[Insert name of Aspirant Foundation Trust]

Yüklə 371,65 Kb.
ölçüsü371,65 Kb.
  1   2   3   4   5

West London Mental Health Trust
BGM Submission Document
Date of self assessment submission to the Board – 27/06/12

Date of BGM Action Plan to the Board – 25/07/12

Date of Independent Appraisal of BGF - Sept 2012
Planned date to enter DH process as per TFA – 01/01/13


Board context 3 - 5
Summary results 6 - 7

  1. Board composition & commitment 8 - 15

2. Board evaluation, development & learning 16 - 28

  1. Board insight and foresight 29 - 41

  1. Board engagement and involvement 42 - 53

  1. Board impact case studies 54 - 58

Board context

This section should set the overall context for the Trust and should include a brief overview of the Trust, together with a summary of the Board’s key strategic objectives and how the Trust is performing against them. This overview links into section 3.3 of the Board Memorandum under good practice point 5 which covers the Board’s strategic focus. It provides the Board with an opportunity to summarise what is important to the organisation, how it performs against KPIs and what patients think of the services provided.
In this section please provide a brief overview of:

  1. Your organisation in terms of income, staff and key services provided;

  2. Your organisation’s key strategic objectives;

  3. Summary of the KPIs the Board uses to track performance against these objectives and how it is currently performing;

  4. Summary of the Trust position with regards patient feedback

West London Mental Health NHS Trust (WLMHT) is based in North West London and was formed in 2001 following the merger of Ealing, Hammersmith & Fulham Mental Health Trust, and Broadmoor Hospital Authority. The Trust was further enlarged by the absorption of Hounslow Mental Health Services following the dissolution of the Hounslow and Spelthorne Community and Mental Health Trust in April 2002. In April 2003, the remainder of the Hounslow services for adults and older people joined the Trust.
WLMHT provides a range of specialist and forensic mental health services, including High Secure care at Broadmoor Hospital. The Trust also provides a full range of local mental health services for children, young people and families, adults and older people living in the London boroughs of Ealing, Hammersmith & Fulham, and Hounslow. The Trust is registered with the CQC with no conditions.
The Trust’s vision is to become a leading provider of specialist mental health services, which promotes recovery.
Our three local London boroughs have a combined population of 739,4501. The Trust has a forecast income for 2012/13 of £230m. In 2011/12 we employed 3615 WTE, this included bank and locum staff. In addition to this we utilised 170 WTE agency staff. This volume of temporary staff has been used as part of the Trust’s approach to reorganisation, giving a flexible approach, reducing the requirement for redundancies and lowering costs.
The high-level structure for the Trust is detailed below:

*As at 25th June 2012
The Trust is organised into three Clinical Service Units (CSUs):

  • Local Services (1147 full-time equivalents* (FTE)):

Mainstream local mental health services covering the three London boroughs of Hounslow, Hammersmith & Fulham and Ealing, and delivering:

  1. Adult services

  2. Older people’s services

  3. Children & Adolescent Mental Health Services (CAMHS)

  • Specialist and Forensic Services (782 FTE):

    1. Medium secure services

    2. Low secure services

    3. Challenging behaviour services

    4. National specialist services:

      1. Gender re-assignment

      2. Personality disorders for young people

  • High Secure Services (798 FTE):

    1. Broadmoor Hospital

The CSU structure underpins the Trust’s commitment to providing consistent, high quality and effective care for our service users through the development of pathway specific services. Our focus is on recovery and delivering the highest standard of care to service users and their carers. Each of our CSUs is led by a Director, who works closely with clinical colleagues to ensure that the planning and implementation of major service change such as the transformation programme we are currently undergoing are do not impact on the quality and safety we deliver. Each CSU has an individual business plan, updated annually as part of the business and financial planning cycle that sets out key details of activity, workforce and actions to deliver over the year.

The Trust intends to position itself as a high quality mental health provider by capitalising and focusing on core expertise of providing mental health services. We wil:

  • Deliver consistently excellent community mental health services

  • Build on the existing expertise within the Trust of delivering best practice across a wide range of forensic services including a number of national pilot services

  • Develop further specialist mental health services and our profile as a centre of research and academic excellence.

The Trust’s medium term or corporate objectives are:

  • C01 – To provide a safe and effective service

  • C02 – To deliver excellent personalised care, treatment and support

  • C03 – To become a provider of choice

  • C04 – To continuously improve the quality and productivity of our services

  • C05 – To build an engaged workforce that is focused on recovery and the needs of service users and their carers

Our priorities for 2012/13 are:

  • To Redevelop Broadmoor and St Bernard’s Hospitals

  • To deliver new service models and service redesign

  • To implement the Trust’s quality strategy

  • To continue preparations to become an NHS Foundation Trust

  • To maintain financial stability

Each element of the Trust’s objectives and supporting strategies are performance managed through the Board scorecard and regularly reported to Board through the Integrated Performance Report (IPR)

The Director of Nursing & Patient Experience has organised service user and carer meetings which are attended by the Board. The Trust also receives feedback on patient experience at every Board meeting. This is supplemented by a detailed Board visit programme and more recently introduced an electronic patient feedback system known as Meridian.

Summary results

Overview of BGM sections 1 to 3 inclusive

1. Board composition and commitment



Self-Assessment rating

Any additional notes


Board positions and size




Balance and calibre of Board members




Board member commitment



2. Board evaluation, development and learning


Effective Board-level evaluation




Whole Board development programme




Board induction, succession and contingency planning




Board member appraisal and personal development



3. Board insight and foresight


Board performance reporting




Efficiency and Productivity




Environmental and strategic focus




Quality of Board papers and timeliness of information



Summary results
Overview of BGM sections 4 to 5 inclusive

4. Board engagement and involvement



Self-Assessment rating

Any additional notes


External stakeholders




Internal stakeholders




Board profile and visibility




Future engagement with FT Governors



5. Board impact case studies

Key points to highlight


Performance issues in the areas of quality

Quality: Response to delays in implementing actions to Serious Incident Reporting


Performance issues in the areas of finance

Finance: The management of investment decisions relating to the Broadmoor Hospital redevelopment programme


Organisational culture change

Culture change: The QUASIC Programme



Organisational strategy

Vision and Strategy Shaping


1. Board composition and commitment
1.1 Board positions and size
Section RAG rating:


Evidence of compliance with good practice

(Please reference any supporting documentation below and attach with your submission)

Action Plans to achieve good practice

(Please reference Actions Plans below and attach with your submission)

Explanation if not complying with good practice

Q1. The size of the Board (including voting and non-voting members of the Board) is appropriate for the requirements of the business.

A1. The size of the Board is determined by the Trust’s Establishment Order and is considered appropriate for the size of the business, including provision for high secure services.

Evidence: Establishment Order 2000 No 2562

Q2. All voting positions are substantively filled.
A2) All voting positions bar CEO substantially filled from 1 April 2012. CEO appointed and commenced on 25th June 2012.

Evidence: NEDs appointment letters, EDs HR records, Minutes of Board Meetings.

Q3. The Board has a Senior Independent Director (SID) in place.
A3) Geoff Rose was appointed Senior Independent Director in April 2011.

Evidence: Minutes of Board Meeting 27th April 2011, role profile of SID, letter from Company Secretary confirming appointment.

Q4. The Board has a Foundation Trust Secretary (or equivalent) in place.
A4) Nigel Leonard commenced the duties of the Foundation Trust Secretary in February 2010.
Evidence: Job description/HR records, minutes of Board meetings, profile on website.

Q5. It is clear who on the Board is entitled to vote.

A5) Voting position is clear
Evidence: Trust Standing Orders and minutes of Board meetings.

Q6. At least half the Board of Directors, excluding the Chair, comprise NEDs determined by the Board to be independent (refer A3.2 and C2.2 in the Monitor NHS Foundation Trust Code of Governance).

A6) None of the NEDs has any past or current substantive connection with the Trust and are therefore considered independent in line with Monitor’s Code.
Evidence: NEDs biographies, Register of Declaration of Interests
Q7. Where necessary, the appointment term of NEDs is staggered so they are not all due for re-appointment or leave the Board within a short space of time
A7) Appointment of NEDs is staggered. Majority of NEDs serve their first term and term periods vary between 2 to 4 years.
Evidence: NEDs appointment letters, summary table of NEDs periods of appointment


Q5) Update the organisational charts (photo charts that Comms produce) to include asterisk and footer clarifying voting and non voting members. Revision to Committee ToR to limit members to voting Directors with others in attendance.

Red Flags

Action plans to remove the Red Flag(s) or mitigate the risk presented by the Red Flag(s)

Notes/ comments

Q1. The Chair and/or CEO are currently interim or the position(s) vacant.
Q2. There has been a high turnover in Board membership in the previous two years (i.e. 50% or more of the Board are new compared to two years ago).
Q3. The number of people who routinely attend Board meetings is unwieldy compared to other NHS Provider Trusts.


Section RAG rating:

. Board composition and commitment
1.2 Balance and calibre of Board members

Evidence of compliance with good practice

(Please reference any supporting documentation below and attach with your submission)

Action Plans to achieve good practice

(Please reference Actions Plans below and attach with your submission)

Explanation if not complying with good practice

Q1. The Board can clearly explain why the current balance of skills, experience and knowledge amongst Board members is appropriate to effectively govern the Trust over the next 5 years. In particular, this includes consideration of the value that each NED will provide in helping the Board to effectively oversee the implementation of the Trust’s IBP.
A1. The Board can clearly explain why the balance of skills, experience and knowledge of Board members is appropriate to govern the Trust for 5 yrs; including value of each Board member. An assessment of Board skills was undertaken in the Autumn 2011 as part of the succession planning and the recruitment of a new NED (Lynne Weedall).
Evidence: Notes of Chief Executive, Chairman and Company Secretary
Q2. In selecting Board members, the Chair and CEO have given due consideration to various qualities that are essential for the person to be effective in their Board role (e.g. effective at working in teams, independence of thought, well developed political/ influencing skills, sound judgement, ability to build trusting and respectful relationships, ability to listen first and then assert their view).
A2. Chair/CEO & Board have given due consideration on qualities that are essential for each Director to be effective in their Board role (including. independence, political/influencing, good judgement etc)
Evidence: Discussion prior to appointment of Lynne Weedall, Board etiquette, person specification for LW’s appointment
Q3. The Board has an appropriate blend of NEDs from the public, private and voluntary sectors.
A3. NED blend at WLMHT is a mix of public, private & voluntary

Evidence: Board profiles

Q4. The Board has given due consideration to the diversity of its composition in terms of the protected characteristic groups in the Equality Act 2010.
A4 The Board has actively promoted applications from ethnic minorities in line with the Equality Act 2010.
Q5. There is at least one NED with a clinical healthcare background (e.g. a doctor, nurse or allied health professional who is not conflicted).
A5. Two NEDs have clinical healthcare background (Professor Lefkos Middleton and Geoff Rose). Professor Middleton represents academic interests in line with the Establishment Order. Geoff Rose is a pharmacist.

Evidence: Board profiles

Q6. There is an appropriate balance between Board members (both Executive and NEDs) that are new to the Board (i.e. within their first 18 months) and those that have served on the Board for longer.
A6. There is an appropriate mix of Board members with below and above 18 months experience in the Trust

Evidence: Appointment letters

Q7. The majority of the Board are experienced Board members.

A7 Majority of the Board are experienced Board members

Evidence: Board profiles

Q8. The Chair of the Board has a demonstrable and recent track record of successfully leading a large and complex organisation, preferably in a regulated environment.
A8. The Chairman is a chartered accountant with a background in corporate finance, aerospace and the software sector. He was Vice Chair of St Mary’s NHS Trust for eight years and has chaired the Board of Governors at Bournemouth University for 6 years.

Evidence: Chairman’s profile

Q9. The Chair of the Board has previous non-executive experience.
A9. Chair has previous NED experience in the NHS, university and private sectors.

Evidence: Chairman’s profile

Q10. At least one member of the Audit Committee has recent and relevant financial experience.
A10. Christine Higgins, Chair of Audit Committee, is a chartered accountant.

Evidence: Audit Committee chair’s profile

Red Flags

Action plans to remove the Red Flag(s) or mitigate the risk presented by the Red Flag(s)

Notes/ comments

Q1. There are no NEDs with a recent and relevant financial background.
Evidence: Nigel McCorkell and Christine Higgins are chartered accountants.

Q2. There is no NED with current or recent (i.e. within the previous 2 years) experience in the private/ commercial sector.

Examples: Nigel McCorkell, Christine Higgins, Geoff Rose, Barbara Kerin, Neville Manuel, and Lynne Weedall have experience in the private/commercial sectors.

Evidence: Profiles

Q3. The majority of Board members are in their first Board position.
Evidence: Profiles

Q4. The majority of Board members are new to the organisation (i.e. within their first 18 months).

Evidence: Majority are on the Board for more than 2 years as evidenced by appointment letters.


Yüklə 371,65 Kb.

Dostları ilə paylaş:
  1   2   3   4   5

Verilənlər bazası müəlliflik hüququ ilə müdafiə olunur ©www.genderi.org 2023
rəhbərliyinə müraciət

    Ana səhifə