03/03/2009 Adult, Community Services and Health Overview and Scrutiny Panel - Agenda

TO: MEMBERS OF THE ADULT, COMMUNITY SERVICES & HEALTH OVERVIEW & SCRUTINY PANEL

COUNCILLOR MEADOWCROFT (CHAIRMAN)
COUNCILLOR MRS ENDACOTT (VICE-CHAIRMAN)
COUNCILLORS MRS S EVANS, LENTON, MAJEED, MRS NAPIER & MRS PROCTOR

SUBSTITUTE MEMBERS
COUNCILLORS HERDSON, MRS KEMP, MRS LUXTON, MRS NEWBOUND, PENFOLD, D. WILSON & MRS YONG

In the event of the fire alarm sounding or other emergency, please leave the building quickly and calmly by the nearest exit. Do not stop to collect personal belongings and do not use the lifts. Congregate in the Town Hall Car Park, Park Street, Maidenhead (immediately adjacent to the Town Hall) and do not re-enter the building until told to do so by a member of staff.

ITEM	SUBJECT	WARD	PAGE NO
1	APOLOGIES FOR ABSENCE To receive any apologies for absence
2	DECLARATIONS OF INTEREST To receive Declarations of Interests from Members of the Panel in respect of any item to be considered at the meeting.		-
3	MINUTES To confirm the Part I Minutes of the meeting of the Panel held on 29 January 2009.	All	i-iv
4	DEVELOPMENT OF ACUTE MEDICINE AND FUTURE PLANS FOR SERVICES AT HEATHERWOOD HOSPITAL - PROPOSALS FOR CONSULTATION to receive details of proposed changes to acute medical services at heatherwood hospital.	Various	-
5	RIGHT CARE RIGHT PLACE To receive an update on the implementation of the proposals to modernise health services in East Berkshire arising from the Right Care Right Place consultation.	All	-
6	SAFEGUARDING ADULTS To comment upon the report being submitted to Cabinet on 26 March 2009 on the safeguarding of vulnerable adults.	All	1
7	SERVICE MONITORING REPORT To consider activity within the Adult Services and Health services during the period to 31 January 2009.	All	7
8	WORK PROGRAMME The following items are scheduled for discussion at the meeting of the Panel to be held on 5 May 2009. Update on the Outcomes arising from the Annual Performance Assessment of Adult Social Care Service Monitoring Report Work programme	All	-
9	LOCAL GOVERNMENT ACT 1972 – EXCLUSION OF THE PUBLIC To consider passing the following resolution:- “That under Section 100(A)(4) of the Local Government Act 1972, the public be excluded from the remainder of the meeting whilst discussion takes place on items 10 - 13 on the grounds that they involve the likely disclosure of exempt information as defined in Paragraph 2 and 3 of part I of Schedule 12A of the Act"

DEVELOPMENT OF ACUTE MEDICINE AND FUTURE PLANS FOR SERVICES AT HEATHERWOOD HOSPITAL - PROPOSALS FOR CONSULTATION

Draft 1: Care of medical emergency patients and future services at Heatherwood Hospital – preparing for public consultation

Introduction

Heatherwood Hospital is a thriving local hospital providing about a third of the capacity of the Heatherwood and Wexham Park Hospitals NHS Foundation Trust. Each year Heatherwood sees some 75,000 outpatients, 20,000 admissions and day cases, and 24,000 Minor Injury cases.

1. Right Care Right Place

During the Right Care Right Place Consultation in 2008 Berkshire East Primary Care Trust stated that their plans to offer more services such as outpatients in the community meant that hospital services would change but that there were no proposals to close any local hospitals. The PCT also stated that its proposals over time would result in real improvement in the quality, effectiveness and accessibility of healthcare for people in east Berkshire.

The proposals included:

Moving more outpatients out of the main hospitals into community hospitals and clinics

Setting up new urgent care centres

Providing in east Berkshire more local specialist services such as renal dialysis and radiotherapy for which patients have in the past had to travel to Reading or into London.

These moves are now being put into effect for example through the planned major new Healthspace in Bracknell town centre which will include outpatients transferred from the main hospitals and radiotherapy and renal dialysis. Berkshire East PCT plans to select its preferred provider for the Healthspace by the end of March 2009.

Local minor injuries services have been improved with the establishment of a Minor Injuries Unit at St Marks Hospital in Maidenhead run by Heatherwood and Wexham Park Hospitals NHS Foundation Trust.

The PCT’s strategic goals set out in the Right Care place Consultation document included:

Lengthen the life expectancy of the people we serve by an extra year
Enhance the quality and safety of patients services
These goals were supported by key themes including:

Supporting need – respond to local peoples’ needs by developing services that meet the health priorities
Commissioning treatments that work – ensure standards of care meet national expectations
Improve quality – improve quality of services in line with national standards

Taking clinical advice:

The Right Care Right Place consultation referred to the continuing dialogue between local GPs and consultants to work out how best their care could be delivered taking account of public views and national evidence. These discussions have continued and have informed the proposals in this paper.

Major conditions

Right Care Right Place referred to new treatments which will help save lives in certain conditions. The Consultation Document referred to improvements in stroke and cardiac care:

Rapid access clinics for ‘mini strokes’ – Transient Ischaemic Attacks, and clot busting drugs for certain types of stroke caused by a blood clot
Introducing a new `immediate treatment for some heart attacks which can save lives – Primary Percutaneous Coronary Intervention – PPCI – inserting a tiny tube into arteries which will then expand and increase blood flow.

The Trust’s plans set out below include proposals for both these new developments over the next few months subject to final agreement with the PCT and funding in 2009/10.

Hospital services

Right Care Right Place referred to local hospitals services as follows:

Wexham Park Hospital

‘Wexham Park would continue as the major local hospitals with A&E, trauma and orthopaedics, coronary stroke and intensive care facilities, obstetrics, children’s services and inpatient medical and surgical beds. However the proportion of outpatients seen in local settings rather than at the main hospitals would rise to 75%.’

Heatherwood Hospital

Right Care Right Place commented as follows:

‘Development of services within Bracknell will have an impact on the volume of some services delivered within Heatherwood. This should not affect the viability of the hospital.

The proposed pattern of service on the Heatherwood site is:

A newly designated GP surgery to provide facilities for practices currently in the High Street area
Inpatient services

Heatherwood inpatients is a key facility locally for delivering planned operations such as hip replacements since it separates planned and emergency care, which is mainly carried out at Wexham Park. Day surgery is also delivered in large numbers and we propose that this should continue and will work with the Trust to develop new facilities to support this, after the results of the consultation, as we anticipate that patients will continue to choose to have care delivered locally.

Heatherwood Hospital will continue to provide beds for people who need a stay in hospital providing assessment and rehabilitation for patients with complex ongoing needs. If any alterations to the medical assessment service are proposed in the future because of the European Working Time Directive changes to doctors’ hours in 2009 or for any other reasons they will be the subject of a further consultation led by Heatherwood and Wexham Park NHS Foundation Trust.’

2. National plans and priorities

Since the Right Care Right Place Consultation at the beginning of 2008 the10 year blueprint for the NHS – led by Lord Ara Darzi – High Quality Care For All – NHS Next Stage Review Final Report - has been published. The Report confirms many of the themes in Right Care Right Place. The Report acknowledges the advances in care that the NHS has made over the last 10 years and aims to put quality of care at the heart of everything we do in the NHS, moving from high quality care in some aspects to high quality care in all.

One of the key themes in the NHS Next Stage Review has been the determining of what will work best involving patients, carers, the general public and staff. The plans were the result of the work of more than 2,000 clinicians and other NHS and social care staff considering the best available clinical evidence, working in partnership with thousands of patients and listening to the needs and aspirations of the public.

One of the Report’s key principles is that changes to health services must be locally led, patient centred and clinically driven and must reflect the needs of local communities. The Report confirms the Right Care Place aim that more planned care should be provided closer to people’s homes and that outpatient care should not always mean a trip to hospital.

For acute/emergency care the working groups gave compelling arguments for saving lives by creating specialised centres for major trauma, heart attack and stroke care supported by skilled ambulance services.

For stroke care, which is the third largest cause of death and single largest cause of disability in the UK, the Report states that the clinical evidence clearly demonstrates that the quality of care is greatly improved if stroke is treated in specialist centres with access to 24/7 brain imaging and thrombolysis – for appropriate patients – delivered by expert teams

The Report lists the challenges the NHS faces including the ageing population, the rise in lifestyle disease caused by poor diet, smoking and lack of exercise and rising public expectations. In response the NHS must use effective new drugs and technology that offer higher quality care and work out better for patients and the taxpayer.

For example day surgery is safe with little or no risk of infection and it avoids the use of expensive overnight hospital accommodation. Another example is the state of the art surgical robot recently installed at Wexham Park which provides a less invasive option for prostate surgery reduces length of stay and reduces the possible side effects of a major open surgical procedure.

The report emphasises that improvements in services must be led by front line staff who must be given the freedom to use their expertise, creativity and skill to find innovative ways to improve the quality of care for patients. The Foundation Trust status which we enjoy allows us to empower frontline staff to design the best services for the people we serve.

3. Berkshire East Primary Care Trust plans and priorities

Berkshire East PCT has set out its medium term plans for 2008 to 2013 in its Strategic Plan published in October 2008.

The Plan sets out the PCT’s objectives for the next five years:

‘What we are trying to achieve’

Over the next five years, we will focus on delivering improvements to health and services in the following key areas:

We will increase the life expectancy of our population through better health screening, preventing disease and promoting healthy living
We will tackle and reduce health inequalities by accelerating improvements in the health of our communities with significant levels of deprivation and ill-health
We will relentlessly drive up the quality and safety of all of the services we commission, ensuring better outcomes and all round patient experience of NHS care
We will increase accountability to our local population so that in the local population patients give an 80% good or excellent approval rating for health services that they experience
We will accomplish all of the above whilst achieving sustained financial stability.

Various initiatives in the PCT’s strategic plan require changes and improvements to services in Heatherwood and Wexham Park Hospitals to meet current best practice. The following extracts from the PCT Strategic Plan confirm again the PCT’s priorities for expanding community services, changes in hospital services and improvements especially in areas of cardiac and stroke care.

‘Initiative A. Commissioning to extend life

Stroke

The project will deliver improved outcomes through the re commissioning of stroke services as a pathway rather than as number of disparate services. This is supported by an information framework that will improve our commissioning capabilities through predictive modelling associated with locally agreed outcome metrics.

Initiative C. Commissioning for Excellence

1. Keeping people out of hospital

This is a whole system project led by Berkshire East PCT but with engagement from all stakeholders locally including our main acute trust Heatherwood and Wexham Park, the ambulance service, our community provider, mental health provider and the three unitary authorities. The aim of the programme is to prevent unnecessary attendances and admissions to hospital and to ensure that when people do have to go in and out of hospital that their journey through the health and social care system is free from unnecessary system blockages. The programme is designed to ensure that the capacity of all health providers, whether that be hospital, community services like District Nursing or intermediate care service jointly provided with Unitary Authority partners is used most effectively.

2. Commissioning quality services for our patients

This project will deliver proactive relationship and contract management, through the management of existing providers and new contracts with a particular emphasis on quality and cost effectiveness. The role and function of the PEC has been reconfigured to ensure that there is effective clinical leadership on the quality and assurance agenda for all commissioned services and a clinical quality forum has been established including a patient representative.

Initiative F. Right Care Right Place

This programme will implement the recommendations of the Board in May 2008, following extensive public consultation. This initiative is made up of six projects which will contribute in different ways to the goals we have identified: Midwifery changes have already occurred and the pilot minor injuries unit in Maidenhead commenced.

Bracknell Healthspace

This project will improve satisfaction by providing better care

Urgent Care Centres at Wexham Park and Bracknell

This project will establish two Urgent Care centres; one co-located with A&E and one with the future Bracknell Healthspace offering treatment for minor illnesses and injuries in a new service model.

Cancer services in Slough and Bracknell

This project will deliver two cancer treatment outreach centres on a hub and spoke basis from the existing cancer centre.

Outpatients

This project will deliver specialist care closer to home.’

The PCT Strategic Plan also sets out how it expects providers like Heatherwood and Wexham Park to respond to its strategic aims: further extracts are set out below:

‘Acute Care

We have worked with our main acute trust in understanding the impact of the shifts in care, particularly around outpatients through our Right Care Right Place activity modelling. We mutually agreed the impact that our changes would have with the hospital and as a foundation trust; they incorporated these assumptions into their planning models. Joint working with Heatherwood and Wexham Park Hospitals NHS Foundation Trust meant that our consultation for Right Care Right Place informed the timing and extent of their own proposal for the regeneration of their hospitals.

Engaging providers in change

We have traditionally engaged with clinicians and managers from our local providers in developing and improving services for example with our Right Care Right Place programme of changes when we worked with local clinicians and managers to agree the scope and extent of the changes. More recently we have reviewed this approach in the light of the publication of The Principles and Rules of Collaboration and Competition and developed new approaches to engaging with potential providers of services.

For example, we are currently commissioning two urgent care centres, one as an integral part of our main A&E service and one as a stand-alone service within the Bracknell Health Space.’

The Plan refers to improvements needed in stroke care;

‘An illustration of a category for market intervention is stroke rehabilitation, focusing on two specific post-acute markets:

‘Step Down or Intermediate Bed-based Care’ and ‘Home-based Care’. This is driven by our need to improve stroke care in this area following patient feedback and external assessments. …In addition the development of optimum stroke care pathways will reduce the mortality and morbidity associated with this condition. Benchmarking shows that improvements are needed in these services across east Berkshire. Another of the agreed World Class Commissioning outcomes is access to brain scan within 24 hours (for strokes) a key marker.

These extracts from local and national strategic plans demonstrate that the Trust must respond to the challenge to offer the best possible care for patients taking into account both accessibility where more local outpatients will bring care closer to home but also more specialisation - for example in stroke and cardiac care - where lives will be saved by concentrating scarce staff resources and equipment in more specialised centres. The following sections set out how these aims will affect acute medicine at Heatherwood and Wexham Park.

4. The case for changing emergency medical care at Heatherwood and Wexham Park Hospitals

The main aim of these changes is to offer best practice in emergency medical care for all medical patients in accordance with the Darzi Report – High Quality Care for All and the more detailed Department of Health guidance eg. Mending Hearts and Brains, and Royal College Guidelines.

The Trust is also required to adhere to the European Working Time Directive for all junior doctors by August 2009. This case makes best use of medical staff.

Current arrangements

At present emergency medical patients are admitted to both Heatherwood and Wexham Park Hospitals - on average 12 patients per day to Heatherwood and 24 to Wexham Park. The majority of the admissions to Heatherwood are from GPs with most of the 999 calls admitted to Wexham Park. Heatherwood has a 15 bed Medical Assessment Unit and 79 medical beds in Wards 8, 16 (temporary building) and 10.

Wexham Park has 20 beds in the Acute Medical Unit and a further 172 medical beds in 8 wards including the specialist Stroke Unit and the Oncology ward. The Specialist Coronary Care and Intensive Care Units are at Wexham Park.

If a medical emergency admission is found to need Intensive or Coronary Care or emergency surgery the patient has to be transferred to Wexham Park.

At any time there is a medical team on duty at both Heatherwood and Wexham Park with a consultant on call for each site but as can be seen from the figures above twice as many emergency admissions per day at Wexham Park.

Improving care for emergency medical admissions

Guidance was issued by the Department of Heath in 2006 - ‘Mending Hearts and Brains’ - which sets out best practice standards for the provision of improved emergency clinical care for cardiac and stroke patients. The paper proposes the creation of Specialist Centres (also described as ‘super A&E’), with the following facilities:

Primary Angioplasty as a first treatment for heart attack, 24/7 access to specialist consultant care
Thrombolysis for stroke, 24/7 access to specialist consultant care and CT

At present the Trust does not comply with these guidelines. We admit stroke and heart attack patients at both the Heatherwood and Wexham sites, and the Consultant Physicians run on call rotas on both sites. The Trust is working with the PCT to agree new pathways for stroke care and aims to introduce thrombolysis for stroke at Wexham Park over the next few weeks.

Our plans for primary angioplasty will be to offer appropriate heart attack patients primary angioplasty in the Angiography Suite at Wexham Park from 8.00am to 6pm with out of hours support from the Harefield Hospital.

The Trust has a single angioplasty suite with specialised equipment at Wexham Park and enough consultant medical staff to provide primary angioplasty for part of the day/week but at the moment these staff are spread across both sites and would need to be centralised at Wexham Park before this kind of service could be offered.

The expensive facilities and the highly skilled staff necessary for these specialised services cannot be provided from both the Wexham Park and Heatherwood sites. In other areas – London for example – these specialised treatments will only be offered in bigger designated centres and not in every hospital equivalent to Wexham Park.

The impact of these changes will be that it will not be possible to offer heart attack and stroke care at Heatherwood.

5. Changes and new services at Heatherwood

The aim of the Trust and the PCT is to maintain a thriving local hospital at Heatherwood working in a complementary way with the planned new Healthspace in Bracknell.

Heatherwood provides a number of other services which are not affected by the proposed medicine changes:

Orthopaedic surgery including hip and knee replacement, planned general surgery, urology, plastic surgery and gynaecological surgery.

Outpatients and diagnostics including MR and CT scanning; although there will be fewer outpatients in future as Bracknell patents are transferred to the new Bracknell Healthspace from 2010

Children’s Day Assessment unit

Physiotherapy and Occupational Therapy

Midwife Led maternity Unit

Minor Injuries Unit – subject to review when the PCT sets out its plans for the Urgent Care Centre in the Bracknell Healthspace

The effect of the medicine changes will be to change the use of two wards and to close the Medical Assessment Unit – part replaced by new Rapid Assessment Clinics and to take the temporary ward 16 out of use. A number of new services are planned for Heatherwood.
6. New services planned for Heatherwood

New services are planned for Heatherwood as follows:

Consultant Rapid Assessment Clinics

Not all medical emergency or GP referred patients need to be admitted to hospital. Around 40% of emergency patients in the Acute Medicine Unit at Wexham Park are discharged home the same day. It is planned to open a daily Rapid Assessment Clinic at Heatherwood staffed by a consultant emergency physician each weekday to which GPs will be able to refer patients for whom they want a consultant opinion but not necessary admission.

We estimate that up to 1400 of the current 4400 emergency admissions to Heatherwood may be seen in these Clinics - subject to a prospective audit of current admissions to assess what proportion could be seen in the Rapid Assessment Clinic.

Medical Investigations Day Unit

Some medical patients require day treatment – biopsies and blood transfusions for example. These treatments are currently arranged at Wexham Park but it is planned to open a Medical Investigations Day Unit at Heatherwood. This unit could also be used for investigations for emergency patients seen in the Rapid Assessment Clinics who may be able to go home and have investigation within a day or two in the MIDU. This will also mean that patients will not have to travel to Wexham Park for MIDU care.

Rehabilitation Ward

The effect of these changes is to concentrate at Wexham Park the most seriously ill and unstable patients. Some may go home after a few days (the average stay for medical emergency patients is 8 days) but others may need a period of rehabilitation when their need is for intensive physiotherapy and occupational therapy and nursing care rather than active medical care. We plan a Rehabilitation Unit at Heatherwood led by nurses and rehabilitation staff for patients who may need 2 to 3 weeks rehabilitation before discharge. This centre would be housed on one of present medical wards – Ward 8
This ward was upgraded in 2008.

‘Intermediate Care’ Ward

The Trust is also considering the best way to care for elderly patients who may be waiting for assessment or for a nursing home bed. These patients need support to maintain their ability to live in the most appropriate setting but often do not need daily medical care. We are in discussion with the PCT to see if a ward at Heatherwood would be preferable to a busy acute medical ward at Wexham Park. Ward 10 would be available for his purpose after the medicine changes. These patients would need active involvement of the Trust’s discharge team and the PCT intermediate care teams
Planned pacemaker implantation

This procedure which requires either an angiography suite or an operating theatre is currently undertaken in the angio suite at Wexham Park which is heavily used for emergency procedures. It is planned to transfer this procedure to an operating theatre at Heatherwood

More day and short stay surgery

The enormous benefit of the wards and theatres for surgery at Heatherwood is that there is no risk of a planned procedure being displaced by an emergency case as all the surgical emergencies are admitted to Wexham Park. It also means that the surgical wards can be virtually guaranteed MRSA free since all patients are screened for MRSA before admission.

Over the last 2 years we have increased our day surgery specialities at Heatherwood with a movement of 70 % of our oral surgery work and 80% of plastic day surgery work to Heatherwood.

To vacate space for the new theatre we are moving our Urology clinic area to a refurbished Ward 5, increasing the clinic capacity so that we can expand our TRUS biopsy at Heatherwood (presently only available at Wexham) and link it to a clinic to provide a one stop cancer service.

£2million Operating Theatre improvements

Orthopaedic surgery is also being strengthened at Heatherwood with the installation of a new specialist operating theatre for orthopaedic surgery during the summer. As part of the same scheme two existing general theatres will be upgraded. This will allow more all day orthopaedic operating lists to meet the increased demand particularly in spinal and foot and ankle surgery.

Centralised pain clinic

Once the building works are complete we are hoping to move back into the vacated space with a new pain service, centralising the staff in one area and providing further one stop services to meet the needs of our patients.

The effect of these changes is to introduce more diagnostic and day activity onto the Heatherwood site with a reduction of one ward and the Medical Assessment Unit – part replaced by the new Rapid Assessment Clinics.

The future allocation of beds/ day surgery trolleys is shown in Appendix 1 and Appendix 2 - planned activity - will be completed as soon as plans for 2009/10 are confirmed.

7. Changes at Wexham Park

In order to provide sufficient Medical Assessment capacity an additional 20 medical assessment beds will be provided near to A&E and the two acute wards from Heatherwood will be accommodated either in existing wards used for escalation or in prefabricated wards until the planned new medical ward block is built.

A new Acute Respiratory Unit will be established on Ward 9 so that appropriate patients do not have to be admitted to Intensive Care for some aspects of respiratory support.

8. 999 and seriously ill patients from the Bracknell/Ascot area

GPs will decide where it would be appropriate for their patients to go – either to the new Rapid Assessment Clinics or to the nearest local hospitals which take serious medical emergencies – Frimley Park, Royal Berks or Wexham Park. For 999 cases the ambulance crews will know from the Thames Valley Emergency Network how busy the various hospitals are and will take into account travel time and the pressure on each hospital’s A&E Department and medical assessment unit.

9. Consultation

These changes will be the subject of formal consultation in the Spring through the issue of a formal consultation document, presentations to local public meetings and wide dissemination of the proposals to local groups for comment.

The Overview and Scrutiny Committee is invited to indicate what further engagement it would like prior to consultation and in particular:

- What further information would be helpful in the consultation document?
- How best to disseminate the case for change and the proposals?
- The best process for consultation – proposed to be based on the PCT Right Care Right Place approach
- The pros and cons of including specific questions in the consultation document

Colin Hayton
Strategy Adviser
25 February 2009
Appendix 1. Heatherwood bed allocation:

Ward		Current number of beds	Planned changes
1	Surgery & urology	10+15 day surgery trolleys		25
1G	Gynae	8	Moves to part of Ward 7	8
MAU	Medicine	15	Closed –part replaced by Rapid Assessment Clinics
8	Medicine	28	Rehabilitation Ward	28
4	Orthopaedics	28		28
5	Not in use		Urology diagnostic centre
10	Medicine	25	Intermediate Care	25
16 (temporary ward)	Medicine	26	Dismantled
7	Maternity	9		9
Day Surgery Unit	Surgery	12 day surgery trolleys		12
Ortho day unit wd 3	Orthopaedics	12 trolleys		12
	Total	188 beds/trolleys		147

Appendix 2: Activity plans – to be completed when final plans for 2009/10 confirmed

Heatherwood Current Services	Numbers of cases 2007/8	New/planned services since 2007/8	Est number of cases 2009/10
Orthopaedics		Additional cases when new theatre installed	tbc
General surgery
Urology		TRUS biopsy one stop clinic One stop haematuria clinic	350 extra cases pa 400 extra cases pa
Gynaecology
Outpatients*
X rays/ultrasound*			No change
Births
Children’s Assessment Unit			No change
General medicine admissions			Est 1400 cases pa
General medicine	Ward 8	Rehabilitation Ward	28 bed ward as now
General medicine	Ward 10	Intermediate care Ward
Medical assessment	MAU	closed
General medicine	Ward 16 – temporary ward	dismantled
		Rapid Assessment Clinic
Minor Injuries*			No change
		Pain Clinic
		Pacemaker implants

* This activity will change once the Bracknell Healthspace is open in 2010



Presentation
[attachment "meetings_090303_acshosc_acute_medicine_heatherwood_presentation.ppt" deleted by Karen Williams/RBWM]

RIGHT CARE RIGHT PLACE

Maidenhead MIU

Review one has been completed and will be reviewed by the RCRP Implementation Board on the 6^th March 2009 and released thereafter.
The unit has not yet been able to open to the required hours due to difficulties in the recruitment of suitably qualified and experienced Nursing staff. Adverts have been placed in appropriate journals and there is hope that appointments may be made in the near future.
The unit is currently open weekdays and Saturdays 9-5.
The first patient satisfaction survey will take place in March and meetings are taking place this week to finalise the nature of the questionnaires.

The Members raised an issue regarding confusion regarding opening hours/access to the service. The PCT has advised the provider of its view that 5pm means patients are received until 5pm, not treated until 5pm.

The PCT are constructing a Communication Plan to support RCRP as a whole, and the unit at Maidenhead in particular, which will be reviewed by the Board on the 6^th March 2009. It would be the intention of the Commissioner to remind the public and partners of the availability of the service and what the service can deliver.

Bracknell Healthspace

The Procurement is entering its final selection phase. The PCT are negotiating (following an extensive shortlisting process) with two potential providers for the delivery of the healthspace. It is anticipated that a preferred partner may be announced in March/April 2009. Delivery of the facility is anticipated to be in 2010/11 depending on the preferred partner/scheme.No detailed update is available as there are commercial in confidence issues.

EAPMS

The Procurement failed to secure a viable bid for the service and will be subject to another procurement exercise. This is likely to be nine months in duration from commencement to operational start on site, as the scheme will be subject to a rescoping exercise. Expectations are for the new service to start in 2010.
Interim arrangements for the continuation of the current services are under discussion currently.

Outpatients

The PCT has a mandate from the RCRP consultation of 2007/08 to endeavour to deliver an increased opportunity to bring community/outpatient services closer to where people live, where possible.
This is central to the development of the Bracknell Healthspace and the future plans to support the existing community hospitals.
The first tranche of revisions to the current situation will be revealed under the Bracknell healthspace initiative.

Cancer Services

Outcomes for this development are part of the Bracknell healthspace Procurement.

Urgent Care reform

The PCT are engaging in a systematic review of urgent care services across the area with the intention of delivering:

Revised contracts for urgent care at Wexham Park hospital
Revised contracts for urgent care at Bracknell healthspace
Revised contracts for urgent care at Upton hospital (EAPMS)
Revised contracts for urgent care at St. Marks’ hospital (subject to review of pilot study)

The PCT has invited interested parties to three workshops and will endeavour to engage all interested and difficult to reach groups during April, May & June 2009. The results of the workshops will be communicated through the RCRP communications programme.

The PCT anticipates that there will be a review of service contracts/specifications consequent to this process which will commence in late 2009.

Urgent Care Definition
Urgent care services are medically necessary services which are required for an illness or injury that would not result in further disability or death if not treated immediately, but require professional attention and have the potential to develop such a threat if treatment is delayed longer than 24 hours. An urgent care condition could be a sprain, sore throat or rising temperature.

Emergency Care Definition
Emergency conditions are those that threaten your life, limb or eyesight. TRICARE defines an emergency as a medical, maternity or psychiatric condition that would lead a “prudent layperson” (someone with average knowledge of health and medicine) to believe that a serious medical condition existed, or the absence of medical attention would result in a threat to his or her life, limb or sight and requires immediate medical treatment or which has painful symptoms requiring immediate attention to relieve suffering.

Maternity at Heatherwood

It is our understanding that the Provider will report on the activity of this service.

 Meetings 090303 Acshosp Right Care

 Meetings 090303 Acshosp Right Care Miu

 Meetings 090303 Acshosp Right Care Miu Leaflet

 Meetings 090303 Ashosp Right Care1

 Meetings 090303 Ashosp Right Care2

 Meetings 090303 Ashosp Right Care3

 Meetings 090303 Ashosp Right Care4

 Meetings 090303 Ashosp Right Care Maternity

Presentation.

 Meetings 090303 Acshosc Right Care Maternity

RELEASE OF SERVICE USERS FROM SECURE ACCOMMODATION

 Meetings 090303 Acshosc Release Secure Accom Presentation

6

Title: SAFEGUARDING ADULTS

Date: 26^th March 2009

Member Reporting: Cllr Simon Dudley

Contact Officer(s): Ed Thompson – 01628 683614

Wards affected: All Wards

1. SUMMARY

1.1 This council has a responsibility to ensure that there are effective multi-arrangements in place to safeguard and protect vulnerable adults from all forms of abuse, and to intervene when concerns of possible abuse are raised.

1.2 Given the vital importance of safeguarding and the fact that it has moved to the centre of activity within adult services, it is proposed to carry out extensive publicity and training within the Royal Borough. This will involve significantly increasing the profile around adult safeguarding in the light of an increasing national emphasis on safeguarding and the development of the new policy procedures. This includes involvement with partner agencies including the independent and voluntary sector with the Royal Borough acting lead agency.

2. RECOMMENDATION:- That Cabinet:

Notes the multi-agency work led by Adult Services to safeguard vulnerable adults;

Support the establishment of a Safeguarding Board for Adults within the Royal Borough;

That the Strategic Director and Lead Member for Adult and Community Services are authorised to appoint an Independent Chair of the Safeguarding Board in cooperation with key partners on a sessional basis for 2 years;

Approve the establishment of a Safeguarding Vulnerable Adults Manager within Adult Social Services who will also carry out co-ordination of DOL’s (Deprivation of Liberty) work;

What will be different for residents as a result of this decision?

All vulnerable citizens within the Royal Borough should feel confident that the Council is committed to operating zero tolerance in respect of adult abuse and that effective arrangements will have been put in place to protect the vulnerable people living in the Borough.

3. SUPPORTING INFORMATION

Background

3.1 In March 2000, the Department of Health (DoH) issued ‘No Secrets’, a national framework for the development of adult protection work. Adult protection is now more generally referred to as ‘safeguarding adults’.

3.2 The aim of ‘Safeguarding Adults’ work is to help vulnerable adults to live a life that is free from abuse and neglect. This includes - but is not limited to - arrangements for responding to allegations of abuse by all agencies.

3.3 Local authorities in particular have a responsibility to follow the Department of Health guidance outlined in ‘No Secrets’ and coordinate a multi-agency approach to safeguarding against abuse and taking appropriate action when somebody is being abused or is at risk of abuse. In 2005 the Association of Directors of Adult Social Services in conjunction with other agencies with a responsibility for safeguarding issued a National Framework on which the current policies and procedures are based.

3.4 The terminology ‘Safeguarding Adults’ has been widely adopted nationally and locally but this area of work is still sometimes known as: Adult Protection, Protection of Vulnerable Adults, POVA, Protecting Vulnerable Adults and in some cases just ‘vulnerable adults’.

3.5 For the purposes of safeguarding adults, a vulnerable adult is defined in No Secrets as: A person aged 18 years or over “who is or may be in need of community care services* by reason of mental or other disability, age or illness; and who is or may be unable to take care of him or herself, or unable to protect him or herself against significant harm or exploitation.”

*Community care services in this context refer to all care services provided in any setting or context.

3.6 There is an East Berkshire Safeguarding Adults Partnership Board, a multi-agency group currently chaired by Bracknell’s Chief Officer for Adults’ Services. The Board is responsible for setting the strategic direction and securing senior management engagement across the area. The Board provides leadership in developing policy and standards to deliver improved practice in addressing adult safeguarding issues. This board currently oversees our work locally to safeguard vulnerable adults from abuse.

3.7 The current policies and procedures were completed during 2008 and there was a general launch of the final draft of the procedures across Berkshire during the summer of 2008. This well established multi-agency safeguarding procedure provides the framework to ensure that there is a co-ordinated and effective response when concerns about possible abuse are identified.

3.8 Safeguarding investigations generally relate to concerns of abuse against an individual, and may relate to physical, sexual, financial, psychological or institutional abuse. In 2007/08 there were 99 investigations into concerns of abuse against individuals, this was an increase of 50% over the previous year. The number of alerts and investigations have continued to increase during the current year (circa 30%) as awareness improves. In the last two years officers have also conducted a number of “serious concerns about establishments” investigations, where concerns about the overall standard of care in a particular establishment are raised, for example following a high number of complaints about a home care agency, or a number of complaints about a single care home.

3.9 Both locally and nationally, issues around the protection of children are more widely recognised and multi-agency arrangements for safeguarding children are generally more established. However, there is now increasing recognition of abuse of vulnerable adults, and campaigns, for example by Action on Elder Abuse, have helped to raise this profile. The Commission for Social Care Inspection (CSCI) have identified safeguarding as a priority, and this now forms the basis of all inspections of local authorities with responsibility for adult social services. In the Royal Borough an inspection is planned in 2009.

3.10 It is important to note three important points in relation to safeguarding adults’ work:

1. Domestic Violence and Safeguarding Adults are not the same; however, domestic violence also becomes a safeguarding adults issue when the victim is a vulnerable adult.

2. A high proportion of adult abuse and neglect does not constitute a criminal offence because unlike Safeguarding Children, there is no all-encompassing Safeguarding Adults legislation.

3. Whilst any forms of abuse could be the result of deliberate intent, they could equally be due to negligence or ignorance.

3.11 It is a widely acknowledged that the incidence of adult abuse is being under-reported. This may be due to safeguarding of adults not receiving the same sort of publicity as abuse of children or being seen as a serious issue by many parts of society. Safeguarding will only work if people have the confidence to report harm, whether carried out by unknown people, paid staff or family members. There is a need to improve awareness and publicity of adult abuse as safeguarding will only work if people who experience abuse understand and trust the process of reporting and responding. Issues involved in not reporting harm need to be looked at in culturally sensitive ways, and the BME, voluntary sector and advocacy groups have important roles to play.

3.12 Concerns about the possible abuse of a vulnerable adult may come from a number of sources: a family carer, a care worker, a friend or neighbour, a GP, or the service user themselves. Wherever the referral comes from, it is the responsibility of the local authority to ensure that this is looked into. In this context, the Adult Care Services Learning Disability (LD) and Adult and Older Persons (ACS), Community Mental Health Team (CMHT) Mental Health Team for Older People (MHTOP) Teams are known as the “investigating teams”.

3.13 Most safeguarding adult’s abuse investigations begin with an initial assessment by telephone by an experienced care manager/social worker. The need for the immediate protection of the vulnerable adult is the first consideration, and if it appears that a criminal act may have been committed, the investigating team will contact the police. A safeguarding strategy meeting will be held where there is a suspicion or concern of abuse. Consideration must be given to involving the alleged victim and/or family carers. The main aim of the meeting is to produce an initial protection plan for the vulnerable adult. The action plan details roles, responsibilities and timescales, and where necessary follow up meetings are held.

3.14 The Accreditation and Monitoring team are currently involved in all Safeguarding adult investigations relating to adult residential/nursing placements and a number of domiciliary and supported living incidents. This involvement begins once the S.A Co-ordinator receives an alert and a member of the team is involved in a strategy discussion. Once an investigation is underway and protection- planning meetings are held, the team are key in identifying areas of concern relating to the provider as a whole, and therefore the users of the service. The team’s approach is to safeguard the service, as well the individual concerned in the alleged incident.

3.15 Throughout the safeguarding process, the Accreditation and Monitoring team establish where improvements can be made and assist providers to prevent such situations recurring. An action plan will be agreed covering areas of concerns such as: Lack of robust policies and procedures, deficits in staff knowledge and training, management support, users unaware of complaints procedures and so on. This action plan is monitored where applicable for progress and completion. Often the provider will require specific monitoring for these reasons, the results of which are relayed to the SA co-ordinator and CSCI. The team’s input has received compliments from Care management, TVP and CSCI for the positive contribution it makes.

Future Working Arrangements

3.16 Given the focus on Transforming Social Care which will lead to vulnerable people being able to purchase their own care, officers see that it is of vital importance safeguarding becomes the centre of activity within all adult services. Therefore the following developments are proposed:

Ensure that Safeguarding Adults work within the Royal Borough adheres to national guidance and best practice.

Establish a Safeguarding Adults Partnership Board (SAPB) within the Royal Borough.

Appoint an Independent Chair of the SAPB.

Establishment of a Safeguarding Vulnerable Adults Manager within Adult Social Services who will also carry out co-ordination of DOL’s (Deprivation of Liberty) work.

Improve knowledge and practice of safeguarding of adults across all partners and care providers/givers impressing the need to view this as being ‘everybody’s business’.

Carry out extensive publicity and training within the Royal Borough. This will involve significantly increasing the profile around adult safeguarding in the light of the development of the new procedures and will also involve involvement with partner agencies including the independent and voluntary sector. There also needs to be some discussion about the need to involve users and carers where appropriate and this will be part of the action plan.

4. OPTIONS AVAILABLE AND RISK ASSESSMENT

4.1 Options

	Option	Comments	Financial Implications
	1. Do nothing	This is not feasible as it could lead to the abuse of vulnerable people would continue to be under-reported and the reputation of the council being at risk due to not protecting vulnerable people. In addition at the last East Berkshire Safeguarding Partnership Board meeting it was agreed that each LA would make its own arrangements for safeguarding.	Revenue - none Capital - NA
	2. Develop local service as outlined in 3.16	This will ensure that Safeguarding Adults work within the Royal Borough adheres to national guidance and best practice so as to prevent, respond to and minimise abuse.	Revenue - £54k for the manager; £6k for the Independent Chair to be funded within current resources Capital - NA

4.2 Risk assessment

Assessing and managing risk is essential to safeguarding vulnerable adults. There is a multi-agency responsibility to identify vulnerable adults at risk of abuse, to put safeguards in place to prevent abuse and to ensure that where there are concerns of abuse having occurred, risks are managed to protect vulnerable adults from further abuse.

Since 2006 Local Authorities have had increased responsibilities to safeguard vulnerable people. If this authority does not have in place effective and robust safeguarding arrangements then it could be exposed to the risk of a legal challenge. Therefore it is essential that service developments outlined in 3.16 are supported so as to protect not only vulnerable people within the borough but also to protect the reputation of the council.

5. CONSULTATIONS CARRIED OUT

Internal process only

6. COMMENTS FROM THE OVERVIEW AND SCRUTINY PANEL

7. IMPLICATIONS

The following implications have been addressed where indicated below.

Financial	Legal	Human Rights Act	Planning	Sustainable Development	Diversity & Equality
ü	ü	ü	N/A	N/A	ü

7.1.2 All financial implications associated with the recommendations set out in section 2 will met within existing budgets.

7.1.3 At present there is no specific ‘Safeguarding Adults’ legislation in England, however the safeguarding of vulnerable adults sits within a wide legislative framework and our statutory duty to safeguard and take relevant action when abuse may have occurred is incorporated into a number of Acts, including: The Mental Health Act 1983; The NHS and Community Care Act 1990; The Human Rights Act 1998; The Care Standards Act 2000; The Mental Capacity Act 2005; The Safeguarding Vulnerable Groups Act 2006; and The Mental Health Act 2007.

7.1.4 On 14 June 2007, Ivan Lewis (the then Parliamentary Under Secretary of State for the Department of Health) announced a review of the ‘No Secrets’ guidance. The case for specific legislation to safeguard vulnerable adults is to be considered as part of the review.

Background Papers:
No Secrets – DH 2000
Berkshire Safeguarding Adults Policy and Procedures 2008
--------------------------------------------------------------------------------------------------------------------------
Authorisation:

	Legal	Finance	Planning	Property	Procurement	DMT
Name:	Jayne Pringle	Alan Abrahamson	NA	NA	NA	Jim Gould
Date Approved:	23/02/09	23/02/09	NA	NA	NA	19/02/09

	SMT	Lead Member	Ward Cllrs (if Appropriate)	Leader’s Office	Scrutiny Panel
Name:		Cllr Dudley	NA	Cllr Burbage
Date Approved:	24/02/09	19/02/09	NA	19/02/09

Title: SERVICE MONITORING REPORT

Date: 26 February 2009

Member Reporting: Councillor Hilton

Contact Officer(s): Andrew Brooker, Head of Finance, x6341

Wards affected: All

1. SUMMARY

1.1 This service monitoring report provides a monthly update on service delivery with emphasis on the impact on the council’s financial position.

1.2 Services are currently projecting expenditure of £86,330k (down £55k since last month’s £86,385k). The approved estimate is £86,097k (up £76k from last month’s £86,021k). The expected overspend is therefore £233k (last month: £364k). See sections 3 for more details.

1.3 General balances at year end are projected to be £5.949m (last month £5.818m) - see section 4 for more details.

1.4 The approved capital programme reflects the Budget Report to February 2009 Cabinet. See section 5 for more details.

2. RECOMMENDATION: That:

i) The provisional revenue and capital outturn figures be noted.

ii) The capital programme variances and slippage identified in Appendix C be approved.

iii) That Directors work with Lead Members to develop proposals to contain expenditure within current budget limits.

What will be different for residents as a result of this decision?

The Council is responsible for ensuring that it has put in place the proper arrangements to secure economy, efficiency and effectiveness in its use of resources. If the management of services and their budgets are not regularly reviewed, any and all services for residents could be adversely affected and Council Tax levels may be affected.

3. SUPPORTING INFORMATION

3.1 Background

3.2 As at 31 January 2009, total service expenditure for 2008/9 is expected to be £86,280k (down £105k from last month’s 86,385k).

3.3 Summaries of the Council’s provisional outturn Revenue and Capital financial reports are contained in Appendices A and B respectively. The revenue report includes income and expenditure statements together with a short Directorate report drawing members’ attention to key activities affecting the current and future years.

3.4 Learning & Care reports that its 2008-9 costs are projected to be overspent by £98k (down £56k from last month’s £154k) on its approved estimate of £48,508k (last month’s approved estimate was £48,506k ).

Children’s Services are expected to be overspent by £455k, an increase of £27k on last month, after contract changes on a number of Home to School Transport routes, and new foster care placements.

Adult Social Care is expecting to underspend by £352k (down £133k from an expected underspend last month of £219k). There is a projected underspend on Learning Disability team costs, Mental Health team non-salary costs and increased income from service users on the Elderly and Physical Disability residential budgets.

There has been an increase in demand for temporary accommodation from larger families, increasing pressure on the Housing budget by an estimated additional £50k in the current year.

3.5 Community Services reports a variance of £110k (up £35k from last month) from the approved estimate of £22,810k (same as last month).

Highway gritting costs, streetcare and urgent highway defect repair costs have increased due to adverse Winter weather conditions. See report for further details.

3.6 The Chief Executive reports that Corporate Services expenditure is expected to be £25k higher (last month: £135k higher) than the approved estimate of £14,779k (last month £14,705k). The increase of £74k is because of an LPSA grant award for democratic services (£50k) and a supplementary estimate to cover severance costs in Business Improvement (£24k). There have been staff vacancy savings in various areas and an underspend on consultation amongst other things.

4. OVERALL POSITION

Appendix A summarises the projected outturn position and shows projected year-end reserves to have increased by £105k to £5.949m from the previous month. This is made up of an increase of £76k in supplementary estimates (after roundings, per section 3.6 above) and a net reduction in service variances of £181k.

5. CAPITAL

5.1 Capital Budget Movements Since Budget Report

The approved 2008-9 capital budget as at 31^st December reported to Cabinet on 12^th Februrary was £11,417k net. Budget movements and variances identified for January are as follows:-

Exp Inc Net
£'000 £'000 £'000
Approved Budget December 26,240 -14,823 11,417
Budget movements January 2009 128 -128 0
Projected capital programme 2008/2009 26,368 -14,951 11,417
Variances -601 200 -401

The budget movements are to do with a new three-year Safer Stronger Communities grant (£61k), adjustments to Oak Lodge Day Centre (-£16k) and an extended schools scheme for Larchfield (-£7k), schools s106 funds (£77k) and an additional grant for Mobile Technology (£13k).

5.2 Overall Programme Status

The project statistics show the following position as at the end of January 2009:

Number of Schemes in Programme 468
Yet to Start 6%
In Progress 47%
(Of which Ongoing Annual Programmes 6%
e.g.. Disabled Facilities Grant)
Completed 33%
Devolved Formula Capital Grant schemes 14%
(Data not available on budgets devolved to schools)

6. OPTIONS AVAILABLE AND RISK ASSESSMENT

6.1 Options

	Option	Comments	Financial Implications
	1. Accept the report	Directors have a responsibility for managing their Services within the Budget approved by Council. Cabinet has limited power to vary those budgets within the overall budget and policy framework or to re-define the priorities agreed when the budget was approved. Cabinet does however have responsibility for considering the impact on future year’s budgets of the decisions taken.	Revenue Capital
	2. Reject the report	This is not an option as The Local Government Act 2003 requires the Royal Borough to monitor its financial position	Revenue Capital

6.2 Risk assessment

Risk assessments are carried out as a matter of course for the delivery of individual services. The main Financial risks are included on the Council’s Risk Register . paragraphs 3.8 to 3.15 discuss the risks associated with the current economic downturn.

The Councils Financial Strategy outlines the measures available to it in the event of a series of events that lead to significant projected budget variances being reported.

7. CONSULTATIONS CARRIED OUT

No specific consultation is carried out as this is a regular monitoring report

8. COMMENTS FROM THE OVERVIEW AND SCRUTINY PANEL

Relevant components of this report will be considered by each of the four scrutiny panels as part of their next round of meetings.

IMPLICATIONS

9. The following implications have been addressed where indicated below.

Financial	Legal	Human Rights Act	Planning	Sustainable Development	Diversity & Equality
ü	ü	N/A	N/A	N/A	N/A

Background Papers: Cabinet 24 July 2008 – Monitoring report.

 Meetings 090303 Acshosp Service Monitoring Appx1

 Meetings 090303 Acshosp Service Monitoring Appx2

 Meetings 090303 Acshosp Service Monitoring Appx3

 Meetings 090303 Acshosp Service Monitoring Appx4

How do you rate this information/service?