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The next meeting will be held on Wednesday 18th February 2015 starting at 10.15am
At Easthampstead Baptist Church, South Hill Road, Bracknell
(At 9:45am prior to the start of the formal meeting, Governors will have the opportunity for a private
meeting with Mr Chris Fisher, Non-Executive Director)
Welcome & introductions
Apologies for Absence
Company Secretary
Declarations of Interest
1. Amendments to Register
2. Agenda items
Minutes of previous meetings – 11 December 2014
Matters Arising
Committee/Steering Groups
1. Reports:
a. Living Life to the Full (Enclosure)
b. Membership & Public Engagement
c. Quality Assurance (verbal)
d. Appointments & Remuneration Committee
Carer Strategy Update
Executive Reports from the Trust
1. Performance Report (Enclosure)
2. Patient Experience Quarter 3 Report (Enclosure)
3. Annual Operating Plan & Financial Plan 2015/16
Update (Oral)
John Barrett/Verity Murricane
Philip Brooks
Gray Kueberuwa
Jenni Knowles, Project Lead
Chief Executive
Director of Nursing & Governance
Chief Executive
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Trust Constitution – Review & Revision
To consider for approval a revised constitution
Company Secretary
NHS Providers Governor Policy Board
Company Secretary
To consider and agree a nomination to the NHS
Providers Policy Board
Chair’s Remarks
Any Other Business/Governor Questions
Date of Next Meeting
20 May 2015
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Council of Governors
Meeting - Wednesday 11 December 2014
In attendance:
John Hedger, Trust Chair
Public Governors
Ruffat Ali-Noor
John Barrett
Peter Bestley
Dolly Bhaskaran
Philip Brooks
Veronica Cairns
Gray Kueberuwa
Verity Murricane
Paul Myerscough
Pat Rodgers
Gary Stevens
Staff Governors
Paul Corcoran
Jeremy Lade
Amanda Mollett
Appointed Governors
Adrian Edwards
Alison Melabie
Bob Pitts
In attendance:
Keith Arundale, Non-Executive Director & Chair of Audit
Julian Emms, Chief Executive Officer
Dr Minoo Irani, Clinical Director Children’s Services
Helen Mackenzie, Director of Nursing
Elaine Williams, Listening into Action Lead
Dr Justin Wilson, Medical Director
Joanne Lees, KPMG
Fleur Nierboer, KPMG
John Tonkin, Company Secretary
Caroline Comer-Stone, Executive Assistant
Public Governors:
Amrik Banse
Michelle Chestnutt
Mohinder Chana
Mavis Henley
June Leeming
Robert Lynch
Nina Sethi
Staff Governors:
Julia Prince
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Appointed Governors:
Sabia Hussain
Craig Steel
Bet Tickner
Welcome & Introductions
John Hedger, Chairman, welcomed all to the meeting.
The Chairman reported the sad death of partnership Governor, Councillor Alan
Kendall paying tribute to him for his long, conscientious and invaluable contribution to
the Trust over many years. Governors expressed their sadness and individual and
collective gratitude for Alan’s considerable contribution to the work of Council – he
would be sorely missed. All present extended their condolences to his partner and
Apologies for absence were received as noted above.
Declarations of Interest
Amendments to Register –
Declarations of Interest -
there were none declared
there were none declared
Minutes of the previous meetings – 24 September 2014
The Minutes of the previous meetings were agreed as a correct record of
Matters Arising
[email protected]
The Director of Nursing & Governance updated Council on the [email protected]
initiative the purpose of which was to keep acutely ill people at home and develop a
pathway to avoid unnecessary A&E admission. Two pilots have been completed
encompassing A&E and Westcall; a proof of concept was completed with identified
criteria. Proof of Concept was conducted over two weeks during which no patients
were admitted on to the service for varying clinical reasons. A review showed that 14
patients would have been admitted to the service if it was fully operational, far fewer
than had been expected. Partners were now considering next steps and, in
particular, putting a focus on reduction in length of hospital stay.
The pilot provided good information about what will make a difference for patients in
the west of the county working with RBH. The initiative will recommence Q1/Q2 in the
west of Berkshire.
Peter Bestley enquired if there could have been earlier intervention for the patients
concerned. Helen Mackenzie advised that in the future it may be possible to manage
acutely ill patients in the community and therefore focusing on length of stay is the
primary concern. With regard to patients remaining in hospital (e.g. frail elderly), she
advised that the need is to ensure that services work with patients and families to
ensure discharge to home or specified areas.
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Jeremy Lade advised that during the project it was pleasing to note the meetings with
people from all areas of community care, social services and hospital working
together in a way not previously achieved and there is now a set of pathways which
can be used to implement early discharge.
Adrian Edwards noted his concern about additional pressures on social services
adding that local authorities are finding themselves in financial difficulty and seeking
funds from elsewhere. Helen Mackenzie commented that commissioners are using
the Better Care Fund to provide additional resource to councils to support
[email protected], as well as discussion with third sector charities e.g. Red Cross.
Patient Experience Report Quarter 2
The Patient Experience Report Quarter 2 was taken as read.
Gray Kueberuwa advised that the report had previously been presented by Nancy
Barber to the Governor Quality Assurance Group and Governors had been
disappointed to see the complaints from the flagship high profile Oakwood Ward.
Nancy Barber had agreed to provide further information in this regard to the Group.
Helen Mackenzie advised that the complaints concerned 3 members of staff and
training is in place particularly around better communication with patients.
Following a query, Helen Mackenzie noted that some higher figures in WAM were
caused because a Trust-wide service is hosted by the locality. It was agreed that the
information narrative should be expanded in future reports to explain such factors.
Paul Myerscough noted the excellence of the information provided in the report but
enquired about the very small number of complaints in the survey showing as not
handled well. Helen Mackenzie advised that the survey reflected a very small cohort
of respondents hence the difficulty in extrapolating data. When complaints are not
upheld people can feel aggrieved although the Trust has handled the complaint
Committee/Steering Group Reports – John Barrett/Verity Murricane
Living Life to the Full
John Barrett presented the report of the Living Life to the Full Group. He
offered his congratulations to Mark Hardcastle on the excellent conference
‘Angels & Demons in all of us’ suggesting that a similar event will take place
next year and discussions are underway with Alison Durrands in this regard.
Vicki Matthews had updated the Group with regard to the memory services
and presented the Dementia Carers’ Handbook. This was initially compiled by
Luke Solomons, in collaboration with Reading University, and funded by the
west Berkshire CCGs. An electronic version is available on the Trust website.
It is hoped funding might be secured to roll out the programme in the east of
the county.
Verity Murricane advised that the conference was a very good opportunity for
staff to get together and share information; she enquired what mechanism is
in place to disseminate the information particularly that from working groups.
Some members of staff felt that their concerns went unheeded by the Board
but other thought the Board did listen. John Hedger noted a similar
experience with split opinions about pressures in general on frontline staff.
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John Barrett & Verity Murricane to ask Mark Hardcastle for
further information about the conference feedback
Membership & Public Engagement
The report of the Membership & Public Engagement group was taken as
Philip Brooks drew attention to paragraphs 1 & 2 relating to raising Governor
profiles; he requested that photographs be supplied of individuals and if
possible, groups of locality Governors.
The Trust is maintaining the membership target of 10k; there is a high
turnover in Reading mainly around university students. It has been suggested
that discussions with Craig Steel could assist in promoting a more actively
engaged student membership particularly around mental health for
With regard to community mapping, it was noted that Clare Bright is working
with third sector organisations and charities and will be attending the next
meeting of the Living Life to the Full group. The Membership & Public
Engagement group had agreed that this topic should logically sit with the
Living Life to the Full Group.
John Barrett to contact Clare Bright
Quality Assurance
The report of the Quality Assurance Group was taken as read.
Gray Kueberuwa added that Alan Kendall was very much missed, having
brought a great deal of experience to the group.
He highlighted the feedback from a quality visit to Slough CAMHs which had
raised some concerns. Governors had felt higher than expected levels of
stress and workload which were highlighted in the report. John Hedger noted
that this challenging service position had been recently discussed by the
Trust Board and the Quality Assurance Committee. Julian Emms advised that
mitigation is in place to keep the service safe but noted quality impacts in
terms of waiting times and pressure on staff. Discussions were continuing
with commissioners to achieve a better outcome for the CAMHs service
provision and there had been some encouraging signs.
From the Wokingham Older Adults CMHT service, it was noted that a
vacancy had been open for a long period of time owing to long-term sickness
and cannot therefore be filled as the post holder is likely to eventually return
to work.
Governor Visits
The Report of Governor service awareness visits was presented and taken as
read. John Tonkin thanked Caroline Comer-Stone for her work in collecting
information and producing a very helpful report and it was pleasing to note
that over half the total number of Governors had been involved in the visits.
Subject to sufficient interest, it is hoped to put together another visit
programme in 2015 particularly for areas where visits had been limited.
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Helpful feedback had been supplied by Governors and this was very much
appreciated by staff.
Audit Matters
Governors received a report on audit matters from Chair of Audit, Keith Arundale.
Inter alia, the following matters provide a snapshot of some of the areas considered
by the Committee during the year. Governors were reminded that the Committee’s
minutes are available for reading on the Trust’s website.
External auditors, KPMG, looked at financial statements particularly around
securing economy, effectiveness and efficiencies in use of resources, and an
audit quality report on charitable fund accounts.
Internal auditors review and evaluate risk management systems and governance
arrangements to assist the Trust in achieving its strategic objectives.
Audit Committee reviews the Trust Board Assurance Framework every quarter
seeking assurance on management of key risks to achievement of strategic
objectives. Deep dive reviews of severe and high risks are undertaken for further
assurance on mitigation action.
CQC registration: Baker Tilly, internal auditors, commended the Trust as being at
the leading edge of all FT providers in terms of CQC registration processes.
Information Assurance Framework reviewed quarterly to provide assurance on
the quality of data. Both internal and external auditors advised that the Trust is
very proactive in terms of data quality and an exemplar in terms of other FT
Review of the Annual Plan: progress checked against plan at each meeting.
Both internal and external auditors commented on the Trust’s strong focus on the
Clinical Audit programme.
Review of Counterfraud activity on a quarterly basis. One issue was investigated
concerning a potential procurement fraud. However the Trust is looking into this
in detail and amended processes to cover off.
In conclusion, Keith Arundale thanked Alex Gild and the finance team, Non-Executive
Directors, external and internal Auditors and John Tonkin, Company Secretary.
Paul Myerscough commented that the verbal report was interesting and provided
good information but suggested that more information on the work of the Committee
and on any issues identified could have been included within the written report. Keith
Arundale replied that whilst the report followed the pattern found acceptable by
Governors in previous years, he was happy to expand the report in future if that was
the wish of Council. However, he assured Governors that there are no substantial
issues to concern Governors. All issues are being addressed and there is nothing
noted which would cause the Trust not to meet its objectives.
Peter Bestley suggested it might be helpful to have the two reports (written and
verbal) more aligned but noted his confidence in the non-Executive Directors role in
terms of audit.
John Hedger agreed that the report could be expanded but stredded the importance
of not turning Council into an Audit Committee. Council needs to be assured that the
work of the Trust is externally audited satisfactorily and that the Audit Committee has
a clear process and timetable for reviewing risks and assuring itself that action is
being taken.
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A policy relating to Audit Committee approval of non-audit work by the external
auditor was presented for Council approval and Keith Arundale explained the
purpose which would ensure greater assurance around the commissioning of work
by external audit beyond their contractual activity.
The policy and rationale for it was noted and a proposal was put for approval of the
Proposed by: Peter Bestley
Seconded by: John Barrett
All Governors supported the proposal and the policy was thereby approved.
Council also approved the recommendation that KPMG continue for a further year in
line with their contract.
Annual Audit Letter – KPMG
Fleur Nieboer, KPMG Partner, advised that it is common practice for the external
Auditors to attend the December meeting of the Council of Governors to present the
Annual Audit letter, copies of which had been provided to all Governors.
She reminded members of the external auditors role in examining the Trust’s
financial statements and she was able to confirm that an unqualified opinion had
been given again for 2013/14.
She further advised that the accounts presented for audit were of good quality and
well prepared with very few audit adjustments. She was pleased also to report an
excellent working relationship between the auditor and Trust staff and the Audit
Governors were informed of forthcoming changes around reporting that would see
the introduction of a requirement for an enhanced audit report containing more detail
in the published opinion to the public.
Fleur was thanked for her report.
External Audit Quality Governance Report
Joanne Lees, KPMG, presented the report noting that KPMG had been able to
provide the required limited assurance opinion on the Trust’s Quality Report.
Big Conversations with Patients and Carers
John Hedger welcomed Dr Minoo Irani and Elaine Williams noting that the context of
the discussion concerns listening to patients and members of the community and
public about changes they would like to see in Trust services going forward.
Elaine Williams advised that LiA (Listening into Action) is one of the main BHFT staff
engagement methods – holding conversations with staff questioning how we listen to
and engage with patients, etc. Through October and November six external events
were held including with families, adolescents and learning disability services. It was
made clear that the context was specific to BHFT and not RBH or Wexham Park.
Questions around values generated a great deal of discussions with a great many
people involved; feedback from the sessions is now available on the website. A letter
was sent to all 160 attendees noting the common themes of communication and staff
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Minoo Irani advised his attendance at all events as sponsor noting the unique
opportunity to collect information rather than just complaints, but it is a bold step to
invite opinions externally. The intention of bringing the information to Council is to
highlight the importance of Governor contact with the general public; he invited any
interested Governors who would wish to support the initiative to contact him.
John Hedger thanked Minoo Irani and Elaine Williams for the update emphasising
the importance of listening to what patients and others have to say and noting the
need to ensure the initiative continues and remains part of the Trust business ethos
going forward. The Governors have a large part to play and it would be extremely
helpful if any Governor would be prepared to assist.
Verity Murricane noted that this is a very good start and her willingness to get
involved. She enquired if the events had attracted new contributors to help improve
the richness of opinion obtained. In response, she was advised that the Trust had
ensured that attendees were representative of the population and had included
representation from Healthwatch. Actions plans are in place to implement developed
themes e.g. staff attitude; the first impression of the organisation and how people are
made to feel welcome.
John Hedger thanked Minoo and Elaine for their updates and Governors for their
interest. He asked Council if they felt confident in their ability to reflect the view of
their constituents and what the Trust could do to assist. He suggested that this could
be the subject of a future workshop discussion linked with the forthcoming external
review of the governance of the Trust.
CCS to provide email addresses of interested Governors to Elaine
Quality Account
The Quality Account was presented by the Medical Director, Dr Justin Wilson, and
was taken as read.
The definitive report will be published in June 2015; this draft version is brought to
the Council for the purpose of achieving a decision regarding the indicators and for
Governor contribution to the final published document.
The document currently includes Quarter 2 data but does given an indication as to
the position with previously set priorities.
The Quality Account requirement is set out by the Department of Health; Monitor
stipulates that FTs must produce a quality account which includes assurance from
external auditors on mandated indicators. As a mental health Trust, BHFT is required
to choose 2 of 3 mandated indicators in relation to 7 day follow up, minimising
delayed transfer of care and gatekeeping. Governors are asked to identify another
indicator and the recommendation this year is that assurance should be provided on
all 3 of the mandated indicators including delayed transfer of care.
Following in-depth discussion, it was agreed that all three mandated indicators be
included as stated without a substitution.
Justin Wilson added that when the full account is published, key messages will be
available to the general public and any feedback is welcome. It is now important to
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consider priorities for the year ahead and develop these over the next couple of
The review was noted and endorsed.
Executive Report from the Trust
Performance Report
The Performance Report was taken as read. Julian Emms advised that 2 new
risks were flagged CAMHs and Demand & Capacity but overall the Trust’s
performance remained stable and in line with plan.
Patient Experience Annual Report
Discussed above
Partnership Organisations
Noting the continuing absence of a local authority appointed Governor for WAM,
Adrian Edwards expressed concern at the current situation. John Hedger agreed that
this was a concern and had been subject to communication with that Royal Borough
but he would now be writing to the leader of the WAM council to try and secure a
representative to the Council of Governors.
Noting the need to replace a number of partnership organisations that had not been
actively involved for some time, Governors agreed that John Hedger should
approach the British Red Cross.
Governors also suggested Depression Alliance and the Berkshire Diabetic
Association as potentially suitable organisations to consider. John Hedger would
follow-up these ideas.
Chair’s Remarks
John Hedger advised that BHFT is required to commission, at its expense, an
external review of the governance of the Trust. This must take place within the next 3
years and at its December meeting, the Trust Board decided that the review should
be commissioned if possible in the summer of 2015. This will be an expensive and
detailed review conducted by an external independent organisation with considerable
experience in the field. It is likely that a representative cross-section of Governors will
be interviewed as part of the process. It is expected that the review will look at the
operation of Council and its committees. Further details will be provided in due
The Trust Board has completed a self-assessment exercise to identify governance
strengths and potential development areas.
Non-Executive Director pre-meet
Philip Brooks commented on a very successful pre-meet session today with Angela
Williams and requested that this approach continues alongside regular sessions with
chairs of Board Committees.
Date & Time of next Council meetings
5th February: 10am EBC, Joint meeting of the Trust Board & Council of Governors
18th February, 10am EBC, Council of Governors
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I certify that this is a true, accurate and complete set of the Minutes of the business
conducted at the meeting of the Council held on 11 December 2014.
(John Hedger, Chair)
18 February 2015
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Report of Living Life to the Full Group
Council of Governors meeting - Wednesday 18th Feb 2015
Since the last Council of Governors meeting on 11th December 2014 there has been one
meeting of the Living Life To The Full Group on 28th January 2015.
1. Actions from the 30th October 2014
5th December Conference – “Angels & Devils in all of us!”
Very successful with good attendance and excellent guest speaker presentations. The
presentation delivered by Penny Campling has been distributed to all attendees and
members of this group. Mark Hardcastle has requested similar material from Dr Deborah
Lee and Geoff Brennan from Star Wards.
2. Collaborative Ventures:
In previous meetings several areas where parts of BHFT were working in
collaboration with various charities had been mentioned. This meeting invited speakers
from two of these to give brief presentations on the work they are doing. The benefits to
the BHFT service were explained by Trust staff involved in these cases.
a. Younger People With Dementia (Berkshire West) & BHFT Memory Services
Charlie Draper – Ops Manager & Dr Jacqui Hussey – Consultant Psychiatrist
The impact of dementia in the 40/50 age bracket is significant, effecting things such as
partner, teenage children, mortgage and aged parents.
50% of partners/carers need to stop working with the consequent impact on life.
It takes on average twice as long to get a diagnosis – on average 4.5 years.
The current YPWD figures for Wokingham show circa 250 early-onset dementia but the
figure is closer to 500 or more.
Following surveys and ‘big conversations’ three things were prioritised: education,
support worker and someone to take the journey alongside.
The charity was formed in May 2012 with four of the six trustees having a background in
the NHS and Social Services.
Courses specific to patients are adapted to support memory difficulties with excellent
feedback received. Charlie Draper explained the importance of assisting clients to do the
normal things that we take for granted: out to lunch, walking, swimming, socialising etc.
Activities are tailored to be interesting, physically more demanding, varied and specific
and include gardening, art, furniture restoration etc. all giving people a renewed sense of
An Admiral Nurse, funded by a grant from the People’s lottery for fixed term, has
supported 51 families and provided some consultancy to other organisations. Two respite
project workers have also been employed.
Life In Pictures Books – Two produced to date, British Seaside and Around the World in
Many Ways, are a collection of beautiful images and memory prompts, which are
specially designed to aid reminiscence in younger people with dementia.
The charity rent a room in the Memory Clinic with all their staff having honorary contracts
with BHFT. This means they can access Rio and share information with the memory
clinic staff.
b. Depression Alliance, Friends In Need & Talking Therapies
Louise Jones – WAM Coordinator & Sue Scupham – Talking Therapies
Sue Scupham, Clinical Service Manager, Talking Therapies, advised that the service has
140 staff within BHFT. In east Berkshire they are based at Fitzwilliam House, St Mark’s
Hospital and Britwell in Slough amongst others.
Lower level of treatment is provided by Psychological Wellbeing Practitioners for people
with mild to moderate depression and anxiety. This includes self-help, wellbeing groups
and stress control workshops. These cater for 140 people at a time giving the skills and
ability to manage anxiety and depression. A high number of men attend the evening
workshops as there is no perceived stigma.
The WAM CCG provided funding for a support worker to focus on older adults, people
with long term conditions, military families, getting back to work etc.
The Depression Alliance Charity was commissioned to provide this service and Louise
Jones was subsequently employed as WAM Coordinator for the Friends In Need Project.
Louise Jones advised that Friends In Need has the simple aim of bringing people
together to reduce the isolation from depression.
The charity works generally around the 5 Ways to Wellbeing, a set of evidence based
actions which promote people’s wellbeing developed by New Economics Foundation
think tank.
There are: Connect, Be Active, Take Notice, Keep Learning & Give.
Talking Therapies provides the clinical aspect and Friends In Need offers social activities
to ensure social contact is maintained.
Louise is based at St Marks Hospital in the same room as the Psychological Wellbeing
Practitioners and has an honorary contract with BHFT.
About 70% of referrals to Friends In Need are received from Talking Therapies with
clients choosing what they would like to do.
Activities are laid on every day with some evening activities. The result has been that
people previously very isolated are getting together with new friends and organising their
own activities including nights out and spending Christmas Day together.
Peer to peer support is a key part of the activities and people are encouraged to
exchange contact details.
A group has recently started in West Berkshire with the local coordinator based with the
Psychological Wellbeing Practitioners as in WAM.
3. Events and Services – highlights across the county
Verity Murricane drew attention to Feel Good Fortnight 25th April – an opportunity for
anyone in west Berkshire (statutory or voluntary) to highlight special events around
feeling better e.g. 8 Bells art and music group, Sport in Mind etc.
The information will be posted to the Empowering West Berkshire
Alison Durrands advised that beginning on 19th January the Trust is hosting two paid
workers from the Centre for Mental Health to assist current clients within CMHT to return
to work. The two individuals are funded for 12-18 months, based at FWH across all
mental health teams. This will also encourage CMHT teams to create links with other
organisations appropriate to each locality.
4. Optimising work with the 3rd Sector – update – Clare Bright, Project Lead
Brief is to explore how the Trust can work with 3rd sector colleagues and local charities in
the 6 Berkshire localities. This includes NHS care pathways: older adults, adults with
dementia, mental health issues, and community health complex needs etc., in the over
18 age group. This specifically looks at what is available in the voluntary sector in
Berkshire and looking at key organisations with which the Trust could work directly e.g.
Age UK, Red Cross and Richmond Fellowship
The hope is to have a non-clinical coordinator in teams or through CPE (Common Point
of Entry) to work from a 3rd sector perspective within clinical teams to augment and
provide non-clinical interventions particularly in remaining at home for as long as
A volunteer coordinator is now in post on a one year contract which it is hoped to make
substantive (Julie Addison). She has to ensure correct governance then to liaise with
services users and clinical staff to ascertain what is actually needed. There are currently
some 40 people directly volunteering for the Trust.
5. Community Mapping - Website
The Council of Governors meeting of 11th December 2014 formally agreed the transfer
of this topic from Membership & Public Engagement group as it is more aligned with
ongoing agendas. There is still a lack of significant progress.
Clare Bright advised she is looking at a related area, discussing adding local authority
websites as static links to Trust Website. Under the Health & Social Care Act they have
a duty to communicate activities and groups to their respective populations. It is hoped a
6 month pilot can be agreed and the 3rd Sector is being asked for assistance in putting
this together.
John Barrett - Co-Chair, Living Life To The Full Group – 10th February 2015.
Council of Governors - Membership & Public Engagement
21 January 2015
Nic Sevenoaks, Interim Head of Marketing and Communications was welcomed. A
minute of silence was observed in tribute to Alan Kendall and in gratitude for his
sterling work with the Trust and this group.
Notice had been given to Capita; the ongoing requirements are being analysed with
expected tender process commencing end February/early March. Three quotations
will be sought. It was suggested that the database needs to be set up to ensure
members are specifically targeted as to their interest both for new members and
existing. There is no follow up in place other than the initial thanks for registering.
The conflict was noted between achieving target numbers and deleting regularly
inactive members. The group was asked to bear in mind the large group of people
who do not use the internet or current technology but that information can be
received on mobile ‘phones however the implications of wide range of media
available (Tablets, Mobile ‘Phones etc.) was noted.
Volunteer Lead
It was noted that the Governor Living Life to the Full Group would be taking the
community mapping forward in the future.
The Membership and Communications Group strategy will be one part of the
discussion at the forthcoming joint meeting of the Council and Non-Executive
Directors. The workshops will review previous actions and look at requirements going
forward. The 12 point bulleted list will be part of the background information at the
joint meeting. Governors should note however that engagement with the general
public and engagement with the Trust membership remain separate issues.
Membership is an absolute requirement for FTs. Members are a discreet body that
the Trust is expected to manage specifically and only members can stand as
Governors; therefore the focus has to be on that group. Statutorily Governors have a
responsibility for this group as well as endeavouring to bring the two groups together.
Three types of membership package were outlined: bronze, silver and gold (detailed
within the paper presented). The current package sits at bronze level with the gold
level requiring major Trust investment in terms of resource. The silver package would
be achievable with investment and focus. However the two questions remain: what
do Governors want from members; what level of impact should the Trust undertake.
Discussion showed that voting in elections was a high priority together with an
informed electorate making wise choices. It was suggested that the public need to be
considered as well as members; Governors are always able to ‘piggyback’ locality
events to engage with members but need to be mindful of the cost implications of
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inviting constituents. It was suggested that if a particular theme/topic of interest e.g.
Diabetes, was put forward, provided there were sufficiently engaged Governors, a
relatively inexpensive venue could be sought and that localities could link together
e.g. Reading and Wokingham, working more cooperatively with other organisations
in Berkshire. The general public, as well as Members, are invited to the Trust AGM in
September. The need is to identify a theme which fits well with what the Trust is
doing to achieve a synergy of resources with Governors taking part e.g. Healthy
Hearts programme. The database could be used to message members in a particular
location to advise Governor attendance at events. Following further discussion, it was
agreed that the membership strategy discussion would be a part of the forthcoming
joint meeting on 5th February, looking at bronze/silver options.
Governor Profile and Website Development
Contact email now included for Governor contact through John TOnkin. Pictures will
appear in the Governor area of the site. Work will put together Governor profile
page mock-up.
Membership Update
Current eligible population of Berkshire using latest census figures shows a
population circa 827,281. The eligible members are aged 12 years and over. It was
noted that there is a significant shortfall in terms of 12-16yrs; it may be possible to
discuss in schools focusing on young people’s issues e.g. stress, work, family etc.
Parents would need to agree this initiative.
Dr Philip Brooks.
k:\company secretary\governors\governor meetings 2015\18 february 2015 cog\membership public engagement report
Governor Quality Assurance Group
Report to the Council of Governors
We have had one meeting, held on the 12th of February 2015 since the last Council of
Governors meeting.
Guest Speakers - Listening into Action: Patient, Carer & Public Big Conversation
Minoo Irani and Jenni Knowles, from the LiA Sponsor Group, were in attendance to give us
an update on current and prospective Lia initiatives within the Trust.
Minoo gave a short introduction on LiA; its purpose, what has been achieved so far and what
still need to be done to roll out this initiative throughout the Trust. He described the process
followed to engage the public, patients and carer communities in “big conversation” events
across the Trust, and how the captured outcomes have now been analysed and turned into
effective actions to improve our services and the way we deliver them to the community. He
went on to give the latest update on timescales of LiA activities that have been completed or
in progress include:
Staff Communication skills: “Going the extra Smile” initiative – (Launch date: Feb 15)
Staff attitude: Importance of wider cultural shift and a sense of staff feeling valued ongoing
Keeping patients informed - ongoing
Technology: Texting, network social media etc. - ongoing
Patient Feedback – Making it easier for patients to give positive feedback about their
treatment and about staff – Design has now been completed on a “thank you”
postcard that also invite suggestions for improvement.
Minoo concluded by encouraging Governors to give priority to checking some of the
implemented actions of LiA, particularly around “keeping patients informed” during quality
visits. There was also a broad agreement that governors should continue to get involved
with LiA projects in order to ensure success whilst using it as an opportunity to get closer to
the membership of the trust and the general public. Particularly, LiA should be tapped into
by Governors to build up and maintain regular and constructive contacts between us
(Governors), our membership and the general public.
Update from previous meeting
The group had the following updates on actions from the previous meeting from Nancy
1. Update on Psychology services waiting list – in progress
2. Aspects of investigation on Oakwood Ward – provided by Nancy Barber
3. Ali Melabie’s requested for complaints to be broken down into localities – more
clarification from Ali required
4. List of PPH wards and their functions – completed and now available to all governors
Patient Experience Quarter 3 2014/15
Nancy presented the patients experience Quarter 3 document to the group which taken as
This was followed by detailed discussion and QA session on the contents.
Compliments and Complaints
It was encouraging that the number of complaints for the current reporting period (Q3) was
less than the previous two consecutive quarters, and at the same time, the number of
complements received went up from 990 (Q2) to 1140 (Q3). The group expressed the hope
that this trend would continue to the next quarter.
Upheld complaints and lessons learned from them were also looked at, and there was
satisfaction that actions put in place would lead to improvements.
One anonymised complaint was also presented and analysed in detail. It brought out issues
of coordination and capacity management between pilot services and regular services. The
group was satisfied that important lessons had been learned due to this complaint and that it
has been thoroughly investigated and satisfactorily resolved.
Quality Visits Undertaken and Feedbacks
Visits Completed
The following reports on visits completed prior to the last COG were reviewed:
1. Manor Green Children’s Respite Care - Veronica Cairn & June Leeming
2. CMHT, Maidenhead – Veronica Cairn & June Leeming (attachment)
3. Common Point of Entry – Paul Myerscough & Veronica Cairn (attachment)
4. Rowan Ward, PPH – Paul Myerscough & Ali Melabie (attachment)
5. CAMHS Reading – Paul Myerscough & Gray Kueberuwa (awaiting report)
All the reports were discussed in detail with Nancy Barber and issues involved highlighted,
some of which were taken as actions for further investigation and/or resolution by Nancy.
Visits in the pipeline
1. Slough District Nursing Services – June Leeming and Dolly Bhaskaran
2. Jubilee Ward, Slough - Ruffat Ali-Noor and June Leeming
3. Campion Unit, PPH – Paul Myerscough and Gray Kueberuwa
18 February 2015
Carers Strategy Development
The Carers Strategy Development Task & Finish Group continues to meet bi-monthly
to support and drive forward the identified 6 top priority actions:
Health Hub Signposting
Carer Satisfaction Survey
Staff Training & Education
Carer Information on BHFT Website
Carer involvement in training & recruitment
Update on priority actions:
Health Hub Signposting
This has been investigated and not actioned to date due to pressures on service and
currently not being a “public facing” service. Work around signposting is being
developed in other ways in conjunction with Local Authorities.
Carer Satisfaction Survey
Friends & Family Test style survey cards for carers will be distributed to Prospect
Park Hospital (wards and public areas), Memory clinics and Learning Disability
inpatients and community services in the first instance.
Staff Training & Education
Carers Training Plan will be delivered in 3 parts:
• E-learning
• Carer Awareness – 1½ hour team session delivered with carers (some
resource will be required to support this)
• Care Act Awareness
Changes and/or additional information will be included post implementation of the
Care Act in April 2015.
From April 2015 a carers podcast will be shown at Trust Induction to all new starters
to ensure staff are carer aware from the start of their employment with BHFT.
Carers Information on BHFT website
Information is being gathered from localities and will be uploaded to an identified
carer area. Carer related information for staff is also being placed on TeamNet.
Carer related objective has been introduced & cascaded through line management in
localities “Carers should feel supported and are to have a voice”. These have been
shared with teams and are available on TeamNet.
Carer involvement in training & recruitment
Teams are doing as much as they can to involve carers in stakeholder days for
recruitment positions and local events.
Sub Groups of Carer T&F Group:
Triangle of Care (ToC)
BHFT is registered with ToC relating to mental health and awarded 2 ToC stars.
–all localities have completed a self-assessment and an action plan. Actions to be
completed by October 2015. The main work is around ensuring there is training in
place across the Trust for staff to be carer aware.
SHaRON - online network for carers set up
The site is starting to gain momentum with carers signing up and getting on the
site. Video casts to be recorded and put on site to encourage dialogue between
Other local initiatives include:
Bracknell CMHT - Working with Berkshire Carers Service/NHS and Bracknell Forest
Council to provide a monthly Mental Health Carers Support Group. Carer
assessments undertaken jointly with Local Authority.
CAMHs - Service users, parents & carers lived experiences are collected as part of
our participation work; this information is distributed to staff teams. Parent/carer
surveys are part of our routine outcome measures.
Mental Health inpatients - carer drop in facilitated by Berkshire Carers Service;
Carers notice board on each ward.
Newbury CMHT – monthly evening MH Carers Support Group, in addition to monthly
day time group already running
Slough - Joint working with Slough Borough Council, particularly regarding carer
training; Running a Carer Training Programme (10 week programme) for carers of
service users within the Early Intervention Service
WAM - Monthly support group have various guest speakers throughout the year on
topics of interest to carers. Carers information also on RBWM website.
Governors are asked to note the report.
Jenni Knowles
Project Lead Carers Strategy Development
Introduction Q3 2014/15 Governors' Key Performance
Indicator Report
Dear Governor
Enclosed are details of key indicators of trust performance in line with targets laid down by Monitor, (the body responsible for regulating NHS Foundation Trusts) and the Care
Quality Commission. Please find below an explanation of what the targets mean.
The Continuity of Services is a measure of our risk based on the trust's cash position and current surplus/deficit, this is our position at Quarter 3 2014/15.
The Key National targets mentioned here relate to the Department of Health National Service Framework targets which the trust should achieve and are measured as follows:RTT 18 Weeks This is referral to treatment waiting times for consultant led services where there is a requirement for patients to be seen within 18 weeks. There are two measures
completed pathways (that those patients who have been seen) and incomplete pathways (those who are still waiting to be seen). The two consultant led services in the trust are
Paediatrics and Diabetes.
Early Intervention
This is the number of new confirmed cases of first episode psychosis against the annual target set by the Department of Health for this service.
7 Day Follow Ups
This is the percentage of clients on enhanced CPA who have received a follow up within 7 days from their discharge from inpatient care measured against
the Department of Health target for the prevention of suicide.
HTT Gate Keeping
This is the percentage of acute adult mental health admissions which have been assessed by the Home Treatment Teams prior to admission to an acute
inpatient ward.
Delayed Discharges This is the percentage of beds occupied by clients who were deemed to be clinically fit for discharge.
CPA Review
This is the percentage of clients on CPA who have received a review within the past 12 months.
Total Time in A&E
This refers to the patients waiting to be seen within 4 hours at the Slough Walk In Centre and the Minor Injuries Unit at West Berks Community Hospital.
The Care Quality Commission has introduced a new registration system with which all providers of health and social care must comply. Details of the Trusts assessment of
compliance against the regulations and outcomes are shown on page 2 with full details in Appendix B page 7. The Trust was reinspected on 26th August 2014 and found to be
Contract Versus Performance is the activity measured against the contracted activity for the same period. There are now well over 100 contract lines and some service requirements
for this financial year are being discussed with commissioners.
Information on Complaints and Compliments will now be shown in a separate report. Membership details now include a breakdown of ethnicity of members against that of the
Berkshire population.
As a merged organisation of Mental Health and Community Health Services the Corporate Risk Register indicates the current severe risks to the Trust
For Community Health Services, the indicators required for this financial year relate to the Referral to Treatment times within 18 weeks for Consultant led services. In addition the
Trust are required to provide information on compliance levels with 2 national data sets which will be used in future to monitor the performance of both Mental Health and Community
Services. Details of the Trusts compliance of both these indicators can be found on page 5.
As part of the 2014/15 Risk Assessment Framework there are additional indicators for this financial year, these relate to cases of Clostridium difficile. To encourage reporting of
Clostridium difficile (C.Diff) cases, Monitor have asked all Trusts of to report all occurrences of C.Diff on our wards rather than those that are due to lapses in care, there are 3
categories i) those due to lapses in care , ii) total C.Diff YTD (including: cases deemed not to be due to lapse in care and cases under review) iii) C. Diff cases under review.
The Care Quality Commission have introduced a New Intelligent Monitoring report on 20th November 2014. The Trust has been placed in Band 3 when rated against other Trusts.
Band 1 is for Trusts considered to have the highest risks dependent on data included in the report and Band 4 is for Trusts considered to be lower risk.
Julian Emms
Chief Executive
Page 1 of 7
Q3 2014/15 Governors' Key Performance Indicator Report
Continuity of Services Risk Rating at end of Q3
Care Quality Commission Registration:
Regulation Outcomes as at 31st December 2014
Involvement and Information
Personalised Care Treatment and Support
Safeguarding and Safety
Suitability of Staffing
Quality and Management
Suitability of Management
Risk rating is awarded on a scale of 1 to 5
(5 being lowest risk rating)
Net Surplus/(Deficit) Run Rate
Budget - Month
Budget - Cumulative
Forecast incl Reserve Release
Actual - Month
Actual - Cumulative
Best Case
1. Absconding
Early Intervention New Cases
7 Day Follow Ups
HTT Gate keeping
Delayed Discharges
CPA Review within 12 months
Total Time in A&E
Total C. Diff Cases including those not
due to lapses in care and cases under
On plan
Responsible Director: David Townsend
2. CAMHS Commissioning
Responsible Director: David Townsend
3. Clinical record system replacement
Responsible Director: Alex Gild
4. Compliance with the Trust search policy
-200 Apr May Jun Jul Aug Sep Oct Nov Dec Jan Feb Mar
Responsible Director: David Townsend
5. Demand and Capacity
Key National & Local Targets for Mental Health & CHS Services Responsible Director: David Townsend
Target Details
DOH Target
6.Financial Sustainability
Referral To Treatment waiting times:
18 Weeks incomplete pathways
Performance V Contract Quarter
Full details can be found on page 7
Referral To Treatment waiting times 18
Weeks: Non admitted
All services V Contract Quarter 3
95% < 4 hours
Responsible Director: Alex Gild
7.Implementation of payment by results
Responsible Director: Alex Gild
8. Ongoing registration with the CQC
Responsible Director: Helen Mackenzie
9. Workforce
Responsible Director: David Townsend
Page 2 of 7
There are now well over 100 service lines to
report against contract. East and West
Community Health Services are reporting no
major issues with levels of activity against
contracted levels of activity. In Mental Health,
Adult Community Services and Specialist services
have significant levels of over activity. The graph
above reflects an estimate of reported activity
against contract lines.
Q3 2014/15 Governors' Key Performance
Indicator Report
Berkshire Healthcare NHS Foundation Trust membership has gained by 846 since the previous report in January and is now 10,714 as at 9th
January 2015. The target was to reach membership of 10,000 by 31st March 2013. The target of 10,000 membership will be retained again for
the financial year 2014/15.
Membership by Age
0 to 16
17 to 21
Membership by Category 9th January 2015
Public Out of Catchment
22 years +
Public In Catchment
Membership by Ethnicity
No of members
Bracknell Forest
Windsor and Maidenhead
Outside Catchment Area
Eligible Population
% of Members
Page 3 of 7
Other Ethnic
Not specified
Black or Black
Asian or Asian
7% Mixed
Ethnicity of Membership v Population of Berkshire
Berkshire Population
Asian or Asian British
Black or Black British
Ethnic Category
Page 4 of 7
Other Ethnic Group
Not specified
Governors' Key Performance Indicator
Report Data sets
As mentioned in the introduction Monitor have issued the Compliance Framework which will be replaced by the Risk Assessment Framework from 1st October 2013, and included the list of
indicators which will be used to measure governance going forward. Many of the indicators are shown on Page 2 of the report however there are two indicators which are linked to data sets that the
Trust must comply. The first is the Mental Health Minimum data set and the Trust is required to give data on demographics (Identifiers) such as NHS number, date of birth, postcode, gender,
General Practitioner and commissioner details. The target is 97% of information to be completed In addition the Trust is required to provide outcomes data for clients on care plan approach with a
target of 50% of data to be completed.
For the Community Information Dataset, the Trust is asked to provide information on data completeness for community services. These include information on referral to treatment times, community
treatment activity service referrals, data completeness and identifiers. The target is 50% completion of information.
Mental Health Minimun Data Set
Area of Care
Mental Health Inpatient and Community
Mental Health Clients on Care Plan Approach (CPA)
Data completeness
Community Health Data Set
Area of Community Care
Referral to treatment times - admitted and non admitted
Community treatment activity service referrals
Data completeness
Community care referral to treatment information.
Referral information completeness
Activity information completeness
Data completeness
Page 5 of 7
Q3 2014/15 Governors' Key Performance
Indicator Report Appendix
Extreme / Severe Corporate Risks: Additional Information
CAMHS Commissioning
Clinical Record System
Patients absconding, potential patient/public safety, adverse publicity.
Fragmentation of commissioning of CAMHs services in Berkshire across Tiers and difference in locality priorites and service provision which is increasing the volume and acuity of children needing support from Trust services
Clinical record system replacement; programme to procure and replace current national contract for RiO fails to deliver.
Compliance with the Trust's search Policy requires that each admission to an in-patient ward is searched, within 30 minutes of arrival onto the ward. High admission levels increase the difficulty of meeting this policy
Demand & Capacity
Lack of visibility of demand and capacity pressures in services in a timely way to manage service delivery and identify trends requiring remedial plans, leading to increased waiting times.
Financial Sustainability
Financial sustainability - medium term efficiency & CIP planning gaps.
Implementation of Payment By
Implementation of Mental Health Payment by Results destabilising current block funding arrangements and increasing organisation financial risk.
On-going Registration with Care
Maintaining registration of all activities and services without conditions.
Quality Commission for all services
Physical Assaults/Violence
The risk is a member of staff will be injured and that they have not received the appropriate training to manage violence and aggression. The would expose the trust to litigation proceedings.
Shortage of staff with appropriate skills to deliver services in some roles and some services due to lack of availability and / or the Trust’s inability to attract and retain sufficient suitable qualified staff.
Key To Risks
Extreme risk; Chief Exec/Non Exec immediate action
Severe risk; Exec directors immediate attention
High risk; senior management attention required
Moderate risk; Operational managers attention required
Low risk; manage by routine procedures within work teams
Page 6 of 7
Q3 2014/15 Governors' Key Performance
Indicator Report Appendix 2.
Care Quality Commision Regulation Outcomes as at 31st December 2014.
Outcome 1 (R17)
Outcome 2 (R18)
Outcome 4 (R9)
Outcome 5 (R14)
Outcome 6 (R24)
Outcome 7 (R11)
Outcome 8 (R12)
Outcome 9 (R13)
Outcome 10 (R15)
Outcome 11 (R16)
Outcome 12 (R21)
Outcome 13 (R22)
Outcome 16 (R10)
Outcome 17 (R19)
Outcome 21 (R20)
Respecting and involving people who use the services.
Consent to care and treatment.
Care and welfare of people who use services.
Meeting nutritional needs.
Co-operating with other providers.
Safeguarding people who use the service.
Cleanliness and infection control.
Management of Medicines.
Safety and suitability of premises.
Safety, availability and suitability of equipment
Requirements relating to workers
Supporting staff
Assessing and monitoring the quality of service
Patient Experience – Quarter 3 2014/15
Presented by Helen Mackenzie, Director of Nursing and Governance
© Berkshire Healthcare NHS Foundation Trust and its licensors 2007. All rights reserved. No part of this document may be reproduced, stored or
transmitted in any form without the prior written permission of Berkshire Healthcare NHS Foundation Trust or its licensors, as applicable.
Where indicated by its security classification above, this document includes confidential or commercially sensitive information and may not be disclosed in
whole or in part, other than to the party or parties for whom it is intended, without the express written permission of an authorised representative of Berkshire
Healthcare NHS Foundation Trust.
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Berkshire Healthcare NHS Foundation Trust
This overview report is written by the Director of Nursing and Governance so that Board Members
are able to gain her view of services in light of the information contained in the quarter three
patient experience report. In my overview I have considered elements of the feedback received by
the organisation and drawn conclusions.
The requirement for Boards to consider detailed patient experience feedback remains and it’s
important for the Board to remember commissioners receive more detailed information as part of
our contractual requirements.
During quarter three we achieved an average of 88% of complaints responded to within the
timescale agreed with the complainant. In September 2013 I reported that only 40% of complaints
were responded to within agreed timescales so significant progress has been made over the last
16 months. The area which needs more focus is contact and negotiation with complainants about
timescales for investigation. A number of complaints are complex, crossing services and therefore
they do take longer, and consequently investigators need to negotiate a longer timeframe for the
investigation. Some investigators are better at keeping in contact with complainants and more
skilled in negotiation. The complaints team support investigators in this process when asked.
Waiting times for Child and Adolescent Mental Health services (CAMHS) continue to increase
accounting for 55% of complaints about waiting lists. The trust recognises that some families wait
too long for assessment and has asked commissioners for investment into the service to address
these waits using the parity of esteem funding stream. All these complaints are rightly upheld
because children and young people are waiting too long to access an appropriate service.
75% of complaints received about care and treatment provided were attributed to mental health
services. These complaints are often complex with patients unhappy about diagnosis, medication
and the level of provision available i.e. patient expectation. The deep dive survey into Community
Mental Health Team patients will help us understand the improvements we need to make to
services to improve patient experience.
Attitude of staff continues to be a theme with many complaints and the Listening into Action
campaign ‘Smile’ will be launched on 2nd February encouraging staff to think about the person in
front of them and how they might come across. Our Listening into Action public sessions also
showed that the public wanted staff to smile and be more welcoming in our approach.
The Friends and Family test has been rolled out across to other services including our mental
health inpatient wards. Only two months data has been collected about mental health inpatient
wards and currently only 66% of patients are saying that they would be extremely likely or likely to
recommend our services to their friends and family. This is disappointing but again as highlighted
above this might indicate the complexity of care provided in our wards. As more data is shared by
other mental health trusts we will be able to benchmark ourselves with other providers.
The patient and public involvement information shows that when patients are asked by services
how they rate their experience, 95% said it was good or better than expected which is an
improvement on quarter two. 99% of our learning disability service users said that they found their
meeting with us helpful.
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In terms of volume the level of positive feedback received by services far outweighs the negative
feedback found in complaints and on NHS Choices. There is an increasing trend of complaints
about CAMHS waiting times which commissioners need to address.
I believe that services and individuals strive to provide the best possible care and generally
patients have a good experience in our services but as a result of a number of variables, for some
patients their experience is not good and care falls below the standard of care expected. I do not
take these lapses in care lightly and it is important services recognise and take steps to prevent
similar incidents and that this is shared across the organisation. This continues to be work in
Helen Mackenzie
Director of Nursing and Governance
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Berkshire Healthcare NHS Foundation Trust
Executive Summary
This report details the complaints, Patient Advice and Liaison Service (PALS) and compliments
received by the Trust up to an including quarter three 2014/15. As an organisation, the Trust
recognises that by responding well to complaints and feedback from patients we improve the
patient and carer experience and increase public confidence in the services that we provide.
In Quarter three, the Trust received 58 formal complaints in comparison with 67 in quarter two and
61 in quarter one. In addition, eight complaints were received which were being led by a different
organisation (in comparison with nine in quarter two and five in quarter one).
The Services that received the highest number of formal complaints during quarter three were
Adult Acute Mental Health Inpatients (five), Community Mental Health Teams (eleven), Crisis
Resolution/Home Treatment Team (six) and CAMHS (nine).
The main themes from the complaints were care and treatment (23), attitude of staff (11) and
waiting times for treatment (9).
The formal complaint response rate, including those within a timescale re-negotiated with
complainants is 88% for quarter three. The response rate during the months of quarter three was
100% in October, 100% in November and 88% in December. It took an average of 29 days to
investigate and respond to a formal complaint during the quarter. The longest time taken to
respond to a complaint in quarter three was 100 days (in comparison with 79 days in quarter two
and 126 days in quarter one). This was a complaint about Talking Therapies which was closed in
December. The complaint was about the attitude and conduct of a member of staff. Staff have
been reminded of the different forms of intervention which are both suitable and not suitable.
During the investigation process, the investigating officer was in regular contact with the patient
about the complaint and they agreed with the timescales.
NHS Choices
There have been six comments posted; three experiences were about Mental Health Services
relating to care and three were about community mental health sites and services. NHS Choices is
being used more as a platform to share positive experiences rather than anonymous complaints.
Patient and Public Involvement
3,818 service users and carers have provided feedback through the internal patient survey
programme, with 95% saying their experience was good or better. In addition 99% of patients with
a Learning Disability who gave feedback said that they found their meeting with us helpful.
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Berkshire Healthcare NHS Foundation Trust
The Trust is committed to improving patient experience, using complaints and other forms of
feedback to better understand the areas where we perform well and those areas where we need to
do better.
This report details the complaints, Patient Advice and Liaison Service (PALS) and compliments
received by the Trust during quarter three (October to December 2014). As an organisation, the
Trust recognises that by responding well to complaints and feedback from patients we improve the
patient and carer experience and increase public confidence in the services that we provide. The
Trust is also committed to ensuring that the national learning from reviews such as the Keogh
Review, Francis Report and ‘Hart’ Report (complaints) are embedded locally into the core values
of our staff.
NHS Choices
The internal monitoring of NHS Choices postings is important because this activity is monitored by
the CQC and the National Quality Team as part of our quality risk profile. Similar to complaints, for
an individual to take the time to post on a website their experience, means they feel very strongly
about their position and therefore the Trust needs to take these comments seriously and respond
There have been six comments posted on NHS Choices during quarter three; three about mental
health services and three about community health sites and services. During quarter two there
were ten comments which were all about mental health services. All posts are individually
responded to and are discussed at the Service User Feedback Implementation Group.
The feedback posted during quarter three was:
• A patient admitted to one of our mental health inpatient wards said that they were not given
the opportunity to leave the ward as they should have and when they returned to the ward
our staff questioned them. They also reported that we did support them with a physical
condition during their stay.
We invited the patient to contact us to discuss their experience in more depth so we can
respond to their specific concerns appropriately. Their feedback was shared with the senior
management team at Prospect Park Hospital.
• We received feedback that the information online about Upton Hospital in Slough is not very
helpful and needs information about visiting times and parking.
We forwarded the feedback to our Marketing and Communications Team who are updating our
online service information.
• We received positive feedback about a stay on Daisy Ward. The comment noted that they
felt treated with dignity and respect.
We thanked patient for their feedback and shared this with our staff.
• Feedback was posted about the difficulty that had been experienced when trying to park at
Wokingham Community Hospital.
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As the post stated that they attended the hospital over a year ago, we were able to include an
update from our Estates Manager on the parking improvements that have been put in place
since they attended, for example having more spaces available for ‘blue badge’ holders.
• We received feedback about the new booking process for Phlebotomy at West Berkshire
Community Hospital. There was feedback that it was difficult to get through on the
telephone and there was no information available online.
We were able to confirm that a process has been recently implemented which has been
circulated to GP Practices. Information will be provided on our website and routine
appointments will be able to be booked in advance. The long term plan is for appointments to
be made by e-mail.
• We received positive feedback about the care and treatment provided by the Bracknell
community mental health team. The post said that the patient felt treated with respect and
listened to; not judged. They said that our staff were considerate in all aspects of their care,
to the level of how personal correspondence would be received. They said that the staff
smiled despite the patient feeling unhappy.
We thanked the patient for their feedback and shared this with our staff.
Formal complaints
The Trust has received 58 formal complaints in quarter three, a reduction from 67 in quarter two.
In addition, the following complaints have been received by alternate organisations with an
element relating to Trust services:
An acute trust led complaint about the Minor Injuries Unit where a patient was advised that the unit
were not seeing any more patients as they were very busy and asked the patient to return the next
day. This complaint was found to be upheld. The decision was made by the Emergency Nurse
Practitioner with responsibility for the unit that evening and that the department was to close to
new attendances due to the higher than anticipated demand for the service. At that time there
were a number of patients who had already arrived at the department who had a high level of
clinical need. All patients booking in after 8.04pm were advised to attend Accident and Emergency
or return to the unit the following day.
An acute trust led complaint about adult community physiotherapy. This complaint was not upheld.
The patient was given appropriate treatment which due to the nature of their condition
unfortunately did not improve as much as hoped. The patient was referred on to an Orthopaedic
A West Berkshire Council led complaint about social care support with an element relating to the
community mental health team. This was found not to be upheld as the team responded to
requests from the GP for their opinion.
A further complaint being led by West Berkshire Council was received where a patient reported
that they did not receive the level of support that they needed from the community mental health
team following their discharge from Prospect Park Hospital. Upon investigation it was identified
that the member of staff named within the complaint was not employed by the Trust and the
complaint was returned to the council for their management as the staff are within their remit.
An acute Trust complaint about assessment of young child by WestCall who was thought to have
a hernia. The complaint was found not to be upheld as there was a thorough examination which
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showed that the child had no symptoms which led to the eventual admission to the acute hospital
for treatment.
There is an open complaint led by the Central Southern Commissioning Support Unit about a
change in the criteria for a district nursing home visit in Wokingham.
Reading Borough Council is leading a complaint about the nursing care provided by the
Intermediate Care Service. This investigation is currently also ongoing at the time of this report.
A complaint was also received by an acute trust about the discharge arrangements between the
hospital and District Nursing Team in Reading. This complaint was found to be not upheld for the
Trust as the information provided to the service was poor and was received late. Although this was
not upheld, the Trust has recently appointed community assessors who ensure that a hand held
record is in place before visits and care begins for patients.
For reporting purposes, services which operate across the Trust are logged under one Locality, for
example Child and Adolescent Mental Health Services (CAMHS – who are now logged under
Windsor, Ascot and Maidenhead). Westcall Out of Hours GP services are managed by
Wokingham. This should be taken into account when looking at the Locality information because
these services are covering more than one locality.
As previously noted when interpreting the information it is important to take into account that
WestCall see large numbers of patients and the number of complaints that they receive are
proportionately low.
Graph One shows the number of formal complaints over a rolling period from quarter one 2013/14
and alongside the total received over the last two years.
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Berkshire Healthcare NHS Foundation Trust
Graph One: Number of Formal Complaints received since quarter one 2013/14
The Bracknell, Slough, Wokingham and Mental Health Inpatient and Urgent Care localities saw a
decrease in formal complaints received in comparison with quarter two. Corporate (including
policies and access to medical records) reamined the same.
West Berkshire increased from 6 to 9 formal complaints, Reading increased from 7 to 8 and
Windsor, Ascot and Maidenhead remained the same with 11 in comparison with the previous
Table One shows the grading of complaints received during quarter three by Locality. This
information is detailed as Appendix 1.
Table One: Formal complaints received by Locality
Mental Health Inpatients & Urgent
West Berkshire
Windsor, Ascot & Maidenhead
Other Inc. Corporate
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The Services that received the highest number of formal complaints during quarter three were
Adult Acute Mental Health Inpatients (five), Community Mental Health Teams (eleven), Crisis
Resolution/Home Treatment Team (six) and CAMHS (nine).
The main themes of the complaints received during quarter three is in table two.
Table Two: Theme of formal complaints received during quarter three
Number of Formal
Environment, Hotel Services,
Access to Services
Waiting Times for Treatment
Attitude of Staff
Care and Treatment
Grand Total
Care and Treatment (23) – 48% of formal complaints about care and treatment were about the
clinical care.
The highest numbers of complaints about clinical care were received about the community mental
health teams (two in Wokingham and two in West Berkshire). All of these complaints
investigations are currently ongoing.
Each of the following services received one formal complaint each: Snowdrop Ward (Prospect
Park Hospital), Henry Tudor Ward, Crisis Resolution/Home Treatment Team (East), Orchid/Rowan
Ward (Prospect Park Hospital), WestCall out of hours GP service, Podiatry and Psychotherapy
and Complex Needs.
The complaint about environment, Hotel Services and Cleanliness was about the opportunity for a
patient to have a choice of food on the Campion Unit. This complaint was found to be partly
upheld. The investigation showed that there was a variety of different options available; however
there were actions that could be put in place to assist choices being made in an informed way e.g.
the use of picture boards.
The remaining complaints categorised as care and treatment are in table three.
Table Three: Breakdown of care and treatment formal complaints
Failure to examine/examination cursory
Failure to prescribe/incorrect prescription
Failure/Delay in specialist Referral
Failure/incorrect diagnosis
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Clinical Care Received
Attitude of staff
Grand Total
Attitude of staff (11) – 91% of complaints about attitude of staff were about healthcare staff. There
was one complaint about a member of reception staff in the physiotherapy department based at
the Great Hollands Health Centre. This complaint was upheld. Signage was found to be poor
which added to the patient’s frustration. The complaint highlighted this issue and the signage is
being replaced. The investigation showed that there was no independent witness to the
conversation between the reception staff and the patient; however their concerns should have
been escalated at the time.
The complaints about the attitude of clinical staff were attributed to the following areas: three
community mental health teams (West Berkshire, Bracknell and Reading), two in the Crisis
Resolution/Home Treatment Team (Reading), two for Daisy Ward (Mental Health inpatient acute
ward), one for WestCall, one for Highclere Ward (West Berkshire Community Hospital) and one
for CAMHS (Bracknell).
Of the ten complaints about clinical staff, 37.5% were found to be upheld. 25% were partially
upheld and 25% were not upheld.12.5% were not pursued by the complainant further and two
complaints remained under investigation at the time of reporting.
Waiting times for treatment (9) – 55.5% of complaints about waiting times were attributed to
CAMHS during quarter three. These are from across the Trust localities (two Reading, one West
Berkshire, one Wokingham and one Windsor, Ascot and Maidenhead). All of these complaints
were found to be upheld. Where possible appointments and assessments have been brought
forward, however these should be based on the clinical need of the young person. There are ongoing discussions with our commissioners about the level of provision of this service across
There were two complaints about waiting times for the community mental health teams (one in
Wokingham and one in West Berkshire). One complaint was not upheld and one was not pursued
by the complainant. The investigation into the not upheld complaint found that the referral was
acted upon and the patient was offered crisis support while they were waiting for their
appointment. There was a complaint about diabetic eye screening which was not upheld and an
upheld complaint about a child’s combined therapy provision. This investigation showed that there
was a delay in an onward referral which was then not treated as urgent. Further contact was then
not received into the service and acted upon. An apology was given to the complainant and the
child was offered an appointment.
Of the complaints received about care and treatment during quarter three, 73% were attributed to
mental health services and 27% to community health. This is in comparison with 54% in quarter
two and 62% in quarter one.
There were seven secondary complaints received during quarter three, in comparison with four in
quarter two and eleven in quarter one; these are complaints which the Trust has previously
responded to and the complainant remains dissatisfied. As part of the complaints process,
complainants are advised to return to the Trust in the first instance with their concerns and when
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local resolution has been exhausted, approach the Parliamentary and Health Service
Two of these complaints were found to be upheld. Two were partially upheld and one was not
upheld. The remaining secondary complaint was still in the process of being investigated, within
timescale, at the end of quarter three. An action plan has been put in place as a result of
investigation into the complaint about Podiatry which was upheld. This is to address issues with
communication with carers and to ensure informed consent is obtained before any treatment is
carried out.
Action Taken
The actions identified to improve the service we provide to our service users and their carers
arising from complaints continue to be discussed at the Locality Patient Safety and Quality
Groups. Whilst learning from individual complaints is led by the Service, it is recognised that
themes need to be addressed by all Localities.
As part of the process of closing the formal complaint, a decision is made around whether the
complaint is found to have been upheld (referred to as an outcome).
Of the 62 complaints closed in quarter three, 19 were found to be fully upheld (31%). This is an
increase in comparison with 19% in quarter two, 17% in quarter one and 12% in quarter four.
There have been a consistent number of complainants not pursuing their formal complaint each
quarter this financial year (five cases). In cases such as this we leave the option of returning to the
Trust at a later time.
21 complaints (34%) were found to be partially upheld (in comparison with 25% in quarter two).
Partially upheld complaints are where the investigation into these complaints identified that there
was an aspect where the Trust fell short of the high standard of service we strive to achieve.
Actions are expected as a result of partially upheld complaints as they are with upheld complaints.
During quarter two, the 46% of the formal complaints closed were found to be not upheld. There
was a reduction in quarter three to 27%. This is in part due to number of complaints for CAMHS
about waiting times which were found to be upheld.
One formal complaint was resolved through local resolution; where following a discussion between
the investigating officer and complainant, a swift resolution is brought to the complainant and the
complainant states that they do not require a formal response.
Examples of actions made following complaints closed during quarter three and found to be
upheld are:
• A patient of our Common Point of Entry service was unhappy about the telephone
assessment that was carried out and felt that the information that was documented was not
clarified with them before being sent to their GP. The investigation showed that the
information was shared with the GP as part of the standard assessment process. We
apologised as the information contained within the assessment caused distress and
referred to information that was not relevant at that period of time. An amended version of
the assessment has been sent to the patient's GP.
• The daughter of a patient who attended the Slough Walk In Health Centre complained as
they were not seen and were advised to attend the Emergency Department due to their
arrival time. When they attended the Emergency Department they were challenged by the
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staff as an attendance was not required for their presentation. The investigation showed
that the patient should have been given the opportunity to see a nurse before going to the
Emergency Department and there is a protocol for situations such as this.
• A patient contacted us as they had tried repeatedly to contact our physiotherapy service to
confirm their appointment but had not been able to get through on the telephone. He
subsequently drove to the clinic to confirm face to face. There have been issues with the
telephone system at St Marks Hospital. Ten extra lines have been put in and more staff
employed to co-ordinate them. We are hoping to replace the phone system with a digital
exchange which has the facility for call queuing at busy periods.
• The parent of a patient at Prospect Park Hospital explained that they do not feel that they
have been as involved in the care plan as they should have been. The investigation
showed that appropriate advice was given however some staff were reluctant to hear their
concerns due to confidentiality. As an organisation, we are fully signed up to the Triangle of
Care and further training is being provided to staff on the importance on receiving
information from carers.
• Concerns were raised about the general care and treatment on two of our wards at Prospect
Park Hospital, Orchid Ward and Rowan Ward. The investigation showed that
communication should have been better and that staff were not always wearing a clear
uniform with their name badge on display. There were also concerns about staff being
compliant with policies such as patient property which are being followed up.
• A patient who has been receiving the services of the Podiatry service for a number of years
was advised that they were no longer eligible for the service. It was correct to say that
patient was no longer eligible for podiatry service as the criteria has changed. However
they should have been informed of the nail cutting service and offered an appointment.
Therefore complaint upheld due to poor communication.
• We investigated the complaint raised by a family who are seen by the Health Visiting
Service. They feel that their Care Co-ordinator has acted unprofessionally and would like to
be reallocated to another care coordinator. The investigation showed that there were
issues with miscommunication and a breakdown in communication with their Care Coordinator. A number of recommendations were made and actions put in place as a result of
this complaint:
- 1:1 case load supervision for the Care Co-ordinator
- When using templates, staff are to ensure all details for other children is cleared or use
a copy of blank template
- Clinical staff need to ensure that the service user GP is updated when there is a
change in medication plan.
- Clinical staff need to be clear in the appointment letter the purpose of the appointment
and if the child needs to be present. In this case, the appointment was with the parent
and the child was not required to attend the appointment.
- The Bracknell clinic is to inform their families of the appropriate telephone number to
use to get hold of the service to minimise breakdown of communication.
Response Rate
Whilst the Complaint Regulations 2009 state that the timescales for complaint resolution are to be
negotiated with the complainant, the Trust monitors performance internally against both a 25
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working day timeframe and formally, the renegotiated timescale. The investigating managers
continue to make contact with complainants directly to renegotiate timescales for complaints
where there has been a delay and these are recorded on the online complaints monitoring system.
The response rate for quarter three is 88% within a timescale re-negotiated with the complainant.
This is in comparison with 87% in quarter two, 91% in quarter one and 81% in quarter four.
Table Four: Response rate during quarter three
Quarter Three
Including re-negotiated
By monitoring the response rates by Locality, the Trust is able to identify any specific areas which
are having difficulties in undertaking prompt complaint investigations and where a locality is not
making contact with complainants to renegotiate timescales accordingly.
There continues to be targeted work with services around making contact with complainants both
early in the complaints process and to re-negotiate timescales where appropriate.
A revised internal response rate target of 65% resolved within 25 working days and 90% within
negotiated timescale have been set for 2014/15.
The average number of days taken to resolve formal complaints during quarter three was 29, a
slight increase from 28 in quarter two and the same as quarter one. It took an average of 33
working days to resolve a complaint in quarter four 2013/14.
Table Five: Response Rate by working days for complaints closed in quarter three
Mental Health Inpatient
and Urgent Care
West Berks
Windsor, Ascot &
Grand Total
0 to 15
Working days open
16 to 25
26 to 40
41 to 59
60 to 80
The Trust continues to aim for a resolution within 25 working days, unless this is not possible due
to complexities of the complaint. By monitoring complaint response times we are able to identify
any localities which show a longer resolution timescale than generally expected.
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2.3 Parliamentary and Health Service Ombudsman (PHSO)
The Trust continues to work with the PHSO as the second stage within the complaints process.
We received notifications of four new investigations during quarter three. These were for the
Complex Needs Service, Community Inpatients (Jubilee Ward), Physiotherapy and Bracknell
CMHT. We are currently waiting for an update from the PHSO regarding these investigations
An update of the PHSO complaints is attached as Appendix 2.
The Patient Experience and Engagement Group are actively monitoring the action plans that arise
from PHSO investigations on a quarterly basis, which acts as a forum to share practice and
learning across the different specialities and geographical localities.
The Friends and Family Test
The Friends and Family test has been implemented in line with national and local requirements. In
line with the national guidance, the reporting requirements of the Friends and Family Test (FFT)
has been amended to reflect a percentage of people with a combination of those who are either
extremely likely or likely to recommend the service or extremely unlikely or unlikely to recommend.
Where possible we have integrated the FFT into the existing internal patient survey (in line with
national guidance to ensure that all patients are offered the opportunity to complete the FFT) and
for the MSK Physiotherapy Team for example, linked in with the survey they offer to 100% of
patients as part of their service contract with commissioners. The FFT methodologies currently
being used for the FFT are card, text message, handheld device and kiosk. We are in the process
of setting up an integrated patient survey for the School Nursing service on i-phones.
The Trust has been asking a variation of the FFT as part of the internal patient survey programme
for the past two years, however due to specific requirements of the FFT; we are unable to use this
information for national reporting. This information has, and continues to be used internally as one
of our measures for quality.
The services with responses to the formal FFT collected during quarter three are found in the
following tables:
Minor Injuries Unit
% Extremely & likely
% Extremely unlikely
& unlikely
% Extremely & likely
% Extremely unlikely &
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% Extremely
% Extremely
unlikely &
& likely
Walk in
% Extremely &
Mental Health
% Extremely &
% Extremely unlikely &
no responses*
no responses
% Extremely
unlikely &
*no responses received to the text
messaging methodology of the FFT. Cards
introduced alongside this from November.
Talking Therapies
Reading Primary Care
% Extremely &
% Extremely unlikely &
no data
no data
no data
no data
% Extremely &
% Extremely unlikely &
no data
no data
no data
no responses
When interpreting the percentages, it is important to take the number of patients into
consideration, particularly in community inpatients where the number of discharges is low in
comparison with acute trusts.
The FFT is being embraced across a number of areas across the Trust in the spirit that it was
created – to give people an opportunity to give feedback to NHS organisations in a way that is not
obtrusive and can be seen to ward or service level to instigate service improvement. In the same
way, it is also being used to share the positive feedback from users of our services who may not
have given their feedback if the FFT was not promoted.
The Patient Experience Team is assisting teams and specific staff to work through an
implementation issues to ensure that the FFT is being utilised as effectively as possible.
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An action from the Listening into Action (LiA) Big Conversations with Patients and Carers is to
implement the ‘You said, we did’ boards across the Trust. These are currently in a number of our
services, however having this information in a clear, consistent way across services (incorporating
the results of the FFT) will assist in sharing patient experience and actions that arise as a result.
Linking in with the Carer Strategy refresh, an FFT for Carers has been created which will be
distributed to services from February 2015. This will give our carers the opportunity to share their
experience with us in a dedicated way. Whilst this is not mandated within the FFT national
guidance, the Trust recognises the crucial role that carers have and the value that their feedback
The staff FFT and the patient and carer FFTs will give us a real ‘oil stick’ measure into the whole
experience of the services we provide. The Head of Service Engagement and Experience will be
drawing a comparison against these three measures from 2015/16.
15 Steps
2014/15 is the third year of the 15 Steps rolling programme.
Five visits have been undertaken during this quarter, three inpatient wards (Rose Ward,
Donnington Ward, Oakwood Unit) and two outpatient departments (Physiotherapy and Podiatry West Berkshire Community Hospital). All the visits were positive with the main points listed below:
• Staff pride - in all of the visits staff continue to be very positive and proud of their service
and very keen to share their developmental plans which all had and continued to involve
• Activities - activity rooms/areas in place for inpatient areas and there was evidence of
activities, led by activity coordinators. Further work needed to provide activities when the
activity coordinator isn’t on duty and out of hours.
• Patients/client engagement - teams are increasingly engaging with patients/clients when
developing their services.
Appendix 3 contains the full quarterly report showing identifying the feedback and themes from the
15 Steps visits which took place during quarter three.
5. Quality Visits
There have been four Quality Visits during quarter three. These are visits by our Governors and
Executive Team.
There was a visit to the Manor Green Respite Service based at Manor Green School. The respite
service is currently available to around 20-23 families across east Berkshire. There was feedback
from parents and children during this were about the positive impact the service has on their lives.
A visit was undertaken to the Audiology Service at King Edward VII Hospital in Windsor, which is
part of Any Qualified Provider (AQP). The Audiology Unit was the first NHS trust to be UKAS
accredited for all three audiology disciplines (paediatrics, adult and balance) under the Improving
Quality in Physiological Services (IQIPS) scheme. The service is working towards the 3rd reaccreditation. Over 97% of patients consistently report their care to be ‘good’ and ‘excellent’.
At the visit to Henry Tudor Ward at St Marks Hospital in Maidenhead, the ward were able to
demonstrate that there had been no pressure ulcers for over a year and that patients are
encouraged to move around to stay mobile. There was a good ward atmosphere, with both
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patients and staff reporting a positive experience of the ward. There had been no falls on the ward
for 30 days and ‘Falls Safe’ is being used to manage and improve falls risk. Staff said it was a
good ward to work on and commented on how much it had improved and had good leadership.
There was a visit to the Nursery Nursing Team covering the Newbury area. This visit showcased
the work that is undertaken by the team of qualified nursery nurses and a staff nurse who monitor
the health and developmental progress of babies and young children up to five years old. They
also offer advice and support to parents on a range of topics including breast feeding, sleep,
immunisation, teething, safety and accident prevention. A clinic was observed where one mother
commended the ‘brilliant breast feeding support’ she had received.
6. Deep Dive
A Deep Dive Survey into the Community Mental Health Teams across all six geographical
localities has been scheduled for the beginning of quarter four. As part of this programme, a week
has been set aside for survey packs to be given to patients across the teams, followed by a week
of face to face and telephone interviews. The results of the survey will be provided by the end of
quarter four.
An action plan from the Deep Dive Survey undertaken at the Slough Walk in Health Centre earlier
this year is currently being co-produced with Healthwatch Slough.
7. Informal Complaints and Local Resolution
The complaints office has been working with services to devise ways of resolving complaints that
meet the expectation of patients and their families whilst capturing the information for staff in a use
friendly and manageable way.
Informal complaints are complaints which come into the complaints office and are not formal
complaints. Historically, the Trust was keen to promote formal complaints as the predominant form
of resolution and management, and this is not appropriate in all cases or to all people. The
complaints office received specific feedback from some people who had raised complaints and
were surprised to receive a formal acknowledgement from our Chief Executive, explaining that
they didn’t expect, or want their complaint to be managed in this way.
The complaints office will discuss the options for complaint management when people contact the
service give them the opportunity to make an informed decision on if they are looking to make a
formal complaint or would prefer to work with the service to resolve the complaint informally.
Table six shows the number of Informal Complaints received and managed in this way during
quarter three.
Table Six: Informal Complaints received
Adult Acute Admissions (1x Ward 12, 1x
Bluebell/Daisy Ward, 1 access to assessment)
CAMHS - Child and Adolescent Mental Health
CMHT/Care Pathways (1x Slough, 1x Reading)
Older Adults Community Mental Health Team
Health Visiting (West Berkshire)
Number of informal complaints received
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Hearing and Balance Services
LDS Community Patients
Out of Hours GP Services
Physiotherapy (Adult) (Windsor, Ascot and
PICU - Psychiatric Intensive Care
Grand Total
It is also recognised that services are managing concerns effectively on a daily basis and that it
would be beneficial to have a consistent way of collecting and monitoring this information. An
online form has been created as a mechanism for these concerns to be captured. Table seven
shows the number of these local resolution contacts reported by services during quarter three.
Table Seven: Local Resolution contacts received
Admin teams & office based staff
CAMHS - Child and Adolescent Mental Health
Care Home
CMHT/Care Pathways
Common Point of Entry
Community Hospital Inpatient
Diabetic Eye Screening
District Nursing
Health Visiting
Hearing and Balance Services
Learning Disability Service Inpatients
Mobility Service
Musculo-skeletal Triage Service
Palliative Care
Physiotherapy Musculo-skeletal
PICU - Psychiatric Intensive Care
School Nursing
Sexual Health
Talking Therapies
Walk in Centre
Grand Total
Number of Local Resolution recorded
PALS Contacts
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The role of PALS is to offer a signposting service as well as to facilitate the resolution of concerns
with services at the first stage of the complaints process. A programme of PALS community clinics
is being developed; a timetable will be made available in quarter four.
There have been 291 contacts during quarter three, a decrease from 321 in quarter two.
60% of contacts were resolved by PALS on the same day, this is a reduction from 65% in quarter
The majority of contacts (39%; a decrease from 49.5% in quarter two and an increase from 36% in
quarter one) were made following people gaining contact details from the internet. As a result of
the feedback in quarter two, PALS are pro-actively signposting people to NHS England in regards
to GP concerns, rather than taking the lead.
The themes of contacts received during quarter three is broken down as follows:
October (total 128 contacts) – Communication between services (46). This is separate to people
requesting general information and signposting about the Trust and is where PALS is used as a
conduit for information. Examples include a group contacting PALS as they wish to respond to the
implementation of the smoking ban which is coming into force. A further example is contact from a
trainee clinician who is looking to learn more about services for people with dementia and would
like to attend a clinic.
November (total 75 contacts) – Information Requests (32) including copies of Trust leaflets and
specific requests for information about the Circuit Lane GP practice. Information was also
requested about how to get to both Trust and other NHS sites.
December (total 82 contacts) Information Requests (24) including a number of requests for work
experience and volunteering. PALS are working with other services to update the information on
the Trust website to signpost people to the most appropriate person where possible.
During quarter three, the service areas with the highest level of activity were:
CMHTs (20 contacts), Older Adults Community Mental Health Team (12 contacts) and Workforce
queries e.g. placements, HR signposting (18 contacts).
Graph Two shows the number of compliments received since quarter one 2012/13 by Locality.
Since quarter four 2012/13 compliments have been routinely reported directly by services through
the web based Datix system. This method of collating feedback enables the Trust to capture
compliments other than the traditional thank you card. The majority of the compliments that we
receive are thanking staff for their time and care.
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Graph Two: Number of compliments received since quarter one 2012/13.
Table eight shows the number of compliments received during quarter one, by month and locality.
There were 990 compliments received during quarter two in comparison with 1140 received during
quarter three.
Table Eight: Compliments received during Quarter Three
Mental Health Inpatient and Urgent
West Berks
Windsor Ascot and Maidenhead
Q3 Total
Patient and Public Involvement
We continue to work closely with Healthwatch organisations to gather feedback on the services we
provide and ways we can improve this further. The Patient and Engagement and Experience team
hold a meeting every three months where we give an update on patient experience and incidents,
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and invite services that Healthwatch have asked for further information on. Localities also meet
directly with their associated Healthwatch organisation.
Services are using a combination of devices and paper surveys as well as a mixture of surveying
continually throughout the year, rotation of devices between localities and targeted times to
At the end of quarter three we have received feedback from 3,818 patients or carers (compared to
3,787 in quarter two) including 181 from Learning Disabilities.
Learning Disabilities responses
The Learning disabilities figures are not included in the overall ‘Good or Better’ rating as the
current easy read survey does not include the ‘How do you rate your overall care?’ question. There
has been a notable increase in the number of surveys collected during quarter three (181 in
comparison with 89 in quarter two). The survey has been revised and from January 2015 will
incorporate the ‘Good or Better’ question. Learning Disabilities results are detailed in table nine.
Table Nine: Learning disabilities survey responses
A lot
A little
Not at all
Question not
My meeting
with you was
150 (91.4%)
13 (7.7%)
1 (0.6%)
I would tell my
friends that
my meeting
was helpful
129 (80.6%)
24 (15%)
7 (4.3%)
*Percentage of patients who responded to the question
Good or Better results
Total feedback relevant to the good or better rating has been received from 3,637 patients and
carers, of those that provided feedback 94.6% reported the service they received as good or better
compared to 90.2% for last quarter, meaning the percentage has continued to increase
significantly and targets have been met comfortably again this quarter. The vast majority of
services have increased their satisfaction ratings in quarter three; all of the community hospital
wards have increased their satisfaction ratings or maintained a 100% good or better satisfaction
rating. This is also reflected in all but one of the Mental Health inpatient wards (Rowan ward has
decreased from 98.3% rating good or better to 90%). The low number of good or better ratings
continues to be an issue in the Slough Walk in Health Centre. The impact of the implementation of
the Friends and Family Test in this service is going to be monitored specifically.
The service performance against target information for quarter three shows that there are still a
very large number of services that will need to increase their collection numbers in order to reach
their targets for the current financial year. The number of responses will be carefully monitored
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and services kept informed of the numbers still required to achieve this with the help of the
monthly report sent to Locality Directors.
You Said, We Did
Below are examples of evidence that patient feedback has impacted on the service that the Trust
You said…
…We did
Cardiac Rehabilitation service –
Patients said that they want more handouts and to increase the selection of
music available.
MSK Physio - Feedback from patients
is they don't have time to fill a patient
survey after their appointment.
Music players have been updated with new
songs for all three areas. New booklets for
depression, understanding food labels and a
brief understanding of Cardiac Rehabilitation
leaflets have been provided.
The service is trialling each physiotherapist
having a tablet for a day which has the
questions from the patient survey included.
Patients are asked to complete whilst waiting
for print outs of their exercises
Older Adults Community Mental Health
Team – Feedback at our Dementia Forum is
that carers and people with dementia said
they would like to have the opportunity to
meet the memory service team in a forum
setting on a regular basis.
Our service has plans to hold quarterly
dementia forums for patients and their
Psychiatry – Feedback from our Family
psychosis project was that the timing of the
group is too early.
We have heard the feedback and have
changed the time of the group.
Community Based Neuro Rehab – Our
patients told us that they were having difficulty
the selection of answers in
their survey.
Our service met with Patient Experience
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Talking Therapies – Our patients gave us
some feedback on our Silver Cloud leaflet
(part of our online support that is available).
The leaflet wasn’t giving people the
information they needed in the right way.
Mental Health Inpatient Ward – Some of
our current patients requested more cookery
sessions on the ward and also asked that
more art and craft materials be provided.
Common Point of Entry – Patients
wanted a timescale of when they would
be assessed so they knew what to expect
from the service.
Mental Health Inpatient Ward – Some of our
current inpatients said that we needed more
signs for the kitchen and laundry room on the
It would also be good to have more resources
for use during the evenings and weekend, as
well as more help and support for those who
are anxious or distressed
Our leaflet has been updated to reflect the
feedback from our patients.
The activity programme is updated each
week, using the feedback obtained in the
ward community meeting. Extra cookery
groups have been provided.
We are introducing an acknowledgement
letter for all newly referred clients to give
them an idea of when they will be assessed.
Clearer signage has been provided for
the ward. Newspapers are now delivered
daily to the ward, including weekends. A
calm down box is now available from the
nursing office, with items to help those
who are anxious or distressed. More
resources have been provided for use by
patients in the evenings and weekends
including; DVDs and art and craft
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Berkshire Healthcare NHS Foundation Trust
Formal Complaints received during Quarter Three 2014/15
Reporting Locality
Geographical Locality
Mental Health Inpatient Reading
and Urgent Care
Adult Acute Admissions Care and Treatment
The family of a patient report an
Not Upheld
incident in the dining area which
resulted in the wife of the patient
being hit round the head by another
patient. There were no staff around at
the time to manage the situation. The
family are also unhappy that the
patient was discharged so soon after
they had a change in medication.
No complaint was made at
the time of the incident and
staff were not aware of any
concerns. The Consultant
felt discharge was
appropriate as the patient
was established on the new
medication and wanted to go
Apology given if the family
knocked on office door and
were ignored but staff
unable to recall this.
Psychotherapy &
Complex Needs
Patient remains dissatisfied with the
response to their concerns about a
named member of staff.
The concerns about the
member of staff are being
addressed through a
separate process. The
patient hsa asked for
appointments in a different
location and the service has
looked at ways that this
could be provided; they are
unable to offer appointments
at the location requested by
the patient but have agreed
to reimburse his taxi fares to
an alternate. Issues relating
to the information on their
records have been dealt with
Care and Treatment
Partially Upheld
Outcome Description
Reporting Locality
Geographical Locality
Mental Health Inpatient Reading
and Urgent Care
Adult Acute Admissions Attitude of Staff
Patient has felt that named Doctor
Partially Upheld
has been abrupt and rude during two
admissions. Patient requested
discharge to an acute Trust for a
physical intervention and believes if
this had been facilitated sooner her
physical health would be improved.
Windsor, Ascot &
Waiting Times for
Mother is unhappy that referrals to
childrens physiotherapy, speech and
language therapy and occupational
therapy have been delayed. Unable to
get hold of staff by phone to discuss
referrals and staff have told her that
referrals have been lost. It has taken
5 months for her child to be seen by a
West Berks
West Berks
Community Hospital
Attitude of Staff
Staff appeared unsympathetic to the
patient and commented on their
'difficult attitude' on admission.
CMHT/Care Pathways
Attitude of Staff
Patient feels diagnosis is wrong and Not Upheld
that she has PTSD. She feels that
staff at prospect park are responsible
for harrassment and are conducting
social engineering experiments and
mind control experiments.
Outcome Description
The doctor's communication
skills were poor. However
the patient had had a
bladder scan and a physical
exam which showed no
evidence of retention of
urine at that time.
Explanation and apology
Consultant Paediatrician
took 2 months to make the
referral. Then referral not
treated as integrated
referral. Letters and
messages not received.
Apology given and an
appointment offered for 6th
November and if son
requires further treatment
this will be undertaken at
Pain assessments should
have been repeated.
Communication between
staff and family was poor.
Soiled garments given to the
patient's family without
explanation. Discharge not
discussed with stepdaughter but wife was
Apology given for lack of
care and compassion
Patient has not been given a
firm diagnosis but advised to
take anti psychotic
medication. No evidence
that staff are 'gang stalking'
or responsible for
harrassment or
experimentation. Patient
cancelled an appointment on
and is currently refusing to
engage with services.
Reporting Locality
Geographical Locality
Windsor, Ascot &
CAMHS - Child and
Adolescent Mental
Health Services
Waiting Times for
2 points raised by the mother are:
1. Unacceptable waiting times for
assessment of her 2yr old daughter's
(suspected autism)
2. Administration errors and lack of a
named contact within the CAMHS
autism assessment pathway referral
Waiting times are over 6
months due to high volume
of referrals exceeding
commissioned resources.
There were some
administrative errors and
CAMHS will be revising and
improving the information
provided to families and
informing them that the
Team Manager is the care
co-ordinator whilst patients
are on the waiting list and
until one is allocated after
West Berks
Community Based
Neuro Rehab
Care and Treatment
Incident where physio attended the
patient's home who was not known
previously to the patient. The police
became involved as the patient
became confused.
Situation could have been
handled better. Patient
opened the door to physio
staff with a kitchen knife,
they were frightened and
called the police a decision
was made not to visit the
patient at home but he could
receive therapy at Upton
Hospital. Agreed with the
family on 18th July 2014 that
he would have continue with
therapy at his sisters house
with a family escort.
Risk Assessments to include
patients environment as well
as medical condition.
Service to produce guidance
for staff on how to manage
the situation if patients do
not respond and this should
be discussed with the patient
and family. Staff to ensure
telephone numbers are up to
Partially Upheld
Outcome Description
Reporting Locality
Geographical Locality
CMHT/Care Pathways
Waiting Times for
Patient transferred from mental health Not Upheld
service following return home from
University. Was advised by existing
services that she would be appointed
a CPN from the Trust on their return
which did not happen.
CMHT/Care Pathways
Attitude of Staff
Patient felt unsupported by their Care Investigation currently
Co-ordinator following a suicide
attempt. Discharge from CMHT and
subsequent disagreement in meeting
with Advocacy, family and Care Coordinator.
Mental Health Inpatient Reading
and Urgent Care
Crisis Resolution &
Care and Treatment
Home Treatment Team
Patient feels the Crisis Team showed Case not pursued by
an inability to assess her, making
offers which were withdrawn.
Patient withdrew complaint;
she said that on reflection
she feels thankful to staff
and is currently being helped
Speech and language
therapy (ADULTS
Patient was advised by our SLT whilst Not Upheld
in the acute trust that they were to
have liquidised food as at risk of
choking. RBH continued to feed
normal food so son wishes to
complaint about lack of
communication and then the fact that
the SLT advised the residential home
he would need soft food. Residential
home refused for patient to return; a
home had to be found at an additional
Family wish to claim £45,000 for
additional cost to residential home
due to feeding guidance.
Advice re swallowing was
appropriate and well
documented by the SLT
team. The nursing home
visited the patient four times
before refusing to take him
back as he required
increased level of
supervision due to
worsening dementia. A
further nursing home has
confirmed that the patient
has swallowing difficulties
and requires an increased
level of supervision.
Outcome Description
Patient was referred by her
CPN on 8th July the referral
was discussed on 11th July;
and appointment letter sent
for psychiatrist for 9th
September. Crisis team
contact numbers given.
Appointment was brought
forward to 5th August and
was referred to BEDS and
seen on 20th August. Since
5th August there has been a
care plan in place and a
care coordinator was
allocated on 12th
September. Referral has
now been made to complex
Reporting Locality
Geographical Locality
Windsor, Ascot &
Windsor, Ascot and
CAMHS - Child and
Adolescent Mental
Health Services
Patient aged 10 years old prescribed Upheld
risperidone 2 years ago has not had a
follow up appointment with a
psychiatrist to review the medication.
Mother wishes for appt at her son's
school and for 6 monthly follow ups to
be organised.
Appointment bought forward
by telephone call from
service. No written response
required from the Trust.
District Nursing
Access to Services
Patient with kidney disease has been Partially Upheld
informed by the District Nursing
service that she does not fit the
criteria for home visits as she is not
There are criteria for access
to District Nursing service.
However there is the ability
for variation to the guidelines
if the person has illness or
temporary disability. The
patient will be assessed and
has agreed to visit her GP
surgery if able and will only
call the District Nursing
service when too unwell to
leave the house.
West Berks
West Berks
CMHT/Care Pathways
Waiting Times for
First referred in 2011 and feels still
not getting appropriate treatment.
Windsor, Ascot and
Physiotherapy (Adult)
Access to Services
Patient reports that they made 17
telephone calls in one day to confirm
his 45 minute physiotherapy
appointment. As he was unable to get
through, he drove to the clinic to
confirmthe appointment.
Complaint withdrawn by
patient on 11th November
2014 as she has now
received a diagnosis of
complex trauma.
Trust recognises problems
with phone system at St
Marks Hospital. Ten extra
lines have been put in and
more staff employed to
operate them. The Trust is
hoping to replace the phone
system with a digital
exchange which has the
facility for call queueing
during busy periods.
Windsor, Ascot &
Windsor, Ascot and
CAMHS - Child and
Adolescent Mental
Health Services
Waiting Times for
Son has waited over a year for an
appointment and his mother states his
condition has dramatically
Wishes for a prompt diagnosis
Case not pursued by
Outcome Description
Appointment offered for 26th
November and accepted.
Reporting Locality
Geographical Locality
Windsor, Ascot &
Windsor, Ascot and
CAMHS - Child and
Adolescent Mental
Health Services
Access to Services
13 year old has been under CAMHS Partially Upheld
since 9 years old but was discharged
without a diagnosis.
Back under CAMHS having been
asked to leave his school.
Out of Hours GP
Attitude of Staff
Patient's father feels he was spoken
to in an inappropriate way by the
Mental Health Inpatient Reading
and Urgent Care
Adult Acute Admissions Communication
Patient's father does not believe he
has been involved in his son's care
plan as much as he should have been
and he would like a detailed case
Intermediate Care
Unhappy with discharge from acute
Partially Upheld
trust and level of physiotherapy input.
No home visit madeadn they were
taken home alone with no-one to
assist them with getting to bed. The
patient is under the care of the
ntermediate Care team; medication
not always administered or left out of
reach, no handover notes completed.
Changes to care package made
without contact with family members.
Outcome Description
Some elements of the
complaint upheld. CAMHS
working with service user
group to develop CAMHS
website and information
leaflets.CAMHS will coordinate an MDT meeting
including local authority to
address Education Health
Care Plan.
Doctor acknowledges that
he did not handle the
Consultation in the best way
and has apologised.
CRHTT staff were reluctant
to hear father's concerns
due to issues of
confidentiality. Trust has fully
signed up to Triangle of
Care and further training will
be provided to staff on the
importance of receiving
information from carers.
The referral was not
received which led to
medication not being given.
Issues around
communication particularly
regarding the service offered
by Intermediate Care team.
Reporting Locality
Geographical Locality
CMHT/Care Pathways
Care and Treatment
Complaint spans 3 areas, CMHT /
Not Upheld
Local authority and Inpatients.
Patient wishes for the CMHT to make
a referral to a named Professor.
Issues around Direct payment given
by the local authority and questioning
of 2 members of LA staff at a
Patient wishes to know why a Doctor
won't give diazepam when her GP
does and cannot come to terms with a
statement made by a Doctor when
discharged from Ward 12 in 2013 - 'I
don't care if you're suicidal, you're
going home.'
GP has to refer patient to
Professor not CMHT. Issues
around direct payments
were appropriate as LA has
a duty to ensure money
spent on authorised
expenses. Trust guidelines
state doctors should not
prescribe long term
medication this should be
the remit of the GP.
Mental Health Inpatient Bracknell
and Urgent Care
Crisis Resolution &
Access to Services
Home Treatment Team
Failure of NHS to provide patient with Not Upheld
access to a prescriber. Patient has
spent £450 to access a private
prescriber. No care pathway in place
patient left in a hypo manic state. Has
had benefits from medication
prescribed by the cardinal clinic would
like this to continue on NHS and costs
be reimbursed.
Patient advised to obtain a
prescription from her GP or
the out of hours GP.
Appointment offered within
2.5 weeks or referral with
Windsor, Ascot &
Community Hospital
Complainant generally very unhappy Partially Upheld
with her fathers care and treatment
whilst on Henry Tudor ward during
two admissions.
As part of the investigatio, the CQC
wish us to report on whether any
management plans/policies have
been changed and whether there has
been any disciplinary action or referral
to a professional body as a result of
the concerns raised by the family
Regular physiotherapy and
OT given. Patient asked to
have an incontinence pad at
night. Staff were trying to
establish a toileting routine
to prevent him from falling
when he went home. Ward
Sister has acknowledged
she can be abrupt at times.
Apology given.
Windsor, Ascot and
Care and Treatment
Outcome Description
Reporting Locality
Geographical Locality
Out of Hours GP
Care and Treatment
Following 111 call, a Doctor came to Upheld
either unblock or replace the patient's
supra-pubic catheter. Doctor removed
the catheter but did not replace he
advised the family not to call
Ambulance until 4am as they would
not be seen by the urologist until he
came on duty.
Patient was waiting for a bed as an
operation is required to reinsert the
CMHT/Care Pathways
Care and Treatment
Site Services
Environment, Hotel
Services, Cleanliness
Patient remains dissatisfied with our Investigation currently
response to their complaint.
30 points have been raised which
need addressing and she does not
under stand why she has not been
given an apology
Family feel their son is not getting the Partially Upheld
choice of food as per the NHS
Mental Health Inpatient West Berks
and Urgent Care
Crisis Resolution &
Care and Treatment
Home Treatment Team
Patient recently visited every other
Partially Upheld
day by the Crisis team to ensure their
safety. This was then stopped. The
patient still feels the need to call
Crisis most evenings, mother feels
this can either be helpful of unhelpful
depending on the person you speak
Outcome Description
Dr did not stress urgency for
transfer to hospital and there
was misinformation and
miscommunication between
the GP and the oncall at the
RBH. Patients clincial
records to be updated to say
catheter should be replaced
with size 18 if unable to do
so for any reason then
urgent transfer into hospital
for the procedure.
Although there is a choice of
breakfast and lunch
available. The Ward will
develop a picture board with
the available food choices to
aid patient choice. When
family bring in fruit it is
named and put aside no
evidence that staff have
eaten it. Meeting to be
arranged with Head of
Learning Disability Services
to discuss further ongoing
Whilst decision to discharge
from CRHTT to CMHT was
appropriate, communication
and information sharing was
Reporting Locality
Geographical Locality
Outcome Description
West Berks
Care and Treatment
Husband feels there were errors in
our original response to their
complaint and that it detracted from
the real issue of his wife's pain.
Action plan in place to
address issues with
communication with carers
and ensuring informed
consent is obtained before
any treatment is carried out.
Mental Health Inpatient Reading
and Urgent Care
Crisis Resolution &
Attitude of Staff
Home Treatment Team
Patient is looking to receive an
Partially Upheld
apology and compensation for the
unnecessary taxi to the hospital.
Patient feels she receives poor
treatment from the service on a
regular basis, didn't feel listened to
when staff arrived at 6pm. Expects to
receive treatment from someone who
is neutral on matters of gender,
sexuality and religion, thus felt the
person made sexist comments.
Wishes reassurance that staff will be
educated on diversity and ethics and
Reimbursement of taxi fares
for unnnecessary journey re
medication offered. Staff
could have considered
issues around the gender of
staff visiting the home and
offered the same gender if
West Berks
Minor Injuries Unit
Care and Treatment
Patient wishes to know why he was
Not Upheld
not x-rayed when he presented with
an ankle injury. A furthe review and xray at an acute trust diagnosed a
displaced fracture.
Ottawa rules and clinical
findings did not support an X
ray under IMER guidelines
at the time patient was seen
in MIU.
West Berks
West Berks
CMHT/Care Pathways
Care and Treatment
Family and patient feel the system is Investigation currently
failing him, he has covered many
services and his Care Co-ordinator
and Doctor both previously worked
well with the patient now have refused
to have any contact with him.
Mental Health Inpatient Reading
and Urgent Care
Adult Acute Admissions Attitude of Staff
Following an alleged incident on the Investigation currently
ward where a member of staff made a underway
complaint about the visitor, both her
and her partner were only allowed to
see the patient off the ward.
Complainant wishes this over turned.
Reporting Locality
Geographical Locality
Psychotherapy &
Complex Needs
Access to Services
After finishing a year long programme Investigation currently
of therapy under the service, the
patient was advised to contact them
again within 6 months if they need to.
Recent deterioration meant that the
patient needed to contact services
who informed him the rules had
changed and he needed to see GP
for a new referral.
When visiting GP he was advised of
diagosis which he states he was
unaware of.
Patient has requested a formal review
of his treatment to be fed back via a
local resolution meeting.
Windsor, Ascot &
CAMHS - Child and
Adolescent Mental
Health Services
Waiting Times for
Mental Health Inpatient Reading
and Urgent Care
Older Peoples Mental
Health (Ward Based)
Care and Treatment
Father feels he has been waiting a
long time for his son's ADOS
assessment. States he needs a firm
diagnosis to be able to get a
statement for his son in preparation
for the correct schooling.
General Care and treatment on
Orchid and Rowan Ward
Mental Health Inpatient Reading
and Urgent Care
Crisis Resolution &
Attitude of Staff
Home Treatment Team
Outcome Description
There are Long waiting
times for assessment.
Appointment has now been
given for 11th December.
Poor communication and
documentation, policies on
moving and
control/property not followed.
Staff not always wearing
uniform and name badges
Staff were wearing ID
Badges and were dressed
appropriately. The patient
may have felt uncomfortable
having disclosed personal
information about her
husband who was in the
room. Staff say the patient
thanked them when they left.
Staff reminded of the need
for sensitivity when dealing
with patients in crisis.
Patient visited at home by CRHTT
Not Upheld
who they report were unprofessional,
insensitive and looked scruffy. They
ended up asking them to leave her
Reporting Locality
Geographical Locality
Outcome Description
Windsor, Ascot &
CAMHS - Child and
Adolescent Mental
Health Services
Attitude of Staff
Mother feels Care Coordinator has
acted unprofessionally and has
breached confidentiality by giving
over another patients full details.
Wishes new care person.
There were issues with
miscommunication and
communication breakdown
with Care Co-ordinator.
Actions: (1) 1:1 case load
(2) When using templates,
staff to ensure all details for
other children is cleared or
use a copy of blank
(3) Clinical staff need to
ensure that the service user
GP is updated when there is
a change in medication plan.
(4) Clinical staff need to be
clear in the appointment
letter the purpose of the
appointment and if the child
needs to be present. In this
case, the appointment was
with the parent to discuss
sleep hygiene and the child
was not required to attend
the appointment.
(5) Bracknell clinic to inform
their service users to use the
appropriate telephone
number to minimise
breakdown of
Sexual Health
Care and Treatment
Patient had STI screening 5yrs ago
Not Upheld
then again 1 year later. Partner and
patient attended sexual health clinic in
Basingstoke, and were both told they
had genital warts.
Patient feels she was previously
No evidence of either a skin
tag or genital warts present
during any consulations
attended in 2009/2010 or
Reporting Locality
Geographical Locality
Outcome Description
West Berks
Windsor, Ascot and
Access to Services
Patient of 72 has been enjoying the
services of podiatry for approx 15
years but was informed at King
Edward VII that he was no longer
eligible for the service.
Patient wishes a review of this
decision and services to be restored.
Diabetic Eye Screening Waiting Times for
MP complaint - Annual appointment Not Upheld
letter, pt called to request appt at
Tilehurst clinic but was advised no
spaces until February 2015. They
were offered alternative locations
which the patient deemed unsuitable.
Altercation on the telephone appears
to have ensued with 2 members of
It was correct to say that
patient was no longer
eligible for podiatry service
as criteria has changed.
However he should have
been informed of the nail
cutting service and offered
an appointment. Therefore
complaint upheld due to
poor communication.
Several alternative locations
were offered but refused.
Staff felt that they handled
the call as well as they could
but were unable to give the
patient what she wanted.
Patient has subsequently
called again and booked an
appointment for March 2015
at her preferred clinic.
West Berks
West Berks
CMHT/Care Pathways
Care and Treatment
District Nursing Out of
Hours Service
Access to Services
Patient has complained that he is not Investigation currently
getting the support he should be
getting from CMHT.
Patient had a fall and had 15 stitches Partially Upheld
to a head wound. Asked District
nurses to visit to redress wound and
was informed that she would need to
go to surgery in future. She is unable
to visit surgery and this has led to her
dressings not being changed. When
she telephoned the service she
reports that staff were rude and
Clinical policys should be
applied consistently across
the organisation. Risk
assessment process to be
reviewed to ensure any
overiding factors such as
recent trauma/illness are
explored and home visits
Reporting Locality
Geographical Locality
Support Services
Attitude of Staff
Patient says that receptionist was
rude to her and used racist and
offensive language towards her when
she attended for a physiotherapy
Signage is poor which
added to the patients
frustration and caused
confusion. This will be
replaced and improved.
No independent witnesses
to discussion between
patient and member of staff.
However apology given.
Complaint could have been
escalated to complaints
department earlier as Health
Centre Manager was on
Windsor, Ascot &
CAMHS - Child and
Adolescent Mental
Health Services
Waiting Times for
Referral sent from Paediatrician to
CAMHS in August; not received until
November. Long wait for appointment
12-14 months. Feels that referral
should be backdated to August. Also
complaint about PALS departments at
RBH and BHFT as unresponsive.
PALS did not respond in a
timely manner.
Referral was dictated and
transcribed in August but not
received until November
2014. However the referal
has now been backdated to
show received in August.
Upheld as waiting times for
appointments currently 1214 months.
Windsor, Ascot &
CAMHS - Child and
Adolescent Mental
Health Services
Access to Services
Family feel that daughter has ADHD Partially Upheld
and have been led to believe this by
CAMHS. However feedback from the
school did not mirror that of the family
and daughter has subsequently been
diagnosed with ODD and discharged
from CAMHS and behavioural support
withdrawn. Family feel abandoned by
NHS and Social Care.
Whilst initial diagnosis was
appropriate there were
issues with communication.
An appointment has been
given for a second opinion
with a Psychiatrist.
Mental Health Inpatient Windsor, Ascot and
and Urgent Care
Crisis Resolution &
Care and Treatment
Home Treatment Team
Sons feel their mother needs an
inpatient admission based on past
Outcome Description
Investigation currently
Reporting Locality
Geographical Locality
Outcome Description
GP General Practice
Care and Treatment
Registered practice side of the Slough Upheld
walk in health centre.
Mother took patient to see Practice
Nurse who diagnosed allergy. Mother
bought over the counter medications
and waited for prescription. Doctor
refused to prescribe medication
suggested by Practice Nurse and said
patient did not have an allergy,
despite not having met the patient.
Mother took their child to see a
different Doctor the following morning
and was given antibiotics.
Mother wishes to know 1) why
Practise nurse misdiagnosed costing
mother £10.65 which was would like
to be reimbursed for. 2) Mother
doesn't understand why she has to
fight to get advice and diagnosis.
3)Why did Practice nurse not arrange
for her child to see the Doctor? 4)
Why the Doctor then prescribed
paediatric linctus when patient is
15yrs and 9 months.
Practice Nurse gave
incorrect information
regarding anti histamine and
behaved unprofessionally.
However Doctor was right
not to prescribe anti
histamine on prescription.
Patients are advised to buy
over the counter medicines
and Doctor will advice all
staff not to prescribe over
the counter medicines in
West Berks
Community Based
Neuro Rehab
Unhappy with our previous response Partially Upheld
to their complaint. Feels we did not
take into consideration his emotional
changes, his vision problems, feels no
genuine reason was given for him
being 'abandoned' and feels key
members of staff were very
Staff were aware of his
emotional changes and his
vision problems. Following
the incident plans were put
in place to continue his
treatment however this did
take time to arrange.
Communication regarding
the investigation of the
incident could have been
Wife has said that a Doctor
was dismissive (works for
RBH and she will be taking
this up with the RBH
Reporting Locality
Geographical Locality
Mental Health Inpatient Reading
and Urgent Care
Adult Acute Admissions Care and Treatment
Patient feels we did not answer all the Investigation currently
points in our respone to their
complaint about a named Doctor, felt
we focused too much on the patient's
history dating back to adolescence
rather than the last 2 admissions.
CMHT/Care Pathways
Care and Treatment
CMHT/Care Pathways
Care and Treatment
Retired Consultant sent a referral
letter in Febraury 2014 for the patient
to CMHT which she states has only
just been acknowledged. She says
she will not be offered any support
which she feels is wrong when the the
Consultant felt she still needed more
Father believes the actions of his
daughter's CPN has been a
contributor to a deterioration in her
mental health state and her personal
finances. He alleges that his
daughter's CPN has been
cooberating with her husbands CPN.
District Nursing
Care and Treatment
Outcome Description
Investigation currently
Investigation currently
Prior to last summer the 88 year old
Investigation currently
patient was seen by a Nurse twice a underway
week. The patient has been advised
that this could not continue until
another nurse was trained to do
compression bandages and as such
he would now be seen by the District
Nursing team.
The District Nurses advised the
patient that there was a clinic once a
week and his first appt was 18th Nov,
2nd was booked for 27th Nov leaving
the leg 9 days without inspection.
They also advised that the patient
could not be seen at home as they
are not house bound.
Reporting Locality
Geographical Locality
Outcome Description
West Berks
West Berks
CMHT/Care Pathways
Attitude of Staff
Patient is very anxious and needs to Case not pursued by
know when her therapy will start. She complainant
spoke to CMHT stating she was
sucidal and became very angry that
they called the police as a result she
is very disillusioned with CMHT.
Additional email stating she had
called the Trust on the 15th Dec 3
times, 16th Dec 3 times and 17th Dec
twice. She states she was told that
someone would call her back and
then states that no one did so feels
the person answering the phone is
very unprofessional.
Complainant sent an email
withdrawing her complaints
with an apology for any
trouble caused.
Speech and language
therapy (ADULTS
Patient received a letter addressed to Upheld
them, discussing the patient's
symptoms but mentioning another
patient. It contains 'scores' and te
patient does not know who or what
these relate to.
Windsor, Ascot &
West Berks
CAMHS - Child and
Adolescent Mental
Health Services
Waiting Times for
Mother wishes to highlight the issues Upheld
with CAMHS of the aparent under
resource and under funding. She has
struggled with her son and the service
for 3 years and feels this needs
raising with people who have the
'power and resource to change the
current situation'.
Letter was sent to ENT
consultant and copied to
patient. Letter gave
information regarding the
patient and also referred to
another patient by name.
Staff member reminded of
need to carefully check all
correspondence before
sending. Corrected letter
sent to patient, Consultant
and GP.
Waiting lists are too long for
CAMHS services as
resources are not available.
The Trust is working with out
clinical commissioners to
resolve this situation.
Complaint and copy of our
response has been sent to
the CSSU.
Reporting Locality
Geographical Locality
Out of Hours GP
Care and Treatment
Speech and language
therapy (ADULTS
Care and Treatment
Patient's carer contacted 111 to
Referred to other
request a Doctor as her patient had
become incoherent through vomiting
(which the family believe was due to
cancer). 111 operator would not
speak with the carer at first, but after
an hour did. At 10pm she said she
would send a Doctor who sould be
there within 3-4 hours. By 4pm the
following day the Doctor still had not
Complainant has asked that we look Not Upheld
at two points of our original
investigation again.
- Written confirmation required
regarding the swallowing problem
coming and going from day to day.
- The nursing home refused to take
the patient back as they advised they
did not have the staff resources to
monitor that the patient did not eat the
wrong things etc. Son believes that
the nursing home were able to deal
with the patient and wishes to know
why they insisted he go. Son realises
this may need to be answered by the
nursing home.
Outcome Description
No call received by WestCall
from 111 so redirected to
Complainant given written
confirmation that swallowing
problems can vary but this
would be due to patients
cognitive decline.
Complainant advised to take
up any concerns with the
assessment carried out by
original nursing home and
the ongoing care at the new
nursing home as they do not
fall under BHFT remit.
APPENDIX TWO- Parliamentary and Health Service Ombudsman Complaints – Quarter Three update
In February 2012, the
Trust felt it would be
not be appropriate to
admit a patient for
rehabilitation. The
complainant believes
the Trust carried out
an inadequate
assessment and that
the lack of
rehabilitation led to
the patient’s
Older Peoples
Mental Health
(Ward Based)
Letter received from PHSO Requesting copies of
complaint file and medical records.
Action 1
Action 2
Copies of records and
complaint file sent. The
PHSO have confirmed that
an investigator has been
Communication and
care on Jasmine
Ward, Prospect Park
Older Peoples
Mental Health
(Ward Based)
Final report issued and complaint Upheld.
Apology sent on 13.1.14.
Action plan sent on 17.3.14, to be updated quarterly
and updates sent to complainant, PHSO and others.
Action Plan completed.
The PHSO have
reviewed their
previous decision not
to investigate a
complaint that the
Trust has failed to
consider information
that could have
caused reasonable
Health records
PHSO Did not uphold this complaint. Complaint
Closed November 2014
Complaint Closed
November 2014
Regular updates to be
sent to complainant,
PHSO etc. Quarterly
until all actions
Monitored through the
Patient Experience
and Engagement
Group and minutes
can be sent to PHSO.
Action outstanding
about End of Life
doubt to their
Patient states that he
experienced delays in
receiving appropriate
treatment and that
due to this he missed
six months of work,
has suffered trauma
and his conditions
have worsened.
Family of a patient
feel that due to the
failings between the
CCG and BHFT the
start of CHC funding
was delayed which
resulted in the family
paying around
Action 1
Psychotherapy &
Complex Needs
Letter received from PHSO Requesting copies of
complaint file and medical records.
File Copied and sent to
PHSO 11.08.2104 –
Awaiting further
Older Peoples
Mental Health
(Ward Based)
Letter received from PHSO Requesting copies of
complaint file and medical records.
This complaint has been
closed to the PHSO whilst
Local Resolution is being
sought. There is a
discrepancy in the amount
being requested and
conversations are ongoing
with the CCG about a joint
Patient complains
that diagnosis of deep
vein thrombosis
(DVT) was delayed
and her life put at
risk. Trust response
was that patient had
an infection initially
and not a DVT; this
developed and was
diagnosed later.
Letter received from PHSO Requesting copies of
complaint file and medical records.
Draft report has been
received for comment.
Final report due at the end
of January 2015.
Patient reports that
treatment caused
further damage and
that poor advice was
Letter received from PHSO Requesting copies of our
complaint responses.
Copied and sent to PHSO
22.10.2014 –
Awaiting further
Discussion with PHSO Assessor; investigation was
robust and family are looking for reimbursement of
money paid. Looking to resolve without formal PHSO
investigation through joint working with the CCG.
Action 2
Update is required to
the family by
given. Also that the
complaints process
has not resolved the
Patient reports that
they have had
difficulty contacting
their Care Coordinator and their
care package is
Action 1
Mental Health
Letter received from PHSO Requesting copies of
complaint file and electronic medical records.
Copied and sent to PHSO
07.11.2014 –
Awaiting further
Action 2
15 Steps Challenge
Quarter Three 2014/15
The 15 Steps programme continues to receive positive feedback from the services visited.
Due to competing demands this quarter there have been fewer visits although all inpatient
areas on the programme for the quarter have been visited.
Visits have been completed in all podiatry and dental teams and the professional
development nurses are now looking at small specialized services and how they can be
included within the programme. Engagement with these services is in process to ensure the
principles of the programme are maintained in an adapted form when visiting these areas.
Five visits have been undertaken during this quarter, three inpatient wards and two
outpatient departments.
Issues/themes identified:
Staff pride - in all of the visits staff continue to be very positive and proud of their
service and very keen to share their developmental plans which all had and
continued to involve patients.
Activities - activity rooms/areas in place for inpatient areas and there was evidence
of activities, led by activity coordinators. Further work needed to provide activities
when the activity coordinator isn’t on duty and out of hours.
Patients/client engagement - teams are increasingly engaging with patients/clients
when developing their services.
Rose ward - Excellent and professional welcome with staff very keen to show their ward off
and the developments that were in progress. Ward felt safe and the ward had a process in
place for clients with physical health needs. Good leadership demonstrated throughout the
visit with staff witnessed to be working together as a team.
Donnington Ward – Patients appeared relaxed and well cared for, they commented on the
kindness of the nurses. Staff spoke with pride about their ward and good leadership was
demonstrated throughout the visit. There was plenty of evidence of ward activities although
none were in progress during the visit as the activity co-coordinator was not on duty. All
patients were sat by their beds. It would have been nice to have seen activities continued
throughout the day/week by other ward staff.
Oakwood Unit – the ward was sensitively refurbished with particular care to the client group
and the ward felt calm yet industrious. Staff were observed to interact with patients well and
patient feedback was thoughtful and positive with good understanding of care and discharge
planning. Lovely activity room, although no patients engaged in activities at time of visit.
Physiotherapy West Berkshire Hospital - The department felt relaxed and comfortable
despite being busy. Interaction observed was respectful, caring and professional. Although
the department was compact it was well organised and clean with a clear direction on
developing further with the engagement of patients.
Podiatry West Berkshire Hospital - Very professional service with staff observed to have a
very natural rapport with clients. Environment clean and tidy and good procedures for
induction and inclusion for bank staff witnessed. The waiting room was part of the outpatient
clinic which was very busy and it felt difficult to establish if you had not missed your
appointment, although podiatry clients wait in one area and are collected by the clinic staff.
Friends & family team discussion: In all the areas visited, overall the team were confident
in the safe care being delivered should a family member or friend be admitted to the care of
the service/unit or clinic.
Pam Mohomed-Hossen & Kate Mellor
Professional Development Nurses
January 2015
Council of Governors
Meeting Date
18 February 2015
Review and Revision of Trust Constitution
This paper seeks Council approval of a revision of
the Trust’s constitution following a thorough review
undertaken by the Trust’s solicitors and approval by
the Board on 10 February 2015
Company Secretary
The Trust’s constitution sets out the framework for
governance of the organisation in conjunction with
relevant statutory and regulatory requirements. The
constitution largely follows the original ‘model’
constitution adopted by most Foundation Trusts at
The current constitution has been in force, subject to
some amendments largely driven by statutory
changes, since BHFT was authorised in May 2007.
Given the passage of time since authorisation and
the development of better practice in the light of
experience, the Trust’s legal advisers, Beachcrofts,
were instructed to undertake a complete review of
the constitution and to propose changes to bring it in
line with best practice. The opportunity was also
taken to obtain advice for changes resulting from the
Trust’s own experience of working with the current
Changes to the constitution require approval of both
the Board and Council of Governors and accordingly
the Board was invited to approve the revised
constitution at its meeting on 10 February. Approval
was given. The revision is now presented for Council
This paper includes a complete tracked changes
version of the constitution (but excluding the section
on Model Rules for elections to the Council of
Governors which the Trust is not permitted to amend)
but for ease, a summary paper is also provided
highlighting all substantive changes.
Council is also requested to give approval to the
removal of certain partnership organisations –
outlined in the attached paper - from the Council of
Governors in light of continuing lack of Governor
Council is invited:
1. To approve the revised constitution.
2. To approve the removal from the Council of
Governors of the three named partnership
Revision of Trust Constitution
1. The Constitution of the Trust is a key document which frames much of the
governance of the organisation, e.g. the standing orders that govern Board and
Council meetings. It is a statutory requirement that changes have to be approved
by both the Board and Council of Governors and have to be notified to Monitor
(although Monitor no longer has an approval role). Changes cannot however
conflict with relevant statutory requirements.
2. BHFT’s current constitution has been amended over the years to reflect statutory
changes, such as those arising from the Health & Social Care Act, and to address
shortcomings that experience had highlighted (such as size of quorum needed for
a Council of Governors meeting for example). However, given that the Trust was
authorised in 2007 it was apparent that more recent constitutions had benefited
from the experience and development of the FT model. Accordingly, the Trust’s
legal advisers were requested to undertake a thorough review of the BHFT
constitution and to propose changes that:
Ensured full statutory and regulatory compliance;
Reflected improvements that had developed since the introduction of the FT
Addressed the Trust’s own actual experience of operating with the current
Provided clarity in any areas of potential confusion or uncertainty.
3. The constitution is a substantial document, made more so by the inclusion of the
Model Rules for Governor Elections. However, as the Trust is not permitted to
change the Model Rules, that section is omitted from the document attached
which otherwise includes all proposed tracked changes for complete visibility.
4. For ease of identification of key changes, the following Appendix provides a
summary of the main elements of the revision. This Appendix does not highlight
simple text movement within the document although the opportunity has been
taken to re-order certain sections for a more logical reading of the document and
to remove unnecessary duplication. When referring to the tracked changes
document the following colour coding is used:
Blue double underlined text = text insertion
Red text strikethrough = text deletion
Green text strikethrough = text moved from
Green double underlined text = text moved to
Partnership Organisations
5. Council will recall previous discussion regarding current partnership organisations
which have failed to nominate a Governor notwithstanding contact between the
Trust Chair and the organisations in question. This dilutes the input from
partnership organisations and accordingly Council is also invited to consider
approving the removal of the following as partnership organisations:
The Berkshire Autistic Society
Age UK Berkshire
University of West London
The Chair is already in communication with a number of other potential partnership
organisations but is not yet in a position to put proposals forward.
6. Council is invited to:
a. Consider and approve the proposed revision to the Trust’s constitution.
b. Consider approving the removal of the three partnership organisations
referred to in paragraph 5 above.
Summary of Proposed Key Changes to Trust Constitution – February 2015
Page/Para No.
Proposed Change
Pages 1 - 2
A general introduction has been added which incorporates Trust values and core principles
Page 4, paras 5
and 6
Page 6, para 8
Restriction on membership
Clarification of management of membership applications and allocation to constituency and
subsequent variation if a member moves between constituencies
Highlights membership eligibility exclusions
Page 6, para 9.4
Composition of Council
Clarification that more than half of all Governors must be from the public constituencies
Page 8, para 12.1
Council – disqualification and removal
Page 8, paras
12.3, 12.4
Page 9, para 12.5
Governor disqualification
Movement of text from elsewhere in current constitution and addition of disqualification criteria – i.e.
membership of local Healthwatch and Local Authority Overview and Scrutiny Committee for health
Clarifies obligation and process of notification
Page 10, para 12.6
Termination of Governor tenure
Page 12, para
14.2.5 and page
13, para 17
Page 12, para 15.3
Access to Monitor appointed advisory panel
Page 16, para 27
Director disqualification
Page 68, para 2.7
Chairing of Council meetings
Page 71, para
Page 73, para 2.16
Use of written resolution
Termination of Governor tenure
Governor meetings – Director attendance
Electronic communications
Section expanded to cover wide range of reasonable justifications for termination of Governor’s
term of office
Provides greater detail and clarification around process of consideration and action on Governor
removal. Clarifies that approval of a proposal for removal requires 75% of those Governors present
and voting at the meeting. Extends period before such a Governor can be eligible to stand again to
5 years from 3 years
Clarifies the process for access to the panel
Codifies Council’s right to require presence of a Director in relation to obtaining information about
the Trust’s performance
List of reasons for disqualification expanded to provide greater clarity and cover new statutory
provisions, such as fit and Proper Person regulations as well as reflect good governance practice
Clarifies process in absence of Trust Chair
Makes explicit the ability of matters that could be decided at a Council meeting being conducted by
written resolution
Provides for use of electronic communication for meetings where necessary
NHS Providers Governor Policy Board
Nomination for Election
All Governors were invited to indicate whether they wished to be considered as the BHFT
Council of Governors nominee for the NHS Providers (previously the Foundation Trust
Network) Governor Policy Board (GPB). Information on the role and purpose of the Board
was also circulated.
It is for Council to decide who to nominate but any candidate must be able to attend
meetings of the Board (four per year) and participate in other discussions/consultation that
will arise and feel confident that they can contribute to the work of the Board. Induction
training will be provided by NHS Providers.
The nominee will need to supply a biography/statement of a maximum of 250 words to
accompany the actual nomination form.
As at the closing date and time for nominations, two Governors had indicated a wish to be
considered as Council’s nominee to go forward to the NHS Providers election process. The
two nominees are:
Ruffat Ali-Noor
Mavis Henley
As Council can only nominate one Governor, there will be the need for a secret ballot to be
held at Council on Wednesday 18 February – only Governors attending will be able to vote.
The statements provided by the candidates are set out overleaf to allow Governors to make
an informed choice in the ballot.
Governors will be invited to vote for their preferred candidate at Council on 18 February.
John Tonkin
Company Secretary
NHS Providers Governor Policy Board
Candidate Statements
1. Ruffat Ali-Noor
My name is Ruffat Ali-Noor, currently serving as Public Governor for Slough NHS
Foundation Trust and have full involvement in number of specific responsibilities. I'm
a Lawyer by Profession, practiced and lived in Slough for the past forty years. My
basic involvement started as a member of Steering Group with Slough-Links. I'm a
member of Patient Group @ my Local GP Surgery. Being Public Govern I have learnt
so much and still learning and finding ways how to help and improve the Trust
Services. So far my contribution is that:
I'm on Berkshire Equality Panel Group.
. Improving Patient-Outcome Group
. Member of Place Assessment Team.
. Group Member of (Governor Quality Assurance Group).
Though it's a very short period being with Trust but I can assure the Nomination
Committees that after securing this role (Member of National Policy Board) I will put
my best efforts to fulfill this role.
Declaration of Interest
Political Party - Conservative
Financial or other interest in the Trust: None.
2. Mavis Henley
I have been the lead governor of Berkshire Healthcare Trust for three years and in
this time I have in partnership with the Chair developed the role. I use a facilitative
approach to make things happen. I am a good team player, friendly, approachable
and get on well with most people.
I work closely with the Chair making sure that governors are informed fully about
what is happening in the Trust and that their views are taken into account in the
development of policy and strategy. I support newly elected governors through their
inductions and into their role. I introduced a rota of governor attendees at Board
meetings in order to help them hold the non-executive directors to account. It has
been necessary for me to support the resolution of governor conduct issues.
I am a member of the following governor groups:
• Appointments and Remuneration Committee
• Quality Assurance (former chair)
• Membership and Public Engagement (former chair)
• Living Life to the Full
I am a Mental Health Act manager for the Trust.
Prior to retirement I was a strategy and service development manager in adult social
services. I qualified as a group psychotherapist in 1998. For many years I was a
manager and counsellor in a community alcohol service. I spent eight years In the
Scottish Prison Service as an assistant governor. I originally trained as a teacher and
have worked as a trainer throughout my career.