South West London and St George s Mental Health NHS Trust s Foundation Trust Application

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1 Agenda item 8 Paper H South West London and St George s Mental Health NHS Trust s Foundation Trust Application Author: Alwen Williams, Director of Delivery and Development (London) Purpose 1. The purpose of this paper is to consider the Foundation Trust (FT) application from South West London and St George s Mental Health NHS Trust (SWLStG) and the recommendation for the application to be passed to Monitor for assessment. Overview 2. The role of the NHS Trust Development Authority (NHS TDA) is to ensure on behalf of the Secretary of State that aspirant Foundation Trusts are ready to proceed to assessment to Monitor. Foundation Trust status is only possible for NHS Trusts that are delivering the fundamentals of clinical quality, good patient experience and national and local standards and targets, within the available financial resource. 3. The assessment has been made against three domains: quality, delivery and sustainability. This paper sets out the NHS TDA s assessment of the position of South West London and St George s Mental Health NHS Trust against these three domains. The summary assessment against these three domains made at the time of the Board to Board in June 2014 and the subsequent stocktake meeting in March 2015 can be found at Appendix The Trust application was considered at a Board to Board meeting on 19 June The key lines of enquiry at that meeting included: board assurance of the financial modelling, particularly downside mitigations and Cost Improvement Programmes (CIPs), relationships with the Trust s commissioners and capability to develop and implement a large scale estate redevelopment programme. It also took into account the outcome of the inspection by the Care Quality Commission s Chief Inspector of Hospitals, confirmed to the Trust on 10 June 2014, that CQC believes that the Trust is providing care at an appropriate level of quality to proceed in its FT application. 5. The Board to Board concluded that there were no outstanding areas of assurance in relation to the quality and delivery domains. Further assurance was required on aspects of financial assurance, particularly downside mitigation and cost improvement planning. A stocktake meeting on 26 August 2014 chaired by the Director of Delivery and Development confirmed the actions required to enable a recommendation to be made in March 2015 to the NHS TDA Board to refer the Trust to Monitor.

2 6. A further stocktake meeting was held with the Trust on 3 March 2015, chaired by the Director of Delivery and Development (London) and attended by the Trust Chairman, Chief Executive and executive team. This meeting reviewed progress against the issues raised at the Board to Board. The conclusion from this meeting was to submit the FT application from South West London and St George s Mental Health NHS Trust to the Board of the NHS TDA at its meeting on 19 March 2015 with a recommendation that the Trust proceed to the next stage of consideration by Monitor. The following areas were identified that will require a particular focus from the Trust in progressing its FT application through the final stages of assessment, assurance and authorisation by Monitor: The completion and acceptance of a robust Operating Plan for 2015/16 consistent with the LTFM, with signed contracts in place for 2015/16; The submission to the NHS TDA in early May 2015 of a Board-approved Outline Business Case for the estate redevelopment which aligns with the LTFM; Substantive recruitment to the Director of Nursing post, with arrangements confirmed to manage the transition and mitigate risks to quality; Development and implementation of an action plan to address any gaps in assurance identified by Monitor through the Quality Governance Framework assessment. 7. The recommendation to the NHS TDA Board is that South West London and St George s Mental Health NHS Trust should be put forward for the next stage of consideration by Monitor. This paper sets outs the assurance received in relation to the key issues outlined above. Assurance Process 8. A comprehensive assessment of the Trust s readiness has been undertaken by the NHS TDA Delivery and Development, Business Support (Finance) and Clinical Quality Directorates in line with the Accountability Framework and FT Approvals Model. 9. The NHS TDA Assurance Process for the FT application included: Clinical Quality Assessment and Review 10. The NHS TDA Clinical Quality Directorate have been working closely with the Trust to provide support and challenge to their FT application as it has progressed over the last period. This has included an assessment of their IBP and the Clinical Quality and Workforce strategies. 11. The Clinical Quality Directorate conducted a quality desktop review in November The CQC CIH review took place in March As the Trust was in the first wave of Mental Health Trust assessments they did not receive a rating. The CQC Inspection Team judged that the Trust is providing care at an appropriate level of quality to proceed with its FT application. The post- 2.

3 inspection Quality Summit took place on 9 June The NHS TDA has chaired a monthly Clinical Quality Reference Meeting with the Trust to oversee implementation of the action plan produced in response to the CQC report. Business Support (Finance) Assessment and Review 12. The Trust s Long Term Financial Model (LTFM) has been reviewed and improved during the FT application process. The financial plan demonstrates that the Trust meets the financial requirements of an applicant FT. Namely: i) that with a high likelihood the Trust can generate a sustainable net income surplus by year 3 of the projected period and maintain a reasonable cash position; and ii) that the Trust has a minimum Continuity of Services Risk rating (CoSR) of 3 at authorisation and on a quarterly basis for the first 4 years of projections. It is noted that after 2019/20 the base case rating does not get above 2 as modelled. THE NHS TDA is assured that this is technical due to the accounting treatment of the Estates Modernisation Programme. In addition the current modelling of bridging finance/repayment of loans is sub-optimal and can be made more beneficial for the Trust in their updating of their submission to Monitor. NHS TDA Executive Team Assessment and Review 13. A Board to Board was held in June 2014 to determine whether the Trust s FT application was robust enough to be considered by the NHS TDA Board. 14. The decision of the NHS TDA Executive Team following the Board-to-Board meeting was to delay the submission of the FT application from South West London and St George s Mental Health NHS Trust to the Board of the NHS TDA to allow the Trust to further strengthen their financial modelling. 15. A further Executive level stocktake meeting was held on 3 March 2015, chaired by the Director of Delivery and Development (London) and attended by the Trust Chairman, Chief Executive and executive team. The meeting was also attended by the NHS TDA s Medical Director and a senior member of the Business Support team on behalf of the Director of Finance. This meeting reviewed progress against the issues raised at the Board to Board. 16. The conclusion from this meeting was to submit the FT application from South West London and St George s Mental Health NHS Trust to the Board of the NHS TDA at its meeting on 19 March 2015 with a recommendation that the Trust proceed to the next stage of consideration by Monitor. NHS TDA Assessment of the Trust s FT application Quality 17. The Quality assessment considers how the Trust is performing across five key areas: safe, effective, caring, responsive and well-led, as well as taking into account the outcome of the inspection by the Chief Inspector of Hospitals 3.

4 (CIH). At the time of the Board to Board the Trust was assessed as green or amber-green across all five areas. Further detail is provided below in relation to quality. 18. Since the June 2014 Board to Board the Trust performance against a number of quality indicators has improved including incident reporting (NRLS), national community mental health survey results and staff survey results. As a result the Trust is rated as green in four of the five areas, with the remaining area (effectiveness) rated amber-green due to performance against the standard for Improving Access to Psychological Therapies (IAPT), where investment in services is expected to result in improved performance in early 2015/16. Chief Inspector of Hospitals Inspection and Report 19. The assessment by the CQC Chief Inspector of Hospitals as to whether a trust is delivering high quality services is critical, and a good rating is required to progress to Monitor. 20. The Trust inspection took place on March 2014 and as the Trust was in the first wave of Mental Health Trust assessments they did not receive a rating. The CQC Inspection Team judged that the Trust was providing care at an appropriate level of quality to proceed with its FT application. Many areas of good practice were identified across sites, services and pathways. 21. The NHS TDA chaired Part Two of the Quality Summit on 9 June 2014 to discuss the findings from the inspection with key partners across the system. The Trust presented their response to the draft report and key immediate and medium / longer term actions that they had identified. 22. The Trust developed a Quality Improvement Plan to address the areas which must and should improve following the CIH visit. Actions to address CIH compliance actions were reported to CQC in August 2014, and the wider improvement plan was submitted to the NHS TDA. The plans have been developed in collaboration with staff and external partners where support is required. The CQC has not given an indication of the timescale for the Trust to be re-inspected. 23. The NHS TDA London Clinical Quality Team has monitored the implementation of the CIH action plan through the monthly Clinical Quality Reference Group attended by the NHS TDA, the Trust and commissioners. 24. The Trust has robust review and assurance arrangements in place, including regular review by the Executive team and the on-going peer review process that was developed prior to the CIH review. 25. The NHS TDA will continue to monitor progress as part of continued oversight of the Trust as it progresses through the Monitor stage of the application process. 4.

5 Well Led/Governed 26. South West London and St George s Mental Health NHS Trust has a shadow Governance rating of 2 against the Monitor s Risk Assessment Framework (RAF). 27. The Trust s most recent self-assessed Quality Governance Framework (QGF) score is 3.0 as at October An external review by KPMG in October 2013 scored the Trust as Monitor has brought forward the QGF assessment and this has been undertaken in the NHS TDA assessment phase. This assessment is expected to be completed and formally communicated to the Trust in late March. Provisional feedback given by Monitor to the Trust has indicated that the QGF final score is likely to be higher than that which is consistent with authorisation; however, Monitor have indicated that the Trust could realistically expect to make significant progress in reducing this score in the next quarter. A verbal update on this will be provided to the NHS TDA Board. Following this, the NHS TDA will expect the Trust to confirm the actions that it will take to address the gaps in assurance identified through the Monitor assessment, and the associated timescale. 29. The Trust s five year Quality Strategy was refreshed in April 2014 and sets out its quality objectives based on patient safety, clinical effectiveness and patient experience. The strategy has a clear vision for clinical services going forward and shows both clinician and stakeholder engagement. The quality vision is aligned with commissioners and broader health economy and the national strategy. The Quality strategy is underpinned by other key strategies such as Service User Experience Strategy, Workforce and Organisational Development Strategy, IM&T Strategy, Membership Strategy and Estates Strategy. These all form part of the Strategy chapter of the IBP. Current Performance on Quality 30. As part of the Board to Board process in June 2014 a comprehensive review of quality was undertaken and shared with the NHS TDA Executive Team. This review underpinned the key lines of enquiry for the Board to Board that included: The response to the CIH review and the Trust s ambitions to move from Good to Outstanding ; Assurance in relation to embedding learning across disparate sites, divisions and at all levels of the organisation; Safe staffing that is commensurate with quality of care and good clinical outcomes. 31. There were no specific outstanding quality issues from the Board to Board; however this continued to be monitored by the NHS TDA Clinical Quality Directorate, with no further concerns raised. 5.

6 32. The Trust has responded pro-actively to the requirements of Safe Staffing, in line with the national guidance. 33. From a quality perspective the Trust has demonstrated continued quality improvements with a clear strategy and priorities developed with patients, staff and key stakeholders. There are no material quality risks for South West London and St George s Mental Health NHS Trust with evidence of a Trust focus on sustainable quality improvement from Board to Ward. 34. The current NHS TDA Oversight and Escalation rating for quality overall for December 2014 is 4 (standard oversight). The responsive and well-led domain scores are 5 (standard oversight ). The effective domain score assesses performance against only one indicator, IAPT. The NHS TDA Delivery and Development team are satisfied that there are plans in place to address IAPT performance in 2015/16. Delivery 35. The Delivery assessment considers how the Trust is performing across three key areas; good service performance, capable board to deliver and external relationships. At the time of the Board to Board the Trust was assessed as green for good service performance, amber-green for capable board and amber for external relationships. This was revised to amber-green for external relationships in March 2015 with the other two indicators remaining the same. Further detail is provided below in relation to delivery. Capable Board 36. There have been significant changes to the Executive Directors following the appointment of the Chief Executive in July The Director of Finance left the Trust in June 2014 and an interim appointment was made. A substantive Director of Finance has been appointed and will start in post in the next month. The Director of Nursing leaves the Trust in March and an interim is in place. This post has been advertised and interviews will be held shortly. 37. The Trust undertook a further self-assessment against the Board Governance Assurance Framework (BGAF) in December There was improvement in one domain since the last self-assessment in October 2013 (Board Performance Reporting), otherwise all indicators remained the same as either amber-green or green. Good Service Performance/Responsive 38. Appendix 2 outlines NHS TDA s oversight and escalation assessment of the Trust from April 2014 until December At the time of the Board to Board the Trust was not achieving the proportion of those on CPA for at least 12 months who had a CPA review within the last 12 months. The Trust is now achieving this standard and has achieved it since Quarter /15. 6.

7 40. The Trust is achieving all of the mental health indicators identified on Monitor s Risk Assessment Framework. Referral to Treatment 41. South West London and St George s Mental Health NHS Trust has not consistently achieved the non-admitted and incomplete standards in 2014/15. The Trust has remodelled its Child and Adolescent Mental Health Services (CAMHS) to ensure that it does meet the standard. The Trust delivered its trajectory of meeting the non-admitted and incomplete standards from December 2014 and is expected to maintain this position in Proportion of those on Care Programme Approach for at least 12 months who have had a CPA review within the last 12 Months 42. The Trust is now achieving the standard for service users on CPA for more than 12 months having a review within 12 months and has achieved this since Quarter /15. Improving Access to Psychological Therapies (IAPT) 43. South West London and St George s Mental Health NHS Trust provides Improving Access to Psychological Therapies (IAPT) services to three CCGs Merton, Sutton and Wandsworth. Both Merton and Sutton CCGs have invested in specific services from 2015/16 so it is expected that Trust performance against this standard will improve. External Relationships 44. The Trust provides mental health services to five boroughs in South West London Kingston, Merton, Richmond, Sutton and Wandsworth as well as specialist and regional services commissioned by NHS England. The Trust provides a full range of mental health services to children, working age adults and older people and serves a population of 1.05 million people. Wandsworth CCG is the principal commissioner of South West London and St George s Mental Health NHS Trust, commissioning local services and accounting for 25% of NHS patient income. NHS England (London) is the second largest commissioner from the Trust, commissioning specialist services representing 18% of the Trust s NHS patient income. 45. The Trust has letters of support from its key commissioners that were collated in February Sutton CCG (representing 10% of NHS patient income) and Sutton Local Authority did not support the FT application in February 2014; however following further work between the Trust and the CCG, Sutton CCG Governing Body took the decision on 4 March 2015 to support the FT application and as a result the Local Authority is expected to support the application. As commissioners are due to provide letters of support for the Estates Modernisation Programme Outline Business Case due to be submitted to the NHS TDA in early May 2015, the Trust has not asked for further FT 7.

8 letters of support. The Trust has been working with key stakeholders during the intervening period, keeping them up to date. 46. Relationships between commissioners and the Trust have been historically challenged but there has been considerable improvement in this since the Board to Board in June The Trust and commissioners have worked together between September 2014 and March 2015 on the commissioner-led public consultation for the Estates Modernisation Programme which has provided an opportunity for closer working. All CCG governing bodies have now approved the recommended option for the estate redevelopment. Sustainability 47. The Sustainability assessment considers how the Trust is performing across four key areas: financially viable, legally constituted and representative, good business strategy and well-governed. At the time of the Board to Board, the Trust was assessed as green across four of the five areas. It was assessed as amber-red for financially viable due to concerns about a number of areas including mitigation plans for the downside scenario and the strength of the rolling 2-year cost improvement programme. Further detail is provided below in relation to financial viability. Financially Viable 48. In the last three years the Trust has reported normalised surpluses that have declined slightly from 1.3% to 1.0%. 49. For 2014/15 the Trust is forecasting a normalised surplus of 1.6m (1.0%) with a CIP designed to deliver savings of 7.8m (5% of cost base). 50. The NHS TDA Business Support Team has worked with the Trust on a regular basis from June 2014 onwards to both improve and assure the Trust s readiness to meet FT requirements from a financial perspective. This included testing of the Trust s key assumptions underpinning the Trust s Long Term Financial Model (LTFM) (and subsequent versions), efficiency requirements, Cost Improvement Plan (CIP) details and documentation including the Quality Impact Assessment process, downside scenarios and mitigations and the associated versions of the Integrated Business Plan (IBP). 51. The final IBP, LTFM and associated documents were received in February 2015 and have been reviewed in detail. Due to the Estates Modernisation Programme the Trust produced a 10-year rather than a 5 year LTFM. The income and expenditure projections for the 5 years to 2019/20 are set out in Table 2 below. The full 10 year income and projections are in appendix 4. Table 2: Income and Expenditure, LTFM 2014/ /20 8.

9 Actual Outturn Forecast Forecast Forecast Forecast Forecast ( '000s) Mar - 14 Mar - 15 Mar - 16 Mar - 17 Mar - 18 Mar - 19 Mar - 20 Protected/mandatory clinical revenue, Total 147, , , , , , ,082 Other revenue, Total 12,374 11,227 11,241 10,547 10,146 10,099 10,055 Total revenue 160, , , , , , ,136 Employee Benefit Expenses (118,389) (115,068) (110,666) (110,150) (107,655) (105,889) (104,543) Drug expenses (2,777) (2,466) (2,700) (2,636) (2,656) (2,729) (2,794) Clinical supplies and services expenses (670) (638) (630) (622) (601) (575) (554) Contingency 0 (800) (800) (800) (800) (800) (800) Other expenses (24,559) (23,667) (24,749) (25,466) (26,312) (26,505) (23,837) Provision for bad debts (481) Total Operating Expenses (147,762) (143,238) (140,004) (140,303) (138,664) (137,152) (133,190) Surplus/(Deficit) from operations 12,281 13,315 13,827 13,430 13,853 14,441 16,946 Surplus/(Deficit) from operations margin 7.7% 8.5% 9.0% 8.7% 9.1% 9.5% 11.3% Gain/(loss) on asset disposals Impairment Losses (Reversals) net (3,240) (986) (11,684) Total Depreciation & Amortisation (4,612) (5,096) (5,409) (5,632) (5,192) (4,914) (5,019) Interest expense on overdrafts and working capital facilities Total interest payable on Loans and leases (475) (475) PDC Dividend (6,107) (6,655) (6,904) (7,098) (7,139) (8,058) (9,048) Total Non-Operating expenses (9,555) (11,700) (12,249) (12,605) (15,410) (14,334) (26,178) Surplus (Deficit) before Tax 2,726 1,615 1, (1,557) 107 (9,232) Net margin 2% 1% 1% 1% -1% 0% -6% Normalised surplus/ (deficit) 1,624 1,615 1,606 1,612 2,345 2,353 2,261 Normalised margin 1% 1% 1% 1% 2% 2% 2% 52. The LTFM is driven by the following assumptions/factors: The Trust has made assumptions on cost inflation and tariff deflation that equate to an efficiency requirement of 3.73% next year, 3.96% in 2016/17 and 3.73% in each of the following three years. These percentages are slightly below the latest assumptions published by Monitor, although their current assumptions have not been released and the Trust assumed that future years efficiency requirements will remain at the 3.8% that underlies the draft tariff for 2015/16; About two-thirds of the Trust s clinical income is currently under block contracts, with the remainder on a cost-and-volume basis. From 2016/17 it is expected that all mental health Trusts will move to a national mental health tariff payment mechanism; With the implementation of the tariff the Trust has assumed that an annual 1% demographic growth will be funded; 9.

10 The Trust has assumed a small number of service developments including the CAMHS Psychiatric Intensive Care Unit (PICU) which have been modelled in the LTFM. 53. The base case demonstrates a normalised margin of 1.0% rising to 1.5%. Based on Monitor s current risk rating model (Continuity of Service Rating- COSR) the Trust has a risk rating of 3 which meets Monitor s minimum requirement. It is noted that after 2019/20 the base case rating does not get above 2 as modelled. The NHS TDA is assured that this is technical due to the accounting treatment of the Estates Modernisation Programme. In addition the current modelling of bridging finance/repayment of loans is sub-optimal and can be made more beneficial for the Trust in their updating of their submission to Monitor. Cost Improvement Plans (CIP) 54. Detailed CIP plans are available for 2015/16 and 2016/17. The Trust has significantly strengthened its CIP governance arrangements and its CIP planning over the last six to twelve months. This has included: improving delivery against plan and reducing non-recurrent mitigation; aligning the plans to the service direction and maintaining the quality of services; devolving and embedding plans in service line management and improving the ownership and accountability for delivery; improving meaningful engagement and consultation with commissioners, service users, staff and other key stakeholders, (e.g. local authorities), which will assist in the risk management of complex changes to service models and pathways; developing the key underpinning plans that support change but need significant lead in time i.e. workforce and facilities. 55. The Trust has recognised the need to invest in resources, infrastructure and governance in order to improve their recurrent delivery of the savings programme and increase leadership, assurance and visibility on schemes as they are implemented. The savings programme is developed through a combined top-down and bottom-up process, with the more complex crosscutting organisational schemes driven by the Executive team. 56. Every CIP programme is quality impact assessed by the Medical Director and Director of Nursing, both as individual schemes and the collectively. The position is reviewed at the Quality and Safety Assurance Committee. The Finance and Investment Committee review, sign off and monitor the overall CIP position. CIPs are reviewed and approved by commissioners through contracting and the Clinical Quality Reference Group. 57. Just under half of the Trust s efficiency forecasts from 2015/16 and 2019/20 relate to service transformation schemes. These schemes depend upon significant internal workforce restructures, establishing new partnerships/agreements with other parties and a material estates 10.

11 redevelopment. Examples of these schemes include transforming the acute care pathway and older people s service. 58. Due to the transformational nature of the CIP schemes a Transformation Programme Director has been appointed who reports to the Director of Operations and oversees the programme. Clinical leads have been assigned to each programme and there is engagement from staff. Clinical commissioners and commissioning managers have been invited onto each project board and are involved in the planning of all the major transformation schemes. There will be involvement of service users and carers at different stages, depending on the needs of the programme. 59. Each of the workstreams is led by a service director or operational lead and a clinical director or clinical lead. The workstreams are monitored through the Transformation Programme Board, chaired by the Director of Operations and this reports to the Trust Portfolio Board, chaired by the Chief Executive. Downside and Risks 60. The Trust has developed a robust downside scenario with 28 sensitivities modelled against 5 key risk areas including the impact of the Estates Modernisation programme. 61. Risk-specific mitigations are mainly linked to the Estates Modernisation Programme, Terms and Conditions of Service for Staff and an increase in Commissioner QIPP requirements. 62. In the mitigated downside, the normalised margin is maintained at 1% in the first three forward years, reduces in 2019/20 to 0.2% but recovers to 1.6% by the final year of the plan. Cash days are generally higher than in the base case with the exception of 2021/22 when cash is projected to be 0.2m due to the impact of the Estates Modernisation Programme. The COSR rating is stronger in the mitigated downside than the base case as the only years in which it does not get above 2 are years 2021/22 and 2022/23 and it recovers to 3 in 2023/ Whilst the list of risks is not exhaustive and these could change on a regular basis, having worked with the Trust to develop and refine its downside risks and mitigations, the NHS TDA is assured that the Trust has sufficient governance and processes in place to address risks as they arise. Capital 64. The Trust has planned 215.9m of capital investment between 2015/16 and 2023/24, of which 179.0m relates to the Estates Modernisation Programme. The Trust has also planned a significant IT and patient records programme which together total 20.1m over the forecast period. 65. The financial strategy is to use operating cash flows of 70.8m to partly fund the capital programme. The remainder will be funded by land sales as part of the Estates Modernisation Programme (latest valuation 145.1m) between 11.

12 2015/16 and 2021/22, with the Springfield site being the largest component ( 115.1m) 66. There is a projected requirement for temporary financing of 38m to bridge timing differences between capital receipts and construction costs. This is expected to be drawn down in two equal instalments in 2018/19 and 2020/21, with the first and main tranche of repayment starting in 2021/22. Current Financial Position and Risks 67. The Trust is currently on track to deliver its 1.6m normalised surplus in 2014/ Delivery of recurrent CIP is below plan by 2.9m (37%) at the end of January The Trust will make up the shortfall with non-recurrent schemes. The Trust has strengthened its CIP planning for 2015/16 to ensure greater delivery of recurrent schemes. 69. The key risks to the Trust s financial sustainability are: Confirmation of commissioner support to the key transformational efficiency programmes; Finalisation and alignment of an approved Estates Modernisation Programme Outline Business Case with current submission of LTFM projections. Legally Constituted and Representative 70. South West London and St George s Mental Health NHS Trust has obtained written assurance from Capsticks LLP solicitors that the Trust s constitution is compliant. 71. The Trust currently has 3,701 public members and 2,108 staff members as at 13 February The Trust has almost met its targeted public membership of 4,000 by authorisation. Good Business Strategy 72. The Trust s strategy is focused around the following objectives: Quality and value we will provide consistent, high quality safe services that represent value for money ; Partnerships we will develop stronger external partnerships and business opportunities that improve access, responsiveness and service range ; Co-production co-production means delivering public services in an equal and reciprocal relationship between professionals, people using services, their families and their neighbours. Where activities are coproduced in this way, both services and neighbourhoods become far more effective agents of change ; 12.

13 Recovery we will enable increased hope, control and opportunity for our service users ; Innovation we will become a leading innovative provider of health and social care services ; Leadership and Talent we will develop leadership and talent throughout the organisation. 73. The Trust s strategy is underpinned by six areas of transformation: CAMHS remodelling, Acute Care Pathway, Community Services Modernisation, Older People s Pathway, Partnership Improvement and Infrastructure Development. These are all reflected in the Trust s 5-year Integrated Business Plan and Long Term Financial Model. These service developments are set out in Appendix 3. Conclusion 74. The NHS TDA assurance processes have assessed South West London and St George s Mental Health NHS Trust against the fundamentals for aspirant Trusts to progress to assessment by Monitor: delivery of clinical quality, good patient experience and national and local standards and targets, within the available financial resource. The key domains of assessment are quality, delivery and sustainability and the conclusions against each of these domains are: Quality 75. The Trust has a comprehensive Quality Strategy and is making good progress on the key quality priorities and they have demonstrated continued quality improvements in care. 76. There are no material quality risks for South West London and St George s Mental Health NHS Trust, with evidence of a Trust focus on sustainable quality improvement from Board to Ward. 77. Monitor is in the final stage of its pre-referral Quality Governance Framework assessment. Feedback on the provisional findings indicates that the Trust can realistically expect to be able to address the gaps in assurance over the next few months in order to achieve a score consistent with authorisation. A verbal update will be provided to the NHS TDA Board. Delivery 78. South West London and St George s Mental Health NHS Trust is delivering against the performance standards and has addressed issues relating to its performance on RTT and CPA reviews. 79. South West London and St George s Mental Health NHS Trust has a capable Board to deliver the FT agenda. 80. External relationships with commissioners are strengthening. 13.

14 Sustainability 81. Financially viable, the Trust has a good track record in relation to finance, having delivered a normalised surplus over the last 3 years 82. The Trust s constitution is compliant with the National Health Service Act 2006, as amended by the Health & Social Care Act The Trust s transformation schemes will require commissioner support to be implemented. Areas requiring action during the Monitor assessment phase 84. As a result of the NHS TDA s Assurance Process, and following the stocktake meeting on 3 March 2015, the following areas have been identified that will require a particular focus from the Trust in progressing its FT application through the final stages of assessment, assurance and authorisation by Monitor: The completion and acceptance of a robust Operating Plan for 2015/16 consistent with the LTFM, with signed contracts in place for 2015/16; The submission to the NHS TDA of a Board-approved Outline Business Case for the estate redevelopment which aligns with the LTFM; Substantive recruitment to the Director of Nursing post, with aarrangements confirmed to manage the transition and mitigate risks to quality; Development and implementation of an action plan to address gaps in assurance identified by Monitor through the Quality Governance Framework. Recommendation 85. The recommendation to the NHS TDA Board is that South West London and St George s Mental Health NHS Trust should be put forward to Monitor for the next stage of assessment. 14.

15 Appendix 1 Summary Assessment of South West London and St George s Mental Health NHS Trust FT Application 15.

16 Summary Assessment The NHS TDA s Business Support, Delivery and Development and Quality Teams have continued to assure the Trust s application following the Board to Board held on 19 June Further assurance has been obtained that the Trust has addressed the issues raised at the Board to Board and that it is appropriate for the Trust s FT application to be considered by the NHS TDA Board in March 2015 and referred on to Monitor in April The assessment of the Trust in June 2014 was as follows: Quality Delivery Sustainability Safe GA Good Service Performance G Financially Viable AR Effective Caring Responsive G GA GA Capable Board to deliver External Relationships GA A Legally Constituted and Representative Good Business Strategy Well-Governed G G G Well-Led GA The assessment of the Trust in March 2015 is as follows: Quality Delivery Sustainability Safe G Good Service Performance G Financially Viable GA Effective Caring Responsive GA G G Capable Board to deliver External Relationships GA GA Legally Constituted and Representative Good Business Strategy Well-Governed G G G Well-Led G As can be seen there has been an improvement in most of the scores.

17 Summary Assessment of the Trust s FT Application: Independent Assessments Quality Governance Framework (QGF) Trust (Dec 2012) External (Feb 2013) External (Oct 2013) Trust (Oct 14) Board Governance Assurance Framework (BGAF) Trust (Dec 2012) External (Feb 2013) Trust (Oct 2013) Trust (Dec 2014) G x 3 G x 3 G x 6 G X 8 GA x 9 GA x 7 GA x 9 GA X 7 AR x 3 AR x 5 Historic Due Diligence (HDD) Continuity of Services Risk Rating (COSR) Forecast 2014/15 Forecast 2015/16 Shadow RAF rating 2. RAF rating would be 0 if RTT is excluded Forecast 2016/17 Forecast 2017/18 Forecast 2018/19 Forecast 2019/20 Metric Result Result Result Result Result Result Liquid Ratio Capital Servicing Capacity Metric Result Result Result Result Result Result Liquid Ratio Capital Servicing Capacity COSR Score The deterioration in COSR score in 2019/20 is due to the Estates Modernisation Programmed Stage 1 (Feb 2013) Stage 2* (Dec 2013) Green x 2 Green x 4 Amber /Green x 4 Amber /Green x 9 Amber x 10 Amber x 7 Red/Amber X 2 Red/Amber x 1 Red x 5 Red x 4 This is the overall assessment of the Trust by Independent Assessors covering QGF, BGAF and HDD 1 and 2 as well as the COSR generated by the Trust s LTFM; these are also explored in further detail throughout this briefing.

18 Appendix 2 South West London and St George s Mental Health NHS Trust Oversight and Escalation Ratings from April 2014 to December 2014

19 South West London and St George s Mental Health NHS Trust NHS TDA Oversight and Escalation Rating NHS TDA Oversight and Escalation, 2014/15 April May June July August September October November December Overall 4 Standard Oversight 4 Standard Oversight 4 Standard Oversight 4 Standard Oversight 4 Standard Oversight 4 Standard Oversight 4 Standard Oversight 4 Standard Oversight 4 Standard Oversight Quality and Governance This was due to planned underperformance of the RTT standards as part of backlog clearance OVERALL AG AG AG A A A A AG AG Responsive A AG G RA RA AG AG G G Effective* R R R R R R R R R Safe AG AG G G G G AG G AG Caring G G G G G RA RA RA A Well-Led G G G G G G G G G Finance Finance N/A G A A A A A A A Delivering Sustainability This was due to a new indicator being added in September Number of written complaints per 1000 patients in contact with services (Trust Red rated). The improvement in December was due to a new indicator being added in - % staff recommending their organisation as a place for care from FFT (Trust Green rated) Sustainability AG AG AG AG AG AG AG AG AG * There are limited indicators for Mental Health Trusts in this domain. The Trust is not achieving the IAPT standard hence the Red rating.

20 Appendix 3 South West London and St George s Mental Health NHS Trust Service Developments

21 South West London and St George s Mental Health NHS Trust Service Development Priorities Four Transformational Change programmes Programme CAMHS remodelling Acute Care pathway Community Services modernisation Older People s pathway Brief Details This programme is close to completion and an example of the benefits seen is the improvement in the Trust s RTT Non Admitted performance. The remodelling improved access, reduced waiting times and modernised the model of care to deliver the best outcome for children and families. Developing alternatives to admission through Home Treatment Teams; improving inpatient experience with investment in staff and inpatient services provided from fewer sites with more modern facilities Improving access and streamlining referral systems. Reducing the duration of secondary care while improving quality on-going community support and resilience through the co-production of a network of local support and peer-led care. Utilising existing expertise gained from the provision of beacon services for older people in Sutton for developing more community and home based services in South West London. Intensive support from home treatment teams to offer alternatives to admission and a reduction in acute bed use by older adults Cross-cutting Trust wide programmes Programme Partnership Improvement Infrastructure development Brief Details Establish the Trust as the lead within the development of mental health and wellbeing in the South West London sector by working in partnership with health and social care commissioners and other acute and community providers. Improvements in the infrastructure supporting clinical delivery including review of administration functions and processes and medical staffing review

22 Appendix 4 South West London and St George s Mental Health NHS Trust Income and Expenditure projections for 10 years 22.

23 South West London and St George s Mental Health NHS Trust Income and Expenditure projections for 10 years Actual Actual Outturn Forecast Forecast Forecast Forecast Forecast Forecast Forecast Forecast Forecast ( '000s) Mar - 13 Mar - 14 Mar - 15 Mar - 16 Mar - 17 Mar - 18 Mar - 19 Mar - 20 Mar - 21 Mar - 22 Mar - 23 Mar - 24 Protected/mandatory clinical revenue, Total 149, , , , , , , , , , , ,490 Other revenue, Total 13,360 12,374 11,227 11,241 10,547 10,146 10,099 10,055 10,047 10,070 10,062 10,054 Total revenue 163, , , , , , , , , , , ,544 Employee Benefit Expenses (121,248) (118,389) (115,068) (110,666) (110,150) (107,655) (105,889) (104,543) (104,604) (104,260) (104,148) (104,176) Drug expenses (2,902) (2,777) (2,466) (2,700) (2,636) (2,656) (2,729) (2,794) (2,852) (2,910) (2,967) (3,024) Clinical supplies and services expenses (600) (670) (638) (630) (622) (601) (575) (554) (552) (550) (547) (544) Contingency 0 0 (800) (800) (800) (800) (800) (800) (800) (800) (800) (800) Other expenses (24,592) (24,559) (23,667) (24,749) (25,466) (26,312) (26,505) (23,837) (22,457) (22,936) (22,858) (22,713) Provision for bad debts 3 (481) (2) (3) (2) (2) Total Operating Expenses (150,622) (147,762) (143,238) (140,004) (140,303) (138,664) (137,152) (133,190) (131,946) (132,147) (132,023) (131,972) Surplus/(Deficit) from operations 12,573 12,281 13,315 13,827 13,430 13,853 14,441 16,946 19,097 19,789 20,736 21,573 Surplus/(Deficit) from operations margin 7.7% 7.7% 8.5% 9.0% 8.7% 9.1% 9.5% 11.3% 12.6% 13.0% 13.6% 14.0% Gain/(loss) on asset disposals Impairment Losses (Reversals) net (7,160) (3,240) (986) (11,684) (1,045) (14,704) 0 0 Total Depreciation & Amortisation (4,782) (4,612) (5,096) (5,409) (5,632) (5,192) (4,914) (5,019) (6,292) (6,539) (7,706) (8,003) Interest expense on overdrafts and working capital facilities Total interest payable on Loans and leases (475) (475) (950) (950) (275) (150) PDC Dividend (6,170) (6,107) (6,655) (6,904) (7,098) (7,139) (8,058) (9,048) (9,571) (10,054) (10,450) (11,106) Total Non-Operating expenses (18,063) (9,555) (11,700) (12,249) (12,605) (15,410) (14,334) (26,178) (17,808) (32,203) (18,388) (19,213) Surplus (Deficit) before Tax (5,490) 2,726 1,615 1, (1,557) 107 (9,232) 1,289 (12,414) 2,348 2,360

24 Net margin -3% 2% 1% 1% 1% -1% 0% -6% 1% -8% 2% 2% Normalised surplus/ (deficit) 1,670 1,624 1,615 1,606 1,612 2,345 2,353 2,261 2,285 2,321 2,315 2,369 Normalised margin 1% 1% 1% 1% 1% 2% 2% 2% 2% 2% 2% 2% 24.

25 Appendix 5 Letter to South West London and St George s Mental Health NHS Trust from the Care Quality Commission following Chief Inspector of Hospitals Inspection

26 Care Quality Commission Finsbury Tower Bunhill Row London EC1Y 8TG Telephone: Fax: David Flory Chief Executive NHS TDA 10 June 2014 Dear David Re: South West London and St George's Mental Health NHS Trust application to NHS TDA for Foundation Trust Status CQC has inspected South West London and St George's Mental Health NHS Trust under our new inspection model for NHS Trusts. The range of services and locations we inspected, and our findings, are detailed in the inspection report. This letter provides CQC s view of whether the trust is providing care at an appropriate level of quality. I hope that this will assist NHS TDA in deciding whether the trust should progress in its application for foundation trust status. As a wave one pilot, we did not issue the trust with a rating. However, based on the findings of the inspection report that this letter accompanies, CQC believes that the trust is providing care at an appropriate level of quality to proceed in its FT application. Prior to the site visit we liaised with a number of local stakeholders including local authorities, local health watch teams, overview and scrutiny committees, local complaints advocacy services, local independent mental health advocacy services and mental health capacity advocacy services. We also carried out a listening event and met with detained patients to gain their views. Mental Health Providers Forum facilitated a focus group that CQC also attended in order to capture people s experiences and views of the trust. As part of the inspection process CQC reviewed a range of data, including trust wide information, interviewed staff, patients and carers and visited many locations from which the trust provides care. This has enabled CQC to form a rounded view of quality at the trust. However we have not inspected all services provided by the trust. We would note the following: Good practice in the leadership of the trust; noting that the non-executive directors and the Chair were particularly strong. 26.

27 We saw how staff empowered patients and carers to be at the heart of planning their care and treatment. We saw evidence of comprehensive care and risk plans that were developed with reference to relevant National Institute for Health and Care Excellence (NICE) guidance. We found the leadership of governance and quality was outstanding. Safeguarding and whistleblowing processes were embedded across all of the teams in the trust. Application of the Mental Health Act was good. Throughout the inspection, the interactions between people using services and staff were excellent; they treated people as people. Positive work was noted in ensuring that people could access services through the use of CAPA (Choice and Partnership Approach) with a single point of referral scheme and single point of access scheme. We thought that the trust must improve in the following areas: Ensure that where required comprehensive risk management plans are in place for people using the service where a risk to themselves or others had been identified. Ensure that suitable storage, recording and monitoring systems are in place to ensure medications are handled safely and appropriately. Ensure that the mixed gender units comply fully with Delivering same sex accommodation in mental health and learning disability service: Briefing from the NHS Confederation (January 2010). We felt that trust should improve in the following areas: Develop effective arrangements to identify, assess and manage risks consistently across services. Ensure that people using services are protected against the risks of potentially unsafe or unsuitable premises. Develop an effective system in place for making statutory notifications in a timely manner. Ensure that specialist training is provided to all staff working in specialist areas of the trust. Develop the electronic patient notes system to ensure that it supports and evidences true patient involvement in the planning of their care. Develop and implement the falls recording and learning system to ensure that falls are recorded and learning is put into practice. Ensure that all people referred to services are provided with the contact details for a named staff member they can talk to regarding their care and support. We have issued three compliance actions; 1. A compliance action was issued regarding management of medicines in two locations. 27.

28 2. A compliance action was issued regarding care and welfare in relation to the mixed sex accommodation in two locations. 3. A compliance action was issued in relation to risk management plans which were not consistently being put in place for people using the service where a risk to themselves or others had been identified, in three locations. At the Quality Summit held on the 09 June 2014, the trust informed us they are progressing with the action plan put in place to ensure full compliance. The trust will formally informing CQC on completion of their action plan so that a re-inspection can take place within the next three months as per our policies and protocols. While we expect NHS TDA to place significant weight on CQC s view of quality at the trust, we expect our view to be considered as part of Monitor s broader decision making process for determining whether the trust should progress in its foundation trust application. I am copying this letter to David Bennett at Monitor. I have not yet copied it to the trust and would be grateful if we could coordinate our communications with them. Yours sincerely Professor Sir Mike Richards Chief Inspector of Hospitals Care Quality Commission CC: David Bennett, Chief Executive Monitor 28.

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