Board of Directors Meeting - 29 March 2012 - Devon Partnership ...

Devon Partnership NHS Trust Board of Directorspapers are available atwww.devonpartnership.nhs.uk/Board-Papers.346.0.htmlBOARD OF DIRECTORS MEETING9.45am – 12.00pm, Thursday 29 March 2012Boardroom, Trust HQ, Wonford House Hospital, ExeterA G E N D A1. Clinical Directorate Input – Secure Services9.452. Apologies for Absence10.003. Register of Interests & Code of Conduct4.4a.Minutes of the Board of Directors meeting held 27 February 2012Matters Arising10.005. Chief Executive’s Report(Iain Tulley, Chief Executive)10.10Quality & Safety6. Quality & Safety Committee Report(Dr Adrian Jacobs, Non-Executive Director)7. Quality, Compliance & the Experience of Using Services(Alison Moores, Director of Nursing & Practice)8. Workforce Report on National Staff Survey 2011(Martin Ringrose, Director of Workforce & Organisational Development)9. Equality & Diversity Annual Report 2011(Martin Ringrose, Director of Workforce & Organisational Development)10.2010.3010.4010.50Performance10. Finance Report for the Month Ended 29 February2012(Hugh Groves, Director of Finance / Deputy Chief Executive)11. Finance & Investment Committee Report(Ray O’Connell, Non-Executive Director)11.0011.10Page 1 of 156

12. Performance Management Report, including summary Assurance Framework(Anne Sawyer, Director of Compliance & Corporate Development)11.20Regulatory13. Risk Management Strategy(Dr Helen Smith, Co-Medical Director)14. Audit Committee Report(Richard Smith, Non-Executive Director)11.3011.40For Information15. Publications & Guidance(Iain Tulley, Chief Executive)16. Listening to the Experience of People Who Use Our Services11.5011.55Other Items17. Any Other Business12.15Date of Next Meeting –Monday 30 April 2012, Boardroom, Wonford House Hospital, ExeterNotice of Topics to be discussed during the private and confidential session:Finance & Investment CommitteeLangdon DevelopmentBoard StatementsIntegrated Business Plan, Long Term Financial Model & Trust Business Plan UpdateIntegrated Children’s Services Tender – UpdateBoard MemorandumExclusion of the Press/Public - That representatives of the press and other members of the public be excludedfrom the remainder of this meeting having regard to the confidential nature of the business to be transacted,publicity on which would be prejudicial to the public interest. (Section 1(2) Public Bodies (Admissions toMeetings) Act 1960)(C – denotes item taken by consent)Page 2 of 156

3DEVON PARTNERSHIP NHS TRUSTBOARD OF DIRECTORS - SUMMARY REPORTDate of Board meeting: 29 March 2012Name of Report:Author:Approved by:Presented by:Register of Interests & Code of ConductJanet Racibowski, Corporate SecretaryMark Taylor, ChairmanMark Taylor, ChairmanPurpose of the report:To inform the Board of the interests held by Board members and to ensure their continuedadherence to the NHS Code of Conduct.Key points:Not ApplicableAction required, including Recommendations:1. To clarify information is correct and up to date.2. To agree the Register of Interests.3. To confirm adherence to the NHS Code of Conduct, including the Nolan Principles – theseven principles for public life.Links with the Assurance Framework (Risks, Controls and Assurance):Provision of Register of InterestsSummary of Constitutional / Financial/ Legal / PPI / Equality and DiversityImplications:1. Disclosure within annual accounts2. KLOE assessment3. Code of GovernanceLinks to Strategic Aims:Safety X Recovery FocusedTimelySustainablePersonalisedThis report references:CQC RegulationsNonePage 3 of 156

REGISTER OF INTERESTSDesignation Name DeclarationChairman Mark Taylor Accreditation Surveyor for Health Quality ServiceNon-Executive Director Judith Davey Director of Performance and Accountability,ActionAid UKMember of Board of Society of Consumer AffairsProfessionals in EuropeNon-Executive Director Ruth Hawker Trustee, Hospiscare, ExeterChair, Comprehensive Local Research Network(CLRN)Non-Executive Director Adrian Jacobs Partner of Consultancy firm - Primary CareMedical Management ServicesPastoral Support Officer - Devon LMCNon-Executive Director Ray O’Connell Director/Trustee of Almeida Theatre CompanyLimitedNon-Executive Director Richard Smith No interests to declareChief Executive Iain Tulley No interests to declareDirector of Finance Hugh Groves Member of Healthcare Financial ManagementAssociation (HfMA)Co-Medical Director David Somerfield Trustee - The Lupton Trust, BrixhamDirector of Operations Liz Davenport No interests to declareDirector of Compliance & Anne Sawyer No interests to declareCorporate DevelopmentChair, Clinical CabinetDirector of Research &DevelopmentPeter Aitken Co-clinical directorship, Comprehensive LocalResearch Network (CLRN)Medical Examiner – RNLI, ExmouthDirector of Business Ian Harrison No interests to declareDevelopment & StrategyDirector of Nursing & Alison Moores Trustee - Domestic Violence & SupportPracticeCo-Medical Director Helen Smith External Examiner, Birmingham UniversityDirector of Workforce &Organisational DevelopmentMartin RingroseConsultancy work for NHS Devon, by requestCode of Conduct for NHS Managers Selflessness Integrity Objectivity Accountability Openness Honesty Leadership March 2012Page 4 of 156

4DEVON PARTNERSHIP NHS TRUSTBOARD OF DIRECTORS - SUMMARY REPORTDate of Board meeting: 29 March 2012Name of Report:Authors:Approved by:Presented by:Minutes of Board of Directors MeetingJanet Racibowski, Corporate SecretaryMark Taylor, ChairmanMark Taylor, ChairmanPurpose of the report:To provide a summary of Board of Directors discussions on 27 February 2012Key points:Not applicableAction required, including Recommendations:1. To note and approve Board minutes2. To authorise the Chairman to sign minutes as accurate record of the meetingLinks with the Assurance Framework (Risks, Controls and Assurance):Provision of minutes/notes of meeting – links to “positive assurances” sectionSummary of Constitutional / Financial/ Legal / PPI / Equality and DiversityImplications:Not applicableLinks to Strategic Aims:Safe X Recovery-focused XTimely X Sustainable XPersonalisedXThis report references:CQC RegulationsNonePage 5 of 156

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Board of Directors Meeting, 29 March 2012Agenda Item 4plan.Clare Cox, Safeguarding Practice Development Lead, was translating learninginto practice.030/12(Item 2)ApologiesMartin RingroseIain TulleyJudith DaveyDirector of Workforce & Organisational DevelopmentChief ExecutiveNon-Executive Director031/12(Item 3)032/12(Item 4)Register of Interests & Code of ConductMembers of the Board noted the Register of Interests. There were no interests orchanges declared.Minutes of the Board of Directors meeting held 30 January 2012Members of the Board approved the minutes as an accurate record of thediscussion held, subject to the inclusion of formal acknowledgement of the workdone by Chris Burford in support of the Trust’s safeguarding activity.The Chairman was authorised to sign a copy.033/12(Item 4a)Matters ArisingMembers of the Board noted:199/11- Listening to the Experience to include participation from staff to beresolved by staff providing input when Board receive Staff Survey Report.005/12 (228/11) – Recovery. Liz Davenport Confirmed that Mike Cooke, CEOof Nottinghamshire Healthcare NHS Trust would be attending a BoardDevelopment session in May 2012 around ImROC. 006/12 Chief Executive’s Report: The Board noted that the social careagreement had not yet been signed off but progress was being made towardssign off at the end of March 2012. There were currently no implications to theTrust as a result of this ongoing delay. The outline budget position and impactfor social care had been set out but was subject to further scrutiny under thepartnership agreement.007/12 – Quality & Safety Committee Report: Alison Moores confirmed thatthe CQC intended to re-visit previously reviewed sites at the Trust’s requestas soon as possible in April to enable progress to be made with Monitor.Actions List:005/12 – Matters Arising:o FT Key Questions & Answers. Ian Harrison confirmed that theExecutive team had discussed how progress might be made against thestrategy. The document being formulated would include a description ofstrategy and a set of appendices, which would answer the questionsraised. The Board considered comment from Ray O’Connell that therewere many elements to be considered over and above the formal strategydevelopment. Anne Sawyer advised that a series of mock Board to BoardPage 8 of 156

Board of Directors Meeting, 29 March 2012Agenda Item 4style meetings with Directorates were informing strategy development.Ian Harrison would provide a working draft of the questions and answerswithin the next week.oImplementation plan for innovations arising from the Seattle Tripwould be provided for the next meeting by Dr David Somerfield and HughGroves.007/12 – Quality & Safety CommitteeoooCQC reports had been circulated.Sickness absence had been discussed and considered by the Quality andSafety Committee.Review of urgent waiting times (28 days) would be considered by theCommittee at its next meeting.012/12 Safeguarding Children & Safeguarding Adults Annual Reports:ooLiz Davenport and Martin Ringrose have met to discuss metrics aroundreporting of CRB checks.The annual safeguarding children declaration had been completed. 013/12 – Audit Committee Report. Action was complete. Hugh Grovesconfirmed that greater understanding of the specification would be takenthrough the Audit Committee.015/12 – Any Other Business.oAttendance of NHS Devon at the Quality & Safety Committee: LornaCollingwood-Burke, Assistant Director of Quality for NHS Devon, had beennominated to attend.Quality and Safety034/12(item 5)Quality & Safety Committee ReportMembers of the Board noted:The report, which was taken as read.That Monitor required the CQC to “sign off” the actions taken by the Trust toaddress the findings of their review and that this could only be done threemonths post publication.That once sign off had been achieved, the Trust was anticipated to have agreen rating against Monitor’s KPIs.That the Committee had expressed some concern over levels of sickness,which were understood to be too high. In addition to the remedial actionsoutlined in the report, the Committee noted the need for noted need forconstant vigilance, especially by line managers.That the Audit Committee would look at ways of improving on the limitedassurance currently extracted from clinical audit processes.Page 9 of 156

Board of Directors Meeting, 29 March 2012Agenda Item 4Members of the Board considered:Question from Ray O’Connell, who sought and received confirmation that theCommittee was assured on routine Waiting Times, both now and long term,that there was no outstanding issues with the Management Information.Confirmation from Dr Adrian Jacobs that the Committee would provide regularupdates on the above within its Board reports.A reminder from Alison Moores that reducing waiting times was a CQUINtarget.Caution from Mark Taylor, who had observed that average absenteeism hadbeen increasing for the past six months, and care should therefore be taken tomonitor trend lines more closely.That operational information coming to Board should to be reviewed to allowearly identification of adverse trends. Anne Sawyer noted that the 12 monthrolling average remained relatively level overall.Performance035/12(item 6)Finance Report for the month ended 31 January 2012Members of the Board noted:That the Trust was on track to meet its key targets around forecast surplus.That the Trust’s financial risk rating remained at three, with plans to aim for ascore of four as the level of surplus increased over the coming year.That sound liquidity and a good payment record had been maintained.That risk highlighted earlier in the year had been incorporated into theforecast.That the focus would continue on spending and income.That the year end position looked set to be achieved. That reporting around CIPS needed to be tied up. Forecast was for fullachievement at year end and Directorates would be required to declare theirsavings in full. Focus would be maintained on recurring CIPs as the Trustmoves into the new financial year.Members of the Board considered:That for the purpose of context, it would be useful to know what the projectedcash balance was at the end of month 10, and whether there were anyrevisions to the year end.In response to a request from Prof Ruth Hawker for provenance on capitaldisposals / purchases, that such activity was recorded through the Finance &Investment Committee, and figures provided related to consequences ofservices being developed.036/12(item 7)Finance & Investment Committee ReportMembers of the Board resolved: That assistance would be provided to ensure that the remaining recurringPage 10 of 156

Board of Directors Meeting, 29 March 2012Agenda Item 4savings were finalised with the Directorates to ensure that we met ourrecurrent CIPs target for the year.037/12(item 8)Performance Management Report, including summary Assurance FrameworkAssurance Framework:Members of the Board noted:The latest summary assurance framework which key elements as statedwithin the summary report.That Executives would ensure residual levels against S10 (CatastrophicClinical Adverse Event) were reached by the end of March.Progress made as set out, in consultation with Internal Audit.That the Assurance Framework was presented to and considered by key subcommitteesof the Board and the assurance process continued to tighten.That Non-Executive Directors were encouraged to attend Directorate Reviewmeetings.That risk SU1 – Public Spending, would be reviewed by the BusinessExecutive Team.Members of the Board considered:Recommendation that the Board received the full assurance framework twicea year, rather than three times a year as currently required.That this proposal has the support of Internal AuditConcern from Richard Smith over whether the Board had sufficient confidencein its sub-committees carrying our satisfactory reviews of the Framework onbehalf of the Board.Current reporting processes of the sub-committees and assurance that thoseforums reviewed the Framework fully and robustly.That Board members were assured in the sub-committee process.The view Monitor may take of such a decision.That the Executive Directors reviewed each risk in detail each month.That the Board should be in a position for its members to express confidencein its sub-committees and the processes in place to escalate any risk to theBoard outside of the Assurance Framework reporting schedule.A reminder from Alison Moores on how S10 would be reduced to its residuallevel, noting the significant involvement of Directorate reports.Quantitative and qualitative measures.Performance:Members of the Board noted:That the overall governance risk rating remained overridden at amber / red.That the Trust was green against all KPIs expect Early Intervention, whereaction was outlined within the summary report.Page 11 of 156

Board of Directors Meeting, 29 March 2012Agenda Item 4That following discussion with NHS Devon relating to the action plan agreedwith the SHA on the requirements of NICE the rating had now moved fromamber to green.The Quality Risk Profile progress which was highlighted. The position hadimproved to predominantly green, bearing in mind the current amber/redoverride. Ray O’Connell queried the under-performance against target of KPI 283(Waiting Time Performance) and asked if this had been reviewed by Q&SC.Q&SC had not had an opportunity to look into these issues at the last meeting.It was also pointed out that the January data was not yet available due totechnical issues but that these would be resolved before CQUIN targetsapplied next year Alison Moores confirmed that trajectories would be set overquarters one to three, and that care would be taken on how these were set.That care was needed around service provision over the Christmas / NewYear period.Confirmation from Dr Helen Smith that a report would be provided to theQuality & Safety Committee based on the latest Dr Foster data available forthis KPI.Members of the Board resolved:To receive the Assurance Framework twice a year from now on.That the format of the performance report was helpful and that the“comments” boxes could include outline comments from sub-committees asnecessary.038/12(Item 9)Chief Executive’s ReportMembers of the Board noted:Carers Charter:This had been developed following work done last year to improveconnectivity with and care and support provided to families.That a copy of the Charter, developed in consultation with carers, wasprovided as an appendix to the report.That the Trust Management Board had endorsed the Charter and eachDirectorate was developing its own plans for launch in April.That the Charter was brief and now no longer included performancemeasures. This was because the specification of the Charter had evolved forDirectorates in terms of what was expected, what outcomes were anticipatedand how do teams know how well they are performing.(Iain Tulley arrived)Good guidance around patient confidentiality, which had been written with thehelp of carers. Training around that guidance would be part of Directorateimplementation.Page 12 of 156

Board of Directors Meeting, 29 March 2012Agenda Item 4Trust Management BoardMembers of the Board considered:For informationWhether there were an actions required by the Board as a result of the TrustManagement Board’s annual effectiveness review. Liz Davenport confirmedthat she was working with the Corporate Governance team aroundrecommendations against information flows. These recommendations wouldbe considered by the Executive team.039/12(item 10)Publications & GuidanceMembers of the Board notedThe report which was taken as read.Other items040/12(Item 14)Any other businessMembers of the Board noted:An update from Iain Tulley on the University of Plymouth and the PeninsulaMedical School.oooooooThe Dean had written to all organisations announcing a separation of theschools.Rationale, curriculum divergence, etc behind the decision.That the Trust had signed its commitment to both universities (Plymouthand Exeter).That guidance would be issued on academic health science networks inthe next few months which would require representation and influence insplitting arrangements.That Iain Tulley would revert to the Board once details on guidanceemerge.That there may be a risk around income reduction as a result of thisaction.That Board members did not envisage any turbulence for the Trust in thissplit and welcomed the opportunities it presented.Governor awareness sessions had been held ahead of the election process.Good candidates were emerging.There were no further items of business and the meeting was therefore closed.Date of next meetingThursday, 29 March 2012, Boardroom, Trust HQ, ExeterPage 13 of 156

Board of Directors Meeting, 29 March 2012Agenda Item 4SUMMARY OF ACTIONS FROM THE BOARD MEETING ON 27 February 2012ActionResponsible033/12 – Matters Arising: 199/11- Listening to the Experience to include participation from staff tobe resolved by staff providing input when Board receive Staff SurveyReport.Martin Ringrose 005/12 – FT Key Questions & Answers: Working draft to be provided Ian Harrisonwithin the next week. Implementation Plan for Innovations arising from the Seattle Trip: to be Dr Davidprovided for the next meeting.Somerfield /Hugh Groves 007/12 – Quality & Safety Committee: to review urgent waiting times (28days) at its next meeting.Dr Adrian Jacobs037/12 – Performance Management Report, including Summary AssuranceFramework: Full assurance framework to be received twice a year. Anne SawyerAGENDA ITEMS FOR FUTURE BOARD MEETINGS 27 February 2012Agenda itemMeetingPage 14 of 156

Board of Directors Meeting, 29 March 2012Agenda Item 4a (Minute 033/12 refers)DEVON PARTNERSHIP NHS TRUST BOARD OF DIRECTORSMeeting on 29 March 2012UPDATE ON DEVELOPMENTS RELATINGTO THE KINGS FUND STUDY TOUR OCTOBER 20111. Purpose of report1.1. To update the Board about local developments relating to the Kings Fund Tour ofhigh performing healthcare organisations attended by Hugh Groves Director ofFinance and David Somerfield Co-medical Director, October 20112. Provenance2.1. The Board was briefed about the study tour in December 2011 by Hugh Groves andDavid Somerfield. This report provides details of local developments.3. Background3.1. The Kings Fund is an internationally renowned charity specialising in understandinghealthcare systems, influencing policy and health service transformation. The KingsFund has been in the forefront of and a leading voice in discussions and debateabout the Health and Social Care Bill 2012.3.1.1. For some years the Kings Fund has led study tours to Seattle for healthcaremanagers and clinicians. Seattle has several very high performing healthcareorganisations Veterans administration, The Everett Clinic, Harborview MedicalCentre, Virginia Mason Medical Centre, Group Health and Wenatchee Valley MedicalCentre with particular characteristics:High quality care - very high patient and staff satisfaction and excellent outcomesPersonalisation - patient accessible recordsCost efficiency - successful implementation of ‘lean’ techniques, service redesignwith fewer beds, lower lengths of stay and higher levels of integration than in theUK, reducing unnecessary investigations and interventions and a successfulreduction in the cost base of healthcareLeadership and management - use of performance information throughout anorganisation including at clinical team level.Technology – using information technology to improve patient careThe key learning from the study tour has been written up as a paper by Hugh Groves(appendix 1). The conclusions of the learning were that these organisations wereimplementing what we know works successfully through clear methodology anddemonstrating success. This was done by a combination of;Page 15 of 156

Board of Directors Meeting, 29 March 2012Agenda Item 4a (Minute 033/12 refers)A total focus on patient experience and outcomesStaff training and a concentration on maintaining satisfaction. Satisfied staff lookafter patients well and attract high calibre staff to the organisationA robust focus on performance, objectives and cost efficiency3.1.2. The recommendations made to the Trust Board in December 2011 were;i. Enhance and increase all staff focus on performance by weekly top to bottom'huddles', ‘show the data on the wall’ii. Develop TPS methodology - look at standard work, what adds value and what iswaste. Linked to and supported by safety team. Tie in redesign with otherinitiatives - PCAs, safety, supervision & appraisaliii. Increase focus on staff as a key Trust objective ie satisfaction, training and theefficiency of the systems around themiv. Clinician/manager compactv. Consider opportunities for telemedicine eg ED, carer’s for OPMH inpatientsvi. Need a model to clearly articulate personalisation, recovery and a chroniccondition approach eg self-management, education, decision making tools3.1.3. The recommendations from the Kings Fund Study Tour accord with and furthervalidate the Tr ust strategic objectives and increased focus on recovery, quality,safety and cost effectiveness of the care we provide and accord with several currentprojects.The Academy the will in part focus on team development and lean processes.The DART referral management trial in north Devon and Teignbridge is focusingon lean processes to reduce waiting times and the effective use of clinical time.Nick Hopkinson, Associate Director of Information Management and Technologyis leading a working group investigating the use of technology to improve patientcare and the efficient use of staff time.Further iterations of RiO. We have recently had a presentation by CSEHealthcare Systems of RiO 7 to members of the Executive, the RiO developmentteam and IM&T. RiO 7 will be released later this year and include a ‘patient portal’for notes access for patients, improved efficiency of data entry for cliniciansincluding by digital pen and through multiple platforms including tablet PCs andsmart phones. RiO 7 is also completely configurable locally enablingorganisations to create linear and streamlined standard assessments which willsupport improved productivity and quality. Real time data feeds will be availablefor teams.The Clinical Cabinet has recently visited Nottingham, an IMROC demonstratorsite to get a greater understanding of how recovery principles can be embeddedin everyday clinical practice and will be making recommendations to theExecutive and Directorates.3.1.4. The Executive and Directorates commenced a weekly public performance ‘huddle’ inFebruary 2011. The principle is to take a team approach to key performance data –concentrating on process to manage performance. This has now been running for 6weeks and gradually being developed to support key work streams with some earlydemonstrable success. Feedback methodology appears to have beenparticularly successful in managing performance eg CQUIN and Monitor targetswithin the directorates. David Somerfield has been asked by Iain Tulley to explorehow the organisation can use this this methodology at team level across thePage 16 of 156

Board of Directors Meeting, 29 March 2012Agenda Item 4a (Minute 033/12 refers)organisations and is developing this project with Tom Bartlett, Head of Performanceinformation.3.1.5. Current gaps in the recommendations from the study tour are:Some work to develop further the clinical compact between managers andclinicians. The Clinical Cabinet and the work of the Clinical Directorates hasmade significant strides in this area, but further work is needed to define further aclear set of priorities and expectation set out in then job plan of every clinicianwithin the Trust.The consideration of staff development and satisfaction as a key strategicobjective.4. Key points for Board to note4.1. Most of the recommendations from the study tour are being addressed across a widerange of projects.4.2. There appears to be a significant gap in terms of focus on staff development andsatisfaction5. Recommendation5.1 Members of the Board are asked to receive the report and note its contents.Dr David SomerfieldCo-Medical DirectorHugh GrovesDirector of FinanceMarch 2012Page 17 of 156

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Board of Directors Meeting, 29 March 2012Agenda Item 4a (Minute 033/12 refers)Appendix 1Healthcare lessons learned from the Pacific NorthwestBy Hugh GrovesDirector of FinanceDevon Partnership NHS TrustIn September of 2011, I was fortunate enough to participate in a sponsored studytour of six health organisations in Seattle. Organised by The King’s Fund, the tourprovided an excellent opportunity for clinicians and managers to witness, first-hand,what goes on inside the Pacific Northwest’s finest healthcare organisations and todraw some interesting comparisons with what we are doing back here in the UK.Healthcare providers in the United States lead the world in many aspects ofperformance and service integration and, in particular, we were interested infocusing on issues related to:Quality and costExperienced-based design and patient-centred servicesWorld class leadership and technological innovationOrganisational, environmental and personal sustainability.The six organisations that we visited on the tour were the Veterans Affairs healthcentre, The Everett Clinic, Harborview Medical Centre, Virginia Mason MedicalCentre, Group Health and Wenatchee Valley Medical Centre.Our key learning objectives were around relationships and accountability betweenorganisations in a complex system; the improvement of both quality and productivity,the development of workplaces where creativity and learning can flourish and therobust management of clinical systems and performance. We were also interestedin finding out more about ‘hot’ topics such as greater choice among commissioners,new and different funding systems, patient safety, clinical leadership andaccountability.Page 19 of 156

Board of Directors Meeting, 29 March 2012Agenda Item 4a (Minute 033/12 refers)Appendix 1Our group consisted of nine clinicians and managers working in primary care fromNew Zealand and five medical and executive directors working in Trusts from theUK. The group included our own Medical Director, Dr David Somerfield, and hispresence brought an invaluable clinical dimension to the observations andcomparisons that were made throughout the tour.Our first pre-visit session covered broad comparisons between the healthcaresystems in the US, UK and New Zealand. The similarities between New Zealand andthe United Kingdom are numerous, but there are many fundamental differencesbetween the systems of these two countries and those of the US. Perhaps keyamong these is the level of expenditure on healthcare and its predicted trajectory. Inthe US, health expenditure is high - and increasing more rapidly than income andbudget. In fact, national health spending is expected to double over the next tenyears, rising to somewhere in the region of 20% of the country’s GDP.The factors underpinning this situation are too many to list here, but they includesome that we are all too familiar with in the UK. Over-use and inappropriate use ofservices; duplication of resources; poor access, lack of prevention and poor careco-ordination are among them. In the US, other contributory factors include paymentand pricing incentives that reward doing more work without necessarily consideringits quality or value; no overall approach to health commissioning for the needs of thetotal population; a highly litigious environment and a complex healthcare insurancesystem.In addition, new technologies are often introduced without comparative informationon clinical or cost effectiveness, there are rising rates of chronic disease andrelatively few ‘leverage’ points from which to encourage or drive more efficient andeffective care across the whole system.The general consensus in the US, from what we saw and heard, was that thissomewhat fragmented and over-complicated approach to the commissioning anddelivery of services is unsustainable and unaffordable in the long-term. The numberof CT scanners per million people in the US is just one example of the inefficiencythat the current system can produce. In the UK the number is 12, in New Zealand itis 15, but in the US it is 34.The organisationsWithin this system there are, however, islands of excellence from which we can alllearn. The Veterans Affairs health centre in Puget Sound has transformed itself overthe last decade to deliver an integrated system focusing on chronic diseasemanagement. Its bed-day use has been reduced by 78% and it now has the bestsafety record in the country. The hospital has developed a performance ‘dashboard’down to individual clinician level, it has an impressive patient record system and, ofgreat interest to those of us working in mental health, psychiatry is actively integratedinto the whole care package – it’s not an add-on.The Everett Clinic is actually owned by 450 clinicians. It has 40 specialties and1,700 staff. Of particular note is the fact that it makes great use of sharing itsdetailed performance data publicly. It also has routine weekly ‘huddles’ where staffmeet for a short period of time to review and openly discuss performance. This hasPage 20 of 156

Board of Directors Meeting, 29 March 2012Agenda Item 4a (Minute 033/12 refers)Appendix 1helped to achieve very high rates of patient and employee satisfaction – which areamong the 100 US organisations.The Harbour View Medical Centre is a co-operative with a $750 million annualbudget and a mission to prioritise vulnerable people. Managed by the University ofWashington, it has developed international centres of excellence, in particular in itstrauma and burns units. It has a significant focus on quality, with patient satisfactiondata and directorate-specific comparators being followed-up routinely by the MedicalDirector and clinical directors. It also invests a great deal of time and effort into staffselection and development.Wentachee Medical Centre has pioneered a tele-health programme to target patientswith chronic conditions - who were incurring average costs of more than $17,000 peryear each. Two thirds of this patient group were enrolled in the programme and theresults included a reduction in Emergency Room admissions of 17% and generaladmissions of 13%; a 50% reduction in mortality and cost savings of around $3,000per patient per year.At the Virginia Mason Medical Centre, where the internationally-renowned GaryKaplan is CEO and Chair, they have achieved a position in the top 5% of UShospitals for clinical performance and the accolade of top hospital of the decade.Quality and efficiency are inextricably linked to care and ‘compacts’ betweenclinicians, managers and the executive team have been employed to great effect.Here, too, huddles between different groups of staff are a regular feature of the dailyand weekly routine.Significant investment in the Toyota Production System has led the hospital todevelop its own Virginia Mason Production System (VMPS). This managementmethodology is based on manufacturing principles and seeks to continuouslyimprove how work is done. Essentially, it identifies and eliminates waste andinefficiency and equips staff to deliver high levels of quality and safety bystreamlining repetitive and ‘low touch’ aspects of care. This detailed analysis of costand flow enables staff to spend more time with patients, has eliminated waitscompletely for outpatient clinics and introduced multiple efficiency gains.At Group Health, the major focus is on the reduction of hospital admissions, length ofstay and overall cost. The focus is very much on shared decision making betweenthe doctor and patient – striving to correct the historical imbalance between the two.Evidence tells us that when patients are more informed and actively involved, theytend to make more conservative choices and are more satisfied with their outcomes.The rates of invasive surgery at Group Health have been reduced by 23%.So what did we learn?In many ways, not that much that was completely new to us. What we did see wasplenty of single-minded determination and a shared sense of urgency to put wellevidencedtheory into practice, with some impressive results. Far less focus on thepotential downsides of taking action; a ‘bring it on’ attitude to competition; completeintolerance of underperformance and a readiness to tackle it quickly – better to do50% now than 100% much later, or never.Page 21 of 156

Board of Directors Meeting, 29 March 2012Agenda Item 4a (Minute 033/12 refers)Appendix 1We also saw clear organisational objectives from top-to-bottom – widely understoodby everyone. There was an obvious willingness, and even eagerness, on the part ofsenior clinicians to work with financial managers for the benefit of patients and thebottom line – and the huddle and staff compact approaches led to a palpable senseof team and shared ownership.Also striking was the widespread understanding among staff, at all levels, of theneed for high quality performance data and a preparedness to share it openly andwidely. Interestingly, 5% per annum was a common target for efficiency savings andaround 1-2% a common level of turnover to be set-aside to implement redesign andefficiency programmes.And what have we changed?At Devon Partnership NHS Trust we have fed-back our experiences from the PacificNorth West, in some detail, to our Board and Medical Advisory Committee. Many ofthe approaches and ideas that we learned about in the US were, in some form,already prominent in our collective thinking about how we tackle issues aroundproductivity, efficiency, long-term sustainability and staff engagement. What the visithas done is significantly sharpen our focus on where we should concentrate ourthinking and what we should do next to start achieving tangible results.Improving performance through the use of accurate and readily-accessible data hasbeen a major priority for our Trust for the last three years or more. We have alreadydeveloped our own dashboard and performance management system – calledORBIT – but we now recognise the benefits of sharing performance data morewidely and openly, and encouraging more widespread staff ownership of it. OurMedical Director and Safety Lead are currently looking at the use of publicly-situatedperformance dashboards around our organisation, for all to see, and we are activelytying this in to the development of regular team huddles.It would be all too easy for this to be perceived by staff as ‘the latest fad from the US’or something too ‘gimmicky’ for the NHS. I am pleased to report that the concepthas, in fact, been very warmly received and individual directorates are activelyexploring how they might employ it to the greatest effect.We have also invested quite heavily in our service redesign capacity. In particular,we have invested in the development of an internal Improvement Academy which isfocused on supporting team performance, enabling and equipping them tounderstand and improve their performance, safety and quality.We have also set an average 6% per annum cost improvement programme for thenext five years, and have recommended additional project management to deliveragainst this target. This has increased our overall investment in redesign andefficiency programmes by about 0.5% of our turnover, and it now stands at around1.5%.We are developing stronger and clearer accountability for performance in all parts ofour organisation. We are striving to adopt a US-style ‘zero tolerance’ approach toPage 22 of 156

Board of Directors Meeting, 29 March 2012Agenda Item 4a (Minute 033/12 refers)Appendix 1underperformance and this is already bearing fruit. In some ways, this is achallenging cultural journey for some of our staff and the change won’t happenovernight. Although we have established disciplinary procedures to manageunderperformance that cannot be reasonably justified, our aspiration is to foster anenvironment where staff actively want to take ownership of their performance, takeindividual and collective pride in it and constantly strive to improve it.Page 23 of 156

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5DEVON PARTNERSHIP NHS TRUSTBOARD OF DIRECTORS - SUMMARY REPORTDate of Meeting: 29 March 2012Name of Report:Author:Approved by:Presented by:Chief Executive’s ReportExecutive TeamIain Tulley, Chief ExecutiveIain Tulley, Chief ExecutivePurpose of the report:To bring to the attention of the Board significant items of business in progress.Items of business requiring decision or reporting performance against serviceagreements are the subject of specific papers on the Board’s agenda. The ChiefExecutive’s Report provides the opportunity for significant issues to be brought tothe attention of the Board outside this framework.Key points:Update on the outsourcing of audit services, Annual Fire Safety Statement,Foundation Trust application, Trust Management Board.Action required, including Recommendations:Members of the Board are asked to receive the report and note its content.Links with the Assurance Framework (Risks, Controls and Assurance):The Chief Executive’s Report highlights areas of key, national and local context, toensure the Board is sufficiently briefed and to highlight actions that are to be taken.Summary of Constitutional / Financial/ Legal / PPI / Equality and DiversityImplications:No additional implications arise from this paper.Page 25 of 156

Links to Strategic Aims:Safe x Recovery-focused xTimely x Sustainable xPersonalisedxThis report references:CQCRegulationsPage 26 of 156

Board of Directors Meeting, 29 March 2012Agenda Item 5DEVON PARTNERSHIP NHS TRUST BOARD OF DIRECTORSMeeting on 29 March 2012CHIEF EXECUTIVE’S REPORT1 Strategic1.1 Update on the outsourcing of audit services1.1.1 On 5 March, the Audit Commission announced the award of five year auditcontracts to four private firms starting in 2012/13. This is planned to contribute to anoverall reduction in audit fees paid by public bodies by up to 40%.1.1.2 Grant Thornton was awarded the contract for the South West and will be the Trust’sexternal auditors for 2012/13 financial year. Audit Commission staff will continuetheir external audit assignment until September 2012 and will then transfer to GrantThornton in October 2012.1.2 Foundation Trust application1.2.1 A verbal update will be provided at the meeting.1.3 Update on Health & Social Care Bill1.3.1 A verbal update will be provided at the meeting.2 Operational2.1 Annual Fire Safety Statement2.1.1 The Board is asked to note that the Annual Fire Safety Statement for the period 1January 2011 and 31 December 2011 was signed off by the Chief Executive Officerand submitted to the Department of Health as per the national requirement.Additionally this statement will be noted in the Trust Annual Report.2.2 Trust Management Board2.2.1 The Trust Management Board met on 12 March for the quarterly review ofDirectorate performance. In addition to a review of all areas of performance byexception the following areas of were reviewed in detail.Monitor targetsMHMDSCQUINCRSMPCA – compliance and qualityObservation of care visitsLearning from experience- incidents and complaintsAssurance framework – risk of a catastrophic clinical eventFinance and CIP plansPage 27 of 156

2.2.2 The key points for the Board of Directors to note are:Board of Directors Meeting, 29 March 2012Agenda Item 5Monitor targets- progress being maintained but risk identified in relation tothe early intervention target. The action plan to address gap was beingimplemented.MHMDS- All Directorates maintaining a focus on this, additional reporting tosupport timely response to data errors agreed.CQUIN- weekly monitoring through Huddle is leading to improvedperformance against CQUIN, daily reporting has been implemented in areaswere performance is below plan. Detailed work being undertaken to addressperformance in 48 hour follow up in Adult Directorate.PCA compliance- the Heads of Profession and Practice have completed areview of the quality of PCA’s and plans are now in place to addressrequired improvements.Assurance Framework- the review of the risk in relation to a catastrophicclinical event was reviewed, progress noted with further work required in 3 ofthe Directorates before reducing the assessed risk.Sickness absence levels remain above target though in some areas this isreducing. The Workforce Team is reviewing guidance to DirectorateManagers to support compliance with the target.It was confirmed in the Trust Management Board that Jim Masters will withdrawfrom his commitments in the Secure Services Directorate to focus on the leading theLangdon project. The position of Managing Partner will be recruited to internally.Presented byIain TulleyChief ExecutiveMarch 2012Page 28 of 156

6DEVON PARTNERSHIP NHS TRUSTBOARD OF DIRECTORS - SUMMARY REPORTDate of Meeting: 29 March 2012Name of Report:Author:Approved by:Presented by:Quality & Safety Committee ReportDr Adrian Jacobs, Non-Executive DirectorDr Helen Smith, Co-Medical DirectorIain Tulley, Chief ExecutiveDr Adrian Jacobs, Non-Executive DirectorPurpose of the report:To provide assurance to the Board of Directors of key issues in relation to Quality &SafetyKey points:The Quality & Safety Committee met on 22 March 2012 and considered a range ofissues, work streams and developments. Of note:Assurance FrameworkBalanced ScorecardDirectorate GovernanceSub-Committee ReportsSafety & RiskClinical EffectivenessSafeguarding, including Mental Health Act Report & Risk StrategyWorkforce & DiversityLearning Disability Services: Internal MeasuresNHS ConstitutionResearch & Development ReportMedical Registration & RevalidationQuality, Compliance & the Experience of Using ServicesAction required, including Recommendations:Members of the Board are asked to receive the report and note its contentsLinks with the Assurance Framework (Risks, Controls and Assurance):Page 29 of 156

Impact across many of these issues identified in the Assurance FrameworkSummary of Constitutional / Financial / Legal / PPI / Equality and DiversityImplications:There is no implication to report, although all elements were considered during themeetingLinks to Strategic Aims:Safe X Recovery-focused XTimely X Sustainable XPersonalisedXThis report references:CQCRegulationsAllPage 30 of 156

Board of Directors Meeting, 29 March 2012Agenda Item 61. Purpose of reportDevon Partnership NHS Trust Board of DirectorsMeeting 29 March 2012Quality and Safety Committee Report1.1 To provide assurance to the Board of Directors of key issues arising in relation toquality and safety.2. Provenance2.1 This report is sourced from discussions arising from the Quality and SafetyCommittee of 22 March 2012 and the reports received by the Committee.3. Assurance Framework3.1 The Committee considered and approved the removalof RP6 “High Number ofConsultant Vacancies within OPMH, which may Affect the Consistency and Qualityof Care”.3.2 The Committee reviewed a further five risks:S1 – Supervision & AppraisalS2 – SafeguardingS3 – CQC RegistratonS9 – Violence & AggressionRP1 – Multiple Care RecordsAnd approved the plans in place to further manage these risks.4. Balanced Scorecard4.1 The Committee noted the current governance risk rating remained overridden toAmber / Red.4.2 The Trust is awaiting written confirmation from CQC that the override can beremoved.4.3 The Committee noted that all potential risks to the Monitor Governance Risk Ratingwere green, with plans in pace to sustain this position. The Committee further notedthat al other key performance indicators (KPIs) reported by exception had plans inplace to mitigate this and, and therefore approved these actions.Page 31 of 156

Board of Directors Meeting, 29 March 2012Agenda Item 65. Directorate Governance5.1 The Committee noted that a quarterly Directorate Performance meeting had takenplace on 12 March 2012. It was noted that Director Governance continues todevelop and become more robust.5.2 Plans are in place and teams identified through composite risk process.6. Sub-Committee Reports6.16.1.1Safety & RiskThe Committee was pleased to note that:There had been no ‘Never Events’ since the last meeting.The Trust had moved up into the top 25% of incident reporters in the south westand into the top 15 of mental health trusts nationally.6.1.2 The Committee also noted:The findings of the recent ligature audit. The Committee supported actionsrequired to rectify issues raised; these had financial implications which wouldrequire further approval.That there was a lack of availability of psychological therapies as describedwithin NICE guidance. Plans are in place to resolve these issues.The revision of the Risk Management Strategy, and approved its onwardpresentation to Board.6.26.2.16.36.3.16.46.4.1Clinical EffectivenessThe Committee noted that the 2012/13 Audit Plan continues in development andDirectorates will be expected to deliver the audit plan before embarking onadditional audits.Safeguarding, including Mental Health Act ReportThe Committee received the Mental Health Act Report for the period 2010 – 2011and noted its content. The report recognised the need for an emphasis onimprovement and the Committee noted and supported the plans in place to deliverthis. The Committee noted that this report had initially been reviewed by theSafeguarding Committee, who had given it due consideration before onwardsubmission to Quality & Safety Committee. Neither Committee had identified anyrisks or issues for particular note to the Board.Workforce & DiversityThe Committee noted additional plans to improve absence management andendorsed recommendations made. Members further noted the up and comingappointment of a lead for Equality & Diversity.The Committee received the Equality & Diversity Report and approved its onwardsubmission to the Board. Members also received a report on the findings of thePage 32 of 156

Board of Directors Meeting, 29 March 2012Agenda Item 6NHS National Staff Survey for 2011, which showed marginal improvement overprevious years.7. Other7.17.1.1Learning Disability Services: Internal MeasuresThe Committee received a presentation from Learning Disability Services, whichdescribed issued raised by the CQC and the implementation of changes takingplace within services to address these.The Committee recognised the challenges described and were assured by theinnovative work being undertaken.7.27.2.17.37.3.17.47.4.17.57.5.1NHS ConstitutionThe Committee noted that the Trust was fully compliant with the NHS Constitutionand that within this full compliance further improvements had been made.Research & Development ReportThe Committee noted the report, and agreed that there was a need for discussionaround the evaluation fund needed to take place amongst the Executive.Medical Registration & RevalidationThe Committee noted that the Trust is on track to meet revalidation requirements formedical staff.Quality, Compliance & the Experience of Using ServicesThe Committee noted:That there have been no reportable breaches in the past twelve months in termsof compliance with the requirements of Eliminating Mixed Sex Accommodation. That Commissioning for Quality and Innovation (CQUIN) targets for 2012 /13had been agreed.That work was underway with Heads of Profession and Practice, modernmatrons and senior managers to improve the reliability of the providercompliance assessment (PCA) checking process.That the CQC Mental Health Act inspectorate have carried out a review ofCommunity Treatment Orders (CTOs) within the Trust.That a quality, safety and effectiveness dashboard has been agreed withcommissioners.8. Recommendations8.1 Members of the Board are asked to receive this report and note its content.Page 33 of 156

Board of Directors Meeting, 29 March 2012Agenda Item 6Compiled by:Dr Adrian JacobsNon-Executive Director /Dr Helen SmithCo-Medical DirectorPresented by:Dr Adrian JacobsNon-Executive Director23 March 2012Page 34 of 156

7DEVON PARTNERSHIP NHS TRUSTBOARD OF DIRECTORS - SUMMARY REPORTDate of Meeting: 29 March 2012Name of Report:Authors:Approved by:Presented by:Quality, Compliance and the Experience of Using ServicesAlison Moores, Director of Nursing and PracticePenny Criddle, Senior Infection Prevention and ControlNurseLaura McMahon, Service Development managerLinda Stapleton, Patient Experience LeadIain Tulley, Chief ExecutiveAlison Moores, Director of Nursing and PracticePurpose of the report:To inform the Board about: The Trust’s progress with its quality improvement plans The current level of compliance with regulatory and internal standards of practice The reported experience of using services The quality of the care environment.Key points:This report will have been considered in detail at the Quality and Safety Committee on22 March 2012The Trust is required to review and refresh its statement of compliance with therequirements of Eliminating Mixed Sex Accommodation. There have been noreportable breaches in the past twelve months and the Board is asked to approve thepublication of the statement in section 10 (page 14)The Trust has agreed the Commissioning for Quality and Innovation (CQUIN) targetsfor 2012 /13. These targets have been agreed through reference to national mandatorytargets and local commissioner and provider priorities.The Heads of Profession and Practice are working with modern matrons and seniormanagers to improve the reliability of the provider compliance assessment (PCA)checking process. This will enable the Board of Directors to have improved confidencein KPI 290 which is the principle measure of assurance in relation to team levelassessments of compliance with CQC outcome standards.The Care Quality Commission Mental Health Act inspectorate has carried out a reviewof Community Treatment Orders (CTOs) within the Trust. The findings of the reviewwere still awaited at the time of writing.A quality, safety and effectiveness dashboard has been agreed with commissioners.From April 2012, this will form the basis of the Trust’s monthly contract quality reviewsand will be included in future quarterly reports to the Board. A modified version iscurrently being piloted with commissioners.Page 35 of 156

Action required, including Recommendations:Members of the Board are asked note the contents of the report and approve thedeclaration of compliance with the requirements of Eliminating Mixed SexAccommodationLinks with the Assurance Framework (Risks, Controls and Assurance):This report links principally to risk S3: CQC Registration:Failure to maintain existing systems to assure the Board that basic outcome standardsare being met.Summary of Constitutional / Financial/ Legal / PPI / Equality and DiversityImplications:Devon Partnership NHS Trust is required to be compliant with all standards set byregulation.Links to Strategic Aims:Safe X Recovery-focused XTimely X Sustainable XPersonalisedXThis report references:CQCRegulationsAll outcome areasPage 36 of 156

Board of Directors Meeting, 29 March 2012Agenda Item 7DEVON PARTNERSHIP NHS TRUSTBOARD OF DIRECTORSMeeting on 29 March 2012QUALITY, COMPLIANCE AND THE EXPERIENCE OF USING SERVICES1. Purpose of the reportTo inform the Board of Directors of: The Trust’s progress with its quality improvement plans The current level of compliance with regulatory and internal standards of practice The reported experience of using services The quality of the care environment2. ProvenanceThe Trust has developed a quality improvement framework based on the measurementof regulatory compliance, standards of practice and the evaluation of services bypeople who use them. These measures are combined with other quality andperformance information to allow monitoring through team dashboards.3. Key points for the Board to note3.1 This report will have been considered in detail at the Quality and Safety Committee on22 March 20123.2 The Trust is required to review and refresh its statement of compliance with therequirements of Eliminating Mixed Sex Accommodation. There have been no reportablebreaches in the past twelve months and the Board is asked to approve the publicationof the statement in section 10 (page 14)3.3 The Trust has agreed the Commissioning for Quality and Innovation (CQUIN) targetsfor 2012 /13. These targets have been agreed through reference to national mandatorytargets and local commissioner and provider priorities.3.4 The Heads of Profession and Practice are working with modern matrons and seniormanagers to improve the reliability of the provider compliance assessment (PCA)checking process. This will enable the Board of Directors to have improved confidencein KPI 290 which is the principle measure of assurance in relation to team levelassessments of compliance with CQC outcome standards.3.5 The Care Quality Commission Mental Health Act inspectorate have carried out a reviewof Community Treatment Orders (CTOs) within the Trust. The findings of the reviewwere still awaited at the time of writing.3.6 A quality, safety and effectiveness dashboard has been agreed with commissioners.From April 2012, this will form the basis of the Trust’s monthly contract quality reviewsand will be included in future quarterly reports to the Board. A modified version iscurrently being piloted with commissioners.Page 37 of 156

4 Quality improvementBoard of Directors Meeting, 29 March 2012Agenda Item 74.1 Several work streams within the 2011/12 quality improvement action plans arecomplete. Actions remaining in others are shown below. There are no significant (amberor red) delays to delivery. The delivery of these quality improvement action planscontinues to be monitored by the SHA and NHS Devon through a sub group of thecontact quality review meeting (CQRM). This group last met on the 7th March 2012 andconfirmed that it had a good level of assurance about the delivery of these plans.Current02.03.12Last09.12.11HASCAS ACTION PLAN (completion date March 2013)1 Records ↑2 Access to Psychological Therapies ↔3 Dual Diagnosis pathway and Training ↔4 Care Programme Approach ↔5 Operational Policies ↔6 Depression ↔7 Risk Management ↔10 Serious Untoward Incidents ↔13 Discharge from inpatient to community ↔CEDARS ACTION PLAN (completion date March 2012)3 Engagement ↔4 Risk assessment and management 7 Family support 8 Safeguarding ↔11 Operational management of the ward Complete ↔12 Medicines management ↔OTHER QUALITY IMPROVEMENT THEMES (completion date March 2013)2 Clinical Practice and Record Keeping ↔3 Specialist Skills Training 5 Medicines Management ↔7 Staffing ↑8 Business Development ↔Trend4.2 Quality safety and effectiveness dashboardThe Trust has agreed a suite of quality, safety and effectiveness indicators with itscommissioners. These indicators will form the basis of the Trust’s contractual qualityperformance monitoring and include benchmarks, targets and triggers for exceptionreporting. These will continue to be developed as local and national data becomesavailable. The 2012/13 quality, safety and effectiveness dashboard is shown atappendix 1.4.3 2012 / 13 Commissioning for Quality and Innovation (CQUIN)The 2012/13 CQUIN goals and indicators have been agreed with the commissionersand are summarised at appendix 3. Their combined value is 1.5% of the Trust’s basecontract. In addition to the Trust-wide CQUINs which relate to our main block contract,services commissioned by the Specialist Commissioning Group (SCG) have anadditional 6 CQUIN targets specific to secure, gender dysphoria and eating disorderservices. The CQUINs have been agreed but the process allows for modification andadjustment as additional guidance is developed by the Department of HealthPage 38 of 156

5. Compliance with regulatory standardsBoard of Directors Meeting, 29 March 2012Agenda Item 75.1 The Trust is registered without condition by the Care Quality Commission (CQC). Theframework of CQC regulation allows for both routine and responsive inspection. In thepast twelve months the Trust has been subject to:Planned reviews of all registered locationsResponsive reviews in response to particular, site specific issues and concernsRoutine Mental Health Act Commission inspectionsNational themed reviews of Learning Disability servicesNational CQC (Mental Health Act Commission) review of the implementation ofCommunity Treatment Orders (CTOs)The CQC report of the CTO review on the 5 th March 2012 is awaited. Reports havebeen received and published for all other inspections. The Trust has received, compliedwith and reported improvement and compliance actions where required and theeffectiveness of these actions has been confirmed through subsequent inspection. Theonly exception to this is the actions taken in response to the learning disability reviewwhich have yet to be verified by inspection. It is anticipated that the CQC will conductan inspection in early April to confirm current compliance within these services5.2 Internal assurance:Compliance with the CQC outcome standards is formally monitored through the ClinicalDirectorate review process. Exceptions and associated action plans are reported inaccordance with an agreed impact assessment matrix. A composite summary of theTrust’s provider compliance assessments (PCA) is shown below by registered site. Theonly amber or red rated exceptions are in relation to HMP Exeter as previously reported.This will be resolved with the closure of the inpatient unit by the end of March5 th March 2012 OUTCOMESite 1 2 4 5 6 7 8 9 10 11 12 13 14 16 17 21Whipton HospitalHMP ExeterFranklyn HospitalNDDHTorbay HospitalLangdonWonford InpatientWonford CommunityThe composite compliance position is based on team PCAs. The assurance process forPCAs is shown at appendix 2. PCAs are checked at prescribed intervals (KPI 290) andverified through peer audit (observation of care visits). Modern matrons / seniormanagers are responsible for completing the ‘check function’.The Board have expressed concern about variability in the quality and content of teamPCAs and that shortfalls in standards may not be being picked up and addressed.The Heads of Profession and Practice were tasked with carrying out a review of all PCAsby the end of February and working with matrons and managers to improve standardsand to ensure they fully understand their responsibilities for compliance. The relevantHead of Profession will, as a one off exercise, personally sign off each PCA when it is ofa satisfactory standard. The PCA improvement work is expected to be completed by theend of May. The purpose is to improve confidence in the routine checking process andKPI 290 as a measure of assurance. This confidence will be maintained throughsampling of PCAs by the Head of Profession as part of Directorate governance.Page 39 of 156

6. Compliance with Trust standards of practiceBoard of Directors Meeting, 29 March 2012Agenda Item 7Compliance with standards of clinical record keeping and practice is monitored throughthe review of a monthly sample of clinical records by the clinical team leader / wardmanager using the Clinical Record Self Monitoring tool (CRSM). Effective monitoring isdependent on a high rate of return of the monthly samples sent to clinical team leaderseach month. Completion rates continue to show improvement, from 68% overall in thelast report to 76% in this one.6.2 KPI 193 is a measure of the standard of clinical record keeping (the right informationrecorded in the right place at the right time). The target of 80% is met. SecureServices show a considerable improvement of 9% but across the Trust, compliance isdown by approximately 2%.6.3 KPI 235 is a measure of the content of the clinical records and the degree to whichthese meet the Trust practice standards. Directorates are not yet meeting the target of80% compliance and have been asked to provide additional support to teams with thelowest results. All directorates have shown an improvement since the last quarter withPage 40 of 156

Board of Directors Meeting, 29 March 2012Agenda Item 7Secure Services showing the biggest improvement of 10%. Across the trust there wasan improvement of 4%.6.4 Compliance with the 12 elements of care planning and clinical record keeping whichmake up the CRSM has increased by 15% since the last quarter. The greatestimprovement has been in the proportion of clinical records in which the person’s desiredoutcomes are identified.Page 41 of 156

7. The experience of using servicesBoard of Directors Meeting, 29 March 2012Agenda Item 77.1 The Trust worked with people who use services to identify the key qualities of serviceswhich underpin a good experience and positive outcomes. A questionnaire wasdeveloped to measure the degree to which people consider they have experiencedthese qualities and their satisfaction with the service provided. This is sent to a sampleof 1,000 people each month. The response rate for November to January was 23.3%(700 responses). The graphs show data for the months in which feedback was received(ie February data shows feedback from questionnaires completed in January).7.2 Satisfaction trends for 2011/127.3 Measures of satisfaction by Clinical Directorate7.4 The quality and safety committee and Board of Directors will continue tomonitor those aspects of service user experience in which the Trust performedpoorly against the national average in the 2011 National Mental healthCommunity Services survey. The questions with most relevance to theseaspects are shown below.Page 42 of 156

Board of Directors Meeting, 29 March 2012Agenda Item 7Q 6: I have been fully involved in all decisions about my care, treatment and support.Q 9: The care and support I need to achieve my goals has been available to meQ 15: I have known at all times who is responsible for arranging the care and support I need.Page 43 of 156

Board of Directors Meeting, 29 March 2012Agenda Item 7Q 19: Support has been available to me in times of crisis or urgent need.Q 22: The purpose of any medicines I have been prescribed has been discussed with me.Q 23: The possible side effects of any medicines I have been prescribed have beendiscussed with me.The Trust has begun a joint project with the Patients’ Association to achieve a betterunderstanding of the barriers to effective communication about medication and todevelop proposals for addressing these. Information about medication and the regularreview of medicines are both CQUIN targets for 2012/3 (see section 4.2)Page 44 of 156

Board of Directors Meeting, 29 March 2012Agenda Item 77.5 Comments, concerns, appreciation and complaints7.5.1 This report provides information about quarter 3 (October – December 2011). Themain reason for contacting PALS continued to be requests for information and adviceabout services and sources of support. Of the 155 complaints received, 104 werecomplaints from prisoners in HMPs Exeter, Dartmoor and Channing’s WoodOctober - December 20116040200Comment Compliment Complaints Concern EnquiryOctNovDec7.5.2 The subjects of complaints are shown below. The category of ‘other’ would includesubjects where complainant is unclear about why they are complaining; where theTrust is not able to resolve the issue, such as inter-family relationships or lack of(specialist) advice and support for benefit claims. Complaints about aspects of anysurvey would also be included within this category.October - December 20116050403020100DPTHMPConcerns7.5.3 Complaints made to the ombudsmanYear Number Current Position2009/10 1 Awaiting HSO decision following review2010/11 1 Further local resolution proceeding2011/12 7 4 closed – HSO decision not to investigate1 HSO investigation proceeding, awaiting result2 Awaiting HSO decision following reviewPage 45 of 156

7.5.4 Acting on feedbackBoard of Directors Meeting, 29 March 2012Agenda Item 7Clinical Directorate governance groups routinely consider comments, concerns,complaints, the results of the survey and other forms of feedback. It is theirresponsibility to review, investigate and take action as appropriate. Examples of serviceimprovements resulting from feedback during quarter 3 include:The introduction of a range of information, including Looking after yourself , FiveWays, and leaflets for Early Discharge, the Perinatal Service and DAS. The latterhas been distributed to GP surgeries to promote self referral and changes incontact details and involved people in its drafting.The development of an information pack produced for people using ForensicServices as well as friends and family pack. The pack and newsletter has beensent to all those on the approved visitor list for Langdon Hospital.Choice and medication website introduced.Review of ‘customer care’ training resulting in the introduction of ‘MixedMessages’ in 2012. This is now core e-learning for all staff.8. Engaging people with service development and improvement8.1 NHS organisations have a statutory duty to involve people (directly or throughrepresentatives), in the planning of healthcare services, in the development andconsideration of proposals for changes in the way those services are provided and indecisions affecting the operation of those services.8.2 The principle forum for engagement of people, including FT members, is the NetworkAction Group (NAG). The objectives of NAGs are to: Provide information about national, local and Trust developments. Encourage feedback about the quality of services. Encourage feedback about proposed service development or change. Offer partner organisations an opportunity to promote their services and engage indiscussions about integrated care pathways. Provide the opportunity for people to meet with senior staff.8.3 In Quarter 3 the planned Network Action Groups were postponed; meetings willcontinue from Quarter 4. During this period the Trust has continued to support otheractivities to ensure people influence Trust policy and service development, including: Informing FT members and other stakeholders through mail outs, providing furtheropportunities for people to become directly engaged. Involving people through focussed activity, such as the Quality Improvement andSafety meetings. Routine liaison with a range of stakeholders, including Be Involved Devon and‘carer’ representatives across Devon and Torbay. The latter has resulted in theagreement of a Carers Charter that will be implemented by the Trust from April2012. Establishing liaison meetings with Devon LINk to provide a more focussedapproach to issues raised by their participants. Future meetings will includeproviding updates on service developments within DAS, and OPMH which havebeen the subject of Devon LINk project work. Establishing a liaison with the Patients’ Association (PA) which is now operationalin the South West. As a result, the PA is project managing work aimed atimproving information to people about medication.Page 46 of 156

9. Infection prevention and controlBoard of Directors Meeting, 29 March 2012Agenda Item 79.1 The Trust has a dedicated infection prevention and control team available 24 hours aday/7 days a week via an SLA with the Royal Devon and Exeter Foundation Trust,reporting directly to the Trust’s Director of Infection Control (DIPC). The infectioncontrol committee has representation from all directorates and professions. Thecommittee meets quarterly and reports to the Quality and Safety committee via theSafety and Risk Committee. The Board of Directors have approved the 2011/12 annualinfection prevention and control programme of activity which is mapped to the Code ofPractice for health and social care on the prevention and control of infections andrelated guidance, and received and approved the 2010/11 annual report.9.2 Key Points9.2.1 Progress against the annual plan: Performance data continues to be provided monthly. Hand hygiene monitoringcontinues, the reduction in monthly hand hygiene returns was discussed, andMatrons were asked to discuss with ward managers the option of link practitionershaving protected time to complete audits. Compliance was at or above 85% in allareas, although for technique this was below 85% in the older peoples’ directorateand is being addressed through education. The infection prevention and control team (IPCT) continues to have considerableto building projects (Haldon, HMP Exeter, Langdon) to ensure compliance withInfection Control in the built environment and other standards. Five infection control policies were reviewed as per schedule and the hotelservices cleaning policy was brought to the committee for approval. This wasthen forwarded to the Safety and Risk committee and should be ratified by theBoard of Directors. Planned activities to assess infection prevention and control standards in relationto home visits and community work will now take place in March and April 2012.Activities are planned to improve awareness of the importance of IPC in thesesettings and to assess current practice. Further link practitioners or key contactsare being sought to co-ordinate these activities.The draft risk assessment audit was presented. Overall the compliance rate forcompleting an infection control risk assessment audit was only 26.5% (althoughthe range was 0% to 100%). In response to the poor completion of hard copyforms, a care plan on RiO has been developed, and will be trialled in the NorthDevon units and then rolled out Trust-wide. The guidance will be re-issued and arapid reminder sent to all other areas in the meantime.9.2.2 E-learning and Other Training9.2.3 Audit reportsCore training (e-learning) will become 3 yearly from 2012. Face to face trainingwill continue to be annual requirement for all in-patient and medical staff throughdirectorate training plans. Current compliance with e-learning is high; the Teamare working with units to actively improve compliance with face to face training.Plans are already in place to ensure medical staff have face to face training fromApril. This will be provided through MAC as well as on induction.Annual infection control audits should now inform the PCA process rather than askingfor duplicate action plans to be returned. This quarter showed improved compliancewith this process, although not universal, and this will be discussed again at TrustManagement Board.Page 47 of 156

9.2.4 Outbreaks and Incidents• There were no outbreaks in this quarter.• There was one MRSA new isolate in this period.Board of Directors Meeting, 29 March 2012Agenda Item 7• The RCA into the Clostridium difficile case in October 2011 has been completedand reviewed The source of C.difficile was unknown, as there were no othercases identified during the time of the person’s stay. However, the RCA processidentified a number of leaning points for the service, regarding recording andacting on increased episodes of faecal incontinence. Although there was noevidence that cross infection had taken place, the need to improve hand hygienemonitoring and address some compliance issues was included in the action planto ensure infection risks are minimised. Education on these issues has beendelivered by the IPCT.9.2.5 Exeter Prison (Healthcare Areas)The refurbishment work at HMP Exeter is almost complete; primary care will becompliant with environmental standards under Outcome 8 on completion of thiswork.Weekend cleaning of the primary care areas at HMP Exeter continues to beundertaken by nursing staff, NHS Devon has agreed to follow up progress of thePrison service business case to resolve this.Action plans are in place at HMP Channing’s Wood and Dartmoor to rectify recentcleaning deficits there.Cleanliness audit scores have now been received from all 3 prisons. The in-patient unit will be known as a supported living unit from the 1 st April.Devon Partnership Trust will de-register this site with the CQC and althoughhealthcare staff will continue to have a role, responsibility for this unit will transferto the prison.9.2.6 PEAG actions and outcomes Mattress audit. This is planned by the IPCT and undertaken collaboratively withthe link practitioners.Cleanliness Validation audits. Some scores are lower than the 91% target,although this may reflect only one room on the day of audit. Therefore to provideaccurate information and assurance to the Trust, It was proposed that PEAG reevaluatehow monitoring is reported with a view to inclusion of the routinemonitoring undertaken by housekeeping staff and the use of a stretch target.The Hotel Services Manager is continuing to work to ensure that there is regularin-house monitoring on the Langdon site. This is unresolved currently.New bins have been ordered for all adult areas to ensure compliance with thesafety notice concerning removal of plastic bags.New beds have been ordered to negate the potential ligature risk associated withthe main type in use.Page 48 of 156

10 Eliminating Mixed Sex AccommodationBoard of Directors Meeting, 29 March 2012Agenda Item 710.1 The NHS Operating Framework requires all providers of NHS funded care to re-confirmwhether they are compliant with the national definition ‘to eliminate mixed sexaccommodation except where it is in the overall best interests of the patient, or reflectstheir patient choice’. Those organisations that either do not make a declaration ordeclare they are not compliant will face penalties. Trust Boards must refresh theirdeclarations no later than 1 April 2012 and must ensure that they are clearly visible ontheir website.10.2 The compliance declaration should be accompanied by a commitment to audit dataquality and to publish the results. The purpose of the audit is to ensure that allepisodes of unjustified mixing are captured and reported, and that mixing is onlyclassified as “justified” if it is genuinely in the patient’s overall best interests. Noreportable breaches have occurred since the Trust first declared its compliance inMarch 2011; therefore no audit has been necessary10.3 A matrix for determining clinically justified breaches has been agreed with NHS Devonas the lead commissioner and reporting arrangements are in place through themonthly contract quality review meetings.Declaration of complianceDevon Partnership NHS Trust is pleased to confirm that we are compliant withthe Government’s requirement to eliminate mixed-sex accommodation, exceptwhen it is in the patient’s overall best interest, or reflects their personal choice.We have the necessary facilities, resources and culture to ensure that patientswho are admitted to our hospitals will only share the room where they sleep withmembers of the same sex, and same-sex toilets and bathrooms will be close totheir bed area. Sharing with members of the opposite sex will only happen whenclinically necessary such as where people need the highest level of one to onenursing support and observation for short periods of time (for example in a highdependency or ‘extra care’ area in an acute inpatient ward).If our care should fall short of the required standard, we will report it. We will alsoset up an audit mechanism to make sure that we do not misclassify any of ourreports. We will publish the results of that audit as part of our ‘quality of care andpatient experience’ report in September 2012.11 Recommendation to the Board of DirectorsThe Board is asked to receive the report and note its contents and to approve thestatement of compliance with eliminating mixed sex accommodation requirements asset out above.Alison MooresDirector of Nursing and Practice12 th March 2012Appendix 1: Quality, safety and effectiveness performance indicators 2012/13Appendix 2: PCA quality assuranceAppendix 3: 2012/13 CQUIN targetsPage 49 of 156

Experience 2Appendix 1: Quality, safety and effectiveness performance indicators 2012/13Board of Directors Meeting, 29 March 2012Agenda Item 7Domain Indicator Benchmark 1 ExceptiontriggerI would recommend this service to a member of my family 80%I have been treated with courtesy and respect at all times 90 %I would rate this service as 4 or 5 star (good or excellent) 75%I have been fully involved in all decisions about my care 85%I have been supported to set my own goals 70%The care & support I need to achieve my goals has been available tome75%Support has been available to me at times of crisis or urgent need 60%I have been given information and support to maintain my wellbeing -I have been supported to maintain important aspects of my life(occupation, parenting, social roles etc)55%I have known at all times who was responsible for arranging my careand support65%Any concerns I have raised have been responded to in a way that Iconsider satisfactory-The purpose of prescribed medicines has been discussed with me 70%Number of breaches of same sex accommodation 0 ≥1April May June July Aug Sept Oct Nov Dec Jan Feb Mar% of carers of peopled diagnosed with dementia who have beenoffered an assessment of their needsNumber of PALs contacts: CommentComplimentConcernComplaintEnquiry% of complaints acknowledged within 3 working days -Number of appeals received (complainant unsatisfied with CEOresponse)Target80%

SafetyDomain IndicatorTarget Exceptiontrigger% Medicines reconciliation within 72 hrs of admission 95% < 85%% of people who report that possible side effects of medication havebeen discussed with them% of people who report that staff have supported them to keepthemself safe% 48hr follow up after discharge 95%

CQUIN 4Effectiveness 3Board of Directors Meeting, 29 March 2012Agenda Item 7Domain Indicator Target trigger April May June July Aug Sept Oct Nov Dec Jan Feb Mar% of people who report that the service has met their needs at alltimes85%% of clinical records which meet Trust standards (assessment,planning, review.)85% ≤75%% of clinical records with a formulation and diagnosis 85% ≤75%% of clinical records where the person has identified their desiredoutcomes85% ≤75%% of clinical records with a care plan for all identified needs 85% ≤75%NICE guidelines published in period -NICE guidelines reaching level 2 consideration -NICE guidelines bypassing level 2: sent to working group for actionplanning-NICE guidelines still under review -NICE guidelines triaged as appropriate for DPT -Already considered fully compliant -NICE guidelines received by cross directorate working group -% of urgent referrals seen in 5 working days: Q4: 90%% of routine referrals seen within 10 working days: Q4: 90%% of people admitted to an adult inpatient unit with a completedVTE risk assessment / number of admissions90% ≤90% / / / / / / / / / / / /% of OPMH services with full safety thermometer data 100% ≤100%% of people over 75 admitted to acute inpatient units who havebeen asked the dementia screening questionQ4:90%% of people over 75 admitted & screened units who have had adementia risk assessmentQ4:90%% of people over 75 admitted & assessed as high risk of dementiawho have been referred for specialist assessment.Q4:90%% OPMH CMHT staff with training in end of life care planning Q4:90%% of people with a medicines review in past 6 months Q4: TBCPBR: % open cases which have been care clustered Q4:95%PBR: % clustered cases within review timescales Q4:95%PBR: % clustered cases without data error Q4:95%3 Clinical record compliance data based on approximately 550 completed CRSM record audits per month4 CQUIN : quarterly reports will be provided as per schedule.Page 52 of 156

Appendix 2 PCA quality assuranceVerification Peer audits(observations of care) Other auditCheck functionTeam PCAsand actionplans Senior Manager /Modern Matron Review of PCA andaction plan forcompleteness andquality Minimum reviewperiodsExecutive monitoring: Weekly composite riskreview by executiveteamMonthly ClinicalDirectorategovernance andperformancemeetings Complianceposition Action planprogress Exceptions forresolution orescalation Completion andquality of checkfunction Executivechallenge andsupportQuarterly reviewof ClinicalDirectoratePerformance Complianceposition Action planprogress Completion ofcheck function Exceptions forresolution orescalationBoard of Directors Meeting, 29 March 2012Agenda Item 7Moderatedcompositedeclaration Quality andsafetycommittee Board Regulators CommissionersPage 53 of 156

Appendix 32012/13 CQUIN targetsBoard of Directors Meeting, 29 March 2012Agenda Item 7Goal Indicator % value1. VTE 90% of all adult in patients will have evidence of a VTE and bleeding risk 5%assessment carried out on admission using the national tool. (penalties if VTErisk assessment slips below 90% in any month)2. Safety Implement safety thermometer in OPMH settings10%Thermometer(penalties if any part of data set not submitted in any month)3. PBR PBR Clustering Review Reducing data error4. Patient Increase the number of people who report that they have been givenexperience information about the purpose and possible side effects of medication at thepoint of prescription (Patients’ Association project – baseline and improvementtrajectories to be agreed in quarter 1)People who are prescribed medication by DPT for their mental health problemswill have this reviewed at least once in every 6 months. (baseline andimprovement trajectories to be agreed in quarter 1)6. Dementia 90% of all patients aged 75 and over who have been screened followingadmission to an adult or OPMH (functional) acute inpatient unit, using thedementia screening question. (Baseline and improvement trajectories to beagreed in quarter 1)7. IAPT /long termconditions8. Improvingresponsetimessecure servicessecure servicessecure servicesGender DysphoriaservicesSecure and eatingdisorder servicesSecure, eating disorderand gender Dysphoriaservices90% of all patients aged 75 and over, who have been screened as at risk ofdementia, who have had a dementia risk assessment within 72 hours ofadmission to an adult or OPMH (functional) acute inpatient unit using a hospitaldementia risk assessment tool (MMSE) (Baseline and improvement trajectoriesto be agreed in quarter 1)90% of all patients aged 75 and over, identified as at risk of having dementiawho are referred for specialist diagnosis (Baseline and improvement trajectoriesto be agreed in quarter 1)90% of OPMH community staffed trained in advance directives (including endof life care planning) – in year trajectories set by directorate and agreed2 year CQUIN: Developing the provision of psychological support servicesspecific to people with a long term physical health condition (data collection ,analysis of needs and proposals for service development in year 2)2 year CQUIN: Improved response times for non urgent referrals – baselinesand improvement trajectories to be agreed in accordance with referralmanagement roll out.2 year CQUIN: Improved response times for urgent referrals – baselines andimprovement trajectories to be agreed in accordance with referral managementroll out.SCG CQUINS15%5%5%5%5%5%5%10%15%15%Developing a shared pathway and outcomes based on the principles of recoveryImplement a standard secure pathway and introduce and monitor keymilestones on the patient pathway in order to make the pathway more efficientand reduce length of stay.Secure forensic care pathway feasibility pathway - implement, review andfeedback the requirements set out in the Feasibility Implementation BookletThe provider will be involved in developing a Clinical Quality Network that willdevelop standards of care which will be monitored by a peer review processImplementing service user defined CPA standardsThe implementation of a clinical dashboardPage 54 of 156

8DEVON PARTNERSHIP NHS TRUSTBOARD OF DIRECTORS - SUMMARY REPORTDate of Meeting: 29 March 2012Name of Report:Author:Approved by:Presented by:Workforce Report on National Staff Survey2011Sarah Frazer, Organisational DevelopmentLeadMartin Ringrose, Director of Workforce andOrganisational DevelopmentMartin Ringrose, Director of Workforce andOrganisational DevelopmentPurpose of the report:To provide further analysis of the key findings from the National Staff Survey 2011,following the Trust Board Report in January, to recommend an organisationalresponse and to recommend an approach to creating more local action and obtainingregular feedback from our staff.Key points: This report summarises the Trust findings from the national staff survey 2011It provides direct comparison for 38 key findings against other Mental Health andLearning Disability Trusts in the regionIt emphasises where the key action is required, supporting the actions already inplace in the wider Workforce Strategy and demonstrates the need to regularlycheck staff morale and build staff engagement at all levels within the Trust.Action required, including Recommendations:The Board is asked to note the content of the report and key findingsThe Board will receive further updates through the regular Workforce Report.Links with the Assurance Framework (Risks, Controls and Assurance):A number of the results from the Staff Survey relate directly and further work onthese identified areas will support the delivery of the ongoing corporateassurance framework.Summary of Constitutional / Financial / Legal / PPI / Equality and DiversityImplications:It is our commitment to respond to these findings and work with staff in making theirworking lives better. The financial implication of this report is in the capacity requiredto build in additional feedback mechanisms, analyse and respond to such feedback.Page 55 of 156

Links to Strategic Aims:Safe x Recovery-focusedTimely Sustainable xPersonalisedxThis report references:CQCRegulationsOutcome 14Page 56 of 156

Board of Directors Meeting, 29 March 2012Agenda Item 8DEVON PARTNERSHIP NHS BOARD OF DIRECTORSMeeting on 29 March 2012WORKFORCE REPORT on NATIONAL NHS STAFF SURVEY 20111. Purpose of report1.1. Provide a commentary on significant issues and key findings relating to thepublication by the Department of Health of the 2011 National Staff Survey carried outin the Trust during October to December 2011 by Capita Surveys and Research.2. Provenance2.1. This report complements the January Board Report which drew on the raw data fromthe Sample Frequency Data and was comparable with 19 other Mental Health andLearning Disability Providers which used Capita Surveys and Research to carry outand analyse their survey.2.2. This final National Report is weighted against all 59 Mental Health and LearningDisability Trusts and is presented against the four pledges to staff in the NHSConstitution and additional themes of staff satisfaction and equality and diversity.2.3. This enables the Trust to continue to focus action on the key areas that the NHS hascommitted to delivering for its staff, maintaining continuity on last year’s approach.2.4. The full report is available on the Staff Survey section of the intranet and internet.2.5. The full report provides detailed breakdowns of the key findings scores bydirectorate, occupational and demographic groups and details of each questionincluded in the core questionnaire.3. Background3.1. All NHS Trusts are required to carry out an annual staff survey each autumn. Thesurvey was conducted independently by NHS Capita Health Service Partners(previously NHS Partners); one of the approved national providers.3.2. The survey results are used to provide a temperature gauge for the organisation andensure progression against identified areas for improvement.4. Key points for Board of Directors to note4.1. Response rate4.1.1. The final official response rate was 50% which is below the average against thebenchmark for Mental Health and Learning Disability Trusts at 56% and significantlybelow the response rate of 59% last year.4.1.2. This is disappointing given the amount of promotion for the survey and the regularupdates and encouragement through each of the directorates to improve ourresponse rate on last year.Page 57 of 156

Board of Directors Meeting, 29 March 2012Agenda Item 84.2. Executive summary4.2.1. Compared to 2010 the Trust improved significantly in three of the 38 key findings, 33showed no significant change and two decreased significantly.4.2.2. In 18 out of the 38 key findings the Trust was better than the Mental Health/LearningDisability Trust benchmark.4.2.3. In 11 out of the 38 key findings the Trust was equal to the Mental Health/LearningDisability Trust benchmark.4.2.4. In 9 of the 38 key findings The Trust was below the Mental Health/Learning DisabilityTrust benchmark.4.2.5. Although reported as no significant change in 33 key findings we have in factmarginally improved in 21 of those key findings and were equal in 34.2.6. The headline statistic used by the Department of Health is Staff Engagement. This isbased on three key findings as follows: staff ability to contribute towardsimprovements at work, staff recommendation as a place to work and staff motivationat work. There was significant improvement in one of the findings (staffrecommendation of the Trust as a place to work or receive treatment) and no changein the other two. However overall the Trust is below average for staff engagementwith a score of 3.59 against the national benchmark of 3.61.4.2.7. In overall terms there has been a marginal improvement in most areas.4.2.8. The action plan already formulated does not require significant alteration but ratherneeds to be continued to be implemented.4.3. Top four ranking scores4.3.1. Support from immediate managers (a score of 3.93 against a national average scoreof 3.79) The Trust attained the highest ranking score nationally within Mental Healthand Learning Disability Trusts for this key finding.4.3.2. Percentage of staff feeling valued by their work colleagues (85% against a nationalaverage of 79%) This was also a top score last year.4.3.3. Trust committed to work-life balance (a score of 3.73 against a national averagescore of 3.55).4.3.4. Percentage of staff receiving health and safety training in the last 12 months (93%against a national average of 83%) This was also a top score last year.4.4. Bottom four ranking scores4.4.1. Percentage of staff receiving job relevant training, learning or development in the last12 months (74% against a national average of 80%) This was also a bottom scorelast year.4.4.2. Percentage of staff agreeing that their role makes a difference to patients (87%compared to a national average of 90%).Page 58 of 156

Board of Directors Meeting, 29 March 2012Agenda Item 84.4.3. Percentage of staff feeling satisfied with the quality of work and patient care they areable to deliver (63% compared to a national average of 74%).4.4.4. Fairness and effectiveness of incident reporting procedures (score of 3.35 comparedto a national average of 3.45) This was a bottom score last year.4.5. Largest local changes since the 2010 survey where staff experience hasimproved4.5.1. Percentage of staff experiencing discrimination at work in the last 12 months –decrease from 16% to 11%.4.5.2. Percentage of staff experiencing physical violence from patients, relative or the publicin the last 12 months – decrease from 14% to 8%.4.5.3. Staff recommendation of the Trust as a place to work or receive treatment from ascore of 3.17 to 3.30.4.6. Largest local changes since the 2010 survey where staff experience hasdeteriorated4.6.1. Percentage of staff having equality and diversity training in the last 12 months –decrease from 80% to 62%.4.6.2. Percentage of staff appraised in last 12 months down from 89% to 83%4.7. STAFF PLEDGE 1: to provide all staff with clear roles, responsibilities andrewarding jobs4.7.1. There was no significant change in all nine of the key findings.4.7.2. The Trust is in the highest 20% for three findings, above average for one, belowaverage for one and in the worse 20% for two findings.4.7.3. The main issue is improving how satisfied staff feel with the quality of work they candeliver and whether their role makes a difference to patients.4.7.4. The development of the Improvement Academy demonstrates the commitment toensure staff are supported and have clarity within their roles.4.8. STAFF PLEDGE 2: To provide all staff with personal development, access toappropriate training for their jobs and line management support to succeed4.8.1. There is no significant change in five of the six key findings and a decrease in onewhich was the percentage of staff appraised. However this is still in line with theaverage.4.8.2. The Trust attained the highest score for support from immediate managers.Page 59 of 156

Board of Directors Meeting, 29 March 2012Agenda Item 84.8.3. However it is worse than average for opportunities to develop and in the worst 20%for relevant job training.4.8.4. Whilst a slight deterioration on last year this demonstrated the continued commitmentto supervision and appraisal but highlights the need to improve on relevant jobtraining and development opportunities.4.8.5. The impact of providing managers with support through the managementdevelopment programmes is extremely positive and demonstrates the commitment ofour managers.4.9. STAFF PLEDGE 3: To provide support and opportunities for staff to maintaintheir health, well-being and safety.4.9.1. The Trust was in the best 20% or above average in eight of the 14 key findings,average in four and in the worst 20% or below average in two of the key findings.4.9.2. The main issues link to the fairness and effectiveness of incident reporting and thepercentage of staff experiencing harassment, bullying or abuse from patients,relatives or the public.4.9.3. Progress is being made in this area particularly regarding the dissemination andlearning from incidents, including the publication of regular safety briefings and theongoing work of the patient safety lead..4.10. STAFF PLEDGE 4: To engage staff in decisions that affect them, the servicesthey provide and empower them to put forward ways to deliver better and saferservices.4.10.1. The Trust was in the best 20% for staff being able to contribute towardsimprovements at work but below average with regards to good communicationbetween senior management and staff.4.10.2. This has been a recurrent theme and there is an organisational commitment anddedicated resource through the Organisational Development lead to focus on staffengagement as a key priority for the Trust.4.10.3. Improvements through the development of the new intranet and use of interactivemedia such as the weekly Performance Huddle will be a major platform for the staffengagement agenda.4.11. Additional theme – Staff Satisfaction4.11.1. The Trust was better than average in two of the four key findings, average in oneand in the worst 20% for the other.4.11.2. Despite being above average for staff job satisfaction and intention to leave jobs theTrust was in the worst 20% for recommendation of the Trust as a place to work orreceive treatment. However this did represent a significant improvement on lastyear.4.11.3. Only 57% of staff are able to deliver the patient care they aspire to compared to 65%in other providers and down 4% on last year.Page 60 of 156

Board of Directors Meeting, 29 March 2012Agenda Item 84.11.4. Only 53% of staff agree they are able to do a job they are personally pleased with butfewer staff think about leaving the Trust (29% down 6%) or are looking for anotherjob (16% down 3%).4.11.5. This is also better than other providers in which 31% think about leaving and 24% willprobably look for another job.4.12. Additional theme – Equality and Diversity4.12.1. The Trust is in the best 20% for staff experiencing discrimination at work, better thanaverage in take up of equality and diversity training and average in equalopportunities for career progression..5. Summary5.1 It is encouraging that small improvements have been made but this highlights therequirement to further concentrate our efforts on ensuring staff feel valued andsupported in working for the Trust.5.2 It is also encouraging that the Trust compares favourably in most areas against otherMental Health and Learning Disability Providers.5.3 Of particular note is the support staff receive from immediate line managers and thisshould encourage the continued focus of ensuring managers are competent, capableand feel confident to carry out their roles and support staff.5.4 Improvements within the responses regarding learning and development could bereflective of the fact that the workforce development department has undergonerestructuring in the past year.5.5 Staff can feel some of the benefits of putting in simpler processes for learning anddevelopment. This includes supporting the development of training plans withindirectorates to meet the needs of the business, ensuring that training is relevant,meets professional requirements and keeps staff up to date.5.6 The key issues from recent years remain and further work to support ongoing actionsneeds to be identified:Staff engagement – ensuring staff feel supported and valued in their work andable to influence changes and make developmentsCommunication – at all levels and with emphasis on the relations between seniormanagers and staffLearning from incidents and sharing best practice – continue the workprogressing through patient safety and quality improvementLearning and development – roll out core training programme, respond to theaudit on supervision and appraisal to develop a culture of feedback and supportand ensure role clarityManagement development – build on the management development programmeto ensure access to development opportunities which will enhance the way weworkPage 61 of 156

Board of Directors Meeting, 29 March 2012Agenda Item 86. Action6.1. As stated above there has been little change to the key issues identified last yearwhich can be expected as cultural change in the way staff work and the impact ofimproving systems and process will take time to take effect. Although this has begunto happen in some areas.6.2. It is proposed that the current action plan in response to last year’s survey which isintegrated into the wider Workforce Action Plan should remain in terms of the Trust’scorporate response to the issues raised with minor revisions as required.6.3. To complement this there will be a much stronger focus on local directorateresponses which will be informed by the individual directorate reports, which alsoincluded Medical staff and Head Quarters.6.4. The relevant Managing Partner or Director will hold overall responsibility for theirlocal approach but will be supported by Sarah Frazer, Organisational DevelopmentLead who will hold an overall strategic approach, and their local Workforce BusinessPartners who will provide general workforce support.6.5. Local actions will be monitored through performance reports as part of the widerperformance agenda.6.6. To support these actions feedback should also be considered from the results of therecent Devon County Council staff survey which includes assigned staff. The issuesraised were very similar to our own with three key areas to address: appraisals,leadership visibility and staff engagement.6.7. Simultaneously work is being progressed to support staff engagement andrecognition within the Trust and it is also proposed through a separate paper todevelop a Key Performance Indicator (KPI) for staff satisfaction based on thosequestions from the staff survey. This will be measured through a monthly staffsatisfaction audit across all directorates.6.8. It is also proposed as part of this whole agenda that teams could be supported bythe Improvement Academy and mechanisms put in place to share learning andshowcase best practice.7. Recommendation to the Board of Directors7.1. Members of the Board are asked to receive the report and note and discuss itscontents.7.2. Further update reports and progress will be presented to the Board through theregular Board Workforce Report.Compiled bySarah Frazer, Organisational Development LeadPresented byMartin Ringrose, Director of Workforce and ODMarch 2012Page 62 of 156

9DEVON PARTNERSHIP NHS TRUSTBOARD OF DIRECTORS - SUMMARY REPORTDate of Meeting: 29 March 2012Name of Report:Author:Approved by:Presented by:Equality & Diversity Annual ReportChukumeka Maxwell, Equality & Diversity andHuman Rights Advisor and Co-ordinatorMartin Ringrose, Director of Workforce andOrganisational DevelopmentMartin Ringrose, Director of Workforce andOrganisational DevelopmentPurpose of the report:To present the Equality and Diversity information and update on activity as requiredannually.Key points:This is a report of our performance on equality issues, incorporating all our reportingagainst legal duties, including:EthnicityAgeGenderDisabilitySexual OrientationReligious BeliefAction required, including Recommendations:Accept and approve the content of the report which will be then uploaded on to theTrust’s website as required under legislation.Links with the Assurance Framework (Risks, Controls and Assurance):No issues to note.Summary of Constitutional / Financial / Legal / PPI / Equality and DiversityImplications:This is a report of our performance on equality issues, incorporating all our reportingagainst legal duties.Links to Strategic Aims:Safe Recovery-focused XTimely Sustainable XPage 63 of 156

PersonalisedXThis report references:CQCRegulationsPage 64 of 156

Board of Directors Meeting, 29 March 2012Agenda Item 9Devon Partnership NHS Trust Board of Directors Meeting29 March 2012EQUALITY AND DIVERSITY AND HUMAN RIGHTS REPORT1. Purpose1.1 The purpose of this report is to provide the annual report of Equality and Diversity andHuman Rights (E and D and HR) with the evidence that the organisation is fulfilling its legalduty under the Equality Act 2010. The report is a public commitment of how DevonPartnership NHS Trust seeks to meet the duties placed upon it by the Equality Act 2010,the Race Relations (Amendment) Act 2000, Disability Discrimination Act 2005 and the SexDiscrimination Act as amended by the Equality Act 2006. It also includes information onage, gender identity, religion and belief and sexual orientation, which are aimed atimproving employment, goods, facilities and services (these were in place prior to thelegislative provision of the Equality Act 2010).1.2 The NHS has now moved on to the Equality Delivery System (EDS) (see appendix 4). TheEDS does not replace legislative requirements for equality; rather it is designed asperformance and quality assurance mechanism for local NHS Boards and a means bywhich NHS organisations are helped to meet the requirements of their public sector Dutyunder the Equality Act (2010) and the NHS Act (2006).2. Context & Background2.1 The Equality Act 2010, which came into force on the 1 October 2010 supersedes andsimplifies existing equality and anti-discrimination legislation.2.1.1 Within the Act, public sector organisations such as Healthcare Trusts have specificduties, which need to be fulfilled. This is known as the public sector equality duty (PSD).2.2 The PSD consists of a general duty and a number of specific duties. These replace thethree old public sector duties for race, disability and gender. The general duty has threeaims and requires public sector organisations to have due regard to the need to:Eliminate unlawful discrimination, harassment and victimisation.Advance equality of opportunity between people from different groups.Foster good relations between people from different groups.2.3 The specific duties require public bodies to set specific, measurable equality objectivesand to publish information about their performance on equality, so that the public canhold them to account.3. Ethics3.1 Devon Partnership NHS Trust is a major employer and service provider of Mental HealthServices in Devon and Torbay. The needs and aspirations of its workforce and peoplewho use services will obviously vary according to individual circumstances, but the Trustrecognises that their preferences and choices about employment and service provision atthe Trust, must not be disadvantaged by race, disability, gender and gender identity, age,Page 65 of 156

Board of Directors Meeting, 29 March 2012Agenda Item 9sexual orientation, marriage and civil partnership, pregnancy and maternity, genderreassignment or by religion or belief (known as the nine protected characteristics seeappendix 1). There are however other groups who are vulnerable and at risk of socialexclusion. The diversity of the workforce and the people who use our servicesenriches us all, and allows the Trust to deliver best-in-class policy and service.3.2 The content of our reports are set out by a number of national drivers and legalimperatives.3.2.1 The main ones are: Reducing Inequalities Changes in Legislation and meeting the legal duties imposed on all publicbodies Monitoring Requirements Meeting the Care Quality Commission (CQC) Standards, especially ongovernance, patient focus, accessible and responsive care Equality and Human Rights Commission (EHRC) codes of practice (and codesissued by predecessor organisations) Monitor, the Independent Regulator of NHS Foundation Trusts, will be reviewinghow we ensure the standards are being met. The NHS Equality Delivery System (EDS) Equality Act 20103.3 The report also highlights the on-going development work that is taking place inresponse to emerging guidance and forms an on-going process of learning from TheEquality Delivery System (EDS). Please note that use of the EDS does not automaticallylead to better equality performance. For this to happen, the EDS must be used well,championed by committed leadership with a workforce that is supported to be confidentand competent in dealing with equality.4. Risks4.1 The risks of not fulfilling our equality duties (see Appendix 2) are that we could beprosecuted and fined by the EHRC and lose our CQC registration and damage ourreputation. The Chief Executive of South Devon Healthcare Foundation Trust is thenational lead for the new NHS Equality Delivery System (EDS), so the region is nowmore visible than before on the national stage. As the Trust continues to embed andmainstream its equalities work we are confident that we will be aware of and addressany adverse consequences, which may arise as decisions are taken. We will also ensurewe actively promote the requirements of the Equality Act 2010 general duty in everythingwe do.5. What the Data says: - Where are we in relation to the Gold/Purple Standard?5.1 In a recent national PSD audit summary of returns of all the regional NHS organisations(See Appendix 3). In our SHA region the gold standard in regards to E and D in MentalHealth Trusts is being achieved in the north of the region by the 2gether NHSFoundation Trust. It is being achieved by Nottingham Healthcare Trust and SussexPartnership Trust whom have been recognised nationally for their work. Our Dataheadlines are an indication that we have access to some data. However in other Truststhey clearly demonstrate inclusive activity and engagement by all levels of the Trustand a true commitment to the agenda. In the new EDS the highest standard will bedefined a purple rating. All our amber and red ratings are in the process of beingworked upon in the E and D action plan.Page 66 of 156

Board of Directors Meeting, 29 March 2012Agenda Item 96. The Equality and Diversity and Human Rights Agenda6.1 In the period covered by the report the Trust has had to respond to a long CQCinvestigation focusing on Quality and Safety, its Foundation Trust application, demandsfrom the regulator Monitor. It also had to work solely and in partnership in implementinga robust Safeguarding agenda.6.2 It has had to plan ahead to meet the challenges of operating in a less financially secureenvironment and the changing political landscape and an NHS re-organisation, whilstattempting to do business as usual in mental health, which is increasingly affectingmore and more of society.6.3 Though the above issues have been prioritised the Trust has not fully embraced theworkforce and people who use its services in the design of services that enable thedelivery of a robust Equality and Diversity and Human Rights agenda. There has beenlimited acknowledgement of the importance of the Equality and Diversity agenda in theTrust’s main business plans. Equality, Diversity and Human Rights is not a minorityissue as it has been seen in the past, rather it should and needs to be a central part ofan organisational culture underpinned by values for the Trust to deliver its vision of“Being good enough for my family.”6.4 Two objectives from the vision Personalised and Recovery-Focused have at theirheart the essence of equality and diversity. The Trust’s ability to respond to the diverseneeds of all with Human Rights free from unwitting discrimination has to be theresponsibility of the Trust and its prominence to staff and external stakeholders. Aspart of the future work and consultation to the above agenda an audit will need to takeplace to ascertain how well we know the constituents from the nine protectedcharacteristic groups.6.5 The new EDS gives the Trust scope for improvement and the opportunity to addressthis agenda, somewhat like it has done around Safeguarding and Recovery agenda,neither of which can be delivered effectively without Equality, Diversity and HumanRights.6.5.1 Kieran Poynter, Chairman of PriceWaterhouseCoopers where he worked for 37 yearsstates:“Our experience has shown that building a strong business case for diversity, making ita strategic imperative backed up by policies and processes is just not enough.Tackling the complexity of organisational culture requires focus on what drivesbehaviour – this has taken us into the realms of organisational psychology so that wecan each better understand each other and thus ourselves.7. Timescale7.1 As a public institution, the Trust will continue to screen for the negative outcomeanalysis of any decisions, which could unfairly affect any particular group. The Trusthas recently update its public sector duty response on 31January 2012. However whatthe process highlighted was that there needed to be a much broader understanding ofE and D and support for key deliverables. Our next timescale is relatively short topublish.7.2 We need to have consulted and agreed our equality objectives by 6 April 2012. This isin line with the national EDS which has to be delivered. This provides a starting point forthe Trust that can be built upon with effective leadership, commitment and support fromPage 67 of 156

the Trust Board and all staffBoard of Directors Meeting, 29 March 2012Agenda Item 98. What is the plan for improvement and resource implications?8.1 The Trust needs to invest in an Equality and Diversity and Human Rights agendaintensely over the next 18 months to 3 years and beyond. The implementation of EDSrequires a timetable of work especially in terms of the evidence gathering. It isrecommended that the Trust Board partakes in the NHS Leadership Councils ‘Connectthe Board’ programme (see appendix 5).8.1.1 An E and D and EDS Implementation group led by the Director of Workforce andOrganisational Development will have an initial steer to represent the full sign up to theEDS from the Trust Board and Executive Team. This will also ensure the commitmentto the implementation of the Equality and Diversity Leadership CompetencyFramework. It will report to the Trust Board quarterly and monthly to the ExecutiveTeam.8.2 A Human Rights Advisor/Co-ordinator is in the process of being appointed to asubstantive post. It is important to realise that there is need for more support aroundthis agenda especially at the beginning as both internal and external stakeholders needconsulting. The post holder will liaise with the clinical directorates specifying theoutcomes required which will be reflected in their quality improvement plans. He or shewill also support the development of directorate action planning and design measuresfor success criteria. The specification can then be fed into an agreed qualityimprovement planning process. These will in the future be used by the EDS in relationto CQC and NHS Constitution. This will enable the Trust to have an accurate gradingacross the protected characteristics and the broader equality agenda.8.3 The agenda is a paper audit exercise as well as a practical and culture changingexercise in line with the Trust’s vision of being able to take care of the mental healthneeds of the population it serves. All levels within the Trust need a commitment toEquality and Diversity and a small equalities team could support the theoretical andpractical implementation of “No Health Without Mental Health” in partnership withexternal and internal stakeholders.8.3.1 Workforce members and foundation members need to be consulted and virtual as wellas real action groups, and community networks need to be established to deliver thework across the Trust.8.4 The Trust needs to invest properly in its link for developing a recovery oriented Trustand work with the commissioners to develop partnership working with specialistorganisations in order to deliver a service that is equitable and diverse at all levelswithin the organisation.8.5 The Trust is now focussing on the broader agenda of Equality and Diversity and HumanRights. It is part of a South West EDS cluster working closely with other equalitycolleagues in other Trusts at this time of rapid change. It is really important as theTrust moves forward to it foundation status that Equality and Diversity sits within theheart and mind of the new organisation based on recovery principles. EDS helpsorganisations to be responsive to the people they serve.“Health and Healthcare are a Human Right for all People”9 Recommendations 2012-2015 are as follows9.1 A request to the Trust Board for the consideration and appointment an Non-Executivelead responsible for supporting the E and D agenda alongside the executive leads.Page 68 of 156

Board of Directors Meeting, 29 March 2012Agenda Item 99.2 A commitment to the ‘Connect the Board’ programme which is offered to the TrustBoard and a focus to enable the Trust to improve its diversity agenda within the nexteighteen months.9.3 Establish networks and reference groups engaged with external stakeholders especiallyGeneral Practitioners.9.4 Review all Equality and Diversity information from DPT Intranet website and redesignand publish on the intranet and internet a clear robust communication strategy for the Eand D and HR agenda which can communicate messages with all the Trust’s internaland external stakeholders.9.5 The design and delivery of training packages around Culture and Values in theworkplace across all the protected characteristics and incorporating the broaderequalities agenda as well as social inclusion into policy and working practice.9.6 The design and implementation of a quality Pastoral care provision, supervision andcoaching. Equality and Diversity can enhance the workforce to deliver quality results forall the people we serve.9.7 A chaplaincy service and pastoral care service needs to be established comprising ofpaid and non-paid volunteers within the next eighteen months.9.8 Continually review and improve our E and D and HR agenda.10. Action Required by the Quality and Safety Committee10.1 The Committee is invited to note the context proposal to adopt the NHS EDS and toapprove the development and implementation of the EDS in 2012/13 with due regard toresources and delivery through service improvement and quality.10.2 The Committee is asked to note and endorse the content of this report10.3 The Committee is asked to support the formation and establishment of the EqualityGroupPrepared by:Chukumeka MaxwellInterim E&D Human Rights Advisor and Co-ordinatorPresented by:Martin RingroseDirector of Workforce and OD18 March 2012Page 69 of 156

Board of Directors Meeting, 29 March 2012Agenda Item 9Appendix 1'Protected characteristics'.Known as the nine protected characteristics.AgeWhere this is referred to, it refers to a person belonging to a particular age (e.g. 32 year olds) or rangeof ages (e.g. 18 - 30 year olds).DisabilityA person has a disability if s/he has a physical or mental impairment which has a substantial and longtermadverse effect on that person's ability to carry out normal day-to-day activities.Gender reassignmentThe process of transitioning from one gender to another.Marriage and civil partnershipMarriage is defined as a 'union between a man and a woman'. Same-sex couples can have theirrelationships legally recognised as 'civil partnerships'. Civil partners must be treated the same asmarried couples on a wide range of legal matters.Pregnancy and maternityPregnancy is the condition of being pregnant or expecting a baby. Maternity refers to the period afterthe birth, and is linked to maternity leave in the employment context. In the non-work context,protection against maternity discrimination is for 26 weeks after giving birth, and this includes treatinga woman unfavourably because she is breastfeeding.RaceRefers to the protected characteristic of Race. It refers to a group of people defined by their race,colour, and nationality (including citizenship) ethnic or national origins.Religion and beliefReligion has the meaning usually given to it but belief includes religious and philosophical beliefsincluding lack of belief (e.g. Atheism). Generally, a belief should affect your life choices or the way youlive for it to be included in the definition.SexA man or a woman.Sexual orientationWhether a person's sexual attraction is towards their own sex, the opposite sex or to both sexesPage 70 of 156

Board of Directors Meeting, 29 March 2012Agenda Item 9Appendix 2Theregulatoryframework forequalities andhuman rightscan beunderstood interms of threeintersectingdomains thatare set outbelow.DomainThe EqualityAct (2010)Human RightsAct (1998NHS Equality Delivery Scheme(EDS)EssentialStandardsAppliesprimarily toMonitoringand regulationEmployees andserviceusers/familycarersEquality andhuman RightsEmployees and serviceusers/family carersCommissioners/HealthwatchServiceusers/familycarersCQCCommissionSanction Legal action Loss of Contract QualifiedRegistrationThe framework is underpinned by S.242 of NHS Act (2006) which places a duty on all NHSorganisations to consult with patients and the wider public on all aspects of service change anddevelopment. Consultation and involvement are fundamental to effective promotion of equalities.Page 71 of 156

Page 72 of 156Board of Directors Meeting, 29 March 2012Agenda Item 9

Appendix 3Board of Directors Meeting, 29 March 2012Agenda Item 9EDS BoardBuy inNominatedEDS leadsPublishedgradingOtherPSDevidencePublishedEDSobjectivesEngagementstaff/ tradeunionsLinks/HealthwatchGPs/CCGseng.with EDSclusterVolSectorPatientsandCarersProtectedCharacteristicGroupsAnyothergroupsE&D leadin post ResourcesSouth West Strategic Health Authority G G A A A G G G G G G G G G G A A G A A South West Strategic Health AuthorityEIAassuranceTrainingandawarenessPreparednessfor continueddeliverySupportfor staffTrust Boardappraised ofequalityPrimary Care Trusts Primary Care TrustsNHS Bath and North East Somerset G G A A G A A A A A A R n/a R G G A G R G NHS Bath and North East SomersetNHS Bournemouth and Poole G G A A A G G A G A A A A G G A G A A A NHS Bournemouth and PooleNHS Bristol G G R A A R A R G A A A n/a G G G G A G G NHS BristolNHS Cornwall and the Isles of Scilly G G A G A G G G G G G G n/a G G G G A A G NHS Cornwall and the Isles of ScillyNHS Devon G G A A A A A G G G G G G A A G A G A A NHS DevonNHS Dorset G G A A A G G A G A A A A G G A G A A A NHS DorsetNHS Gloucestershire G G A A G A A G G G G G G G G G G G A G NHS GloucestershireNHS North Somerset G G A A R G A A G A A A G G A G A A G G NHS North SomersetNHS Plymouth G G A A A A A G G G G G G A A G A G A A NHS PlymouthNHS Somerset G G A A A A G G G A A A n/a G G A A A A A NHS SomersetNHS South Gloucestershire G G R R R A A A G A A A A G G G G A A A NHS South GloucestershireNHS Swindon G G A A A A A R G A R A n/a G R A G A A G NHS SwindonNHS Wiltshire G G A A A G A A A A A A A G G G G G G G NHS WiltshireTorbay Care Trust G G A A A A G A G A A A n/a A A G A G A A Torbay Care TrustAcute Trusts Acute TrustsDorset County Hospital NHS Foundation Trust G G A A A G A R G A A A G G R G G A A G Dorset County Hospital NHS Foundation TrustGloucestershire Hospitals NHS FoundationTrust G G G A A G G R G G A A n/a G G G A G A GGloucestershire Hospitals NHS FoundationTrustGreat Western Hospital NHS Foundation Trust G G G G A G G A G G G G G R R G G G G G Great Western Hospital NHS Foundation TrustNorth Bristol NHS Trust G G A A A G A n/a G A A A n/a G A A G G G A North Bristol NHS TrustNorthern Devon Healthcare NHS Trust G G A G A A A A G A A A n/a G R G G A R G Northern Devon Healthcare NHS TrustPlymouth Hospitals NHS Trust G G A A R G G n/a G A A A G G A A A A A A Plymouth Hospitals NHS TrustPoole Hospital NHS Trust G G A A A G A R G A A A G G R G G G A G Poole Hospital NHS TrustRoyal Bournemouth and Christchurch HospitalsNHS Foundation Trust n/a n/a n/a G G n/a n/a n/a n/a n/a n/a n/a n/a A R A G G G GRoyal Bournemouth and Christchurch HospitalsNHS Foundation TrustRoyal Cornwall Hospitals NHS Trust G G A A A A G G G A A A n/a G A A A A A A Royal Cornwall Hospitals NHS TrustRoyal Devon and Exeter NHS Foundation Trust G G G G G G G G G G G G G G G G G G G G Royal Devon and Exeter NHS Foundation TrustRoyal National Hospital for RheumaticDiseases NHS Foundation Trust G G A A A G G G G G G G G G G G G G G GRoyal National Hospital for RheumaticDiseases NHS Foundation TrustRoyal United Hospital Bath NHS Trust G G A A A A A A A A A A A G G G G G A G Royal United Hospital Bath NHS TrustSalisbury NHS Foundation Trust G G A G A G G A G G G G G G G A G G G A Salisbury NHS Foundation TrustSouth Devon Healthcare NHS Foundation Trust G G A A A G G n/a G G G G G G G G G G G G South Devon Healthcare NHS Foundation TrustTaunton and Somerset NHS Foundation Trust A G R A R A A R G R A R n/a G G A A A A A Taunton and Somerset NHS Foundation TrustUniversity Hospitals Bristol NHS FoundationTrust G G R A A A R R G R R R n/a G A A G A A AUniversity Hospitals Bristol NHS FoundationTrustWeston Area Health NHS Trust G G A A A A A A A A A A n/a A G G G G G G Weston Area Health NHS TrustYeovil District Hospital NHS Foundation Trust G G A A A A G G G G G G G G G A A A A A Yeovil District Hospital NHS Foundation TrustAmbulance Trusts Ambulance TrustsGreat Western Ambulance Service NHS Trust G G R G A A G G G A A A n/a G A G A G A A Great Western Ambulance Service NHS TrustSouth Western Ambulance Service NHS Trust G G A A A G A A G R A A n/a G G G G A A G South Western Ambulance Service NHS TrustMental Health Trusts Mental Health Trusts2gether NHS Foundation Trust G G A G A G G G G G G G G G G G G G G G 2gether NHS Foundation TrustAvon and Wiltshire Mental Health PartnershipNHS Trust G G A G G A G A G G G G A G G A A G A GAvon and Wiltshire Mental Health PartnershipNHS TrustCornwall Partnership NHS Trust G G A G G G A n/a G A A A n/a A A A G A A G Cornwall Partnership NHS TrustDevon Partnership NHS Trust A G A G A A A R G A A A A G A A G A A A Devon Partnership NHS TrustDorset Healthcare NHS Foundation Trust G G A A A G G R G A A A A G G A A A G A Dorset Healthcare NHS Foundation TrustSomerset Partnership NHS Foundation Trust G G A A R G G A G G G G n/a G G G G G A G Somerset Partnership NHS Foundation TrustSocial Enterprises* Social Enterprises*Bath and North East Somerset CommunityBath and North East Somerset CommunityHealth and Care ServicesHealth and Care ServicesBristol Community Health Bristol Community HealthGloucestershire Care Services Gloucestershire Care ServicesNorth Somerset Community Partnership A G R A A A n/a n/a n/a R R n/a A G A A A A G A North Somerset Community PartnershipPeninsula Community Health Peninsula Community HealthPlymouth Community Healthcare CIC Plymouth Community Healthcare CICSwindon Care and Support Partnership Swindon Care and Support PartnershipRed 0 0 6 1 5 1 1 9 0 4 3 3 0 2 6 0 0 0 2 0 RedAmber 3 0 32 30 31 19 19 15 4 22 24 23 9 6 12 18 16 20 26 19 AmberGreen 38 41 3 11 6 21 20 12 36 15 14 14 15 34 24 24 26 22 14 23 GreenNot applicable 1 1 1 0 0 1 2 6 2 1 1 2 18 0 0 0 0 0 0 0 Not applicableKey Red: not started yet/ not in place KeyAmber: in progress or partially doneGreen: competed or in place* Social enterprises were not required to respond to this audit, although it was suggested that they might want to use this methodology as a way of reviewing whether they meet the requirement of the general duty of the Equality Act 2010for their publicly funded functionsPage 73 of 156

Appendix 4Board of Directors Meeting, 29 March 2012Agenda Item 9The Equality Delivery Council (EDC) was established in 2009 and includes Director Generals of theDepartment of Health, representatives from each strategic health authority and other interests. TheEDC supports NHS staff and organisations to work closely with the communities they serve to deliverservices that are personal, fair and diverse; to champion continuous improvement in the quality ofpatient services; promote good practice; and support the NHS to implement the Equality Act 2010.The EDS is one of the first products initiated by the EDC. The purpose of the EDS is to drive upequality performance and embed equality into mainstream NHS business. It has been designed tohelp NHS organisations, in the current and new NHS structures, to meet:-The requirements of the public sector Equality DutyEquality aspects of the NHS ConstitutionEquality aspects of the NHS Outcomes FrameworkEquality aspects of CQC's Essential StandardsEquality aspects of the Human Resources Transition FrameworBenefits of the EDSOnce effectively implemented the EDS will:Help the NHS deliver on the Government’s commitment to fairness and personalisation,including the equality pledges of the NHS Constitution and maintain a focus on equality duringthe NHS transition.Help organisations to respond more readily to the Equality Act duty – something they will needto do in any event.Deliver improved and more consistent performance on equality.Support commissioners to develop commissioning plans that address needs of theircommunities, especially local needs and local health inequalities.Help providers to respond better to CQC registration requirements.Improve efficiency and bring economies of scale by providing a national equalities frameworkfor local adaptation.Provide excellent evidence of engagement and consultation with patients and staff.As the foundations of the NHS are being recast, it is an ideal opportunity to put fairness into theheart of the new NHS. The introduction of the EDS as a vehicle that will help NHSorganisations to meet their public sector equality duty obligations (which has to be publishedon 31 January 2012) from 1 April 2012.Which functions do the EDS apply to?The EDS applies to both NHS commissioners and NHS providers – both in the current NHS and thenew NHS as set out in the White Paper and Health & Social Care Bill. This means that the EDSapplies to Primary Care Trusts/PCT Clusters (PCTs), until they are abolished, and to GP Consortiathat emerge to take over the commissioning work of PCTs, from 1 April 2014.Page 74 of 156

Board of Directors Meeting, 29 March 2012Agenda Item 9The EDS applies to NHS providers including Foundation Trusts, all of whom are registered toprovide services by the CQC.It may also be applied, through contracts, to those healthcare organisations that are not a part of theNHS, but which may work to contracts issued by NHS commissioners.How have service users and local people been involved?The EDS is designed for the NHS by the NHS. It is based upon the views of 700 people coveringpatient, staff and other interests at 35 engagements events in 2010 and early 2011. When the EDSregional consultation events are concluded in 2011, it is estimated that over 2,000 people will havecontributed to the EDS design. It is hoped that Board will give its full backing to use the EDS as a wayof consulting staff for issues it is engaged inHow does this fit with the organisations Operational Planning Process?The EDS should form part of the organisation’s strategic and annual business cycle and help guidefuture planning and resource allocation. The Board is asked to approve this in words and action.HOW DOES THIS CONTRIBUTE TO REDUCING HEALTH INEQUALITIES?Social class, poverty and deprivation are often closely related to the incidence of ill health and the takeup of treatment. In addition many people with characteristics afforded protection under the EqualityAct 2010 are challenged by these factors, and as result experience difficulties in accessing, using andworking in the NHS. For this reason, work in support of protected groups is best located in work toaddress health inequalities in general with a focus on improving performance across the board andreducing gaps between groups and communities.Financial implicationsThere is a substantial financial input arising from the new framework dependant on the overallcommitment to the agenda. However there will be on-going resource implications in terms of:Developing and implementing an on-going community engagement exercise arounddeveloping equality objectives and prioritised actions and assessing organisationalperformance against these.Participating in a regional grouping cluster of NHS Trusts to share good practice and peersupport.However it should be noted that as organisations need to meet the Equality Act 2010 duty, the abovecost implications would be incurred regardless. The NHS organisation and/or legacy organisationswould be at risk of legal challenge if it failed to meet its duties under equality legislation, or if itknowingly or unknowingly allowed discrimination to occur.9 Legal issuesThe EDS does not replace legislative requirements for equality; rather it is designed as a performanceand quality assurance mechanism for local NHS Boards and a means by which NHS organisations arehelped to meet the requirements of their public sector duty under the Equality Act (2010) and the NHSAct (2006).Next stepsThe organisation has to have fully signed up to the EDS by 1 April 2012. Subject to the Board’sapproval and as a matter of urgency the organisation should identify a Lead Non-Executive Boardmember to work with the Director of Workforce and Organisational Development, Martin Ringrose, andthe Equality and Diversity Advisor/Co-ordinator with responsibility for EDS implementation. TheyPage 75 of 156

Board of Directors Meeting, 29 March 2012Agenda Item 9should work closely with the SHA and, where appropriate the PCT Cluster, on the regional EDSimplementation plan and milestones and also with the EDS Programme Office to achieve successfulimplementation during 2011-12.The NHS EDS Programme office has highlighted the following timelineDate ActivityBy 4 March 2011EDS guidance, including the revised outcomes and supported by the Equality Impact Assessment, aremade available for regional engagement events by the Programme.March and early April 2011Regional engagement events are held to review and refine the EDS guidance.By June 2011The EDS will be approved by the EDC and others, and issued to the NHS.By 31 July 2011*The Board will need to publish a range of data on workforce and services and any consultationscarried out in line with the requirements of the public sector equality duty.September and October 2011 *NHS organisations identify their local interests with whom organisational performance will be graded inpartnership.November and December 2011 *NHS organisations in collaboration with local interests, should analyse and grade organisationalequality performance and identify 4-5 equality priority actions for the following financial year(2012/13).31 January 2012 (Public sector duty published on website) and February 2012 *The Board, via LINks (or Health Watch) should send their ratings of performance and priority actionsto Local Authority Overview and Scrutiny Committees and (in due course) to Health and Well BeingBoardsBy 1 March 2012Grades are reported to the EDS Programme Office and the NHSCB.6 April 2012Using the EDS, all NHS bodies will have published their Equality Objectives, and related priorityactions as required by the Equality Act.The analysis of the outcomes must cover each protected group, and be based oncomprehensive engagement, using reliable evidence.Page 76 of 156

Board of Directors Meeting, 29 March 2012Agenda Item 9Appendix 5Building Inclusion and diversity into theBusiness at Board LevelA Board development programme to develop Inclusive Leadershipdelivered by Shapiro Consulting on behalf of the NLCNLC Programme AimsThe aim of the NLC programme is to co-produce an accelerateddevelopment process which will support Boards to focus on inclusion in a way that engagesthem in the reality of the challenges they face as commissioners, providers and employers inthe communities they serve. The programme explores how Boards can use inclusion as astrategic lever for improving access and quality in health care and reducing inequalities inhealth; release untapped innovation and productivity within the workforce; generateconnection with the populations we serve, and improve prevention.An Introduction to Shapiro ConsultingOver the past decade Shapiro Consulting have helped a wide range of public and private sector organisations toimprove their performance on inclusion and diversity and draw strategic advantage from diversity. This hasbeen achieved by drawing on our extensive research base in this field as well as our experience inorganisational change, quality improvement and leadership development. We are currently carrying outresearch on Inclusive Leadership in partnership with Opportunity Now, sponsored by BAE Systems, KPMG,MMC and Nomura. Our work on inclusion and diversity has covered all the legally protected groups and hasalso considered wider complexities including, for example, social and economic backgrounds, professions andhierarchical levels. We recognise that every client is unique and that we can never know your organisation aswell as you do. We place a premium on working in close partnership with you – our client and providingbespoke solutions that, whilst sometimes challenging, are always achievable.The Shapiro team have experience of working with and within the NHS, and across a range of other publicsector organisations. Recent clients include; Broadcast Equality and Training Regulator, Eversheds LLP, GeneralMedical Council, General Pharmaceutical Council, KPMG LLP, Hereford Hospitals Trust, NHS Rotherham, NHSNottinghamshire County PCT, Rotherham, Doncaster and South Humber NHS Mental Health Foundation Trust,UK Film Council, Yorkshire and the Humber SHA. The team will be led by Dr. Gillian Shapiro, Managing Directorof Shapiro Consulting with senior Shapiro consultant Juliette Brown.Further information on the consultant team and our contact details are provided at the end of this document.Page 77 of 156

Board of Directors Meeting, 29 March 2012Agenda Item 9The Connect Approach - helping Boards respond to meeting 21 st Centuryleadership challengesThe Next Stage Review clearly set out a vision for the NHS which has quality, innovation, improvement andmeeting the clinical and care needs of patients and the public at its core. This needs to be achieved whilst alsoreducing costs and responding to the health care challenges raised by changing demographics and lifestyles.This vision and context sets an important challenge to NHS leaders. In terms of inclusion and diversity, we seethe challenge as two fold. Firstly, there is a critical need for leaders to develop a strategic response to meetingthe varying health and health service needs of different groups within our society, which is one in whichsignificant health inequalities already exist, that is aligned with their core strategy. Secondly, is the need todevelop a strategic organisational approach that considers the diversity implications of developing an engagedworkforce and future leadership that can realise the high standards of quality, innovation and improvementsought. The CONNECT programme provides a methodology to help NHS organisations respond to thesechallenges.CONNECT OutcomesThe programme will deliver: An understanding of the critical relationship between diversity and inclusion issues, the strategicpriorities of the NHS organisation and national NHS challenges e.g. World Class Commissioning,Healthy Ambitions, the DH report, Quality, Innovation, Productivity and Prevention (QIPP); Knowledge of how to identify and consider relevant diversity and inclusion issues in the strategicplanning and decision-making process; Increased commitment and capability to build diversity and inclusion into leadership of the NHSorganisation at every level; Awareness of the role and impact participant leaders within the programme have in creating greaterdiversity in leadership and increased ability to ensure diversity and inclusion is embedded across theirorganisation.Four Stages of the CONNECT ProgrammeCONNECT comprises four stages which combined, help to improvethe commitment, confidence and capability the Board needs to builddiversity and inclusion into the leadership of their organisation.Assess conducts an overview of the organisation’scontext including strategic priorities and challenges,approaches to and progress on inclusion and diversity, successes and challenges, patientand public profiles etc.Data is gathered using documentation and conversations with key stakeholders including inmost cases the Chief Executive and Chair, HR Director, Strategy / operations director,Medical Director and equality lead. It includes feedback from other key stakeholders such asgovernors, clinicians, nursing and other staff, patients and service users.Review seeks to understand the changing social, political and organisational environmentand priorities as it relates to diversity and inclusion, and how this affects the NHSorganisation. It works with individual Board members to explore how building diversity andinclusion into their own leadership approach can add value to their areas of responsibility andachieving the overall strategic priorities of the organisation. It uses the Strategic InclusiveLeadership & Governance Framework© and coaching-style conversations.Page 78 of 156

Board of Directors Meeting, 29 March 2012Agenda Item 9The results of the Assess and Review stages are presented as a report to the Board andused to design the workshop within the next programme stage – Build.Build identifies the strengths and weaknesses of the Board’s approach in leading inclusion and diversity andbuilding it in to the business at board level as well as opportunities for further improvement. It plays theseback to the Board within a workshop setting. The workshop, using tailored questions and case studies providesan opportunity for the Board to further develop their combined commitment to leading inclusion and diversityand identify the actions and changes needed to achieve improvement.The results of the workshop are written up by the consultants into a working document, including theconsultants’ analysis and recommendations. This is used by the Board to put into action the changes theyidentified at the workshop.Act provides continued consultant support to the Board in the form they need. This varies between Boards butusually includes input and support on a specific issue such as developing a strategy, plan or key performanceindicators or subjects such as engagement or equality impact assessments. This final stage helps to ensure thatthe learning developed on the programme is transferred into action and positive outcomes.Summary of Individual Board Member’s Involvement in CONNECTActivity Timescale Guide to timeCompletion of the Strategic Inclusive Leadership self assessment tool& pre-readingOne-to-one coaching conversation with a CONNECT consultantCONNECT workshopImplementation & learning reviewThe Shapiro Consultant Teamrequired1 hour1.5 hours¾ dayTBCDr. Gillian Shapiro (PhD)Gillian is founder and Managing Director of Shapiro Consulting, an expert organisationestablished in 1989 dedicated to promoting diversity, inclusion and engagement within theworkplace. She is Director of the UK Work Organisation Network (UKWON) which iscommitted to developing new ways of organising work that lead to sustainablecompetitiveness and a high quality of working life. She is the diversity advisor to theBroadcast Equality and Training Regulator that works in partnership with UK licensedbroadcasters to promote the levels and quality of equality and training acrosstheir workforces.Gillian was previously a senior research fellow at the Centre for Research inInnovation Management within the University of Brighton Business School. Inthis role she led a number of pan-European research programmes across anumber of sectors on employee diversity and engagement as well as knowledgemanagement. Her PhD focused on the career development of women into senior leadershiproles within the IT sector.Dr. Gillian Shapiro has an excellent track record for helping organisations across the publicand private sectors increase the diversity of their workforce and leadership teams. She isvalued for her ability to draw strategic value from inclusion and diversity by building on it tosupport employee engagement and innovation, helping her clients to increase quality,customer satisfaction and market share. She is recognised for her research in the fields ofinclusion, diversity and employee engagement and has published and presented her worknationally and internationally. Her principal areas of expertise and experience lie in:Page 79 of 156

Board of Directors Meeting, 29 March 2012Agenda Item 9Developing leaders to lead on inclusion and diversity and build on them for strategicadvantage;Successfully delivering change programmes to increase workforce diversity and createmore inclusive work cultures;Working across multiple organisational settings including within finance, professionalservices, film and broadcasting, health, education and third sectors in the UK and acrossEurope;Creating measurement tools to assess the impact of change programmes on inclusion,diversity and engagement;Practically applying academic knowledge and research techniques to improveorganisational understanding of and approaches to achieving workplace diversity,inclusion and engagement.Juliette Brown BA (Hons), MCIPDJuliette is owner and Managing Consultant of JJB Personnel & Training Consultancy, whichshe set up in 1999 and an Associate Consultant of Shapiro Consulting. Juliette has abackground in HR and training and is a highly experienced diversity and equality pioneerwithin the television broadcast industry and its regulatory bodies.Juliette has spent 9 years as a non-executive director on a number of NHS Mental HealthTrusts and held a wide variety of positions of responsibility for areas such as corporategovernance, was the responsible NED for whistle-blowing complaints (for staff);Chair of the User Complaints Committee; chaired grievance, disciplinary andappeal meetings; chaired investigations into untoward and other serious incidentssuch as suicide and was for several years Chair of the Suicide PreventionCommittees at the Bethlem & Maudsley NHS Mental Health Trust andsubsequently at Broadmoor Special Hospital.Juliette spent 18 years as an HR practitioner working in the television broadcast industry withthe BBC and ITV and 8 years as a Regulator of that industry with the Independent TelevisionCommission and then Ofcom, the regulator for the communications industry with whom sheworked for 8 years. She wrote a Handbook for broadcasters entitled ‘Equal opportunities: atoolkit for broadcasters’. She has been joint architect of successful professional and personaldevelopment programmes that clients have re-commissioned over a number of years.Juliette is a Corporate Member of the Chartered Institute of Personnel & Development.Her clients include: Motorola, JPMorgan Chase, the Law Society and the Chartered Instituteof Purchasing and Supply in the private sector and The Cabinet Office, The National Schoolof Government, and the Home Office in the public sector.Juliette’s principle areas of expertise include:Diversity strategy development including designing equality schemes; undertaking andreporting on diversity audits; complaints investigation and mediation;Over ten years experience as a coach and facilitator and trainer of others in facilitationskills;Design and delivery of professional and personal development programmes;Extensive experience of job design, job evaluation and recruitment and selection;Qualified in occupational testing.Page 80 of 156

Shapiro Consulting Team Contact DetailsDr. Gillian ShapiroConsultant and Programme LeadJuliette BrownConsultantClaire AyrtonProgramme AssistantBoard of Directors Meeting, 29 March 2012Agenda Item 9E: g.shapiro@shapiroconsulting.co.ukT: 01273 401659M: 07718390844E: jjbconsult@gmail.comT: 07930540379E: c.ayrton@shapiroconsulting.co.ukT: 07810 536981We look forward to working with you on CONNECT. If you have any queries, please do not hesitate tocontact the CONNECT programme lead, Dr. Gillian ShapiroPage 81 of 156

Page 82 of 156Board of Directors Meeting, 29 March 2012Agenda Item 9

10DEVON PARTNERSHIP NHS TRUSTBOARD OF DIRECTORS - SUMMARY REPORTDate of Meeting: 29 March 2012Name of Report:Authors:Approved by:Presented by:Financial Report for the period ended 29February 2012Hugh Groves, Director of FinanceIain Tulley, Chief ExecutiveHugh Groves, Director of FinancePurpose of the report:To report on the financial position of the Trust at the end of February 2012Key points:1. Surplus of £728k achieved against planned surplus of £728k at month 112. Financial risk rating of 3 is in line with plan3. Forecasting full achievement of CIPS Programme4. PSPP achieved 98.1% by number and 99.3% on value of bills paidAction required, including Recommendations:1. Note the financial risk rating at 29 February 20122. Note the income & expenditure and Balance Sheet at 29 February 20123. Note and review progress of the 2011/12 CIP ProgrammeLinks with the Assurance Framework (Risks, Controls and Assurance):Achievement of financial targets is considered within the Assurance Framework andlogged as a low scoring riskSummary of Constitutional / Financial/ Legal / PPI / Equality and DiversityImplications:Financial information included within the reportLinks to Strategic Aims:SafetyRecovery FocusedTimely X Sustainable XPersonalisedThis report references:CQC RegulationsNonePage 83 of 156

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Board of Directors Meeting, 29 March 2012Agenda Item 10DEVON PARTNERSHIP NHS TRUST BOARD OF DIRECTORSFINANCIAL SUMMARYMeeting on 29 March 2012FINANCE REPORT EXECUTIVE SUMMARYMonth 11 2011/12Post impairment surplus of £728k achieved against a planned surplus of £728k and in linewith £285k post impairment surplus for the year and £785k pre impairment surplus.Achieved Financial Risk Rating of 3 as planned.Compliant with DOH Performance Framework, achieving maximum weighted score of 3 at29 February.Risk on CIPS plan being deliveredSound cash position.INCOME£4.7m favourable variance at Month 11 of which £5.1m favourable variance relates toadditional income for IPP receivable under the risk sharing arrangements. This has beenpartly offset by an adverse variance for EDU and Forensic services of £391k and £219krespectively due to occupancy levels below target in the year to date. Risk againstdelivery of Income CIPS.EXPENDITURETrust Expenditure £5,019k above budget with non pay over-spend on IPP budgetoffsetting under-spends on pay budgets.QIPP PLANSTotal CIPS target of £5m. Achieved £4.1m as at M11 against target of £4.3m at Month 11.Forecasting to fully achieve target of £5m.PUBLIC SECTOR PAYMENTS PERFORMANCE95% payment target exceeded on value of bills paid for the period to 29 Feb (actual result99.27%)95% payment target achieved on number of bills paid for the period to 29 Feb (actualresult 98.08%)BALANCE SHEET/CASH FLOW/CAPITALCash has increased by £8.8m since 31 March 2011.£3.4m increase in Trade & Other Receivables.Cash Balance of £20m at the end of Month 11.£12.5m Capital programme completed as at Month 11 against a target of £16.5mPage 85 of 156

Board of Directors Meeting, 29 March 2012Agenda Item 10Scoring Thresholds 5 4 3 2 1 Value RatingUnderlying Performance 11% 9% 5% 1%

Board of Directors Meeting, 29 March 2012Agenda Item 10Table 1DEVON PARTNERSHIP NHS TRUSTINCOME & EXPENDITURE POSITION AS AT 29th February 2012 (Month 11)CY BUDGET ACTUAL VARIANCE ForecastBUDGET Month 11 Month 11 Month 11 Outturn£'000 £'000 £'000 £'000 £'0001.0 INCOME1.1 Block 84,861 76,429 76,429 0 84,8281.2 Cost and Volume 34,010 31,167 34,984 3,817 37,5141.3 Clinical Partnerships 10,882 9,915 10,590 675 11,5641.4 Other Operating 3,146 2,881 3,056 175 3,3001.5 TOTAL 132,899 120,392 125,059 4,667 137,2062.0 EXPENDITURE2.1 Pay 83,437 76,621 76,313 307 83,7602.2 Non Pay 43,857 38,645 43,971 (5,326) 48,2622.3 TOTAL 127,294 115,266 120,284 (5,019) 132,0223.0 EBITDA 5,606 5,126 4,775 (352) 5,184EBITDA % 4.2% 4.3% 3.8% 3.8%4.0 4.1 Other Costs 2,806 2,551 2,509 43 2,7494.2 PDC Dividend 2,015 1,847 1,513 335 1,6504.5 TOTAL 4,821 4,398 4,022 377 4,3995.0PRE IMPAIRMENT NETSURPLUS / (DEFICIT) 785 728 753 25 7856.0 Impairment 0 0 25 (25) 5007.0POST IMPAIRMENT SURPLUS /(DEFICIT) 785 728 728 (0) 285Page 87 of 156

Board of Directors Meeting, 29 March 2012Agenda Item 10Table 3DEVON PARTNERSHIP NHS TRUSTCAPITAL PROGRAMME 2011-12£'0002011/2012 Capital Funds per Annual Plan 17,615Revision to Plan - February 2012 (2,615)2011/2012 Capital Funds 15,000Expenditure to 29/02/12 (12,477)Forecast to 31/03/12 2,5232011/12 Capital InvestmentsOriginal RevisedPlan Plan Actual Forecast£'000 £'000 £'000 £'000Clinical Directorates Adults/OPMH/Specialist Services 4,621 5,087 5,060 5,334Clinical Directorate - Secure Services 1,038 1,044 538 701Langdon Main Scheme 10,464 8,292 5,223 6,920Business Developments 350 201 156 159Estates Infrastructure/Health & Safety 487 275 224 254I T 330 539 407 546Equipment/Vehicles 55 55 57 91General Provisions 250 337 172 355Other Schemes b/fwd 2010/11 20 53 40 40Purchase of Land - Whipton ASU 0 600 600TOTAL 17,615 15,882 12,477 15,000Page 89 of 156

Board of Directors Meeting, 29 March 2012Agenda Item 10DEVON PARTNERSHIP NHS TRUSTTable 4BALANCE SHEET AS AT 29TH FEBRUARY 2012Balance sheet As at As at As at31 March 2011 31 January 2012 29 February 2012 MovementNon-Current Assets£000 £000 £000 £000Land 16,798 16,573 17,173 375Buildings 34,769 33,214 33,089 -1,680Plant & Equipment 1,200 1,049 1,032 -168Transport Equipment 95 109 107 12Information Technology 1,634 1,490 1,443 -191Furniture & Fittings 761 806 794 32Intangible Assets 114 601 584 470In course of construction 10,112 18,609 20,463 10,350Trade and Other Receivables 0 0 0 0Total fixed assets 65,485 72,451 74,685 9,200Current assets (Money owed to Trust)Inventories 69 69 69 0NHS Receivables - Revenue 1,001 3,722 4,340 3,339Non NHS Receivables - Revenue 755 339 434 -321Provision for Impairment of Receivables -131 -127 -43 88Prepayments and Accrued Income 179 558 459 280VAT 241 226 198 -43Other Receivables 156 143 168 13Cash and Cash Equivalents 11,179 20,662 20,009 8,831Current assets 13,448 25,591 25,634 12,186Non-Current assets Held for Sale 745 745 745 0Total current assets 14,193 26,336 26,379 12,186Current liabilities (Money the Trust is due to pay)NHS Payables - Revenue 3,906 6,048 4,555 649NHS - Capital 15 0 1 -14Non-NHS Trade Payables - Revenue 595 88 360 -235Tax & Social Security Costs 1,617 1,684 1,747 130Non-NHS Trade Payables - Capital 751 973 2,003 1,251PDC Dividend Payable 0 568 584 584Other 1,012 1,042 5,184 4,172Accruals & Deferred Income 3,597 9,660 7,312 3,715NHS Loan Interest Accrual 0 76 92 92Short term Loans 126 539 539 413Provisions for liabilities & charges 1,046 1,015 900 -146Total current liabilities 12,664 21,693 23,276 10,611Net current assets / (liabilities) 1,529 4,643 3,104 1,575Total assets less current liabilities 67,014 77,094 77,789 10,775Non-current liabilitiesLong Term Loans 1,140 10,664 10,664 9,524Provisions for liabilities & charges 1,206 1,221 1,235 29Total non-current liabilities 2,346 11,885 11,899 9,553Total assets employed 64,668 65,209 65,890 1,222Financed by taxpayers equityPublic Dividend Capital 38,569 38,569 39,169 600Retained earnings 7,798 9,395 9,434 1,636Revaluation reserve 18,277 17,244 17,287 -990Donated asset reserve 24 0 0 -24Other reserves 0 0 0 0Total taxpayers equity 64,668 65,209 65,890 1,222Page 90 of 156

Links to Strategic Aims:Safe X Recovery-focusedTimely Sustainable XPersonalisedThis report references:CQC RegulationsNonePage 92 of 156

Board of Directors Meeting, 29 March 2012Agenda Item 11inpatient services.Both Specialist Services and Secure Services Directorates are under-spent. Withinthe Specialist Services Directorate the Devon Drug Service contract remains overspenthowever joint work with EDP and Devon DAAT has improved this position.Headquarters budgets are under-spent and are forecasting a position below budgetby the year-end.The IPP budget is forecasting an over-spend of £5.366m however, under the termsof the risk sharing arrangement with commissioners the Trust bears the risk of £300kof this over-spend, the residual risk rests with the commissioners. It was noted thatPICU average occupancy reduced in Month 11 however the latest information showsoccupancy rates for Devon patients are above budget.2. CIPSAt month 11 the Trust had achieved £4.1m against the savings target at this stage ofthe year of £4.3m however the Trust is forecasting to meet its target at the year end.3. CapitalThe Trust has a capital resource limit of £16m, supported by property sales of £1.6mgiving a capital programme for the year of £17.6m. Capital spend to the end ofmonth 11 was £12.5m against an original plan of £16.5m and a revised plan of£13.8m. The revised expenditure plan reflects the timing of the approval of the loanrelating to the Langdon development.4. Balance SheetCash has increased by £8.8m at the end of month 11 compared to the year endposition, relating largely to the receipt of the second tranche of the Langdon loan.Debtors have increased by £3.4m relating largely to NHS receivables. Currentliabilities have increased by £10.6m. The Trust is meeting its PSPP targets in termsof the number and value of bills paid within 30 days and at month 11 thepercentages were 98.08% and 99.27% respectively.5. Risks & MitigationsThe key risks were noted and a verbal update was given to the Committee.6. Key RatiosAt month 11 there were two Monitor indicators rated red, relating to Capitalexpenditure and the planned EBITDA margin.44.1Treasury ReportThe report for month 11 was agreed. The content of the report was discussed and itwas agreed that the level of detail met the needs of the committee at this time.Page 94 of 156

Board of Directors Meeting, 29 March 2012Agenda Item 1155.15.25.366.177.17.27.37.488.199.1Assurance FrameworkThe Committee considered the latest Assurance Framework for the Trust and inparticular noted the risks included in the sustainable section.It was noted that SU1 did not have an end date as such and should be reviewed atregular intervals. SU2 is to be updated to reflect the potential impact of potentialBMA industrial action. It is anticipated that the risk score for SU3 would move to 5x3in the new financial year. The risk score for SU12 will reduce to 4x1 at the year end.The Committee approved the report.Capital PlanChanges to the plan around property sales have been updated to reflect progress todate. Some capital expenditure projects have been delayed to manage the resourceavailable. The Committee asked for a review of estates plans where relocation andother costs might exceed asset disposal proceeds. The Committee also asked ifconsideration could be made for the benefit of early sale of Melrose to mitigate anyother delay of sales.IM&T Strategy UpdateProgress on the 11/12 plan was reported with improvements to a number of areasincluding telephony services, remote access working and wireless connectivitynoted. There were 3 top priority objectives identified for 11/12 and the reduction ofservice providers was noted as North Devon is now almost fully transferred to theRD&E server. The other priorities around training and integration with social caresystems have moved to a lower status as demand for change / action has beenminimal.The IM&T Outline Delivery Plan for 12/13 was presented and the top 3 priorities for12/13 were noted as the introduction of an SLA between IM&T and the ClinicalDirectorates, which will allow user input to service developments, to expand on BestPractice audits to support staff in utilising the equipment provided, and to support theestate and office rationalisation programme.There were a number of other possible IM&T projects which still required fundingdecisions including; extension of Trust Wi-Fi support for video-conferencing,provision of tablet computers, smartphones and support for their infrastructure.These projects would fall below the FIC approval limit but the expectation was thatthey would be subject to the usual rigorous cost/benefit evaluation.The Committee endorsed the plan and the priorities identified.HDD Action PlanThere had been no changes to the HDD action plan that were recorded in the month.Finance & Investment Committee WorkplanThe FIC workplan was approved on the basis that some flexibility is available toreprioritise certain items, if required, over the coming months.Page 95 of 156

Board of Directors Meeting, 29 March 2012Agenda Item 111010.1Any Other BusinessSustainabilityBest practice around sustainability should be noted and the Committee was informedthat Monitor considers sustainability to be a core requirement for a FT.Ray O’ConnellChair of Finance and Investment CommitteeMarch 2012Page 96 of 156

12DEVON PARTNERSHIP NHS TRUSTBOARD OF DIRECTORS - SUMMARY REPORTDate of Meeting: 29 March 2012Name of Report:Authors:Approved by:Presented by:Performance ManagementDavid Godley, Senior Information Analyst - Performance InformationAnne Sawyer, Director of Compliance and Corporate DevelopmentAnne Sawyer, Director of Compliance and Corporate DevelopmentPurpose of the report:This report provides the Board of Directors with a position statement on the Performance andAssurance Frameworks.Key points:Performance ExceptionsThe position (as at 29 February 2012) and actions taken for key performance indicators (KPI) isreported in appendix 1. Exceptions of note are as follows:KPI-290 % of up to date PCA self-assessments. The position is 78% against a target of82%. Following the Head of Professions and Practice group report for this indicator, afocused piece of work is being undertaken by the Directorates to address performanceissues (please refer to the Quality, Compliance and Experience report for further details).The indicators trajectory has been adjusted to take into account this planned work. KPI-274 CQUIN 2011/12 composite score. The position at the end of February is 7measures met out of a total of 8 measures. Close monitoring of CQUIN performance duringMarch and corrective actions have been taken where necessary. Following this it isanticipated that the CQUIN targets will be met by the end of the quarter. The CQUINmeasure below target is ‘KPI-279 Improving follow-up on discharge from inpatient services’and for this indicator there is daily performance monitoring in place. There is alsoagreement with commissioners that any cases not followed up but found to be not in breachof the target, for example, where a client was transferred to another hospital, can beretrospectively discounted from the figures.KPI-284 Clustering Report. To address the slight dip in performance below 95%, teamlevel reports are to be sent out to CTLs requesting that they record missing clusterinformation to bring their individual teams performance up to 95% or above.Page 97 of 156

Monitor Performance Framework KPI-120 Monitor risk rating for governance. Following a CQC ‘National ThematicReview on Learning Disability Services’, the Trust has applied a manual override to itsgovernance risk score rating it as Amber-Red.Monitor has advised that the Compliance Framework for 2012/13 will be published on itswebsite by Friday 30 March 2012.Department of Health Performance FrameworkIn March 2012 the Department of Health is due to release details of any changes to theNHS Performance Framework for Mental Health. The Trust will assess performanceagainst this framework, ensuring that monitoring and action is taken via the TrustManagement Board.Assurance FrameworkThe Assurance Framework is reported in appendix 2, and sets out two key risks scoring 16 and of 60above. These are:Public spending environment and near level NHS spending required to meet continuingincreased demand Catastrophic clinical adverse event occurs (plan to reach residual level by JULY 2012).Action required, including Recommendations:Members of the Board are asked to receive the report and note its contents.Links with the Assurance Framework (Risks, Controls and Assurance):The performance management report links performance with the assurance framework and therisks associated with not meeting the Trust’s key objectives.Summary of Constitutional / Financial / Legal / PPI / Equality and Diversity Implications:No additional implications arise from this paper.Links to Strategic Aims:Safe X Recovery-focused XTimely X Sustainable XPersonalisedXThis report references:CQC RegulationsWhole registration systemPage 98 of 156

Board of Directors Performance ReportReport Updated: 22 March 2012Key Description Key DescriptionGreenImprovedAmber No ChangeAmber-RedDeterioratedRedNote: the Directorate breakdowns refer to the in month positionFollow up within 7 days of discharge - for clients on CPAKPI-010Adult (97%)OPMH Specialist SecureIn MonthFeb 2012QTDJan - Mar 2012StatusValue Target97% 95%StatusValueTarget98% 95%Current position against year end targetYear End Target 95%Persons on CPA having formal review within 12 monthsKPI-272Adult (94.9%) OPMH (90%) Specialist (96.1%) Secure (95.2%)In Month Status Value TargetFeb 2012QTD StatusJan - Mar 201294% 95%Value Target95%95%Current position against year end targetYear End Target95%100%90%80%70%60%100%90%80%70%60%Actual and forward forecast against target (in month)97%100% 100% 100% 100%97% 96% 96% 96% 96% 96% 96%Actual Forecast Absolute TargetActual and forward forecast against target (in month)84%89% 91%95% 95% 94% 95% 95% 95% 95% 95% 95%Actual Forecast Absolute Target100%90%80%70%60%100%90%80%70%60%Quarterly ViewComments94%Qtr1(Apr-Jun)99% 100% 98%Qtr2(Jul-Sep)Qtr3(Oct-Dec)Qtr4(Jan-Mar)Proactive action: Daily updates are emailed toCTLs and ward managers detailing all adultdischarges that are yet to be followed up.Actual TargetQuarterly View Comments84% 84%Qtr1(Apr-Jun)Qtr2(Jul-Sep)95% 95%Qtr3(Oct-Dec)Qtr4(Jan-Mar)The February 2012 OPMH position of 90% represents 18clients reviewed out of a total of 20 clients; the Adultposition is 94.9% which represents 1,303 clients reviewedout of a total of 1,373 clients. The overall Trust February2012 position is 94.8% which represents 1,408 clientsreviewed out of a total of 1,484 clients.Actual TargetPage 1 of 7Page 99 of 156

Board of Directors Performance ReportReport Updated: 22 March 2012Minimising Delayed Transfers of CareKPI-178 Actual and forward forecast against target (in month)Adult (2.07%) OPMH (4.64%) Specialist (0.00%) Secure (0.00%) 10.0%8.0%In Month StatusValue Target 6.0%Feb 2012 1.9%

Board of Directors Performance ReportReport Updated: 22 March 2012Completeness of Mental Health Minimum Data Set - IdentifiersKPI-269 Actual and forward forecast against target (in month)Adult (99.7%) OPMH (99.9%) Specialist (99.2) Secure (100%) 100.0%In MonthStatusValue TargetFeb 2012 99.7%99.0%QTD Status Value TargetJan - Mar 201299.7%99.0% 60.0%90.0%80.0% 99.5% 99.5% 99.5% 99.5% 99.5% 99.7% 99.5% 99.5% 99.5% 99.5% 99.5% 99.5%70.0%Current position against year end targetYear End Target99.0%Actual Forecast Absolute TargetCompleteness of Mental Health Minimum Data Set - Outcomes (Based only on RiO Data)KPI-282 Actual and forward forecast against target (in month)Adult (92%) OPMH (89%) Specialist (93%) Secure (86%) 100%90%80%In Month Status Value Target70%Feb 2012 92% 50%84%88% 91% 92% 92%60% 75%QTD Status Value Target 50%Jan - Mar 2012 91% 50%40%80% 80% 80% 80% 80% 80%Current position against year end targetYear End Target50%Actual Forecast Absolute TargetAccess to healthcare for people with a learning disabilityKPI-177 Actual and forward forecast against target (in month)Adult OPMH Specialist Secure 100%In Month Status Value TargetFeb 2012 100% 100%QTD Status Value TargetJan - Mar 2012100% 100%60%90%80% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100%70%Current position against year end targetYear End Target100%Actual Forecast Absolute Target100.0%90.0%80.0%70.0%60.0%100%90%80%70%60%50%40%100%90%80%70%60%Quarterly View Comments99.5% 99.5% 99.5% 99.7%Qtr1(Apr-Jun)Qtr2(Jul-Sep)Qtr3(Oct-Dec)Qtr4(Jan-Mar)Actual TargetQuarterly ViewComments90% 91%70% 73%Qtr1(Apr-Jun)Qtr2(Jul-Sep)Qtr3(Oct-Dec)Qtr4(Jan-Mar)Actual TargetQuarterly View Comments100% 100% 100% 100%Qtr1(Apr-Jun)Qtr2(Jul-Sep)Qtr3(Oct-Dec)Qtr4(Jan-Mar)The Adult Directorate have a focused piece ofwork in place at the moment to review theevidence to support the 100% compliancereported. This work, initially due to be completedin February and to report back in March, will nowbe completed in April 2012.Actual TargetPage 3 of 7Page 101 of 156

AmberGreenAmberGreenGreenGreenGreenGreenGreenAmberGreenAmberGreenBoard of Directors Performance ReportReport Updated: 22 March 2012Service compliant with registration standardsKPI-231 Actual and forward forecast against target (in month)Adult OPMH Specialist Secure 100%90%In MonthStatus ValueTarget80%Feb 2012 100% 100%QTD StatusValue Target70%Jan - Mar 2012 100%100%60%100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100%Current position against year end targetYear End Target100%Actual Forecast Absolute TargetMonitor risk rating for governanceKPI-120 Actual and forward forecast against target (in month)Adult OPMH SpecialistSecureGreenIn Month Status Value TargetFeb 2012 GREENQTD Status Value TargetJan - Mar 2012 GREENAmber-GreenAmber-RedRedCurrent position against year end targetYear End TargetGREENActual Forecast Absolute TargetMonitor Overall Weighted Rating for FinanceKPI-165 Actual and forward forecast against target (in month)Adult OPMH SpecialistSecure54In Month StatusValueTarget3Feb 20123 32QTDJan - Mar 2012Status ValueTarget3 34 4 4 4 43 3 3 3 3 3 310Current position against year end targetYear End Target3Actual Forecast Absolute Target100%90%80%70%60%GreenAmber-GreenAmber-RedRed543210Quarterly View Comments100% 100% 100% 100%Qtr1(Apr-Jun)Qtr2(Jul-Sep)Qtr3(Oct-Dec)Qtr4(Jan-Mar)Whilst this KPI demonstrates the Trust is overall100% compliant with the registration standards,please refer to the comments in 'KPI-120 Monitorrisk rating for governance', in relation to specificelements raised in a CQC National ThematicReview of Learning Disability Services.Actual TargetQuarterly View CommentsThe Trust has taken the decision to override thegovernance risk score to Amber-Red to take intoaccount the CQC’s recent review.Qtr1(Apr-Jun)Qtr2(Jul-Sep)Qtr3(Oct-Dec)Qtr4(Jan-Mar)Actual TargetQuarterly View Comments3 3 3 3Qtr1(Apr-Jun)Qtr2(Jul-Sep)Qtr3(Oct-Dec)Qtr4(Jan-Mar)Actual TargetPage 4 of 7Page 102 of 156

6,3936,5076,5396,1116,8496,9156,3937,1357,1607,1857,2107,2357,2607,2856,8497,135Board of Directors Performance ReportReport Updated: 22 March 2012Number of reported outbreaks healthcare associated infections: MRSA Bacteraemia & Clostridium DifficileKPI-281 Actual and forward forecast against target (in month)Adult OPMHSpecialist Secure4In Month Status Value TargetFeb 2012QTDStatusJan - Mar 20121 0Value1Target03210 0 0 0 0 1 0 0 0 0 0 00Current position against year end targetYear End Target0Number of membersKPI-129AdultOPMHSpecialistSecure7,000Actual and forward forecast against target (in month)In MonthFeb 2012QTDJan - Mar 2012Status Value Target7,135 3,380StatusValue7,135 Target3,3806,0005,0004,0003,000Current position against year end targetYear End Target3,380Actual Forward Projection Minimum per constitutionProbable Suicide CasesKPI-280AdultOPMH Specialist SecureActual and expected prevalence (in month)8In MonthValueFeb 2012 2QTDJan - Mar 2012664204333 3 3 3 3 3102Current position against year end expected prevalenceCurrent Cases25 Exptd Year End36Actual Expected Prevalence Target432107,0006,0005,0004,0003,0001086420Quarterly View Comments0 0 0 1Qtr1(Apr-Jun)Qtr2(Jul-Sep)Qtr3(Oct-Dec)Qtr4(Jan-Mar)There has been one new case, on Delderfieldward, of Clostridium Difficile in February. A rootcause analysis has been undertaken but thesource of the infection is unknown.Quarterly View CommentsQtr1(Apr-Jun)Qtr2(Jul-Sep)Qtr3(Oct-Dec)Qtr4(Jan-Mar)Actual TargetQuarterly View Comments6Qtr1(Apr-Jun)9Qtr2(Jul-Sep)4Qtr3(Oct-Dec)6Qtr4(Jan-Mar)These are probable suicides (suicide must be recorded bya coroner) of people who were either in contact withTrust services, were in contact with Trust services in the12 months prior to their death or who were referred toTrust's services but not seen prior to their death.Page 5 of 7Page 103 of 156

AmberAmberAmberAmberAmberAmberAmberGREENGREENGREENGREENGREENGREENGREENGREENGREENBoard of Directors Performance ReportReport Updated: 22 March 2012CQUIN 2011/12 composite scoreKPI-274 Actual and forward forecast against target (in month)Adult OPMHSpecialist Secure10In Month StatusFeb 2012QTDStatusValue Target7 8Value TargetJan - Mar 20127 80864 8 8 8 8 88 8 8 8 8 872Current position against year end targetActual Forecast TargetYear End Target8Position statement in relation to NICE guidanceKPI-271 Actual and forward forecast against target (in month)Adult OPMHSpecialist Secure GreenIn Month Status Value TargetAmberFeb 2012 GREEN GREENQTDStatus ValueTargetJan - Mar 2012GREEN GREEN RedCurrent position against year end targetYear End TargetGREENActual Forecast Target% of Up-to-date PCA Self-AssessmentsKPI-290 Actual and forward forecast against target (in month)Adult (85%) OPMH (100%) Specialist (69%) Secure (50%) 100%80%In MonthStatusValueTarget 60%Feb 201278%82%40%QTD Status ValueTarget 20%Jan - Mar 201278%82%0%68% 72% 77% 75% 77% 78%85% 88% 91% 94% 97% 100%Current position against year end targetYear End Target85%Actual Forecast Target02#REF! #REF! #REF!86420GreenAmberRed100%80%60%40%20%0%Quarterly View Comments8 8 8Qtr1(Apr-Jun)Qtr2(Jul-Sep)Qtr3(Oct-Dec)Actual Target7Qtr4(Jan-Mar)To meet the CQUIN target there has been closemonitoring of CQUIN performance during March andcorrective actions have been taken where necessary.Following this it is anticipated that the CQUIN targets willbe met by the end of the quarter. The CQUIN measurebelow target is KPI-279 Improving follow up on dischargefrom inpatient services and for this indicator there is dailyperformance monitoring in place. There is alsoagreement with commissioners that any cases notfollowed up but found to be not in breach of the target,for example, where a client was transferred to anotherhospital, can be retrospectively discounted from thefigures.Quarterly ViewCommentsQtr1(Apr-Jun)Qtr2(Jul-Sep)Qtr3(Oct-Dec)Qtr4(Jan-Mar)Actual TargetQuarterly View CommentsQtr1(Apr-Jun)68%Qtr2(Jul-Sep)75% 78%Qtr3(Oct-Dec)Actual TargetQtr4(Jan-Mar)A PCA assessment is up to date if the assessmenthas been updated within the last 6 months.Following the Head of Professions and Practicegroup report for this indicator, a focused bit ofwork is being undertaken by the Directorates toaddress performance issues (please refer to theQuality, Compliance and Experience report forfurther details). The indicators trajectory hasbeen adjusted to take into account this plannedwork.Page 6 of 7Page 104 of 156

Board of Directors Performance ReportReport Updated: 22 March 2012Waiting Time Performance - % Referrals Seen Within 28 DaysKPI-283Adult (64%) OPMH (69%) SpecialistSecure 100%Actual and forward forecast against target (in month) Quarterly View Comments100%In Month Status Value TargetDec 2011 66%QTDCurrent position against year end targetYear End TargetStatus Value TargetOct - Dec 2012 73%80%60%40%20%0%65%73%84%66%0%Actual Target Target Forecast90% 80%60%80%40%70%20%60%0%84% 64% 84% 66%Qtr1(Apr-Jun)Qtr1(Apr-Jun)Qtr2(Jul-Sep)Qtr2(Jul-Sep)95% 95%73%Qtr3(Oct-Dec)Qtr3(Oct-Dec)Actual Actual Target TargetQtr4(Jan-Mar)Qtr4(Jan-Mar)This indicator measures the number of externalreferrals from GPs seen by the Adult and OPMHdirectorates within 28 days. The figures for thisindicator will always be reported one-monthbehind other indicators. The Decemberperformance was affected by the Christmas andNew Year holiday period. As a comparison the %seen within 42 days was 78% for December. Dueto technical issues, with RiO, there is no figureavailable for January 2012.Clustering ReportKPI-284 Actual and forward forecast against target (in month) Quarterly ViewAdult (94%) OPMH (94%)In MonthFeb 2012QTDJan - Mar 2012Current position against year end targetYear End TargetStatusSpecialist (87%) SecureStatus Value Target93% 95%Value Target93% 95%100%100%90%80%70%60%65%88%98%95% 93% 95% 95% 95% 95% 95% 95%Actual Target Target Forecast100%90%80%60%80%40%70%20%60%84% 84%Qtr1(Apr-Jun)Qtr2(Jul-Sep)98%95% 95% 93%Qtr3(Oct-Dec)Actual Actual Target TargetQtr4(Jan-Mar)CommentsTo address the slight dip in performance below95%, team level reports are to be sent out to CTLsrequesting that they record missing clusterinformation to bring their individual teamsperformance up to 95% or aboveNumber of CQC Clinical Outcomes Rated Amber or Red in the Quality and Risk Profile (QRP)KPI-287 Actual and forward forecast against target (in month)CommentsAdult OPMH Specialist SecureIn Month Status ValueFeb 2012 0QTD Status ValueJan - Mar 2012 0Current position against year end targetTargetThere has been a significant improvement in theTrust's position for this indicator during thecurrent financial year. In May 2011 the Trust had3 Red, 3 Amber and only 1 Green rated outcome.In February 2012 there were 0 Red or Amber and9 Green rated outcomes.Year End TargetPage 7 of 7Page 105 of 156

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ASSURANCE FRAMEWORK AND CORPORATE RISK REGISTER - March 2012 - Board of Directors (16 & over)Board of Directors Meeting, 29 March 2012Agenda Item 12IDActivity/Objective/Risk Description Contributory issue Source of risk ExecSafe1. This will be definedaccording to circumstancesbut likely to be moresignificant than a single SUI& where all governancearrangements are calledinto question.HS(JR)KPIRefCQCOutcomesRiskTypePrevMonth'sRiskActionPlanprogressCurrentRiskResidualRiskCurrent AssuranceAction Plan(Evidence of effective actions) Committee (Evidence of action to address control/assurance gaps)1. Strengthened & recognised SUIprocesses.2. Historic evidence of managing theseincidents both internally & externally.1. Dedicated RCA investigators appointed. Some appointed, furtherappointments to take place. Target date: May 2011 (completed)13/9/11 - all RCA investigators appointed. One yet to start.2. Incident occurred - highlights potential issue relating to environmental& practice factors - immediate action plan in place monitored throughExec.3. Commissioned four part review (2 RCA, system review & model ofcare). Target date: 31 Jul 2011. Review completed & with SHA. (Allcompleted). Paper prepared for Directorates to consider whether theywant to maintain the Dedicated RCA investigator team (funding availabletill mid 12) or develop another investigatory process.S10Catastrophic clinical adverse 2. Improvement in practice 1. Team dashboards &event occurs.is limited as a result of lack composite risk scores.of delayed & sustained 2. Serious incidentimprovement in CTL reports.leadership.HS4 S/OHigh(5x4=20)High(5x4=20)Moderate 1. Quality/performance matrix in place(4x2=8) for teams not meeting requiredquality/practice standards.2. Composite risk scoring.(i)Q&S1. Exec approval for sustainable improvement academy - pilot to beundertaken. Target date: Dec 2012. 10/1/12 pilot work with teams hastaken place, paper to exec on 16/1/12. (completed)2. Consultant - support & coaching where necessary - ongoing.3. Rapid improvement work - ongoing.4. Prompt list to be developed to identify high risk people & teams fromMDT discussion. Target date: Sept 2011, revised target date: Dec2011, revised target date: Apr 2012.5. Draft risk guidance drafted by Co-Medical Director, awaiting commentsfrom Senior Management Teams within Directorates, then forimplementation. Target date: Feb 2012. Currently being piloted in somecommunity teams. Revised target date: Mar, Apr 2012 followingDirector review.6. Monthly performance meetings with Directorates.**Timescale to achieve residual risk level: to remain at higher risklevel until assurance rec'd thro Clinical Directorate reporting thatquality & safety issues have been addressed. (Apr 2012, revised toJul 2012)SU1SustainableEXTERNAL RISK1. Public spendingenvironment & near levelNHS spending required tomeet continuing increaseddemand.2. Public spending reductions& effect on local authoritysocial care budgets mayresult in Health Servicesincluding DPT having toabsorb some social carecosts.1. Spending on mentalhealth & learning disabilityservices is squeezed due toblock contractarrangements.2. Sub set risk (4x4=16)3. Commissioner overspendon IPPs in 2011/12.4. National CommissioningBoard assessment of MHservices being 10% aboveachievable cost.1. Trust wide riskassessment of externaleconomic environment.IFH 6, 26 S/FHigh(5x4=20)High(5x4=20)1. Active participation in NHS SW &NHS Devon QIPP programmes with lowexpectations of cost savings from MH &LD services which have now beenconfirmed with QIPP financial planningforecasts & corresponding impact onprovider income.2. Board receive regular reports &Significant additional informal discussion.(4x3=12) 3. Monthly review by FIC/BE.4. Current joint managementarrangements.(i)BE(ii)FICSU1 & SU5 combined as at Dec 20111. Main action is ongoing revision & review of financial plans as newinformation comes to light. No specific project is required & the situationis reviewed regularly at FIC.2. IPP Remediation Strategy being developed in conjunction withCommissioners. Target Date: Oct 2011 (completed)3. The Trust is monitoring closely any emerging potential impact.4. The Trust has produced a prudent LTFM.5. Further mitigated plans have been developed & will be approved byMar 2012.**Timescale to achieve residual risk level: Mar 2012Red indicates movement in original timescaleDefinitionsRisk Type S - Strategic, C - Corporate level operational risk due to material impact, O - Operational, F- Financial, IMT- Information Management & TechnologyPrev Month's Risk Risk status - February 2012 (consequence x likelihood)In Month Movement Change (reduction, improvement or no change) in risk status from February 2012 to March 2012Current Risk Risk status - March 2012 (consequence x likelihood)Residual Risk Risk status - once all actions have been implemented / remaining inherent riskResponsible Committee(s)Q&S Quality & Safety Committee BEFICFinance & Investment CommitteeBusiness ExecutiveRef: Combined Assurance Framework Corporate Risk Register Page 1 of 1Page 107 of 156

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13DEVON PARTNERSHIP NHS TRUSTBOARD OF DIRECTORS - SUMMARY REPORTDate of Meeting: 29 March 2012Name of Report:Author:Approved by:Presented by:Risk Management Strategy, Policy and RiskAssessment ProcessBarry Barber, Clinical Risk ManagerQuality & Safety CommitteeDr Helen Smith, Co-Medical DirectorPurpose of the report:This document describes the Trust’s Risk Management Strategy and the frameworkfor the establishment and implementation of a risk management process. Thepurpose of this strategy and policy is to provide a framework for the establishmentand implementation of a risk management process which will support and assist inthe achievement of the Trust’s strategic objectives and the fulfilment of the Trust’sgovernance agenda.Key points:This policy revision has:Given the description of the process of risk management as an appendix ratherthan incorporating in the main body of the policyEnsured that the work improving the Assurance Framework/Risk Register atteam, LDU, Directorate and Corporate level, including committee structures andrisk escalation matrix, is reflected in policyIncorporated the role of the Operational Risk Committee as an important conduitfor risk management information and check in relation to assurance in relation torisk management.Action required, including Recommendations:The Board of Directors is requested to review and approve the policy.Links with the Assurance Framework (Risks, Controls and Assurance):Supports S6 on the Assurance Framework – Clinical Governance Structures andAssurance.Page 109 of 156

Summary of Constitutional / Financial/ Legal / PPI / Equality and DiversityImplications:Links to Strategic Aims:Safe X Recovery-focused XTimely X Sustainable XPersonalisedXThis report references:CQCRegulationsNHSLA Risk Management StandardsPage 110 of 156

Board of Directors Meeting, 29 March 2012Agenda Item 13Risk Management Strategy,Policy & Risk Assessment ProcessPolicy: R03Policy DescriptorThis document describes the Trust’s Risk Management Strategy and theframework for the establishment and implementation of a risk managementprocess.Do you need this document in a different format?Contact PALS – 0800 0730741 or email dpn-tr.pals@nhs.netDocument ControlPolicy Ref No & Title:Version: v3.0R03 - Risk Management Strategy,Policy & Risk Assessment ProcessReplaces / dated: Previous policy dated October 2010Author(s) Names / Job Titleresponsible / email:Ratifying committee:Director / Sponsor:Primary Readers:Additional ReadersDate ratified:Date issued:Date for review:Date archived:NHSLA standards reflected:Barry Barber, Clinical Risk Managerbarrybarber@nhs.netBoard of DirectorsCo – Medical Director (Clinical Governance)This policy is under review and feedback can be submitted1.1 - Risk Management Strategy1.3 - High Level Risk Committee(s)1.4 - Risk management process1.5 – Risk Register3.6 – Risk Awareness Training for Senior ManagementPage 111 of 156

ContentsBoard of Directors Meeting, 29 March 2012Agenda Item 131. Introduction ............................................................................................................................. 42. Purpose ................................................................................................................................... 43. Duties within the organisation ................................................................................................. 44. Definitions ............................................................................................................................... 65. Risk Management Structure .................................................................................................... 76. Sources of Risk ....................................................................................................................... 77. Communication ....................................................................................................................... 88. Training ................................................................................................................................... 99. Assurance Frameworks and Risk Registers ......................................................................... 1010. Risk Scoring .......................................................................................................................... 1011. Risk Escalation ...................................................................................................................... 1012. Review of the Assurance Frameworks and Risk Registers .................................................. 1113. Organisational Learning from Investigations/Analysis .......................................................... 1114. Monitor and Review: ............................................................................................................. 1215. References ............................................................................................................................ 13Appendix A - The Risk Assessment Process .................................................................................. 14Appendix B - Risk Assessment Form ............................................................................................. 19Appendix C - Governance Reporting Structure .............................................................................. 26Appendix D - Risk Escalation Matrix ............................................................................................... 29Page 112 of 156

Board of Directors Meeting, 29 March 2012Agenda Item 13Risk Management StrategyThe Trust is committed to the management of risk, both clinical and non-clinical,throughout the organisation in order to:Ensure that the safety of people in receipt of services is promoted whilst maintaining arecovery focussed approach.Ensure that risk to the quality and delivery of services are minimised.Protect the services, reputation and finances of the Trust.Create a culture where staff acknowledge risk as the responsibility of everyone, andwhich also supports the provision of realistic resources, training and information.Ensure the Trust meets its statutory obligations.In order to achieve this, the Trust has the following objectives:To understand the risks the Trust faces, their causes and how they may be controlled.To identify, control, eliminate or reduce to an acceptable level all risks which mayadversely affect the quality of care or the health, safety and welfare of those in receiptof services, their supporters, staff and members of the public, and the ability of the Trustto provide a quality service.To develop and maintain a positive image and public confidence by building a safeorganisation.To work together with partnership organisations and agencies to ensure a cohesive andcoherent approach to the management of risks.Responsibility for implementation of the strategy will be through the:Chief Executive who has overall accountability for risk management.Executive Directors with delegated responsibility for co-ordinating and implementingrisk management throughout the organisation.Quality & Safety Committee which has the responsibility to consider, monitor andreview the significant risks identified within the combined Trust Assurance Framework &Risk Register for quality and safety related risks, providing quarterly reports andassurance to the Audit Committee.Development and ratification of associated policies, procedures and guidelines to assiststaff and others in the control and supervision of risks.Use of training, learning and development in order to integrate risk management intoeveryday Trust activities.Chief Executive:Chair:Page 113 of 156

1. IntroductionBoard of Directors Meeting, 29 March 2012Agenda Item 131.1. This strategy applies to all Health and Social Care staff working in the Devon PartnershipNHS Trust including assigned staff.1.2. The Trust is committed to the proactive management of all risk and recognises that this isessential to the efficient and effective delivery of its service aims and objectives andorganisational culture. Risk management is integral to the Trust’s philosophy, practicesand business plans and not considered as a separate entity.1.3. The implementation of the Risk Strategy, Policy and Process is part of an ongoingapproach within the Trust to achieve integrated governance. This strategy will include allaspects of risk: clinical, organisational and financial, and will ensure the provision of a safeenvironment for those in receipt of services, their supporters and members of the public.2. Purpose2.1. The purpose of this strategy and policy is to provide a framework for the establishment andimplementation of a risk management process which will support and assist in theachievement of the Trust’s strategic objectives and the fulfilment of the Trust’s governanceagenda.3. Duties within the organisation3.1. Managing risk is the responsibility of all staff. It is a key part of the work and roles ofmanagers and clinicians within the Trust. Each unit/department/team in the Trust hasresponsibility for identifying, assessing, controlling and managing risk within theirdepartment and for communicating risk management policies and procedures to their staff.3.2. Any risk identified that cannot be effectively managed locally, or which may have Trust-wideimplications, should be reported to the relevant committee/group and the responsibleClinical Director, Managing Partner or Head of Profession. This will ensure that problemsand solutions are addressed at an appropriate level.3.3. To ensure that the highest standards of care are maintained by all professionals involved inthe delivery of services, clinical performance will be assessed and monitored throughclinical and managerial supervision.3.4. Chief Executive3.4.1. Has overall accountability to the Board for the effective implementation of the RiskManagement Strategy, Policy and Risk Assessment Process. The responsibility forclinical risk is delegated to the Co - Medical Director, the responsibility for financialrisk is delegated to the Director of Finance, the responsibility of the Trust AssuranceFramework and Risk Register is delegated to the Director of Compliance andCorporate Development and the responsibility for Health & Safety risk is delegated tothe Director Workforce and Organisational Development.3.5. Chief Executive and the Board of Directors3.5.1. Commitment to risk management through endorsement of the Risk Strategy, Policyand Risk Assessment Process and arrangements for the organisational structure forsuccessful risk management.3.5.2. Ensuring that responsibilities for the management and co-ordination of risks areclear and unequivocal.Page 114 of 156

Board of Directors Meeting, 29 March 2012Agenda Item 133.5.3. Ensuring that the functions of the Quality & Safety Committee interface effectivelywith the work of the Audit Committee.3.5.4. Ratification of the Trust’s principle risk management policies and procedures.3.5.5. Ensuring the combined Trust Assurance Framework and Risk Register is updatedand monitored monthly to enable the accurate prioritisation of risks.3.5.6. Identification and allocation of resources required to mitigate identified risks.3.5.7. Provision of continuing support to the Quality & Safety Committee and its subgroups.3.6. Executive Directors and Clinical Directors3.6.1. Formal acknowledgement of responsibility and accountability for the activeimplementation of the Risk Management Strategy, Policy and Risk AssessmentProcess.3.6.2. Ensuring that appropriate directorate specific risk management, procedures andsystems are actively in place.3.6.3. Ensuring that adverse incidents, complaints and claims are reported appropriately,reviewed at a local level and escalated as necessary.3.6.4. Ensuring that a systematic approach is employed to the analysis of incident,complaints and claims as defined within this policy.3.6.5. Ensuring all investigations are progressed and completed to a high standard in aneffectively and timely manner.3.6.6. Ensuring that all recommended changes to practice identified throughinvestigations/analysis are implemented across the directorates/organisation.3.6.7. Raising risk awareness amongst staff at an operational level through developingstaff capability and mindfulness in relation to risk assessment and management anddisseminating the learning arising from the review of incidents to minimise thelikelihood of recurrence.3.6.8. Seeking advice and support on risk management issues from appropriate specialistpersonnel.3.7. Managing Partners/Team Managers:3.7.1. Are responsible for compliance with the Risk Management Strategy, Policy and RiskAssessment Process3.7.2. Ensuring that risk assessments are undertaken throughout their area ofresponsibility on a pro-active basis.3.7.3. Maintaining their directorate, local delivery unit and team assurance frameworks/riskregisters and monitor action plans.3.7.4. Maintaining and promoting general risk awareness at all times.Page 115 of 156

Board of Directors Meeting, 29 March 2012Agenda Item 133.7.5. Notifying line managers of any identified risks or hazards and where appropriatetaking remedial action.3.7.6. Encouraging staff awareness and compliance with Trust policies and procedures.3.7.7. Ensuring that adverse incidents, complaints and claims are reported appropriatelyand reviewed at a local level and,3.7.8. Ensuring that a systematic approach is employed to the analysis of incidents,complaints and claims as defined within this policy.3.7.9. Ensuring that all investigations are dealt with effectively and appropriately.3.7.10. Ensuring that changes to practice as a result of investigations/analysis areimplemented across the directorates/organisation.3.7.11. Ensuring participation in risk management education and training.3.8. Staff:3.8.1. All staff are responsible for compliance with the Risk Management Strategy, Policyand Risk Assessment Process.3.8.2. All staff, whether permanent or temporary or volunteer are responsible foridentifying risks to both individuals and to the Trust as a whole, this includes anybreaches of Trust policy or procedures.3.8.3. All staff have a duty to take action to improve services and minimise risk.3.8.4. Any identified risk should be reported immediately to their line manager or theperson in charge of the shift.3.8.5. An adverse event or near miss/hit must be reported in line with Trust policy onIncident Reporting3.8.6. Every employee has a duty to become familiar with the Trust’s policies andprocedures appropriate to their area of work.3.8.7. Every employee has a duty of care to themselves and those around them, those inreceipt of services and their supporters, colleagues and the general public.4. Definitions4.1. Organisational risk can be defined as any activity, which could have a detrimental effecton the day-to-day performance of the Trust and the services it provides. These includerisks relating to the recruitment and selection of staff; training and education; finance andinformation systems; confidentiality and communication.4.2. Financial Risk can be defined as any financial restraints or irregularities, which may affectthe Trust’s ability to resource the services it provides.4.3. Clinical Risk can be defined as any clinical activity, which could have a direct effect oncare delivery. These may include the lack of availability of services or staff, thecompetency and supervision of staff and adherence to the Trust’s clinical and operationalpolicies.Page 116 of 156

Board of Directors Meeting, 29 March 2012Agenda Item 134.4. Health & Safety Risk may include, fire safety, security, buildings, plant and machinery,unsafe systems of work, failure to comply with Health & Safety legislation.4.5. Other risks may relate to Information Governance/Technology; Human Resources.5. Risk Management Structure5.1. The corporate responsibility for achieving the objectives of the risk management agendarests with the Board of Directors and its delegated committees/groups.5.2. The holistic approach to risk management by the Trust will include communication betweenrelevant committees, external agencies and those within the Shared Service arena.5.3. To ensure the effective co-ordination of risk management throughout the Trust, agovernance reporting structure has been developed (Appendix C). This will provide thenecessary support for the line management structure to reduce and control risks.5.4. The functions of the committees shown in the governance reporting structure are describedin more detail within their Terms of Reference, as are the committees/work streams.5.5. The various committees and groups within the Governance Structure include:Board of DirectorsTrust Management BoardAudit CommitteeFinance & Investment CommitteeRemuneration & Terms of Service CommitteeQuality & Safety CommitteeSafety and Risk CommitteeOperational Risk CommitteeClinical Effectiveness GroupSafeguarding CommitteeTrust Risk Incident Review GroupMedicine Management Governance GroupDirectorate Governance MeetingsLocal Delivery Unit Governance MeetingsTeam Meetings6. Sources of Risk6.1. The term ‘risk’ represents the possibility of incurring injury, damage, misfortune or loss. Itcovers both the physical environment and the process of delivery of care and services, forexample:Page 117 of 156

Board of Directors Meeting, 29 March 2012Agenda Item 13Accident: An unplanned and uncontrolled event that could lead to injury, ill health, ordamage to property or equipment.Incident: Any event or circumstance that could lead to harm, loss or damage. Theymay be clinical or non-clinical e.g. suspected suicide, drug error, missing person,violence, fire, theft.Complaint: An expression of dissatisfaction by a person in receipt of services, theirsupporters or member of the public.Hazard: Something with the potential to cause injury, ill health or damage and mayinclude substances, buildings, equipment, or work practice.Near Miss/Hit: Is an incident that did not lead to injury, harm or damage but had thepotential to do so, and where lessons can be learned from changes in procedures,processes and systems.6.2. The source or risk captures where the risk was identified; this may be internally orexternally. Examples of where a risk could be identified is as follows:In response to a incident, claim or complaintArising from an external assessment or reportRisk assessment arising from triangulated dataTrust wide risk assessmentMedicines management reviewArising from committee review and action required6.3. Some of the areas of potential risk within the Trust include the following: Buildings and Maintenance Business and Financial Risks Security Fraud Clinical Practice Infection Control Emergency Planning Health & Safety Information Governance Fire Safety Hazardous Substances Waste Management Lone Working Stress Moving, Lifting & Handling Violence & Aggression Information and Management Technology (IM & T)7. Communication7.1. Communication and reporting is essential so that informed decisions can be maderegarding risk. Utilising an effective communication system will:Develop a clear understanding of the organisation’s strategy to address riskmanagement;Clarify each party’s responsibilities and risks;Clarify the nature and complexity of the organisation’s specific risks;Minimise disruption, cost and time in negotiating an agreed risk allocation;Facilitate receipt of more information;Develop an understanding of the need for and scope of integration;Generate confidence in the risk management process.7.2. A critical issue with communication is to ensure that all stakeholders have access torelevant information, both internally and externally. Effective communication with allPage 118 of 156

Board of Directors Meeting, 29 March 2012Agenda Item 13stakeholders will ensure that there is a clear understanding of risk identification andreporting, development of action plans to address the risk and a mutual agreementpertaining to risk treatment is reached.7.3. The Trust is committed to providing clear communication and support:With its staffWith those in receipt of services and their supporters.With external agencies, authorities and other stakeholders both within and outside theNHSWith the general public7.4. During the review of serious incidents, communication issues are often one of thecontributory factors associated with the event. It is therefore imperative that we encouragegood communication between those in receipt of services, and their supporters, staff andexternal agencies to minimise the effect on those involved and provide adequate support.8. Training8.1. The provision of information, education and training is an important means of achievingcompetence and helps to ensure safe working practices. This contributes to theorganisation’s risk management culture and is required at all levels, including the ExecutiveTeam and Board of Directors.8.2. Ongoing risk assessment will help determine the level of information, instruction andtraining that will be required.8.3. The Trust will ensure that members of staff are informed in the process of riskmanagement. Staff should be adequately trained in the principles of risk management,clinical governance, health & safety, incident and near miss reporting, through induction,ongoing training and supervision, in order to promote the highest standards of riskmanagement and clinical care.8.4. The Workforce Planning and Development service supports the maintenance of thecompetences required by staff in various roles throughout the Trust to ensure that thepolicy can be implemented safely and effectively to enable high quality delivery of services.The training needs analysis details training to be undertaken by staff at all levels in theorganisation.8.5. The risk management training needs analysis will be updated/further developed, informedfrom the directorates and coordinated by the Workforce Planning and DevelopmentDepartment, to identify the training needs of all Trust staff. Training programmes aredeveloped/commissioned to ensure that identified training needs are met. The WorkforceDevelopment Steering Group will consider and monitor training needs provision andcompletion.8.6. The Trust has a responsibility to ensure that staff are released from their workplace toattend training sessions; any staff who are unable to attend their mandatory training due tophysical or other restraints must be notified to the training department.8.7. The Trust has a responsibility to ensure that adequate resources are available to implementthe organisation’s training programme for all staff.8.8. The Trust will ensure that all necessary staff (qualified, unqualified, other clinical staff, bankand agency staff) are appropriately trained in line with the organisation’s training needsanalysis.Page 119 of 156

Board of Directors Meeting, 29 March 2012Agenda Item 139. Assurance Frameworks and Risk Registers9.1. The Trust will hold a corporate combined Assurance Framework and Risk Register. Thisdocument will identify risks to the Trust’s strategic objectives (Safe, Timely, Sustainable,Recovery Focussed and Personalised) and provide assurance of mitigating actions andtimescales for each risk identified.9.2. The combined Trust Assurance Framework and Corporate Risk Register will beadministered by the Assistant Director of Corporate Development and Governance9.3. Each Directorate will hold a combined Assurance Framework and Risk Register and is theresponsibility of the Managing Partner/Clinical Director/Head of Profession and Practice.9.4. Local delivery units and teams will hold a risk register (Appendix B) which is theresponsibility of the local delivery unit manager or team manager.9.5. The main processes involved in the risk assessment process are: (refer to Appendix A formore detail):Establish the Context;Identify the Risks;Analyse the Risks;Evaluate the Risks;Treat the Risks- Develop Treatment or Mitigation Strategies;Monitor the Risks- Review Risk Treatment/Mitigation;Communicate and Consult (with internal and external stakeholders as appropriate).9.6. Assurance Frameworks and Risk Registers are reviewed at the appropriate governancemeeting to discuss addition or removal of risk; also to establish mitigating action plans andtimescales to reach residual risk level.9.7. A record is to be kept of removed risks for audit purposes.9.8. In addition to the risk registers held at team, local delivery unit, directorate and corporatelevels, specific registers are maintained by certain central functions including; MedicinesManagement, Estates, Information Management and Technology. These risk registersinform the other risk registers held through both the committees to whom they report andthe Operational Risk Committee.10. Risk Scoring10.1. The level of risk is assessed in accordance with the Risk Scoring Matrix (Appendix B). Thismatrix identifies both the consequence and likelihood of the risk; the aim of risk scoring is tosystematically establish relative priorities.11. Risk Escalation11.1. Risks will be monitored and escalated in the following way:Team risk registers: risks of 9 and above to be reviewed at the Local Delivery UnitGovernance meeting and escalated to Local Delivery Unit risk register as necessaryLocal Delivery Unit register: risks of 12 and above to be reviewed at the DirectorateGovernance meeting and escalated to Directorate Assurance Framework as necessary.Page 120 of 156

Board of Directors Meeting, 29 March 2012Agenda Item 13Directorate Assurance Framework: risks of 16 and above to be reviewed at the TrustManagement Board and escalated to Trust Assurance Framework as necessary. The Risk Escalation Matrix is given as Appendix D.12. Review of the Assurance Frameworks and Risk Registers12.1. Each Assurance Framework will identify the committee(s) responsible for reviewing,monitoring and escalating individual risks.12.2. Frequency of review of risks on the Assurance Frameworks and Risk Registers is asfollows:12.2.1. Trust (Corporate):All risks of 16+ are reviewed by the Board of Directors monthly.All risks are reviewed twice a year by the Board of Directors.All risks to quality and safety are to be reviewed by the Quality and Safety Committeeon a monthly basis.12.2.2. Directorate:All risks are presented to the Operational Risk Committee on two monthly basis.All risks are reviewed four times a year by each directorate.All risk scores of 12+ are to be reviewed at every directorate governance meeting.12.2.3. Local Delivery UnitAll risks are reviewed four times a year by each local delivery unit.All risk scores of 12+ are to be reviewed at every local delivery unit governancemeeting.12.2.4. Team All risks are reviewed four times a year by each local team. All risk scores of 12+ are to be reviewed at every team meeting.13. Organisational Learning from Investigations/Analysis13.1. Learning from experience is critical to the delivery of safe and effective services. It isrecognised that ‘human factors’ play a significant part in incidents, near misses, complaintsand claims and that such factors cannot ever be entirely eliminated.13.2. The systems and processes which operate must be designed to minimise the risk of humanerror at every stage and therefore each event must be looked upon as a learningopportunity. The Trust is committed to ensuring that lessons learned are embedded into theorganisation’s culture and practice. To achieve this, the following activities are undertaken:The Risk Management Team distributes alerts from the following agencies toappropriate managers for cascading to relevant staffNational Patient Safety AgencyMedical Device AlertsNHS EstatesClinical alerts e.g. contaminated illicit drugsCentral Alert System (CAS)Page 121 of 156

Board of Directors Meeting, 29 March 2012Agenda Item 1313.3. Managers are responsible for highlighting lessons learned at a local level with staff inteam/service / local governance meetings13.4. All serious incidents reported include a requirement to complete an initial managementreview; this includes recommendations, lessons learned and actions taken/planned bothlocally and corporately.13.5. All Serious Incidents Requiring Investigation are considered by Root Cause Analysisinvestigations. The reports of these investigations are considered by the Trust Risk IncidentReview Group.13.6. All lessons learned identified as a result of serious incidents are considered on a fortnightlybasis by members of the Trust Risk Incident Review Group and fed back to clinicians andmanagers for action as appropriate. Monitoring of these actions is the responsibility of theTrust Risk Incident Review Group. Monthly safety briefings are also developed anddistributed to all managers to feedback learning from incidents.13.7. During the complaints investigation process, feedback forms are completed by theinvestigating officer which identify learning points at both local and corporate level. Theselearning points are reported in the quarterly Patient Experience Team’s report to the Qualityand Safety Committee.13.8. Any risks which cannot be rectified immediately are assessed and considered for inclusionon either a local risk register or the corporate risk register and associated action plans aredeveloped.13.9. Where indicated, relevant policies, procedures and guidance will be amended to reflectchanges in practice as a result of lessons learned from investigations/analysis.14. Monitor and Review:14.1. It can take time to plan and implement change. A robust monitoring and review system isessential to ensure actions are followed through, that priorities are re-assessed, so that riskmanagement is an ongoing process that is embedded into normal management systems. Itis crucial that when undertaking these assessments and reviews that details of when thesewere carried out and by whom are documented.14.2. Continuous monitoring and review of risks ensures that new risks are detected andmanaged, action plans are implemented and managers and stakeholders are keptinformed. The availability of regular information on risks can assist in identifying trends,likely trouble spots or other changes that have arisen.Monitoring Item Action Required/Frequency ResponsibilityAll incident reports includingSerious Incidents, complaints,claims, PALSInitial Management Review ofSerious IncidentsTrust Risk Incident ReviewGroup meeting notescirculated fortnightly to Headsof Practice for informationand action at Directorate levelSerious Incidents andSerious Incidents RequiringInvestigation; investigationsand action plans arising fromTrust Risk IncidentReview Group, RiskManagement Team andPatient Experience TeamPage 122 of 156

Assurance Framework andCorporate Risk RegisterBoard of Directors Meeting, 29 March 2012Agenda Item 13the reports of investigationsMonthly reporting to theSafety and Risk CommitteeMonthly and quarterly reportsto DirectoratesComplaints/PALS reportedquarterly to Quality andSafety CommitteeRegular update and review withrelevant leads – updated monthlyAssociate Director ofCorporate Developmentand Governance andExecutive LeadsRisk AssessmentsCQCUpdate, review and monitorMonitor compliance with coreoutcomes. Monthly reporting withinperformance scorecard and formalsix month position to the Board ofDirectorsLocal ManagersHealth & Safety ManagerExecutive and lead roles,Compliance OfficerBoard of DirectorsNHSLA Risk Standards Monitor compliance with standards Risk Management TeamAudit & Research15. ReferencesConsider recommendations, identifyimprovements and action requiredClinical EffectivenessGroupAudit CommitteeQuality & SafetyCommitteeOrganisation with a Memory – Department of Health. June 2002Building a Safer NHS for Patients – Department of Health. April 2001Risk Management Standards for Mental Health & Learning Disabilities – NHSLA. January 2012Page 123 of 156

Board of Directors Meeting, 29 March 2012Agenda Item 13Appendix A - The Risk Assessment ProcessEffective risk management processes are applied both strategically and operationally at all levels.The risk management process model is based upon the following key concepts/steps: -Establish the Context;Identify the Risks;Analyse the Risks;Evaluate the Risks;Treat the Risks- Develop Treatment or Mitigation Strategies;Monitor the Risks- Review Risk Treatment/Mitigation;Establish the Context:Establishing the specific risk management issues pertaining to the Trust can provide anunderstanding of the environment in which the risk of harm might take place.Identify the Risks:There are many methods of risk identification within an organisation. The following is a list of riskidentifiers:Health & Safety Inspections:Any risks identified from health and safety inspections should be documented andreported to the Health & Safety Committee for consideration.Audit – Clinical (including walkaround audits), Financial and Internal Audit:The co-ordination of clinical audit is the responsibility of the Co Medical Directors’portfolio; any risks identified by this method will be documented and risk assessed.Financial audit responsibility will rest with the Director of Finance who will bring internalaudit reports and any counter fraud investigation reports to the attention of the AuditCommittee.Legislation/Policy:All staff have a duty to understand their responsibilities under current legislation. TheTrust would be at risk of complaint or litigation where any legislation had beenbreached.Reports from Assessments/Inspections by External Bodies:All members of staff have a duty to highlight risks identified within external body reports.Surveys and Questionnaires:A summary of the feedback from patient, staff and external stakeholder surveys shouldbe reported on annual basis to the Board in order to identify common trends or riskissues. The responsibility for this lies with the Director of Nursing and Practice.Issues arising from routine Patient and Public Involvement activities:The Trust leads or participates in a range of activities to learn from patients and theircarers, including specific focus group work, e.g.Network Action GroupsLearning Disability County Carers ForumLocal Involvement Networks (LINks)The responsibility for identifying issues arising from this work and reporting these to theDirector of Nursing and Practice is the Patient Experience Lead.Page 124 of 156

Board of Directors Meeting, 29 March 2012Agenda Item 13Incident, Complaints, Claims and PALS Reporting:The risk management department provides copies of individual incident forms torelevant specialist managers e.g. in respect of medication errors, violence & aggressiontowards staff, safeguarding incidents etc.Summaries of the data relating to incidents, complaints, claims and PALS (PatientAdvice & Liaison Service) are reported regularly to the Quality & Safety and Safety andRisk Committees.Provider Compliance Assessments:Managers will identify any risks in their review of these assessments.Training:Managers will monitor any risks in meeting compulsory training requirements set by theTrust.National Reports:The Trust will consider all national reports and policies for action.Media:All staff have a duty to alert the communications team of any events that could generatemedia interest for the Trust.Central Alert System (CAS):Hazard/safety notices are received by the designated Central Alert System (CAS) andcascaded to teams for action by the Risk Management Team.Information RiskInformation risk is inherent in all administrative and business activities. Informationrisks are managed in accordance with the Information Risk Procedure (GV00) producedby the Information Governance Dept which can be found on the Trust intranet.Freedom Of Speech (Whistleblowing):Risk issues identified form whistleblowing should be communicated in a confidentialmanner and dealt with according to the Freedom of Information (Whistleblowing) Policy(Ref HR No.21).Grapevine and Intuition:Some pertinent risk management issues can be picked up through ad hoc comments,hearsay or intuition. All staff have a responsibility to discuss issues of concern witheither their line manager or a senior manager.Trade Unions:All union representatives are required to feedback risks, which have been identifiedboth locally and/or nationally to the risk management team or through the LocalPartnership Forum (LPF) or the Health and Safety Committee.Exit Interviews with Staff:Exit interviews could include issues pertaining to training, line managementsupervision/support, working practices, etc which could put the patients, staff and/or theorganisation at risk.Page 125 of 156

Board of Directors Meeting, 29 March 2012Agenda Item 13Backlog Maintenance:The responsibility to highlight areas of risk from backlog maintenance lies with theEstates Manager and the Executive team.Coroners Inquests:Any recommendations received will be considered and implemented; those that cannotbe implemented immediately will be progressed via an action plan. The responsibilityfor these documents lies with the Clinical Risk Manager.NPSA, NICE and Other Professional Body Guidelines:The Trust will monitor all professional body or Special Health Authorityrecommendations or guidelines. Any risks identified will be risk assessed and actioned.Observation:Any members of staff within the organisation may observe or become aware of potentialrisks or hazard and as such have a responsibility to highlight their concerns for furtherinvestigation.All risks, hazards or concerns identified via any of these risk identifier methods must bedocumented and assessed as per the guidelines in order for them to be considered for inclusion tothe local, directorate or corporate risk register, as necessary.Analysing the RiskA standardised approach to risk assessment is being used within Trust. This risk assessmentdocumentation has been agreed between the Devon Council and Devon PCT in order to ensureconsistency in approach across the service areas. (Appendix B).A risk assessment is a careful examination of what could cause harm or damage to people,buildings, equipment, the environment, and organisation etc. to enable a review of whether thereare sufficient precautions in place to prevent or minimise any harm or damage.Any risks identified during this process will be added to the appropriate Assurance Framework &Risk Register and escalated in line with Appendix D where necessary.Line Managers must ensure that for their area of responsibility, risk assessments are carried outand risks that are not adequately mitigated reflected within the Assurance Framework & RiskRegister, and that the necessary control measures are implemented in order to reduce the risks.The level of detail in the risk assessments and any subsequent action taken should be proportionalto the risk.Evaluating the RiskThe Trust has a legal (and ethical) responsibility to identify and categorise risks and eithereliminate them or reduce them to the ‘lowest level that is reasonably practicable’.What is reasonably practicable also takes into account the costs involved in eliminating them orreducing the risks through control mechanisms.Risk evaluation therefore is to be undertaken at two stages;(a) proactively, to assist in the allocation of appropriate resources, and(b) reactively, following an adverse event; to critically re-examine and consider what actionor measures need to be taken and at what level.Page 126 of 156

Board of Directors Meeting, 29 March 2012Agenda Item 13The process of evaluation requires the assessment of all risks, prioritising them and identifyingmedium to high risks, which require immediate treatment. Risk evaluation is about decidingwhether particular risks are acceptable or not, taking into account:The controls already in place;The consequences of managing risk or leaving them untreated;Benefits and opportunities presented by the risks;The risks borne by other stakeholders.Risk Treatment:The purpose of risk treatment is to determine what will be done and who will be responsible for therisks that have been identified. Risk treatment converts the risk assessment into an action plan;this information is then recorded in the operational and Trust Assurance Framework & RiskRegister.The Trust accepts that it will not be possible to eliminate or minimise all risks identifiedimmediately. Some may require further information or research; others may require financialplanning or have a lead time to undertake the work.By omitting to consider the context of the risk and not performing appropriate analysis andevaluation, those undertaking the risk assessment may implement inadequate ‘quick fixes’. It istherefore important to consider underlying systems when undertaking these assessments. Insome cases, it may be necessary to implement short term solutions, but in considering all theinformation, the risk assessment process can help to inform longer term planning processes.Risk treatment options are evaluated in terms of feasibility, costs and benefits with the aim ofchoosing the most appropriate and practical way of reducing risk to a tolerable level. Risk ActionPlans will manage different risks in different ways. They may seek to;Avoid, such as deciding not to proceed with the activity to reduce the likelihood ofoccurrence;Reduce, such as making a trade off between the level of risk and the cost of riskreductions to minimise the consequences;Transfer, such as sharing the risk with another party e.g. insurers;Accept, such as following risk reduction methods the risk must still be accepted by theorganisation.Monitor the Risk Acceptable Risk:Individual risks which have been assessed, and fall into the low risk and very low riskcategories can be deemed to be acceptable by service/team managers. However, wheretrends/recurrences are identified further assessment may be required. A series of risks orthemes, which sit within the very low, low or moderate categories must be reassessed andregraded.Higher graded risks will be escalated as described in the Risk Escalation Matrix (Appendix D). Assurance Frameworks and Risk RegistersThe risk assessment process will inform the Trust’s local, directorate and corporate AssuranceFramework & Risk Registers. Where risks cannot be readily mitigated they will be added to thisdocument. The compilation and maintenance of up to date and comprehensive AssuranceFramework & Risk Registers is one of the key elements of the Trust’s risk managementstrategy.Page 127 of 156

Board of Directors Meeting, 29 March 2012Agenda Item 13An action plan to reduce the risk to the lowest practicable level, or to a level determined asacceptable is included on the Assurance Framework & Risk Register. All identified risks will bemonitored and reviewed on a continuous basis by the relevant committees.The aims of the Assurance Framework & Risk Registers are;Identification of all potential risks and hazards that the Trust may be exposed toIdentify risks as Inherent (fixed cannot be removed) or Controllable (variable can bereduced)To evaluate the level of existing internal control in place to address the risk;To provide the means to deal with the riskTolerate (Accept and live with it and monitor)Eliminate or MinimiseTransfer (e.g. via Insurance cover)Treat (do something about it)A ‘living’ document to record and report risks and the risk management process.The outcome is a list of risks with agreed priority ratings from which decisions can be made aboutacceptable levels of tolerance for particular risks and where greatest effort should be focused. Thisprocess considers whether the risk level is such that action needs to be undertaken to treat therisk. Many factors will be considered in the process. These will include alternative options to avoidthe risk, practicality of treating the risk adequately to significantly minimise the risk.Where a risk is accepted, it should be monitored via reports of incidents, complaints or PALSfeedback and the acceptance reviewed in light of on going intelligence.Each Clinical Director/Managing Partner will be responsible for ensuring the administration,management and review of their Directorate’s Assurance Framework and Risk Register andensuring that any changes in the level of risk are communicated to the Assistant Director ofCorporate Development and Governance to amend the combined Trust Assurance Framework andRisk Register as necessary.Page 128 of 156

Board of Directors Meeting, 29 March 2012Agenda Item 13Appendix B Risk Assessment FormGeneral Risk Assessment RecordLocation: Assessment undertaken by: Assessment Verified by(responsible manager):Work Activity / Area Assessed: Name: Name: Name:Signed: Signed: Signed:Date: Date: Date:Staff Representative Consulted:Yes / No Name:Please indicate the reason for conducting this Risk Assessment: STEP 5Periodical review Change in room (zone) usage Assessment ReviewChange in legislation Change in equipment or work practiceDate:Other (Please specify)STEP 1 STEP 2 STEP 3ResidualRiskLikelihoodImpactRequired controls andtimescalesList any immediate or longertermaction required & timescale(complete action plan and riskregister). Also details of costswhere known.RiskLikelihoodImpactCurrent controls (if any)List existing control measures ornote where information may befound.Who mightbe harmedand how?ObservationsList significant hazards andunsafe practicesPage 129 of 156

Board of Directors Meeting, 29 March 2012Agenda Item 13Page 130 of 156

Guidance - 5 Steps to Risk AssessmentSTEP 1 STEP 2 STEP 3Board of Directors Meeting, 29 March 2012Agenda Item 13ObservationsWho might be harmed?Current controls & required controlsOnly look for hazards which you couldreasonable expect to result in significantharm under the conditions in yourworkplace. Use the following examples asa guide.There is no need to list individuals by name – butyou must consider employees, visitors,contractors and the public. Think about groups ofpeople doing similar work or who may beaffected, for example:For the hazards identified in Step 1, do the precautions alreadytaken:Meet the standards set by legal requirement?Slipping/ tripping hazards (e.g. poorlymaintained floors or stairs)Fire (e.g. from flammable materials)ChemicalsElectricity (e.g. poor wiring)Manual handlingNoisePoor lightingPatientsEmployees - Nursing Staff / DoctorsClientsCleanersOffice StaffMaintenance and ContractorsPeople sharing your workspaceMembers of the publicComply with a nationally recognised industry standard?Represent good practice?Reduce risk as far as reasonably practicable?Where risks are not adequately controlled, indicate what moreyou need to do. List any immediate or longer-term actionrequired, timescales and lead person. Complete the Action Planand operational Assurance Framework/Risk Register. Also detailexpected costs where known.Low temperatureViolencePay particular attention to:Staff with disabilitiesVisitorsInexperienced staffLone Workers as they may be more vulnerablePage 131 of 156

Board of Directors Meeting, 29 March 2012Agenda Item 13STEP 4 STEP 5Record your findingsReview and RevisionYou must share your findings with relevant staff. Risk assessments by law must be suitableand sufficient. You need to be able to show that:A proper check was madeSet a date for review of the assessment. On review check thatthe precautions for each hazard still adequately control the risk.If not indicate the action needed. Note the outcome. If necessarycomplete a new risk assessment.You considered who might be affectedYou dealt with all the obvious significant hazards taking into account the people who could beinvolved.Making changes in your workplace i.e. bringing in newequipment, substances or procedures may introduce significanthazards, which should prompt a review of the risk assessment.The precautions are reasonable, and the remaining risk is lowKeep the written record for future reference; it can help you if an inspector asks whatprecautions you have taken, or if you become involved in any action for civil liability. Riskassessments help to show that you have done what the law requires. Please email a copy ofyour risk assessment to the Health and Safety Manager: mark.abbotts@nhs.netPage 132 of 156

Board of Directors Meeting, 29 March 2012Agenda Item 13PROCESS OF RISK EVALUATIONASSESSMENT OF LIKELIHOOD OF RISKScore Description Description5 Certain Likely to occur on many occasions, a persistent issue: e.g. daily4 Likely Will occur, but is not persistent issue3 Possible May occur / recur occasionally: e.g. monthly2 Unlikely Could occur at some time: e.g. quarterly1 Rare Exceptional circumstances only: e.g. less than 1 per yearASSESSMENT OF IMPACT OF RISKImpact 1Minimal (includingno harm / near miss)Clinical (PatientSafetyIncidents)No injury / preventedincidentMinor cuts, bruising2MinorExtra Observation /TreatmentFirst AidMajor cuts, bruisingMinor illnessSafety Minor cuts/ bruising Under 3 daysabsence. Majorcuts / bruising3ModerateFurther treatment neededReferred to otherdepartment / hospital /A&EAdditional treatmentrequired up to 1 yearRIDDOR reportable (causedby incident)A & ERIDDOR reportable4MajorMajor InjuryMajor clinicalinterventionPermanentincapacityUnexpected deathDeath caused by theincidentUnexpected death.Permanent disability5CatastrophicMultiple deathsSuspected HomicideMultiple deaths.Out of controlinfection.Financial £1000- £20,000 £20,000-£100,000 £100,000- £500,000 £500,000- £2.5m Above £2.5mLegalTribunalNHSLAinvolvement(potential for claim)Defensible legal actionHSE prosecution orother criminalprosecution.Civil litigation (1person)HSE prosecution orother criminalprosecution (major)Civil litigation (> 1person)PerformanceReputationWritten complaints(some verbalcomplaints may beconsidered,depending uponcontext)Failure to meetlocal standardsLetters in localpressFailure to meet nationalstandardsAdverse articles in localpress.S4BH lapseFailure to meetprofessionalstandards orstatutoryrequirementsAdverseletters/articles inExtensive local presscoverage.S4BH lapseSustained failure tomeet professionalstandards orstatutoryrequirementsMajor censure byHealthcareCommission,Ombudsman, etc.Nationwide mediacoveragePage 133 of 156

Board of Directors Meeting, 29 March 2012Agenda Item 13RISK SCORING MATRIX1 Rare 2 Unlikely 3 Possible 4 Likely 5 Certain1 Minimal 1 2 3 4 52 Minor 2 4 6 8 103 Moderate 3 6 9 12 154 Major 4 8 12 16 205 Catastrophic 5 10 15 20 25Key to risk level:GreenYellowAmberRedLow risk (1-4) – Manage locallyModerate risk (5-8) – Review control measuresSignificant risk (9-12) – Controls / action plan to be put in place before work continuesHigh risk (15-25) – Work should not start or continue until risk has been reducedPage 134 of 156

Board of Directors Meeting, 29 March 2012Agenda Item 13Team/Local Delivery Unit Risk RegisterTeamLDUID Principle RiskWhat is the risk?Sourceof RiskHow wasthe riskidentified?CQCOutcome refKey ControlsWhat systems do we have inplace now to reduce the risk?CurrentRiskRatingIn format:C X L =Score(Low/Moderate/Significant/High)ResidualRiskRatingIn format:C X L =Score(Low/Moderate/Significant/High)Lead Action PlanWhat are we going to do toimprove our controls/reducethe risk?CommitteeCommitteeor forumwhere riskand actionplans arereviewedandminuted.Reviewdate ofactionplanDate forreview.SafeS1S2S3SU1SU2SU3T1T2T3RP1RP2RP3SustainableTimelyRecovery focussed andpersonalisedReview risks of 9+ on the team Risk Register at the Monthly LDU meeting. Any risks higher than 12 will be escalated to the DirectorateGovernance Monthly meeting for review25Page 135 of 156

Appendix C- Governance Reporting Structure26Board of Directors Meeting, 29 March 2012Agenda Item 13Page 136 of 156

KeyStandingcommitteeNED chairedStandingcommitteeED chairedFinance &InvestmentCommitteeLangdon ProjectBoardAssurance routeReporting and assurance routeUIC – Urgent Inpatient CareRIL – Recovery & Independent LivingShadowCouncil ofGovernorsAuditCommitteeSafeguardingGovernance Reporting StructureOctober 2011Version OneBoard ofDirectorsQuality & SafetyCommitteeClinicalEffectiveness WorkforceSafety & RiskOperationalRisk27Remuneration &Terms of ServiceCommitteeAdults ClinicalDirectorateQualityImprovement &Safety GroupExeterEast & MidDevonNorth DevonSouth & WestDevonTorbayFT Steering Group(via CEO Report)BusinessExecutiveOPMHClinical DirectorateExeterEast & MidDevonNorth DevonSouth & WestDevonTorbayBoard of Directors Meeting, 29 March 2012Agenda Item 13Executive TeamMeetingTrust ManagementBoardRiO ProjectBoardQuarterly DirectoratePerformance MeetingSecure ServicesClinical DirectorateSpecialist ServicesClinical DirectorateProfessionsDirectorateForensicsAutisticSpectrumConditionMedical AdvisoryCommitteePrisonsPsychologicalTalkingTherapiesSubstanceMisuseTrust NursingCommitteePsychologyAdvisoryCommitteeLearningDisabilitySocial WorkEatingDisorders,Perinatal &GenderDysphoriaOccupationalTherapyPharmacyPage 137 of 156

28Board of Directors Meeting, 29 March 2012Agenda Item 13Page 138 of 156

Appendix D – Risk Escalation MatrixBoard of Directors Meeting, 29 March 2012Agenda Item 139-12SCORERISK ACTION REPORTING REQUIREMENTSCxL1-4 Low Accept risk. Manage through Manage at team level.normal control measures.5-8 Moderate Accept risk. Manage throughnormal control measures.Manage at team level.9+ Significant Take to LDU governance Escalate to Directoratemeeting and review.Assurance Framework if review12+ Significant Take to Directorategovernance meeting andreview.considers it necessary.Escalate to Trust AssuranceFramework if review considers itnecessary.15-2515 High Take to DirectorateGovernance meeting andreview.16+ High Take to Trust ManagementBoard and review.20-25 High Immediate seniormanagement actionrequired. Directors to beinformed. Action plans to bedeveloped, implemented andmonitored.Escalate to Trust AssuranceFramework if review considers itnecessary.Consider impact on achieving theTrust’s objectives. Escalate toTrust Assurance Framework ifreview considers it necessary.Review by Trust ManagementCommittees. Consider impact onachieving the Trust’s objectivesand entry to Trust AssuranceFramework / Risk Register.29Page 139 of 156

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14DEVON PARTNERSHIP NHS TRUSTBOARD OF DIRECTORS - SUMMARY REPORTDate of Meeting: 29 March 2012Name of Report:Author:Approved by:Presented by:Report of the Audit CommitteeRichard Smith, Non-Executive DirectorHugh Groves, Director of FinanceRichard Smith, Non-Executive DirectorPurpose of the report:To provide the Board with an update of the discussions at the Audit Committeemeeting held 6 March 2012Key points:The Committee considered the following points at the meeting:Counter FraudQuality and SafetyAssurance FrameworkVAT ReviewAnnual Accounts PlanningInternal Audit ReportExternal AuditLosses and Compensations RegisterSelf Assessment ReportAction required, including Recommendations:Members of the Board are asked to receive the report and note its contents.Links with the Assurance Framework (Risks, Controls and Assurance):Provision of minutes/notes of meeting – links to “positive assurances” section.Summary of Constitutional / Financial/ Legal / PPI / Equality and DiversityImplications:None applicablePage 141 of 156Page 1 of 2

Links to Strategic Aims:SafeTimelyPersonalisedRecovery-focusedSustainableThis report references:CQC RegulationsPage 142 of 156Page 2 of 2

Board of Directors Meeting, 29 March 2012Agenda Item 14Devon Partnership NHS Trust Board of Directors Meeting29 March 2012Audit Committee Report1. Purpose of report1.1 To provide the Board with a summary of the discussions at the Audit Committeemeeting held on 6 March 2012, in order to bring the Board’s attention to significantissues. The full minutes of the January meeting are appended to this report for thefurther information of Board members.2. Counter Fraud2.1 The Committee received the Counter Fraud update and agreed the 2012/13Counter Fraud plan which included a total of 90 days (consistent with 2011/12plan) with a particular focus on procurement fraud. The committee consideredproposals to reduce the plan, but considered it advisable to maintain the currentlevel of counter fraud measures3. Quality and Safety3.1 The Annual Inspection Log was presented and considered by the Audit Committee.It noted that nearly all issues raised from previous inspections had now been dealtwith.3.23.2.1The Committee considered a report from the Co Medical Director which consideredthe following points:Clinical Audit plan for 2012/13This was discussed in outline. However, the Audit Committee considered that, infuture, greater assurance would be achieved if the Audit Committee reviewed theplan after it had been presented to and approved by the Quality and SafetyCommittee.3.2.2Executive WalkaroundIt was reported that good progress had been made in resolving the backlog ofoutstanding actions. A programme of walkarounds is planned and it was reportedthat NED’s would be included in walkarounds as lay participants.3.2.3Peer Verification VisitsThe following points were noted:Adult Directorate making good progressPage 143 of 156

Board of Directors Meeting, 29 March 2012Agenda Item 14OPMH about to commence (note there was an agreed delay in the startdate for this due to work pressures)Secure currently have their own in-house visits in place but it wasconsidered that these could be made more rigorousNo update available for specialist services.3.2.4It was further reported that a formal Directorate reporting structure was in placewith Quality and Safety Committee receiving primary assurance and the AuditCommittee receiving overarching assurance through Q&S reporting.4. Assurance Framework4.1 The Committee reviewed the Assurance framework. It was noted that goodprogress was being made to set completion dates for all mitigating strategies.4.24.3The Committee noted that the risk of deferral or continued delay in achieving FTstatus was included in the Framework (SU12).The Audit Committee discussed the process by which risks are removed from theassurance framework. In particular, there was concern that risks which had beenpreviously ranked high, but now with successful mitigation strategies in place couldbecome “below the radar”. In these cases, the committee should be assured thatthe mitigation strategies were in full operation to maintain residual risk at anacceptable level. It was therefore agreed that the Audit Committee would carry outan annual review of high ranking risks that have reached mitigation and areremoved from the register that is presented to the Trust Board.5. VAT Review5.1 The Committee considered the approach taken in relation to the VAT on theLangdon Development and noted the view of External Auditors that this appearedto be a sensible approach to take.6. Annual Accounts Planning6.1Going Concern Report and Accounting PolicesThe Committee considered a report from the Director of Finance and agreed thatthe financial accounts should be prepared on a going concern basis and that anumber of minor changes to accounting policies be adopted6.2Timetable for Submission of AccountsThe Committee considered the timetable for submission of the Trust’s annualaccounts. In line with previous years it was agreed that:The Board, when considering the draft accounts would be requested todelegate authority to the Audit Committee to authorise non materialamendments to the accounts prior to signature and final submissionPage 144 of 156

Board of Directors Meeting, 29 March 2012Agenda Item 14 Nevertheless, a potential Extraordinary Board Meeting be pencilled in for 7June 2012 to consider the final accounts should there be any materialamendments to the accounts.6.3Audit Assurance LetterA draft letter of assurance to be provided by the Audit Committee to the ExternalAuditors was considered and approved..6.4Annual Governance Statement (Previously called the “Statement of InternalControl”)The Committee considered the timetable for submission of the Annual GovernanceStatement and agreed that this would be approved by circulation. Guidance is stillawaited from the DoH on the content of the statement: however, this will beinformed by the Head Of Internal Audit’s opinion on assurance – which at thisstage is predicted to be “significant”.7. Internal Audit7.17.1.1The Committee considered a report from Internal Audit. The following are areasthat the Committee wished to highlight to the Board:Reports IssuedEight Internal Reports issued since the previous Audit Committee meeting.One Supervision and Appraisal – Assurance Amber – A discussion washeld as to the Terms of Reference of the Report and it was noted that adistinction needed to be drawn between process and quality. It was furtherreported Clinical Audit were considering the quality aspects of supervisionFive Financial Audits had been completed - Assurance Green on allTwo Third Party Assurances had been completed – The Assurance onpayroll audit was Green and Charitable Funds was Amber.7.1.2Outstanding RecommendationsIt was noted that there were 15 outstanding recommendations, with no major itemsoutstanding and that this reflected significant reduction from the numberoutstanding six months ago.7.1.3Audit PlanThe Committee considered the audit plan for 2012/13 to 2014/15 and noted thestrong links to the major risks outlined in the Assurance Framework. It agreed aplan for 2012/13 which consists of 370 audit days - a reduction of 20 from theprevious yearPage 145 of 156

8. External AuditBoard of Directors Meeting, 29 March 2012Agenda Item 148.18.2The Committee received an update on the procurement process regarding AuditCommittee services. It was reported that Grant Thornton has been awarded thecontract which covered DPT and would be taking this role on from 30 September2012. Audit Commission staff will TUPE to Grant Thornton and it is not expectedthat we will see a significant change in audit leads.The Committee received a review of the material information systems audit fromExternal Audit and noted the contents and recommendations, of which there werethree.9. Losses and Compensations Register9.1 The Committee received an update on the losses and compensations register10. Self Assessment Report10.1 The Committee considered and agreed the self assessment report. It was agreedthat this would be included within the Annual Report to the Board which isscheduled to be considered at the next Audit Committee meeting.11. Recommendation to the Board11.1 Members of the Board are asked to receive the report and note its contents.Prepared & presented by:Richard SmithNon-Executive Director/Chair of Audit CommitteeMarch 2012Page 146 of 156

15DEVON PARTNERSHIP NHS TRUSTBOARD OF DIRECTORS - SUMMARY REPORTDate of Meeting: 29 March 2012Name of Report:Author:Approved by:Presented by:Publications & GuidanceAnne Sawyer, Director of Compliance & CorporateDevelopmentIain Tulley, Chief ExecutiveIain Tulley, Chief ExecutivePurpose of the report:To bring to the attention of the Board significant items of national context for local guidanceKey points:1. New calculators for the NHS Pension Scheme proposals2. Online patient feedback linked to hospital performance3. Management of SHA and PCT administration estate4. NIHR appoints National Director for Public Participation and Engagement5. CHRE consult on standards for NHS board members and governing bodies6. Payment by Results (PbR): confirmation of arrangements for 2012/137. Quality Accounts8. GMC launches new guidance for doctors on raising and acting on concerns9. Reports on management of controlled drugs in different healthcare settings10. Commissioning for Quality and Innovation scheme11. Final annual report of the National Leadership Council12. NHS National Sustainability Day13. Performance and capability review of the Care Quality Commission14. GPs to ‘prescribe’ apps for patients15. Secretary of State appoints Dame Fiona Caldicott to lead Information GovernanceReview16. Promoting of personal injury legal services in NHS premises17. Healthcare public health advice18. Duration of the NHS Standard Contract 2012/1319. NHS Choices Annual Report 201120. The National Institute for Health Research Clinical Research Network21. Children and Young People's IAPT extension22. 'Act FAST on Stroke' campaign launch23. NHS Funded Nursing Care Bandings 2012/1324. Understanding the current NHS pricing systems25. Signals – emerging patient safety issues – NPSAPage 147 of 156

Action required, including Recommendations:Members of the Board are asked to receive the report and note its content.Links with the Assurance Framework (Risks, Controls and Assurance):To bring to the attention of the Board significant items of national context for local guidance.Summary of Constitutional / Financial/ Legal / PPI / Equality and DiversityImplications:No additional implications arise from this paper.Links to Strategic Aims:Safe x Recovery-focused xTimely x Sustainable xPersonalisedxThis report references:CQCRegulationsAs applicable to each itemPage 148 of 156

Board of Directors Meeting, 29 March 2012Agenda Item 15DEVON PARTNERSHIP NHS TRUST BOARD OF DIRECTORSMeeting on 29 March 2012PUBLICATIONS AND GUIDANCE1 New calculators for the NHS Pension Scheme proposals1.11.2The Government set out the key terms of an improved pension offer for NHS staffon 20 December 2011. Since then, the Department of Health has held constructivetalks with NHS Employers and the NHS trades unions to consider the details.A new pension fact sheet and online calculator are available on the Department ofHealth website. The calculator relates to proposals for a new NHS pension schemefrom 2015 and has been developed by an independent pension specialist workingwith NHS trades unions, the Department of Health and NHS Employers. Thecalculators allow members of the scheme to a) estimate their future benefits and b)see any changes to their current scheme under the Government’s new proposals1.3 More information is available atwww.dh.gov.uk/health/2012/02/pension-calculators1.4 Action: Director of Workforce and Organisational Development2 Online patient feedback linked to hospital performance2.12.2Imperial College London has published independent research that links onlinepatient feedback and objective measures of hospital performance.The research, which looked at patient feedback on the NHS Choices website, foundthat better-rated hospitals tend to have lower death rates and lower readmissionrates. Hospitals rated as cleaner by patients were also found to have lower MRSArates.2.3 More information is available atwww.dh.gov.uk/health/2012/02/imperial-research2.4 Action: Director of Nursing and Practice3 Management of SHA and PCT administration estate3.1 A letter and accompanying paper from Peter Coates, the Department of Health'sDirector of Procurement, Investment and Commercial, sets out a framework for themanagement of the SHA and PCT administrative estate and for decisions withrespect to the future office requirements for the NHS Commissioning Board andother arm’s length bodies at sub-national and local level.3.2 More information is available atwww.dh.gov.uk/health/2012/02/management-administration-estatePage 149 of 156

Board of Directors Meeting, 29 March 2012Agenda Item 154 NIHR appoints National Director for Public Participation and Engagement4.1 The National Institute for Health Research has asked Simon Denegri, Chair ofnational advisory group INVOLVE, to take on the additional role of NIHR NationalDirector for Public Participation and Engagement in Research. The new role willprovide strategic direction and leadership to initiatives aimed at encouraging morepeople to take part in research.4.2 More information is available atwww.nihr.ac.uk/news/Lists/News/DispForm.aspx?ID=12954.3 Action: Director of Research and Development5 CHRE consult on standards for NHS board members and governing bodies5.1 The Council for Healthcare Regulatory Excellence is consulting on draft standardsfor members of NHS boards and governing bodies in England. The standards wouldcommit individuals to a code of personal behaviour, technical competence andbusiness practices.5.2 More information is available atwww.chre.org.uk/satellite/4135.3 Action: Director of Compliance and Corporate Development6 Payment by Results (PbR): confirmation of arrangements for 2012/136.1 Information and guidance in support of Payment by Results in 2012/13 has beenpublished. The 2012/13 PbR guidance has been clarified and expanded in anumber of areas in response to feedback received on the draft guidance.6.2 More information is available atwww.dh.gov.uk/health/2012/02/confirmation-pbr-arrangements6.3 Action: Director of Finance7 Quality Accounts7.1 The Department has asked the Audit Commission to instruct auditors to undertakeexternal assurance of NHS acute and mental health trusts' 2011/12 QualityAccounts. New mandatory information is proposed for the 2012/13 round of QualityAccounts and trusts are invited to consider including this in their 2011/12 Accounts.7.2 More information is available atwww.dh.gov.uk/health/2012/02/quality-account-reporting7.3 Action: Director of Compliance and Corporate Development8 GMC launches new guidance for doctors on raising and acting on concerns8.1 The General Medical Council recently published new guidance that makes clear theexpectation that all doctors should raise and act on concerns about the safety,dignity and care of patients. Part one gives advice on raising concerns and part twoexplains the responsibilities entailed when colleagues or others raise concerns.8.2 More information is available atPage 150 of 156

Board of Directors Meeting, 29 March 2012Agenda Item 15www.gmc-uk.org/guidance/ethical_guidance/11758.aspwww.gmc-uk.org/guidance/ethical_guidance/raisingconcerns.asp8.3 Action: Dr David Somerfield – Co-Medical Director9 Reports on management of controlled drugs in different healthcare settings9.1 The National Prescribing Centre has this week published three reports on theirwebsite concerning the management of controlled drugs by ambulance trusts, byparamedics, by private prescribers and in prisons. A letter from Dr Keith Ridge,Chief Pharmaceutical Officer, to all PCT chief executives draws attention to thefindings and recommendations.9.2 More information is available atwww.dh.gov.uk/health/2012/02/npc-reports9.3 Action: Dr David Somerfield – Co-Medical Director10 Commissioning for Quality and Innovation scheme10.1 Patient experience CQUIN data is now available to all NHS trusts and availablefrom the end of February 2012 to all SHAs to share with commissioners. This willsupport assessment and setting of thresholds for the national goal of improvingresponsiveness to the personal needs of patients.10.2 More information is available atwww.institute.nhs.uk/world_class_commissioning/pct_portal/cquin.html10.3 Action: Director of Nursing and Practice11 Final annual report of the National Leadership Council11.1 The final annual report of the National Leadership Council (NLC) is now available,summarising the significant progress made on developing NHS leadership over thelast two years. From April 2012, the new NHS Leadership Academy will beunderway. It will be a national hub for leadership development and talentmanagement and a centre of leadership excellence for all NHS clinical andmanagerial staff or staff providing care funded by the NHS.11.2 More information is available atwww.nhsleadership.org/about-nlcfirstyearthefoundat.asp11.3 Action: Director of Workforce and Organisational Development12 NHS National Sustainability Day12.1 On 28 March 2012 NHS organisations across the country were invited to take partin the first ever NHS Sustainability Day. Organised by the NHS SustainableDevelopment Unit and University College London Hospital's NHS Foundation Trust,this event will focus on how we can all deliver more efficient and sustainablehealthcare.12.2 More information is available atwww.nhssustainabilityday.co.ukPage 151 of 156

Board of Directors Meeting, 29 March 2012Agenda Item 1512.3 Action: Director of Business Development and Strategy13 Performance and capability review of the Care Quality Commission13.113.2The Department has published the report of its performance and capability review ofthe Care Quality Commission. The review is intended to provide robust assuranceto the public, the Department and Parliament that CQC is improving its performanceand that action will be taken to build and sustain its capability for the future.The review ran from October 2011 to February 2012. It gathered evidence from arange of external stakeholders and CQC staff and considered findings of the recentreports from the Health Select Committee and the National Audit Office.13.3 More information is available atwww.dh.gov.uk/health/2012/02/cqc-performance-review14 GPs to ‘prescribe’ apps for patients14.114.2People could soon be directed to free or cheap apps by their GPs to allow them tomonitor and manage their health more effectively. At an event held yesterday,showcasing the best ideas for new and existing health smart phone apps, theHealth Secretary, Andrew Lansley said: “Innovation and technology canrevolutionise the health service, and we are looking at how the NHS can use theseapps for the benefit of patients, including how GPs could offer them for free.”This follows a call to find the best new ideas and existing smart phone apps thathelp people and doctors better manage care, which received nearly 500 entries andmore than 12,600 votes and comments.14.3 More information is available atwww.dh.gov.uk/health/2012/02/apps14.4 Action: Dr David Somerfield – Co-Medical Director15 Secretary of State appoints Dame Fiona Caldicott to lead InformationGovernance Review15.1 Recently, the Future Forum recommended a review to ensure the appropriatebalance between the protection of patient information and the use and sharing ofinformation to support care. The Secretary of State has now appointed Dame FionaCaldicott to lead an independent expert panel to conduct the review. The review,which will cover both health and social care, is expected to report in the summer.15.2 More information is available athttp://mediacentre.dh.gov.uk/2012/02/17/dame-fiona-caldicott-to-lead-review-intoconfidentiality-and-the-sharing-of-health-and-social-care-information15.3 Action: Dr David Somerfield – Co-Medical Director16 Promoting of personal injury legal services in NHS premises16.1 Following recent media and parliamentary interest in advertising and other forms ofPage 152 of 156

Board of Directors Meeting, 29 March 2012Agenda Item 15promotion of the services of personal injury lawyers or claims managementcompanies on NHS premises, David Nicholson has written to clarify that theseshould not be supported as they risk undermining the NHS's relationship with, andresponsibilities to, patients.16.2 More information is available atwww.dh.gov.uk/health/2012/02/personal-injury-legal-services16.3 Action: Dr Helen Smith – Co-Medical Director17 Healthcare public health advice17.1 The latest draft guidance on the healthcare public health advice (the 'core offer'),intends to help commissioners with local planning in this transition year. To helprefine the guidance and issue it to the service in a timely way, people are invited tocomment by 30 March 2012.17.2 More information is available atwww.dh.gov.uk/health/2012/02/local-public-health-guidance18 Duration of the NHS Standard Contract 2012/1318.1 The 2012/13 NHS Standard Contract was issued with a default duration and willexpire on 31 March 2013. SHA clusters have the discretion to approve an extendedduration up to a maximum of three years. A letter from David Flory gives guidanceon the processes to be adopted.18.2 More information is available atwww.dh.gov.uk/health/2012/02/guidance-nhs-standard-contract18.3 Action: Director of Finance19 NHS Choices Annual Report 201119.1 The NHS Choice Annual Report 2011 has been published. The report gives anoverview of the NHS Choices service and its achievements over the past year. NHSChoices has grown to become the most popular health website in the UK and nowhas more than 11 million visits each month.19.2 More information is availablewww.nhs.uk/aboutNHSChoices/professionals/developments/Pages/annualreport.aspx20 The National Institute for Health Research Clinical Research Network20.1 The National Institute for Health Research Clinical Research Network has issued anonline publication showing how seven trusts and one GP practice have embeddedclinical research as core business. This is also available on the Guardian ClinicalResearch Zone, which features a league table of each NHS trust's researchperformance.20.2 More information is available athttp://viewer.zmags.com/publication/a503d4af#/a503d4af/1Page 153 of 156

Board of Directors Meeting, 29 March 2012Agenda Item 1520.3 Action: Director of Research and Development21 Children and Young People's IAPT extension21.1 Health Minister Paul Burstow and Deputy Prime Minister Nick Clegg todayannounced a further investment of up to £22 million, on top of the existing £32million, over the next three years in the Children and Young People's ImprovingAccess to Psychological Therapies (IAPT) project. This will:make treatment available to more young people with mental health problemsprovide access to a wider range of therapiesextend the skills of professionals who work with young people.21.2 More information is available athttp://mediacentre.dh.gov.uk/2012/02/29/too-many-young-people-suffering-insilence-with-mental-health-problems21.3 Action: Director of Business Development and Strategy22 'Act FAST on Stroke' campaign launch22.1 The award winning Act FAST on Stroke campaign will be returning for another burstof activity in 2012. Originally launched in 2009, the objectives of the campaign are toraise awareness of the signs of stroke and to encourage the public to call 999immediately if they identify any single one of the leading stroke symptoms. Thenational TV advertising ran from Monday 27 February – Sunday 25 March. Thecampaign consisted of a dedicated strand of radio activity targeting BME (black,minority and ethnic) audiences.22.2 More information is available atwww.dh.gov.uk/health/2012/02/act-fast23 NHS Funded Nursing Care Bandings 2012/1323.1 A note sets out the position regarding the level of NHS contribution towards thecosts of a place in a care home with nursing for those people assessed as requiringthe help of a registered nurse. From 1 April 2012, the two rates will remainunchanged.23.2 More information is available atwww.dh.gov.uk/health/2012/03/care-bands/www.dh.gov.uk/en/Publicationsandstatistics/Publications/PublicationsPolicyAndGuidance/DH_10623024 Understanding the current NHS pricing systems24.1 A new report, published by Monitor but undertaken by PricewaterhouseCoopersabout the current NHS pricing system highlights the importance of good qualityinformation. The Government wants Monitor to take on joint responsibility for pricingwith the NHS Commissioning Board, subject to passage of the Health and SocialCare Bill.24.2 More information is available atwww.monitor-nhsft.gov.uk/home/news-events-and-publications/our-Page 154 of 156

Board of Directors Meeting, 29 March 2012Agenda Item 15publications/browse-category/about-monitor/monitors-proposed-n-025 Signals – emerging patient safety issues – NPSA25.1 The National Patient Safety Agency (NPSA) has published its latest set of Signals –emerging patient safety issues identified from a review of serious incidents. TheNPSA would be pleased to receive comments and anonymised local investigations.25.2 More information is available atwww.nrls.npsa.nhs.uk/resources/type/signals25.3 Action: Dr Helen Smith – Co-Medical DirectorPage 155 of 156

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