Agenda Item No:
SUMMARY REPORT / MENTAL HEALTH AND SAFEGUARDING COMMITEE / 23 Nov 2016
Report title: / ASSOSSIATE HOSPITAL MANAGERS ASSURANCE REPORT
Executive Lead: / Nigel Leonard
Report Author(s): / Karlien Saayman on behalf of Steve Currell
Report discussed previously at: / NA
Level of Assurance: / Level 1
2 / 
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Purpose of the Report
This report is provided to the Mental Health and Safeguarding Committee by the Chair of the Associate Hospital managers (AHM) Committee. It is designed to provide assurance to the Mental Health and Safeguarding Committee that risks that may affect the achievement of the organisations objectives are being managed effectively and to provide assurance that the committee is discharging its terms of reference and delegated responsibilities effectively. This is an integral part of the Trust’s agreed assurance system. / Approval / 
Discussion
Information / 
Recommendations / Action Required
The Mental Health and Safeguarding Committee is asked to:
  1. Consider the risks, issues and hotspots and where appropriate the mitigating actions as identified in the report.
  2. Note the positive assurance provided in respect of matters relevant to organisational governance/ compliance.
  3. Request further action / information as required.
  4. Agree matters of concern that should be brought to the attention of the Board of Directors.

Summary of Key Issues
The key Issues:
  • Training:
The committee members undertook safeguarding training at the previous meeting.
  • Care Plans:
The meeting raised concerns about the completion of care plans presented at hearings as the plans don’t always evidence that the patient has been involved in the planning of the care plan and that they aren’t always reviewed in a timely manner. The members felt that the care plans are important documents for gaining up to date information on the patient’s care. The members were given assurance that operational leads will continue to keep the pressure on staff to ensure compliance with the completion of care plans.
  • Hearing reports and audit of reports:
The meeting expressed concern and queried whether hearings should be adjourned if a Responsible Clinician does not attend. Advice was given that a doctor who knows the patient should attend and this might not always be the RC.
The meeting were informed that an audit of the decisions was completed. Twelve decisions had been audited and all were of a good standard and gave good evidence for using your powers appropriately, the decisions were informative.
  • Travel Expenses and Taxes:
The Trust has acted in good faith based on information given by HMRC. Following numerous discussions with HMRC new advice has been issue in that AHM’s do not have to pay tax on their travel expenses. The letter of agreement has been amended by HR to reflect this advice.
  • CQC visits and MHA audit report:
The committee were presented with the report and AHM’s expressed concerns that the same recurring themes are still being identified; with regard to s17 leave forms, T2/T3 and s132 rights.The MHA office undertakes regular audits and changes in staff need to be taken into consideration.
Relationship to Trust Strategic Priorities
SP 1: Quality Services / 
SP 2: Quality Leadership & Workforce
SP 3: Sustainability of Service Provision / 
SP 4: Innovative & Transformational Approach to Efficiency and Effectiveness
Relationship to the Board Assurance Framework
Are any existing risks in the Board
Assurance Framework affected? / No
If yes, insert relevant risk
Do you recommend a new entry tothe
Board Assurance Frameworkis made as a result of this report? / No
Corporate Impact Assessment OR Board Statements: Assurance(s) against:
Impact on CQC Regulation Standards, Commissioning Contracts, Trust Annual Plan & Objectives / 
Data Quality Issues / 
Involvement of Service Users/ Healthwatch
Communication and Consultation with stakeholders required
Service Impact/Health Improvement Gains / 
Financial ImplicationsCapital £
Revenue £
Non Recurrent £
Governance Implications / 
Impact on Patient Safety /Quality / 
Impact on Equality & Diversity
Equality Impact Assessment (EIA) Completed? / Yes / No / If yes, EIA Score
Acronyms / Terms used in the report
CEO / Chief Executive Officer
AHM / Associate Hospital managers
CQC / Care Quality Commission
NHS / National Health Service
Supporting Documents &/or Further Reading
  1. The AHM Committee last met on the 22nd of September 2016. The unconfirmed minutes are attached at Appendix A of this report.
  2. Performance against work plan: The work plan for 2016/2017 is attached at to this report at Appendix B, actions ongoing within set time frames.

Executive Lead
Insert Name and signature
Nigel Leonard
Steve Currell

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