout of 24.5% was achieved.
Turnout for elections is healthy
The Trust has a comprehensive programme to encourage members to stand as Governor Members including coffee mornings and drop in sessions as well as new written materials explaining the role and the support available. The Trust provides individual support for prospective Governor Members including additional support to users and carers as required to encourage nominations from under-represented groups. 5 seats were available for election in 2010 comprising 3 Public/Service User/Carer Governor Members (1 South Staffordshire, and 2 Shropshire and Telford & Wrekin) and 2 Staff Governor Members (Medical and Qualified Nurses). All of the seats were filled.
Governor Member, Michael Allen, with to John Thompson at the Annual General Meeting
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2010-11 2010-11 Annual Report Report Annual
Contact details are as follows: The Membership Office FREEPOST RLUS_GBES_KBYL St Georges Hospital Corporation Street Stafford ST16 3AG Telephone: 01785 221431 or 01785 221379 E-mail:
[email protected] or
[email protected] http:// www.southstaffsandshropshealthca reft.nhs.uk/Partnership/ Membership/Default/ Introduction.aspx Membership Office Manager: Jenny Smit Membership Co-ordinator: Luke Thornley
Contact with Members Members are encouraged to attend Membership Council meetings including the Annual Members Meeting held in September each year. Members are also invited to a wide range of specific Trust wide events and meetings including for example the Trust’s Stigma campaign and a small focus group to look at the provision of psychological services across the Trust. Our members receive high quality quarterly information updating them on the Trust’s progress and on key service initiatives and developments. There is also a members’ section on the Trust website which has been redesigned. Members are communicated with on a regular basis with regards to consultations, public events and member constituency meetings. Members can also access the Trust facebook page – Combating Stigma, a social movement to end discrimination, encouraging involvement and engagement from younger members. Members have also been sent a questionnaire designed to evaluate people’s views around the stigma in mental health. The Trust received an excellent response to this, the results will be evaluated. The questionnaires will be sent again next year and the results compared to gauge how effective the time to change campaign has been locally. The Membership Council’s annual appraisal and selfassessment review is fed back directly to members at the Annual Members Meeting and focuses on how the Membership Council has discharged its responsibilities to its members. The review for 2009 / 2010 was the most positive we have ever received.
The Membership Team, Jenny Smit and Luke Thornley
2010-11 Annual Report
Members may contact Governor Members through the Membership Office or via the Trust website.
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Page 50 Allied Health Profession Shropshire/Telford and Wrekin
Staff
Staff
Public/Service User/ Carer
Staff
Jennie Holland
Joseph Wickens
Julia Evans
Julie Hayward
Nursing Regional National
Staff
Staff
Public/Service User/ Carer
Mark Butler
Martin Kinsella
Medical
Voluntary Sector Mental Health Forum
South Staffordshire
Shropshire/Telford and Wrekin
Shropshire/Telford and Wrekin
Non-Clinical Support
Social Care
Maha El-Nadeef
Lilian Owens
Keith Bury
Kathryn Pryce
Karl Bailey
Public/Service User/ Carer Public/Service User/ Carer Public/Service User/ Carer Partner
Staffordshire County Council
Partner
South Staffordshire Carers Association South Staffordshire
South Staffordshire
Shropshire/Telford and Wrekin
Frances Carlin Gill Wyatt
Enrique Mateu
Daphne Sharp
South Staffordshire
Clinical Support
23/09/2008
22/09/2010
22/09/2010
01/06/2007
27/09/2009
27/09/2009
27/09/2009
27/09/2006
23/09/2008
27/09/2009
27/09/2009
04/08/2009
23/09/2008
27/09/2009 27/09/2006
27/09/2006
27/09/2006
27/09/2006
19/01/2010
27/09/2009
23/09/2008
22/09/2010
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23/09/2008
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23/09/2011
23/09/2013
23/09/2013
23/09/2012
23/09/2012
23/09/2012
23/09/2011
23/09/2011
23/09/2012
27/09/2012
23/09/2011
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18/09/2013
23/09/2012
23/09/2011
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Graham Riley Ivan Jennings (Councillor)
Staff
Shropshire/Telford and Wrekin
South Staffordshire
17/02/2011
23/09/2008 23/09/2008
01/03/2011
21/09/2010
Public/Service User/ Carer Public/Service User/ Carer Public/Service User/ Carer Partner Public/Service User/ Carer
David Jenkins
David Gill
Colin Wilkinson
Prison Service
North Staffordshire People First
South Staffordshire PCT
Start Date
End Date (n/a for appointed members)
14/04/2010
Partner Public/Service User/ Carer Public/Service User/ Carer
Partner Public/Service User/ Carer Partner
Alison Wynne
Sub-Division
Term of Office (for Elected Governors)
19/01/2011
Andrew Millward Andrew Smith Bridie Oakes Richards
Constituency
Governor Member
If reelected new start date
Membership Council
2010-11 Annual Report
2010-11 Annual Report
Partner Partner Public/Service User/ Carer Public/Service User/ Carer Partner Public/Service User/ Carer Public/Service User/ Carer Public/Service User/ Carer
Paul Taylor Paula Burton
Partner
Partner
Teeranlall Ramgopal
Tony Price
Governor Member
Gill Howland Rick Robson Michael Ratcliffe John Evans Lynda Jones Paul Newton Harvey James
William Oliver-Healey Christian Dunn Stephen How Sue Brookes John Wicks Paul Donohue
Status
Left Left Left Left Left Left Left
Left Left Left Left Left Left
Leavers
* - Not in Post
Partner
Simon Jones (Councillor)
Robin Harvey
Roger Boughton
Ravi Bhakhri
Phil Clancey
Peter Cross
Public Staff Public Public Partner Partner
Shropshire Medical Regional/National Regional/National South Staffordshire PCT Telford & Wrekin Council
22/09/2010 27/09/2006 27/09/2006 27/09/2006 05/01/2007 31/07/2009
16/10/2010 27/09/2006 27/09/2006 27/09/2006 27/09/2006 25/03/2010 01/05/2007
3 3 3 3 Appointed Appointed
Appointed 3 3 3 3 Appointed Appointed
10/10/2010 21/09/2010 21/09/2010 21/09/2010 01/03/2011 01/06/2010
30/06/2010 31/07/2010 21/09/2010 16/07/2010 21/09/2010 07/09/2010 31/07/2010
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23/09/2012
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23/09/2013
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21/09/2011
23/09/2012
End Date
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23/09/2009
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Start Date
27/09/2006
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01/072010
South Staffordshire Housing Association
31/07/2009
16/01/2008
22/09/2010
22/09/2010
25/11/2009
27/09/2006
23/09/2008
01/06/2010 01/08/2010
27/09/2006
27/09/2006
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Shropshire County Council
Shropshire
Shropshire
South Staffordshire
MIND
South Staffordshire
South Staffordshire
Telford and Wrekin Council Shropshire County PCT
Age Concern South Staffordshire
South Staffordshire
Constituency
Partner
Nick Maslen
Pauline Pearsall
Public/Service User/ Carer
Michael Allen
19/02/2011
Page 51
How are we checking that what we do is right? The Board of Directors The role of the Board of Directors is to manage the Trust by:
setting the overall strategic direction of the Trust within the context of NHS priorities
regularly monitoring objectives
providing effective financial stewardship through value for money, financial control and financial planning
ensuring that the Trust provides high quality, effective and patient-focused services through clinical governance
ensuring high standards of corporate governance and personal conduct
promoting effective dialogue between the Trust and the local communities we serve.
our
performance
against
Decisions delegated to management are as defined within the Scheme of Delegation which is available on request from the Company Secretary. The Membership Council (our equivalent of the Board of Governors as described in legislation) advises the Trust on how to carry out our work to help us best meet the needs of our service users and the wider community. It has a number of statutory duties, including to appoint the Chairman and Non-Executive Directors, and to ratify the appointment of the Chief Executive. The Membership Council also determines the remuneration of the Chairman and Non-Executive Directors, receives the Trust’s Annual Report and Accounts and Auditor’s report, and appoints the Trust’s external auditor.
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Board of Directors: The Board recognises that organisational development and effective leadership and management is a key strand of sustaining and delivering excellence within our organisation. In 2010, the National Leadership Council report, The Healthy NHS Board Principles for Good Governance, identified the three key roles that effective boards undertake in order to demonstrate leadership: 1. Formulating strategy for the organisation; 2. Ensuring accountability by holding the organisation to account for the delivery of the strategy, and through seeking assurance that systems of control are robust and reliable; and 3. Shaping a positive culture for the board and the organisation. Throughout 2010/11, the Board has focussed its development work in these three key areas to ensure that from the Board and through the whole organisation it can both attract and develop skilled leaders and managers at all levels and across all disciplines who understand the challenges and have the confidence, knowledge, skill and competence to work effectively in a successful NHS foundation trust.
2010-11 Annual Report
During 2009/10, the Board worked with the NHS Institute for Innovation and Improvement using its Board Development Tool to provide a framework for reviewing and improving Board performance. The outcomes of this process were reported to the Board in April 2010 and also helped inform the Board’s Development priorities for 2010/11. The Board of Directors regularly reviews its own performance through a process of selfassessment and peer review. Throughout the year externally facilitated Board Development Sessions have taken place on a quarterly basis. There has also been a continued focus on ensuring all Board members maintain compliance with mandatory training requirements. In the Trust’s Organisational Development Implementation Plan for 2010/11 an outcome measure was agreed for the Trust Board. This was “to provide visionary leadership and act as ambassadors for change, cham pioning a transformational organisational culture of development”. Progress and actions to deliver this outcome are regularly received and reviewed at Board meetings to evaluate and monitor the Board with respect to: its current effectiveness in leading the organisation its approach in framing the culture of the organisation its approach in engaging the organisation its approach to framing organisational development
2010-11 Annual Report
As a consequence of this and following Board development workshops held in July and November 2010, an organisational culture paper was presented to the Board by the Chief Executive on 28 October 2010. This identified a process to define how we "live" our 3 Trust core values and define the behaviours we expect from staff for each of these and included four facilitated sessions on 20 December 2010 and 7 January 2011. Subsequently, a Trust wide culture change programme “Delivering Service Excellence – Caring about People” was agreed for implementation during 2011/12 and will be reported on in the 2011/12 annual report. To further support this achievement of the agreed outcome measure, Board members each undertake a programme of personal development on a yearly basis which is individually agreed and monitored at appraisal. Board members are also actively involved in leading sessions as part of the Trust’s Leadership Development Programmes and during 2010/11 took part in a new initiative to undertake a rolling programme of “back to the floor” visits on a monthly basis which have a number of key objectives: to impart agreed key messages to staff to explore agreed key areas of Staff Opinion Survey results to test and address key findings. to demonstrate the desired culture, behaviours and approach by leading by example Committees: South Staffordshire and Shropshire Healthcare NHS Foundation Trust has consistently achieved a rating of green for governance from Monitor, the independent regulator of NHS foundation trusts and prides itself on its ability and future potential to thrive as an NHS foundation trust. During 2010/11 an internal audit governance review was undertaken, along with a full assessment against the Audit Commission Report “Taking it on Trust” and this has been followed up with a self assessment process undertaken by all Board subcommittees to review their terms of reference, overall performance and effectiveness and to ensure they were aligned to the achievement of the Trust’s strategic aims. Directors: Annual performance appraisals are routinely undertaken for all Board Members, summaries of which are made available to the Remuneration Committees. With respect to Non Executive Directors, the appraisal processes include an evaluation and assessment of the independence of all Non Executive Board members.
Page 53
Sub Committees of the Board: (membership in brackets under individual Board members) a. Audit Committee - responsible for ensuring that the Trust Board receives independent assurance. b. Finance and Performance Sub Committee - creates a control and performance management environment for a high performance organisation. c. Business Development and Investment Committee - ensures strategy is integrated, contestable and cost effective. d. Remuneration and Terms of Employment Committee - NonExecutive Directors advise the Board on appropriate remuneration for Directors and staff awards and pay. e. Human Resources and Organisational Development Committee - ensures a culture of staff engagement and staff learning and development is advanced. f. Quality, Effectiveness and Risk Management Committee responsible for developing systems that ensure services are safe, sound and compliant. g. Service User and Carer Committee - reports to the Membership Council and ensures that the views of service users and their carers are represented and actioned resulting in a user centred approach to strategic development. h. Trust Board of Directors accountable for internal control. i.
Modernisation of Mental Health Services in Shropshire and Telford & Wrekin Supervisory Committee - oversees the project for the redevelopment of mental health services in Shropshire and Telford & Wrekin.
Page 54
Stephen Jones Chairman Start date: November 2002. Chairman from October 2006 Current term of office end date: June 2013 Extensive business experience in training and consultancy; Past President of Dudley Chamber of Industry and Commerce; Chair of P3, a large social inclusion charity. Elected member of NHS Confederation Mental Health Network Board and member of Foundation Trust Network board. Mr Jones’ commitments outside the Trust are for 2 days per week. (d, h, i)
Steve Jones
Eleanor Chumley-Roberts Non-Executive Director/Vice Chairman and Senior Independent Director Start date: January 2002 Vice Chairman from October 2006 Term of office end date: 30 April 2010 Experience at senior manager/director level – NHS, local government and voluntary sector. Partner in private sector environmental health, charity and management consultancy. Director of one public sector company. Special interest in Service User and Carer involvement and membership. (a,d,e,g,h) Roger Craven Non Executive Director /Vice Chairman and Senior Independent Director (from 1 May 2010) Start date: February 2005 Current term of office end date: January 2012 35 years UK banking experience including senior management roles in relationship and credit management and project management, followed by 7 years experience with a US Rating Agency working with computer-based credit risk systems. Acted as treasurer and then chairman of a local charity. Member of investment panels of the Foundation Trust Financing Facility and the Social Enterprise Investment Fund, both sponsored by the Department of Health (a,b,d,h,i)
Roger Craven
Roger Evans Non Executive Director Start date: October 2002 Term of office end date: 30 April 2010 Professor of Socio-Legal Studies and Director of the School of Law at Liverpool John Moores University. Qualified Social Worker. Extensive experience of strategic and financial planning and project management of large funded collaborative empirical research projects and policy and practice orientated research. Leads on measuring the performance and impact of the Board. (a,d,f,h)
2010-11 Annual Report
Dr Susie Green
Ron Hilton
Richard Moore
Dr Susie Green Non Executive Director Start date: September 2007 Current term of office end date: September 2013 Susie and her family have used the NHS throughout their lives. She also has extensive experience as clinician and researcher in community, mental health, children’s and learning disability services, having pioneered and written about innovative schemes enabling those who use services to have an influence on them. Formerly freelance facilitator for the 'Having a Say in the NHS' learning resource and toolkit, and Senior Research Fellow at University of Birmingham. (a,d,e,f,g,h) Ron Hilton Non Executive Director Start Date: 1 May 2010 Current term of office end date: April 2013 Mr Ron Hilton has recently retired as Chief Executive of Staffordshire County Council. He had been with the Council for 8 years starting as a Corporate Director and working his way up to Chief Executive. During his time at the Council it moved from being a low rated organisation to its current status as one of the highest performers in the country. (a,c,d,e,h,i) Richard Moore Non Executive Director Start date: 1 April 2010 Current term of office end date: March 2013 Mr Richard Moore is a business consultant and company director with a wide range of board level experience across a number of sectors. He trained as an accountant with Ernst and Young and worked for Rolls Royce before developing two of his own business ventures. Subsequently he was Deputy International Director at Oxfam GB and a Director of BBC Children in Need where he supported the annual appeal and oversaw the grant application and distribution process (a,b,c,d,f,h)
Dr Liz Nicholson
Dr Liz Nicholson Non Executive Director Start Date: 1 May 2010 Current term of office end date: April 2013 Dr Liz Nicholson was the Director of Children and Young People’s Services at Shropshire Council for 10 years. She also took on the role of Interim Director of Community Services which involved working with local primary care trusts and hospitals to develop services for vulnerable adults and the elderly. In her role a chair of QERC undertakes infection control visits, and reviews security managements issues and complaints. She also attends a number of sub-committees including Audit, Service Users and Carers, Modernisation and Infection Control. (a,d,h,i)
Peter Woolrich
Peter Woolrich Non Executive Director Start date: November 2005 Current term of office end date: October 2012 Senior Commercial Manager/Director roles in the electrical industry for UK and International markets. Has extensive experience in team building, developing new business opportunities and in re shaping commercial teams following Mergers and Acquisitions and addressing the post merger issues of cultural change and differing practices. Non Exec Director of a small engineering company and a Trustee and Company Secretary for the local League of Hospital Friends and a supported housing association. (a,b,c,d,e,h)
2010-11 Annual Report
Page 55
Neil Carr OBE Chief Executive Start date: May 2001, Chief Executive 16 May 2007 A nurse by background with significant interest in strategic and transformational leadership and Mental Health strategy. Instrumental in delivering one of the first Mental Health FTs and in 2007 led the first successful acquisition. Keen advocate of innovative partnerships and using FT freedoms to be positively different, eg partnership with the MoD on national contracts for serving personnel and first national FT network of provision. OBE for services to healthcare and holds an Honorary Doctorate for contribution to leadership in health care. In April 2010 awarded a Fellowship of the Royal College of Nursing in recognition of an exceptional contribution to leadership. (h,i)
Neil Carr
Jayne Deaville Director of Finance and Performance and Deputy Chief Executive Start date: March 2001 NHS Director of Finance since 1992; Experience of financial modelling, planning and monitoring; performance measurement and monitoring; strategic business planning; Areas of interest, finance and performance management, clinical effectiveness and risk management, strategic direction and planning, service modernisation and redesign. Responsibility for information technology (b,c,h,i) Dr Claire Barkley Medical Director Start Date: October 2008 28 years of NHS experience, including 16 as a consultant forensic psychiatrist in West Midlands. Qualified in Edinburgh in 1983 and trained in Edinburgh, Cambridge, The Maudsley and Manchester. Has been involved in forensic mental health service developments in Stafford from 1995-2002 (Hatherton Centre) and Birmingham (Ardenleigh) from 2002-2007, rejoining the Trust in 2007. A part-time psychiatrist member of the Parole Board for E & W since 2001 and is also assessor for the Royal College of Psychiatrists. Interests include service development and organisational psychology (c,f,h)
Jayne Deaville
Richard Beeken Chief Operating Executive Start date: October 2007 End date: 14 June 2010 Held a number of management positions in acute hospitals across the country including Divisional Manager, Wolverhampton Hospitals NHS Trust; Chief Operating Officer, Birmingham Children’s Hospital NHS Foundation Trust. NHS General Management Training Scheme graduate. A graduate in Political Science and Geography (Dundee University) and Healthcare Management (University of Manchester). (e,f,g,h,i)
Dr Claire Barkley
Page 56
2010-11 Annual Report
Dr Neil Brimblecombe
Dr Neil Brimblecombe Chief Operating Officer/Director of Nursing (from June 2010, previously Director of Nursing/Quality and Professional Practice) Start date: October 2007 Qualified as a nurse in 1986. Clinical and managerial experience in CAMHS, acute inpatient and crisis services. Director of Mental Health Nursing at the Department of Health for 5 years. Led national reviews of mental health and learning disability nursing. Published widely in the professional press. Degrees in nursing and medical anthropology. PhD on outcomes in crisis services. Areas of interest: new ways of working, service evaluation and research. (b,c,e,f,h) Steve Grange Director of Commercial & Business Development Start date: January 2005 Director 1 April 2010 Steve started in Industry and has worked across many NHS sectors including the Department of Health, Strategic Health Authority, Modernisation Agency, Primary Care Trusts, Specialised Services, Acute Sector and in the USA with the US Veterans. Steve has a background in Specialised Clinical and IT Purchasing Emergency Care, Clinical Networks and general acute management. Steve is formally qualified in industry level Business and Project Management at degree level. Steve has managed a number of large projects, many of them national and is very proud to have project-led one of the first mental health style foundation trusts. (c,g,h)
Steve Grange
Therèsa Moyes
Theresa Moyes Director of Quality and Clinical Performance Start Date: September 2005 Director from 1 March 2011 Qualified as a clinical psychologist in Liverpool in 1986 after gaining both her first degree in psychology and computer science and teaching qualifications at Keele. Clinical and managerial experience across the spectrum of mental health services in various places around the country. Therèsa became involved in service improvements and redesign methodologies in the late 1990’s. In 2001 this interest enabled her to win regional and national awards for clinical governance and modernisation. She has since taken on leadership roles including rolling out the mental health NSF, developing psychological services in Leeds and more recently, developing performance and quality for the Trust. She has a strong interest in strategy and in being able to evidence we do what we say we do. (a,b,f,h) Based on the expertise and experience listed above, the Foundation Trust is confident that the necessary range of knowledge and skills exists within the Board of Directors and that its balance, completeness and appropriateness to the requirements of the NHS Foundation Trust constitutes a high performing Board. Non Executive Directors are normally appointed for a term of three years. If any of the grounds for exclusion or disqualification set out in the Constitution as it may be amended from time to time apply to a NED, then the appointment may be terminated. A NED must immediately notify the Chairman and the Company Secretary if any event occurs which would or may disqualify them from or make them ineligible to continue in the role as a NED. In addition, a NED may be removed as a NED at a general meeting of the Membership Council at which the removal is approved by three-quarters of the members of the Membership Council.
2010-11 Annual Report
Page 57
Trust Board of Directors Attendance
25/03/2010
29/04/2010
27/05/2010
06/2010
29/07/2010
26/08/2010
01/10/2010
28/10/2010
16/12/2010
27/01/2011
24/02/2011
31/03/2011
Steve Jones Eleanor Chumley-Roberts Roger Craven Roger Evans Susie Green Ron Hilton Richard Moore Liz Nicholson Peter Woolrich Neil Carr Jayne Deaville Claire Barkley Richard Beeken Neil Brimblecombe Steve Grange Theresa Moyes
√ √ √ √ x * * * √ √ √ √ √ √ * *
√ x x √ √ * √ * √ √ √ x √ √ √ *
√ * √ * √ √ √ √ √ √ √ √ √ √ √ *
** ** ** * ** ** ** ** ** ** ** ** ** ** ** **
√ * √ * √ √ √ √ √ √ √ √ * √ √ √
√ * √ * x √ √ √ √ √ x x * √ √ √
√ * x * √ √ √ x x √ √ √ * √ √ x
x * √ * √ x √ √ √ √ √ √ * x √ √
√ * √ * √ √ √ √ √ √ √ √ * x √ √
√ * √ * √ √ x √ √ √ √ √ * √ √ √
√ * √ * √ √ √ √ √ √ √ √ * √ √ √
√ * √ * √ √ √ √ √ √ √ √ * √ √ √
Membership Council Attendance
14/04/2010
14/07/2010
21/09/2010
19/01/2011
Steve Jones Eleanor Chumley-Roberts Roger Craven Roger Evans Susie Green Ron Hilton Richard Moore Liz Nicholson Peter Woolrich Neil Carr Jayne Deaville Claire Barkley Richard Beeken Neil Brimblecombe Steve Grange Theresa Moyes
√ √ x x √ * * * x √ √ √ √ x √ *
√ * √
√ * √ * √ √ √ x √ √ √ √ * x √ x
√ * √ * √ √
Page 58
* √ √ √ √ x √ x √ * x √ √
* denotes not in post ** no meeting held in June
x √ x √ √ √ * √ x √
2010-11 Annual Report
Non Executive Director Nominations Committee Non Executive Director appointments are made through the Nominations Committee, comprising Governor Members. The purpose of this Committee as defined within its terms of reference is “ … to assist the Board of Directors with its oversight role by:
Periodic review of the numbers, structure and composition (including the person specifications) of Non-Executive Directors, to reflect the expertise and experience required, and to make recommendations to the Membership Council. Developing succession plans for Non-Executive Directors, taking into account the challenges and opportunities facing the Trust Identifying and nominating candidates to fill NonExecutive Director posts Keeping the leadership requirements of the Trust under review, to ensure the continued ability to provide cost effective, high quality and appropriate health services.
The Non-Executive Director Remuneration Committee met once during 2010/11 for the purpose of considering the reappointment of one Non Executive Director whose first term of office expired on 30th September 2010. The Nominations Committee were asked by the Board of Directors to ensure a robust and thorough re-appointment process to ensure the performance of the individual proposed for re-appointment continued to be effective, that commitment to the role continued to be demonstrated along with the non-executive director’s independence. The re-appointment of Susie Green, Non Executive Director, was subsequently approved and ratified by the Membership Council at its September 2011 meeting.
Nominations Committee
2010-11 Annual Report
01/09/2010
Andrew Millward
√
Tony Price
√
Jenni Hodson
x
Roger Craven (Chair)
√
Steve Jones
√
Page 59
All Directors confirm that so far as they are aware, there is no relevant audit information of which the Trust auditor is unaware and they have taken all the steps required to make themselves aware of any such information and establish that the Trust auditor is aware of it.
Summary of Audit Committee Role The Audit Committee is responsible for ensuring the establishment and maintenance of an effective system of integrated governance, risk management and internal control, across the whole of the organisation’s activities in support of the achievement of the organisation’s objectives. It achieves this by:
In July 2010, the Audit Committee and the Trust Board agreed a policy for the Engagement of External Auditors for Non Audit Work. This policy sets out what threats to audit independence theoretically exist and thus provides a definition of nonaudit work which can be shared by the Trust and KPMG. It then seeks to establish the approval processes and corporate reporting mechanisms that will be put in place for any nonaudit work that KPMG is asked to perform.
ensuring that there is an effective internal audit function providing appropriate independent assurance to the Audit Committee, Chief Executive and Board. reviewing the work and findings of the External Auditor reviewing the findings of other significant assurance functions, both internal and external to the organisation reviewing the work of other committees within the organisation, whose work can provide relevant assurance to the Audit Committee’s own scope of work. requesting and reviewing reports and positive assurances from directors and managers on the overall arrangements for governance, risk management and internal control reviewing the Annual Report and Financial Statements before submission to the Board and ensuring that the systems for financial reporting to the Board, including those of budgetary control, are subject to review as to completeness and accuracy of the information provided.
The committee submits annual reports to the Board on the work that has been undertaken during the year, and undertakes a review of its effectiveness incorporating the views of the External and Internal Auditors. 01/04/2010
03/06/2010
15/07/2010
13/10/2010
08/12/2010
25/01/2011
Dr Susie Green
√
x
√
√
x
√
Peter Woolrich
√
√
x
√
√
x
Richard Moore
√
√
√
√
√
x
Roger Craven (Chair)
√
√
√
√
√
√
Ron Hilton Liz Nicholson
* *
√ √
√ √
√ √
√ √
√ √
Eleanor Chumley Roberts
√
*
*
*
*
*
Roger Evans
x
*
*
*
*
*
Audit Committee Core Membership Attendance
* denotes not in post
Page 60
2010-11 Annual Report
Business Development & Investment Committee Core Membership Attendance
21/04/2010
21/07/2010
20/10/2010
15/12/2010
16/02/2011
30/03/2011
Peter Woolrich
√
√
√
√
√
√
Ron Hilton
x
√
√
√
√
√
Richard Moore
x
√
√
√
√
√
Jayne Deaville
√
√
√
x
√
√
Steve Grange
√
√
√
√
√
√
√
√
Claire Barkley
**
Theresa Moyes
**
**
x
√
**
x
x
**
**
Service User & Carer Committee Core Membership Attendance
14/04/2010
09/06/2010
11/08/2010
08/12/2010
09/02/2011
Eleanor Chumley-Roberts
√
*
*
*
*
Susie Green
√
√
√
x
√
Liz Nicholson
*
√
x
√
√
Richard Beeken
√
*
*
*
*
Steve Grange
**
**
**
√
√
No meeting in October due to Service User and Carer Awards
23/11/10
10/02/11
10/03/11
2010-11 Annual Report
18/10/10
* denotes not in post ** not core member of group
12/08/10
Steve Jones
14/06/10
Roger Craven
12/05/10
Modernisation of Mental Health Services in Shropshire/Telford & Wrekin Committee Core Membership Attendance
√
x
√
√
√
√
√
√
√
√
X
√
x
√
Liz Nicholson
√
√
x
√
√
√
x
Ron Hilton
√
√
√
√
√
√
√
Jayne Deaville
√
√
√
√
√
√
√
Neil Brimblecombe
X
x
√
√
√
X
√
Neil Carr
√
x
x
√
√
√
x
Claire Barkley Steve Grange
√ x
√ x
√ x
x x
x x
√ x
x x
Page 61
07/04/2010
18/05/2010
07/07/2010
04/08/2010
01/09/2010
01/09/2010
06/10/2010
03/11/2010
08/12/2010
13/01/2011
02/02/2011
09/03/2011
Richard Moore
√
x
√
x
√
√
√
√
√
√
√
√
Peter Woolrich
√
√
√
√
√
√
x
x
x
x
x
x
Roger Craven
√
√
√
√
√
√
x
√
√
√
√
√
Theresa Moyes
√
√
x
x
√
√
√
√
√
√
√
x
Jayne Deaville
x
√
√
√
√
√
√
√
√
√
√
√
Finance & Performance Committee Core Membership Attendance
08/04/2010
13/05/2010
10/06/2010
12/08/2010
14/10/2010
11/11/2010
09/12/2010
10/02/2011
Liz Nicholson**
*
√
x
x
√
√
√
√
Susie Green**
√
x
√
√
x
√
x
√
Richard Moore**
*
√
√
x
x
x
x
x
Jayne Deaville***
x
x
√
x
x
x
x
x
Neil Brimblecombe***
√
x
x
√
√
x
√
√
Theresa Moyes***
√
x
√
√
√
√
√
√
Quality Effectiveness & Risk Committee Core Membership Attendance
* denotes not in post ** shared attendance *** only attend when required
11/05/2010
13/07/2010
14/09/2010
09/11/2010
11/01/2011
08/03/2011
Human Resources & Organisational Development Committee Core Membership Attendance Ron Hilton
√
√
x
√
√
√
Susie Green Peter Woolrich
√ x
√ x
√ √
x √
√ x
√ √
Eleanor Chumley-Roberts
√
*
*
*
*
*
Richard Beeken
√
*
*
*
*
*
Neil Brimblecombe
√
√
√
x
√
√
Jayne Deaville
√
x
√
√
x
√
* denotes not in post
Page 62
2010-11 Annual Report
Making Sure the Board Understands the Views of Governor Members and Members Board members meet with Governor Members prior to each Membership Council meeting and are encouraged to attend the meeting itself. The Chief Executive and the Director of Finance and Performance each lead on standing agenda items at each Membership Council meeting. Summary reports of Membership Council meetings are received by the Board and in turn Governor Members receive the minutes and agenda for Board meetings and are encouraged to attend the public section. The Board and Membership Council hold joint sessions each year and in response to the outcome of the Membership Council self-assessment process undertaken during the summer 2009, have been enhancing and improving the emphasis placed on ensuring the involvement of the Membership Council in developing, shaping and commenting on the Board’s strategic vision and forward planning. A Non Executive Director also sits on all Governor Member Engagement Groups and two Non Executive Directors routinely attend the Governor Member Steering Group.
2010-11 Annual Report
Page 63
Colin Wilkinson
√
√
Lilian Owens
√
√
Michael Allen
√
√
Tony Price
√
√
Remuneration Committee
29/07/2010
Non Executive Directors: The Remuneration Committee, established to consider the remuneration of non executive directors which comprises Governor Members and is chaired by the Lead Governor/ Deputy Chair of the Membership Council, met twice during 2010/11. The Committee received benchmark information on the remuneration of chairs and non executive directors across the foundation trust sector and noted the above decision of the Executive Director Remuneration Committee. The Committee concurred with the decision of the Executive Director Remuneration Committee that no increase or inflationary uplift should be paid to the Chairman and Non Executive Directors for 2010/11.
01/09/2010
Executive Directors: The Remuneration Committee, established to consider the remuneration of executive directors which comprises non executive directors and is chaired by the Chairman, met on one occasion during 2010/11. The Committee was very mindful of the economic climate facing the country and the NHS and were in full support of David Nicholson, the NHS Chief Executive's recommendation that all NHS bodies including Foundation Trusts to take account of his recommendation that no inflationary uplift should be awarded for Executive Directors for 2010/11. The Committee agreed that no increase or inflationary uplift should be paid to Executive Directors for 2010/11. The remuneration paid to Executive Directors no longer included a performance element and therefore no performance bonus was applied.
16/07/2010
Summary of Remuneration Committee Role
Non Executive Director Remuneration Committee
Liz Nicholson
√
Peter Woolrich
√
Richard Moore
√
Roger Craven
√
Ron Hilton
√
Steve Jones
√
Susie Green
√
There is no performance element to the remuneration of Board members. All executive directors have permanent contracts and notice periods of six months. All other Trust employees are employed on Agenda for Change pay bands and terms and conditions of service.
Page 64
2010-11 Annual Report
Compliance with the NHS Foundation Trust Code of Governance The Board of Directors and the Membership Council are committed to the principles of good corporate governance as detailed in the NHS Foundation Trust Code of Governance. Following publication of the Code of Governance in September 2006, a detailed review of the compliance position was undertaken by the Board and work undertaken to enable a declaration of compliance with the Code to be made. Subsequently in March 2008, the Executive Director Remuneration Committee amended its terms of reference, and as a result the Trust is not able to declare compliance with the following Code Provision: Code Provision E2.2 The remuneration committee should have delegated responsibility for setting remuneration for all executive directors, including pension rights and any compensation payments. The committee should also recommend and monitor the level and structure of remuneration for senior management. The definition of ‘senior management’ for this purpose should be determined by the Board but should normally include the first layer of management below Board level. Explanation The Remuneration Committee has delegated responsibility for setting the remuneration for executive directors only. This is because all senior managers are paid on Agenda for Change payscales and salaries are set according to the job matching and evaluation processes which are applied to all Trust staff (other than the Executive Directors). The Board is currently reviewing its compliance with the revised code of governance issued by Monitor in March 2010 but anticipates making, with the above exception, a declaration of compliance.
2010-11 Annual Report
Page 65
Register of Interests NAME Stephen Jones Chairman
Neil Carr Chief Executive
NATURE OF INTEREST Managing Director
NAME OF ORGANISATON Bacchus Racing Ltd
OTHER RELEVANT INFORMATION Shareholder
Chairman
P3
Added to Register 31/01/10
Director
Breeze Consultancy Services Ltd
Shareholder
Doctor
Staffordshire University
Fellow
Royal College of Nursing
Added to Register 01/05/10
Stakeholder Panel Member
Healthcare Purchasing Consortium
Added to Register 12/09/07
Executive Directors Jayne Deaville
Associate Governor
Stafford College
Dr Neil Brimblecombe
Visiting professor (honorary)
University of Nottingham
Dr Claire Barkley
Member
Part-time Psychiatrist Member of Parole Board for England and Wales
Steve Grange
None to declare
Woodseaves Charity
Therèsa Moyes
None to declare
Added to Register 01/06/09
Non Executive Directors Roger Craven
Member
Investment Panels of the Foundation Trust Financing Facility and the Social Enterprise Investment Fund, both sponsored by the Department of Health.
Added to Register April 2008
Dr Susie Green
Visiting Senior Research Fellow
University of Birmingham
Added to Register Oct 2007
Freelance Facilitator
'Having a Say in the NHS' learning resource and toolkit
Added to Register April 2009
Ron Hilton
Managing Director Board Advisor Board Advisor
Added to Register Dec 2010 Added to Register Dec 2010 Added to Register Dec 2010
Richard Moore
Director
Ron Hilton Consultancy Ltd Enterprise plc Senn Delaney Leadership Consultancy Group LLC Momentum Advisers Limited
Director
Momentum002 Limited – t/a Soccer City
Shareholder
Momentum003 Limited – t/a Lutterworth Football Academy
Director
Peppercorn Serviced Offices Limited
Shareholder Added to Register Dec 2010
Dr Liz Nicholson
Director
Carrig House Consultancy
Provides mentoring to newly appointed LA Directors of Children's Services under contract with the National College for Leadership of Schools and Children's Services
Peter Woolrich
Trustee and Company Secretary Director
Stafford League of Hospital Friends
Director
Page 66
Fresh Foundations, Community Interest Company Acrastyle Ltd
Shareholder Added to Register Dec 2010 Shareholder Added to Register Dec 2010 Added to Register Dec 2010
Added to Register April 2009 Added to Register Dec 2009
2010-11 Annual Report
Salaries and Pension Benefits Name and Title
2010-2011
2009-10
Salary (bands of £5,000)
Other Remuneration (bands of £5,000)
Benefits in kind (to the nearest £00)
Salary (bands of £5,000)
Other Remuneration (bands of £5,000)
Benefits in kind (to the nearest £00)
£000
£000
£00
£000
£000
£00
55-60
0
0
55-60
0
0
E Chumley-Roberts – Non Executive left 30/410
0-5
0
0
20-25
0
0
R Craven – Non Executive
15-20
0
0
15-20
0
0
0-5
0
0
15-20
0
0
S Green – Non Executive
15-20
0
0
15-20
0
0
P Woolrich – Non Executive
15-20
0
0
15-20
0
0
R Moore – commenced 1/4/10
15-20
0
0
0
0
0
E Nicholson – commenced 1/5/10
10-15
0
0
0
0
0
R Hilton – commenced 1/5/10
10-15
0
0
0
0
0
160-165
0
6,400
160-165
0
7,300
R Beeken – Chief Operating Officer left 14/6/10
20-25
0
0
105-110
0
0
N Brimblecombe – Director of Nursing until 15/6/10 then Chief Operating Officer
100-105
0
0
95-100
0
0
J Deaville – Director of Finance, Workforce & Performance
125-130
0
4,600
125-130
0
4,600
C Barkley – Medical Director from Sept’08
45-50
140-145
0
45-50
130-135
0
S Grange – Director of Commercial Development, commenced 1/4/10
95-100
0
4,600
0
0
0
T Moyes – Director of Quality & Clinical Performance, commenced 1/7/10
70-75
0
0
0
0
0
S Jones –Chairman
R Evans – Non Executive left 30/4/10
N Carr – Chief Executive
‘Benefits in kind’ relates to motor vehicles.
2010-11 Annual Report
Page 67
Pension Benefits Name and Title
Real increase in pension at age 60 (bands of £2,500)
Real increase in pension lump sum at aged 60 (bands of £2,500)
Total accrued pension at age 60 at 31 March 2011 (bands of £5,000)
Lump sum at age 60 related to accrued pension at 31 March 2011 (bands of £5,000)
Cash Equivalent Transfer Value at 31 March 2011
Cash Equivalent Transfer Value at 31 March 2010
Real increase in Cash Equivalent Transfer Value
£000
£000
£000
£000
£000
£000
0
0
80-85
240-245
1,588
1,732
0-2.5
0-2.5
20-25
70-75
264
274
2.5-5
10-12.5
35-40
110-115
617
607
0-2.5
0-2.5
30-35
95-100
576
612
0
0-2.5
2.5-5
15-20
50-55
190
213
0
0-2.5
2.5-5
25-30
85-90
525
481
24
£000
N Carr – Chief Executive R Beeken – Chief Operating Officer, left 14/6/10 N Brimblecombe – Director of Nursing until 15/6/10 then Chief Operating Officer J Deaville – Director of Finance & Performance S Grange – Director of Commercial Development, commenced 1/4/10 T Moyes – Director of Quality & Clinical Performance, commenced 1/7/10
0
0
0
Note: Non-Executive members do not receive pensionable remuneration C Barkley Medical Director from Sept’08 employment is non-pensionable.
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2010-11 Annual Report
Cash Equivalent Transfer Values A Cash Equivalent Transfer Value (CETV) is the actuarially assessed capital value of the pension scheme benefits accrued by a member at a particular point in time. The benefits valued are the member’s accrued benefits and any contingent spouse’s pension payable from the scheme. A CETV is a payment made by a pension scheme or arrangement to secure pension benefits in another pension scheme or arrangement when the member leaves a scheme and chooses to transfer the benefits accrued in their former scheme. The pension figures shown relate to the benefits that the individual has accrued as a consequence of their total membership of the pension scheme, not just their service in a senior capacity to which disclosure applies. The CETV figures and the other pension details include the value of any pension benefits in another scheme or arrangement which the individual has transferred to the NHS pension scheme. They also include any additional pension benefit accrued to the member as a result of their purchasing additional years of pension service in the scheme at their own cost. CETVs are calculated within the guidelines and framework prescribed by the Institute and Faculty of Actuaries. Real Increase in CETV This reflects the increase in CETV effectively funded by the employer. It takes account of the increase in accrued pension due to inflation, contributions paid by the employee (including the value of any benefits transferred from another scheme or arrangement) and uses common market valuation factors for the start and end of the period.
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How are we managing the money? STATEMENT OF THE CHIEF EXECUTIVE’S RESPONSIBILITIES AS THE ACCOUNTING OFFICER OF SOUTH STAFFORDSHIRE AND SHROPSHIRE HEALTHCARE NHS FOUNDATION TRUST The National Health Service Act 2006 states that the chief executive is the Accounting Officer of the NHS foundation trust. The relevant responsibilities of Accounting Officers, including their responsibility for the propriety and regularity of public finances for which they are answerable, and for the keeping of proper accounts, are set out in the NHS Foundation Trust Accounting Officer Memorandum issued by the Independent Regulator of NHS Foundation Trusts (“Monitor”). Under the National Health Service Act 2006, Monitor has directed the South Staffordshire and Shropshire Healthcare NHS Foundation Trust to prepare for each financial year a statement of accounts in the form and on the basis set out in the Accounts Direction. The accounts are prepared on an accruals basis and must give a true and fair view of the state of affairs of South Staffordshire and Shropshire Healthcare NHS Foundation Trust and of its income and expenditure, total recognised gains and losses and cash flows for the financial year. In preparing the accounts, the Accounting Officer is required to comply with the requirements of the NHS Foundation Trust Annual Reporting Manual and in particular to: Observe the Accounts Direction issued by Monitor, including the relevant accounting and disclosure requirements, and apply suitable accounting policies on a consistent basis; Make judgements and estimates on a reasonable basis; State whether applicable accounting standards as set out in the NHS Foundation Trust Annual Reporting Manual have been followed, and disclose and explain any material departures in the financial statements; and Prepare the financial statements on a going concern basis. The Accounting Officer is responsible for keeping proper accounting records which disclose with reasonable accuracy at any time the financial position of the NHS foundation trust and to enable him/her to ensure that the accounts comply with requirements outlined in the above mentioned Act. The Accounting Officer is also responsible for safeguarding the assets of the NHS foundation trust and hence for taking reasonable steps for the prevention and detection of fraud and other irregularities. To the best of my knowledge and belief, I have properly discharged the responsibilities set out in Monitor’s NHS Foundation Trust Accounting Officer Memorandum.
Signed Neil Carr Chief Executive
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Date: 6th June 2011
2010-11 Annual Report
STATEMENT OF DIRECTORS’ RESPONSIBILITIES IN RESPECT OF THE ACCOUNTS Under the National Health Service Act 1977 (in relation to the period as a NHS trust) and under paragraph 25 of Schedule 1 of the 2003 Act (in relation to the period as a NHS foundation trust) the organisation’s directors have specific responsibilities in respect of the preparation of the accounts for 2010/11. The Trust’s directors are required to prepare these accounts to give a true and fair view of the state of affairs of the Trust and of the income and expenditure of the Trust for that period. In preparing those accounts, the directors are required to: Apply on a consistent basis accounting policies laid down by the Secretary of State with the approval of the Treasury Make judgements and estimates which are reasonable and prudent State whether applicable accounting standards have been followed, subject to any material departures disclosed and explained in the accounts. The directors are responsible for keeping proper accounting records, which disclose with reasonable accuracy at any time the financial position of the Trust and to enable them to ensure that the accounts comply with requirements outlined in the above mentioned legislation (and in line with guidance as issued by the Department of Health and Monitor). They are also responsible for safeguarding the assets of the Trust and hence for taking reasonable steps for the prevention and detection of fraud and other irregularities. After making enquires, the directors have a reasonable expectation that the NHS foundation trust has adequate resources to continue in operational existence for the foreseeable future. For this reason, they continue to adopt the going concern basis in preparing the accounts. The directors confirm to the best of their knowledge and belief they have complied with the above requirements in preparing the accounts. By order of the Board
Date:
6th June 2011
Neil Carr, Chief Executive
Date:
6th June 2011
Jayne Deaville, Director of Finance
2010-11 Annual Report
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STATEMENT ON INTERNAL CONTROL 2010/11 Scope of responsibility As Accounting Officer, I have responsibility for maintaining a sound system of internal control that supports the achievement of the NHS foundation trust’s policies, aims and objectives, whilst safeguarding the public funds and departmental assets for which I am personally responsible, in accordance with the responsibilities assigned to me. I am also responsible for ensuring that the NHS foundation trust is administered prudently and economically and that resources are applied efficiently and effectively. I also acknowledge my responsibilities as set out in the NHS Foundation Trust Accounting Officer Memorandum. The purpose of the system of internal control The system of internal control is designed to manage risk to a reasonable level rather than to eliminate all risk of failure to achieve policies, aims and objectives; it can therefore only provide reasonable and not absolute assurance of effectiveness. The system of internal control is based on an ongoing process designed to identify and prioritise the risks to the achievement of the policies, aims and objectives of South Staffordshire and Shropshire Healthcare NHS Foundation Trust, to evaluate the likelihood of those risks being realised and the impact should they be realised, and to manage them efficiently, effectively and economically. The system of internal control has been in place in South Staffordshire and Shropshire Healthcare NHS Foundation Trust for the year ended 31 March 2011 and up to the date of approval of the annual report and accounts.
All new members of staff are required to attend a mandatory induction that covers key elements of risk management. This is further supplemented by local induction. The organisation provides mandatory and statutory training that all staff must attend, and in addition to this, specific training appropriate to individuals’ responsibilities as detailed within the Risk Management Strategy, is also provided. All training courses are available to all staff, and managers are encouraged to support further risk management training for all. There are many ways that the organisation seeks to learn from good practice and this includes incident reporting procedures, complaints and pro-active risk assessment. This information is filtered to frontline staff via the intranet, Directorate reports and staff newsletters. The risk and control framework The Risk Management Strategy clearly defines leadership, structure and the risk management process and is closely linked to the performance management system in operation within the Trust. Risks within the organisation are identified in many ways using many different
Capacity to handle risk Leadership arrangements for risk management are clearly documented in the Risk Management Strategy, and further supported by Trust Business Plan objectives and individual job descriptions. Leadership starts with the Chief Executive having overall responsibility, and delegation to named Executive Directors and Trust Clinical and Divisional Directors. The leadership is further embedded by ownership at a local level by managers taking responsibility for risk identification, assessment and analysis. In addition, the risk management system provides a holistic approach to risk, and terms of reference clearly outline the responsibilities of the overarching committee for risk management and other supporting risk committees and groups.
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2010-11 Annual Report
methods. Once identified each risk is assessed and evaluated using the Australian / New Zealand 5 x 5 matrix (likelihood x impact, where 1 is low and 5 high). This method is the recognised NHS Risk Management Standard. The risk management process ensures that the process is an ongoing exercise with a rolling programme of risk identification, assessment and analysis. Each Directorate maintains its own risk register and any risk identified with a risk-rating factor of 15 or over is included in the Trust Risk Register, which is monitored by the Trust Board. The Trust’s risk appetite has been clearly defined by the Business Developm ent and Investment Committee and adopted by the Trust Board and indicates how much, or little the Trust wishes to commit in terms of risk when reviewing service changes or investment. This is based on a score of low, medium and high risk on existing services which then informs the level of risk that the Trust is willing and able to support for service change / investment. This is reviewed on a six monthly basis and helps to support well managed risk taking Risk Management is embedded within the organisation. A culture of
fair blame aids the confident use of the incident reporting procedures throughout the organisation without stifling innovation. The Trust is conscious that this culture needs to be supported by staff and has therefore introduced many opportunities for staff to be trained not only in the mandatory and statutory areas but also risk management, including how to undertake risk assessments and how to report incidents. The Trust has a performance management system that measures performance monthly against Trust Business Plan objectives, which ensures that the risk management process is ongoing and embedded. Along with regular Trust wide and Directorate reports on Incidents, Complaints and Claims, the Trust also produces a comprehensive annual Risk Management report. The Trust uses the information governance toolkit to identify and manage information risks and reports all incidents regularly to the Trust Board. Data Security risks are managed as part of a comprehensive framework of risk management concerning IM&T and Information Governance within the Trust. Risks are managed through use of a risk register. Action plans are developed where necessary. Specific issues are also raised through the Information Governance Group. This group reports to the Finance and Performance Committee, which in turn reports to the Trust Board. Assurance is also provided through a comprehensive programme of internal and external audit which provides assurance on the effectiveness of security controls. Data security risks are further managed through close working with the Health Informatics Service and regular Information Security reviews. The Trust continually seeks to improve its Assurance Framework, refine its Principal Objectives, and further develop the Assurance Plan in order to assess the potential risks that threaten the achievement of the organisational objectives, the existing control measures in place, where assurances are gained and any gaps in the same. The Trust has maintained its assurance plan which has been subject to regular review to support the 2010/11 Business Plan objectives. Assurance for 2010/11 can further be drawn from regular performance reporting, review of the risk register and specific Board and Committee reporting on key issues and assurances which provides assurance to the Chief Executive to enable sign off of the Statement of Internal Control. The organisation is involved with a multitude of partners including Primary Care Trusts, Social Services, Education, Police, Prisons and the voluntary sector. The Trust Executive, Clinical and Divisional Directors work closely with the above partners, to provide a local integrated service to our public and stakeholders.
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The Foundation Trust is fully compliant with the requirements of registration with the Care Quality Commission (CQC), but during 2010/11 the CQC made an unannounced visit and found that Shelton Hospital was at risk of non compliance under outcome 16 noting that although risk audits had been carried out they were not necessarily translated into actions and outcomes for people using the service and were concerned that the Trust had not acted quickly enough to make changes to high risk areas following serious untoward incidents. An action plan was developed and all actions have been implemented. As an employer with staff entitled to membership of the NHS Pension scheme, control measures are in place to ensure all employer obligations contained within the Scheme regulations are complied with. This includes ensuring that deductions from salary, employer’s contributions and payments in to the Scheme are in accordance with the Scheme rules, and that member Pension Scheme records are accurately updated in accordance with the timescales detailed in the Regulations. Control measures are in place to ensure that all the organisation’s obligations under equality, diversity and human rights legislation are complied with. The Foundation Trust has undertaken risk assessments and Carbon Reduction Delivery Plans are in place in accordance with emergency preparedness and civil contingency requirements, as based on UKCIP 2009 weather projects, to ensure that this organisation’s obligations under the Climate Change Act and the Adaptation Reporting requirements are complied with. Review of economy, efficiency and effectiveness of the use of resources The Trust has a dynamic process for setting business objectives across the whole organisation which is documented and reviewed on an ongoing basis in order to drive forward improvements in clinical and non clinical services. The Trust engages with its partners both individually and on a grouped basis. In particular the Trust makes full use of its Membership Council to influence and drive service improvements. All objectives are quantifiable and measurable and are regularly reviewed via the performance management arrangements embedded within the organisation. In 2010/11 the Trust reviewed its performance management and monitoring system and implemented a new system entitled “Performance+” which more simply enables key performance indicators and targets to be effectively monitored. The system, like the old one, continues to enable all Directorates and Divisions to use it to take forward required actions and to deposit evidence that work has been delivered. This is subsequently used to provide evidence to third parties where required but also to the Board so that they can have assurance with evidence. Both systems supported the internal performance management sessions where Directorates and Divisions are held to account for those areas that they are expected to deliver on. During the year the Trust proactively used internal audit to look at the areas of the Assurance Framework and Care Quality Commission registration as part of the Trust’s arrangements for reviewing economy, efficiency and effectiveness of our use of resources. The Trust has a dynamic strategy to communicate effectively with its staff, service users and carers and partners. The sharing of this information drives forward the delivery of business objectives and ensures action is taken on feedback from any quarter. The Trust has worked hard to communicate with all its population including hard to reach groups. The Membership Council has played a significant role in the sharing and dissemination of such information. The Trust has an embedded performance management, monitoring and improvement system. All performance areas based around the Care Quality Commission’s domains are evidenced and centrally collected. Risks to any area are entered onto risk registers and actions plans to resolve issues developed, managed and monitored for delivery through the Delivering Quality / Performance+ systems.
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The Audit Committee has reviewed these systems and approved them as being appropriate and sufficient for purpose. During the last year the Trust further improved Service Line Management which is used to ensure that services operate within the income available to it and will inform management on areas that require cost improvement. This was further expanded to include the patient experience to deliver a more rounded approach to service quality, delivery and improvement. The Trust has strong evidence of delivery against cash releasing improvement plans (CRIP). This enables demonstrable sustainability and regular improvements in economy and efficiency. New Ways of Working are an embedded function of service delivery in both clinical and non clinical areas, where services are regularly reviewed and benchmarked to provide evidence of improvements. The Finance and Performance Committee regularly reviews the delivery of all finance plans and pays particular attention to the delivery of all finance plans and pays particular attention to the delivery of recurrent CRIP. Annual Quality Report The Directors are required under the Health Act 2009 and the National Health Service (Quality Accounts) Regulations 2010 to prepare Quality Accounts for each financial year. Monitor has issued guidance to NHS foundation trust boards on the form and content of annual Quality Reports which incorporate the above legal requirements in the NHS Foundation Trust Annual Reporting Manual. Quality is central to the delivery of our Trust strategy and through the hard work and commitment of our staff we continue to deliver safe, effective and high quality services whilst at the same time targeting priority areas for improvement. Quality services are monitored through our clinical directorate structure through to the Board committee tasked with ensuring Quality, Effectiveness and Risk. Directors have taken steps to satisfy themselves that the content of the quality report is consistent with internal and external sources of information including feedback from commissioners, governors and LINKS’s, the Trust’s complaints report published under regulation 18 of the Local Authority Social Services and NHS Complaints regulations 2009, the 2010 Community Mental Health Survey, the National NHS Staff Survey 2010, CQC quality and risk profiles and the Head of Internal Audit annual opinion over the Trust’s control environment. Trust policies are available on the website and all staff are
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encouraged to participate in consultation around new and updated policies through regular updates on the intranet. Newly approved policies are published through a network of policy leads and also in the monthly briefing issued to staff. Engaging staff is at the heart of this organisation’s culture – they facilitate and empower rather than control or restrict and they treat others with appreciation and respect showing commitment to development and improvement. Learning and development opportunities are available for all staff, at all stages of their learning journey. A comprehensive menu of formal and self directed and innovative approaches are offered to equip individuals with the knowledge and skills they need to lead and manage effectively. The Trust celebrates achievement through the annual staff awards ceremony launched to recognise and celebrate individuals and teams who have made an exceptional contribution to patient care. The Trust aims to keep staff informed about finance and performance issues, what’s on, opportunities and examples of good practice, by a range of briefings and newsletters produced regularly in a number of ways. The Trust has an extensive website and an intranet which reaches the majority of staff. The well being of staff is of prime importance and as part of its commitment to providing comprehensive support services as an Exemplar Employer, the Trust launched a Staff Health and Wellbeing service. The Trust has an over arching engagement strategy which sets out how it engages with service users, carers, partners and staff. The staff opinion survey is carried out each year across the NHS and is designed to collect the views of staff about how they feel about their job, their personal development and the organisation they work for. Their views are used nationally and locally to help provide better care for patients and improve the working lives of those providing the care. The Trust has achieved a level 2 performance against the Information Governance Toolkit key performance indicators, however data quality weaknesses have been identified in four internal audit reports relating to the processes for recording, collating and reporting of the actual performance information within many operational areas of the Trust. This is expanded below.
have responsibility for the development and maintenance of the internal control framework. I have drawn on the content of the quality report attached to this annual report and other performance information available to me. My review is also informed by comments made by the external auditors in their management letter and other reports. My review is also informed by and I have received assurances from a range of sources as listed below;
NHSLA Level 2 (Mental Health and Learning Disability standard)
Mental Health Act Commission Reports (CQC)
Internal/External Audit Reports
Clinical Audit Reports
Complaints / Compliments Reports
Claims Reports
Incident Reports – including serious incident reports
Staff and Patient surveys
Care Quality Commission Registration I have been advised on the implications of the result of my review of the effectiveness of the system of internal control by the Trust Board, Audit Committee, Human Resources & Organisational Development Committee, Finance & Performance Committee, Quality
Review of effectiveness As Accounting Officer, I have responsibility for reviewing the effectiveness of the system of internal control. My review of the effectiveness of the system of internal control is informed by the work of the internal auditors and the executive managers within the NHS Foundation Trust who
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2010-11 Annual Report
Effectiveness & Risk Committee, Business Development & Investment Committee, Service User & Carer Committee and the organisational structure that supports these groups to contribute to internal control. A plan to address weaknesses and ensure continuous improvement of the system is in place. Positive opinions in respect of the majority of work undertaken in 2010/11 by internal audit have been issued. The Trust performed especially well in the areas of High Level Review of Complaints, Inc idents , Ser i ous Unto war d Incidents and PALS, along with the review of the evidence gathering process to support the Care Quality Commission registration where substantial (green) assurance was gained. The trust also continued to demonstrate a strong internal control framework within its key financial systems, again achieving substantial (green) assurance in the IT Finance Controls, Asset Management, Creditors, Income and Debtors, Cash Management, General Ledger and Budget Reporting and Charitable Funds reviews.
clear outcome measures”. The weaknesses identified were within the processes for recording, collating and reporting of the actual performance information within many operational areas of the Trust. Follow up reviews will be undertaken in 2011/12. The Trust regularly reviews the interface and terms of reference of each of the committees and groups mentioned above that support internal control. The last review was undertaken during the last quarter of the 2009/10 financial year and recommended changes were in place for the whole of 2010/11. Conclusion No significant internal control issues have been identified.
Neil Carr, Chief Executive Date: 6th June 2011
Four reports were issued with “Red/Amber” opinions and one report was issued with a “Red” opinion. These relatively low assurance ratings related to data quality which may have impacted on the Trust’s strategic objective “to provide high quality services, built on best known practice and evaluated through service user feedback and
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Financial Report Financial performance 2010/11 The Trust was authorised as an NHS foundation trust on 1st May 2006. The financial review below covers the organisations achievements during the fourth financial period as a NHS Foundation Trust. The review finally highlights key service and financial issues across the year as a whole, before taking a forward look into 2011/12. The NHS Foundation Trust Financial Regime Operating under the Foundation trust regime the Trust has to operate within a ‘prudential borrowing limit’ which provides:
The maximum annual amount of long term borrowing. This is set by reference to five ratio tests set out in Monitor’s prudential borrowing code. The amount of any working capital facility approved by Monitor.
Further information on the prudential borrowing code and compliance framework for NHS foundation trusts can be found on the website of Monitor, the Independent Regulator of Foundation Trusts. Foundation trusts are therefore able to operate – and plan to operate – flexibly so long as those elements of the prudential borrowing code are adhered to. In the case of this Trust a planned income and expenditure surplus of £3.84m for the year was agreed with Monitor. In the event, through close cost control the Trust achieved a surplus of £4.07m for the year. In terms of long term borrowing – ie, for capital investment purposes, the Trust had a prudential borrowing limit for 2010/11 of £32.6m. The Trust actually undertook no long term borrowing in 2010/11. Capital investment was £10.2m was funded through internally generated resources together with Public Dividend Capital of £2.65m. In terms of working capital, the Trust had an approved facility of £12m. Again, the Trust actually made no use of its short term working capital facility in the course of the year. The Trust’s cash position during 2010/11 continued at a similar level to 2009/10. The Trust had planned for a reduction in cash but, partly as a result of the slippage on the capital programme mentioned above, but also because the NHS foundation trusts financial regime does not require the achievement of an artificial year-end cash balance the balance did not substantially reduce. Operational review, 2010/11 The year saw the integration of Shropshire Services into the Clinical Information systems used by Trust thus completing the overall integration plan. During the year the Trust completed the business case for the re-provision of Mental Health Services in Shropshire, Telford & Wrekin. This business case was approved by Monitor and to fund it a loan for £30m was obtained from the Foundation Trust Financing Facility. In addition to the new hospital Shropshire County PCT and Telford & Wrekin PCT are both re-investing savings and committing to additional resources to the new model of care. The total capital expenditure is £45m. South Staffordshire PCT has ongoing plans to make reductions in their investment with us. This continues to require us to both make greater operational efficiencies and disinvest from some elements of service. The Trust is currently in consultation with the South Staffordshire PCT with regards these plans and will continue to work on these into 2011/12. During the year the Trust has been working on a number of significant projects that will impact in future years:
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The Trust has continued to work on pilots to evaluate how PbR can be introduced to Mental Health Services. Allocation of clients to care clusters is now operational The Trust was previously selected as the NHS provider of Low Secure LD services in the West Midlands. The capital scheme has been completed in 2010/11 Taking account of the overall economic downturn the Trust updated its future financial plans
2011/12 - Forward Look As mentioned above the Trust financial plans continue to take account of the overall economic downturn which continues to require us to both make greater operational efficiencies and disinvest from some elements of service. The approval of the Shelton business case in 2010/11 and the commencement of the capital programme will continue with the new hospital to be opened in October 2012. In 2011/12 significant changes in the model of care will be undertaken to facilitate this. The changes to NHS commissioning as GP clusters develop will require the Trust to remain focussed on providing services that are valued both by service users and carers and commissioners. The Trust has been working towards changes in contracting currencies. Significant challenges have been identified that will be addressed in 2011/12 to enable the contracts to operate on a cluster basis. The organisation will also continue to seek market opportunities in terms of expanding its service and contract portfolio. The Trust will continue to respond to Tenders in areas where it has clinical expertise. Much of the Trust’s success has come from ‘doing the basics well’. We are well aware of the possibility of concentrating on developmental issues at the expense of the basics. To ensure an appropriate balance between these issues the Director of Finance has drew up in 2008/09 a five year financial strategy for the Trust. The objectives within that strategy have been designed to support the Trust in its overall clinical vision whilst at the same time ensuring ongoing financial control. In line with the development of a revised Clinical Strategy it is intended that the Financial Strategy will be refreshed in 2011/12.
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Independent auditors’ report to the directors of the board of South Staffordshire and Shropshire Healthcare NHS Foundation Trust on the summary financial statements To be inserted once received KPMG LLP 2 Cornwall Street Birmingham B32DL 4 June 2009
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2010-11 Annual Report
Auditors report cont
2010-11 Annual Report
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STATEMENT OF COMPREHENSIVE INCOME FOR PERIOD ENDED 31 MARCH 2011
31 March 2011
31 March 2010
£000
£000
Operating income from continuing operations
161,903
157,030
Operating expenses of continuing operations
(155,741)
(167,509)
6,162
(10,479)
123
136
0
0
PDC Dividends expense
(2,219)
(2,395)
Net Finance Costs
(2,096)
(2,259)
4,066
(12,738)
(0)
(9,393)
Operating Surplus/(Deficit) Finance Costs Finance income Finance expense
Surplus/(deficit) from continuing operations Revaluations (losses) & impairment losses property, plant and equipment
1
0
Revaluation (losses) & impairment losses arising from classifying non current assets as Assets Held for Sale
(0)
(596)
Reduction in the donated asset reserve in respect of depreciation, impairment, and/or disposal of donated assets
(0)
(66)
(3)
0
(0)
480
4,064
(22,313)
Asset Disposals
Other recognised (losses) Actual gains on defined benefit pension schemes Total Comprehensive Income/(Expense) for the Period
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2010-11 Annual Report
STATEMENT OF FINANCIAL POSITION AS AT 31 MARCH 2011
31 March 2011 £000
31 March 2010 £000
Non Current Assets Intangible assets Property, plant & equipment Trade & other receivables Total Non Current Assets
0 83,649 42 83,691
0 74,816 22 74,838
Current Assets Inventories Trade & other receivables Other financial assets Non-current assets for sale and assets in disposal groups Cash and cash equivalents Total Current Assets
219 7,719 0 455 28,682 37,075
266 10,222 0 865 29,362 40,715
(9,980) (5,895) (3,661) (6,732) (26,268)
(12,198) (3,784) (3,641) (8,137) (27,760)
Current Liabilities Trade & other payables Provisions Tax payable Other liabilities Total Current Liabilities Total Assets less Current Liabilities Non-Current Liabilities Provisions Other liabilities Total Non-Current Liabilities Total Assets Employed
94,498
87,793
(157) (83) (240)
(166) (83) (249)
94,258
87,544
75,698 20,279 78 480 (2,277) 94,258
73,048 20,481 81 480 (6,546) 87,544
Financed by (taxpayers equity): Public dividend capital Revaluation reserve Donated asset reserve Pensions reserve Income and expenditure reserve Total Taxpayers Equity
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STATEMENT OF CHANGES IN TAXPAYERS EQUITY
Pension Reserve
£000
Donated Assets Reserve £000
Total
£000
Income & Expenditure Reserve £000
73,048
30,470
147
0
5,596
109,261
0
0
0
0
(12,738)
(12,738)
Revaluation (losses) and impairments losses property, plant and equipment
0
(9,393)
0
0
0
(9,459)
Revaluation (losses) and impairment losses arising from classifying non current assets as Assets Held for Sale
0
(596)
0
0
0
(596)
Reduction in the donated asset reserve in respect of depreciation, impairment and/or disposal of on donated assets
0
0
(66)
0
0
(66)
Actuarial gains on defined benefit pension schemes
0
0
0
480
0
480
Transfers to the income and expenditure account in respect of assets disposed of
0
0
0
0
596
596
73,048
20,481
81
480
(6,546)
87,544
Surplus for the year
0
0
0
0
4,066
4,066
Asset Disposals
0
(202)
0
0
203
1
Other recognised (losses)
0
0
(3)
0
0
(3)
2,650
0
0
0
0
2,650
75,698
20,279
78
480
(2,277)
94,258
Taxpayers equity at 1 April 2009 (Deficit) for the year
Taxpayers Equity at 31 March 2010 / 1 April 2010
PDC Received Taxpayers Equity at 31 March 2010
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Public Dividend Capital £000
Revaluation Reserve
£000
2010-11 Annual Report
STATEMENT OF CASHFLOWS FOR THE YEAR ENDED 31 MARCH 2011
31 March 2011 £000 Cash Flows from Operating Activities Operating surplus/(deficit) from continuing operations
6,162
(10,479)
2,163 0 (3) 2,483 47 (2,218) (1,405)
2,908 15,836 (66) (4,990) (29) (364) (1,269)
2,102
1,508
20
(73)
(1,151)
545
8,200
3,527
Cash Flows from Investing Activities Interest received Sales of financial instruments Purchase of property, plant and equipment Sale of property, plant and equipment Net Cash Generated from/(Used in) Investing Activities
123 0 (10,178) 398 (2,037)
136 0 (3,179) 1,006 (2,037)
Cash Flows from Financing Activities Public dividend capital received Interest paid PDC Dividends paid Net Cash Generated from/(Used in) Financing Activities
2,650 0 (1,873) 777
0 0 (2,757) (2,757)
Increase/(Decrease) in Cash and Cash Equivalents Cash and Cash Equivalents at 1 April Cash and Cash Equivalents at 31 March
(680) 29,362 28,682
(1,267) 30,629 29,362
Non Cash Income and Expense: Depreciation and amortisation Impairments Transfer from donated asset reserve (Increase)/Decrease in trade and other receivables (Increase)/Decrease in inventories (Decrease) in trade and other payables (Decrease) in other liabilities Increase in provisions Tax (paid)/received Other movements in operating cash flows Net cash Generated from/(Used in) Operations
2010-11 Annual Report
31 March 2010 £000
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How we want to make a difference Through a continued commitment from the Trust Board This year we have foregone the traditional Chairman and Chief Executive forewords in favour of an introduction by the people who really matter to us, our service users and carers, and our members. Their stories of how they believe this organisation makes a difference to them are much more powerful than any words from Trust management. So, these few pages are a summing up and a continued commitment from the Trust Board that we will continue to have a vision to make a positive difference through positive partnerships and positive practice. We have worked together across the Trust to identify what this really means in practice and have identified clear pledges which recognise the importance of dignity and respect, safe effective services and listening and engaging – all of which are equally important to our service users and carers, our staff and our partners. In all areas of our business we will be working to ensure these pledges are a reality over the coming year. As Chairman of both the Trust Board and the Membership Council I am delighted to be leading such strong and committed teams. The Membership Council goes from strength to strength and as one of the first mental health foundation trusts I believe we have led the field in identifying how our Governor Members can best make a difference to leading services locally. We have strengthened and developed the Trust Board to take account of the increasing focus on competition within health service provision and the option for commissioners to look at “any qualified provider”. We have appointed a business development director and looked for strengths in business and quality assurance in new non executive director appointments and I believe our current Board has strength and depth and proven leadership qualities.
Steve Jones, Chairman
Our organisation is committed to “playing to its strengths” and maintaining a clear focus on high quality, specialist mental health and learning disability services. We will continue to develop and improve services and look to enhance our portfolio, but within this area of expertise, ensuring no dilution of the quality of care we provide. I believe this has been a successful and effective year and that once again we have demonstrated our commitment to delivering high quality services and I am confident that we can continue to drive forward over the coming year.
Steve Jones Chairman Page 86
2010-11 Annual Report
Through a continuing focus on ensuring we provide high quality services Good mental health and resilience are fundamental to our physical well being, our relationships, our education, our work and to achieving our potential. South Staffordshire and Shropshire Healthcare NHS Foundation Trust aims to make a positive difference to the well being of all those who use our mental health, learning disability and children’s services, their families and carers, and the people in our local communities. We have a particular responsibility for providing specialist mental health services for those with severe and enduring mental health problems, but we are also committed to working in partnership to ensure comprehensive mental health and well being services are provided across health and social care, and within both statutory and voluntary services. These partnerships are equally important in ensuring effective, high quality learning disability and children’s services. Neil Carr, Chief Executive
The engagement and involvement of clinicians in every aspect of our business is vital to enable us to continue to challenge the way we provide services and ensure that these services are effective in meeting the needs of those who use them. I celebrate the fact that we are able to grow and improve because of our strong relationships with our clinicians and local primary care colleagues. There has been a significant emphasis on improving mental health services over the past year with the publication of both the “No health without mental health” mental health outcomes strategy in February 2011 and the Public Health White Paper, Healthy Lives, Healthy People, published in November 2010 which clearly recognises the contribution of mental well-being and mental illness to physical health. We are committed to ensuring our services contribute to the improvements envisaged in these documents and to recognising and embracing the shift towards localism and increasing involvement of local government in health policy and decision making. I also welcome the commitment of the NHS reforms White Paper; Equity and Excellence: Liberating the NHS published in July 2010 and particularly its theme of “no decisions about me without me”. The reforms proposed will have a significant impact on how local services are commissioned and provided and we will work closely with our local GPs and other clinicians to ensure effective, high quality services are provided in South Staffordshire, Shropshire and Telford & Wrekin.
2010-11 Annual Report
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Our Core Values The coming financial year will be a challenging one despite the Government’s commitment to protecting health services funding. We will not compromise on the quality of the services we provide and will need to be innovative and creative in ensuring we continue to deliver the mental health, learning disability and specialist children’s services needed locally. I hope you have enjoyed reading this annual report and commend to you the range of achievements and developments from the past year. I am proud to be the Chief Executive of an organisation which continues to work so hard to make a positive difference to all those who need our services. I am particularly pleased that we were recognised by our peers and were named Mental Health Services Provider of the Year by the Royal College of Psychiatrists. I am delighted that the hard work of staff has received the acclaim of such a distinguished organisation. The Ministry of Defence Military and Civilian Health Partnership Award for the inpatient mental health service we provide in partnership with NHS colleagues, was also a welcome affirmation of the success of this partnership which has seen some innovative and creative joint working between military and health services and which has made a really positive difference to serving personnel needing mental health care. In addition, our children’s services were worthy winners of the Health and Social Care award for the specialist care they provide for looked after and adopted children. We have also continued to improve and develop services and we are all very excited that work has finally started on building the new inpatient services in Shropshire. It will be wonderful to have a new, purpose built, modern facility, but even more important is the investment in improving community services, enabling people to stay in their own homes and communities. I am pleased we have been able to work in partnership with our local primary care trusts and commissioners, both in Shropshire, Telford & Wrekin and in South Staffordshire, to further develop and modernise services.
People who use our services are at the centre of everything we do We will treat you with dignity, respect and courtesy at all times We will provide you with safe and effective services We will actively listen, engage and involve you in decisions and discussions that may affect you We value our staff We will treat you with dignity, respect and courtesy at all times We will ensure you have opportunities to develop your knowledge and skills to deliver safe and effective services We will actively listen, engage and involve you in decisions and discussions that may affect you Our partnerships are important to us We will treat you with dignity, respect and courtesy at all times We will work in partnership with you to deliver safe and effective services We will actively listen, engage and involve you in decisions and discussions that may affect you
I also welcomed the opening of the new low secure unit for people with a learning disability which offers specialist care for this challenging group, both locally and from across the West Midlands; saw new contracts for Improving Access to Psychological Therapies; adopted new approaches to the way we care for inpatients; opened new premises in more appropriate facilities and locations and recognised the importance of the arts in good mental well being. We have continued to invest in the learning and development of our staff. It is vitally important that we
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2010-11 Annual Report
Mental health problems – the statistics At least one in four people will experience a mental health problem at some point in their life and one in six adults has a mental health problem at any one time. One in ten children aged between 5 and 16 years has a mental health problem, and many continue to have mental health problems into adulthood. Half of those with lifetime mental health problems first experience symptoms by the age of 14 and three-quarters before their mid-20s.
encourage and grow leaders fit for the future and I have been delighted at the impact of new learning and development opportunities offered to staff. We are committed to learning for all staff and value their enthusiasm for new skills and new ways of working. We have listened to our patients and engaged and involved those who use our services in all aspects of our business. Initiatives such as the Real Time Feedback surveys and the work of our Patient Ambassador enable us to respond to the issues that really matter to our service users. I look forward to another full and exciting year with a continued focus on ensuring the services we provide are high quality, cost effective, and make a positive difference to our service user and carers.
Self-harming in young people is not uncommon, 10–13% of 15–16-yearolds have self-harmed. Almost half of all adults will experience at least one episode of depression during their lifetime. One in ten new mothers experiences postnatal depression.
Neil Carr Chief Executive
About one in 100 people has a severe mental health problem. Some 60% of adults living in hostels have a personality disorder. Some 90% of all prisoners are estimated to have a diagnosable mental health problem (including personality disorder) and/or a substance misuse problem.
2010-11 Annual Report
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A large print version of this document is available on request. If you would like a copy of this document in another language or format, please let us know. South Staffordshire and Shropshire Healthcare NHS Foundation Trust St George’s Hospital Corporation Street Stafford ST16 3SR tel 01785 257888 email
[email protected] www.southstaffsandshropshealthcareft.nhs.uk
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2010-11 Annual Report
