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Board of Directors Thursday 07 December 2017
08:30am
Boardroom, Trust HQ, Sceptre Point, Sceptre Way, Walton Summit, Preston, PR5 6AW
Board of
Directors
Quality Committee
Finance & Performance Committee
Nomination / Remuneration
Committee
Audit Committee
Board of Directors
Meeting Board of Directors Meeting
Location Boardroom, Trust HQ, Sceptre Point, Sceptre Way, Walton Summit, Preston,
PR5 6AW
Date Thursday 07 December 2017
Time 08:30am Formal Public Board meeting
Reference Item Lead Action Enc. FOIA
PART ONE (PUBLIC MEETING)
TB 179/17 Welcome and opening comments Chair Verbal
TB 180/17 Apologies for absence and confirmation of quoracy
Chair Verbal
TB 181/17 Declarations of Interest Chair Verbal
TB 182/17 Minutes of the previous meetings Chair Decision Paper
TB 183/17 Action Tracker Chair Decision Paper
SCRUTINY & ASSURANCE
TB 184/17 Finance Report Chief Finance Officer Noting Paper
TB 185/17 Performance Report Chief Operating Officer Noting Paper
TB 186/17 Trust Chair’s Report Chair Noting Paper
TB 187/17 Quality Committee Chairs Report Committee Chair Noting Paper
TB 188/17 Chief Executive’s Report Chief Executive Discussion Paper
TB 189/17 Quality Report Director of Nursing and
Quality/Medical Director Noting Paper
PART TWO (PRIVATE MEETING)
TB 190/17 Minutes of the last meeting Chair Decision Paper
TB 191/17 Chief Executive Report Chief Executive Noting Paper
TB 192/17 Public Health Initiatives in LCFT Medical Director Noting Pres.
TB 193/17 Inpatient Reconfiguration Programme
Chief Executive Decision Paper
TB 194/17 Cumbria Strategic Options Business Case
Chief Finance Officer Noting Paper &
Pres.
TB 195/17 Staffing for Safety and Quality Action Plan Update
Director of Nursing Noting Paper
TB 196/17 Any Other Business Chair Verbal
TB 197/17 Date & Time of the Next Meeting
04 January 2018, 8.30am
Chair Verbal
Declaration of Interest – Board of Directors
Date of Declaration
Surname First Name
Job Title Nature of Interest
Do you envisage a conflict of interest between outside employment and
your NHS employment?
Nil Declaration
21/02/2017 Eva David Trust Chair Employed by Union Learn as National Manager
Yes TUC funds learning in relation to apprenticeship and Trade Union representation.
06/02/2017 Tierney-Moore
Heather Chief Executive
1. Director of Lancashire Sport Partnership2. Trustee of Community Integrated Care3. Macmillan Allumni Patron4. Retained Consultant Glenview5. Patron Breakthrough Mental Health Charity
Yes Potential risk of CIC bidding to provide services in Lancashire that are also of interest to LCFT
06/09/2017 Furlong Gwynne Non-Executive Director &
SID
1. 1. Non-Executive Director of Together HousingGroup
2. 2. CEO of Regain Sports Charity3. 3. Trustee of Chorley Youth Zone4. 4. Non-Executive Director of subsidiary of
Progress Housing Group called Concert LivingLimited
No
13/02/2017 Ballard Peter Deputy Chair & Non-
Executive Director Chief Executive DSE Service No
29/03/2017 Dickinson Louise Non-Executive Director
1. Director at Talegar Limited2. Consultancy Services at Talegar Limited3. Foundation Governor and Finance Chair at
St.Vincents Primary School
No
03/02/2017 Wilson Isla Non-Executive Director
1. NED - Progress Housing Group2. Shareholder – FSquared Ltd3. Shareholder - Ruby Star Associates Ltd4. Consultancy/Advisory Work – Ruby Star
Associates5. Chair - Borough Care Stockport
No
Declaration of Interest – Board of Directors
03/02/2017 Curtis David Non-Executive Director 1. Director at Clinical and Corporate Governance
Limited2. Clinical Associate at MIAA (Advisory Section)
No
07/02/2017 Gregory Bill Chief Finance Officer
1. Trustee of Healthcare Financial ManagementAssociation
2. Governor of Stockport College3. Co-opted member of Lancaster University
Financial and General Purpose Committee.4. Director of Red Rose Corporate Services
No
02/10/2017 Possener Julia Non-Executive Director (Start date 01.02.2017)
1. Lay member of the Lancaster UniversityManagement School and Faculty of Arts andSocial Science Ethics Committee. Although theTrust and LU have a working relationship andcollaborate such matters do not fall usuallywithin these Faculties.
2. My partner's sister is the owner of a domiciliarycare business which does have contracts withThe Trust. I am including this for the sake ofcompleteness. Bluebird Lancaster and SouthLakeland Ltd. I have no formal nor informalinvolvement in that business.
No No business with the Trust or other NHS organisation or organisations providing services to NHS No unrelated faculties or formal or informal business.
13/02/2017 Roach Dee Executive Director of
Nursing & Quality
06/02/2017 Marshall Max Medical Director
06/02/2017 Moore Sue Chief Operating Officer
07/02/2017 Gallagher Damian Director of HR
BOARD OF DIRECTORS
Minutes of the Part One Board of Directors Meeting held on 02 November 2017 Training Rooms 1 & 2, the Harbour, Blackpool
PRESENT: David Eva, Trust Chair (Chair)
Heather Tierney Moore, Chief Executive Max Marshall, Medical Director Peter Ballard, Deputy Chair Bill Gregory, Chief Finance Officer Sue Moore, Chief Operating Officer Dee Roach, Director of Nursing Damian Gallagher, Director of HR Louise Dickinson, Non-Executive Director Isla Wilson, Non-Executive Director Julia Possener, Non-Executive Director David Curtis, Non-Executive Director Jo Alker, Company Secretary
IN ATTENDANCE: Darren Conway, Quality Improvement Manager accompanying service user (Agenda Item TB 159/17) Bev Howard, Head of Communications Julie-Ann Bowden, Associate Director of Risk & Assurance Viv Prentice, Deputy Company Secretary (minutes)
OBSERVERS: Lisa Knight, Insight Development Programme
Pauline Walsh, Public Governor Adnan Gharib-Omar, Staff Governor Public Member: Jinette Hindmarsh, Partner Engagement Office, MHC UK
TB 154/17 WELCOME & OPENING COMMENTS
The Chair welcomed everyone to the meeting and introductions were made.
TB 155/17 APOLOGIES FOR ABSENCE & CONFIRMATION OF QUORACY Apologies for absence were received from Non-Executive Director, Gwynne Furlong and confirmation of quoracy was provided.
TB 156/17 DECLARATIONS OF INTEREST A declaration was made by the Chief Finance Officer in relation to his position on the Red Rose Corporate Services Board.
TB 157/17 MINUTES OF THE PREVIOUS MEETING
The minutes of the previous meeting held on 05 October 2017 were approved as a true and accurate record subject to including the detail of a discussion around care co-ordinators attendance at CPA meetings that was raised by a Non-Executive Director.
TB 158/17 ACTION TRACKER The Board reviewed the action tracker and noted the updates provided. Items were closed off as necessary. The actions relating to future staffing and clinical pathways were discussed at the Finance & Recovery Group and it was agreed that a further update would be provided at the December Board. ACTION
UNCONFIRMED
TB 159/17 PATIENT STORY The Board heard a patient story from a service user who had previously used the Trust’s CAMHS inpatient service. They spoke of their experience and journey to recovery providing the Board with examples of good practice and areas they felt could be improved.
TB 160/17 TRUST CHAIR’S REPORT
The Chair presented his report which included an overview of the activity of both Non-Executive Directors and Governors. An update was provided following the Chair’s recent visit to Scarisbrick Inpatient Unit at Ormskirk Hospital which provided the Chair with the opportunity to speak with staff about some of the challenges they face. The Board noted the content of the Chair’s Report.
TB 162/17 CHIEF EXECUTIVE REPORT The Chief Executive introduced her report and confirmed that 30% of employees had now received the flu vaccination. Areas of success were highlighted which included the recent visit from HRH Prince Harry to the MyPlace project at Brockholes Nature Reserve. The MyPlace project is a partnership supported by Big Lottery Funding and is one of 31 UK projects co-ordinated through Our Bright Futures. Constitutional changes in relation to the Council of Governors constituencies had been approved at the Annual Members’ Meeting. The election process was currently underway and the Board would be kept informed of the outcome. The Medical Director provided an update following a visit undertaken with colleagues to Northumberland, Tyne & Wear NHS Foundation Trust that had been successful in applying lean methodology focusing on improving patient experience. This discussion would be picked up with the Board as part of the scheduled session in January 2018. ACTION
TB 162/17 AUDIT COMMITTEE CHAIR’S REPORT
The Chair of the Audit Committee introduced the Chair’s Report and highlighted the key areas of discussion and focus for the Committee. This included an update on the delivery of the Internal Audit Plan which was currently amber rated in terms of progress. It was noted that this was not a concern and the delay would be mitigated in quarter three. Assurance had been received that sufficient processes and mechanisms were in place for staff to raise concerns within the organisation. The Quality Report that formed part of the Board agenda would provide an overall view of the key themes and hot spots from those concerns. Assurance had been received from the Corporate Governance and Risk Management health-checks undertaken during quarter two in the Children & Young People Network and the HR Directorate. In addition, the annual assurance programme update highlighted the key pieces of work that had been undertaken within the last twelve months relating to risk assurance. The Committee considered the extension of the internal and external audit contracts and it was agreed that stakeholder feedback in relation to the internal audit contract would be obtained prior to approving a contract extension. With
regards to external audit, a recommendation would be put forward to the Council of Governors in November to extend the contract for a further two years.
The Board noted the content of the Audit Committee Chair’s Report.
TB 163/17 QUALITY COMMITTEE CHAIR’S REPORT The Chair of the Quality Committee introduced the Chair’s Report and highlighted the key areas of discussion and focus for the Committee which included recognition of the significant amount of work that had been undertaken at HMP Liverpool.
It was noted that work was currently underway to enhance the Quality & Safety Surveillance Reports and that work was being undertaken to address staffing levels as a result of the reduction in staff from the EU.
The Board noted the Trust’s achievement of 100% compliance with PREVENT training.
The Board noted the content of the Quality Committee Chair’s Report.
TB 164/17 FINANCE & PERFORMANCE COMMITTEE CHAIR’S REPORT The Chair of the Finance & Performance Committee introduced the Chair’s Report and highlighted the key areas of discussion and focus for the Committee. This included an update on the EPR programme and the work that was being undertaken to address the small amount of overpayments to staff.
In relation to the perinatal business case update, the Chief Operating Officer confirmed that the Trust was close to signing the lease for the perinatal facility and had agreed access with Lancashire Teaching Hospitals for the inpatient reconfiguration work. The Chief Finance Officer also confirmed that funding had been approved by NHS Improvement.
The Board noted the content of the Finance & Performance Chair’s Report.
TB 165/17 QUALITY & PERFORMANCE REPORT The Chief Operating Officer presented the Quality & Performance Report for month six and confirmed that the Trust was compliant with all NHS Improvement indicators with the exception of performance against the Early Intervention in Psychosis (EIS) 2 week target. The Chief Operating Officer outlined the context of the discrepancy and the actions that were being taken to address this.
It was noted that CAMHS Tier 4 was underperforming and whilst A&E was still challenged there had been a significant reduction in the number of 12 hour breaches. The Trust also remained challenged in terms of beds and occupancy.
Patients with over 180 day’s length of stay on mental health wards had increased slightly due to the patient cohort. The lead commissioner had formally been informed of the position and the financial impact of holding chronic presentations on acute mental health wards.
The Board’s attention was drawn to the Memory Assessment Service (MAS) which, with the exception of the Central Lancashire MAS team, continued to perform well against the 79% target for the six week referral to assessment standard.
Non-Executive Director, David Curtis, highlighted that the target for Care Coordinators attending CPA reviews had not been achieved again this month. Following a question from the Chair in relation to secure services, the Chief Operating Officer outlined the work that was being undertaken with the psychology associates which included looking at violence reduction and the number of wards vs number of patients.
TB 166/17 FINANCE REPORT The Chief Finance Officer presented the finance report and confirmed that the financial position in month 6 was similar to month 5 and showed a gap of £2.6m at the half year point. Whilst staffing pressures and OAPs continued to be an issue, a task force was underway to address staffing led by the Director of Nursing and Quality. In addition, the high number of PICU OAPs was being addressed with the commissioners. An update was provided on land disposals which included the conclusion of the Ridge Lea offer. In addition, it was highly likely that a VAT reclaim relating to a capital scheme would be concluded this year. Financial pressures relating to the prison contract had been discussed with the commissioners and a response was currently awaited. In addition, the Board noted that the Trust had secured a contribution to establish the Core 24 liaison service. The Chief Finance Officer confirmed that the cash position was back on plan and that progress against the capital programme was slow due to issues with the Chorley site. Work had been progressing on a revised format of the Finance Report and therefore month 6 would be re-presented in the new format for comment. ACTION
TB 167/17 QUARTERLY WORKFORCE REPORT
The Director of HR presented the workforce report for quarter two and highlighted that whilst levels of sickness absence remained the same as the previous year work was underway to address this. This included the back to basics programme. The turnover rate for quarter two had seen a slight increase, reporting 13.95% at the close of the quarter. The Director of HR confirmed that future reports would also include additional detail in respect of the breakdown of reasons for leaving. It was referenced that there had been fewer registrations from EU workers and an increase in leavers indicating a future problem. Whilst appraisal compliance was below the Trust target, this was being addressed within the Networks. Overall mandatory and statutory training compliance continued to improve, reporting an overall compliance of 89% at the close of quarter two. For those individual subjects that remained non-compliant, Networks were agreeing new trajectories to support their achievement of the Trust target by December.
Following the percentage drop in visa compliance, the Director of HR assured the Board that this related to one individual whose application was currently being processed. Non-Executive Director, Isla Wilson, took the opportunity to update the Board following her attendance at a recent Workforce Quality Standard event. A discussion ensued in relation to the importance of increasing the Trust’s awareness of diversity. Following a question in relation to the spike in sickness rate figures in the Children and Young People’s Network, the Chief Operating Officer outlined the reasons that this could be attributed to. This included the recent changes in the network and long term sickness absence. The Director of Nursing responded to a question in relation to mandatory training from a Non-Executive Director and advised that a detailed piece of work was being undertaken in respect of moving to competency based training. This would ensure that staff are able to evidence competencies around core skills.
TB 168/17 BOARD ASSURANCE FRAMEWORK
The Associate Director of Risk and Assurance presented the Board Assurance Framework (BAF) Quarter 2 Review and provided an update on BAF risks 1.1 and 4.2 that had moved in score at the end of Quarter 2. The Board’s attention was drawn to the appendices to the BAF which included a thematic summary of the operational risks scored at 12 and above. Following a question from a Non-Executive Director in relation to CIP targets, the Chief Finance Officer explained that whilst the overall position was directly related to the mental health run rate scheme he was confident it would result in a satisfactory conclusion. The Chief Operating Officer confirmed that the current position in relation to secure services transformation would be mitigated before the end of the year. The Board approved the BAF 2016/17 Risk Register at Quarter 2.
TB 169/17 MENTAL HEALTH ACT MANAGERS The Director of Nursing presented the Assurance Report on the effective discharge of duties of Hospital Managers under the Mental Health Act and confirmed that a development session was planned for the Board in relation to its responsibility in discharging the Act. A discussion followed in relation to the responsibilities of Non-Executive Directors and it was agreed that their responsibilities would be agreed following the development session in February 2018. ACTION
TB 170/17 LEARNING FROM DEATHS
The Director of Nursing presented the Learning from Deaths Assurance Report and drew the Board’s attention to the baseline assessment against the national guidance. The Board noted that the Trust was compliant with all deadlines and would achieve upcoming deadlines by Q3/Q4. The Medical Director highlighted that that this was an important development in supporting a safety culture within the NHS in the context of openness and
transparency. It was noted that there would also be potential media interest as Trusts begin to publish their reports.
TB 177/17 On behalf of the Board, the Chair thanked Non-Executive Director, Peter Ballard for his valued contribution and support following his many years’ service within the Trust adding that as a personal colleague he would be incredibly missed.
TB 178/17 DATE AND TIME OF NEXT MEETING 07 December 2017 @ 08:30a.m. Training Room 1 & 2, The Harbour
Board of Directors
Agenda Item TB 184/17 Date: 07/12/2017
Report Title Finance Report
FOIA Exemption Part Exemption
Prepared by Shannon Carroll, Financial Services Director
Presented by Bill Gregory, Chief Finance Officer
Action required Noting
Supporting Executive Director Chief Finance Officer
PURPOSE OF THE REPORT:
Report purpose To summarise and analyse actual and forecast financial performance and standing of the Trust, the implications and any proposed management action.
Strategic Objective(s) this work supports
To provide excellent value for money in a financially sustainable way
Board Assurance Framework risk 5.1 The Trust does not achieve financial performance sufficient to maintain resilience and sustainability
CQC domain Effective
Summary
Actual Plan Var Forecast Plan VarSustainability
EBITDA 6,820 9,696 -2,876 15,860 17,745 -1,885Operational Deficit -2,255 610 -2,865 2,194 2,167 27Deficit after Impairment* -3,358 -1,274 -2,084 -1,359 -1,390 31
CIPs (against Trust Plan) 7,386 8,440 -1,054 15,100 15,100 0Cash and Liquidity 11,441 11,829 -388 24,601 10,989 13,612Capex 1,834 5,989 -4,155 13,661 9,591 4,070UOR
Capital Service 4 2 3 2Liquidity 1 2 1 2I&E Margin 4 2 2 2I&E Variance 3 1 2 1Agency 2 1 2 1Overall 3 2 2 2
Sustainability
CIPs
Liquidity
Summary continued overleaf
The cash position remains strong but shows a minor adverse variance from plan of £0.4m. The capital position continues to offset the I&E position. High debtors are placing some pressure on working capital though this is considered transient. Forecast cash is currently expected to exceed plan, a combination of an improved opening position, capital funding, and anticipated disposals. - see Cash and Liquidity for more details.
Current Out-Turn
At month 7 with CIPs of c£7.4m against a plan of c£8.4m the Trust is £1.1m behind plan, a deterioration of £0.1m on month 6 (£1.0m behind plan). The adverse variance is mainly due to a lack of performance on Run Rate Reduction Programmes on staffing pressures. Compensating schemes have, and continue to be, developed and confirmation of transactions are expected in month 8. Networks continue to create and implement measures aimed at improving the position.
Month 7 sees a year to date operating deficit of -£2.3m, excluding planned Sustainability and Transformation funding of £0.9m, against a planned surplus to date of £0.6m. This shows an improvement on month 6 and represents a small budgetary surplus in month and nearly £0.2m when excluding STF monies. The position remains driven by staffing pressures in ward and prison areas and consequential impact on cost improvement programmes (rising agency costs will also impact Use of Resources targets). Additionally OAPs expenditure continues to exceed funding - see Out Of Area Activity for more details. The forecast assumes current pressures and risks are addressed or mitigated in line with the recovery plan (see forecasting) and financial performance achieves (or exceeds) plan but the unmitigated projection indicates a gap of c£4.8m, c£6.9m without STF monies. This is represents an improvement on month 6 forecasts (£6.2m), and is driven by excess OAPs of c£0.8m (all be that significantly below last month), prisons (see also Bank and Agency section) and additional mental health pressures. Delivery of the recovery plan and financial targets will required a significant and coordinated response with robust management and oversight. After taking in to account £1.7m of disposals, which are accounted for after EBITDA, EBITDA is broadly in line with I&E Margin. The new Use of Resources (UoR) metric is rated at 3, but will rise to a 2 should the Trust meet its financial plans and targets, see below.
Capital and Financing
Use of Resources (UoR) risk ratings
Forecasting
Recovery Plan
#
Whilst it would appear that the gap can be bridged through the plan, this is not without significant risk. Delivery will only be achieved with a considerable coordinated and sustained effort across the organisation. The plan will continue to be refined and presented in more detail to the Financial Recovery Group along with the actions required.
Progress against the capital programme has been slow to date with expenditure at £1.8m against the original profile of £6.0m. The scheduling profile of many schemes was dependent on a number of tendering exercises (the last of which, Perinatal, has now been completed), agreements with third parties (now substantially resolved) and final funding approval (Inpatient schemes approval now received from NHSI, awaiting final confirmation of funds and timing from DH). Schedules for these and related/dependant schemes are now being finalised through discussions with the incumbent contractors and the Trust is pushing forward with work on the affected projects. Discussions with contractors indicate the delays will cause slippage, mainly on the Inpatients (Chorley site - c5 weeks) though a risk of slippage on the Perinatal scheme remains and is being worked on. Impacts on the respective projects have yet to be finalised and incorporated in to forecasts.
Revised year end control totals are being provided to networks in line with the recovery plan and will require:• Progress and delivery of ward staffing actions• Implementation of the recovery plan.• Agreement of OAPs mitigations with commissioners.• Progress on land sales.
Though slightly improved the current I&E position continues to give a rating of 4 and a Capital Service rating of 4 constraining the current overall UoR to a 3. Assuming current pressures and risks are addressed through the recovery plan and I&E performance achieves (or exceeds) forecast the Trust will achieve a UoR of 2 in line with the plan. However, though forecast would achieve the overall target rating, Capital Service is based on EBITDA and since part of the Trusts recovery plan is based on disposals (which are excluded from EBITDA) the Trust is not forecast to achieve planned Capital Service. The Trust is also forecast to exceed its liquidity and slip against it's planned Agency target. Should conditions persist and costs not be managed within the control total then the resulting deterioration might trigger a review of our segmentation.
Forecast ForecastYTD YTD Out-turn Out-turn
Oct 2017 Sep 2017 at Oct 2017 at Sep 20177 6 Note 12 12 Note
Plan 0.610 0.321 Plan 2.167 2.167
Major Variances Major VariancesCIP Slippage -1.054 -0.982 - See CIP section CIP Slippage 0.000 0.000 - See CIP sectionOAPs -0.773 -0.773 - See OAPs section OAPs -1.792 -1.792 - See OAPs sectionStaffing -5.471 -5.000 - See also Bank and Agency section Staffing -8.139 -8.201 - See also Bank and Agency sectionOther Bud Vars 1.708 1.791 - See Services section Other Bud Vars 1.929 0.601 - See Services sectionReserves 3.210 3.040 - See Reserves section Reserves 7.231 8.899 - See Reserves sectionIncome -0.699 -0.688 - See Reserves section Income 0.584 0.514 - See belowMinor Variances 0.000 0.000 Minor Variances 0.000 0.000
Variance -3.079 -2.612 Variance -0.187 0.021
Actual -2.469 -2.291 Actual Forecast 1.980 2.188
----
Surplus - YTD (£m) Surplus - Out-turn (£m)
This month sees an operating deficit of £2.5m, £2.3m after adjusting for impairments, £2.9m behind plan. Of this £0.9m relates to STF funding leaving a net gap from plan of £1.9m.
YTD income variance relates mainly to STF funds which are assumed in forecast along with additional funds re NCAs and R&D
Staffing variance has increased in part due to phasings of development funding in mental health, but more materially due to ward pressures.The full year projection is a surplus of £2.0m, £2.2m after adjusting for impairments. The position models an upside of c£7.0m and includes profit on disposals of c£1.7m.
-10,000.0
-8,000.0
-6,000.0
-4,000.0
-2,000.0
0.0
2,000.0
4,000.0
Plan CIP Surplus OAPs Staffing Other BudVars
Reserves Addl Income MinorVariances
2,167.0 0.0 -1,792.0 -8,139.1 1,928.8 7,231.4 584.1 0.0
-8,000.0
-7,000.0
-6,000.0
-5,000.0
-4,000.0
-3,000.0
-2,000.0
-1,000.0
0.0
1,000.0
Plan CIP Shortfall OAPs Staffing Other BudVars
Reserves Addl Income MinorVariances
610.0 -1,054.2 -773.0 -5,471.3 1,708.2 3,209.9 -698.53 0.0
Forecast ForecastYTD YTD Out-turn Out-turn
Oct 2017 Sep 2017 at Oct 2017 at Sep 20177 6 Note 12 12 Note
Plan 193.922 166.144 Plan 332.908 332.908
Major Variances Major VariancesCommunity Services 1.073 0.659 - Note 1 Community Services 2.232 2.172 - Note 1Mental Health 2.956 2.380 - Note 2 Mental Health 2.704 2.598 - Note 2Specialist Services -0.355 -0.196 - Note 3 Specialist Services -1.160 -1.145 - Note 3Non NHS Healthcare Income-1.018 -0.835 - Note 4 Non NHS Healthcare Income-1.804 -1.758 - Note 4R&D 0.274 0.180 R&D 0.389 0.600ETR 0.204 0.167 - Student Income ETR 0.356 0.297 - Student IncomeMiscellaneous -0.047 0.209 - Note 5 Miscellaneous 2.260 1.529 - Note 5STF -0.939 -0.730 STF 0.000 0.000
Minor Variances 0.000 -0.039 Minor Variances 0.000 0.015
Variance 2.148 1.794 Variance 4.978 4.308
Actual 196.070 167.938 Actual Forecast 337.886 337.216
12
345 Major increases in the latter part of the year generated by AHSN.
Monthly Income Variances (£m) Cumulative Income Variances (£m)
Major decrease due to Southport commencing in May and not April offset by minor gains in other services including Rheumatology and District Nursing.Major increases revolve around the phasing of the Out of Area Placements expenditure, in addition to Liaison & Diversion and Eating Disorders. Major decreases in Rehabilitation Services and Hospital Liaison.Income is in line with plan at this stage. Year end variances are driven by the anticipated cessation of the HIV contract.Major decrease in respect of lower than planned activity in Sexual Health services and forecasts for Sexual Health and Offender Health later in the year.
0.000
5.000
10.000
15.000
20.000
25.000
30.000
35.000
Apr May Jun Jul Aug Sep Oct Nov Dec Jan Feb Mar
Actual/Forecast
Plan
0.000
50.000
100.000
150.000
200.000
250.000
300.000
350.000
400.000
Apr May Jun Jul Aug Sep Oct Nov Dec Jan Feb Mar
Actual/Forecast
Plan
Forecast ForecastYTD YTD Out-turn Out-turn
Oct 2017 Sep 2017 at Oct 2017 at Sep 20177 6 Note 12 12 Note
Budget 164.955 141.407 Budget 281.644 281.506
Major Variances Major VariancesMental Health -6.479 -5.654 - Note 1 Mental Health -9.257 -9.961 - Note 1Community & Wellbeing -0.216 -0.274 - Note 2 Community & Wellbeing -0.401 -0.489 - Note 2Children & Young People 0.844 0.705 - Note 3 Children & Young People 0.824 0.866 - Note 3Pharmacy 0.188 0.169 - Note 4 Pharmacy 0.260 0.265 - Note 4Property Services 0.000 0.000 - Note 5 Property Services 0.000 0.000 - Note 5Corporate 0.073 0.089 - Note 6 Corporate 0.571 -0.073 - Note 6
Variance -5.590 -4.965 -8.002 -9.392
Actual 170.545 146.372 Actual Forecast 289.646 290.898
1
23
456 Corporate services are slightly ahead of plan year to date, with overspends in IM&T currently met by underspends in Medical and Human Resources.
Mental Health in year overspend is driven more acutely by excess staffing costs, primarily on wards, (£3.9m). Actions to review the patients in inpatients setting, their appropriateness for the ward and levels of staffing associated with acuity are advanced and should furnish us with the appropriate information to discuss necessary action to recover the position, though risk remains until this is enacted. There is also significant CIP slippage, as all CIPS have been withdrawn but some schemes are still in development (c£1.9m). The Network's position is diminished further by ward overspends in Secure Services wards (c£1.2m). OAPs are now manifesting as overspends (£0.8m for the year)
Community's position is impacted by undelivered CIPs to date (£0.35m). Underspends on community teams and non-pay continue to alleviate the current position.Children and Young People have similarly been impacted by a shortfall on CIP delivery(£0.25m) and Sexual Health activity shortfall (£0.2m) but is currently being compensated for by vacancies and non-pay underspends.
YTD Service Net Expenditure Variance (£m) Forecast Service Net Expenditure Variance (£m)
Pharmacy is performing broadly in line with plan, with some underspends on staffing.Property Services are performing in line with plan and are expected to remain so.
-£7,000
-£6,000
-£5,000
-£4,000
-£3,000
-£2,000
-£1,000
£0
£1,000
£2,000Mental Health
Community &Wellbeing
Children &Young People Pharmacy
PropertyServices Corporate Total
Service Forecast Variance
-£10,000
-£8,000
-£6,000
-£4,000
-£2,000
£0
£2,000Mental Health
Community &Wellbeing
Children &Young People Pharmacy
PropertyServices Corporate Total
Service Year to Date Variance
CIP Achievement (£)Notes
Year to Date PerformanceAt month 7 with CIPs of £7.4m against a plan of £8.4m the Trust is c£1.1m behind plan, a deterioration of £0.1m on month 6 (£1.0m behind plan). The adverse variance is mainly due to the continued lack of performance on Run Rate Reduction Programmes on staffing pressures. Compensating schemes have, and continue to be, developed and network management team are being supported by to implement measures aimed at improving the position.
Schemes to be Transacted£0.9m of schemes are yet to be transacted at month 7 leading to year to date slippage of c£0.5m. There is a good degree of confidence in the delivery of these schemes.
Schemes In Process£1.5m of additional schemes identified are not yet sufficiently detailed to transact and after allowing for slippage factored into plan this results in slippage of c£0.6m. There is some confidence in the delivery of these schemes.
Schemes to be IdentifiedIncluding pipeline schemes plan totals exceed target and though not without risk forecast continues to be broadly in line with plan requirements.
ForecastThe programme is currently expected to achieve the Annual Plan however risk of slippage, particularly on mental health and community schemes, remains.
Plan Actual Variance Plan Forecast Variance
£'m £'m £'m £'m £'m £'m
Cost Improvement Programmes 6.11 6.69 0.58 11.10 13.10 2.00
Run Rate Reduction Programmes 2.33 0.70 -1.63 4.00 2.00 -2.00
Total 8.44 7.39 -1.05 15.10 15.10 0.00
Plan Actual Variance Plan Forecast Variance
£'m £'m £'m £'m £'m £'m
Monitored Schemes 7.31 7.39 0.07 12.74 12.73 -0.01
Schemes to be transacted 0.52 -0.52 0.89 0.89 0.00
Schemes in Process 0.61 -0.61 2.12 1.51 -0.61
Slippage/Schemes to be identified 0.00 -0.65 -0.03 0.62
Total 8.44 7.39 -1.05 15.10 15.10 0.00
Year to Date Annual
Year to Date Annual
Month Month Month MonthOct 2017 Sep 2017 Oct 2017 Sep 2017
7 6 Note 7 6 Note
Agency Spend 774 863 Note 1 Bank Spend 1,388 1,813
Network Analysis Network AnalysisMental Health 564 554 - Note 2 Mental Health 1086 1484 - Note 2Children & Young Peoples 11 64 - Note 3 Children & Young Peoples 81 80 - Note 3Community & Wellbeing 282 215 - Note 4 Community & Wellbeing 160 197 - Note 4Corporate Services -83 30 - Note 5 Corporate Services 60 52 - Note 5
Actual 774 863 Actual 1,388 1,813
1
2
34
5
The Trust has been given a ceiling by NHS Improvement for agency spend. This target is£7.695m for the year. At the end of period 7, the Trust is -£758k, or 17% above it'strajectory. The new Use of Resources rating measures agency against target and containstrigger points. Key trigger points are a requirement for 50% and 25% or better for ratings of3 and 2 respectively. An individual rating of at least 3 is required to obtain an overall ratingof 2 (see also Use of Resources section).
Corporate Services is net of the charge levied for agency staff. Agency spend is negligible with the exceptions of Health Informatics.
Agency Costs Over Time (£'000) Bank Costs Over Time (£'000)
A high level of vacancies is supported by bank and agency, though increased levels of recruitment mean overall staffing costs remain high. Agency costs have decreased from last month as well as bank costs.Mental Health Networks bank and agency costs are primarily due to the level of acuity on inpatient wards being beyond the level established although the in month decrease in bank is almost entirely attributable to staffing on Adult and Secure wards.Children and Young Peoples temporary staffing remains relatively minor and consistent.Community and Wellbeing sees an increase in both Agency but a fall in Bank, with the major agency change being the with regard to Learning Diability, and bank recovering in Integrated Teams and Southport.
Apr May Jun Jul Aug Sep Oct Nov Dec Jan Feb Mar
2015/16 935 1108 932 1180 1119 1176 1139 1183 1170 1072 1289 1209
2016/17 1536 1521 1728 1390 1238 1570 1154 1219 1401 1289 1321 1613
2017/18 1312 1268 1625 1365 1481 1813
0200400600800
100012001400160018002000
Apr May Jun Jul Aug Sep Oct Nov Dec Jan Feb Mar
2015/16 1030 988 1262 1242 909 1202 1149 939 1073 1077 978 1174
2016/17 1098 862 1250 1184 986 1133 781 827 825 738 661 1006
2017/18 647 691 711 704 825 863
0
200
400
600
800
1000
1200
1400
Agency Ceiling Apr May Jun Jul Aug Sep Oct Total Projection
Actual 647 691 711 704 825 863 774 5,216 8,353Plan 639 639 639 636 636 636 633 4,458 7,695Variance -8 -52 -72 -68 -189 -227 -141 -758 -658% of Plan -17% -9%
Month Month YTD ForecastOct 2017 Sep 2017 Oct 2017 Out-turn
7 6 Note 7 12 Note
Plan 0.2 -3.6 Plan 11.8 11.0
Major Variances Major VariancesI&E -0.3 -0.6 - Note 2 I&E -3.1 -2.1 - Note 2Capital & financing 0.6 0.8 - Note 2 Capital & financing 4.4 11.8 - Note 2Contract Vars and Adjs 0.2 -1.1 Note 3 Contract Vars and Adjs -2.7 Note 3Debtors -1.7 1.2 - Note 4 Debtors -3.7 -0.3 - Note 4Timing of settlements to suppliers -0.3 2.9 - Note 4
Timing of settlements to suppliers 0.0 0.5 - Note 4
Provisions and deferred income 0.6 0.0 - Note 5
Provisions and deferred income 1.4 0.4 - Note 5
Opening cash 0.0 0.0 Opening adjustment 2.7 2.7
Minor Variances 0.2 0.3 Minor Variances 0.5 0.6
Variance -0.7 3.4 Variance -0.4 13.6
Actual -0.5 -0.2 Note 1 Forecast Actual/Forecast 11.4 24.6 - Note 1
1
2
34
56 Provisions and Deferred Income are currently generating gains of c£1.9m over plan. Crystallisation of income and redundancy settlements are expected to reduce gains and this is
factored into forecasts.
Monthly Cash and Liquidity Variance (£m) Forecast Cash and Liquidity (£m)
Timing of settlements to suppliers are broadly in line with plan.
Reductions in capital expenditure are supporting cash more than compensating for the impact of the deficit. Forecasts assume planned revenue and capital forecasts are achieved, that PDC for the inpatients Programme is in line with expectations, and that the disposal of Westfields, Ridge Lea and Ribbleton take place in 2017/18.
Late payments by CCGs (£1.0m) and local authorities (£2.1m) coupled with outstanding CQUIN (£0.5m) have lead to a large adverse position on debtors. Late payments were largely settled in early November and the issues are being addressed accordingly (as problems over payment timing rather than disputes). CQUIN payments are a national issue and payment is expected by March.
Forecast cash is ahead of plan by c13.6m partly due to the change in opening position c2.7m, but mainly due to assumptions around disposals (net improvement c£5.75m - Westfields, Ribbleton and Ridge Lea) and the assumed external cash funding of a substantial part of the Inpatient Scheme (net improvement £4.6m). The forecast assumes that proposed management action to bring financial performance back in to line is achieved (including profit on disposals), that capital receipts are in line with expectations, and that the Trust maintains eligibility for Sustainability Funding (achieves the control total).
Cash shows an adverse variance from plan of £0.4m. The capital position continues to offset the I&E position and pressures on working capital have been reduced - see below.
Contract variations and phasing adjustments negatively impact on cash and are not included in plans.
-10.000
-5.000
0.000
5.000
10.000
15.000
Apr May Jun Jul Aug Sep Oct Nov Dec Jan Feb Mar
Opening cash balance
Financing and Other
Capital and Investment Activities
Changes to WC
Non Cash Flows
Cash flows from operating activities
0.000
5.000
10.000
15.000
20.000
25.000
30.000
Apr May Jun Jul Aug Sep Oct Nov Dec Jan Feb Mar
Forecast
Plan
YTD Plan YTD Act Annual ForecastOct 2017 Oct 2017 Variance Plan Out-turn Variance
£000 £000 £000 £000 £000 £000
IT Schemes 1.015 0.664 -0.351 1.900 1.900 0.000 - Note 1
Estate and infrastructure SchemesLarge Schemes
MH Inpatient Schemes 3.194 0.401 -2.793 4.580 5.700 1.120 - Note 2
Perinatal 0.000 0.113 0.113 0.000 2.470 2.470 - Note 3
Places of Safety 0.000 0.100 0.100 0.000 0.490 0.490 - Note 4
High Priority Schemes 0.697 0.147 -0.550 1.263 1.260 -0.003 - Note 5
Maintenance and Replacement 0.543 0.310 -0.233 0.930 0.930 0.000Other (inc. contingency) 0.541 0.099 -0.442 0.918 0.911 -0.007
Total 5.989 1.834 -4.155 9.591 13.661 4.070
12
3
4
5
6 The underspend largely relates to contingency and reserves. Some delays as a result of dependencies/focus on large schemes and fire safety have resulted in slippage rather than the expected pressures on contingency. Transfers between revenue and capital transacted are as required.
Note 6-
£3.5m of external cash funding was allocated for the Perinatal project, £2.5m in 2017/18. Again issues with third parties have caused some delays and whilst it was hoped this can be managed, some slippage may be likely. The impact has yet to be finalised and incorporated in to forecast.
£0.5m of external cash funding was allocated for Places of Safety. Funding currently exceeds planned work and should spend not be required this year then funding will be retained by DoH.
Capital Expenditure
Progress against the capital programme has been slow to date with expenditure at £1.8m against the original profile of £6.0m. The scheduling profile of many schemes was dependent on a number of tendering exercises (the last of which, Perinatal, has now been completed), agreements with third parties (now substantially resolved) and final funding approval (Inpatient schemes approval now received from NHSI, awaiting final confirmation of funds and timing from DH). Schedules for these and related/dependant schemes are now being finalised through discussions with the incumbent contractors and the Trust is pushing forward with work on the affected projects. Discussions with contractors indicate the delays will cause slippage, mainly on the Inpatients (Chorley site - c5 weeks) though a risk of slippage on the Perinatal scheme remains and is being worked on. Impacts on the respective projects have yet to be finalised and incorporated in to forecasts.
IT programme is expected to be delivered on forecast.External cash funding was provisionally allocated to the Inpatient project through the STP and was approved by NHSI in October. DH have requested additional information, including additional governance requirements, and final approval remains to be confirmed. Work has commenced though delays in relation to the Chorley site, primarily caused by third parties, have meant that works have started later than originally intended and whilst it was hoped this could be managed, slippage of c5 weeks now appears likely. The impact has yet to be finalised and incorporated in to forecast.
Schemes are underway and despite some delays, partly as a result of inpatient development, schemes are expected to be completed in line with planned outturns.
Use Of Resource Metric
unitsPlan
YTD ending 31-Oct-2017
Actual YTD ending 31-
Oct-2017
Variance YTD ending 31-May-17
Plan YTD ending 31-
Mar-2018
Forecast YTD ending 31-
Mar-2018
Forecast Variance
Year ending31-Mar-18
Threshold 1 2 3 4
\ Capital Service Cover 2.5 1.75 1.25 <1.25Capital Service Cover Liquidity 0 -7 -14 <-14
I&E Margin 1.00% 0.00% -1.00% <=-1%
Capital service metric 0.0x 1.803 1.208 (0.594) 1.909 1.647 (0.262) Variance from plan 0.00% -1.00% -2.00% <=-2%
Capital service rating Rating 2 4 2 3 Agency 0.00% 25.00% 50.00% >=50%
Liquidity Metric Weighting
Capital Service Cover rating 20.00%
Liquidity metric £m (1.062) 3.807 4.869 (0.433) 13.631 14.064 Liquidity rating 20.00%
Liquidity rating Rating 2 1 2 1 I&E Margin rating 20.00%
Variance From Plan rating 20.00%I&E Margin Agency Spend 20.00%
I&E Margin metric % 0.31% (1.15%) (1.46%) 0.65% 0.65% (0.00%)
I&E Margin rating Rating 2 4 2 2
I&E Variance From Plan
I&E Variance from plan metric % (1.46%) (0.00%)
I&E Variance from plan rating Rating 3 2
Agency
Agency metric % (0.65%) 16.24% 16.88% (0.95%) 7.87% 8.82%
Agency rating Rating 1 2 1 2
Use Of Resources Rating
Overall rating unrounded Rating 2.80 2.00 If unrounded score ends in 0.5 Rating - -Rounded score Rating 3 2
Use Of Resources Rating before overrides Rating 3 2
4 Rating Trigger for Use Of Resources Rating Text Trigger No trigger
Use Of Resources Rating after 4 rating override Rating 3 2
Control total override - Control total accepted Text YES YES
Is the provider in Financial Special Measures? Text No No
Use Of Resources Rating after overrides Rating 3 2
Finance and use of resources is one theme of 5 in the Single Oversight Framework. Segmentation and therefore autonomy and support is dependent on performance across all themes.
Note that under the Single Oversight Framework a score of 1 is now the best rating and 4 the worst. A rating of 4 on any metric or an average rating of 3 triggers a concern and a potential support need.
Though slightly improved the current I&E position continues to give a rating of 4 and a Capital Service rating of 4 constraining the current overall UoR to a 3. Assuming current pressures and risks are addressed through the recovery plan and I&E performance achieves (or exceeds) forecast the Trust will achieve a UoR of 2 in line with the plan. However, though forecast would achieve the overall target rating, Capital Service is based on EBITDA and since part of the Trusts recovery plan is based on disposals (which are excluded from EBITDA) the Trust is not forecast to achieve planned Capital Service. The Trust is also forecast to exceed its liquidity and slip against it's planned Agency target. Should conditions persist and costs not be managed within the control total then the resulting deterioration might trigger a review of our segmentation.
• Capital Service is currently a 4 against a plan of 2, an increase in operating performance of c£0.2m would be required to increase the rating to 3.
• Liquidity is currently a 1 against a plan of 2, a deterioration in the liquidity metric of c£3.8m would be required to reduce the rating to 2.
• I&E Margin rating is currently 4 against a plan of 2, an increase in operating performance of c£0.3m would be required to increase the rating to 3 - Note that the adjusted deficit of -£2.3m is £2.9m behind the RCT (£1.9m exc STF)).
• I&E Variance from Plan is currently 3, an increase in operating performance of c£0.3m would be required to increase the rating to 2.
Reserves
Reserve Budget Actual £ Annual Projected £
To Date To Date Variance Budget Actual Variance Narrative
£'000 £'000 £'000 £'000 £'000 £'000
Capital Charges £8,966 £9,168 -£202 £15,546 £13,852 £1,694 Anticipated Profit on Disposals offset by var due to revaluation of estate
Pay Reserve £1,166 £566 £600 £1,529 £969 £559 Charge for Apprentice LevyPressures Reserve £293 £117 £176 £503 £201 £302 Funds to be applied to servicesCIP Reserve £1,028 -£47 £1,075 £1,834 -£80 £1,914 Gain on CIP to be applied to service pressuresEmerging Pressures -£315 £0 -£315 -£2,261 £0 -£2,261 Utilisation of Reserves to meet Emerging PressuresDevelopments £729 £280 £449 £934 £250 £684 Costs to be applied as incurredContracts £168 £0 £168 £227 £0 £227 Minor contract gains to be applied to servicesOrganisational Reset £1,017 £235 £782 £1,734 £573 £1,162 Funds to be returned to Networks, with some staffing chargesAgency & Direct Engagement -£350 -£343 -£7 -£600 -£612 £12 Premium for using non-contracted staffNon Clinical Development £4 £0 £4 £22 £0 £22 Premium for using non-contracted staffSavings to be Identified £0 -£2 £2 £0 -£2,420 £2,420 Additional savings required to deliver control total
Non Pay Inflation £638 £162 £477 £794 £216 £578 Funds to be applied for inflationary pressures
Total £13,346 £10,136 £3,210 £20,263 £12,949 £7,313
MATTERS
ID Meeting DatePaper Status
2017/01 Jul-17 VerbalPartial
2017/02 Jul-17 VerbalPartial
2017/03 Jul-17 VerbalPartial
2017/04 Jul-17 VerbalPartial
2017/05 Jul-17 Verbal
Excluded
2017/06 Jul-17 VerbalExcluded
2017/07 Jul-17 Verbal Excluded
2017/08 Jul-17 VerbalExcluded
The Trust is actively exploring the potential for land sales. Gains may crystallise in 17/18 dependent on timing and profits willcontribute toward the control total.
On-going Claims: The process of reclaiming VAT in relation to older developments continues. Communications with HRMC progressthough timing and amounts remain uncertain. Treatment is being discussed with external audit but initial indications are positive. Thevalue may be up to £2m, though less than half this amount is included in plans and forecasts. Our advisors are actively engaged inbringing this to a final resolution.
SubjectA number of disputes require resolution and may result in arbitration. These concern NHSE, West Lancs, and Pennine CCGs. These arebeing escalated through NHSI.
NHSI is currently clarifying the position around elements of the national contingency reserve, £0.5m of which is now outstanding.
The forecast trajectory with regard to Out of Area Placements (OAPs) is currently projected to £1.6m, with the assumption that the50% risk share applies.
Provision for charges incurred as a result of the organisational reset have been made, the process is largely complete, but somechallenges remain and these may have financial consequences.
STF monies have been included in forecasts on the assumption that the Trust will achieve its revenue control total. Should this not bethe case £2.1m of funding would be lost.The Trust is assessing the impact of recent court decisions around pay for sleepover in Learning Disabilities care placements.
OUT OF AREA ACTIVITY
NetworkActual/ Forecast Apr May Jun Jul Aug Sep Oct Nov Dec Jan Feb Mar TotalAcute OAPs (places) 15 11 14 13 10 11 13 15 9 9 9 9 138PICU OAPs (places) 9 13 9 12 12 11 9 9 8 8 8 8 116Total Beds 24 24 23 25 22 22 22 24 17 17 17 17 254Acute OAPs (£'000) 244 185 228 218 168 179 218 244 151 151 137 151 2274PICU OAPs (£'000) 206 308 206 284 284 252 213 206 189 189 171 189 2697Total £'000 450 493 434 502 452 431 431 450 340 340 308 340 4971
1
23
4
567
The Trust has written to commissioners about the pressure caused by patients awaiting alternative placements.The Trust has opened negotiations with commissioners about the financial impact of patients inappropriately occupying our beds in excess of 180 days.
The Trust is mobilising Acute Therapy Services in Pennine and Chorley, Crisis Support Units in Preston and Blackpool, and a Crisis House in Coppull. These services have an impact on the bed trajectory and variations in timing will alter the OAPs usage accordingly.
There is a fund of c£3m for OAPs, financed 50:50 by the Trust and Lancashire CCGs. After this fund is exhausted, any additional OATs are accounted for on the basis of 50:50 split between the Trust and CCGs.
Current projection suggest there will be expenditure of £5.0m for OAPs in 2017/18., though slippage on developments takes the net impact to £4.8m as reported elsewhere.
Commissioners have asked for, and are receiving, monthly actual performance against the profile.
If the current trajectory persists this would present pressure in the order of £2.3m (net).
ForecastActuals
Board of Directors
Agenda Item TB 185/17 Date: 07/12/2017
Report Title Performance Report (QPR)
FOIA Exemption No Exemption
Prepared by Louise Corlett, Head of Business Intelligence
Presented by Sue Moore, Chief Operating Officer
Action required Noting
Supporting Executive Director Chief Operating Officer
PURPOSE OF THE REPORT:
Report purpose To appraise the Board of Directors of key elements and themes from the Month 7 QPR
Strategic Objective(s) this work supports
To provide high quality services
Board Assurance Framework risk 2.1 The Trust is unable to reposition in the marketplace to become established as a provider of choice achieving excellence
CQC domain Well-led
The Board are asked to note the QPR for month 7 with following comments below:
All NHS I metrics are compliant with the exception of the Early Intervention in Psychosis 2-week
target.
The revised Single Oversight Framework from NHS I contains changes to Operational
Performance metrics, in particular introduction of a new measure on Inappropriate Out of Area
Placements. A reduction in the number of bed days used for inappropriate OAPs is expected
against an agreed baseline and trajectory, both of which are currently being formulated in
conjunction with the STP. This will be presented in further detail at the next Trust Board.
The measures within the Board Balanced Scorecard continue to show the challenges faced by
the organisation currently in relation to our financial position and attracting the best people.
Are we SAFE? Current CQC rating is ‘requires improvement’
Progress on the 16 key priorities in the Quality plan are being monitored through the designated sub-
committee and as shown in the BBSC the current status is that we are on track with 14 priorities and 2
are off track. A detailed update was presented to Board through the Q2 update report.
In month 7, we reported one incident of a potentially avoidable pressure ulcer (grade 3 and 4) however
this is in line with the annual rolling average and is not thought to be the start of a new upward trend.
Nevertheless, a full root cause analysis of the incident is being conducted to identify any new learning
points not already in practice.
As reported last month, levels of physical violence towards staff is still tracking at higher than average in
month 6, and has remained largely static for the last 3 months at around 220 (219 this month). There are
no new areas of concern and the work into the hotspots (PICU and OAMH) continues: The report on a
deep dive review conducted on PICUs has been reported to the Quality and Safety sub-committee and
recommendations accepted which are now being implemented. In addition, the review of personal care
activities on Older Adult wards continues, alongside provision of specific training, and will identify if there
are any changes in clinical practice required. However, as reported last month, the impact of this work
on physical violence against staff is unlikely to deliver a reduction in the short term, and therefore it is
positive that incidence is not increasing.
The incidence of physical violence towards staff alongside the in-month increase in the use of restraint
has also impacted on the performance against the mental health harm free care metric, which has fallen
to 80% against the 90% target in month 7. These 2 metrics are likely to be linked, with the increase in
violence resulting in the requirement for restraint.
The number of Serious Incidents has slightly increased this month and is above the rolling 12-month
average of 7.7 at 10.
Are we CARING?
Current CQC rating is ‘Good’.
We maintain 100% compliance against mixed sex accommodation breaches.
Feedback received through the Friends and Family test is not available at the time of writing for month
7.
The number of compliments has risen slightly in month to 549, however this continues to be well below
the rolling 12 month average. There is a lag in submission of compliments in some areas therefore this
number may increase slightly.
Are we EFFECTIVE?
Current CQC rating is ‘Good’.
The improvement in readmission rate for both 30 and 90 days, across both adult and older adult services
has been retained for the fourth consecutive month in month 7. Whilst for 30d the standard of below 8.7%
was achieved, for 90d readmission the target number of 28 was met and the 15% standard exceeded by
only 0.1%. This position demonstrates the impact of maintaining the team leader reviews at
CMHT/CRHTT clinical discussion meetings and maintaining the profile of this cohort of patients at locality
governance groups.
Average Length of stay still remains just above the 31 day standard at 38.8 days. The length of stay on
adult wards includes PICU patients and it is noted that PICU length of stay has fallen slightly to 34 days.
Over the last 4 months, the positive impact of the Joint Advisory Group has been evident and whilst the
focus has been maintained on the patients with a length of stay of greater than 180 days it is inevitable
that the LOS will be variable as patients are discharged. In future months the QPR will also contain LOS
for current inpatients so that we are able to review a complete picture.
Are we RESPONSIVE?
Current CQC rating is ‘Good’.
The Trust continues to perform well against NHS I indicators, however, as reported last month an issue
has been identified regarding performance in the Early Intervention in Psychosis service against the 2
week target. Current performance falls significantly below the required 50% at 9.5%. A remedial action
plan to address the under-performance has been developed and is being monitored through a fortnightly
task group. Operationally, the requirement to enable timely access and treatment for this patient group
within 2 weeks, is being managed through a daily call with all team leaders. This daily call is enabling
current referrals to be managed in accordance with the 2 week standard, notwithstanding patient choice.
However, the impact of long waiting patient referrals on our performance throughout the remainder of Q3
will make recovery of the target challenging. A formal report was received by SLT in November and SLT
will be kept briefed on progress in achievement of the Q3 target. In addition, formal reporting against the
remedial action plan will be reported to Corporate Governance and Compliance sub-committee.
Responsiveness is also demonstrated through our achievement of the 18 week referral to treatment
(RTT) standard for AHPs and for dental waiting times. In the Community Wellbeing Network, the dental
service RTT in Liverpool prison has recovered back to 100% following the failure to meet the 95% target
in month 6. The Community Well Being Network are compliant against all contractual RTT measures.
In the Children and Young People’s Wellbeing Network, 3 out of 5 services across which we report in
month 7 against the 18 week RTT pathways are compliant, which maintains the improvement seen in
month 5 and month 6.
The Children’s Speech and Language Therapy service have achieved the RTT measure of 92% of
patients on the waiting list having waited less than 18 weeks for the third consecutive month, reporting
98% and as such are no longer required to submit an exception report.
The 2 areas of performance which remain challenged are Child Psychology and CAMHs Tier 3.
Performance in Child Psychology for month 6 has improved to 89%, a further increase on the 84%
reported in month 6 against the 95% RTT standard. In addition, the number of children on the waiting list
who have waited >18 weeks continues to reduce (from 49 in month 6 to 32 in month 7) which is a positive
indicator of the impact that the recovery plan is having and moves the service closer to being able to
achieve the 95% target once the backlog is cleared.
Conversely, performance in the CAMHS Tier 3 service has deteriorated further and the service are
reporting 57% against the 95% RTT standard for completed pathways (compared to 59% in month 6).
The Chorley and South Ribble team continue to be the main contributor to the under-performance with
264 of the 289 service users who are on the waiting list having waited greater than 18 weeks. This is a
result of capacity shortfalls caused by sickness and vacancies, an issue that is being addressed by the
appointment of a new team leader and further appointments are expected in Q3. The longest waiters
are being focussed on in month 8 with all patients waiting greater than 36 weeks being offered
appointments. Weekly meetings are being held with teams to manage the actions necessary to deliver
improvements in line with the trajectory.
In Mindsmatter, a number of measures are monitored that indicate our overall responsiveness. The
service continues to perform well against the NHS I indicators for referral to treatment in 6 and 18 RTT
weeks and percentage of patients entering recovery. Also positive is the reduction in the number of
patients on the waiting list who have waited longer than 26 weeks which has fallen this month to 14. This
will be monitored closely to ensure it drops further. Performance against
prevalence continues to be challenging at team level. Cumulative prevalence is being measured against
the current target and the trajectory required to meet the 16.8% by Q4 (for all teams except BwD). Teams
are largely on track with the current target (with exception of St Helens) but are falling short against the
increased targets for Q4. In depth monitoring and a number of interventions are underway to increase
prevalence.
The high demand for inpatient beds continues, with occupancy levels exceeding 100%, consequently,
the number of out of area placements (OAPs) continues to exceed plan. Work on reducing the number
of patients who have a length of stay of greater than 180 days continues, as identification of alternative
provision would potentially enable the resolution of the OAPs position. As reported last month STP leads
have supported the view that the financial impact of this cohort of patients is separate to the OAPs spend
and as a result the Network have secured support for the implementation of an integrated discharge team
from the end of December.
Mental health liaison teams (MHLT) are reporting an improved position in relation to the 12 hour breach
numbers with a reduction from 8 to 6 in month 7. This demonstrates the impact of the significant
operational management oversight on patient flow and ensuring patients access care in a timely manner.
Demand for the teams continues to be challenging and performance against the 1h and 4h metrics
remains below target. Improvement is expected over coming months given the early investment that has
been secured around Core 24, of which we were notified on the 1st November.
This month the number of complaints has reduced very slightly to 145 compared to 149 in month 6, but
is only marginally above the rolling average of 136 per month. The number of upheld complaints has
risen sharply in month to 43 from 21 in month 6 against an average of 26.7. Notable themes within the
upheld complaints are communication and treatment are addressed via service level action plans. The
number of re-opened complaints and those escalated to the ombudsman remains extremely positive and
may demonstrate the satisfaction of complainants with the outcome of their complaints.
Are we WELL-LED?
Current CQC rating is ‘Good’.
As reported last month, the staff engagement score for the Q2 position shows a static position with only
a decimal point increase on the Q1 position. A further update will be available after Q3.
Sickness rates have risen again to 6.88%, off track in relation to achieving a 4.5% target. The increase
is largely driven by increases in the Mental Health Network where the percentage is 8.5%. Work
continues on absence management across all areas in accordance with policy.
Summary and Recommendations
The information in the QPR provides evidence of our performance against key metrics aligned to each
CQC domains. From this, and the exception reporting against each measure, we are able to provide
information that supports the assessment of our position against each domain.
Quality & Performance
Report
Month 7 – October 2017
Performance Management
Quality and Performance Report:-
Section 2:- Performance and Data Quality
Section 2.1:- Performance Activity
• NHS Improvement Indicators Dashboard • NHS Improvement Indicators Kitemarking • Key Exceptions • CCG Level Data • Network Level Summary • Key Network Exceptions
Section 2.2:- Patient Flow • Patient Flow Summary • Key Patient Flow Exceptions
Section 2.3:- Data Quality • Data Quality Summary • Key Data Quality Exceptions
Section 3:- Finance and Contracting
Section 3.1:- Financial Activity
• UoR Risk Rating • Summary I&E Position • Summary of Clinical Services • CIPS • Capital Expenditure
Section 3.2:- Community Contract Activity • Community & Wellbeing – Network Line Totals • Community & Wellbeing – Service Line Totals • Community & Wellbeing – Total Activity Split by CCG • Community & Wellbeing – Activity Exception Reports by CCG • Children & Young People’s Wellbeing – Service Line Totals • Children & Young People’s Wellbeing – Exception Reports by
Service • Children & Young People’s Wellbeing – Total Activity Split by CCG • Mental Health – Total Activity Split by CCG • Mental Health – Activity Totals
Section 3.3:- Commissioning for Quality & Innovation • CQUIN Executive Summary
2
Section 6:- Risk
• Board Assurance Framework
Section 4:- Quality
• Quality and Safety Tile • Quality Surveillance – Safe • Quality Surveillance – Effective • Quality Surveillance – Caring • Quality Surveillance – Responsive • Quality Surveillance – Well Led • Delivering the Strategy
Section 5:- Workforce
• Actual Workforce Costs Compared to Budget • Sickness Absence Rates • Appraisals and Mandatory Training Compliance • Vacancy Management and Active Recruitment • Core Workforce Headcount • Workforce Turnover
Section 1:- Board Balanced Score Care
• Trust Strategic Priorities • Board Summary • Quality & Safety • Service Delivery • People & Leadership • Finance
Appendix 1:- Southport & Formby
• NHS Improvement Indicators Dashboard • NHS Improvement Indicators Kitemarking • Southport & Formby Summary • Finance & Contracting • Quality • Workforce
Performance Management
Board Balanced Score Card
Section 1
3
Performance Management
1. Board Balanced Score Card Trust Strategic Priorities
Strategic Priority Strategic Blueprint
Co
mp
as
sio
n
To provide high quality
services
We will ensure that people who use our services are at the heart of everything we do, and the people who deliver and support
delivery of services are motivated, engaged and proud to provide high quality, compassionate, continually improving care. We
will empower people to share their stories so that we know how we are doing and we will listen to learn and to improve quality
together. We will continue to strive to be the best that we can be by upholding our 8 quality commitments and the ‘I’ statements,
empowering everyone to embrace these personal pledges.
Inte
gri
ty
To deliver sustainable services
that meet the needs of local
people
We will collaborate with partners to deliver system wide transformation and we will be an active partner in delivering a bespoke
offer to a number of Accountable Care Systems by
being the prime provider of specialist, acute and community mental health services, and
a lead provider in delivering new models of integrated physical and mental health out of hospital services, and
realising the benefits of our geographical footprint to deliver system wide sustainable infrastructure solutions and
organisational vehicles for new models of care.
Whilst our principal footprint for delivery of services is Lancashire and South Cumbria, we will continue to seek opportunities
across North West STP footprints.
Te
am
wo
rk
To become recognised
for excellence
Our service users and carers will tell us that our services are of high quality. Our people will recommend us to family and
friends. We will be respected by our commissioners and other providers as a co-producing partner in shaping new service
models that deliver our aligned strategies with an emphasis on place based care.
Res
pe
ct
To employ the best
people
We will develop an organisational culture and leadership team equipped to meet its strategic intent and the needs of both its
workforce and the population it serves; in short, a culture of high performing, continually improving and compassionate care.
Staff will be motivated, engaged, high performing and proud of the service they provide. We will proactively support staff to look
after their own health and wellbeing, and to reach their full potential. We will identify and grow our future leaders. People will
want to work here.
Ac
co
un
tab
ilit
y
To provide financially
sustainable services
We will restore and maintain financial balance, and provide services that offer excellent value for money without compromising
financial sustainability. We will work with local partners to deliver system wide efficiency measures. We will actively seek
business opportunities that add value for local people.
Ex
ce
lle
nc
e
To innovate and exploit
technology to transform
care
We will develop and promote digital enabled care, and lead research and innovation to enhance patient experience, reduce
costs and/or improve quality. We will have a culture where staff are given the time, training and resources to research and
innovate. Research will validate innovations and innovations will direct research. Partnerships with third party organisations will
enable rapid execution and exploitation of innovation projects.
4
Performance Management
Research Studies
Aug Sep Oct
127 60 38
Business Gained - Lost
Aug Sep Oct
-£2,230,000 -£602,688 -£51,600
OAPS
Aug Sep Oct
23.68 26.17 24.58
NHSI Compliance
Aug Sep Oct
92.9% 92.9% 92.9%
Sickness Absence
Aug Sep Oct
6.18% 6.35% 6.88%
Agency Ceiling
Aug Sep Oct
-188,237 -222,185 -132,475
UoR
Aug Sep Oct
3 3 3
Revenue Control Total
Aug Sep Oct
-1.4% -1.4% -1.2%
CIP
Aug Sep Oct
86% 86% 88%
Liquidity
Aug Sep Oct
1 1 1
1. Board Balanced Score Card Summary
Capital Expenditure
Aug Sep Oct
33% 29% 31%
Contract Performance (MH)
Aug Sep Oct
+0.88% +0.84% -0.84%
Contract Performance (Comm)
Aug Sep Oct
-1.2% -0.4% -0.6%
Engagement Score
Q4 16-17 Q1 17-18 Q2 17-18
3.77 3.73 3.74
National COPD Audit
Programme
Report due Feb
2018
Use of depot/LA
antipsychotics for relapse
prevention – baseline audit
Report due Nov 2017
Prescribing for bipolar
disorder (use of sodium
valproate) re-audit
Report due Feb 2018
Quality Plan
17/18 objectives 16
On track Off track
12 4
Service Delivery Quality & Safety
People & Leadership Finance
5
Prescribing of high dose
antipsychotics
Acute wards & PICU rank 14/57
Secure Services 20/46
Performance Management
1. Board Balanced Score Card Quality & Safety
Quality Plan
Four Quality Priorities are currently marked as “off track” which are: violence to staff, pressure ulcers, new professional roles
and mental health law. In all cases this is due to the outcome measure not being achieved, the actual improvement projects
themselves are on track. A mid year review is planned for December to review each programme in detail.
Target: 16 objectives
On track 12 Off track 4
Research Studies
Data is subject to a 6-8 week lag as it is uploaded by research teams to a national system retrospectively. Recent recruitment
to the SSHEW clinical trial has an additional 5 weeks until randomisation, leading to significant lag in recruits appearing in
national figures. Local data shows that activity is currently forecast to meet this year’s annual target. Target: 100 participants monthly
38
6
National Audit –
National COPD Audit
Programme
The aim of the project is to audit the activity of the 2 LCFT PR programmes against BTS Quality standards for Pulmonary Rehabilitation in Adults
and compare results with the initial audit which took place in 2015.
The report is due February 2018. Target: Upper quartile nationally
National Audit –
Prescribing for bipolar disorder
(use of sodium valproate) re-
audit
The aim of this topic is to identify any improvement in practice around prescribing in bipolar since the initial audit carried out by POMH-UK.
The report will be published Feb 2018.
Target: Upper quartile nationally
National Audit –
Use of depot/LA antipsychotics
for relapse prevention –
baseline audit Data for this project has been submitted and a report is due November 2017.
Target: Upper quartile nationally
National Audit –
Prescribing of High dose
antipsychotics
A total of 3 standards were included in the audit. The results demonstrated the trust were in the upper quartile for 2 standards.
These standards assessed that the dose of an antipsychotic was within SPC/BNF limits and that only one antipsychotic should
be prescribed at a time. Upper quartile performance was not achieved for standard 3, this was a newly introduced audit
standard. However, overall across all 3 standards acute wards and PICUs were in the upper quartile nationally. Secure
Services were not in the upper quartile, this was a smaller sample than for acute wads and PICUs and an improvement plan has
been developed.
Target: Upper quartile nationally
Achieved
Performance Management
1. Board Balanced Score Card Service Delivery
Business Gained – Business
Lost
Target: 1.5% over next 12 months
(year-end)
Out of Area Placements
(OAPS) The average number of OAPs decreased slightly in October by 1.59 alongside a decrease in the OAP OBD in October with a position of 762, a
decrease of 23 from September.
The overall number of OAPs remains relatively static against an assumed fall in the trajectory.
Target: 15 contracted beds
24.58
Contract Activity - Community
Target achieved. Target: 100% (+/-10%)
-0.6%
Contract Activity – Mental
Health Following an investigation into MAS data being inflated due to ‘Notes’ being included within reporting, LCFT have removed ‘Notes’ from the
following affected services: MAS, ADHD, Eating Disorders and Hospital Liaison, which has seen the Trust overall variance against last year’s plan
fall from 0.84% to -0.84%. Target: 100% (+/-10%)
-0.84%
NHSI Compliance
All NHSI measures are compliant for M7 apart from EIP (MR13), which has been under a period of revalidation and investigation. Work within the
Network is currently ongoing and it is anticipated that performance is still achievable for Q3. Target: 100% in each quarter
92.9%
7
Performance Management
Agency Ceiling
Usage of Agency in Community, HMP Liverpool and Medics has been
consistent across the last two months, with only small deviation.
The percentage of annual leave in month has dropped considerably
and this can be seen in the reduction in Agency spend.
Target: 641,250
Not achieved
1. Board Balanced Score Card People & Leadership
Aug Sep Oct
YTD Target 641,250 641,250 641,250
YTD Actuals 829,487 863,435 773,725
Under/(Over)
Agency
Usage
-188,237 -222,185 -132,475
Engagement Score Q2 2017/18 period results :
• Recommend LCFT as a place to receive treatment (Workforce Advocacy): Yes – 71.41%, No – 10.31%, Don’t Know – 18.28%
• Recommend LCFT as a good place to work: (Workforce Involvement and Motivation): Yes – 51.75%, No – 27.35%, Don’t Know – 20.89%
Improvement Initiatives:
A Wellbeing dimension has been added to the Quarterly Staff FFT questionnaire. This supplements the 3 existing dimensions of Advocacy,
Motivation and Involvement. The first Staff FFT report to include this new dimension will be available in January 2018.
Target: Top 25% of other Trusts
Not achieved
Sickness Absence
The sickness absence rate for October has increased, reporting at 6.88%. Please refer to the relevant M7 QPR detailed slides for information
about Improvement plans and initiatives. Target: 4.5%
6.88%
8
Performance Management
1. Board Balanced Score Card Finance
Use of Resources (UoR)
The current I&E position gives a rating of 4 and delivers a Capital Service rating of 4 constraining the current overall UoR to a 3. Assuming
current pressures and risks are addressed through the recovery plan and I&E performance achieves (or exceeds) forecast the Trust will achieve
a UoR of 2 in line with the plan. Target: 2
3
Capital Expenditure Progress against the capital programme continues to be slow with year-to-date expenditure at £1.8m against the original
profile of £5.9m. A number of issues have recently been resolved which will allow the Trust to push forward with the work
required to complete its capital programme in line with its control total and funding, however given the delays, risks of slippage
remain.
Target: 85-100%
31%
Revenue Control Total A number of risks and pressures have been identified that if not addressed will compromise the Trusts ability to deliver the planned control total
for 2017/18. Whilst it would appear that the gap can be bridged through the recovery plan, this is not without significant risk. Delivery will only be
achieved with a considerable coordinated and sustained effort across the organisation. Target: ≥0%
-1.2%
Cost Improvement
Programmes (CIPs) At £7.4m in month 7 the Trust is c£1.1m behind the plan of £8.4m. The adverse variance is mainly due to a lack of performance on Run Rate
Reduction Programmes on staffing pressures. Compensating schemes have, and continue to be, developed and network management team are
being supported by to implement measures aimed at improving the position. Target: ≥100%
88%
Liquidity
Forecasts indicate that with the delivery of the planned surplus the Trust will achieve a liquidity of 1. Target: 2
1
9
*Under the Single Oversight Framework, the Trust is now managed against the Use of Resource Metrics (UoR). Under the Single Oversight Framework, a score of 1 is now the
best rating and 4 the worst. A rating of 4 on any metric or an average rating of 3 triggers a concern and a potential support need.
Performance Management
2. Performance and Data Quality
10
Section 2:- Performance and Data Quality
Section 2.1:- Performance Activity
• NHS Improvement Indicators Dashboard
• NHS Improvement Indicators Kitemarking
• Key Exceptions
• CCG Level Data
• Network Level Summary
• Key Network Exceptions
Section 2.2:- Patient Flow
• Patient Flow Summary
• Key Patient Flow Exceptions
Section 2.3:- Data Quality
• Data Quality Summary
• Key Data Quality Exceptions
Performance Management
Performance Activity
Section 2.1
11
Performance Management
2.1 Performance Activity NHS Improvement Indicators Dashboard
12
.
Indicator Target Nov-16 Dec-16 Jan-17 Feb-17 Mar-17 Apr-17 May-17 Jun-17 Jul-17 Aug-17 Sep-17 Oct-17 Q1 17-18 Q2 17-18 YTDRolling 12
Month Sparkline
MR01 - 7 Day Follow Up 95.00% 96.9% 98.2% 98.8% 96.1% 97.6% 98.6% 96.8% 95.9% 94.1% 96.8% 99.5% 98.0% 97.1% 96.7% 97.04%
MR02 - CPA Review within 12 Months 95.00% 97.4% 97.8% 96.9% 97.1% 97.5% 97.0% 97.1% 96.1% 95.9% 97.0% 96.4% 96.5% 96.7% 96.4% 96.57%
MR03 - Mental Health Delayed Transfers of Care ≤ 7.5% 3.68% 4.19% 3.81% 2.84% 2.59% 3.01% 3.21% 3.36% 2.80% 2.52% 2.77% 2.65% 3.19% 2.70% 2.90%
MR05 - RTT - Consultant Led (Completed Pathway) 95.00% 95.2% 96.3% 96.7% 97.6% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 100.00%
MR06 - RTT - Consultant Led (Incomplete Pathway) 92.00% 95.2% 95.4% 97.3% 100.0% 99.2% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 99.7% 100.0% 100.0% 99.94%
MR07 - IP Access to Crisis Res. Home Treatment 95.00% 100.0% 100.0% 98.6% 99.4% 97.7% 100.0% 100.0% 99.5% 100.0% 100.0% 100.0% 100.0% 99.8% 100.0% 99.92%
MR08 - MH Data Completeness - Identifiers 97.00% 99.6% 99.6% 99.6% 99.6% 99.6% 99.6% 99.6% 99.7% 99.4% 99.4% 99.4% 99.4% 99.6% 99.4% 99.51%
MR09 - MH Data Completeness - Outcomes 50.00% 83.7% 83.8% 83.4% 83.2% 83.4% 83.7% 82.2% 81.8% 81.8% 81.7% 80.8% 81.2% 82.5% 81.4% 81.83%
MR13 - 2 Week wait for Treatment for EIP Programme 50.00% 74.3% 76.7% 82.0% 81.4% 74.4% 11.1% 7.1% 0.0% 9.5% 11.8% 15.6% 9.5% 6.0% 12.6% 9.42%
MR14 - RTT - IAPT 6 Weeks 75.00% 93.0% 96.5% 95.1% 95.7% 93.4% 96.4% 94.7% 95.1% 94.5% 94.4% 94.5% 94.6% 95.4% 94.4% 94.85%
MR15 - RTT - IAPT 18 Weeks 95.00% 99.0% 99.8% 99.4% 99.8% 98.8% 99.4% 99.2% 99.7% 99.3% 99.4% 99.5% 99.7% 99.5% 99.4% 99.47%
Performance Management
2.1 Performance Activity NHS Improvement Indicators Kitemarking
Kitemarking key:
• SOP – Does the indicator have an associated SOP that is within date?
• External Audit – Has this measure been subjected to an external audit within the last 2 years?
• Internal Audit – Has this measure been subjected to an internal audit within the last 2 years?
• Electronically Populated – Is this indicator produced using electronically generated numerators and denominators?
• Manual Overrides – Has the performance for this indicator been produced using manual overrides to indicate false positives or
negatives?
13
Performance Management
2.1 Performance Activity NHS Improvement Indicators Kitemarking
14
Performance Management
Trust position for Lancashire CCGs:
- In Month 7, the Trust has achieved a performance of 97.9%
against a target of 95% across 8 CCGs.
CCG position:
- In Month 7, the Trust has underperformed in 1 CCG: Greater
Preston.
Unassigned CCG:
- In Month 7, there were 4 records unassigned a CCG, of which
100% (4) were completed.
15
Trust position for Lancashire CCGs:
- In Month 7, the Trust has achieved a performance of 96.6%
against a target of 95% across 8 CCGs.
CCG position:
- In Month 7, the Trust has achieved compliance for all CCGs.
Unassigned CCG:
- In Month 7, there were 61 records unassigned a CCG, of which
88.5% (54) were completed.
CPA 12 Month Review 7 Day Follow Up
2.1 Performance Activity NHS Improvement Indicators reported by CCG
Note: The total figures in the tables above differ from page 12 as they are
representative of only 8 contracted CCGs.
Jun-17 Jul-17 Aug-17 Sep-17 Oct-17
100.0% 90.9% 94.7% 100.0% 100.0%
97.4% 100.0% 92.9% 96.2% 100.0%
100.0% 83.3% 100.0% 100.0% 100.0%
93.5% 95.7% 100.0% 100.0% 98.0%
100.0% 95.5% 100.0% 100.0% 100.0%
100.0% 94.7% 100.0% 100.0% 93.8%
100.0% 100.0% 86.7% 100.0% 95.0%
90.0% 90.9% 100.0% 100.0% 100.0%
97.5% 94.6% 97.2% 99.5% 97.9%
NHS Fylde & Wyre CCG
NHS Greater Preston CCG
NHS Morecambe Bay CCG
NHS West Lancashire CCG
7 DFU CCG
NHS Blackburn with Darwen CCG
NHS Blackpool CCG
NHS Chorley & South Ribble CCG
NHS East Lancashire CCG
Total Figure - 8 CCGs
Jun-17 Jul-17 Aug-17 Sep-17 Oct-17
97.2% 95.3% 98.8% 96.7% 95.6%
95.8% 95.5% 96.2% 96.8% 95.5%
95.2% 95.1% 96.6% 94.0% 95.3%
95.1% 95.6% 96.0% 96.0% 96.5%
96.0% 95.6% 98.0% 98.0% 99.6%
97.9% 97.9% 98.4% 98.2% 98.0%
96.7% 97.0% 95.5% 96.8% 96.1%
95.6% 95.6% 96.9% 95.2% 97.8%
96.2% 96.0% 97.1% 96.5% 96.6%Total Figure - 8 CCGs
NHS East Lancashire CCG
NHS Fylde & Wyre CCG
NHS Greater Preston CCG
NHS Morecambe Bay CCG
NHS West Lancashire CCG
12 month CPA
NHS Blackburn with Darwen CCG
NHS Blackpool CCG
NHS Chorley & South Ribble CCG
Performance Management
Note: The total figures in the tables above differ from page 12 as they are
representative of only 8 contracted CCGs.
2.1 Performance Activity NHS Improvement Indicators reported by CCG
Delayed Transfers of Care (DToC)
16
IP Access to Crisis Resolution Home Treatment
Trust position for Lancashire CCGs:
- In Month 7, the Trust has achieved a performance of 2.61%
against a target of <7.5% across 8 CCGs.
CCG position:
- In Month 7, the Trust has achieved compliance for all CCGs.
Unassigned CCG:
- In Month 7, there were 2 records unassigned a CCG, of which
0% (0) were delays.
Trust position for Lancashire CCGs:
- In Month 7, the Trust has achieved a performance of 100%
against a target of 95% across 8 CCGs.
CCG position:
- In Month 7, the Trust has achieved compliance for all CCGs.
Jun-17 Jul-17 Aug-17 Sep-17 Oct-17
3.97% 1.57% 1.56% 1.55% 1.63%
0.68% 0.00% 0.09% 2.32% 2.00%
2.00% 6.70% 3.82% 2.64% 4.05%
3.20% 2.69% 2.53% 2.92% 3.91%
4.20% 3.37% 2.80% 2.21% 2.11%
5.68% 4.49% 4.63% 3.56% 2.64%
0.00% 0.00% 0.13% 2.09% 0.00%
0.14% 0.00% 3.67% 4.28% 4.98%
2.99% 2.55% 2.47% 2.72% 2.61%
NHS East Lancashire CCG
NHS Fylde & Wyre CCG
NHS Greater Preston CCG
NHS Lancashire North CCG
NHS West Lancashire CCG
Total Figure - 8 CCGs
DToC
NHS Blackburn with Darwen CCG
NHS Blackpool CCG
NHS Chorley & South Ribble CCG
Jun-17 Jul-17 Aug-17 Sep-17 Oct-17
100.0% 100.0% 100.0% 100.0% 100.0%
100.0% 100.0% 100.0% 100.0% 100.0%
100.0% 100.0% 100.0% 100.0% 100.0%
100.0% 100.0% 100.0% 100.0% 100.0%
100.0% 100.0% 100.0% 100.0% 100.0%
100.0% 100.0% 100.0% 100.0% 100.0%
94.7% 100.0% 100.0% 100.0% 100.0%
100.0% 100.0% 100.0% 100.0% 100.0%
99.4% 100.0% 100.0% 100.0% 100.0%
% IP Access to CRHTT
NHS Blackburn with Darwen CCG
NHS Blackpool CCG
NHS Chorley & South Ribble CCG
NHS East Lancashire CCG
NHS Fylde & Wyre CCG
NHS Greater Preston CCG
NHS Morecambe Bay CCG
NHS West Lancashire CCG
Total Figure - 8 CCGs
Performance Management
Note: The total figures in the tables above differ from page 12 as they are
representative of only 8 contracted CCGs.
2.1 Performance Activity NHS Improvement Indicators reported by CCG
RTT – Consultant Led (Completed Pathway)
17
RTT – Consultant Led (Incomplete Pathway)
Trust position for Lancashire CCGs:
- In Month 7, the Trust has achieved a performance of 100%
against a target of 95% across 8 CCGs.
CCG position:
- In Month 7, the Trust has achieved compliance for all CCGs.
Trust position for Lancashire CCGs:
- In Month 7, the Trust has achieved a performance of 99.7%
against a target of 92% across 8 CCGs.
CCG position:
- In Month 7, the Trust has achieved compliance for all CCGs.
Note: NHS England guidance published in October 2015 confirmed that the incomplete pathway operational standard should became the sole
measure of patients’ constitutional right to start treatment within 18 weeks. And whilst we are required to maintain reporting on the completed
admitted pathway, the removal of the completed admitted pathway as an operational standard means that there is no longer any provision to report
pauses or suspensions in RTT waiting time clocks in monthly RTT returns to NHS England. This means that patients choosing to cancel
appointments can impact negatively on this measure.
Jun-17 Jul-17 Aug-17 Sep-17 Oct-17
100.0% - - 100.0% -
- - - - 100.0%
100.0% 100.0% 100.0% 100.0% 100.0%
- - - - -
- 100.0% - 100.0% -
100.0% 100.0% 100.0% 100.0% 100.0%
100.0% - - - -
100.0% - - - -
100.0% 100.0% 100.0% 100.0% 100.0%Total Figure - 8 CCGs
NHS East Lancashire CCG
NHS Fylde & Wyre CCG
NHS Greater Preston CCG
NHS Morecambe Bay CCG
NHS West Lancashire CCG
RTT Complete
NHS Blackburn with Darwen CCG
NHS Blackpool CCG
NHS Chorley & South Ribble CCG
Jun-17 Jul-17 Aug-17 Sep-17 Oct-17
- - - - -
- - 100.0% 100.0% -
100.0% 100.0% 100.0% 100.0% 100.0%
- - 100.0% - -
100.0% - 100.0% - -
100.0% 100.0% 100.0% 100.0% 99.4%
- - 100.0% 100.0% 100.0%
- - - - -
100.0% 100.0% 100.0% 100.0% 99.7%
RTT Incomplete
NHS Blackburn with Darwen CCG
NHS Blackpool CCG
NHS Chorley & South Ribble CCG
Total Figure - 8 CCGs
NHS East Lancashire CCG
NHS Fylde & Wyre CCG
NHS Greater Preston CCG
NHS Morecambe Bay CCG
NHS West Lancashire CCG
Performance Management
Note: The total figures in the tables above differ from page 12 as they are
representative of only 8 contracted CCGs.
2.1 Performance Activity NHS Improvement Indicators reported by CCG
MH Identifiers
18
MH Outcomes
Trust position for Lancashire CCGs:
- In Month 7, the Trust has achieved a performance of 99.6%
against a target of 97% across 8 CCGs.
CCG position:
- In Month 7, the Trust has achieved compliance for all CCGs.
Unassigned CCG:
- In Month 7, there were 3120 records unassigned a CCG, of
which 94.3% (2941) were completed.
Trust position for Lancashire CCGs:
- In Month 7, the Trust has achieved a performance of 81.3%
against a target of 50% across 8 CCGs.
CCG position:
- In Month 7, the Trust has achieved compliance for all CCGs.
Unassigned CCG:
- In Month 7, there were 175 records unassigned a CCG, of which
84.6% (148) were completed.
Jun-17 Jul-17 Aug-17 Sep-17 Oct-17
99.8% 99.8% 99.8% 99.8% 99.8%
99.9% 99.7% 99.7% 99.8% 99.8%
99.7% 98.8% 98.8% 98.8% 98.9%
99.8% 99.8% 99.8% 99.8% 99.8%
99.7% 99.7% 99.7% 99.7% 99.7%
99.8% 99.6% 99.6% 99.6% 99.6%
99.7% 99.7% 99.7% 99.7% 99.6%
99.7% 99.7% 99.7% 99.7% 99.6%
99.8% 99.6% 99.6% 99.6% 99.6%
MH Identifiers
NHS Blackburn with Darwen CCG
NHS Blackpool CCG
NHS Chorley & South Ribble CCG
NHS East Lancashire CCG
NHS Fylde & Wyre CCG
NHS Greater Preston CCG
NHS Morecambe Bay CCG
NHS West Lancashire CCG
Total Figure - 8 CCGs
Jun-17 Jul-17 Aug-17 Sep-17 Oct-17
77.3% 76.0% 74.7% 72.9% 73.8%
78.6% 77.7% 78.6% 78.1% 79.3%
86.8% 86.6% 86.0% 85.0% 84.2%
83.0% 83.4% 83.4% 82.8% 82.5%
84.9% 84.8% 84.9% 86.0% 85.8%
80.4% 80.6% 80.9% 80.4% 80.5%
89.5% 90.1% 89.4% 89.0% 89.9%
77.1% 78.1% 78.2% 75.6% 75.2%
81.9% 81.9% 81.7% 80.9% 81.3%
MH Outcomes
NHS Blackburn with Darwen CCG
NHS Blackpool CCG
NHS Chorley & South Ribble CCG
NHS East Lancashire CCG
NHS Fylde & Wyre CCG
NHS Greater Preston CCG
NHS Morecambe Bay CCG
NHS West Lancashire CCG
Total Figure - 8 CCGs
Performance Management
Note: The total figures in the tables above differ from page 12 as they are
representative of only 8 contracted CCGs.
2.1 Performance Activity NHS Improvement Indicators reported by CCG
2ww EIS
19
Trust position for Lancashire CCGs:
- In Month 7, the Trust has achieved a performance of 9.5% against a target of
97% across 8 CCGs.
CCG position:
- In Month 7, the Trust has underperformed for 7 CCGs: Blackburn with
Darwen, Blackpool, Chorley & South Ribble, East Lancs, Fylde & Wyre,
Greater Preston and West Lancs.
Due to ongoing validation, CCG split is only available for October.
Jun-17 Jul-17 Aug-17 Sep-17 Oct-17
16.7%
0.0%
0.0%
0.0%
0.0%
0.0%
50.0%
0.0%
9.5%
2ww EIS
NHS Blackburn with Darwen CCG
NHS Blackpool CCG
NHS Chorley & South Ribble CCG
NHS East Lancashire CCG
NHS Fylde & Wyre CCG
NHS Greater Preston CCG
NHS Morecambe Bay CCG
NHS West Lancashire CCG
Total Figure - 8 CCGs
Performance Management
Note: The total figures in the tables above differ from page 12 as they are
representative of only 7 contracted CCGs.
2.1 Performance Activity NHS Improvement Indicators reported by CCG
IAPT – 6 Weeks
20
IAPT – 18 Weeks
Trust position for Lancashire CCGs:
- In Month 7, the Trust has achieved a performance of 94.2%
against a target of 75% across 8 CCGs.
CCG position:
- In Month 7, the Trust has achieved compliance for all CCGs.
Trust position for Lancashire CCGs:
- In Month 7, the Trust has achieved a performance of 99.8%
against a target of 50% across 8 CCGs.
CCG position:
- In Month 7, the Trust has achieved compliance for all CCGs.
Jun-17 Jul-17 Aug-17 Sep-17 Oct-17
77.3% 78.7% 82.0% 83.8% 79.6%
97.4% 95.6% 95.1% 99.1% 92.4%
96.1% 98.1% 97.5% 97.4% 97.4%
97.6% 94.1% 96.7% 94.4% 97.8%
95.3% 94.4% 91.9% 94.8% 99.2%
94.2% 91.1% 92.4% 90.4% 88.7%
97.3% 93.9% 98.6% 92.7% 98.5%
94.4% 93.6% 93.8% 94.1% 94.2%
Not Commissioned
NHS East Lancashire CCG
NHS Fylde & Wyre CCG
NHS Greater Preston CCG
NHS Morecambe Bay CCG
NHS West Lancashire CCG
Total Figure - 7 CCGs
RTT IAPT 6 Wks
NHS Blackburn with Darwen CCG
NHS Blackpool CCG
NHS Chorley & South Ribble CCG
Jun-17 Jul-17 Aug-17 Sep-17 Oct-17
98.7% 100.0% 100.0% 100.0% 100.0%
100.0% 100.0% 99.2% 100.0% 100.0%
100.0% 100.0% 100.0% 100.0% 100.0%
100.0% 97.1% 98.9% 98.9% 100.0%
100.0% 99.2% 98.1% 98.7% 100.0%
98.1% 96.7% 100.0% 97.9% 98.1%
100.0% 100.0% 100.0% 100.0% 100.0%
99.6% 99.2% 99.4% 99.4% 99.8%
RTT IAPT 18 Wks
NHS Blackburn with Darwen CCG
NHS Blackpool CCG
NHS Morecambe Bay CCG
NHS West Lancashire CCG
Total Figure - 7 CCGs
Not Commissioned
NHS Chorley & South Ribble CCG
NHS East Lancashire CCG
NHS Fylde & Wyre CCG
NHS Greater Preston CCG
Performance Management
2.1 Performance Activity Summary – Mental Health
21
Indicators achieved Target Type Target Oct-16 Nov-16 Dec-16 Jan-17 Feb-17 Mar-17 Apr-17 May-17 Jun-17 Jul-17 Aug-17 Sep-17 Oct-17Rolling 12 Month
Sparkline
NHS Improvement
CPA 7 Day Follow Up (Total Network Performance) NHSI 95.00% - 96.7% 98.1% 98.7% 96.7% 97.8% 98.5% 96.8% 95.7% 94.3% 96.6% 99.4% 97.8%
CPA 7 Day Follow Up (AMH) NHSI 95.00% 97.5% 96.8% 98.4% 98.5% 96.9% 98.4% 98.9% 96.9% 96.2% 94.4% 96.0% 99.4% 97.5%
CPA 7 Day Follow Up (OA) NHSI 95.00% 83.3% 95.5% 95.7% 100.0% 95.0% 93.5% 96.2% 100.0% 96.0% 92.3% 100.0% 100.0% 100.0%
CPA 7 Day Follow Up (SS) NHSI 95.00% - 100.0% 100.0% 100.0% 50.0% 100.0% 0.0% 80.0% 50.0% 100.0% 100.0% 100.0% 100.0%
CPA 12 Month Review (Total Network Performance) NHSI 95.00% - 97.3% 97.7% 96.7% 97.0% 97.5% 97.0% 97.2% 95.9% 95.7% 96.8% 96.3% 96.4%
CPA 12 Month Review (AMH) NHSI 95.00% 97.4% 96.9% 97.4% 96.3% 96.6% 97.3% 96.5% 96.8% 95.3% 95.1% 96.3% 95.7% 95.9%
CPA 12 Month Review (OA) NHSI 95.00% 98.8% 100.0% 99.7% 100.0% 100.0% 100.0% 99.7% 100.0% 99.1% 98.4% 99.7% 99.7% 99.4%
CPA 12 Month Review (SS) NHSI 95.00% 98.8% 100.0% 100.0% 98.2% 98.2% 97.0% 100.0% 98.8% 100.0% 100.0% 99.4% 100.0% 100.0%
Delayed Transfers of Care (Total Network Performance) NHSI ≤ 7.50% - 4.20% 4.79% 3.76% 2.60% 2.39% 3.10% 3.33% 3.48% 2.89% 2.39% 2.55% 2.49%
Delayed Transfers of Care (AMH) NHSI ≤ 7.50% 1.82% 1.23% 3.06% 3.66% 2.19% 2.27% 3.26% 3.42% 2.94% 2.31% 1.06% 0.49% 0.66%
Delayed Transfers of Care (OA) NHSI ≤ 7.50% 16.59% 14.48% 10.34% 4.11% 3.92% 2.70% 3.27% 2.06% 3.08% 2.72% 4.03% 6.29% 6.01%
Delayed Transfers of Care (SS) NHSI ≤ 7.50% 1.35% 2.41% 2.77% 3.91% 3.80% 3.08% 2.74% 3.85% 4.61% 4.00% 3.82% 4.03% 3.68%
IP Access to Crisis Res. Treatment (Gatekeeping) NHSI 95.00% 98.3% 100.0% 100.0% 98.6% 99.4% 97.7% 100.0% 100.0% 99.5% 100.0% 100.0% 100.0% 100.0%
MH Data Completeness - Identifiers NHSI 97.00% - - - - - - 99.6% 99.6% 99.7% 99.5% 99.5% 99.6% 99.5%
MH Data Completeness - Identifiers (AMH) NHSI 97.00% 99.6% 99.7% 99.7% 99.7% 99.8% 99.7% - - - - - - -
MH Data Completeness - Identifiers (SS) NHSI 97.00% 98.1% 98.1% 97.9% 98.4% 98.4% 98.5% - - - - - - -
MH Data Completeness - Outcomes NHSI 50.00% - - - - - - 85.8% 84.8% 84.5% 84.6% 84.5% 83.6% 83.7%
MH Data Completeness - Outcomes (AMH) NHSI 50.00% 84.4% 85.1% 85.3% 85.2% 85.2% 85.4% - - - - - - -
MH Data Completeness - Outcomes (SS) NHSI 50.00% 84.3% 85.1% 83.4% 82.5% 81.3% 79.6% - - - - - - -
Other Indicators
AQ Dementia (OA) (1 month in arrears) NHSE 59.30% 100.0% 90.9% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% -
Memory Assessment Service (MAS) seen within 6 weeks (OA) NHSE 70.00% 40.5% 40.2% 39.5% 25.7% 40.3% 48.4% 47.0% 52.1% 70.4% 79.8% 80.4% 79.6% 78.1%
PBR Clustering NHSE 95.00% 94.2% 96.1% 96.4% 96.8% 96.4% 96.5% 96.5% 96.6% 96.7% 96.4% 95.7% 95.9% 95.1%
No of Patients without a Care Co-ordinator Allocated > 2 Weeks (Total
Network Performance)NHSE 0
407 331 307 313 255 260 267 255 211 233 210 - -
No of Patients without a Care Co-ordinator Allocated > 2 Weeks (AMH) NHSE 0324 292 266 262 222 253 245 243 187 203 183 - -
No of Patients without a Care Co-ordinator Allocated > 2 Weeks (SS) NHSE 0 83 39 41 51 33 7 22 12 24 30 27 - -
MHLT
MHLT 1hr compliance Commissioners 95.00% 37.8% 52.6% 45.7% 46.9% 38.7% 51.8% 51.6% 45.9% 47.5% 40.8% 39.5% 42.5% 45.5%
No of 4hr breaches (Percentage of total) 5.00% 4.8% 10.1% 7.7% 11.2% 15.4% 9.7% 9.5% 11.4% 14.8% 16.1% 15.1% 16.4% 14.5%
No of 4hr breaches (Number of breaches) 36 25 53 49 75 102 71 67 79 110 116 102 108 104
No of 12hr breaches (Percentage of total) 0.00% 1.5% 2.1% 0.9% 1.5% 1.2% 3.3% 0.9% 1.4% 4.0% 1.8% 2.5% 1.2% 0.8%
No of 12hr breaches (Number of breaches) 0 800.0% 11 6 10 8 24 6 10 30 13 17 8 6
Stretch
Stretch
Performance Management
2.1 Performance Activity Summary – Mental Health (Secure)
22
Indicators achieved Target Type Target Oct-16 Nov-16 Dec-16 Jan-17 Feb-17 Mar-17 Apr-17 May-17 Jun-17 Jul-17 Aug-17 Sep-17 Oct-17Rolling 12 Month
Sparkline
Secure Mental Health Business Unit
Overall Gross Occupancy NHSE 93.00% 90.5% 90.5% 90.2% 91.8% 93.3% 93.7% 97.2% 95.9% 96.0% 94.2% 91.3% 91.0% 92.4%
Violent Incidents resulting in Restraint Stretch ≤ 20.00% 23.8% 20.3% 16.1% 20.8% 17.5% 20.5% 18.4% 15.6% 22.2% 27.1% 17.2% 29.1% 19.3%
% of SU that have had a CPA Review in last 6 months Stretch 100% 100.0% 100.0% 100.0% 100.0% 99.3% 99.3% 98.0% 97.4% 96.1% 94.5% 97.2% 96.0% 100.0%
% of service users who have a Care Coordinator allocated within 2 weeks Stretch 100% - 60.0% 62.5% 75.0% 77.8% 75.0% 66.7% 100.0% 50.0% 66.7% 99.3% 100.0% 100.0%
% of CPA reviews attended by Local Care Coordinators Stretch 80% - 37.5% 50.0% 25.0% 42.9% 39.3% 65.2% 33.3% 51.7% 42.9% 44.0% 48.1% 43.5%
% of service users who have Cardiometabolic risk factors assessed within
12 months Stretch 90% - 94.4% 94.6% 96.0% 89.7% 96.8% 100.0% 100.0% 99.4% 100.0% 100.0% 100.0% 100.0%
25hrs Meaningful Activity - Offered NHSE 100% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0%
25hrs Meaningful Activity - Uptake NHSE 100% 87.9% 82.4% 82.8% 85.0% 80.4% 79.9% 75.6% 82.3% 81.3% 86.8% 74.1% 78.2% 85.2%
Community Business Unit
% of caseload with a Local Care Coordinator allocated Stretch 100% - 89.8% 96.1% 96.0% 97.9% 100.0% 95.3% 97.0% 95.5% 100.0% 97.0% 100.0% 100.0%
% of caseload carried longer than 12 months post SMHBU discharge Stretch ≤ 20.00% - 57.1% 58.8% 72.0% 66.7% 74.0% 60.9% 60.6% 59.7% 63.5% 58.2% 60.9% 66.0%
% of CPA Reviews Attended by Local Care Coordinators / Local Teams Stretch 80% - 42.9% 50.0% 62.5% 75.0% 30.0% 33.3% 40.0% 54.5% 33.3% 50.0% 63.6% 25.0%
No of Incidents exceeding PACE Clock Commissioners 0 6 4 3 4 3 5 7 3 4 5 5 9 3
Health & Justice Business Unit - HMP Liverpool
GP Waits over 2 Weeks NHSE 0% 43.6% 52.6% 64.1% 55.0% 59.5% 64.2% 49.4% 22.8% 0.0% 18.8% 43.6% 43.1% 44.9%
NHS Health Checks NHSE 40.00% 13.5% 19.8% 3.6% 26.1% 13.2% 8.9% 1.9% 57.1% 28.6% 14.3% 22.6% 0.0% 33.3%
Well Man Assessment completed NHSE 100.00% - 98% 98% 97% 95% 89% 75% 63% 33% 96% 120% 98% 124%
Hep B Vaccinations completed NHSE - 0.0% 25.0% 30.4% 25.0% 0.0% 3.7% 0.0% 8.6% 0.0% 0.0% 4.2% 0.0%
Chlamydia Screening U25's Uptake NHSE 50.00% 8.8% 6.3% 20.7% 14.3% 33.3% 5.3% 13.0% 27.3% 63.6% 100.0% 21.4% 13.3% 17.7%
Men C Vaccinations Uptake NHSE 95.00% 12.8% 5.7% 5.7% 12.2% 4.9% 2.6% 2.4% 21.1% 44.7% 5.3% 7.7% 7.1% 19.4%
MMR Vaccinations Uptake NHSE 95.00% 21.7% 50.0% 4.4% 11.1% 0.0% 14.3% 23.8% 3.6% 2.3% 2.3% 1.0% 1.7% 4.1%
Prison 6 Month CPA Reviews NHSE 100.00% 100.0% 100.0% 100.0% - 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 0.0%
QOF NHSE 238 302 322 327 323 314 319 316 323 334 354 385 381 410
Performance Management
2.1 Performance Activity Summary – Community & Wellbeing
23
Indicators achieved Target Type Target Nov-16 Dec-16 Jan-17 Feb-17 Mar-17 Apr-17 May-17 Jun-17 Jul-17 Aug-17 Sep-17 Oct-17Rolling 12 Month
Sparkline
NHS Improvement
RTT - Consultant Led (Completed Pathway) NHSI 95% 95.2% 96.3% 96.7% 97.6% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0%
RTT - Consultant Led (Incomplete Pathway) NHSI 92% 95.2% 95.4% 97.3% 100.0% 99.2% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 99.7%
RTT - IAPT 6 Weeks NHSI 75% 93.0% 96.5% 95.1% 95.7% 93.4% 96.4% 94.7% 95.1% 94.5% 94.4% 94.5% 94.6%
RTT - IAPT 18 Weeks NHSI 95% 99.0% 99.8% 99.4% 99.8% 98.8% 99.4% 99.2% 99.7% 99.3% 99.4% 99.5% 99.7%
Waiting Times - AHP RTT
Adult Learning Disability Service NHSE 95% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0%
Community Stroke Service NHSE 95% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% -
Intermediate Care NHSE 95% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0%
Podiatry NHSE 95% 99.9% 100.0% 100.0% 99.8% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0%
Pulmonary Rehabilitation NHSE 95% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0%
Rapid Assessment Team NHSE 95% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0%
Adult Speech and Language Therapy NHSE 95% 100.0% 100.0% 100.0% 100.0% 99.0% 100.0% 100.0% 100.0% 98.6% 100.0% 98.6% 100.0%
Community Neuro Team NHSE 95% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0%
Community Respiratory Service NHSE 95% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 98.7%
Continence Service NHSE 95% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 97.8% 100.0% 100.0% 98.5% 98.3% 100.0%
Domiciliary Physiotherapy NHSE 95% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0%
Falls Team NHSE 95% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 99.5% 100.0% 100.0% 99.0% 100.0%
Nutrition & Dietetics NHSE 95% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0%
Other Indicators
RTT Complete Learning Disablity Commissioner 95% 98.1% 98.8% 98.9% 98.9% 100.0% 98.7% 96.1% 96.3% 99.2% 99.2% 100.0% 100.0%
12 Week Dentist Waits - HMP Liverpool Commissioner 95% 100.0% 98.7% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 94.6% 100.0%
Community Dental Waits Commissioner 95% 91.2% 95.2% 96.1% 98.0% 99.4% 97.1% 98.3% 100.0% 97.5% 98.2% 98.1% 100.0%
Unallocated Cases NHSE 0 12 11 12 12 7 15 13 2 7 19 - -
Performance Management
2.1 Performance Activity Summary – Community & Wellbeing
24
Indicators achieved Target Type Target Nov-16 Dec-16 Jan-17 Feb-17 Mar-17 Apr-17 May-17 Jun-17 Jul-17 Aug-17 Sep-17 Oct-17Rolling 12 Month
Sparkline
IAPT
IAPT in Month Prevalence Trust NHSE 1.44% 1.39% 1.67% 1.28% 1.72% 1.05% 1.32% 1.43% 1.32% 1.27% 1.31% 1.38%
IAPT in Month Prevalence
Blackburn with Darwen CCGCommissioner 1.18% 1.02% 1.22% 1.32% 1.26% 0.89% 0.74% 1.85% 1.13% 1.27% 1.38% 1.20% 1.09%
IAPT Cumulative Prevalence
Blackburn with Darwen CCGCommissioner 8.28% - - - - - 0.74% 2.59% 3.72% 4.99% 6.37% 7.57% 8.66%
IAPT in Month Prevalence
East Lancashire CCGCommissioner 1.25% 1.30% 1.05% 1.56% 1.11% 1.77% 1.00% 1.13% 1.64% 1.42% 1.22% 1.30% 1.38%
IAPT Cumulative Prevalence
East Lancashire CCGCommissioner 8.75% - - - - - 1.00% 2.13% 3.76% 5.19% 6.41% 7.72% 9.09%
IAPT in Month Prevalence
Chorley & South Ribble CCGCommissioner 1.25% 1.40% 1.42% 1.59% 1.08% 1.44% 1.29% 1.53% 1.47% 1.31% 1.45% 1.38% 1.40%
IAPT Cumulative Prevalence
Chorley & South Ribble CCGCommissioner 8.75% - - - - - 1.29% 2.81% 4.29% 5.60% 7.05% 8.43% 9.83%
IAPT in Month Prevalence
Greater Preston CCGCommissioner 1.25% 1.45% 1.14% 1.24% 1.18% 1.20% 0.92% 1.38% 1.46% 1.41% 1.07% 1.24% 1.67%
IAPT Cumulative Prevalence
Greater Preston CCGCommissioner 8.75% - - - - - 0.92% 2.30% 3.76% 5.17% 6.23% 7.48% 9.15%
IAPT in Month Prevalence
West Lancashire CCGCommissioner 1.25% 1.02% 1.26% 1.71% 0.83% 1.53% 1.13% 1.51% 1.34% 1.08% 1.48% 1.21% 1.33%
IAPT Cumulative Prevalence
West Lancashire CCGCommissioner 8.75% - - - - - 1.13% 2.64% 3.98% 5.06% 6.54% 7.75% 9.08%
IAPT in Month Prevalence
Fylde and Wyre CCGCommissioner 1.25% 0.95% 1.55% 1.33% 0.96% 1.40% 1.23% 1.33% 1.36% 1.44% 1.35% 1.37% 1.33%
IAPT Cumulative Prevalence
Fylde and Wyre CCGCommissioner 8.75% - - - - - 1.23% 2.55% 3.91% 5.35% 6.70% 8.07% 9.39%
IAPT in Month Prevalence
Morecambe Bay CCGCommissioner 1.25% 1.19% 1.64% 1.31% 1.22% 1.41% 1.34% 1.07% 1.40% 1.46% 1.32% 1.27% 1.03%
IAPT Cumulative Prevalence
Morecambe Bay CCGCommissioner 8.75% - - - - - 1.34% 2.41% 3.81% 5.27% 6.59% 7.86% 8.88%
IAPT in Month Prevalence
St. Helens CCGCommissioner 1.25% 1.26% 0.74% 1.31% 1.02% 1.67% 0.88% 1.13% 1.31% 1.07% 1.09% 1.43% 1.56%
IAPT Cumulative Prevalence Trust Commissioner 8.75% 11.76% 13.15% 14.82% 16.10% 17.82% 1.05% 2.36% 3.79% 5.11% 6.38% 7.69% 9.07%
IAPT Cumulative Prevalence
St. Helens CCGCommissioner 8.75% - - - - - 0.88% 2.01% 3.32% 4.39% 5.48% 6.91% 8.47%
IAPT Waiting Times (Internal Target) Stretch 0pts >26 wks - - - - - 22 23 23 25 14 26 14
IAPT Recovery NHSE 50% 56.3% 56.3% 53.8% 57.0% 53.4% 54.5% 52.6% 57.0% 50.0% 55.1% 57.3% 53.6%
Performance Management
2.1 Performance Activity Summary – Children & Young People’s Wellbeing
25
Indicators achieved Target Type Target Oct-16 Nov-16 Dec-16 Jan-17 Feb-17 Mar-17 Apr-17 May-17 Jun-17 Jul-17 Aug-17 Sep-17 Oct-17Rolling 12 Month
Sparkline
NHS Improvement
CPA 7 Day Follow Up NHSI 95.00% 75.0% 100.0% 100.0% 100.0% 100.0% 95.5% 100.0% 100.0% 100.0% 88.9% 100.0% 100.0% 100.0%
CPA 12 Month Review NHSI 95.00% 98.8% 97.6% 98.3% 99.5% 98.5% 97.9% 97.5% 95.6% 99.0% 99.5% 100.0% 98.7% 98.7%
MH Data Completeness - Identifiers NHSI 97.00% 99.6% 99.7% 99.7% 99.7% 99.7% 99.7% 99.6% 99.6% 99.7% 99.6% 99.6% 99.5% 99.6%
MH Data Completeness - Outcomes NHSI 50.00% 67.1% 67.2% 66.3% 64.8% 81.3% 64.9% 63.5% 60.7% 59.3% 58.1% 57.9% 56.7% 58.8%
2 Week wait for Treatment for EIP Programme NHSI 50.00% 69.0% 74.3% 76.7% 82.0% 81.4% 74.4% 11.1% 7.1% 0.0% 9.5% 11.8% 15.6% 9.5%
Waiting Lists - RTT 18 Weeks (Completed Outcomes)
EIS Therapies (The Hub) NHSE 95.00% 86.8% 90.3% 93.0% 83.9% 80.0% 94.7% 92.7%
Child Psychology - Total Network Performance NHSE 95.00% 70.7% 69.9% 70.9% 71.0% 60.3% 64.8% 66.6% 62.4% 66.9% 74.1% 77.7% 84.4% 89.0%
CAMHS Tier 3 - Total Network Performance NHSE 95.00% 96.4% 99.0% 97.5% 100.0% 98.1% 88.8% 79.4% 78.0% 78.4% 68.1% 64.5% 59.1% 56.9%
Waiting Lists - RTT 18 Weeks (Incompleted Outcomes)
CITNS - Occ Therapy - Total Network Performance NHSE 92.00% 83.1% 81.8% 81.8% 88.2% 91.2% 95.1% 94.9% 94.0% 96.4% 99.1% 96.3% 98.2% 97.9%
CITNS - Physiotherapy - Total Network Performance NHSE 92.00% 100.0% 100.0% 100.0% 98.1% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 99.4%
CITNS - SLT- Total Network Performance NHSE 92.00% 92.6% 86.9% 86.9% 86.6% 83.6% 82.7% 84.2% 86.7% 87.0% 88.4% 96.2% 96.3% 98.0%
CAMHS Tier 4
Bed Occupancy - The Cove NHSE 85.00% 83.0% 65.0% 55.0% 65.5% 80.5% 90.5% 92.8% 86.5% 96.7% 94.6% 68.8% 68.2% 78.9%
Average Length of Stay (days) - The Cove Bench 83 80.00 78.00 57.00 44.00 41.00 39.00 67.00 57.00 33.30 60.70 27.70 48.10 26.60
National Child Measurement Programme
NCMP - Central NHSE 90.00% 4.4% 19.3% 26.8% 39.5% 52.6% 64.5% 73.8% 88.7% 94.4% - - - 5.1%
NCMP - BwD (Cumulative) NHSE 95.00% 5.5% 17.8% 24.9% 37.1% 46.3% 60.2% 67.6% 82.2% 95.7% - - - 22.4%
NCMP - East (Cumulative) NHSE 90.00% 9.1% 21.9% 30.3% 44.3% 56.0% 67.9% 79.5% 93.0% 98.5% - - - 6.4%
Other Indicators
ADHD - New < 18 Weeks NHSE 95.00% 35.7% 38.3% 40.1% 36.1% 31.6% 37.7% 46.4% 39.0% 35.7% 22.7% 20.9% 34.7% 36.7%
PBR Clustering NHSE 95.00% 95.7% 94.9% 93.6% 96.2% 96.3% 95.4% 96.0% 97.2% 96.4% 96.5% 95.1% 95.3% 95.1%
Number of Patients without a Care Co-ordinator Allocated > 2 Weeks NHSE 0 16 13 14 8 18 29 23 5 4 2 2 - -
Currently being validated
Performance Management
2.1 Patient Flow Mental Health – Mental Health Liaison Team (MHLT)
26
MHLT:
1 Hour Compliance:
The Network is reporting low compliance against target for patients to be seen within 1 hour of referral, with 45.48% compliance in M7.
4 Hours Breaches:
The Network is reporting 104 actual 4 hour breaches in A&E for which LCFT were responsible in month 7, reporting 85.5% compliance.
12 Hours Breaches:
The Network is reporting 6 actual 12 hour breaches in A&E from the decision to admit time in month 7, this is 0.8% of all A&E referrals to
MHLT.
Actions: Due: Owner: Outcome:
CORE 24 workshops in progress for development of the working
models. Apr-18
Deputy Head of
Operations
Workshop with Acute Trusts completed
18th September to agree key points of
clinical SOP, with LCFT finalisation
workshop booked for 30th November.
Performance Management
2.1 Patient Flow Mental Health – Mental Health Liaison Team (MHLT)
27
Performance Management
28
Occupancy:
Throughout October, although occupancy levels across the service continue to be below the contracted threshold, occupancy has
increased to 92.43%. The following rationale illustrates the reasons for the monthly bed occupancy:
• Bleasdale ABI Medium had 3 vacancies - 1 allocated to SU in Ashworth awaiting MOJ permission to step down
• Whinfell Ward Male Medium ABI had 4 vacancies - no one currently on the waiting list
• Elmridge Ward Medium had 1 vacancy - Female Community Bed
• Hermitage ABI/MI Step down Community House had 1 vacancy - Male Community Bed
• Calder Ward Male MSU had 1 vacancy
• Fairsnape Ward MSU had 1 vacancy - 1 SU on the waiting list waiting medical recommendations to be completed and to apply to MOJ
for transfer warrant
There are no actions for this measure.
2.1 Performance Activity Mental Health (Secure Services) – Occupancy
OBD Available %
2112 2325 90.84%
1685 1736 97.06%
902 1023 88.17%
4699 5084 92.43%
Low Secure Wards
Step down Wards
Total
Oct-17
Medium Secure Wards
Performance Management
29
Violent Incidents resulting in Restraint:
In October 2017, staff reported a total of 150 incidents of verbal and physical violence within the inpatient unit. The overall use of restraint
as a response to violent incidents has decreased slightly with 19% of violent incidents ending in restraint, compared to 29% in September
2017.
Elmridge ward has a significantly higher than average use of restraint. In total there were 40 incidents on the ward which resulted in the
use of restraint.
2.1 Performance Activity Mental Health (Secure Services) – Violent Incidents
resulting in Restraint
Actions: Due: Owner: Outcome:
The service is looking at recruiting to a new post that will support teams in
the use of restraint and debriefs.
End of
Quarter 3
Care Group
Manager
New Band 7 Quality Lead to be in
post.
Performance Management
30
CPA Reviews within 6 Months:
In October, all of the 144 eligible service users have had a CPA within the last 6 months.
Through monitoring of the planned reviews, the service is expecting all planned reviews to take place next month.
2.1 Performance Activity Mental Health (Secure Services) – CPA Reviews
Within 6 Months
Actions: Due: Owner: Outcome:
Review the process for arranging CPA reviews.
Sep-17 revised
to End of
Quarter 3
Performance
Analyst
This has been extended as a role
review is involved and is continuing.
Performance Management
31
Attendance of CPA reviews:
Attendance at CPA reviews has reduced to 43.5% for October due to a reduced number of planned CPAs. Of the 23 CPAs planned for
October, 10 local care co-ordinators attended, 1 sent apologies and 12 did not attend.
This issue has been flagged to the Network for urgent resolution by the Chief Operating Officer. All dates of CPAs have been provided to
the Deputy Head of Operations, who has received confirmation of named attendees from community teams. This work commenced in
November and thus has not impacted on reported October activity.
2.1 Performance Activity Mental Health (Secure Services) – Attendance of
CPA reviews
Actions: Due: Owner: Outcome:
1) All teams have been asked to forward the names of attendees for
all planned CPAs until the end of December 2017. 10-Nov-17
Care Group
Manager
2) Outlook invites are now being included within the invite process
and the secretaries will be following up all invites where apologies or
the name of the attendee have not been received.
10-Nov-17 Admin
Manager
Attended Apologies DNA
21 10 1 10
2 0 0 2
Breakdown of LCCNo of CPA
reviews
LCFT LCC
Non LCFT LCC
Oct-17
Performance Management
32
25hr Meaningful Activity:
In October, 4 wards failed to meet the 100% target in relation to meaningful activity uptake. Overall, uptake has continued to improve
across most wards increasing from 78.23% in September to 85.23% for October.
There are wards that continue to experience high acuity resulting in a static level of activity uptake. Work is ongoing with service users to
improve engagement and to take up opportunities of activity both on and off the ward. Levels of recording have improved and the wards
continue to work with staff to accurately record activity.
2.1 Performance Activity Mental Health (Secure Services) – 25hr Meaningful Activity
Performance Management
33
2.1 Performance Activity Mental Health (Secure Services) – 25hr Meaningful Activity
Actions: Due: Owner: Outcome:
1. Lead OT to meet with Clinical Audit team to agree the set of
standards to audit for 25hr meaningful activity in September. 01-Dec-17
Care Group
Manager
Audit took place 27th October 2017 and
the results are due to be available by the
end of Q3.
2. Ward Managers and Team Leaders on Fairoak and Mallowdale
wards to work with the named nurses and OT assistants in supporting
service users to take up activities, with a view to gaining a greater
understanding of the importance of structured activity on wellbeing.
31-Oct-17
Ward
Manager/
Team Leader Completed.
3. Marshaw ward will have a new OT Assistant in post with effect from
mid-September. The new Ward Manager is working with staff to
ensure that weekly activity plans are formulated. 31-Oct-17
Care Group
Manager Completed.
4. Ensure that 25 hours activity is a standing agenda item on the team
debrief at the end of every shift on Fairoak ward, and check daily that
staff on duty are completing the activity recording form. 31-Oct-17
Ward
Manager/
Team Leader Completed.
5. Ward Managers and Team Leaders on Fairoak Ward and
Mallowdale Ward to ensure that 25hr activity is discussed with staff at
the end of each shift to improve the recording of activity and the
promotion for service user wellbeing.
End of Q3 Ward
Manager
6. Following the work with the service users on Marshaw ward to
understand what activities they would like to do, staff to purchase new
games and introduce new activities to improve uptake. End of Q3
Ward
Manager
7. The ward manager of Fairoak Ward to send a recurring email to
shift leaders to promote accurate recording of activities. End of Q3
Ward
Manager
Performance Management
2.1 Performance Activity Mental Health (Secure Services) – % of FCMHT
Caseload with Care Co-ordinator allocated
34
% of FCMHT Caseload with Care Co-ordinator allocated:
The service has continued to achieve 100% for October.
There has been a reduction in the caseload figure for community from October. It has been identified that pre discharge patients have
been included in the caseload count when they are still counted within inpatients until their actual discharge to the community.
Performance Management
35
% of FCMHT Caseload >12 months:
There are currently 50 service users on the FCMHT case load; 33 of these service users have been on the FCMHT caseload for over 12
months.
There has been a reduction in the caseload figure for community from October. It has been identified that pre discharge patients have
been included in the caseload count when they are still counted within inpatients until their actual discharge to the community.
The team will be discussing the clinical appropriateness of this target with the Commissioner.
2.1 Performance Activity Mental Health (Secure Services) – % of FCMHT
Caseload >12 months
Actions: Due: Owner: Outcome:
1. The service manager will continue to work with the team to
review pathways and the continued need for intensive input by the
FCMHT.
End of
Quarter 3
Care Group
Manager
Continued FCMHT input is dictated by a
balance of risk, legal status and psychological
need and now reviewed on a weekly basis.
2. A meeting is taking place with the commissioner and the
percentage of caseload being carried over 12 months will be
discussed with a suggestion for a more clinically appropriate target.
Oct-17
revised to
Dec-17
FMCT Care
Group
Manager
Due to change in managerial positions, this
discussion will take place at the next
commissioner meeting in December.
Performance Management
36
Attendance of CPA Reviews within Community Services:
Attendance of CPA reviews in October has decreased to 25% with 2 out of 8 CPA reviews attended by the local care coordinators.
The FCMHT continues to work with all local care coordinators to improve attendance. Out of those not attended, any actions/minutes will
be communicated. No delayed transfers of care have resulted from local care coordinator non-attendance.
2.1 Performance Activity Mental Health (Secure Services) – Attendance of
CPA Reviews within Community Services
Actions: Due: Owner: Outcome:
Admin staff to contact local care co-ordinators in week
prior to planned CPA to increase levels of attendance at
CPA reviews and identify an alternative representative if
care co-ordinator is unable to attend due to leave or
sickness.
End of Q3 Service
Manager
Performance Management
2.1 Performance Activity Mental Health (Secure Services) – Number of
Incidents exceeding PACE Clock
37
Number of Incidents exceeding PACE Clock:
There has been a reduction in PACE breaches in October. Of the 3 breaches that took place, one was in excess of 50 hours, one in
excess of 20 hours and one in excess of 10 hours longer in Police custody than the PACE Limit of 24hrs. Two occurred at Preston and
one at Skelmersdale.
One was a transfer back to own commissioning area, one was due to no beds being available and the other was an out of hours
assessment with the crisis team which became delayed.
There are no actions for this measure.
Performance Management
HMP Liverpool – HJIP Indicators:
GP Waiting Times:
There are currently 156 patients on the GP waiting list with the longest wait now up to 24 working days, an increase of 4 days from
September. One GP clinic session was lost though 32 more appointments were offered than in the previous month, however the DNA rate
was also increased by 3% to 38.7%. There was a reduction in the number of appointments seen by the Nurse Practitioner as 13 clinics
were dedicated to the flu campaign. Enablement issues are highlighted below.
NHS Health Checks:
Six men were eligible for the NHS Health Check at the start of the month. Seven men were called up: three attended but declined on
arrival, two DNAd and two were seen. The uptake of the NHS Health checks is very poor with the client base.
Wellman Screening:
The Integrated Mental Health Team has worked hard to catch up with the Wellman Screening. The backlog has been cleared and as of 1st
October, they are screening new receptions within the 72 hour timescale.
Immunisations and Vaccinations:
In October, 151 Imms & Vacs appointments were offered and 66 DNA (44%). Enablement issues are highlighted below.
Pharmacy ordered 50 MMR vaccinations however delivery was not possible due to a national shortage. The supplier has informed us that
this could continue until March 2018; the same applies to Hep B vaccinations. The seasonal flu campaign is going well; at the 1st
November 2017 there are 6 men eligible. 91 patients were vaccinated last month. 84 declined the influenza vaccination and 235 declined
the offer of Hep B vaccination.
DNA - Enablement Issues:
During October, there has been no improvement on the enablement issues, however the prison have now agreed to attend the Local
Delivery Group meeting on Thursday 9th November. The following items are on the agenda:- Amey (works) issues, ACCT reviews,
CQC/HMIP Action plan, Enablement, Access to Mental Health and Social Care Beds, Wheelchairs, Low officer presence in inpatients and
medication hatches, Safeguarding referrals, Stabilisation Unit, Body Worn cameras, Chromatic Doors and Gated rooms on healthcare.
2.1 Performance Activity Mental Health (Secure Services) – HMP Liverpool
HJIP Indicators
38
Performance Management
2.1 Performance Activity Mental Health (Secure Services) – HMP Liverpool
HJIP Indicators
39
Actions: Due: Owner: Outcome:
1. Enablement issues. 09-Nov-17 Care Group
Manager
Prison representatives to attend the Local Delivery
Group Meeting 9th November to discuss various
issues.
2. NHS Health Checks:
Primary Care manager has been tasked by Head of
Healthcare with targeting NHS Health Checks.
09-Nov-17 Care Group
Manager
This is continuing to take place and all eligible men are
being provided appointments.
3. Wellman Screening:
Continue the good work and target “first timers”
through reception. 09-Nov-17
Care Group
Manager Achieved.
4. Immunisation and Vaccination:
Continue to offer as many appointments as possible
for Men C and MMR but the current emphasis will be
on Influenza vaccinations.
09-Nov-17 Care Group
Manager
Continue to liaise with supplier regarding vaccination
supplies.
Performance Management
2.1 Performance Activity Mental Health (Secure Services) – HMP Liverpool
HJIP Indicators
40
Dec-16 Jan-17 Feb-17 Mar-17 Apr-17 May-17 Jun-17 Jul-17 Aug-17 Sep-17 Oct-17
165 134 258 247 103 14 14 21 31 22 6
3.64% 26.12% 13.18% 8.91% 1.94% 57.14% 28.57% 14.29% 22.58% 0.00% 33.33%
29 28 18 19 23 11 11 6 14 51 17
20.69% 14.29% 33.33% 5.26% 13.04% 27.27% 63.64% 100.00% 21.43% 13.33% 17.65%
35 41 41 38 41 38 38 19 26 28 31
5.71% 12.20% 4.88% 2.63% 2.44% 21.05% 44.74% 5.26% 7.69% 7.14% 19.35%
23 27 25 21 21 225 132 129 203 241 222
4.35% 11.11% 0.00% 14.29% 23.81% 3.56% 2.27% 2.33% 0.99% 1.66% 4.05%
1 0 5 2 6 2 2 4 1 2 3
100.00% - 100.00% 100.00% 100.00% 100.00% 100.00% 100.00% 100.00% 100.00% 0.00%
Patients received NHS
HC Screen
Patients Accpeting
Men C Vacc
Patients Accpeting
MMR Vacc
SU received CPA
review <6 months
Total Eligible
% Screened
Total Eligible
% Recieved
Total Eligible
% Recieved
Total Eligible
% Recieved
Patients Screened for
Chlamydia
Total Eligible
% Screened
Dec-16 Jan-17 Feb-17 Mar-17 Apr-17 May-17 Jun-17 Jul-17 Aug-17 Sep-17 Oct-17
257 276 307 375 261 336 358 422 359 307 274
253 269 292 335 196 211 117 406 432 301 341
98.44% 97.46% 95.11% 89.33% 75.10% 62.80% 32.68% 96.21% 120.33% 98.05% 124.45%% completed
Wellman Checks
No. of new receptions
No. of Wellman checks completed
Dec-16 Jan-17 Feb-17 Mar-17 Apr-17 May-17 Jun-17 Jul-17 Aug-17 Sep-17 Oct-17
5 6 7 8 9 10 11 16 27 44 16
51 27 49 41 19 18 39 54 28 35 37
39 41 59 35 52 31 45 47 69 57 33
166 127 169 165 80 23 0 27 96 103 70
GP Waits
0-2 days
3-7 days
8-14 days
14+ days
Dec-16 Jan-17 Feb-17 Mar-17 Apr-17 May-17 Jun-17 Jul-17 Aug-17 Sep-17 Oct-17
239 248 260 296 261 336 358 422 359 307 274
84 23 12 3 27 35 35 99 55 24 43
21 7 3 0 1 0 3 0 0 1 0
33 29 13 7 31 61 72 53 54 24 60
25.00% 30.43% 25.00% 0.00% 3.70% 0.00% 8.57% 0.00% 0.00% 4.17% 0.00%
Hep B Vaccinations
No. of new receptions
No. of patients accepting Hep B
Patients vaccinated >4wks
Total vaccinations in month
% patients accepting within 4 wks
Performance Management
2.1 Performance Activity Community & Wellbeing – Improving Access to
Psychological Therapies (IAPT) Prevalence
41
IAPT - Prevalence:
• West Lancs CCG teams have met the 15% contractual target for M7, but not met the 16.2% internal cumulative target
• Fylde and Wyre CCG have met the 15% contractual target for M7, but not met the 16.2% internal cumulative target
• BwD CCG teams have not met the 14.2% contractual target
• Morecambe Bay have not met the 15% contractual target for M7, or the 16.2% internal cumulative target
A cumulative prevalence model is in place to direct and support teams to achieve the 16.8% prevalence target set by NHS England by 31st
March 2018. Quarter 3 's contractual target remains at 15% (BwD is 14.2%), however teams have now moved to an internal cumulative
target of 16.2% in preparation. St Helens CCG have agreed that prevalence will stay at 15% as they have not received any national LTC
funding. Blackburn with Darwen CCG's prevalence target has been confirmed as 14.2% with an expectation that this will increase and
funds will be reattributed to this locality next year.
The teams are aware that December has historically been a lower month for referrals and prevalence. In order to prepare for this, the
teams are working to increase referrals and assessments in October and November.
The leadership team, including the recently appointed interim team leaders and admin leads have daily oversight of performance across all
teams. Performance data is examined daily to enable teams to respond quickly to areas of deficit in prevalence and, in conjunction with
team members, directs resources within each specific locality. Deficits and risk areas to achieve prevalence are highlighted at team and
management level and are escalated to the Leadership team and the Network managers immediately in order to expedite actions.
The team continues to increase 'Taster' and awareness sessions in M7 to improve prevalence across teams. Mindsmatter continues to
enhance the diversity of the audience for taster sessions.
Performance Management
2.1 Performance Activity Community & Wellbeing – IAPT Prevalence
42
Actions: Due: Owner: Outcome:
1. West Lancs additional taster sessions planned for
Aug, Sept, Oct.
31-Aug-17
revised to
31-Dec-17
Team Leader This action is ongoing for 3 months to increase
prevalence. Taster sessions continue alongside
exploring direct referral options.
2. Action plan developed with Preston and St Helens to
increase prevalence.
30-Sep-17
revised to
31-Dec-17
Service Manager Acton plan remains in place.
Jun-17 Jul-17 Aug-17 Sep-17 Oct-17
1.13% 1.27% 1.38% 1.20% 1.09%
1.47% 1.31% 1.45% 1.38% 1.40%
1.64% 1.42% 1.22% 1.30% 1.38%
1.36% 1.44% 1.35% 1.37% 1.33%
1.46% 1.41% 1.07% 1.24% 1.67%
1.40% 1.46% 1.32% 1.27% 1.03%
1.31% 1.07% 1.09% 1.43% 1.56%
1.34% 1.08% 1.48% 1.21% 1.33%
1.43% 1.28% 1.22% 1.26% 1.30%
CWB IAPT Prev CCG (Monthly)
NHS Blackburn with Darwen CCG
NHS Chorley & South Ribble CCG
NHS East Lancashire CCG
NHS Fylde & Wyre CCG
Total Figure - 8 CCGs
NHS Greater Preston CCG
NHS Morecambe Bay CCG
NHS West Lancashire CCG
NHS St Helens CCG
Performance Management
2.1 Performance Activity Community & Wellbeing – IAPT Prevalence
43
Performance Management
2.1 Performance Activity Community & Wellbeing – IAPT Prevalence
44
Performance Management
2.1 Performance Activity Community & Wellbeing – IAPT Waits
45
IAPT - Waits:
• 1 person has been waiting over 26 weeks for CBT in BwD, this is an increase from September
• 1 person has been waiting over 26 weeks for CBT in Greater Preston, this is an increase from September
• 2 people have been waiting over 26 weeks in West Lancs, this is a reduction from September
• 9 people have been waiting over 26 weeks for CBT in Fylde and Wyre, this is a reduction from September
• All people waiting over 26 weeks have been reviewed.
In Preston and BwD, the patients have been reviewed and either appointments offered or the wait is due to patient request.
In Fylde and Wyre, an action plan has been implemented to manage and reduce the waiting list. The action plan will remain in place,
supported by the Clinical Lead for CBT with weekly monitoring by the Leadership team. This will remain in place until significant
improvement is sustained. Supplementary CBT resource has been introduced from the Women's Centre and CBT staffing across teams
is being reviewed to increase input into the Fylde and Wyre team.
In West Lancs, the increase in counselling waiting times is due to staff leaving and sickness. An action plan is in place supported by the
Clinical Lead for Counselling. In addition, counselling staff via the existing Women's Centre contract have recently commenced in
increase the resource in the West Lancs Team.
Waiting times across each waiting time bracket are also being reviewed weekly by the leadership team and priority areas are being
addressed at management and team level.
Direct referral is being explored to improve waiting times.
Performance Management
2.1 Performance Activity Community & Wellbeing – IAPT Waits
46
Actions: Due: Owner: Outcome:
Internal performance reporting increased and reviewed to closely
monitor waiting times across the teams.
30-Sep-17
revised to
31-Dec-17
Service
Manager
This will remain in place as there is a large
amount of staff movement in Quarter 3 which
will have an impact on waiting times.
Performance Management
2.1 Performance Activity Children & Young People’s Wellbeing – EIS
47
EIS (Therapies):
Findings from validations conducted from concerns raised, indicated that the EIS 2ww standard has been reported at an inflated rate due
to inaccuracies within data recording. These issues have been raised to an executive level. Following on from this, a validation of all
records from April 2017 has been completed and data has been updated.
Main issues that have been identified as causing delay with the 2ww standard are:
• Lack of timely referrals to the EIS team
• Lack of timely telephone/Face to face treatment contact
It is estimated that to be able to achieve quarter performance, the network will have to achieve 80-90% for November and December,
although this forecast should improve when further analysis is completed Oct-17.
Performance Management
2.1 Performance Activity Children & Young People’s Wellbeing – EIS
48
Actions: Due: Owner: Outcome:
1. Establishment of daily teleconference focusing on achieving
the 2 week target for new referrals Oct-17
Deputy Head of
Operations These calls are now fully embedded.
2. Develop PTL and performance forecasting/tracking tool to
inform daily huddles Oct-17 Performance Lead Complete
3. Review and amend SOP to ensure clarity and triangulation
with most recent national Guidance Jan-18 Deputy Director Underway
4. Validate PTL to ensure it presents an accurate starting point
of current patients waiting Nov-17
Network Lead
Psychologist On target for completion
5. Provide additional oversight to monthly validation of patients
treated each month Oct-17 Performance Lead
October complete and plan in place
for future months
6. Appoint 2 week wait coordinator to manage pathways of
referred patients Nov-17
Deputy Head of
Operations Candidate appointed and has a start
date of 27/11/17
7. Appoint to vacant Band 8a Manager post Jan-17 Deputy Head of
Operations Currently out to advert
8. Review demand, activity and capacity across EIS pathway Nov-17 Deputy Head of
Operations
DTOC cases being progressed by
Care Group Manager, Productivity
and caseload information under
examination.
9. Review of referral processes to ensure timely receipt by
service, including a review of impact of Bluelight 71 Dec-17
Deputy Head of
Operations
In the interim, contact being made
daily with SPoA and AMH teams in
each locality. This is being extended
to include AMH admission wards
10. Review of allocation processes for telephone and first face
to face with case manager to plan for sufficient timely first face
to face treatment appointments. Dec-17
Deputy Head of
Operations and
Lead Psychologist
11. Establish an operational team to clear long term EIS case
backlog Dec-17
Head of
Operations
12. Training update for staff and team leaders on NCRS,
EDMS and records management Jan-18
Deputy Head of
Operations
Performance Management
2.1 Performance Activity Children & Young People’s Wellbeing – Child Psychology
49
Child Psychology (Total Network Performance):
In M7, overall service performance increased to 89%, an increase of 4.6% from M6, and this is the fifth consecutive monthly increase (+26% since May
17).
Three out of the five team’s performance remains above the target of 95% (BwD/EL; Blackpool; Fylde and Wyre) and two teams under the target. The
total number of SUs on the waiting list reduced to currently 290 from 315 in M6, of which 32 are waiting over 18 weeks – a reduction from 17 in M6.
75% of waiters over 18 weeks are now from Lancaster Team (24).
Issues affecting performance:
Preston Community
Performance increased to 93% in M7. The total number of children waiting over 18 weeks for treatment has reduced further to 2, the lowest level in the
last year. One of the 3 over 18 weeks DNA’d their appointment and the other 2 have TCI dates.
Lancaster
Performance decreased to 55.6% in M7 from 60.6% in M6 - the only area that saw worsening performance. Of the 24 SUs waiting over 18 weeks, 4
have a TCI date in M8 and 1 in M9.
An agency clinical psychologist completed her contract in M5, whilst another clinical psychologist is on long term sickness, leaving a capacity gap.
Funding has been provided for an additional one day a week from a CAMHS practitioner and there is an agency psychologist assisting with caseloads.
These actions make some steps to manage demand; however there is a national shortage of psychologists which is impacting on the opportunities to
improve performance.
Performance Management
2.1 Performance Activity Children & Young People’s Wellbeing – Child Psychology
50
Actions: Due: Owner: Outcome:
In Lancaster CPS, a request for extra capacity in the team will be
discussed with the Care Group Manager. 30-Nov-17
Service
Manager
Performance Management
2.1 Performance Activity Children & Young People’s Wellbeing – CAMHS Tier 3
51
CAMHS Tier 3
In M7, overall service performance reduced by 2.2% from 59.1% to 56.9% (382 SUs). This equates to 289 out of 671 waiting over 18
weeks for treatment. The total number of SUs on the waiting list increased to currently 671 from 575 in M6. Two out of the five team’s
performance remains above the target of 95% (West Lancashire and Fylde and Wyre) and three teams under the target.
Issues affecting service level performance:
Chorley and South Ribble
Performance increased in M7 to 40.2% from 39.9% in M6. There are currently 264 out of 440 SUs waiting over 18 weeks. 22 SUs have
TCI dates in November so far and more slots are available. The longest wait is currently 52 weeks. Processes are in place for the top 25
waiters to be written to each week from the beginning of M8. This action will ensure that all families down to 36 week wait will have been
contacted in M8. Families are invited to call and can be offered an appointment, or advise they no longer require a service. If no response
results from the letter, the referrer is written to advising of no further action from CAMHS. As appointments are being booked at families
discretion, the longest waits may not show improvement until the end of M10.
Vacancies are being progressed and one long term sickness absence with no anticipated date for return at present is being progressed
within the LCFT Absence Management Policy.
Preston
Performance reduced to 85.6% in M7 from 89.6% in M6. There are currently 18 out of 125 SUs waiting over 18 weeks. 16 SUs have TCI
dates. The longest waiter is 33 weeks.
Lancaster
Performance also reduced in M7, from 75% in M6 to 57.9%. There are currently 8 out over 19 SUs waiting over 18 weeks. 6 SUs have
TCI dates. The longest waiter is 25 weeks.
The increase in waiting times reflects a reduction in capacity to meet demand due to sickness in the team. There is an agency
psychologist assisting with caseloads, and other strategies to improve capacity are being considered.
Performance Management
2.1 Performance Activity Children & Young People’s Wellbeing – CAMHS Tier 3
52
Actions: Due: Owner: Outcome:
1. Weekly SITREP has been established to monitor progress with all
underperforming teams attending.
Weekly
review
Dep Head of
Ops/ Service
Manager
Improve effectiveness of the team.
2. Waiting list reduction trajectory developed and populated ready for
RAC to use. 23-Oct-17
Network
Performance
Analyst
This has now been implemented and
will be reviewed weekly.
3. HR still supporting the long term sickness absence. 31-Dec-17 Service
Manager Ongoing.
4. Admin processes are being reviewed in the Referral Assessment
Centre (RAC). Options paper to be drafted regarding future functioning of
the RAC.
23-Oct-17
revised to
30-Nov-17
Service
Manager
Ensure correct cases are on waiting
list each week.
5. 25 validation letters a week to be sent to waiters down to 36 weeks for
CSR. 30-Nov-17
Service
Manager
6. 12 Initial Appointments each week to be arranged. 30-Nov-17 Performance
Analyst
Performance Management
2.1 Performance Activity Children & Young People’s Wellbeing – Occupancy
53
Occupancy:
In M7, bed occupancy performance at The Cove increased to 78.9% from 68.2% in August 17, against the target of 85%. The CAMHS
Outreach Team received 31 referrals at The Cove, and 15 of these referrals resulted in admission.
There were 13 discharges from The Cove in October 2017.
Length of stay of discharges during August 2017 was 26.6 days against the national benchmark of 83 days.
Issues affecting performance:
The Cove was open to admissions through August and was running at full capacity. Bed occupancy was reflective of demand for beds
throughout the North West.
There are no actions for this measure.
Performance Management
2.1 Performance Activity Children & Young People’s Wellbeing – ADHD
54
ADHD:
The proportion of new referrals to the ADHD service waiting under 18 weeks for treatment was 36.7% as at the end of M7. This equates to
104 out of 283 new referrals waiting under 18 weeks. Performance improved slightly from M6 (34.7%).
Issue affecting performance
• A request to recruit has been completed to fill a current vacant post for an NMP, and has been identified for the North area.
• It is expected that this will create 3 NMP posts each with a specific locality as their prime caseload, North, Central and East and will
provide further efficiencies.
• The NMP recently joining the service has now begun independently prescribing under close supervision of the team leader, again
creating capacity.
• Improvements in data processes have been completed with teams to ensure timely, accurate and appropriate reporting of performance.
• In M7, a presentation was delivered to Mental Health Quality and Performance Group, describing lessons learnt from the delivery of
Adult ADHD Service. The presentation included the analysis of New and Transitional referrals, and highlighted strategies to improve
the service offer going forward. CSU advised further discussion would occur between Trust and Commissioners
Actions: Due: Owner: Outcome:
1. A new service model to be developed, focusing on effective gatekeeping
and triage alongside robust efficiency of treatment. 30-Nov-17
Service
Manager
More effective service
provision.
Reduction in waiting
times.
2. Change the referral route process. 30-Nov-17 Service
Manager
3. Validate existing waiting lists. 31-Dec-17 Service
Manager
4. Set up a virtual neuro-development assessment team. 31-Jan-18 Service
Manager
5. Review all service users who are stable and also open to Adult Mental
Health (AMH) with aim to transfer to AMH. 31-Mar-18
Service
Manager
6. Seeking approval to recruit to additional permanent Band 7 nurse
prescriber, to help reduce waiting list. 30-Sep-17
Service
Manager Recruitment is ongoing.
7. A second NMP has been in post for 3 months and training is still in
process. There will be a gradual improvement to the waiting list following this
preceptorship.
End of Oct Service
Manager Improved staff capacity.
Performance Management
2.1 Performance Activity Children & Young People’s Wellbeing – ADHD
55
Performance Management
Patient Flow
Section 2.2
56
Performance Management
2.2 Patient Flow Summary – Patient Flow
57
Indicators achieved Target Type Target Oct-16 Nov-16 Dec-16 Jan-17 Feb-17 Mar-17 Apr-17 May-17 Jun-17 Jul-17 Aug-17 Sep-17 Oct-17Rolling 12 Month
Sparkline
Patient Flow
Average Number of Patients (OAPS) Commissioner 15 22.65 33.10 27.42 22.48 23.29 23.42 24.27 25.52 25.67 24.23 23.68 26.17 24.58
OAPS Occupied Bed Days Commissioner 465 702 993 850 697 652 726 728 791 770 751 734 785 762
LCFT and OAPS Occupancy % (Total Network Performance) Commissioner 85.00% - 104.8% 100.6% 101.1% 98.2% 96.8% 105.7% 106.1% 106.4% 105.4% 107.4% 107.6% 107.9%
Number of LCFT and OAPS Occupied Bed Days (Total Network
Performance)Commissioner 9836 - 10943 10880 10667 10009 10927 10593 10988 10665 10917 11120 10777 11171
LCFT and OAPS Occupancy % (AMH) 102.4% 107.1% 101.0% 102.9% 102.8% 101.2% 108.6% 107.9% 108.0% 107.7% 107.6% 108.9% 108.3%
Number of LCFT and OAPS Occupied Bed Days (AMH) 8351 8481 8297 7799 7630 8317 8148 8364 8097 8349 8340 8167 8394
LCFT and OAPS Occupancy % (OA) 97.7% 97.7% 99.2% 96.5% 85.8% 85.0% 97.0% 100.8% 101.9% 98.6% 106.8% 103.6% 106.6%
Number of LCFT and OAPS Occupied Bed Days (OA) 2544 2462 2583 2868 2379 2610 2445 2624 2568 2568 2780 2610 2777
LCFT only Occupancy % (Total Network Performance) NHSE 85.00% 99.5% 99.6% 96.9% 98.7% 100.1% 98.5% 98.5% 98.5% 98.8% 98.7% 100.3% 101.9% 100.5%
Number of LCFT only Occupied Bed Days (Total Network Performance) Stretch 9836 7649 9950 10030 9970 9357 10201 9865 10197 9895 10216 10386 10212 10409
LCFT only Occupancy % (AMH) 99.5% 100.3% 96.1% 99.6% 99.9% 99.1% 99.2% 98.3% 99.0% 98.7% 98.9% 99.9% 99.5%
Number of LCFT only Occupied Bed Days (AMH) 7649 7491 7447 7102 6990 7679 7437 7622 7426 7648 7665 7492 7715
LCFT only Occupancy % (OA) - 97.6% 99.2% 96.5% 100.6% 96.9% 96.3% 98.9% 98.0% 98.6% 104.5% 107.9% 103.5%
Number of LCFT only Occupied Bed Days (OA) - 2459 2583 2868 2367 2522 2428 2575 2469 2568 2721 2720 2694
Secure Overall Gross Occupancy NHSE 93.00% 90.5% 90.5% 90.2% 91.8% 93.3% 93.7% 97.2% 95.9% 96.0% 94.2% 91.3% 91.0% 92.4%
Average Episode Length of Stay (LOS) (AMH) Bench 31 41.70 31.30 31.20 29.72 40.23 33.00 34.70 36.10 46.40 47.60 29.60 33.30 38.80
Average Ward Length of Stay (LOS) (PICU) 47.70 58.50 45.08 58.50 55.20 37.80 39.90 35.10 38.80 30.10 27.60 38.10 34.00
Average Episode Length of Stay (LOS) (OA) 119.60 109.40 144.50 123.56 95.35 115.60 122.30 135.50 97.90 104.50 86.90 95.00 129.80
Re-Admission Rates - 30 Days (AMH) % NHSE <8.7% 9.9% 9.1% 16.7% 7.8% 12.6% 9.5% 15.3% 13.8% 14.8% 11.5% 6.9% 6.7% 8.6%
Re-Admission Rates - 30 Days (AMH) Number of patients NHSE 16 20 22 36 18 24 22 31 30 30 24 14 13 16
Re-Admission Rates - 30 Days (OA) % NHSE <8.7% - 0.0% 4.5% 0.0% 0.0% 3.4% 8.0% 0.0% 4.0% 0.0% 3.7% 0.0% 0.0%
Re-Admission Rates - 30 Days (OA) Number of patients NHSE 1 - 0 1 0 0 1 2 0 1 0 1 0 0
Re-Admission Rates - 90 Days (AMH) % NHSE 15% 17.7% 12.8% 25.0% 16.5% 23.0% 19.0% 20.7% 22.6% 22.2% 18.7% 17.3% 12.9% 15.1%
Re-Admission Rates - 90 Days (AMH) Number of patients NHSE 28 36 31 54 38 44 44 42 49 45 39 35 25 28
Re-Admission Rates - 90 Days (OA) % NHSE 15.00% - 0.0% 4.5% 0.0% 0.0% 13.8% 0.0% 10.3% 4.0% 5.3% 7.4% 0.0% 0.0%
Re-Admission Rates - 90 Days (OA) Number pf patients NHSE 2 - 0 1 0 0 4 - 3 1 1 2 0 0
Performance Management
2.2 Patient Flow Out of Area Placements (OAPS)
58
OAPS:
The average number of OAPs decreased slightly in October by 1.59 alongside a decrease in the OAP OBD in October with a position of
762, a decrease of 23 from September.
The overall number of OAPs remains relatively static against an assumed fall in the trajectory. As reported last month, given the positive
impact of Intensive Community Support Schemes on admission numbers, focus remains on those patients of over 180+ day Length of
Stay on acute mental health wards. Case review confirms that these patients are ready for their next stage of treatment away from the
acute ward or PICU that they are on. The patient cohort have chronic mental health presentations with slow responses to treatment.
Typically, their presentations fall short of the threshold for a secure services bed, but will not be accepted by independent providers.
LCFT have agreed with commissioners to establish an integrated discharge team to manage this patient cohort, with a planned go-live
of December for this team. STP leads have agreed that the costs of ‘discharge to assess' beds are not within the OAPs spend, as this is
a clear and distinct cohort of patients to those require an OAP due to an acute presentation. As report in October, from the current
inpatient cohort, zero 180+ day cases would result in zero acute OAPs and LCFT occupancy on acute wards below 100%, zero older
adult OAPs and LCFT occupancy on older adult wards below 100%, and zero PICU OAPS. The lead commissioner has responded to an
initial formal letter regarding the impact of 180+ Day LOS, and further dialogue is underway.
Performance Management
2.2 Patient Flow OAPS
59
Actions: Due: Owner: Outcome:
1. Maintain focussed case review panel with senior
commissioning managers. Nov-17
Capacity &
Flow Manager
Ongoing; benefits are realised with
focussed discussions.
2. Daily bed calls with Service Managers to address blocks to
discharge such as funding delays. Nov-17
Bed
Management Ongoing.
3. Maintain the process of identifying and escalating all 180+ day
LOS inpatients for review. Fortnightly scheduled meeting in
place with stakeholders regarding review of these patients.
Nov-17 Capacity &
Flow Manager
Fortnightly meetings are taking place
improving the flow of patients with a LOS
of 180+ days.
4. Continue regular review of C&WL OAPs to identify any that
can be stepped to the Crisis House/beds. Nov-17
Capacity &
Flow Manager /
Central CGM
Ongoing.
5. Produce report on the use of Habilitation beds. Nov-17 Capacity &
Flow Manager
6. Desktop review of all LCFT PICU patients with a longer than
anticipated LOS to ensure they are in the right care setting.
Action plans to be developed for all patients not in the right care
setting.
Oct-17
Deputy Head of
Operations /
Capacity &
Flow Manager
Reviews have taken place, and cases are
being review by the PICU CAG (joint
LCFT/CSU review group) to identify
appropriate providers for onward treatment
when indicated.
Performance Management
2.2 Patient Flow OAPS Trajectory
60
Performance Management
2.2 Patient Flow Occupancy – Mental Health
61
Occupancy:
LCFT and OAPs Occupancy position in October increased from the September position at 107.89%. The occupancy for LCFT beds in
October was 100.53%, thus the requirement for OAP beds.
Actions: Due: Owner: Outcome:
1. MCAP standardisation workshop for defining non-qualified bed days
consistently across Trust Wards Dec-17
Deputy Head
of Operations
2. Integrated Discharge Team to become operational Dec-17 Head of
Operations
Performance Management
2.2 Patient Flow Occupancy – Mental Health Total
62
Performance Management
2.2 Patient Flow Occupancy – Adult Mental Health
63
Performance Management
2.2 Patient Flow Occupancy – Older Adults
64
Performance Management
2.2 Patient Flow Mental Health – Average Length of Stay – PICU
65
Average Ward Length of Stay - PICU:
The Network is reporting an average length of stay of 34 days. This is above the Trust set target of 30 days however is a decrease from
September's position.
The Network has maintained a LOS under 40 days for eight months for PICU, indicating a level of stability. The Joint Advisory Group is
having a positive impact on PICU LOS and the feedback from Care Co-ordinators and the Gateway team is positive about this group.
Average LOS in PICU skewed by use of PICU to provide medium/long-term placement for patients with high dependency needs and no
identified available suitable placement.
Actions: Due: Owner: Outcome:
1. Commissioners are also joining twice weekly conference calls to
assist with alleviating any blockages in the discharges of patients. Nov-17
Capacity &
Flow Manager Ongoing.
2. Discharge planning for all patients near completion of
assessment/treatment to be discussed daily at the bed call. Nov-17
Capacity &
Flow Manager
3. Escalation routes are clear - the capacity and flow manager is to be
utilised to expedite any difficulties. Nov-17
Capacity &
Flow Manager
Performance Management
2.2 Patient Flow Mental Health – Average Episode LOS – Adult
66
Average Ward Length of Stay - Adult:
The Network is reporting an average LOS of 38.80 days for October, an increase from September's position. PICU LOS is included within
the Average Network LOS.
Actions: Due: Owner: Outcome:
1. Commissioners are also joining twice weekly conference calls to
assist with alleviating any blockages in the discharges of patients. Nov-17
Capacity &
Flow Manager Ongoing.
2. Discharge planning for all patients near completion of
assessment/treatment to be discussed daily at the bed call. Nov-17
Capacity &
Flow Manager
3. Escalation routes are clear - the capacity and flow manager is to be
utilised to expedite any difficulties. Nov-17
Capacity &
Flow Manager
Performance Management
2.2 Patient Flow Mental Health – Average Episode LOS – Older Adult
67
Average Episode Length of Stay – Older Adult:
M7 has seen an increase in the average length of stay, reporting an average LOS 129.8 days.
Continued efforts in proactive discharge management across all wards and an additional member to the discharge facilitator team has
added support across the wards, working towards timely discharge.
Actions: Due: Owner: Outcome:
1. Commissioners are also joining twice weekly conference calls to
assist with alleviating any blockages in the discharges of patients. Nov-17
Capacity &
Flow Manager Ongoing.
2. Discharge planning for all patients near completion of
assessment/treatment to be discussed daily at the bed call. Nov-17
Capacity &
Flow Manager
3. Escalation routes are clear - the capacity and flow manager is to be
utilised to expedite any difficulties. Nov-17
Capacity &
Flow Manager
Performance Management
2.2 Patient Flow Mental Health – Readmission Rate (90 days)
68
Re-Admission Rate (90 Days):
The Network achieved compliance with the 90 day re-admission rate this month with14% for M7. This includes Older Adult ward data.
The underlying position with Adult Wards has declined from M6 with a position of 15.14%. Older Adults had no re-admissions in M7.
28 cases were re-admitted within 90 days. These include the 16 cases re-admitted within 30 days. 12 cases were re-admitted 31-90 days
after discharge.
Actions: Due: Owner: Outcome:
1. Team Leaders to ensure to review in CMHT/CRHTT
Clinical Discussion Meetings.
Nov-17 revised
to Jan-18 Team Leaders
Target date revised, this process will be
designed within sectorisation process, and
delayed timescale to ensure appropriate
process has been decided on given that the
target is being met currently and so there is no
urgent pressure on this indicator.
2. Re-admission data to be routinely reviewed in Locality
Governance groups.
Nov-17 revised
to Jan-18 Team Leaders
Target date revised, this process will be
designed within sectorisation process, and
delayed timescale to ensure appropriate
process has been decided on given that the
target is being met currently and so there is no
urgent pressure on this indicator.
Performance Management
2.2 Patient Flow Mental Health – Readmission Rate (90 days)
69
Performance Management
Data Quality
Section 2.3
70
Performance Management
2.3 Data Quality Summary – Data Quality
71
Indicators achieved Target Nov-16 Dec-16 Jan-17 Feb-17 Mar-17 Apr-17 May-17 Jun-17 Jul-17 Aug-17 Sep-17 Oct-17 Sparkline
PBR Clustering
Trust PBR Clustering 95% 96.06% 96.28% 96.75% 96.37% 96.43% 96.45% 96.66% 96.64% 96.44% 95.70% 95.90% 95.00%
Mental Health PBR Clustering 95% 96.12% 96.43% 96.78% 96.37% 96.48% 96.47% 96.63% 96.65% 96.44% 95.70% 95.90% 95.10%
Children & Young People's Wellbeing PBR Clustering 95% 94.90% 93.60% 96.16% 96.31% 95.35% 95.99% 97.17% 96.35% 96.51% 95.10% 95.30% 95.10%
Allocated Patients (within 2 weeks)
Trust Allocated Patients 0 472 454 461 413 443 430 300 228 242 223 - -
Mental Health Allocated Patients 0 331 307 313 255 260 267 255 211 233 203 - -
Community Wellbeing Allocated Patients 0 12 11 12 12 7 15 13 2 7 19 - -
Children & Young People's Allocated Patients 0 13 14 8 18 29 23 5 4 2 2 - -
Manual Overrides
Trust NHSI Manual Overrides 0 6 16 21 11 13 2
MR01 NHSI Manual Overrides 0 5 4 6 8 1 0
MR07 NHSI Manual Overrides 0 1 11 6 3 8 0
Other NHSI Manual Overrides 0 0 1 9 0 4 2
Note: Allocated patients figures are not provided for September or October as the report is offline due to a technical error. The report has been redefined and rebuilt and is
in the process of final validation.
Performance Management
2.3 Data Quality Data Quality – Manual Overrides
72
Manual Overrides:
A combination of better recording, checking and reporting has seen manual overrides greatly reduce. Meetings have been diarised
aimed at addressing those that remain.
Performance Management
73
Section 3:- Finance and Contracting
Section 3.1:- Financial Activity
• UoR Risk Rating
• Summary I&E Position
• Summary of Clinical Services
• CIPS
• Capital Expenditure
Section 3.2:- Contract Activity
• Community & Wellbeing – Network Line Totals
• Community & Wellbeing – Service Line Totals
• Community & Wellbeing – Total Activity Split by CCG
• Community & Wellbeing – Activity Exception Reports by CCG
• Children & Young People’s Wellbeing – Service Line Totals
• Children & Young People’s Wellbeing – Exception Reports by Service
• Children & Young People’s Wellbeing – Total Activity Split by CCG
• Mental Health – Total Activity Split by CCG
• Mental Health – Activity Totals
Section 3.3:- Commissioning for Quality & Innovation
• CQUIN Executive Summary
3. Finance and Contracting
Performance Management
Financial Activity
Section 3.1
74
Performance Management
Use of Resources rating (UoR)
The current I&E position gives a rating of 4 and delivers a Capital Service rating of 4 constraining the current overall UoR to
a 3. Assuming current pressures and risks are addressed through the recovery plan and I&E performance achieves (or
exceeds) forecast the Trust will achieve a UoR of 2 in line with the plan. However, though forecast would achieve the overall
target rating, Capital Service is based on EBITDA and since part of the Trusts recovery plan is based on disposals (which
are excluded from EBITDA) the Trust is not forecast to achieve planned Capital Service. The Trust is also forecast to
exceed its liquidity and slip against it's planned Agency target.
Should conditions persist and costs not be managed within the control total then the resulting deterioration might trigger a
review of our segmentation.
3.1 Financial Activity Use of Resources (UoR) Risk Rating
75
FINANCE AND USE OF RESOURCES RATING
Plan Actual Plan Forecast
Capital service cover rating 3 4 2 3
Liquidity rating 2 1 2 1
I&E margin rating 2 4 2 2
I&E margin: distance from financial plan 1 3 1 2
Agency rating 1 2 1 2
Overall 2 3 2 2
Year to Date Annual
Performance Management
Sustainability
Month 7 sees a year to date operating deficit of -£2.3m, excluding planned Sustainability and Transformation funding of
£0.9m, against a planned surplus to date of £0.6m. This represents a small budgetary surplus in month and nearly £0.2m
when excluding STF monies and indicated the position has improved in month. The position remains driven by staffing
pressures in ward and prison areas and consequential impact on cost improvement programmes (rising agency costs will
also impact Use of Resources targets). Additionally OAPs expenditure continues to exceed funding. The forecast assumes
current pressures and risks are addressed or mitigated in line with the recovery plan and financial performance achieves (or
exceeds) plan but the unmitigated projection indicates a gap of c£4.8m, c£6.9m without STF monies. This is represents an
improvement on month 6 (£6.2m), and is driven by excess OAPs of c£0.8m (all be that significantly below last month),
prisons and additional mental health pressures. Delivery of the recovery plan and financial targets will required a significant
and coordinated response with robust management and oversight.
3.1 Financial Activity Summary I&E Position
76
FUNDED WTE BUDGET DETAIL BUDGET ACTUAL £ ANNUAL PROJECTED £
EST. ACTUAL TO DATE TO DATE VARIANCE BUDGET ACTUAL VARIANCE
£'000 £'000 £'000 £'000 £'000 £'000
Healthcare Income 178,911 178,212 -699 303,991.4 304,576 584
5,731.5 5,771.4 Clinical Services -134,317 -139,980 -5,663 -228,457 -237,031 -8,574
761.8 702.9 Corporate Services -30,638 -30,565 73 -53,187 -52,615 572
Reserves and Capital Charges -13,956 -10,136 3,820 -22,348 -12,949 9,398
6,493.3 6,474.3 -2,469 -2,469 1,980 1,980
Performance Management
3.1 Financial Activity Summary of Clinical Services
77
FUNDED WTE BUDGET DETAIL BUDGET ACTUAL £ % ANNUAL PROJECTED £
EST. ACTUAL TO DATE TO DATE VARIANCE VARIANCE BUDGET ACTUAL VARIANCE
£'000 £'000 £'000 £'000 £'000 £'000
PAY
2,956.8 3,181.7 ADULT PAY 68,171.7 73,959.1 -5,787.3 -8.5 116,697.6 124,971.6 -8,274.0
NON PAY 6,901.8 7,875.8 -974.0 -14.1 10,206.4 11,817.2 -1,610.8
PATIENT RELATED INCOME -335.6 -485.4 149.9 -44.7 -496.7 -871.3 374.6
NON PATIENT RELATED INCOME -1,205.5 -1,337.7 132.2 11.0 -2,066.6 -2,320.0 253.4
2,956.8 3,181.7 TOTAL 73,532.4 80,011.7 -6,479.3 -8.8 124,340.7 133,597.6 -9,256.8
1,616.4 1,525.6 ADULT COMMUNITY PAY 32,474.5 33,087.7 -613.2 -1.9 55,868.6 56,741.0 -872.5
NON PAY 7,162.2 6,815.7 346.4 4.8 12,339.3 12,243.2 96.1
PATIENT RELATED INCOME -5,102.6 -5,180.2 77.7 -1.5 -9,016.5 -9,416.3 399.8
NON PATIENT RELATED INCOME -1,553.5 -1,526.6 -26.9 -1.7 -2,572.5 -2,548.3 -24.2
1,616.4 1,525.6 TOTAL 32,980.7 33,196.6 -215.9 -0.7 56,618.9 57,019.6 -400.7
1,103.2 1,013.2 CHILDREN AND FAMILY PAY 24,753.3 23,961.9 791.5 3.2 42,169.4 41,383.7 785.7
NON PAY 3,041.5 2,539.9 501.6 16.5 4,830.0 4,295.7 534.3
PATIENT RELATED INCOME -1,093.0 -569.6 -523.4 47.9 -1,534.1 -910.4 -623.7
NON PATIENT RELATED INCOME -762.7 -837.1 74.4 9.8 -1,164.6 -1,291.9 127.3
1,103.2 1,013.2 TOTAL 25,939.2 25,095.1 844.0 3.3 44,300.7 43,477.0 823.7
55.2 51.0 PHARMACY PAY 1,566.4 1,428.7 137.8 8.8 2,685.3 2,463.8 221.6
NON PAY 298.4 250.7 47.8 16.0 511.6 477.9 33.7
NON PATIENT RELATED INCOME 0.0 -2.7 2.7 No Budget 0.0 -4.8 4.8
55.2 51.0 TOTAL 1,864.9 1,676.6 188.2 10.1 3,196.9 2,936.8 260.1
5,731.5 5,771.4 TOTAL 134,317.1 139,980.1 -5,663.0 -4.2 228,457.3 237,031.1 -8,573.8
Performance Management
Cost Improvement Programmes
At month 7 with CIPs of c£7.4m against a plan of c£8.4m the Trust is £1.1m behind plan, a deterioration of £0.1m on
month 6 (£1.0m behind plan). The adverse variance is mainly due to a lack of performance on Run Rate Reduction
Programmes on staffing pressures. Compensating schemes have, and continue to be, developed and network
management team are being supported by to implement measures aimed at improving the position.
Note a number of schemes are still being transacted and that mapping of individual schemes to projects and programmes is still
being finalised.
3.1 Financial Activity CIPs
78
Plan Actual Variance Plan Forecast Variance
£'m £'m £'m £'m £'m £'m
Cost Improvement Programmes 6.11 6.69 0.58 11.10 13.10 2.00
Run Rate Reduction Programmes 2.33 0.70 -1.63 4.00 2.00 -2.00
Total 8.44 7.39 -1.05 15.10 15.10 0.00
Year to Date Annual
Performance Management
Capital Expenditure
Progress against the capital programme continues to be slow with year-to-date expenditure at £1.8m against the original
profile of £5.9m. The scheduling profile of many schemes was dependent on a number of tendering exercises (the last of
which, Perinatal, has now been completed), agreements with third parties (now substantially resolved) and final funding
approval (Inpatient schemes approval now received from NHSI, awaiting final confirmation of funds and timing from DH).
Schedules for these and related/dependant schemes are now being finalised through discussions with the incumbent
contractors and the Trust is pushing forward with the work required to complete its capital programme in line with its control
total and funding. Risks of slippage due to the delays remain.
3.1 Financial Activity Capital Expenditure
79
YTD Plan YTD Act Annual Forecast
Oct 2017 Oct 2017 Variance Plan Out-turn Variance
£000 £000 £000 £000 £000 £000
IT Schemes 1.015 0.664 -0.351 1.900 1.900 0.000
Estate and infrastructure Schemes
Large Schemes
MH Inpatient Schemes 3.194 0.401 -2.793 4.580 5.700 1.120
Perinatal 0.000 0.113 0.113 0.000 2.470 2.470
Places of Safety 0.000 0.100 0.100 0.000 0.490 0.490
High Priority Schemes 0.697 0.147 -0.550 1.263 1.260 -0.003
Maintenance and Replacement 0.543 0.310 -0.233 0.930 0.930 0.000
Other (inc. contingency) 0.541 0.099 -0.442 0.918 0.911 -0.007
Total 5.989 1.834 -4.155 9.591 13.661 4.070
Performance Management
Contract Activity
Section 2.2
80
Performance Management
81
3.2 Contract Activity – Variance to Plan Community & Wellbeing - Network Line Totals
2017-18 M7 Activity
LCFT are now providing variances against monthly plans at CCG level, however where C&SR and GP provide services that flex to meet the
demands of the central Lancashire area these will be reported as Central Lancashire Locality. Where services are reporting over and
underperformance of 10% or more, LCFT will produce exception narrative as follows:-
• Underperformance – Explain the current position and issues and where known provide a timeframe of when the service anticipates to be back
on plan.
• Over performance – Explain the reasons for the over performance.
For those services that have been reporting underperformance of 10% or more for 3+ months LCFT have submitted exception reports for the worst
preforming services at CCG level as of M6 with a recovery plan and comprehensive narrative explaining the reasons for their under-performance.
LCFT will provide an exception report with a recovery plan and comprehensive narrative for all other services that have been reporting
underperformance of 10% or more for 3+ months in M7 and M8.
Network17-18 Monthly
PlanApr-17 May-17 Jun-17 Jul-17 Aug-17 Sep-17 Oct-17 YTD 17-18
YTD 17-18
Variance
YTD 17-18
Variance (%)
Planned YTD
17-18
Community & Wellbeing Total 96,998 90,069 94,927 98,778 90,684 91,640 90,102 95,299 651,499 9,435 1.5% 642,064
Children and Young People's
Wellbeing Total 11,118 6,830 9,676 8,101 7,920 7,188 8,855 9,362 57,932 -14,073 -19.5% 72,005
Trust Total Against Plan 108,116 96,899 104,603 106,879 98,604 98,828 98,957 104,661 709,431 -4,638 -0.6% 714,069
Performance Management
82
3.2 Contract Activity – Variance to Plan Community & Wellbeing - Service Line Totals
Service17-18 Monthly
PlanApr-17 May-17 Jun-17 Jul-17 Aug-17 Sep-17 Oct-17 YTD 17-18
YTD 17-18
Variance
YTD 17-18
Variance (%)
Planned YTD
17-18
Adult Learning Disability Service Total 2,603 1,646 2,345 2,312 2,017 2,080 1,985 1,939 14,324 -1,725 -10.7% 16,049
Adult Speech and Language Therapy Total 266 349 298 375 415 368 311 351 2,467 674 37.6% 1,793
CHESS Total 372 307 427 300 96 213 133 246 1,722 -639 -27.1% 2,361
Children's Learning Disability Service Total 1,307 1,235 1,660 1,655 1,363 1,214 1,585 1,578 10,290 2,000 24.1% 8,290
Community IV Service BwD Total 303 84 97 66 118 92 62 145 664 -1,107 -62.5% 1,771
Community Matrons Total 1,658 1,264 1,199 1,293 1,236 1,093 879 848 7,812 -2,504 -24.3% 10,316
Community Neuro Team Total 1,216 1,067 1,245 1,254 1,246 1,260 1,123 1,081 8,276 845 11.4% 7,431
Community Respiratory Service Total 1,814 1,968 2,074 1,933 1,918 2,110 1,798 2,268 14,069 2,391 20.5% 11,678
Community Stroke Service Total 486 339 359 382 431 467 399 557 2,934 -574 -16.4% 3,508
Complex Case Management Total 475 413 395 385 321 294 543 641 2,992 -26 -0.9% 3,018
Continence Service Total 342 227 304 223 234 287 290 267 1,832 -205 -10.1% 2,037
Dermatology Service Total 441 455 489 400 333 433 276 423 2,809 -272 -8.8% 3,081
DESMOND Total 94 65 78 64 75 68 94 123 567 32 6.0% 535
Diabetes Specialist Nursing Total 1,240 847 956 974 1,038 1,152 1,081 1,114 7,162 -856 -10.7% 8,018
District Nursing Total 38,400 40,895 40,999 39,943 37,898 38,888 37,705 39,840 276,168 9,581 3.6% 266,587
Domiciliary Physiotherapy Total 479 701 610 708 704 784 800 918 5,225 2,243 75.2% 2,982
Falls Team Total 419 425 658 656 685 667 727 805 4,623 2,047 79.5% 2,576
Heart Failure Service Total 526 147 249 261 213 220 251 274 1,615 -1,719 -51.6% 3,334
Intermediate Care Total 3,929 2,804 3,168 3,223 2,779 2,747 2,900 2,755 20,376 -5,663 -21.7% 26,039
Nutrition & Dietetics Total 239 269 262 251 289 211 265 334 1,881 220 13.2% 1,661
Oxygen Service Total 356 237 269 313 445 371 333 292 2,260 30 1.3% 2,230
Phlebotomy Total 18,985 16,855 16,160 22,004 17,610 16,671 17,630 18,013 124,943 11,541 10.2% 113,402
Podiatry Total 5,328 4,396 5,455 5,071 5,009 5,083 4,848 5,055 34,917 -1,170 -3.2% 36,087
Pulmonary Rehabilitation Total 569 441 598 680 618 790 597 631 4,355 899 26.0% 3,456
Rapid Assessment Team Total 1,705 1,527 1,735 1,659 1,730 1,700 1,479 1,502 11,332 781 7.4% 10,551
Rheumatology Total 1,568 1,306 1,587 1,729 1,440 1,684 1,641 1,760 11,147 1,176 11.8% 9,971
Specialist Nurse TB Total 343 618 381 525 471 481 533 428 3,437 683 24.8% 2,754
Tissue Viability Service Total 272 228 247 267 296 297 247 282 1,864 -263 -12.4% 2,127
Treatment Room Total 11,218 8,862 10,500 9,768 9,574 9,895 9,446 10,752 68,797 -9,216 -11.8% 78,013
Viral Hepatitis Service Total 45 92 123 104 82 20 141 77 639 231 56.6% 408
Community & Wellbeing Total 96,998 90,069 94,927 98,778 90,684 91,640 90,102 95,299 651,499 9,435 1.5% 642,064
Performance Management
3.2 Contract Activity – Variance to Plan Community & Wellbeing – Total Activity Split by CCG
Community & Wellbeing - Total Activity split by CCG17-18 Monthly
PlanApr-17 May-17 Jun-17 Jul-17 Aug-17 Sep-17 Oct-17 YTD 17-18
YTD 17-18
Variance
YTD 17-18
Variance
(%)
Planned YTD
17-18
Central Lancs Locality Total 18,985 16,855 16,160 22,004 17,610 16,671 17,630 18,013 124,943 11,541 10.2% 113,402
NHS Blackburn with Darwen CCG Total 24,752 21,957 24,654 23,309 23,422 23,699 22,170 24,413 163,624 -4,150 -2.5% 167,774
NHS Blackpool CCG Total 64 150 120 142 97 108 139 72 828 321 63.3% 507
NHS Chorley and South Ribble CCG Total 23,766 26,116 26,299 26,278 24,088 25,577 24,647 25,358 178,363 16,997 10.5% 161,366
NHS East Lancashire CCG Total 866 649 948 772 668 647 887 796 5,367 -22 -0.4% 5,389
NHS Fylde & Wyre CCG Total 499 322 330 478 391 430 464 584 2,999 -167 -5.3% 3,166
NHS Greater Preston CCG Total 27,220 23,281 25,375 24,630 23,500 23,637 23,388 25,237 169,048 -16,038 -8.7% 185,086
NHS Morecambe Bay CCG Total 440 341 486 584 456 396 373 405 3,041 246 8.8% 2,795
NHS West Lancashire CCG Total 406 398 555 581 452 475 404 421 3,286 707 27.4% 2,579
Community & Wellbeing Totals 96,998 90,069 94,927 98,778 90,684 91,640 90,102 95,299 651,499 9,435 1.5% 642,064
Performance Management
3.2 Contract Activity – Variance to Plan Community & Wellbeing – Activity Exception Reports by CCG
Community & Wellbeing Planned Contract Activity M7
The Community & Wellbeing Network has provided the following explanations as to why certain services are underperforming by more than 10% against the baseline.
Commissioner: NHS Blackburn with Darwen CCG
Under Performance Exception Reporting:-
Adult Learning Disability Service 59%-
Current position and issues:
The ongoing work regarding data capture has provided an increase in activity for October. This is despite a reduction of staff during the month. Long term sickness for
the clinical psychologist continues and there have been a number of absences during the month.
Actions:
1. Ongoing validation of the data.
2. Monthly Performance meetings with Team Leaders, Service Manager and Care Group Manager to review performance.
Forecast:
A deep dive into the data continues so understand the full extent of the under-performance however the return from sickness and the improved data capture should start
to have a more positive impact on baseline activity.
Until these further investigations have been carried out it is difficult to propose an accurate recovery trajectory and therefore this will be proposed once the increase in
activity of the returning staff has been quantified.
Service17-18 Monthly
PlanApr-17 May-17 Jun-17 Jul-17 Aug-17 Sep-17 Oct-17 YTD 17-18
YTD 17-18
Variance
YTD 17-18
Variance (%)
Planned YTD
17-18
Adult Learning Disability Service 482 135 189 178 160 143 178 237 1,220 -1,753 -59.0% 2,973
Children's Learning Disability Service 94 106 121 179 109 140 144 124 923 324 54.1% 599
Community IV Service BwD Total 303 84 97 66 118 92 62 145 664 -1,107 -62.5% 1,771
Community Respiratory Service 603 644 596 578 570 621 566 670 4,245 528 14.2% 3,717
Community Stroke Service 486 339 359 382 431 467 399 557 2,934 -574 -16.4% 3,508
DESMOND (Completed Courses) 36 28 25 6 19 11 35 42 166 -40 -19.4% 206
Diabetes Specialist Nursing 515 274 387 265 305 429 414 362 2,436 -901 -27.0% 3,337
Pulmonary Rehabilitation 569 441 598 680 618 790 597 631 4,355 899 26.0% 3,456
Tissue Viability Service 82 105 119 111 121 97 92 126 771 117 17.9% 654
Treatment Room - Non-Serious Injury 130 141 195 189 184 144 166 169 1,188 245 26.0% 943
Treatment Room Total 7,178 5,590 6,359 5,721 5,659 6,008 5,686 6,373 41,396 -8,465 -17.0% 49,861
Treatment Room - Ulcer & Vascular 173 164 260 330 270 272 195 200 1,691 551 48.3% 1,140
Performance Management
3.2 Contract Activity – Variance to Plan Community & Wellbeing – Activity Exception Reports by CCG
Commissioner: NHS Blackburn with Darwen CCG
Under Performance Exception Reporting:-
Community IV Service BwD 62.5%-
Current position and issues:
In M7 the IV team became a step down service only. The service continues to work with BWDCCG and ELHT to maximise referrals. The IV team have capacity to
accept and see more referrals. In M7 the team had the highest number of contacts in this financial year.
In M7 there was a staff member on long term sickness which has had an impact upon our ongoing promotions.
The service continues to support the nursing element of IHSS to ensure all service needs and demands are delivered in a timely way to provide acute responses.
Recovery action plan:
We will continue to promote the IV service in ELHT and other acute sites and liaise with the OPAT nurse at ELHT daily regarding potential patients to try and increase
referrals to the service.
Trajectory:
From October 1st 2017 the service stopped accepting step up referrals from primary Care so this will have a further impact on referrals to the service.
Forecast:
As we will cease to receive step-up referrals this will have an impact on our proposed recovery trajectory.
The IV service continues to work with stakeholder colleagues to promote and identify patients for Community IV therapy.
The staff member who was on long term sick has now returned to work. This will increase our teams capacity and ensure further promotion work can be completed.
Community Stroke Service 16%-
Current position and issues:
The teams monthly plan was to achieve 486 contacts. For M7 this target was exceeded however previous months positions left us at 16.% negative variance. This has
been due to a number of factors. Long term sickness has impacted on our capacity for a number of months but we have also had some short term sickness. In M7 we
have had reduced staff sickness levels.
We continue reviewing the vacancies in terms of skill mix and in line with the Pennine Lancashire stroke specification which is currently being worked on. We aim to start
recruitment as soon as possible.
A locum has now been in place since the beginning of M7 to support Speech and Language Therapy until permanent staff are in place.
Forecast:
With increased staffing levels over the coming months we expect that we will be back within tolerance by M11 and the YTD Plan will be met.
We will continue to build on our working relationships and promoting the service within the acute trust to facilitate timely discharges.
Performance Management
3.2 Contract Activity – Variance to Plan Community & Wellbeing – Activity Exception Reports by CCG
Commissioner: NHS Blackburn with Darwen CCG
Under Performance Exception Reporting continued:
DESMOND (Completed Courses) 19%-
Current position and issues:
Month 7 is showing a negative variance of 19% which equates to a total of 42 contacts. This is an improvement on the previous month of 7.7%.
The service has had problems with long term sickness throughout 17/18 which has reduced the amount of courses it has been able to offer, this was particularly
challenging in months 3,4 &5 but has recovered in recent months with the past 2 months being over plan.
Recovery action plan:
An action plan has been agreed with the CCG which includes the following:
• Team to contact all patients that have been referred in by telephone to give more detail of the value and benefits of attending a DESMOND course
• Increase the number of people trained in Desmond to enable backfill when staff are off sick.
Forecast:
There are 4 courses planned for Month 8 and 2 for Month 9 which should maintain our recovery trajectory which has been set at 10% above monthly plan. If achieved our
year end position should be within our target performance tolerance.
Diabetes Specialist Nursing 27%-
Current position and issues:
The monthly plan was 515 contacts and the team achieved only 362 in M7 leaving us in a -27% negative variance. Due to unplanned levels of sickness within our
Diabetes Education Programme (DESMOND), Diabetes Specialist Nurses supported the education courses so that patients did not have to be cancelled. This however
has had a negative impact on our own Diabetes baseline figures.
Recovery action plan:
A member of staff on long term sickness had now returned to work in M8. In M8 we will expect to see an increase in number of contacts completed.
Forecast:
With the new member of staff in post and DESMOND staff returning to work in M8, we would expect to see an increase in contacts over the coming months leaving us in a
positive year-end position.
Treatment Room
Meetings are taking place in November with Commissioners to understand decreasing activity. The outcomes and subsequent action plans from the meetings will be
published in month 8 QPR.
Performance Management
3.2 Contract Activity – Variance to Plan Community & Wellbeing – Activity Exception Reports by CCG
Commissioner: NHS Blackburn with Darwen CCG
Over Performance Exception Reporting:-
Children's Learning Disability Service 54%+
Current position and issues:
There have been a number of groups running over the past 2 months which has increased our activity figures leaving us in a positive variance of 54% in M7. These
groups are set to continue throughout the year.
Community Respiratory Service 14%+
Current position and issues:
We continue to see high levels of referrals and the service responds to the demand and needs of the population.
Pulmonary Rehabilitation 26%+
Current position and issues:
The current position in maintaining activity over plan is due to the numbers of patients attending and successfully completing their course. This is due to intensive work
contacting patients, building relationships within the service/stakeholders which has resulted in more patients completing a six week course.
Tissue Viability Service 17%+
Current position and issues:
The team have noted an increase in the complexity of the patients requiring more visits. The team are now completing an increasing number of reviews due the
increased number of referrals which are more complex, including referrals from the acute, nursing homes and district nurses. The team continue to meet current
demands.
Performance Management
3.2 Contract Activity – Variance to Plan Community & Wellbeing – Activity Exception Reports by CCG
Commissioner: NHS Blackpool CCG
Over Performance Exception Reporting:-
Specialist Nurse TB 63%+
Current position and issues:
Increased numbers of referrals over several months has contributed to a positive in month variance against plan.
Commissioner: Central Lancs Locality
Under Performance Exception Reporting:-
Community Matrons 24%-
Current position and issues:
Referrals into the matron service have decreased over the last three months which has impacted on activity linked to new face to face contacts and associated reviews.
A reduction in WTE linked to vacancy and implementation of the action plan to support the CHESS service has also impacted on matron activity.
All patients referred have been seen and care plans formulated. New care pathways are being developed between matrons and specialist teams to ensure seamless care
across pathways are in place. This may see a reduction in follow up activity for matrons moving forwards as patients are managed along specialist pathways.
Forecast:
Additional vacancy from the end of November is likely to further impact on activity. It is unlikely that the service will be fully recruited to before M10 and this will further
impact on activity with a projected negative end of year variance of -22%.
Service17-18 Monthly
PlanApr-17 May-17 Jun-17 Jul-17 Aug-17 Sep-17 Oct-17 YTD 17-18
YTD 17-18
Variance
YTD 17-18
Variance (%)
Planned YTD
17-18
Specialist Nurse TB 64 150 120 142 97 108 139 72 828 321 63.3% 507
Service17-18 Monthly
PlanApr-17 May-17 Jun-17 Jul-17 Aug-17 Sep-17 Oct-17 YTD 17-18
YTD 17-18
Variance
YTD 17-18
Variance (%)
Planned YTD
17-18
Adult Speech and Language Therapy Total 266 349 298 375 415 368 311 351 2,467 674 37.6% 1,793
Community Matrons Total 1,658 1,264 1,199 1,293 1,236 1,093 879 848 7,812 -2,504 -24.3% 10,316
Community Neuro Team Total 1,216 1,067 1,245 1,254 1,246 1,260 1,123 1,081 8,276 845 11.4% 7,431
Community Respiratory Service Total 1,211 1,324 1,478 1,355 1,348 1,489 1,232 1,598 9,824 1,863 23.4% 7,961
DESMOND (Completed Courses) Total 58 37 53 58 56 57 59 81 401 72 21.9% 329
Domicillary Physiotherapy Total 479 701 610 708 704 784 800 918 5,225 2,243 75.2% 2,982
Falls Team Total 419 425 658 656 685 667 727 805 4,623 2,047 79.5% 2,576
Heart Failure Service Total 526 147 249 261 213 220 251 274 1,615 -1,719 -51.6% 3,334
Intermediate Care ACS Total 2,799 1,938 2,102 2,155 1,809 1,745 1,954 1,798 13,501 -5,045 -27.2% 18,546
Nutrition & Dietetics Total 239 269 262 251 289 211 265 334 1,881 220 13.2% 1,661
Tissue Viability Service Total 90 49 50 48 53 57 53 50 360 -380 -51.4% 740
Performance Management
3.2 Contract Activity – Variance to Plan Community & Wellbeing – Activity Exception Reports by CCG
Commissioner: Central Lancs Locality
Under Performance Exception Reporting continued:-
Heart Failure Service 51%-
Current position and issues:
The existing staff are supporting the Chorley expansion until new staff in post. This has contributed to the drop in Greater Preston activity in month.
Intermediate Care ACS 27%-
Current position and issues:
Activity in Intermediate Care is to be viewed in the context of Falls and Community Therapies. These are collectively above baseline and delivered as one overall service
specification. Taking account of the overall activity of the combined Community Therapy teams overall they are over-performing. Staff are flexed across all areas within the
Integrated rehabilitation Team to respond according to clinical demand - performance of the combined team is showing well above activity taking into account the
Intermediate Care, Domiciliary Physio and Falls data.
Tissue Viability Service 51%-
Current position and issues:
The patient pathway following referral has been reviewed, and opportunities to access the multi-disciplinary team have been maximised. This supports clear case holding
responsibility and access to services in the wider neighbourhood team, most suited to the patient need (e.g. podiatry). This supports increased availability for consultation
and supervision. Referral rates remain constant.
Over Performance Exception Reporting:-
Adult Speech and Language Therapy 37%+
Current position and issues:
The service have increased their use of non face to face reviews which has had a positive impact on our activity levels. There has also been a significant increase in
referrals over the last 2 quarters of the year. New staff have commenced employment and have full caseloads.
Community Neuro Team 11%+
Current position and issues:
Team resource is flexed across the Central Lancs locality and overall the demand has increased for the service which is reflected in the increase numbers of referrals
across the locality. Overall the service is showing a positive variance.
Performance Management
3.2 Contract Activity – Variance to Plan Community & Wellbeing – Activity Exception Reports by CCG
Commissioner: Central Lancs Locality
Over Performance Exception Reporting Continued:-
Community Respiratory Service 23%+
Current position and issues:
An increase in the number of in month referrals combined with increased acuity of caseload has contributed to increased activity in month.
DESMOND (Completed Courses) 21%+
Current position and issues:
The service currently has an action plan in place to increase uptake of diabetes structured education. This is continuing to deliver improvements in attendance and
contributing to a positive variance in month against plan.
Domiciliary Physiotherapy 75%+
Current position and issues:
The Team's continued over performance reflects activity delivered to support admission avoidance. This activity should also be taken in conjunction with all other
community therapy activity (as part of one combined service specification for Central Lancs Community Rehabilitation Team). This combines Domiciliary Physiotherapy
and Falls Team data. Whilst Intermediate care is showing an underperformance, collectively the rehabilitation team is significantly overperforming on activity - as per
previous exception narrative. Note, Falls data does not include that of Steady On which is reported separately to LCC.
Falls Team 79%+
Current position and issues:
The Team's continued over performance reflects activity delivered to support admission avoidance. This activity should also be taken in conjunction with all other
community therapy activity (as part of one combined service specification for Central Lancs Community Rehabilitation Team). This combines Domiciliary Physiotherapy
and Falls Team data. Whilst Intermediate care is showing an underperformance, collectively the rehabilitation team is significantly overperforming on activity - as per
previous exception narrative. Note, Falls data does not include that of Steady On which is reported separately to LCC.
Nutrition & Dietetics 13%+
Current position and issues:
A high demand for the service combined with increasing numbers of patients requiring ongoing follow up reviews continues to place the service under pressure and
contributes to higher than planned activity.
Performance Management
3.2 Contract Activity – Variance to Plan Community & Wellbeing – Activity Exception Reports by CCG
Commissioner: NHS Chorley & South Ribble CCG
Under Performance Exception Reporting
Adult Learning Disabilities 13%-
Current position and issues:
There have been unfilled vacancies since July and also maternity leave and sickness absence With a significant amount of annual leave in October (half term) this has
contributed to lower activity levels in M7.
Over Performance Exception Reporting:-
Children's Learning Disability Service 48%+
Current position and issues:
Overactivity is due to the number of groups that the team now undertake. The additional activity within Chorley & South Ribble team to see ASD referrals has also
contributed to the increase in activity.
Rheumatology 16%+
Current position and issues:
Increasing numbers of referrals is contributing to increased activity which is both positive in month and YTD variance against plan.
Specialist Nurse TB 28%+
Current position and issues:
Increased numbers of referrals over several months has contributed to a positive in month variance against plan.
Viral Hepatitis Service 19%+
Current position and issues:
Increases in group activity continues to contribute to a positive in month variance.
Service17-18 Monthly
PlanApr-17 May-17 Jun-17 Jul-17 Aug-17 Sep-17 Oct-17 YTD 17-18
YTD 17-18
Variance
YTD 17-18
Variance (%)
Planned YTD
17-18
Adult Learning Disability Service 382 295 394 315 290 263 254 234 2,045 -309 -13.1% 2,354
Children's Learning Disability Service 299 351 504 462 408 273 421 388 2,807 919 48.7% 1,888
Rheumatology 641 579 677 745 631 695 703 720 4,750 674 16.5% 4,076
Specialist Nurse TB 23 35 6 0 39 5 93 62 240 53 28.3% 187
Viral Hepatitis Service 14 20 13 0 15 0 89 15 152 25 19.7% 127
Performance Management
3.2 Contract Activity – Variance to Plan Community & Wellbeing – Activity Exception Reports by CCG
Commissioner: NHS Fylde and Wyre CCG
Under Performance Exception Reporting:-
Adult Learning Disability Service 15%-
Current position and issues:
The revision of the baseline and the continuing validation of the data is reflected in the improving performance and the diminishing YTD variance.
Actions:
1. Ongoing validation of the data.
2. Analysis of data on a weekly basis to identify issues in advance.
3. Monthly Performance meetings with Team Leaders, Service Manager and Care Group Manager to review performance. The focus of these meetings being on
performance and contributing factors.
Forecast:
With the revised baseline and the work to improve data capture coming to fruition it is felt that we will over perform against the new monthly plans by approximately 10%
each month however this will be reviewed and adjusted accordingly once the revised activity levels have been quantified over the next few months.
This trend is expected to continue and may result in a review of baselines for 2018.
Over Performance Exception Reporting:-
Specialist Nurse TB 60%+
Current position and issues:
Increased numbers of referrals over several months has contributed to a positive in month variance against plan
Service17-18 Monthly
PlanApr-17 May-17 Jun-17 Jul-17 Aug-17 Sep-17 Oct-17 YTD 17-18
YTD 17-18
Variance
YTD 17-18
Variance (%)
Planned YTD
17-18
Adult Learning Disability Service 346 168 184 268 210 284 268 415 1,797 -337 -15.8% 2,134
Specialist Nurse TB 36 59 29 83 69 55 101 69 465 176 60.9% 289
Performance Management
3.2 Contract Activity – Variance to Plan Community & Wellbeing – Activity Exception Reports by CCG
Commissioner: NHS Greater Preston CCG
Under Performance Exception Reporting:-
CHESS 39%-
Current position and issues:
The CHESS team supports services across both GPCCG and CSRCCG. Both localities have seen reduced numbers of referrals from 29 in M4 down to only 5 in M7
which is a significant reduction and which has led to reduced activity, although activity has significantly increased in M7.
The team experienced substantial unplanned absence from June onwards which will have contributed to the reduced referrals and impacted upon activity levels over the
last 5 months. Coupled with this, there has been an increase in vacant beds in both homes over the latter months which will also have impacted on referrals to the service
and associated activity.
Recovery Actions:
LCFT have been in regular communication with the CCG and have put actions in place to address the immediate staffing issues within the CHESS service using a rotation
of senior matrons to manage the two intermediate care facilities. This is now working more smoothly and activity has increased in M7. Longer term LCFT has formulated
a business case to create a sustainable integrated frailty service able to work in an integrated and flexible manner to deliver the specifications set out in the Frailty,
CHESS and Community Matron service lines and establishing a longer term sustainable service. This business case is awaiting CCG sign off to enable full recruitment
into appropriate skill mixed roles.
Forecast:
Assuming that bed occupancy and associated referrals increases in line with the time of the year based on previous years referral activity then we would expect to see
activity increasing.
It is unlikely that we will meet the plan in year as recruitment to posts proposed in the new model will need to take place. It is estimated that it will take 3 months to
achieve full recruitment. The trajectory has been based on this and will still give a negative variance of approx -37%.
Service17-18 Monthly
PlanApr-17 May-17 Jun-17 Jul-17 Aug-17 Sep-17 Oct-17 YTD 17-18
YTD 17-18
Variance
YTD 17-18
Variance (%)
Planned YTD
17-18
Adult Learning Disability Service 267 185 298 351 381 430 292 186 2,123 474 28.7% 1,649
CHESS 234 151 222 193 63 70 56 150 905 -581 -39.1% 1,486
Children's Learning Disability Service 264 232 271 275 242 246 327 314 1,907 234 14.0% 1,673
Viral Hepatitis Service 27 70 96 91 62 14 34 37 404 160 65.6% 244
Performance Management
3.2 Contract Activity – Variance to Plan Community & Wellbeing – Activity Exception Reports by CCG
Commissioner: NHS Greater Preston CCG
Over Performance Exception Reporting:-
Adult Learning Disability Service 28%+
Current position and issues:
This months over performance is largely due to consistent communications with staff to record all activity they undertake for a patient. There has also been a
significant increase in referrals to this team over the last quarter resulting in increased activity in M7.
Children’s Learning Disabilities 14%+
Current position and issues:
Over activity is due to the groups that commenced in M6 'Riding the Rapids' These courses are set to continue.
Viral Hepatitis Service 65%+
Current position and issues:
Increases in group activity continues to contribute to a positive in month variance.
Commissioner: NHS Morecambe Bay CCG
Under Performance Exception Reporting:-
Adult Learning Disability Service 14%-
Current position and issues:
Sickness has contributed to targets not being met. 1 nurse on long term sick and a number of short term sickness. There has been no impact to patient care.
Service17-18 Monthly
PlanApr-17 May-17 Jun-17 Jul-17 Aug-17 Sep-17 Oct-17 YTD 17-18
YTD 17-18
Variance
YTD 17-18
Variance (%)
Planned YTD
17-18
Adult's Learning Disability Service 368 184 321 384 300 248 271 234 1,942 -324 -14.3% 2,266
Children's Learning Disability Service 33 91 128 99 80 74 69 108 649 437 206.1% 212
Specialist Nurse TB 39 66 37 101 76 74 33 63 450 133 42.0% 317
Performance Management
3.2 Contract Activity – Variance to Plan Community & Wellbeing – Activity Exception Reports by CCG
Over Performance Exception Reporting:-
Children’s Learning Disability Service 206%+
Current position and issues:
Over activity due to the significant number of groups running e.g. 'Riding the Rapids'. A re-evaluation of baselines may need to be considered in respect of the new
activity and capacity in north Lancs (ASD pathways).
Specialist Nurse TB 42%+
Current position and issues: Significant increases in referrals continues to result in a positive variance against plan.
Commissioner: NHS West Lancashire CCG
Over Performance Exception Reporting:-
Adult Learning Disability Service 74%+
Current position and issues:
This months over performance is largely due to consistent communications with staff to record all activity they undertake for a patient. There has also been a small
increase in referrals received over the last quarter which has led to an increase in activity in M7. The complexity of clients on the caseload has also increased the
numbers of contacts undertaken in month.
Specialist Nurse TB 27%+
Current position and issues:
High levels of referrals continue to contribute to a positive variance against monthly plan.
Viral Hepatitis Service 124%+
Current position and issues:
Increases in group activity continues to contribute to a positive in month variance.
Service17-18 Monthly
PlanApr-17 May-17 Jun-17 Jul-17 Aug-17 Sep-17 Oct-17 YTD 17-18
YTD 17-18
Variance
YTD 17-18
Variance (%)
Planned YTD
17-18
Adult Learning Disability Service 157 230 292 324 187 273 184 198 1,688 721 74.6% 967
Specialist Nurse TB 10 6 11 11 27 14 22 15 106 23 27.7% 83
Viral Hepatitis Service 4 2 14 13 5 6 18 25 83 46 124.3% 37
Performance Management
3.2 Contract Activity – Variance to Plan Children & Young People’s Wellbeing – Total Activity by CCG
96
Children & Young People's Wellbeing -
Total Activity split by CCG
17-18
Monthly PlanApr-17 May-17 Jun-17 Jul-17 Aug-17 Sep-17 Oct-17 YTD 17-18
YTD 17-18
Variance
YTD 17-18
Variance (%)
Planned YTD
17-18
NHS Blackburn with Darwen CCG Total 779 561 753 718 591 535 766 770 4,694 -298 -6.0% 4,992
NHS Chorley and South Ribble CCG Total 2,046 1,011 1,339 1,310 1,178 830 1,198 1,196 8,062 -4,975 -38.2% 13,037
NHS East Lancashire CCG Total 4,663 3,448 5,028 4,026 3,971 3,779 4,438 4,935 29,625 -1,230 -4.0% 30,855
NHS Greater Preston CCG Total 2,908 1,399 1,994 1,524 1,751 1,575 1,876 1,988 12,107 -6,394 -34.6% 18,501
NHS West Lancashire CCG Total 722 411 562 523 429 469 577 473 3,444 -1,176 -25.5% 4,620
Children & Young People's Wellbeing
Total 11,118 6,830 9,676 8,101 7,920 7,188 8,855 9,362 57,932 -14,073 -19.5% 72,005
Performance Management
3.2 Contract Activity – Variance to Plan Children & Young People’s Wellbeing - Service Line Totals
97
Service17-18 Monthly
PlanApr-17 May-17 Jun-17 Jul-17 Aug-17 Sep-17 Oct-17 YTD 17-18
YTD 17-18
Variance
YTD 17-18
Variance (%)
Planned YTD
17-18
Children's Occupational Therapy Total 1,164 618 835 851 610 550 799 785 5,048 -2,651 -34.4% 7,699
Children's Physiotherapy Total 879 574 645 632 580 518 648 679 4,276 -1,294 -23.2% 5,570
Children's Speech & Language Therapy Total 3,389 1,960 2,859 2,573 2,361 1,938 2,772 2,981 17,444 -4,146 -19.2% 21,590
Paediatric Liaison Total 5,686 3,678 5,337 4,045 4,369 4,182 4,636 4,917 31,164 -5,982 -16.1% 37,146
Children and Young People's Wellbeing
Total Against Plan11,118 6,830 9,676 8,101 7,920 7,188 8,855 9,362 57,932 -14,073 -19.5% 72,005
Performance Management
3.2 Contract Activity – Variance to Plan Children & Young People’s Wellbeing – Exception Reports by Service
98
Commissioner: NHS Chorley & South Ribble CCG
Under Performance Exception Reporting:-
Children’s Occupational Therapy 23%-
Current position and issues:
October manual activity data was 204 against a baseline of 240. The current YTD total based on CITNS manual count is 1,220 -338 YTD. (Variance % -23.2%).
Based on the planned activity total, the service is required to see an extra 96 contacts in total to meet the 10% threshold.
Average staff capacity in Chorley & South Ribble OT during the 17/18 monitoring year has been at 100%.
The team continues to now meet RTT target during 17/18.
Paediatric Liaison 62%-
Current position and issues:
The service receives 100% of its referrals from the Emergency Department (ED), and have no control over the number of children attending however the activity is
lower than expected as we are currently unable to identify the activity that is deflected through the Go To Doctor service.
Commissioner: NHS East Lancashire CCG
Under Performance Exception Reporting:-
Children’s Occupational Therapy 14%-
Current position and issues:
October manual activity data was 350 against a baseline of 379. The current YTD total based on CITNS manual count is 2,155 -358 YTD. (Variance % -14%). Based
on the planned activity total, the service is required to see an extra 154 contacts in total to meet the 10% threshold.
Average staff capacity in East Lancashire OT during the 17/18 monitoring year has been at 83%.
The team continues to now meet RTT target during 17/18.
Service17-18 Monthly
PlanApr-17 May-17 Jun-17 Jul-17 Aug-17 Sep-17 Oct-17 YTD 17-18
YTD 17-18
Variance
YTD 17-18
Variance (%)
Planned YTD
17-18
Children's Occupational Therapy 240 116 166 223 186 112 213 204 1,220 -368 -23.2% 1,588
Paediatric Liaison 964 261 434 311 366 291 366 277 2,306 -3,788 -62.2% 6,094
Service17-18 Monthly
PlanApr-17 May-17 Jun-17 Jul-17 Aug-17 Sep-17 Oct-17 YTD 17-18
YTD 17-18
Variance
YTD 17-18
Variance (%)
Planned YTD
17-18
Children's Occupational Therapy 379 279 361 363 250 237 314 350 2,154 -359 -14.3% 2,513
Children's Speech & Language Therapy 1,272 667 1,114 1,090 904 804 1,006 1,258 6,843 -1,263 -15.6% 8,106
Performance Management
3.2 Contract Activity – Variance to Plan Children & Young People’s Wellbeing – Exception Reports by Service
99
Commissioner: NHS East Lancashire CCG
Under Performance Exception Reporting Continued:-
Children’s Speech & Language Therapy 15%-
Current position and issues:
October manual activity data was 1258 against a baseline of 1272. The current YTD total based on CITNS manual count is 6843 YTD. (Variance % -15.6%). Based
on the planned activity total, the service is required to see an extra 236 contacts in total to meet the 10% threshold.
Average staff capacity in East Lancs SLT during the 17/18 monitoring year has been at 84%.
The team continues to now meet RTT target during 17/18.
Commissioner: NHS Greater Preston CCG
Under Performance Exception Reporting:-
Children’s Occupational Therapy 26%-
Current position and issues:
October manual activity data was 212 against a baseline of 232. The current YTD total based on CITNS manual count is 1,137 -400 YTD. (Variance % -26%). Based
on the planned activity total, the service is required to see an extra 108 contacts in total to meet the 10% threshold.
Average staff capacity in Greater Preston OT during the 17/18 monitoring year has been at 83%.
The team continues to now meet RTT target during 17/18.
Service17-18 Monthly
PlanApr-17 May-17 Jun-17 Jul-17 Aug-17 Sep-17 Oct-17 YTD 17-18
YTD 17-18
Variance
YTD 17-18
Variance (%)
Planned YTD
17-18
Children's Occupational Therapy 232 118 171 148 145 144 199 212 1,137 -400 -26.0% 1,537
Children's Physiotherapy 360 224 268 229 202 224 290 327 1,764 -523 -22.9% 2,287
Children's Speech & Language Therapy 606 357 562 383 450 341 532 591 3,216 -645 -16.7% 3,861
Paediatric Liaison 1,710 831 1,219 916 1,036 963 1,037 1,076 7,078 -3,738 -34.6% 10,816
Performance Management
3.2 Contract Activity – Variance to Plan Children & Young People’s Wellbeing – Exception Reports by Service
100
Commissioner: NHS Greater Preston CCG
Under Performance Exception Reporting Continued:-
Children’s Physiotherapy 22%-
Current position and issues:
October manual activity data was 327 against a baseline of 360. The current YTD total based on CITNS manual count is 1,764, -523 YTD. (Variance % -22.9%).
Based on the planned baselines, the service is required to record an extra 155 F2F contacts by year end to meet the 10% threshold.
Staff capacity in Greater Preston Physio team during the 17/18 monitoring year has been at 83%.
The team continues to meet RTT target during 17/18.
Children’s Speech and Language Therapy 16%-
Current position and issues:
October manual activity data was 591 against a baseline of 606. The current YTD total based on CITNS manual count is 3,216 -645 YTD. (Variance % -16.7%).
Based on the planned activity total, the service is required to see an extra 259 contacts in total to meet the 10% threshold.
Average staff capacity in Greater Preston SLT team during the 17/18 monitoring year has been at 77%.
The team continues to meet RTT target during 17/18.
Children’s Paediatric Liaison 34%-
Current position and issues:
The service receives 100% of its referrals from the Emergency Department (ED), and have no control over the number of children attending however the activity is
lower than expected as we are currently unable to identify the activity that is deflected through the Go To Doctor service.
Performance Management
3.2 Contract Activity – Variance to Plan Children & Young People’s Wellbeing–Exception Reports by Service
101
Commissioner: NHS West Lancashire CCG
Under Performance Exception Reporting:-
Children’s Occupational Therapy 32%-
Current position and issues:
October manual activity data was 103 against a baseline of 166. The current YTD total based on CITNS manual count is 742 -358 YTD. (Variance % -33%). Based
on the planned activity total, the service is required to see an extra 68 contacts in total to meet the 10% threshold.
Average staff capacity in West Lancashire OT during the 17/18 monitoring year has been at 98%.
The team continues to now meet RTT target during 17/18.
Children’s Physiotherapy 25%-
Current position and issues:
October manual activity data was 155 against a baseline of 194. The current YTD total based on CITNS manual count is 909, -315 YTD. (Variance % -25.7%).
Based on the planned activity total, the service is required to see an extra 83 contacts in total to meet the 10% threshold.
Average staff capacity in West Lancashire Physio team during the 17/18 monitoring year has been at 66%.
The team continues to meet RTT target during 17/18.
Service17-18 Monthly
PlanApr-17 May-17 Jun-17 Jul-17 Aug-17 Sep-17 Oct-17 YTD 17-18
YTD 17-18
Variance
YTD 17-18
Variance (%)
Planned YTD
17-18
Children's Occupational Therapy 166 81 120 124 64 117 133 103 742 -358 -32.5% 1,100
Children's Physiotherapy 194 97 128 130 127 124 148 155 909 -315 -25.7% 1,224
Performance Management
3.2 Contract Activity – Variance to Plan Mental Health – Total Activity Split by CCG
Demand Metrics Apr-17 May-17 Jun-17 Jul-17 Aug-17 Sep-17 Oct-17 YTD 17-18
Adult/PICU Ward Admissions Total 169 195 180 187 175 171 166 1,243
Adult/PICU Ward Discharges Total 167 187 177 165 168 163 159 1,186
CMHT Adult - Accepted Referrals Total 153 171 167 153 212 189 188 1,233
CMHT Older Adult - Accepted Referrals Total 90 139 131 120 142 127 122 871
Community Restart Teams - Accepted Referrals Total 130 176 178 165 163 122 158 1,092
CRHT Teams - Referrals Total 720 793 870 806 769 822 790 5,570
Eating Disorder Service - Referrals Total 73 86 93 79 69 69 94 563
Hospital Liaison Referrals Total 149 171 155 158 175 152 153 1,113
MAS Teams - Referrals Total 492 565 627 607 617 580 579 4,067
Older Adult (Dementia) Inpatient Ward Admissions Total 7 12 6 7 7 9 5 53
Older Adult (Dementia) Inpatient Ward Discharges Total 10 6 8 8 5 6 8 51
Older Adult (Functional) Inpatient Ward Admissions Total 11 9 11 12 9 11 4 67
Older Adult (Functional) Inpatient Ward Discharges Total 12 10 9 14 9 11 7 72
PICU Wards - Transfers In Total 16 27 24 26 21 17 24 155
RITT Referrals Total 169 154 168 151 204 154 145 1,145
Performance Management
3.2 Contract Activity – Variance to Plan Mental Health – Activity Totals
Productivity Metrics Apr-17 May-17 Jun-17 Jul-17 Aug-17 Sep-17 Oct-17 YTD 17-18
ADHD Contacts Total 371 253 390 454 315 268 329 2,380
CMHT AD - Contacts Total 8,189 9,706 9,627 9,171 9,015 8,881 8,936 63,525
CMHT OA Contacts Total 2,584 2,846 2,815 2,754 2,862 2,766 2,712 19,339
CRHT Face to Face Contacts - Below 18 Total 123 242 153 171 130 137 145 1,101
CRHT Face to Face Contacts - 18 to 65 Total 3,667 4,042 3,766 3,921 3,874 3,657 3,697 26,624
CRHT Face to Face Contacts - Over 65 Total 65 74 43 73 39 9 19 322
CRHT Telephone Contacts - Below 18 Total 66 128 96 69 80 96 101 636
CRHT Telephone Contacts - 18 to 65 Total 2,130 2,487 2,148 2,404 2,508 2,518 2,557 16,752
CRHT Telephone Contacts - Over 65 Total 37 106 47 40 41 40 35 346
Criminal Justice Liaison - Contacts Total 571 667 587 580 648 576 595 4,224
Eating Disorder Service - Contacts Total 692 869 964 1,139 1,114 1,043 1,151 6,972
Hospital Liaison Contacts Total 372 410 387 363 470 368 432 2,802
MAS Teams - Contacts Total 2,899 3,399 3,206 3,097 3,268 2,958 3,140 21,967
RITT Contacts Total 1,921 2,265 2,270 2,571 2,742 2,640 2,482 16,891
Mental Health Productivity Total 23,687 27,494 26,499 26,807 27,106 25,957 26,331 183,881
Mental Health - Total Contacts Activity split by CCG Apr-17 May-17 Jun-17 Jul-17 Aug-17 Sep-17 Oct-17 YTD 17-18
NHS BLACKBURN WITH DARWEN CCG 2,665 3,162 2,928 2,848 2,838 2,775 2,922 20,138
NHS BLACKPOOL CCG 2,751 3,225 2,915 2,991 2,991 3,030 3,001 20,904
NHS CHORLEY AND SOUTH RIBBLE CCG 2,339 2,584 2,341 2,219 2,307 2,279 2,494 16,563
NHS EAST LANCASHIRE CCG 4,870 5,770 5,560 5,834 5,612 5,195 5,353 38,194
NHS FYLDE & WYRE CCG 2,398 2,589 2,699 2,549 2,599 2,408 2,262 17,504
NHS GREATER PRESTON CCG 2,898 3,659 3,494 3,389 3,460 3,322 3,622 23,844
NHS MORECAMBE BAY CCG 2,584 2,757 2,823 2,879 2,901 2,863 2,848 19,655
NHS WEST LANCASHIRE CCG 1,419 1,677 1,664 1,676 1,766 1,607 1,517 11,326
Grand Total 21,924 25,423 24,424 24,385 24,474 23,479 24,019 168,128
Performance Management
104
3.2 Contract Activity – Variance to Plan Mental Health – Activity Totals
2017-18 Baseline Proposal
Last month it was reported that the MAS Contact activity has been over inflated due to the reporting of ‘Patient Notes’ and as result an investigation
was required to determine which other teams maybe affected and whether the baselines would need to be adjusted as a result.
Since then a meeting with Practitioners has been carried out to determine whether Patient/Proxy contacts are reported within ‘Patient Notes.’ The
outcome of which concluded that Practitioners have sporadically been using the ‘Notes’ contact type to record patient contacts across all services.
If we therefore take the decision to remove ‘Notes’ from the Schedule 6 reporting we would be excluding a percentage of legitimate patient contacts.
The Performance team are therefore co-ordinating an ad-hoc audit to determine the percentage of Patient/Proxy contacts recorded within ‘Notes’
against each service. The results of this audit, which we are planning to complete by the end of November, will then enable more accurate revised
baselines to be set and for the reported figures to be adjusted appropriately.
Aside from the above audit, LCFT are investigating whether other Contact Types that do not hold Patient/Proxy contacts have been misreported within
the Schedule 6 figures and the results of this investigation will also be known by the end of November.
2017-18 M7 Activity
For M7, LCFT have continued to provide the activity totals and YTD position only whilst the baselines are being finalised.
Following the initial investigation into LCFT including ‘Patient Notes’ within Schedule 6 reporting and the resulting over inflated activity of MAS contact
activity, LCFT have determined that the same error had been replicated in the following services: ADHD, Eating Disorders and Hospital Liaison, and a
decision was taken to remove ‘Patient Notes’ and refresh the activity back to April 17. This refresh has been completed for M7, however following the
Practitioner meeting it has become apparent that this will need to be amended following the aforementioned audit.
Quality Metrics Apr-17 May-17 Jun-17 Jul-17 Aug-17 Sep-17 Oct-17 YTD 17-18
Adult Ward Occupied Bed Days Total 5,744 5,835 5,676 5,885 5,904 5,784 5,908 40,736
Eating Disorder Service DNA's - Follow Up Contacts 94 98 76 123 129 93 87 700
Eating Disorder Service DNA's - New Contacts 7 8 14 14 19 3 6 71
PICU Ward Occupied Bed Days Total 817 849 846 893 952 897 909 6,163
Older Adult (Dementia) Ward Occupied Bed Days Total 812 850 854 909 945 924 969 6,263
Older Adult (Functional) Ward Occupied Bed Days Total 1,034 1,104 1,081 1,102 1,154 1,101 1,119 7,695
Older Adult (Functional) Inpatient 30 Day ReAdmissions 1 0 0 0 0 0 0 1
Older Adult (Functional) Inpatient 90 Day ReAdmissions 1 1 0 1 0 0 0 3
Adult Inpatient 30 Day ReAdmissions Rate (8% Target) 9.58% 7.49% 9.04% 9.09% 6.55% 7.36% 9.43% 8.32%Adult Inpatient 90 Day ReAdmissions Rate (15% Target) 14.97% 13.90% 16.38% 12.12% 7.74% 7.36% 9.43% 13.06%
Performance Management
3.2 Contract Activity – Variance to Plan Children & Young People’s Wellbeing – Sexual Health Activity
as at w/c 23rd October 2017
105
• Revised planned attendances full year are 27,344. Actual attendances during October 2017 was 1,497 – 808 below the
planned total of 2,305.
• Initial income for the 17/18 monitoring year shows a increase in M6 and 7 in comparison to M4, with the total income as at
end of August 2017 at £810,020.
Performance Management
106
3.3 CQUIN Executive Summary
CQUIN Executive Summary:
Quarter 2 submissions for 2017/18 schemes have taken place for the Mental Health & Community contracts. The staff flu scheme is currently
behind plan but is expected to meet the 70% target by the end of February 18. Discussions are ongoing with acute trusts regarding the A&E
scheme, however we are working towards the targets for the scheme with commissioner support. Some further work needs to be done
regarding the Physical Health schemes to achieve the required increase in targets for future quarters. An audit is currently underway.
The Trust has not been successful in achieving the required targets for the preventing illness through the risky behaviours scheme. The
expected loss is £40k relating to Mental Health and £10k for Longridge. Work needs to focus on referrals to the stop smoking services and
staff training to ensure Quarter 3 and Quarter 4 targets are achieved.
Quarter 2 schemes for Southport & Formby contract have been submitted in line with the agreed milestones. No issues are expected.
£1,033k CQUIN funding across CCG contracts is agreed based on the Trust meeting its control total in 2016/17, however there are ongoing
discussions between NHSE and NHSI regarding the payment mechanism. A further £1,033k CQUIN funding across CCG contracts is agreed
based on the Trust's engagement and commitment to the STP process. Confirmation has been received via BWD CCG that this element of
funding has been agreed by the STP.
The Trust is waiting feedback from NHS England regarding the Cumbria Liaison & Diversion scheme submission but are not expecting any
issues.
There are not expected to be any issues with the submission for the Specialist Services schemes for Q2.
Measures are expected to be put into place to ensure that the Trust achieves the remaining
CQUIN funding available and no further losses are seen than those identified in Quarter 2.
Executive Summary
Contract Actual
Loss/
concern Expected
Loss/
concern Expected
Loss/
concern Expected
Loss/
concern % Met Expected
Loss/
concern
Mental Health 100% £652,503 £0 93% £518,134 £40,150 100% £515,457 £0 100% £1,842,663 £0 99% £3,528,758 £40,150
Southport 100% £45,584 £0 100% £48,657 £0 100% £33,294 £0 100% £128,513 £0 100% £256,048 £0
Community 100% £238,378 £0 96% £244,404 £10,042 100% £174,107 £0 100% £672,046 £0 99% £1,328,935 £10,042
NHS England - Spec Comm MH 100% £193,941 £0 100% £193,941 £0 100% £193,941 £0 100% £193,941 £0 100% £775,762 £0
NHS England - Liaison & Diversion 100% £5,201 £0 100% £5,201 £0 100% £5,201 £0 100% £5,201 £0 100% £20,803 £0
NHS England - Imm & Vacc 100% £3,675 £0 100% £3,675 £0 100% £7,350 £0
Qtr. 4
100%
Expecte
d
Position
Full Year
99%£2,842,363 £0 £5,917,656 £50,193£0
Expecte
d
Position
£922,000 £0100%
Oct 2017 CQUIN Position
Expected
PositionTotal
Expected
Position100%
Qtr. 2Qtr. 1
£1,139,282 95% £1,014,011 £50,193
Qtr. 3
Performance Management
Quality
Section 4
107
Performance Management
108
Section 4:- Quality
• Quality and Safety Tile
• Quality Surveillance – Safe
• Quality Surveillance – Effective
• Quality Surveillance – Caring
• Quality Surveillance – Responsive
• Quality Surveillance – Well Led
• Delivering the Strategy
4. Quality
Performance Management
4. Quality Quality & Safety Tile
109
15251 94.40%
92 8701
38
1
10 1632
3930 320
13 0.54
2869
2172
90.05%
95% N/A
83% 9
QUALITY AND SAFETY TILE
CARING
Compliments
F&F Test
RIDDOR incidents
Incidents
STEIS-reportable serious
incidents
EFFECTIVE
Never Events
Number of red flag incidents
(inpatients only)
Core Skills (%)
SAFE
Physical violence to staff from
patients
Serious HCAI incidents
Use of restraint
Potentially avoidable grade 3 and
4 pressure ulcers
As a result of the Network Re-design historical data prior to 15 May 2017 is recorded in the four Network structure and has been aggregated in this report to provide the best available comparison.
Data provided shows the following 12 month figure (where a number) or the rolling 12 month average (where a percentage).
Physical Health HFC Rate (%) Appraisals (%)
Mental Health HFC Rate (%) Concerns raised
Good
Completed within agreed
timeframe (%)
RESPONSIVE
Complaints
Upheld/partially upheld
complaints
WELL LED
Trust CQC rating
Performance Management
4. Quality Safe
110
Domain Indicator Target Nov Dec Jan Feb Mar Apr May Jun Jul Aug Sep Oct12 months
total
12 months
averageSparkline Risk
Incidents n/a 1867 2094 2345 2358 2168 2090 2329 15251 2178.7
Incidents with harm n/a 404 436 487 547 437 473 535 3319 474.1
STEIS-reportable serious
incidentsn/a 6 6 7 9 4 9 8 10 4 11 8 10 92 7.7
RIDDOR incidents n/a 2 6 2 0 3 4 5 2 6 1 6 1 38 3.2
Never Events 0 0 0 0 0 0 0 1 0 0 0 0 0 1 0.1
Medication incidents n/a 127 149 177 150 148 183 186 1120 160.0
Infection control Serious HCAI incidents 0 1 4 1 0 1 1 0 1 0 0 1 0 10 0.8
Use of restraint n/a 349 252 189 263 308 329 300 400 461 335 346 398 3930 327.5
Use of seclusion n/a 85 65 73 68 66 64 65 486 69.4
Safeguarding alerts n/a 100 158 138 129 130 95 152 902 128.9
Potentially avoidable grade 3
and 4 pressure ulcersn/a 0 0 0 2 0 2 0 5 1 2 0 1 13 1.1
Number of instances of 1 or less
qualified on duty (inpatients)0 244 207 192 170 145 139 197 140 132 177 132 84 1959 163.3
Number of red flag incidents
(inpatients only)n/a 316 261 260 268 221 195 270 227 228 258 228 137 2869 239.1
Staff safetyPhysical violence to staff from
patients n/a 162 137 140 129 151 155 150 218 268 220 223 219 2172 181.0
Legal Regulation 28 Notices received n/a 0 0 0 0 1 0 0 1 1 0 0 0 3 0.3
QUALITY AND SAFETY SURVEILLANCE - Safe
Incidents
Patient safety
Staffing
Performance Management
4. Quality Effective
111
Domain Indicator Target Nov Dec Jan Feb Mar Apr May Jun Jul Aug Sep Oct Sparkline Risk
Pressure ulcers (%) - 4.61% 3.96% 2.72% 2.91% 5.27% 3.45% 3.45% 4.04% 3.05% 3.12% 2.55% 2.72%
Falls with harm (%) - 1.76% 1.29% 1.28% 1.64% 1.55% 1.55% 0.60% 0.75% 1.21% 0.64% 0.93% 0.53%
Catheter and UTI (%) - 0.29% 0.18% 0.64% 0.27% 0.26% 0.43% 0.45% 0.27% 0.21% 0.07% 0.23% 0.15%
VTE (%) - 0.59% 0.55% 0.08% 0.36% 0.35% 0.35% 0.15% 0.69% 0.43% 0.43% 0.93% 0.38%
Physical Health HFC Rate (%) 95% 93% 94% 95% 95% 93% 94% 96% 94% 95% 96% 96% 96%
Self harm (%) - 3.69% 3.35% 4.04% 3.55% 3.43% 3.56% 3.76% 3.75% 4.37% 4.63% 3.71% 3.59%
Victim of violence (%) - 2.87% 1.89% 1.62% 2.71% 1.07% 2.30% 1.46% 2.50% 1.66% 1.89% 1.75% 3.17%
Feel safe (%) - 10.86% 9.22% 6.26% 8.35% 9.01% 9.62% 10.65% 7.08% 7.90% 10.53% 8.08% 11.21%
Omission of medication (%) - 15.57% 18.87% 13.74% 16.08% 17.17% 17.99% 18.37% 23.54% 20.37% 19.79% 20.09% 24.10%
Restraint (%) - 5.74% 6.29% 4.65% 4.80% 3.65% 5.23% 5.43% 7.08% 6.86% 7.16% 5.68% 4.86%
Mental Health HFC Rate (%) 90% 82% 83% 86% 84% 85% 83% 83% 84% 81% 80% 84% 80%
QUALITY AND SAFETY SURVEILLANCE - Effective
12 months
average
3%
1%
0%
83%
Physical Health
Harm Free Care
Mental Health
Harm Free Care
0%
19%
6%
95%
4%
2%
9%
Performance Management
4. Quality Effective
112
N/L/R* Compliance Date
L 100% 7.11.17
L 66% 7.11.17
R 100% 7.11.17
R
R
L
L
L
L
R
L
L
L
L
R
R
R
Clinical Audits Date
Prevention of Dehydration MHN 54% Sep-17
NetworkNICE Baseline Assessments
NG73 Endometriosis CYPWN
Network Compliance (%)
MHN
Nursing Management of Clozaril MHN 60% Oct-17 NG71 Parkinsons Disease CWB
Absent Without Leave MHN 55% Oct-17NG6 Mental Health of Adults in contact with
the criminal justice system
* N/L/R - National Audit, Local Audit, Re-Audit (if re-audit, the previous compliance figure will be included).
Carers CYPWN 54% Oct-17
Diabetes MHN 65% Sep-17
83%CYPWNRisk Assessments
Cerebral Palsy in under 25's (NICE) CYPWN 82%
Clozapine
Antibiotics in dentistry
CYPWN
CWN
80%
94%
85%
70%
79%
85%
Nutrition CYPWN 77%
Consent to Treatment MHN 94%
Completion of Waterlow risk assessments
Wound assessment documentation
Care of Dying
Learning Disability
CWN
CWN
CWN
CWN
Use of restrictive practices within LD CWN 93%
Acupuncture - Rheumatology & Physiotherapy CWN 97%
Performance Management
4. Quality Caring & Responsive
113
Domain Indicator Target Nov Dec Jan Feb Mar Apr May Jun Jul Aug Sep Oct12 months
total
12 months
averageSparkline Risk
F&F Test 95% 85% 87% 96% 96% 96% 96% 97% 95% 97% 97% 97% - 94.40%
F&F Test - Response Rate n/a 3371 1744 1659 2042 1562 1263 1815 1218 1241 1652 923 18490 1680.9
Compliments Compliments n/a 719 529 678 1031 788 593 987 697 774 819 537 549 8701 725.1
QUALITY AND SAFETY SURVEILLANCE - Caring
Friends & Family -
Patients
The Friends and Family Test real time reporting is locked and nationally reported on the 19th of each month and will therefore be reported in arrears most months
Domain Indicator Target Nov Dec Jan Feb Mar Apr May Jun Jul Aug Sep Oct12 months
total
12 months
averageSparkline Risk
Complaints n/a 134 150 114 111 167 95 108 152 134 173 149 145 1632 136.0
Upheld/partially upheld
complaintsn/a 42 26 22 21 31 26 23 19 24 22 21 43 320 26.7
Completed within agreed
timeframe (%)n/a 54.0% 54.0% 54.0%
Reopened complaints n/a 3 3 3 4 2 4 4 7 5 0 0 3 38 3.2
PHSO complaints n/a 0 0 1 2 3 1 3 1 0 1 0 0 12 1.0
MP enquiries n/a 8 7 13 9 15 7 8 5 9 11 5 12 109 9.1
Environment Mixed Sex Breaches 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0.0
QUALITY AND SAFETY SURVEILLANCE - Responsive
Complaints
Performance Management
4. Quality Well Led
114
Domain Indicator Target Nov Dec Jan Feb Mar Apr May Jun Jul Aug Sep Oct12 months
total
12 months
averageSparkline Risk
Trust CQC rating Good RI RI Good Good Good Good Good Good Good Good Good Good
Regulatory inspections/visits n/a 4 5 4 3 4 3 2 1 2 1 29 2.9
CQC notifications n/a 0
Core Skills (%) 85% 87.72% 88.24% 89.07% 89.41% 90.68% 90.33% 89.26% 91.06% 91.55% 90.81% 90.87% 91.64% - 90.05%
Supervision (%) n/a -
Appraisals (%) n/a -
Overdue 3 day reviews 0 1652 1305 1176 1267 1295 1695 1349 1573 2192 13,504 1500.44
Overdue 7 day reviews 0 105 80 71 65 77 82 74 59 97 710 78.89
Overdue incident actions 0 94 -
Duty of candour breaches 0 0 0 0 0 0 0 0 1 0 0 0 0 1 0
Overdue safety alerts 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
Concerns raised n/a 9 -
Quality Plan priorities off track 0 0 0 0 0 -
Quality assurance visits n/a 1 0 0 0 2 3 0.6
Assurance
QUALITY AND SAFETY SURVEILLANCE - Well Led
Regulatory
People
Good
Learning and
candour
Performance Management
115
4. Quality Audit 2017
National Audit Data collection period Report due Compliance
National Audit of Intermediate Care
(NAIC)
May 2017 to August 2017
Participants will be asked for outturn data
April 2018
National chronic Obstructive
Pulmonary Disease (COPD) audit
programme
April 2017 to July 2017 February 2018
National Diabetes Audit – Adults April 2017 to July 2017 February 2018
Sentinel Stroke National Audit
programme (SSNAP)
April 2017 to March 2018
Collection: April to July, August to November, December to
March, April to March (annual)
January 2018
UK Parkinson’s Audit: (incorporating
Occupational Therapy
Speech and Language Therapy,
Physiotherapy
Elderly care and neurology)
1 May 2017 to 30 September 2017
May 2018
National Audit of Psychosis Autumn/Winter 2017 TBC
National Audit of Anxiety & Depression TBC TBC
Topic 17: Use of depot/LA
antipsychotics for relapse prevention
– baseline audit
May 2017 to June 2017
Sampling & Data Collection: May 2017
Online Data Submission: June 2017
Nov 2017
Topic 15: Prescribing for bipolar
disorder (use of sodium valproate) –
re-audit
September 2017 to October 2017
Sampling & Data Collection: Sept 2017
Online Data Submission: October 2017
Feb 2017
Topic 6: Assessment of side effects of
depot antipsychotic medication – 2nd
supplementary
February 2018 to March 2018
Sampling & Data Collection: February 2018
Online Data Submission: March 2018
July 2018
Performance Management
4. Quality Delivering the Strategy
116
Not currently assessed
Project Element not in place
Project Element in place but requires update or further
work
Project Element in place and fit for purpose
Project Element not required
Project Element not in place
Key
Exec SRO Sue Moore
Programme SRO Joanne Moore
Programme Manager Carly SteerReporting Period October 2017 (Month 7)
Report date 13-Nov-17
The purpose of Delivering the Strategy (DTS) is to deliver the Trust's transformation programme and the operational annual plan. The focus is on
tranformational schemes that are aligned to the STP and LDPs and on continuous improvement of quality within our services. There are 6 DTS portfolios in
2017/18 aiming to deliver a wide range of redesign programmes.
Programme Description
DTS Programme Report
Overview
Across each network portfolio, for all schemes that have been initiated, work is ongoing to develop detailed delivery plans where this is not already in place status
summarised for each scheme in Programme assurance heat maps.
Complex packages of care within C&YP is now underway for a tender submission in November and work has also started to scope out Transformation of Secure
Services, Core 24 and Core Home Treatment 24/7.
Further work required to establish benefit trackers for each programme, to enable leads to measure performance and provide robust assurance on delivery.
ASSURANCE CRITERIONComplex Packages of Care
(CPOC)
CAMHS Tier 4
Transformation
0-25 Clinical Pathway
including integration of
Child psychology and
LCC contract for Health
Visiting and School
Nursing
PROGRAMME RESOURCE
Project Manager assigned Janet Thorpe Janet Thorpe Janet Thorpe Janet Thorpe
Transformation Lead
assignedTBC Nicola Adams Nicola Adams Michael Orchard
Project Lead assigned TBC Paul AndertonSarah Wright/Anita
DemariaCathy Allen
Clinical Lead assigned Lorna Taylor Terry Drake Julie Ross Debra Wilson
Full resource plan agreed
PROGRAMME
DOCUMENTATION
Programme initiation
document
To be reviewed
Nov/Dec 17
Programme under
review Oct/Nov 17
Not currently required –
pre tender periodMove to the Cove –
in placeTransformation work
Programme PlanUnder review –
deadline 30 Nov
Under review – deadline
30 NovHigh level – Aug 17
Risks and Issues log In place In place In place
Programme Governance In place In place In place
TOR Redrafted Redrafted Agreed
Regular meetings 1st meeting 13 June 1st meeting 13 June 1st meeting 13 June
PROJECT PERFORMANCE
On time
On cost
Benefits tracker in place Not applicable
Children & Young People's Wellbeing DTS Portfolio
QIAs drafted for
Integrated MDT offer and
Point of Access
Quality Impact Assessment
Not currently required –
quality issues addressed
within tender process
Performance Management
4. Quality Delivering the Strategy
117
PROGRAMME RESOURCE
PMO Lead assigned Dawn Killey Dawn Killey Dawn Killey Dawn Killey Dawn Killey Dawn Killey Dawn Killey
Transformation Lead
assignedSarah Neve Helena Owen Sarah Neve Sarah Neve
Natalie Hilton/Fran
RileySarah Neve Sarah Neve
Clinical Lead assigned Lorraine Chadwick Lorraine ChadwickLorraine Chadwick/Claire
BensonGuz Singh Jeremy Tudway TBC Lorraine Chadwick
Full resource plan agreed n/a currently n/a currently
PROGRAMME
DOCUMENTATIONProgramme initiation
documentScoping n/a currently
n/a In Progress
Currently Nov-17In Progress
Nov-17
Programme Governance n/a currently
In Progress
Nov-17
Regular meetings n/a Currently n/a Currently n/a currently
Benefit trackerIn progress- met
with PerformanceStarted to map benefits TBC n/a currently
n/aCurrenty
On cost
On time( from
dashboard)n/a currently 83% 30% 16% n/a n/a
S136
99% 33%
New Models of Care?
Dawn Killey
Sarah Neve
Phil Horner
Transforming Secure
Services
TOR n/a currently
Risks and Issues log
Programme Plan Scoping
Quality Impact Assessment
Signed off by Clinical
Lead, to be presented to
Network Leads on 21st
Phil Horner Bev Liddle
Richard Morgan
Scoping TBC n/a currently Update In progress
n/a currently
n/a currently
Core Home
Treatment 24/7 Core 24
Project Lead assigned Lorraine McDonald-Johnson Bev Liddle Joe Crocock Phil Horner Pauline Cullen
Crisis House eastASSURANCE CRITERIONMental Health
Access Line
Inpatient Reconfiguration
programme
Mental Health DTS Portfolio
Performance Management
4. Quality Delivering the Strategy
118
ASSURANCE CRITERION LD IAPT CPSR South Ribble Central BwD Dental CPOC
ASSURANCE CRITERION LD IAPT CPSR South Ribble Central BwD Dental CPOC
PROGRAMME RESOURCE
Programme Lead assigned Stuart Sheridan Deborah Bretherton Julie Nowell Julie Nowell Tanya Hibbert Tanya Hibbert Andy Jones
Transformation Lead
assignedDeborah Howe
Clinical Lead assigned Mahesh Odiyoor Janine Williams Tracy Cook- Scowen Tracy Cook- Scowen Sarah Procter
Full resource plan agree
PROGRAMME
DOCUMENTATIONProgramme initiation
document
Quality Impact Assessment
Programme Plan Plans to be finalisedTo be updated in line
with new governance
structure
High-level – plan in
place further detail
required.
Risks and Issues log
Programme Governance
TOR
Regular meetings Fortnightly
Benefits Tracker
PROJECT PERFORMANCE
On time
On cost
Community and Wellbeing DTS Portfolio
Mark Wardman
MCP Prime Provider
MCP
Performance Management
119
4. Quality Delivering the Strategy
Annual
Performance
Plan (£000)
Annual
Forecast
Performance
Actual (£000)
15,100
15,100
12,744 12,730
886
Risks
14
2,370 a+b+c
886 d
1,484 (a+b+c)-d
419 a+b+c
Value of schemes at Feasibility
Slippage Against Annual Performance
Gross Risk of Delivery Against Overall DTS
Baseline
Additional Programme Reporting
2017/18
Overall Target
Value of approved schemes
Mitigation
Net Risk of Delivery Against Overall DTS
Value of non-recurrent schemes
Performance Management
120
4. Quality Delivering the Strategy
Programme SRO Goal (£000) MonthTransacted
(£000)Narrative
Q2 502,634
Sep (06) 89,361
Oct (07) 89,361
Q2 2,669,787
Sep (06) 464,539
Oct (07) 464,539
Q2 853,000
Sep (06) 115,039
Oct (07) 115,039
Organisational
reset
Joanne
Moore
Savings delivered through this programme will be reported through the relevant
Network or Corporate services. Phase 2 is in development.
Mobilisation &
DemobilisationLouise Giles
Savings delivered through this programme will be reported through the relevant
Network or Corporate services.
Q2 2,102,128
Sep (06) 350,355
Oct (07) 350,355
Children &
Young PeopleSteve Tingle 2,142,770
Support
Services
£1.4m is registered on the CIP system, £1,172k approved and £254k at feasibility.
Current forecast of £1049k delivery due to £117k slippage on the continence and
dental scheme, which is a static position on last month leaving an in year gap of £962.
However, further work has progressed on the gap and pipeline schemes with current
schemes rated green to the value £392k with further pipeline schemes anticicpated to
convert. CIP plans and additional pipeline schemes are monitored weekly.
£5.4m of schemes are registered as approved leaving a gap of £2.4m. This position
includes £2.4, of schemes related to cost reduction including temporary staffing and
OAPs. This a static position on last month, with schemes worth £384k still in the
pipeline. Further recovery schemes are underway whilst expenditure reduction
schemes are being tested in order to determine the underlying recurrent position. CIP
plans, additional pipeline schemes and recovery plans are being monitored weekly.
£1.54m of schemes are registered on the system, all of which are approved leaving a
gap of £603k. Pipeline schemes to the value of £600k are in train- and if all schemes
are approved this will meet 17/18 target. This is an static position on last month. CIP
plans and additional pipeline schemes are monitored weekly.
Schemes to the value of £4.5m are registered at approved stage. In addition there is
£534k of schemes at feasibility. If delivered, this will give an over-acheivement of
£2m which is offsetting gaps elsewhere. There are £134k worth of pipeline schemes
that are being monitored weekly
Dominic
McKenna2,801,600
Community
Wellbeing
Tanya
Hibbert2,265,460
Mental HealthLisa
Moorhouse7,869,522
Performance Management
Workforce
Section 5
121
Performance Management
5. Workforce
122
Section 5:-
• Actual Workforce Costs Compared to Budget
• Sickness Absence Rates
• Appraisals and Mandatory Training Compliance
• Vacancy Management and Active Recruitment
• Core Workforce Headcount
• Workforce Turnover
Performance Management
123
Actual Workforce Costs Compared to Budget - Quarterly Trend
Peripheral Workforce Spend and Usage
5. Workforce Actual Workforce Costs Compared to Budget
Actual Workforce Costs compared to Budget:
Overall spend on peripheral labour has decreased
slightly in the month of October, when compared
to the September position. MHN and C&WBN
continue to be the highest spenders.
Actions:
Mental Health Network:
Secure Services and the Harbour are holding
weekly Bank and Agency meetings to establish
the reasons for high usage and agree how this
can be mitigated. The content of this meeting
updates the monthly Network Bank and Agency
usage meeting.
Regular reviews are being conducted by the
Care Teams to appraise the level of service
user acuity and staffing levels. Their focus is to
ensure an appropriate level of staffing is in
place to provide safe and effective care.
Community & Wellbeing Network:
Services continue to review their need for the
use of Bank and Agency and usage escalation
processes in place at Longridge have been
extended to Southport & Formby.
Performance Management
5. Workforce Sickness Absence Rates
124
Trust 12 Month, Year on Year Trend
Sickness Absence Breakdown
Sickness Absence Rates:
Sickness Absence has increased in the month of October,
reporting 6.88%. The Trust increase this month is attributable to
the increase in sickness experienced in MHN.
Actions:
Mental Health Network:
The management of sickness absence remains a top priority
for the Network’s Senior Leadership Team as is the focus on
the Back to Basics Sickness Absence Management Action
Plan.
Service Managers are working closely with HR to effectively
manage sickness absence.
Community & Wellbeing Network: Sickness absence management remains a top priority with Network
SMT and the Network continues to review its action plan alongside the Trust Back to Basics plan
Action plans are in place for significant Long Term Sickness Cases in the Network and are monitored by and discussed with Care Group managers on a monthly basis
Children & Young Persons Wellbeing Network:
Q3 & Q4 will see the HRBP’s focus the Network on the
management of Short Term repetitive Absence Management.
Network has agreed a Sickness Absence trajectory to support
its achievement of the Trust Target of 4.5% by the end of Q4.
Performance Management
5. Workforce Appraisals and Mandatory Training Compliance
125
Appraisals and Mandatory Training Compliance:
Networks continue to work closely with Quality Academy and focus on improvement in this key performance measure. Appraisal Compliance for Q3 is
calculated using the number of employees who have objectives and who have completed a PDR review.
Actions:
Mental Health Network:
The Network continue to work closely with the Quality Academy to develop and implement their Network compliance improvement plans for the training
areas that are, individually, below the compliance target.
PDR compliance is monitored on a monthly basis at the Network People Group Meeting and uses the Tier 2 monthly Network People Performance
Report.
The new Network structure has enhanced accountability and responsibility lines for ensuring that there is a quality PDR process in place across the
Network.
Community & Wellbeing Network:
• Network continue to work closely with Quality Academy to improve compliance and enhance data quality.
• PDR compliance has been monitored on a monthly basis at the Network SMT and People Group Meeting using the Tier 2 monthly Network People
Performance Report.
• The new network structure is expected to enhance accountability and reasonability lines for ensuring that Quality PDR process take place and that
compliance across the Network is improved and bi-weekly tracking will continue post reset for Q3.
• Refinement of reporting lines post reset continues to take place and systems updated to ensure alignment of staff to mangers to allow PDR completion.
Children & Families:
• The Network are currently developing a PDR achievement Trajectory and it is anticipated that this will be ready by the close of November 2017. This is
being prepared to facilitate an increase in compliance in delivering the PDR experience and process.
• The Network discuss PDR compliance, compliance recovery and delivery expectations at the monthly People and Leadership Sub-Committee and
through Q3, the Network will be refining the cascade process for recovery activity from this meeting.
Performance Management
5. Workforce Vacancy Management and Active Recruitment
126
Vacancy Management and Active Recruitment:
The Budgeted Establishment Vacancy Rate has increased slightly in October and reports a closing rate of 12.17%. The number of those vacancies
being actively recruited has also increased, moving from 48.55% in September to 57.49% in October.
Actions:
Mental Health Network:
• The new Network have amalgamated the Specialist Services and Mental Health Ongoing Recruitment Programmes, designed to target hard to fill
posts and continue to effectively manage its delivery.
Community & Wellbeing Network:
• Vacancy clarity and management continues to be high on the Network agenda.
Children & Young People’s Wellbeing Network:
• Health Visitor Vacancies, held in in light of the Universal 0-19 contract Tender exercise, will be released through Q3 and actively recruited to as the
Trust is now in receipt of the new Service Specification that we are bidding against.
• The Network continue to hold a number of vacancies across Tier 3 Services as a result of the financial variation to contract removal of the CAHMS
Grant.
Support Services:
• A refresh of the Support Services Organisational Structure has been undertaken. The ESR system updates are complete and Financial EFIN system
updates are underway. The refresh has seen a move of ‘Hosted Services’ out of the Trust main workforce information data set and the temporary non
alignment of the ESR and EFIN systems (due to update timing differences) has resulted in a reported increase in BEVR for Support Services in
September.
Performance Management
5. Workforce Core Workforce Headcount
127
Performance Management
5. Workforce Workforce Turnover
128
Performance Management
129
6. Risks Board Assurance Framework 17/18 Quarter 2
BOARD ASSURANCE FRAMEWORK DASHBOARD 2017/18 – Q2
Strategic
Priority BAF Risk Sub-committee Director Lead
Risk
Score
01.04.17
Risk
Score
Q1
Risk
Score
Q2
Risk
Score
Q3
Risk
Score
Q4
2017/18
Risk
Target
2017/18
Risk
Target Gap
Final
Risk
Target
Final Risk
Target
Gap
SP
1
Qu
ality
1.1 If we do not meet regulatory
standards for quality and safety we will
not be fit for purpose as care provider.
Quality & Safety DoNQ 12
High
12
High
16
Significant
8
High
8
Close Monitoring
4
Moderate
12
Significant
1.2 If we do not create a culture of
learning then we will be unable to
provide high quality care.
Quality & Safety DoNQ 16
Significant
16
Significant 16 Significant
12
High
4
Tolerable
4
Moderate
12
Significant
1.3 If we do not provide integrated
physical and mental health services we
will lose opportunities to improve patient
outcomes.
Quality & Safety MD 16
Significant
16
Significant
16
Significant
12
High
4
Tolerable
4
Moderate
12
Significant
SP
2
Su
sta
inab
le
Serv
ices
2.1 If we do not work collaboratively with
partners we will not be able to influence
system wide transformation.
Business Dev &
Delivery COO
12
High
12
High
12
High
8
High
4
Tolerable
4
Moderate
8
Close Monitoring
2.2 If we do not deliver new models of
care we will cease to be a creditable
lead provider.
Business Dev &
Delivery COO
12
High
12
High
12
High
8
High
4
Tolerable
4
Moderate
8
Close Monitoring
SP
3 E
xcell
en
ce
3.1 If we do not engage with our
patients and service users we cannot
achieve excellence and quality.
Quality & Safety DoNQ 12
High
12
High
12
High
8
High
4
Tolerable
4
Moderate
8
Close Monitoring
3.2 If we fail to project our achievements
then our reputation will not improve.
Business Dev &
Delivery COO
16
Significant
16
Significant
16
Significant
12
High
4
Tolerable
4
Moderate
12
Significant
SP
4
Peo
ple
4.1. If we do not support the health and
wellbeing of staff we will struggle to
attract, recruit and retain our workforce.
People HRD 20
Significant
20
Significant
20
Significant
10
High
10
Concern
5
Moderate
15
Significant
4.2 If staff are not provided with
extensive education, training and
leadership development we will not
have an organisational culture that
supports high performance.
People HRD 9
High
9
High
12
High
6
Moderate
6
Close Monitoring
3
Low
9
Close Monitoring
SP
5
Mo
ney
5.1 If we do not meet financial
objectives we will not be able to provide
sustainable services.
Finance CFO 15
Significant
20
Significant
20
Significant
10
High
10
Concern
10
High
10
Concern
5.2 If we do not work with partners to
deliver system wide efficiencies this will
undermine our own financial position
and that of the STP.
Finance CFO 15
Significant
15
Significant 15 Significant
10
High
5
Tolerable
5
Moderate
10
Concern
SP
6
Inn
ovati
on
6.1 If we do not develop and maintain
infrastructure, we will not be able to
deliver safe, responsive and efficient
care.
Infrastructure CFO 16
Significant
12
High
12
High
8
High
4
Tolerable
4
Moderate
8
Close Monitoring
6.2 If we do not exploit the full
capabilities of the new EPR system and
wider technology to redesign services
we will miss important opportunities to
improve care.
Infrastructure CFO 16
Significant
16
Significant 16 Significant
8
High
8
Close Monitoring
4
Moderate
12
Significant
Performance Management
Southport & Formby
Appendix 1
130
Performance Management
1. Performance Activity Southport & Formby – Summary
131
Southport & Formby - Summary:
The validation of the performance within the teams is still on going. The final teams are scheduled in for their first meeting by the end of
November. The treatment room and continence audit requirements are under discussions with completion schedule by the end of
November.
During October initial contact has occurred with CERT, Dietetics, Phlebotomy, Podiatry and Diabetes. The teams are currently self
validating their with the support of Performance.
Several introductory meetings have been planned for November. These include the teams of Podiatry, Falls, Adult Therapies, Psychology,
Stoma, Pain management, Community Matrons, Chronic Care Coordinators and Leg Ulcers.
The EMIS team continue to provide their expertise in EMIS to aid in this ongoing programme of work.
Performance Management
1. Performance Activity Southport & Formby – Summary
132
ServiceFirst Contact with
TeamData Analysis Data Validation
1st reported in
QPR
(reporting month)
Follow up Audit
Continence May-17 Jul-17 Aug-17 Aug-17 Nov-17
Treatment Rooms Jul-17 Jul/Aug-17 Oct-17 Nov-17 Nov-17
District Nurses Aug/Sept-17 Aug/Sept-17 Oct-17 TBC TBC
District Nurses OOH Aug/Sept-17 Aug/Sept-17 Oct-17 TBC TBC
CERT Oct-17 Oct-17 Nov-17 Dec-17 TBC
Dietetics Oct-17 Oct-17 Nov-17 Dec-17 TBC
Adult Therapies - MS End Oct-17 Oct-17 Nov-17 TBC TBC
Adult Therapies - Neurology End Oct-17 Oct-17 Nov-17 TBC TBC
Adult Therapies - Non Neuro End Oct-17 Oct-17 Nov-17 TBC TBC
Adult Therapies - SALT End Oct-17 Oct-17 Nov-17 TBC TBC
Adult Therapies - Vestibular End Oct-17 Oct-17 Nov-17 TBC TBC
Diabetes End Oct-17 Oct-17 Nov-17 TBC TBC
Pain Management Nov-17 Nov-17 Dec-17 Oct-17 TBC
Psychology Nov-17 Nov-17 Dec-17 Dec-17 TBC
Podiatry Nov-17 Nov-17 Dec-17 TBC TBC
Chronic Care Coordinators End Nov-17 Nov-17 Dec-17 TBC TBC
Community Matrons End Nov-17 Nov-17 Dec-17 TBC TBC
Leg Ulcer End Nov-17 Nov-17 Dec-17 TBC TBC
Falls End Nov-17 Nov-17 Dec-17 Dec-17 TBC
Stoma Awaiting team's availability
Queens Court Hospice Apr-17 Apr-17 May-17 May-17 Nov-17
Phlebotomy (St Helens & Knowsley) Jun-17 Jul-17 Sep-17 Oct-17 Dec-17
Sub Contracts
Complete
Planned/In Progress
Performance Management
1. Performance Activity Southport & Formby – Referrals Summary
133
Unvalidated Figures
Validated Figures
Service CCG May-17 Jun-17 Jul-17 Aug-17 Sep-17 Oct-17 Total
Adult Therapies - MS NHS Southport and Formby CCG 1 1 1 2 1 0 6
Adult Therapies - Neurology NHS Southport and Formby CCG 51 40 39 48 62 45 285
Adult Therapies - Non Neuro NHS Southport and Formby CCG 154 162 140 163 169 147 935
Adult Therapies - SALT NHS Southport and Formby CCG 3 5 3 9 7 8 35
Adult Therapies - Vestibular NHS Southport and Formby CCG 11 10 6 12 4 11 54
CERT NHS Southport and Formby CCG 103 119 85 105 98 137 647
Chronic Care Coordinators NHS Southport and Formby CCG 155 117 141 134 127 119 793
Community Matrons NHS Southport and Formby CCG 35 47 49 35 40 52 258
NHS South Sefton CCG 62 84 77 93 98 119 533
NHS Southport and Formby CCG 68 93 90 149 104 99 603
Diabetes NHS Southport and Formby CCG 81 96 97 73 89 96 532
Dietetics NHS Southport and Formby CCG 251 215 208 209 194 207 1284
District Nurses NHS Southport and Formby CCG 543 683 632 668 770 774 4070
District Nurses OOH NHS Southport and Formby CCG 183 169 207 182 195 231 1167
Falls Service NHS Southport and Formby CCG 81 88 60 72 65 59 425
Leg Ulcer NHS Southport and Formby CCG 6 13 3 6 10 8 46
Pain Management NHS Southport and Formby CCG 29 71 47 33 70 23 273
Phlebotomy NHS Southport and Formby CCG 1738 2215 2234 2261 2090 2315 12853
Podiatry NHS Southport and Formby CCG 369 391 316 366 291 352 2085
Psychology NHS Southport and Formby CCG 18 13 20 26 20 19 116
Stoma NHS Southport and Formby CCG 19 24 70 28 13 25 179
Treatment Rooms NHS Southport and Formby CCG 843 1036 1020 1006 936 1100 5941
Grand Total 4804 5692 5545 5680 5453 5946 33120
Continence
Performance Management
1. Performance Activity Southport & Formby – Contacts Summary
134
Unvalidated Figures
Validated Figures
Service CCG May-17 Jun-17 Jul-17 Aug-17 Sep-17 Oct-17 Total
Adult Therapies - MS NHS Southport and Formby CCG 5 4 3 3 6 4 25
Adult Therapies - Neurology NHS Southport and Formby CCG 309 248 280 293 313 285 1728
Adult Therapies - Non Neuro NHS Southport and Formby CCG 384 424 397 420 477 564 2666
Adult Therapies - SALT NHS Southport and Formby CCG 13 9 7 12 21 19 81
Adult Therapies - Vestibular NHS Southport and Formby CCG 30 41 40 42 36 52 241
CERT NHS Southport and Formby CCG 2146 2529 2567 2495 2393 3154 15284
Chronic Care Coordinators NHS Southport and Formby CCG 478 445 409 320 389 356 2397
Community Matrons NHS Southport and Formby CCG 256 387 370 361 279 405 2058
NHS South Sefton CCG 87 92 120 239 235 172 945
NHS Southport and Formby CCG 66 156 254 296 223 206 1201
Diabetes NHS Southport and Formby CCG 450 446 376 486 468 482 2708
Dietetics NHS Southport and Formby CCG 403 442 439 451 454 436 2625
District Nurses NHS Southport and Formby CCG 6466 8439 7858 8312 7780 8354 47209
District Nurses OOH NHS Southport and Formby CCG 556 480 604 497 549 684 3370
Falls Service NHS Southport and Formby CCG 109 91 90 148 151 145 734
Leg Ulcer NHS Southport and Formby CCG 51 84 95 80 94 100 504
Pain Management NHS Southport and Formby CCG 244 288 278 206 353 317 1686
Phlebotomy NHS Southport and Formby CCG 1337 2214 2063 2128 2003 2127 11872
Podiatry NHS Southport and Formby CCG 1895 2212 2127 2272 2011 2272 12789
Psychology NHS Southport and Formby CCG 250 290 290 376 262 322 1790
Stoma NHS Southport and Formby CCG 95 99 118 107 69 87 575
Treatment Rooms NHS Southport and Formby CCG 2090 2618 2454 2569 2118 2368 14217
Grand Total 17720 22038 21239 22113 20684 22911 126705
Continence
Performance Management
1. Performance Activity Southport & Formby – Continence
135
Southport & Formby - Continence:
Improvements in data recording and waiting list management continue to improve the waiting list profile for the Continence Service. The
latest snapshot from 15/11/2017 shows the team has reduced the high number of +25 weeks and the profile of the waiting list is front
loaded, decreasing in numbers moving through the longer wait bands.
The Continence service is scheduled to be audited by the end of November 17 by the EMIS and Performance teams.
Performance Management
2.1 Finance Activity Southport & Formby
Detail for Southport and Formby can be found in the Trust's main QPR Finance and Contracting Section.
Performance Management
137
A temporary data sharing agreement is in place and data will start to populate the Trust’s data warehouse over the coming weeks and
months. When data has been validated it will appear within this report. A project has been initiated to validate each service’s
data. The projected end date for all services is Oct 2017.
2.2 Contract Activity Southport & Formby
Performance Management
138
2.2 Contract Activity Queens Court – Palliative Care subcontract
CNS MAY JUNE Q1 JULY AUG SEP Q2 OCT Q3 Total
Number of referrals received 88 84 172 83 93 76 252 69 69 317
% appropriate referrals (SEEN BY SERVICE) 80% 79% 79% 78% 78% 74% 77% 91% 91% 82%
Primary health care team (GP) 20 15 35 16 19 22 57 23 23 115
Specialist nurse / team (internal) 9 13 22 9 4 10 23 7 7 52
Other hospital staff (internal) 47 46 93 36 50 30 116 31 31 240
Internal Referral (QCH & SPCS) 11 10 21 21 20 14 55 8 8 84
Other(other) 1 0 1 1 0 0 1 0 0 2
Not recorded 0 0 0 0 0 0 0 0 0 0
Pain/Symptom Control 83 76 159 81 86 66 233 68 68 460
Psychological Support 44 48 92 39 60 40 139 13 13 244
Social/Financial 0 0 0 2 0 0 2 0 0 2
Family Support 0 1 1 1 0 1 2 0 0 3
Other 0 1 1 0 0 0 0 0 0 1
Number of patients 'active' 364 363 727 383 390 390 1163 390 390 2280
82 41 123 37 43 46 126 45 45 294
19 18 37 18 20 20 58 6 6 101
Inappropriate 1 0 1 1 1 2 4 1 1 6
Died within 24hrs of referral 2 2 4 2 4 1 7 1 1 12
Declined 0 1 1 1 1 1 3 0 0 4
Unable to contact (includes admissions) 1 0 1 0 0 4 4 0 0 5
Contact made, appointment arranged 12 11 23 11 10 8 29 3 3 55
Other 3 3 6 5 3 4 12 1 1 19
Unknown 0 1 1 0 1 0 1 0 0 2
Number 70 66 136 65 73 56 194 63 63 393
New and re-referred as % of all patients seen
in month41% 39% 40% 36% 39% 33% 58% 35% 35% 44%
Cancer 42 44 86 42 49 34 125 32 32 243
Non-malignant 28 22 50 23 24 22 69 31 31 150
Not recorded 0 0 0 0 0 0 0 0 0 0
% Primary Diagnosis of Cancer 60% 67% 63% 65% 67% 61% 64% 51% 51% 59%
Total (New Non F2F) 82 84 166 83 93 76 252 69 69 487
Within 48 hours 69 69 138 67 74 54 195 50 50 383
% target achieved 84% 82% 83% 81% 80% 71% 77% 72% 72% 78%
Number of referrals ended (of those seen)
Reason for Referral (maybe more
then 1 per patient)
Referral source
Diagnosis (of those seen)
New and re-referred patients (seen)
Initial Telephone contact
Time from referral to patient contact.
No more than 48hours (75% target)
Referrals not seen (non F:F)
Performance Management
139
2.2 Contract Activity Queens Court – Palliative Care subcontract
New assessment with patient (New F2F) 54 64 118 59 70 49 178 66 66 362
OPD 0 20 44 22 34 21 77 30 30 151
Current place of residence 54 44 74 37 39 28 104 36 36 214
Review FU with patient (face-to-face) 251 266 578 263 220 252 735 303 303 1616
OPD 0 78 139 53 63 49 165 44 44 348
Current place of residence 312 188 439 210 157 203 570 259 259 1268
Review FU with patient (telephone) 270 270 540 301 203 187 691 305 305 1536
Advice & Support relative/carer F:F 185 171 356 166 175 190 531 212 212 1099
Advice/support to a Professional F:F 168 173 341 162 179 145 486 175 175 1002
Advice & Support relative/carer Tel 222 232 454 217 240 231 688 281 281 1423
Advice/support to a Professional Tel 147 184 331 158 207 152 517 166 166 1014
Bereavement visit with relative / carer 0 0 0 1 0 1 2 2 2 4
Bereavement Telephone with relative / carer 11 16 27 17 24 12 53 16 16 96
Bereavement Letter to relative / carer 14 17 31 18 15 9 42 16 16 89
DNA (Total DNA) NR NR NR NR NR NR NR NR NR NR
0 31 23 54 33 37 22 92 22 22 168
1 15 14 29 10 7 9 26 16 16 71
2 5 3 8 0 5 2 7 4 4 19
3 1 5 6 7 4 5 16 1 1 23
4 4 6 10 4 5 6 15 3 3 28
5 1 3 4 2 3 1 6 4 4 14
6 2 1 3 0 6 0 6 4 4 13
7 1 4 5 3 1 4 8 0 0 13
8-14 6 6 12 5 2 6 13 7 7 32
15-21 3 0 3 0 3 1 4 1 1 8
22-28 0 0 0 1 0 0 1 1 1 2
29-41 0 0 0 0 0 0 0 0 0 0
> 42 0 0 0 0 0 0 0 0 0 0
Total 69 65 134 65 73 56 194 63 63 391
Primary healthcare team 24 15 39 22 18 13 53 9 9 101
Internal referral 1 3 4 2 2 0 4 3 3 11
Died 57 21 78 12 19 31 62 33 33 173
Other 0 2 2 1 4 2 7 0 0 9
Not recorded 0 0 0 0 0 0 0 0 0 0
Contacts
(related to caseload)
Discharged to (of those seen)
Time from Referral to Assessment
in days (seen)
Performance Management
140
2.2 Contract Activity Queens Court – Palliative Care subcontract
Average time 119 21 32 19 34 45 33 35 35 33
Shortest time 0 0 0 0 0 0 0 0 0 0
Longest time 1898 154 1898 279 315 572 572 939 939 1136
63% 33% 55% 25% 42% 55% 45% 42% 42% 48%
Home 16 3 19 2 5 6 13 8 8 40
Hospital 21 14 35 9 11 14 34 19 19 88
Hospice 13 0 13 0 1 1 2 4 4 19
Care home 7 4 11 1 2 10 13 2 2 26
Prison 0 0 0 0 0 0 0 0 0 0
Other 0 0 0 0 0 0 0 0 0 0
Unknown 0 0 0 0 0 0 0 0 0 0
PPC achieved 29 9 38 5 7 13 25 19 19 82
PPC not achieved 14 3 17 0 3 7 10 2 2 29
PPC unknown 14 9 23 7 9 11 27 12 12 62
Not recorded 0 0 0 0 0 0 0 0 0 0
0 - 5 57 54 111 56 61 45 162 50 50 323
6 - 14 9 11 20 8 9 10 27 11 11 58
15 - 21 3 0 3 0 3 1 4 1 1 8
22 - 28 0 0 0 1 0 0 1 1 1 2
29 - 42 0 0 0 2 0 0 2 2 2 4
> 42 0 0 0 0 0 0 0 0 0 0
% Non Hospital Deaths (of those seen)
Time on caseload (of those seen)
Time to receiving care
for referrals in this month
(active data)
Deaths (of those seen)
Place of death (of those seen)
Performance Management
141
2.2 Contract Activity Queens Court – Palliative Care subcontract
Activity perfomance indicator Report frequency May June Q1 July Aug Sept Q2 Oct Q3 Annual total
SERVICE USER EXPERIENCE
1. Complaints received Monthly 0 0 0 0 0 0 0 0 0 0
2. Compliments Monthly 6 9 15 3 4 1 8 3 3 26
3. Incidents reported (about the service) Monthly 0 0 0 0 0 0 0 0 0 0
4. Incidents reported (by the service) Monthly 1 0 1 0 2 0 2 1 1 4
5. Iwantgreatcare (number of returns) Annually 0 0
STAFF TURNOVER /ATTENDANCE
1. Left employment Quarterly 1 0 0 1
2. Recruited Quarterly 0 0 0 0
3. Sickness % per establishment Quarterly 10.60% 1.59% TBC 0.00%
STAFF TRAINING / DEVELOPMENT
1. Annual apprisals completed 100% Annually 0
2. Mandatory training completed 100% Annually 0
3. Clinical supervision (hours) 100% Monthly 0 0 0 1.5 0 1.5 3 1.5 1.5 4.5
GSF Attendance Monthly 6 6 12 8 7 11 26 11 11 49
Performance Management
3. Quality Southport & Formby
142
KLOE Domain Indicator Target Nov Dec Jan Feb Mar Apr May Jun Jul Aug Sep Oct12 months
total
12 months
averageSparkline Risk
Incidents n/a 20 50 58 56 53 44 281 47
STEIS-reportable serious
incidentsn/a 0 1 0 0 0 1 2 0
RIDDOR incidents n/a 0 1 0 0 1 0 0 0 0 0 0 0 2 0
Fall incidents n/a 0 0 1 0 1 1 3 1
Pressure ulcer incidents n/a 4 20 20 18 15 11 88 15
Potentially avoidable grade 3
and 4 pressure ulcersn/a 0 0 0 0 0 0 0 0 0 0 0 0 0 0
Safeguarding alerts n/a 1 3 4 3 1 7 19 3
Staff safetyViolence or aggression to staff
from patients n/a 0 0 1 0 0 0 1 0
Pressure ulcers (%) - 1.06% 5.15% 1.09% 1.59% 4.23% 1.95% - 2.51%
Falls with harm (%) - 0% 0% 0% 0% 0% 0% - 0.00%
Catheter and UTI (%) - 0% 0% 0% 0% 0% 0% - 0.00%
VTE (%) - 0.53% 1.47% 1.46% 1.27% 0.94% 0.98% - 1.11%
Physical Health HFC Rate (%) 95% 99% 94% 98% 97% 96% 97% - 96.89%
F&F Test 95% 99.2% 100.0% - 99.60%
F&F Test - Response Rate n/a 126 113 239 120
Compliments Compliments n/a 0 4 16 45 54 25 41 185 26
Complaints n/a 0 0 0 0 0 0 1 2 12 11 1 7 34 3
Upheld/partially upheld
complaintsn/a 0 0 0 0 0 0 0 0 6 6 3 2 17 1
Completed within agreed
timeframe (%)n/a
Reopened complaints n/a
Overdue 3 day reviews 0 2 2 2
Overdue 7 day reviews 0 12 12 12
Overdue incident actions 0 0 0 0
Duty of candour breaches 0 0 0 0 0 0 0 0 0 0 0 0 0 0
Assurance Concerns raised n/a
Learning and
candour
Patient safety
Incidents
FOCUSED QUALITY AND SAFETY SURVEILLANCE - Southport & Formby Services
Safe
Effective
Caring
Responsive
Well Led
Physical Health
Harm Free Care
Friends & Family -
Patients
Complaints
Performance Management
143
Actual Workforce Costs Compared to Budget - Quarterly Trend
Peripheral Workforce Spend and Usage
4. Workforce Actual Workforce Costs Compared to Budget
Spend £ % Spend £ % Spend £ %
Southport & Formby 664,517 14,652 2.0% 49,572 6.8% 0 0.0% 64,224 728,740 8.81%
Flexible
Labour
Reliance
%Business Area
Core
Workforce
Spend £
Bank Agency Medical Agency
Total Spend
£
2017 10
Total
Peripheral
Workforce
Spend £
Performance Management
4. Workforce Sickness Absence Rates
144
Trust 12 Month, Year on Year Trend
Sickness Absence Breakdown
Rate Rate Rate Trend
2017 08 2017 09 2017 10
% Long
Term
Absence
% Short
Term
Absence
12mths
Southport & Formby 5.08% 6.70% 5.07% 45.25% 54.75%
2017 10
Performance Management
4. Workforce Appraisals and Mandatory Training Compliance
145
Conflict
Resolution
3yr
E&D 3yrFire Safety
1yr
Health &
Safety 3yr
Infection
Control
Admin 2yr
Infection
Control
Clinical 1yr
Manual
Handling 1
3yr
Mental
Capacity Act
(Admin) One
Time
Completion
Mental
Capacity Act
(Clinical) 3yr
Resuscitation
1yr
Safeguarding
Children 1
3yr
Safeguarding
Adults 1 3yrCore Total ILS 1yr
Manual
Handling 2
3yr
Manual
Handling 3
2yr
Safeguardin
g Children 2
3yr
Safeguardin
g Children 3
3yr
Information
Governance
Local
Total
Co
re &
Lo
cal
Tota
l
S&F 77% 95% 93% 89% 95% 91% 93% 88% 91% 75% 98% 98% 90% x 96% x 88% x 95% 93% 91% 52%
Core Mandatory & Statutory Training Local Mandatory & Statutory Training
Appraisals
Compliance
Performance Management
4. Workforce Vacancy Management and Active Recruitment
146
Budgeted
Establ ishment (BE)
(FTE)
Actual
Establ ishment (FTE)
Budgeted
Establ ishment
Vacancies
(FTE)
BE Vacancy
Rate
Active Vacancy
Rate
Active Vacancy
FTENo. Pos i tions
Avg. No Days
to Recruit
Southport & Formby 224.10 204.75 19.35 8.63% 62.02% 12.00 16.00 N/A
2017 10
Establ ishment Vacancies Vacancies in Active Recruitment
Performance Management
4. Workforce Core Workforce Headcount
147
Core Workforce
Network Headcount FTE Headcount FTE
Southport & Formby 260 204.51 260 204.75
2017 09 2017 10
Performance Management
148
4. Workforce Workforce Turnover
Board of Directors
Agenda Item TB 186/17 Date: 07/12/2017
Report Title Trust Chairs Report
FOIA Exemption No Exemption
Prepared by Umme Batan, Corporate Governance Support
Presented by David Eva, Trust Chair
Action required Noting and Decision
Supporting Executive Director Chief Executive
PURPOSE OF THE REPORT:
Report purpose The purpose of the report is to provide the Board with an overview of the activity undertaken by the Board and Non-Executive Directors in addition to the Board of Director meetings and Council of Governor meetings.
The Board of Directors is also asked to approve the appointment of the Senior Independent Director and the Deputy Chair.
Strategic Objective(s) this work supports
To become recognised for excellence
Board Assurance Framework risk 1.1 If we do not meet regulatory standards for quality and safety we will not be fit for purpose as a care provider.
CQC domain Well-led
1.0 NON-EXECUTIVE DIRECTOR ACTIVITY
The Non-Executive Directors have been attending the Board Committee meetings of which they are a member (including the Financial Recovery Group) and apologies have been given where they were unable to attend. In addition to the usual Board business, Non-Executive Directors (NEDs) have been involved in their areas of special interest during the period of October 2017 – November 2017: Gwynne Furlong
Attended the Quality Committee Attended the CoG Quality & Assurance Meeting Sat on the panel of a disciplinary hearing Met with the Property Services Director Attended the Hearing Feedback Steering Group Had an introductory meeting with the Head of Operations for the Children and Young
People’s Network Met with the Head of Communications to discuss the delivery of November Team Talk
and filmed Team Talk Attended a meeting with the Trust Chair to discuss Housing Association
Louise Dickinson Met with the Assistant Director from MIAA to discuss 18/19
planning
Met with the Company Secretary to discuss the Audit Committee Effectiveness Review
Julia Possener
Attended the Charitable Trustee Funds Committee meeting
David Curtis Chaired the monthly SI Panel Attended the Audit Committee Effectiveness Review
Met with the Deputy Company Secretary to discuss the Quality Committee agenda
Attended the Quality Committee
Attended the Opportunity Knocks event
Met with the Director of Nursing for their monthly catch up Attended the Clinical Research Unit opening event at Royal Preston Hospital
Isla Wilson
Attended the Quality Committee
Met with the Chief Executive to discuss STP
Attended the planning for the social value workshop
Sat on the panel of an appeal hearing Attended the NHS Workforce Race Equality Standard (WRES) Conference on behalf of
the Chair Met with the Director of HR to discuss WRES Attended the STP Board Development Session Met with Amanda Thornton to discuss BDRW Attended the Opportunity Knocks event
Peter Ballard
Attended the AAC Panel Attended the Council of Governors meeting in November Attended the Opportunity Knocks event Met with the Chair for an exit interview
In addition to the above:
Gwynne, Louise and Peter attended the November Council of Governors meeting Louise, Julia and Isla attended the Audit Effectiveness Review meeting which the
Company Secretary was in attendance for
2.0 CHAIR’S ACTIVITY The Chair attended the Board meetings and Council of Governors meetings. The Chair has been having weekly catch up meetings with the Chief Executive and had
monthly meetings with the Company Secretary and has met with several Board members and Senior Managers and colleagues
The Chair continues to meet with MPs Attended the Partnership Leaders Forum Met with a member of the public Attended a meeting with the Senior Independent Director to discuss Housing
Association
3.0 COUNCIL OF GOVERNORS UPDATE This section has been added to the Chair’s Report in order to keep the Board updated on Council of Governor activity, recognising that since 01 April 2017 Board members have been attending meetings on an invitation basis. Since the last Chair’s Report received on 02 November 2017, the following items have been considered by the Council of Governors: 15th November 2017
The Council of Governors approved the extension of the External Audit contract with
KPMG for a period of two years (from 1 April 2018 until 31 March 2020).
It was confirmed that Staff Governors Max Oosman and James Harper would not apply for a second term of office from December 2017 due to work commitments.
The Chief Operating Officer deputised for the Chief Executive and provided an update on the STP and the high and low points for the month
The Head of Strategy & Business Planning provided a presentation on the Annual Planning 2018/19
The Health & Wellbeing Project Manager provided the Governors with insight into the Health and Wellbeing agenda within the Trust.
4.0 USE OF THE COMMON SEAL To inform the Board that the Common Seal has been used as follows since the Board of Directors meeting on the 02 November 2017:
30/11/2017 – Licence to occupy on short term basis relating to offices at Croston House, Lancashire Business Park, Centurion Way, Leyland between LCFT and Lancashire County Developments (Property) Limited (sign only)
30/11/2017 – Renewal Lease re Friday Street, Chorley, PR6 0AA between LCFT and Bugle Inn Motor Company Limited
5.0 RAISING CONCERNS As Trust Chair I continue to oversee the Dear David process for staff to raise concerns. This
process compliments other mechanisms for staff to raise concerns such as the Raising
Concerns Guardian. During October 2017, the following concerns were raised with me through
Dear David:
Concerns over the proposed installation of baths in initial designs for the Chorley
inpatient unit;
Staff smoking on the road outside Sceptre Way;
High caseload and demand in Community Mental Health Teams;
Lack of commissioned services for people suffering with Autistic spectrum disorder and
behavioural difficulties;
High caseloads in Community Mental Health Teams;
Caseloads, lack of management support and supervision Community Mental Health
Teams;
Staff suffering with stress in Community Mental Health Teams.
The Executive Director of Nursing and Quality (as Executive Lead for Raising Concerns) and Associate Director of Safety and Quality Governance (as Raising Concerns Guardian) continue to administer the Dear David process on my behalf and they have ensured that all concerns are
being reviewed with feedback provided to those raising concerns directly, where possible, and also included in the Quality Matters electronic bulletin to staff.
6.0 DEPUTY CHAIR APPOINTMENT The Board of Directors is aware of the departure of the Deputy Chair Peter Ballard whose term of office finished on 30 November 2017. In line with NHSI requirements the Trust must nominate a Deputy Chair. The Trust Chair proposes that Gwynne Furlong is appointed as the new Deputy Chair with effect from 01 December 2017. Gwynne was re-appointed as a NED for a second term of office in 2015 and will be finishing his term of office in October 2018. Gwynne is the longest serving Non-Executive Director. The Board of Directors is asked to consider and agree with the proposal and make a recommendation to the Council of Governors.
7.0 SENIOR INDEPENDENT DIRECTOR APPOINTMENT In line with NHS Improvement requirements the Trust must nominate a Senior Independent Director, a role which Gwynne Furlong held till 30 November 2017. The Trust Chair proposes that Isla Wilson is appointed as the new Senior Independent Director with effect from 01 December 2017. The Code of Governance states that:
A.4.1. In consultation with the council of governors, the board should appoint one of the
independent non-executive directors to be the senior independent director to provide a
sounding board for the chairperson and to serve as an intermediary for the other
directors when necessary.
The Board of Directors is asked to consider and agree with the proposal and make a recommendation to the Council of Governors.
8.0 NON-EXECUTIVE DIRECTORS ROLES & COMMITTEE MEMBERSHIP On approval of the above Non-Executive Director appointments the new committee membership will be as below effective of 01 December 2017.
Non-Exec Role
David Eva Trust Chair
Gwynne Furlong Deputy Chair
Isla Wilson Senior Independent Director and
Finance & Performance Committee Chair
David Curtis Quality Committee Chair
Louise Dickinson Audit Committee Chair
Julia Possener Non-Executive Director
Board of Directors Audit Committee Quality Committee Finance and Performance Committee
Charitable Trustee Funds
Committee
David Eva
Chair
Louise Dickinson
Committee Chair
David Curtis
Committee Chair
Isla Wilson
Committee Chair
Gwynne Furlong
Committee Chair
Gwynne Furlong
Louise Dickinson
David Curtis
Isla Wilson
Julia Possener
David Curtis
Isla Wilson
Julia Possener
Gwynne Furlong
Isla Wilson
Gwynne Furlong
Louise Dickinson
Julia Possener
9.0 BOARD ACTION
The Board is asked to note the updates provided for information and make a recommendation to the Council of Governors to ratify: The appointment of Gwynne Furlong as the Deputy Chair with effect from 01 December
2017 The appointment of Isla Wilson as Senior Independent Director with effect from 01
December 2017
Board of Directors
Agenda Item TB 187/17 Date: 07/12/2017
Report Title Quality Committee Chair Report
FOIA Exemption No Exemption
Prepared by Viv Prentice, Deputy Company Secretary
Presented by David Curtis, Chair of Quality Committee
Action required Noting
Supporting Executive Director Executive Director of Nursing and Quality
PURPOSE OF THE REPORT:
Report purpose To provide an outline of the activity undertaken by the Quality Committee.
Strategic Objective(s) this work supports
To provide high quality services
Board Assurance Framework risk 1.1 The Trust does not protect services users from avoidable harm and fails to comply with the CQC standards for the quality and safety of services
1.2 The Trust does not deliver safe, appropriate and therapeutic environments to deliver high quality services
3.1 The Trust fails to deliver the benefits of being a Health and Wellbeing provider.
4.1 The Trust is unable to attract, recruit and retain high quality staff impacting on a continued dependency on temporary staffing levels, affecting quality of care and financial costs
4.2 The Trust does not deliver effective education, training and leadership opportunities resulting in a workforce who are unable to deliver high quality, safe care
7.3 The Trust does not comply with Mental Health Legislation
CQC domain Well-led
1.0 INTRODUCTION This Chair Report outlines the activity undertaken by the Quality Committee held on the 13 November 2017. 2.0 COMMITTEE ACTION
The Trust Board is asked to note the content of the Chair’s Report for assurance.
CHAIR’S REPORT
CHAIRS REPORT OF: Quality Committee
DATE OF MEETING: 13 November 2017
BOARD ASSURANCE FRAMEWORK RISKS ALIGNED TO COMMITTEE:
1.1 The Trust does not protect services users from avoidable harm and fails to comply with the CQC standards for the quality and safety of services
1.2 The Trust does not deliver safe, appropriate and therapeutic environments to deliver high quality services
3.1 The Trust fails to deliver holistic whole person care (Physical and Mental Health)
4.1 The Trust is unable to attract, recruit and retain high quality staff impacting on a continued dependency on temporary staffing levels, affecting quality of care and financial costs
4.2 The Trust does not deliver effective education, training and leadership opportunities resulting in a workforce who are unable to deliver high quality, safe care
7.3 The Trust does not comply with Mental Health Legislation
AGENDA ITEMS BAF RISK DISCUSSION, ASSURANCE, RISK OR FURTHER ACTION
Board Assurance Framework Report
1.1, 1.2, 1.3, 3.1, 4.1, 4.2
Assurance
Consideration was given to each of the assurance reports during the meeting and the Committee received assurance that there had been no significant changes to the risks in the last quarter.
Raising Concerns Bi-Annual Report
1.1 Discussion The development work that had taken place to continually promote the right culture to enable staff to raise concerns was outlined. This included engagement with the National Guardian’s office, regular communication with staff and the recruitment of Raising Concerns Advocates. Concerns are now themed against set criteria developed by the National Guardian’s office which highlighted quality and safety as the predominant theme. These concerns related in particular to violence and aggression, caseloads and feelings of stress.
An internal indicator to assess the confidence in the culture of raising concerns indicated that just over half of the staff members that raised concerns wished to remain anonymous. Assurance Significant assurance was provided in relation to the Raising Concerns process and compliance with the system. In addition, both the Audit Committee and the Council of Governors had previously received assurance in respect of the Trust’s systems and processes that are in place to enable staff to raise concerns. Following a survey of all local Guardians undertaken by the National Freedom to Speak up Guardian, the work that was being undertaken to address the three areas of improvement that had been identified were outlined. This included recruiting Raising Concerns Advocates and working closely with the Equality & Diversity Project Manager to ensure hard to reach staff groups are supported and encouraged to raise concerns. The Committee noted that 59 concerns had been raised during the last six months with the majority of concerns raised via the Trust’s ‘Dear David’ method. This clearly highlighted how well embedded this had become as a way for staff to raise concerns. Further Action The Committee agreed with the recommendation to receive future reports on a quarterly basis thereby ensuring more timely information and detail. The Committee consented to the Raising Concerns Guardian appointing a Deputy from the pool of Advocates (on a recurrent 12 month appointment basis) to ensure continuity during periods of absence.
Quality and Safety Surveillance Reports
1.1 Discussion The Committee’s attention was drawn to the lack of Southport & Formby data prior to May 2017 and noted that this was due to the non-availability of data from the previous provider. Assurance The Committee received significant assurance in respect of the Quality Surveillance systems and controls and the continued improvement of the reports, which now included a Mental Health Law Surveillance Report. There had been a decrease in the number of Grade 3 and 4 pressure ulcers and it was noted that an investigation was being undertaken following the Never Event that had occurred earlier in the year. Upheld complaints remained broadly static whilst re-opened complaints had dropped significantly and complaints to the PHSO were very low.
In relation to Mental Health Law, the number of section 136 lasting over 72 hours remained consistent. However, with the introduction of new legislation there was an expectation that this would increase. It was noted that the risk to the organisation was fairly low as the Trust would rely on some common law powers to hold people in their best interests. There had been an increase in compliance with patients having a Section 132 rights form in place at the beginning of the month. As a result of the increase in medication incidents within the Community and Wellbeing Network, there was now renewed visibility in that area. Risk The number of RIDDORs had increased which related to incidents of violence on inpatient units. The use of restraint had also increased with the highest use being reported on PICU wards and older adult wards. A deep dive would therefore be undertaken and a summary provided to the Quality & Safety Sub-Committee. The overall Mental Health Harm Free Care target remained below the Trust aspiration, although it was higher than the previous two months. Whilst overall compliance with Core Skills was above target, compliance with key modules in some subject areas remains challenged. Whilst the number of overdue incident reviews continues to be high, this remains a focus for the networks. A further quality measure has been added to look at the percentage of patients who have their rights read within 24 hours of detention as compliance with this is currently very poor. As a result of the increase in the number of complaints, work is underway to improve the approach to hearing feedback. Further Action
Following a query regarding levels of detention and if there was any data relating to ethnicity, it was noted that following development of the MH Act recording system this information should be extractable. However, the Associate Director of Safety and Quality Governance agreed to look into this further and report back to the MH Law Sub-Committee.
Quality & Safety Sub-Committee Chair’s Report
1.1, 1.2, 3.1 Assurance The Chair’s Report following the meeting held on the 25 October was presented which highlighted the approval of the Quality Assurance Framework.
The Committee were informed that the number of self-harm incidents at The Cove related to a small number of patients.
Further Action
The Executive Director of Nursing confirmed that a development session may be held upon completion of the deep dive into incidents of violence on older adult wards.
People Sub-Committee Chair’s Report
4.1, 4.2 Assurance The Chair’s Report following the meeting held on the 15 June was presented and it was noted that the outcome of the effectiveness review undertaken was positive. In addition, an in-depth discussion had been held in relation to the untapped talent project report which had been well received. The Committee had received positive assurance following the LADO Allegations Thematic Review Report, which provided strong evidence of engagement. Risk It was disappointing to note non-compliance against the core skills target. Further Action An overview of the apprenticeship levy delivery plan was provided. The Director of HR agreed to provide further assurance in respect of the delivery of the plan at the next meeting.
Quality Account 1.1 Assurance The Associate Director of Quality and Experience presented the Quality Account quarter two position and provided an update on the quality priorities reflected in the Quality Account aligned to the four domains of effectiveness, experience of care, safety and well-led. The Committee noted the good progress with the Quality Account. The work that had been undertaken in respect of each domain was outlined. This included the recent ‘thinking space’ session that had been held to drive improvement and consistency in seclusion practice. In addition, eight Always Events had been planned and the Trust were implementing the Care and Compassion programme (adopted from the Sit and See approach) to ensure that feedback informs quality improvements at the point of care. A further quality improvement had seen the launch of the Safety Cross model of reporting, providing teams with an at a glance picture of pressure ulcer prevention. The work being undertaken in partnership with AQuA to develop a ‘bite-size’ quality improvement learning programme was outlined. Small scale testing of the programme had been undertaken with further testing to be undertaken during quarter three. Plans were also being developed for the next Quality Improvement Conference which would provide the opportunity to showcase the quality improvements taking place throughout the Trust.
All NHS Improvement core indicator targets were achieved. It was noted that the data relating to the Early intervention Service (EIS) was currently being reviewed and validated and would be available within the quarter three report.
Risk Assurance 1.1, 1.2, 3.1, 4.1, 4.2, 7.3
Assurance It was agreed that following discussions throughout the meeting adequate assurance had been received and there had been no impact on the risk scores relevant to the Committee.
Board of Directors
Agenda Item TB 188/17 Date: 07/12/2017
Report Title Chief Executive’s Report – Part One
FOIA Exemption No Exemption
Prepared by Heather Tierney-Moore, Chief Executive
Presented by Heather Tierney-Moore, Chief Executive
Action required Discussion/Decision
Supporting Executive Director Chief Executive
PURPOSE OF THE REPORT:
Report purpose The purpose of this report is to provide Board members with an overall summary of the Trust position and highlight areas for further discussion.
Strategic Objective(s) this work supports
To provide high quality services
Board Assurance Framework risk 2.1 – The Trust does not receive assurance of the accuracy, timeliness and consistency of data and reporting with the potential to compromise decision making and service quality
CQC domain Well-led
Introduction This report aims to give Board members an overview of the activity undertaken since the last Board meeting, both within the Trust and externally.
QUALITY AND SAFETY
Serious Incidents
During October 2017, the following serious incidents were reported:
(brief information is provided to protect confidentiality, the term suicide is only used once a Coroner’s
Inquest has returned a verdict of suicide)
Serious self-harm (suspected attempted suicide) of a prisoner at HMP Liverpool;
Death (suspected suicide) of a patient under the care of the Assessment and Treatment Team in Chorley and South Ribble;
Concerns around the care of a patient in Podiatry in Central Lancashire – no immediate concerns for Lancashire Care Foundation Trust (LCFT) services however a patient under the care of Podiatry underwent an operation at an Acute Trust where the wound deteriorated resulting in an above knee amputation;
Death (suspected suicide) of a patient under the care of the Assessment and Treatment Team in Lancaster and Morecombe;
Death (suspected suicide) of a patient under the care of the Rapid Intervention and Treatment Team in Lancaster and Morecombe;
Death (suspected suicide) of a person recently seen by the Mental Health Liaison Team in Central Lancashire;
Death of a patient in an Acute Trust which may have been contributed to by a pressure ulcer, where the patient was under the care of Southport and Formby District Nursing;
Death (suspected suicide) of a prisoner at HMP Liverpool;
Death of a patient under the care of the Mindsmatter Service in West Lancashire.
In all cases, a formal investigation is now underway and the incidents have been reported to
commissioners, NHS England and regulators as required under the NHS Serious Incident
Framework.
Significant Health and Safety Incidents During October 2017, the following incident was reported to the Health and Safety Executive and
Care Quality Commission under the Reporting of Injuries, Diseases and Dangerous occurrences
Regulations (RIDDOR):
(brief information is provided to protect confidentiality)
Injury to a staff member’s back whilst opening a door resulting in absence for over seven days. Raising Concerns During October 2017, the following concerns were reported through the various mechanisms including the Raising Concerns Guardian and through Dear David:
The proposed installation of baths in initial designs for the Chorley Inpatient Unit;
Staff smoking on the road outside Sceptre Way;
High caseload and demand in Community Mental Health Teams;
Staff attack alarms not available to staff when entering wards at the Harbour at the start of their shift;
Lack of commissioned services for people suffering with Autistic Spectrum Disorder and behavioural difficulties;
High caseloads in Community Mental Health Teams;
Caseloads, lack of management support and supervision Community Mental Health Teams;
Culture and clinical practice at the Harbour;
Staff suffering with stress in Community Mental Health Teams. In all cases a review of proportionate scale has been commissioned. The findings from each review
are individually fed back to the person raising the concern if they have provided their name. The
findings from every concern is summarised in the Quality Matters bulletin.
Changes to the Mental Health Act The government has formally announced through regulations laid in Parliament that changes in law to
sections 135 and 136 of the Mental Health Act 1983 will come into effect on 11 December 2017. The
changes are as follows:
section 136 powers may be exercised anywhere other than in a private dwelling;
it is unlawful to use a police station as a place of safety for anyone under the age of 18 in any circumstances;
a police station can only be used as a place of safety for adults in specific circumstances, which are set out in regulations;
the previous maximum detention period of up to 72 hours will be reduced to 24 hours (unless a doctor certifies that an extension of up to 12 hours is necessary);
before exercising a section 136 power police officers must, where practicable, consult a health professional;
where a section 135 warrant has been executed, a person may be kept at their home for the purposes of an assessment rather than being removed to another place of safety (in line with what is already possible under section 136);
a new search power will allow Police Officers to search persons subject to section 135 or 136 powers for protective purposes.
The Trust has been preparing for these changes and the Lancashire-wide multi-agency protocol has
been updated. However, the estimate is that 40% of section 136s will run over the reduced period of
24 hours. Longer term developments in mental health services should reduce this over time. A further
report will go to the Mental Health Law Sub-committee in December 2017.
Modern Slavery/Human Trafficking – ‘Duty to Notify’ “Human trafficking destroys lives and its effects damage communities” (Home Office, 2011). The
Modern Slavery Act (2015) introduced measures to enhance the protection of victims of slavery and
trafficking. Section 52 of the Act refers to the ‘Duty to notify’ the Secretary of State about suspected
victims, improving identification, creating a statutory duty to notify for specified public authorities. This
raises awareness, and builds a picture of the nature and scale of modern slavery/human trafficking, to
inform the law enforcement response. It has been confirmed that health agencies do not have a ‘duty
to notify’ but are encouraged to make voluntary notifications.
The Safeguarding Team have integrated this into the Trust’s safeguarding practices which now
require LCFT practitioners to make voluntary notifications if they suspect someone may be a victim.
This is seen as good safeguarding practice which fully supporting the Trust Values, strategic priorities
and 5 year plan; to provide high quality compassionate care and protect people from harm as part of
our quality plans; doing the right thing at the right time for vulnerable people. It is also consistent with
the Trust’s safeguarding vision.
The Safeguarding Team have now implemented processes and steps to fully embed this agenda into
practice, raise awareness and undertake the ‘duty to notify’ as well as undertaking the following:
Trust Safeguarding Team representation at the Pan Lancashire Human Trafficking Group. Within this forum we were made aware of ‘Duty to notify’. It is acknowledged that this is not a statutory requirement of health organisations; however, it was identified as good practice that LCFT front line practitioners make voluntary notifications, if they suspect someone may be a victim.
Received support from NHS England to fund and deliver a conference in 2016 to raise awareness and highlight the agenda within Lancashire. The conference was fully supported by the Trust Board Chair who published a public declaration describing the Trust’s commitment to ensuring no modern slavery or human trafficking in our supply chains or in any part of our business. As part of our commitment the Trust reviewed its supply chains and will be introducing a ‘Supplier Code of Conduct’ with a view to requesting all existing and new suppliers to confirm that they are compliant with the Act.
Identification of the Safeguarding Operational Lead Nurse as a Strategic Lead to drive the agenda forward. Specific training on human trafficking was accessed and she has recently received a MSc in Safeguarding in an international Context.
Introduction of a notification pathway.
The facilitation of several workshops for staff to introduce the “duty to notify” process, regular workshops are available as part of the safeguarding training offer.
Upskilling of the Safeguarding Team to provide advice, support, information and resource for staff. This supported responses to concerns that a patient may have been trafficked and embedded the agenda into the role of the Safeguarding Team as well as staff providing care.
Updated safeguarding training to raise awareness and include information and resources on human trafficking.
Incorporated human trafficking and modern slavery into adult and child safeguarding policies and practice.
Work with Safeguarding Board partners to monitor local human trafficking trends and consider care needs arising
The steps taken have increased staff awareness significantly. In all cases, staff are encouraged to
trust and act on their instinct and if they have concerns about a child, young person or adult they are
advised to take immediate action to ask further questions to help identify victims and offer support.
The Trust is fully engaged in the multi-agency work taking place across the county, contributing to the
intelligence gathering of potential victims in order to protect vulnerable people. In October 2017 the
Operational Safeguarding Lead and Associate Director Safeguarding were invited to present the work
which the Trust has undertaken at a multi-agency conference led by Lancashire Constabulary. Our
actions were recognised by partners as excellent practice and Trust leads have since been invited to
share our process with partner organisations.
The focus of the event was how to build current partnership working practices. Police colleagues fed
back how significant it was that the Trust highlighted the importance of our role when providing care to
individuals who may present themselves either alone or with perhaps a controlling ‘other’ and take on
the role of a ‘duty to notify’ responder. This step is not yet replicated in other areas of the country and
has been praised by the ‘National Police Transformation Team’, who reported that they are
‘enlightened by LCFT’s approach to this area of work’.
Risk and Assurance The Risk and Assurance Team are continuing to build relationships with other organisations to share
best practice and learn from each other. In facilitating this approach, the Associate Director of Risk
and Assurance is co-chairing a new Governance, Assurance and Risk Network with the Deputy
Director of Governance at The Walton Centre NHS Foundation Trust in Liverpool. GARNet is aimed
at colleagues across health and social care in the north west who have an interest in these areas and
would welcome an opportunity to come together to share best practice, learn from each other and to
general promote a better system-wide understanding of governance, assurance and risk. The first
meeting is scheduled for Tuesday 12 December 2017 and is being hosted by The Walton Centre.
The meetings will be held quarterly with Lancashire Care hosting the next meeting in March 2018.
Awards
Karen Seal, Acting Clinical Lead for the Eating Disorder Service won the Mental Health Worker of the
Year Award at The Gazette Best of Health Awards in September.
The Psychosis and Bipolar Psychological Care Network won the Psychological Therapies in
Secondary Care (NHS England) Award at the National Positive Practice in Mental Health Awards in
October and The Acute Therapy Service (PDMCN) were also highly commended within this category.
Allied Health Professions Return to Practice Guidance The Framework and Mentor Guidance for Allied Health Professions (AHP) Return to Practice has
been finalised and is now in place to guide our provision of placements for these professional groups.
This is part of the recruitment and retention strategy and workforce planning. The Associate Director
for AHPs has now promoted and aligned developments within the Trust with an emerging national
piece of work led by Health Education England with LCFT being a recognised placement provider. A
local marketing campaign is due to commence in early January which will dovetail with national
marketing strategy.
Quality Improvement Showcase A showcase session focussing on areas of harm free care improvement work was co-ordinated by the
Quality Improvement Team with presentations from Nursing, AHPs and Psychology with
commissioner colleagues invited. The three key improvement themes were pressure ulcers, falls and
psychological approaches in children’s mental health. Key quality improvement projects were
presented with outcomes to date demonstrating direct impact at the point of care across the
organisation. These projects will be revisited later in the year to track continuous improvement and
sustained change achievements.
HMP Liverpool The Trust has received the draft of the HMP Liverpool joint HMIP/CQC inspection report. The report is
subject to a factual accuracy checking process before being published.
HMP Liverpool Press Enquiry The Board have been separately briefed on a comprehensive media request from the BBC regarding
the Trust’s contract to provide healthcare services at HMP Liverpool. The questions posed and the
formal response was shared with the Board and were signed off by the Chief Executive and the Chair,
as well as shared with NHS Improvement and NHS England. The Board will continue to receive
updates on when the report will be featured and any subsequent media interest generated as a result.
PEOPLE & LEADERSHIP
Head of Organisational Development Appointed Emma Dawkins joins the Trust on Monday 04 December as the new Head of Learning and
Organisational Development. Emma will report directly to Deborah Cox, Deputy Director of Human
Resources & Quality Academy. Emma has a wealth of experience working within the NHS and more
recently for the North West Leadership Academy. Emma is an experienced OD Professional with a
large amount of knowledge and experience in Leadership Development, Talent Management,
Coaching and Mentoring and Organisational Development.
STP-wide Workforce & OD Appointment Paula Roles will commence with the Trust on 4th December in the position of HR Strategic Lead for
the Healthier Lancashire and South Cumbria Sustainability and Transformation Partnership (STP).
This is a new position funded by Health Education England to strengthen workforce, leadership and
organisational development throughout the STP area. Paula is seconded from Blackpool Teaching
Hospitals where she was the acting Director of Human Resources & Organisational Development.
Paula will report to Damian Gallagher and brings with her vast experience of workforce issues,
leadership and organisational development gained through years of experience working throughout
the North West region.
FINANCE AND PERFORMANCE
Finance Report Month 7 sees a year to date operating deficit of -£2.3m, excluding planned Sustainability and
Transformation funding of £0.9m, against a planned surplus to date of £0.6m. This shows an
improvement on month 6 and represents a small budgetary surplus in month and nearly £0.2m when
excluding STF monies. The position remains driven by staffing pressures in ward and prison areas
and consequential impact on cost improvement programmes (rising agency costs will also impact Use
of Resources targets). Additionally OAPs expenditure continues to exceed funding - see Out Of Area
Activity for more details. The forecast assumes current pressures and risks are addressed or
mitigated in line with the recovery plan (see forecasting) and financial performance achieves (or
exceeds) plan but the unmitigated projection indicates a gap of c£4.8m, c£6.9m without STF monies.
This is represents an improvement on month 6 forecasts (£6.2m), and is driven by excess OAPs of
c£0.8m (all be that significantly below last month), prisons (see also Bank and Agency section) and
additional mental health pressures. Delivery of the recovery plan and financial targets will required a
significant and coordinated response with robust management and oversight. After taking in to
account £1.7m of disposals, which are accounted for after EBITDA, EBITDA is broadly in line with I&E
Margin. The new Use of Resources (UoR) metric is rated at 3, but will rise to a 2 should the Trust
meet its financial plans and targets.
Performance Report & Quality Report The Performance Report can be viewed under item TB 185/17 and the separate Quality Report can be viewed under TB 189/17. Changes to the Single Oversight Framework NHS Improvement has published the updated Single Oversight Framework (SOF) in response to an
exercise to seek feedback from providers. The organisation NHS Providers have produced a helpful
briefing which summarises the changes which have been made as a result by NHS Improvement. The
Senior Leadership Team has already considered how the changes will shape the Trust’s performance
reporting accordingly. The briefing can be accessed here.
High Value Requisition: Perinatal Unit As agreed by the Board in February 2017, the RRCS JV partnership is delivering the Trust’s Capital
Programme for 2017/18. The Board is required to provide authorisation to progress project C3:
Central Perinatal Unit following the Trust successfully winning the tender to provide this service,
awarded by NHSE on 10th April 2017. The scheme is within the financial envelope of £3.5m and the
contracted works will commence December 2017 with completion target date of July 2018. RRCS is
recommending that Board approve the attached purchase order requisition for £2,122,535.28
including VAT to enable the work package to be completed within the agreed timeframes for the
Chorley re-design work.
Autumn Budget Following the recent autumn budget statement from the Chancellor, a helpful briefing has been issued
by NHS Providers which summarises the announcements and the potential implications for the NHS
and providers. The briefing can be accessed here.
Memorandum of Understanding: Ribblesdale Partnership The Ribblesdale Community Partnership (RCP) was formed to involve organisations with looking at
ways that services can be locally developed for the Ribblesdale community. The RCP membership
includes all four Ribblesdale medical practices, which serve a population of around 38,000 people, as
well as other provider organisations including the Trust, East Lancashire Hospitals and Lancashire
County Council.
The RCP have developed a unified vision “To create a new integrated system for the management of
community services in Ribblesdale locality run in partnership by local health and care organisations,
removing organisational boundaries to deliver care pathways designed around the needs of our local
population not organisational structures.”
The vision describes similar aspirations to the development of the Chorley Integrated Community
Wellbeing Service, an initiative which is supported by a detailed Memorandum of Understanding
(MOU). As such, a more concise MOU has been developed and circulated by East Lancashire CCG
for the Ribblesdale Partnership which sets out the broad principles and objectives for working
together as part of the RCP. Work has been undertaken to understand the needs of local
communities and what they feel are the health priorities and the partnership is now seeking
agreement from all organisations to sign up to the MOU and therefore the Board are asked to sign off
the MOU which can be viewed here.
NHS Improvement Quarterly Review Follow Up In October, the Trust had its routine quarterly review meeting with NHS Improvement and received
confirmation it would be remaining within segmentation 1.
22222222 November November November November 2012012012017777
NHS Providers | ON THE DAY BRIEFING | Page 1
THE OBR BORROWING FOTHE OBR BORROWING FOTHE OBR BORROWING FOTHE OBR BORROWING FORECASTRECASTRECASTRECAST
November 2017 Budget
Overview
This was the first Autumn Budget, following Philip Hammond’s announcement that he was changing both
the timing and the frequency of the Government‘s “fiscal event “. The budget outlook was significantly less
optimistic about economic prospects than in March. This cut to Britain’s productivity growth has meant a
downgrading of the growth forecast and signals that the UK economy is weaker than hoped.
The NHS in England received more funding than we had expected, but less than needed. The chancellor
announced £1.6 billion extra revenue for 2018/19; £3.5 billion extra capital funded by the treasury, £0.5bn
this year and an additional £3bn over the next five years; and the government has committed to fund with
new money an increase to agenda for change staff, subject to the recommendation from the pay review
bodies. In addition, the government has committed extra capital and extra revenue for this year.
This briefing outlines the economic headlines within the Budget, key announcements for health and the
wider economy, and NHS Providers’ response.
Economic Overview
• Public sector net borrowing has
been revised down for 2016/17
by £8.4bn, relative to the
estimate published in March.
The downward revision is being
driven by higher than expected
PAYE income tax and NICs
receipts (up by £1.9bn this year),
underspending by Government
departments (down by £3.2bn),
an increase in other receipts,
such as VAT and
exercise duty (revised up by £1.3bn), and a downward revision in various annually managed
expenditure lines, such as state pensions and tax credits (down by £4.7bn).
• The deficit is expected to rise to 2.3% of GDP in 2017/18 before falling steadily over the next four years.
• Economic growth for this year (2017/18) has been revised down from 2% to 1.5%. The OBR has
downgraded the forecasts for the three subsequent years. The average annual growth rate over the
next five years is 1.4%.
NHS Providers | ON THE DAY BRIEFING | Page 2
OBR PRODUCTIVITY GROOBR PRODUCTIVITY GROOBR PRODUCTIVITY GROOBR PRODUCTIVITY GROWTH (OUTPUT PER HOURWTH (OUTPUT PER HOURWTH (OUTPUT PER HOURWTH (OUTPUT PER HOUR) ) ) ) ––––
FORECASTS AND OUTURNFORECASTS AND OUTURNFORECASTS AND OUTURNFORECASTS AND OUTURNS S S S
Productivity • The OBR has revised down its forecast growth over the coming years, based on current productivity
levels.
• Productivity growth has been
revised down by 0.7% a year.
• Employment increased by around
230,000 between the end of 2016
and the third quarter of 2017,
however average hours worked
per person remained flat, rather
than falling.
Department of Health spending profile
Overview of Department of Health spending: revenue and capital
• The Government has increased the Department
of Health’s budget by £2.8bn. This funding has
been made on an ‘exceptional’ basis, which
means it is not clear whether this will be
recurrently carried forward in to 2020/21.
• The allocation has been made directly to the
Department of Health’s budget, rather than NHS
England’s budget as we have seen in previous
years which means that this is genuinely new
funding, rather than taking additional funds
from other non-frontline services, such as
education and training budgets.
OBR GDP forecast growth: 2017/18 to 2021/22OBR GDP forecast growth: 2017/18 to 2021/22OBR GDP forecast growth: 2017/18 to 2021/22OBR GDP forecast growth: 2017/18 to 2021/22
2017/182017/182017/182017/18 2018/192018/192018/192018/19 2019/202019/202019/202019/20 2020/212020/212020/212020/21 2021/222021/222021/222021/22
MMMMarch 2017 forecastarch 2017 forecastarch 2017 forecastarch 2017 forecast +1.6%+1.6%+1.6%+1.6% +1.7%+1.7%+1.7%+1.7% +1.9%+1.9%+1.9%+1.9% +2%+2%+2%+2% --------
November 2017 forecastNovember 2017 forecastNovember 2017 forecastNovember 2017 forecast +1.5%+1.5%+1.5%+1.5% +1.4%+1.4%+1.4%+1.4% +1.3%+1.3%+1.3%+1.3% +1.5%+1.5%+1.5%+1.5% +1.6%+1.6%+1.6%+1.6%
Contact: Name Person, Does This Job name.person@nhsproviders.org
NHS Providers | ON THE DAY BRIEFING | Page 3
• It is estimated that with the increase next year, the Department of Health’s budget will grow from 0.5%
to 1.4%.
• 2019/20 still looks incredibly challenging for the sector, as £665m of the additional £900m will need to
be used to fund additional NHS pension cost increases.
• The Treasury will fund £3.5 billion of capital investment between 2017/18 and2022-23, including:
• £2.6 billion for STPs to deliver transformation schemes that improve their ability to meet demand
for local services and improvements in facilities .The government has today provisionally allocated
up to 10% of this £2.6bn funding to 12 of the schemes it judges the highest quality, on the basis
of their potential to meet future demand and develop local clinical and financial accountability.
The rest of the funds will be allocated ‘in due course’. You can read which schemes have been
provisionally allocated funding here
• £700 million to support turnaround plans in the trusts facing the biggest challenges, and to tackle
the most urgent and critical maintenance issues
• £200 million to support efficiency programmes
• Other sources of capital funding will come from:
• £3.3bn from land sales
• £2.8bn is expected to come from private finance investment.
Funding for pay award • Additional funding in addition to today’s settlement will be provided for NHS staff on the Agenda for
Change contract subject to the Pay Review Body recommendation. This will be linked to productivity
improvements the Government wishes to see through the contract.
• Any pay award for doctors will not be funded by the government, but will need to be funded from
existing NHS budgets.
Increases to the Department of Health’s budgetIncreases to the Department of Health’s budgetIncreases to the Department of Health’s budgetIncreases to the Department of Health’s budget
YearYearYearYear 2017/182017/182017/182017/18 2018/192018/192018/192018/19 2019/202019/202019/202019/20 Total increase between Total increase between Total increase between Total increase between
17/1817/1817/1817/18----19/2019/2019/2019/20
RevenueRevenueRevenueRevenue +£335m+£335m+£335m+£335m +1.6bn+1.6bn+1.6bn+1.6bn +900m+900m+900m+900m £2.8bn£2.8bn£2.8bn£2.8bn
Department of Health budgDepartment of Health budgDepartment of Health budgDepartment of Health budget: RDEL and CDELet: RDEL and CDELet: RDEL and CDELet: RDEL and CDEL
DH RDEL DH RDEL DH RDEL DH RDEL (£bn)(£bn)(£bn)(£bn) 119.1119.1119.1119.1 121.9121.9121.9121.9 124.2124.2124.2124.2
DH CDELDH CDELDH CDELDH CDEL (£bn)(£bn)(£bn)(£bn) 5.65.65.65.6 6.46.46.46.4 6.76.76.76.7
TotalTotalTotalTotal (£bn)(£bn)(£bn)(£bn) £124.7bn£124.7bn£124.7bn£124.7bn £128.3bn£128.3bn£128.3bn£128.3bn £130.9bn£130.9bn£130.9bn£130.9bn
NHS Providers | ON THE DAY BRIEFING | Page 4
Mental Health • The government announced that a green paper will be published in December, which will set out plans
for mental health services for children and young people.
Overview of other key / relevant announcements in the budget
Brexit
• £3 billion will be set aside over the next two years to ensure that the UK is prepared for every possible
outcome in the Brexit negotiations. This is in addition to the £700 million already invested in Brexit
preparations.
National Living Wage (NLW) and National Minimum Wage (NMW)
• Following the recommendations of the independent Low Pay Commission (LPC), the government will
increase the National Living Wage (NLW) by 4.4% from £7.50 to £7.83 from April 2018.
• The government will also accept all of the LPC’s recommendations for the other NMW rates to apply
from April 2018. The recommendations include:
• increasing the rate for 21 to 24 year olds by 4.7% from £7.05 to £7.38 per hour
• increasing the rate for 18 to 20 year olds by 5.4% from £5.60 to £5.90 per hour
• increasing the rate for 16 to 17 year olds by 3.7% from £4.05 to £4.20 per hour
• increasing the rate for apprentices by 5.7% from £3.50 to £3.70 per hour
Business rates
• The government announced that it would be providing a further £2.3 billion of support to businesses
to reduce the burden of business rates.
Pensions and savings • The lifetime allowance for pension savings will increase in line with CPI, rising to £1,030,000 for 2018/19.
• Employees on maternity and parental leave will be able to take up to a 12 month pause from saving
into their Save As You Earn employee share scheme, up from the current six months.
• The tax relief for employer premiums paid into life assurance products or certain overseas pension
schemes will be modernised to cover policies when an employee nominates an individual or registered
charity as their beneficiary.
• The basic State Pension will be increased by the triple lock. This represents a rise of 3% in April 2018, a
cash increase of £3.65 per week for the full basic State Pension.
• There will be an increase to the Standard Minimum Guarantee in Pension Credit to match the cash rise
in the basic State Pension.
• The full new State Pension will also be increased by the triple lock, rising by £4.80 per week.
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Welfare • The Budget confirms that the OBR forecasts welfare spending to remain within the Government’s
welfare cap and margin, and so the fiscal rule is judged to have been met with £2.5 billion of headroom.
• The government is now required to reset the welfare cap for the new parliament which will apply to
welfare spending in 202223.
• In the interim years, progress towards the cap will be managed internally, based on the OBR’s
monitoring of forecasts of welfare spending and performance against the cap will be formally assessed
by the OBR in 202223.
• The government will invest in better use of data to ensure benefit fraud and error related payments are
reduced.
• The government will provide funding for the Department for Work and Pension’s relationship support
work, to help keep families together and reduce parental conflict.
• The government has announced new measures and a £1.5bn package to address concerns about the
delivery of Universal Credit
Taxation Income tax, national insurance and employee benefits
• In 2018-19 the personal allowance and higher rate threshold will increase to £11,850 and £46,350
respectively. The government will now allow marriage allowance claims on personal allowances where
a partner has died before the claim was made, with claims backdated up to 4 years.
• The government will consult on how to tackle non-compliance with off-payroll working rules (IR35) in
the private sector, drawing on the experience of the public sector reforms, including through external
research already commissioned by the government and due to be published in 2018.
• The government will publish a consultation in 2018 on how to make the taxation of trusts simpler,
fairer, and more transparent.
• Following the call for evidence published in March 2017, the government will make changes to the
taxation of employee expenses including self-funded training (the government will consult on
extending the scope of tax relief), subsistence benchmark scale rates (the burden will be reduced) and
guidance and claims process for employee expenses (this will be improved through work with external
stakeholders).
• The scope of Qualifying Care Relief (QCR) will be extended to cover self-funded Shared Lives care
payments, to encourage the use of Shared Lives care.
Business and corporate tax
• The corporate indexation allowance will be frozen from 1 January 2018. Accordingly, no relief will be
available for inflation accruing after this date in calculating chargeable gains made by companies.
• The government will consult in 2018 on the tax treatment of intellectual property (the Intangible Fixed
Asset regime). This will consider whether there is an economic case for targeted changes to this regime,
so that it better supports UK companies investing in intellectual property.
NHS Providers | ON THE DAY BRIEFING | Page 6
• A number of measures relating to non-resident companies and activity in other jurisdictions were also
announced.
Property tax
• The planned switch in indexation from RPI to the main measure of inflation (currently CPI) will be
brought forward to 1 April 2018
• The government will legislate retrospectively to address the so-called “staircase tax”. Affected
businesses will be able to ask the Valuation Office Agency (VOA) to recalculate valuations so that bills
are based on previous practice backdated to April 2010 (including those who lost Small Business Rate
Relief as a result of the Court judgement). The government will publish draft legislation shortly.
• The government will increase the frequency with which the VOA re-values non-domestic properties by
moving to revaluations every three years following the next revaluation, currently due in 2022. The
government will consult on the implementation of these changes in the spring.
• Local government will be fully compensated for the loss of income as a result of these property tax
measures.
New technologies, innovation and infrastructure
Technology
• The government will create a new Centre for Data Ethics and Innovation, invest over £75 million to take
forward key recommendations of the independent review on AI, create new AI fellowships, and
establish a new £10 million Regulators’ Pioneer Fund.
• The government will invest £21 million over the next 4 years to expand Tech City UK’s reach – to
become ‘Tech Nation’ – and support regional tech companies and start-ups to fulfil their potential. Tech
Nation will roll out a dedicated sector programme for leading UK tech specialisms, including AI and
FinTech.
Electric vehicles
• To support the transition to zero emission vehicles, the government will regulate to support the wider
roll-out of charging infrastructure; invest £200 million, to be matched by private investment, into a new
£400 million Charging Investment Infrastructure Fund; and commit to electrify 25% of cars in central
government department fleets by 2022. The government will also provide £100 million to guarantee
continuation of the Plug-In Car Grant to 2020 to help consumers with the cost of purchasing a new
battery electric vehicle.
Research and development
• The National Productivity Investment Fund (NPIF) will grow by a further £2.3 billion of additional
spending in 2021-22, taking total direct R&D spending to £12.5 billion per annum by 2021-22. The
Industrial Strategy White Paper will provide further detail on what this funding will support, including
NHS Providers | ON THE DAY BRIEFING | Page 7
new support to grow the next generation of research talent and ensure that the UK is able to attract
and retain the best academic leaders globally.
• The government will increase the rate of the R&D expenditure credit from 11% to 12% with effect from
1 January 2018. To provide businesses with the confidence to make R&D investment decisions, the
government will also introduce a new Advanced Clearance Service for R&D expenditure credit claims.
• The government will: change immigration rules to enable world-leading scientists and researchers
endorsed under the Tier 1 (Exceptional Talent) route to apply for settlement after three years; make it
quicker for highly-skilled students to apply to work in the UK after finishing their degrees; and reduce
red tape in hiring international researchers and members of established research teams by relaxing the
labour market test and allowing the UK’s research councils and other select organisations to sponsor
researchers. This is alongside the expansion of the exceptional talent route, benefiting current and
future leaders in the digital technology, science, arts and creative sectors.
Housing
House building
• The government will support more housebuilding, raising housing supply to make homes more
affordable in the long term and help those who aspire to homeownership.
• The government has outlined additional measures to boost the supply of skills, resources and building
land, and to create financial incentives to deliver 300,000 net additional homes a year on average by the
mid-2020s:
• Make available £15.3 billion of new financial support for housing over the next five years, bringing
total support for housing to at least £44 billion over this period.
• Introduce planning reforms to ensure more land is available for housing, and that better use is made
of underused land in our cities and towns.
• Provide £204 million of funding for innovation and skills in the construction sector, including to train
a workforce to build new homes.
Grenfell Tower fire
• £28m will be provided to Kensington and Chelsea Council for mental health services, regeneration
support for the surrounding areas and for new community space for Grenfell United community group.
• The government will not let financial constraints get in the way of essential safety work. Any local
authority that cannot access funding to pay for essential fire safety work should contact the
government.
Implications for the NHS and providers
Following today’s budget, our view is that while any additional funding is welcome, there remains an
unfunded gap between the costs currently faced by providers and increasing demand for care which
needs to be addressed.
NHS Providers | ON THE DAY BRIEFING | Page 8
• The announcement of an additional £1.6bn revenue funding in 2018/19 and an additional £900m in
2019/20 is welcome, given the intense financial and operational pressure trusts are facing. We will be
seeking early clarity from NHS England and NHS Improvement about how this additional funding will
flow to providers, including whether there will be a national planning exercise for next year given
today’s announcement.
• In the current financial year, an additional £335m for trusts to help meet the challenge of the
approaching winter period is welcome, and yet, comes too late to have maximum impact. We are
concerned that unrealistic expectations might be set nationally about how this additional funding
might be used to improve performance over winter. Members will be understandably keen to
understand how and when, exactly, additional revenue this financial year and beyond will reach them –
we will update members on this as soon as possible.
• We welcome the announcement that additional funding for Agenda for Change staff will be provided,
conditional on ongoing talks over contract reform. The pay uplift will be determined as always by the
NHS Pay Review Bodies. NHS Providers will actively contribute to this process. At this stage, we
understand that the pay award for doctors will not be funded by the government; instead this will need
to come from existing NHS budgets.
• On capital funding, Sir Robert Naylor’s review of NHS property and estates calculated that £10bn was
required to fund and maintain an NHS estate that could continue to deliver safe, high-quality care for
patients. While the Government today announced an additional £10bn ‘package of capital investment’,
only £3.5bn additional funding from the Treasury has been announced. This falls short of what we know
the NHS needs for backlog maintenance and transformation. Around £3.3bn is expected to come from
land sales, but the Naylor Review itself, for example, calculated that 57% of the total gross risk adjusted
potential financial opportunity for the sector was accounted for by the London Sustainability and
Transformation Partnerships alone. In practice, trusts across the country may continue to find it difficult
to access the capital they need to enable productivity improvements they are committed to delivering.
This is particularly disappointing given capital investment in the NHS has fallen sharply in recent years.
Press statement
NHS Providers press statement setting out our response to the Budget is below and also accessible online
here.
LessLessLessLess thanthanthanthan needed:needed:needed:needed: momomomorererere thanthanthanthan expectedexpectedexpectedexpected –––– NHSNHSNHSNHS ProvidersProvidersProvidersProviders responseresponseresponseresponse totototo thethethethe BudgetBudgetBudgetBudget
Responding to the Budget, the chief executive of NHS Providers, Chris Hopson, said:
“NHS providers needed three things from the Budget: extra revenue for day to day spending in 2018/19;
more capital funding for transformation and tackling the maintenance backlog; and fully funding the
ending of the 1 per cent pay cap.
“The NHS has been given £1.6 billion extra revenue for 2018/19; £3.5 billion extra capital funded by the
treasury; and the government has committed to fund the main NHS pay rise. In addition, the government
NHS Providers | ON THE DAY BRIEFING | Page 9
has committed extra capital and extra revenue for this year, though this has come very late to be used
with maximum impact for this winter.
“Any extra investment in the NHS is welcome given the overall economic context and the other demands
on public expenditure. It is a clear signal that the government has listened to the NHS’ definitive statement
that the existing spending review plans for 2018/19 were undeliverable.
“However it is disappointing that the government has not been able to give the NHS all that it needed to
deal with rising demand, fully recover performance targets, consistently maintain high quality patient care
and meet the NHS’s capital requirements. We also note that the extra revenue has been tied to acute
hospital performance at a point when the pressures across the rest of the health service – community,
mental health and ambulance services – are just as great.
“Tough choices are now needed and trade offs will have to be made. It is difficult to see how the NHS can
deliver everything in 2018/19, for example fully recovering performance targets. The next step is a
conversation with frontline leaders to clearly agree what can and can not be done.
“We are also still trying to live hand to mouth without a sustainable long term financial and capital
settlement for the health and care sector. This makes it impossible to plan effectively. The existing gap
between demand and funding is still scheduled to grow significantly by the end of the parliament and we
must address this underlying problem.
“Overall this new funding is less than the NHS needed but more than was expected. But, as always, NHS
trusts will do their absolute best to provide the highest quality care for patients within the funding
settlement that’s been allocated.”
Useful links
The full Budget document can be accessed here The full text of the Chancellor’s speech is accessible here OBR figures are available here
Ribblesdale Community Partnership Memorandum of Understanding V0.1 14/09/17
RVBC
Ribblesdale Community Partnership Memorandum of Understanding (MOU)
This Ribblesdale Community Partnership MOU is an understanding between Provider Organisations working in the Ribblesdale Neighbourhood to deliver on the objectives outlined in the Ribblesdale Community Partnership Strategy. Furthermore signing up to this document confirms that the Organisation you are representing supports the activities of the Community Partnership. COMMENCEMENT
1 This Memorandum of Understanding is made on the insert relevant date between Organisations’ participating in the Ribblesdale Community Partnership listed in paragraph five of this document. This agreement will be reviewed in April 2018.
RIBBLESDALE COMMUNITY PARTNERSHIP VISION AND AIMS
2 VISION
To create a new integrated system for the management of community services in Ribblesdale locality run in partnership by local health and care organisations, removing organisational boundaries to deliver care pathways designed around the needs of our local population not organisational structures.
3 AIMS/OBJECTIVES
The aims and objectives of the Ribblesdale Community Partnership are to:
Develop the Ribblesdale Community Partnership.
Develop a Ribblesdale Community Partnership Strategy and Plan.
To be the overseeing body to ensure the delivery of the agreed plan.
To test out models of delivery for health, wellbeing and care services within a locality.
To ensure that the model supports the delivery of health, wellbeing and care needs for the Ribblesdale population.
To ensure the maximisation of all available resources.
To performance monitor the impact of the Ribblesdale Community Partnership.
To continually improve the development of the Ribblesdale Community Partnership.
To support the strategic direction of the Pennine Lancashire Transformation Programme.
MEMBERSHIP Member Organisations
4 The membership of the group consists of those listed as follows:-
Sabden & Whalley Medical Practice (Whalley)
The Castle Medical Group (Clitheroe)
Pendleside Medical Practice (Clitheroe)
Slaidburn Country Practice (Slaidburn)
Ribblesdale Community Partnership Memorandum of Understanding V0.1 14/09/17
East Lancashire Hospitals Trust (ELHT)
Lancashire Care Foundation Trust (LCFT)
Lancashire County Council (LCC)
Ribble Valley Borough Council (RVBC)
Hyndburn and Ribble Valley CVS (HRVCVS)
Foundation for Ribble Valley Families (FRVF) Applications from other organisations wishing to join the partnership will be considered following application to the secretariat at the East Lancs CCG. GEOGRAPHIC AREA COVERED
5 The Ribblesdale Community Partnership will support the development of services to patients registered with its constituent practices.
GOVERNING STUCTURE AND ACCOUNTABILITY
6 The Ribblesdale Community Partnership will be accountable to each Partnership Members Organisation. Each partner will be responsible for their own arrangements for reporting progress to their Organisation.
ROLES AND RESPONSIBILITIES OF THE RIBBLESDALE COMMUNITY PARTNERSHIP REPRESENTATIVES
7 The roles and responsibilities of each partner representative is as follows:
To ensure regular attendance at meetings. Where a representative can’t attend a nominated deputy will attend.
To provide all information requested by the Strategy Group on time and ensuring involvement of their organisation.
All information must be shared honestly and transparently.
To cascade information about decisions reached and agreements made by the Board to their respective organisations.
To ensure communication is clear, concise and timely.
To make recommendations on behalf of their organisation.
To develop a communications and engagement strategy in line with the agreed Strategic Plan.
ADOPTION OF THE RIBBLESDALE COMMUNITY MEMORANDUM OF UNDERSTANDING
8 The persons whose signatures and Organisation appear at the bottom of this document are the partners named representatives and sign that on behalf of their member Organisation they shall support as appropriate and applicable the activities of the Ribblesdale Community Partnership.
Organisation
Organisation Representative / Designation
Sabden & Whalley Medical Practice (Whalley)
Ribblesdale Community Partnership Memorandum of Understanding V0.1 14/09/17
The Castle Medical Group (Clitheroe)
Pendleside Medical Practice (Clitheroe)
Slaidburn Country Practice (Slaidburn)
East Lancashire Hospital’s Trust
Foundation for Ribble Valley Families
Lancashire Care Foundation Trust
Lancashire County Council
Ribble Valley Borough Council
Hyndburn and Ribble Valley CVS
Board of Directors
Agenda Item TB 189/17 Date: 07/12/2017
Report Title Quality Report
FOIA Exemption No Exemption Not Applicable
Prepared by Matthew Joyes
Associate Director of Safety and Quality Governance
Presented by Dee Roach, Executive Director of Nursing and Quality
and
Professor Max Marshall, Medical Director
Action required Decision
Supporting Executive Director Executive Director of Nursing & Quality
PURPOSE OF THE REPORT:
Report purpose To provide the Trust Board with latest version of the Quality Report
Strategic Objective(s) this work supports
To provide high quality services
Board Assurance Framework risk 1.1 If we do not meet regulatory standards for quality and safety we will not be fit for purpose as a care provider
CQC domain Well-led
Quality and Safety Report
December 2017
(data from November 2016 to October 2017)
Prepared by: Presented to the Trust Board by:
Matthew Joyes, Associate Director of Safety and Quality Governance Dee Roach, Executive Director of Nursing and Quality
Max Marshall, Executive Medical Director
Lancashire Care NHS Foundation Trust Quality and Safety Report
Page 2 of 34
Contents
Contents ...................................................................................................................................................................................................................................... 2
Quality and Safety Tile ................................................................................................................................................................................................................. 3
Executive Summary ..................................................................................................................................................................................................................... 4
Safe ............................................................................................................................................................................................................................................. 5
Effective .................................................................................................................................................................................................................................... 14
Caring ........................................................................................................................................................................................................................................ 19
Responsive ................................................................................................................................................................................................................................ 22
Well Led .................................................................................................................................................................................................................................... 24
Appendix 1 – Extracts from the Quality and Safety Surveillance Report and Mental Health Law Surveillance Report ................................................................ 29
Lancashire Care NHS Foundation Trust Quality and Safety Report
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QUALITY AND SAFETY TILE
SAFE
Incidents 15251
STEIS-reportable serious
incidents 92
RIDDOR incidents 38
Never Events 1
Serious HCAI incidents 10
Use of restraint 3930
Potentially avoidable grade 3 and
4 pressure ulcers 13
Number of red flag incidents
(inpatients only) 2869
Physical violence to staff from
patients 2172
CARING
F&F Test 94.40%
Compliments 8701
RESPONSIVE
Complaints 1632
Upheld/partially upheld
complaints 320
Completed within agreed
timeframe (%) 54%
WELL LED
Trust CQC rating Good
Core Skills (%) 90.05%
Appraisals (%)
Concerns raised 9
EFFECTIVE
Physical Health HFC Rate (%) 95%
Mental Health HFC Rate (%) 83%
Lancashire Care NHS Foundation Trust Quality and Safety Report
Page 4 of 34
Executive Summary
This is the second report of the new format Quality and Safety Report.
In relation to current quality and safety performance, attention is drawn to:
The levels of physical violence to staff;
The levels of restraint;
The under-performance of the Mental Health Harm Free Care rate;
The high number of overdue incident reviews.
There is a clear correlation between violence, restraint, staffing and the performance of the Mental Health Harm Free Care rate. The Quality and Safety Sub- committee is receiving deep dive presentations into the data across inpatient services. A review of the existing programme and improvement initiatives is underway through the Positive and Safe Group.
The data shows a noticeable increase in serious incidents however this should be considered against the context of a significant reduction over the last 4 years. The number of RIDDOR incidents is noticeably low in the last month.
Mortality review data is included in this report for the first time in accordance with requirements set-out by NHS Improvement. Reporting in this area will improve over coming months as the Trust commences its programme of structured case judgement reviews however there is still an absence of nationally standardised tools and definitions in this area as they relate to mental health and community health services.
Staffing continues to be a challenge and a number of wards at Guild Lodge have high use of bank staff. As mentioned above, there is a correlation between the use of temporary staff, staffing challenges, and levels of violence and restraint on wards. The Staffing for Quality and Safety Group continues to receive Network reports to monitor action being taken locally to mitigate risk. The Executive Director of Nursing and Quality is leading a task and finish group to review and take action in relation to inpatient staffing challenges.
Lancashire Care NHS Foundation Trust Quality and Safety Report
Page 5 of 34
Safe
This section of the report looks at the domain of safety – that services are safe, and people are protected from abuse and avoidable harm. The following
indicators are covered in the report:
Serious Incidents ..................................................................................................................................................................................................................... 6
RIDDOR Incidents ................................................................................................................................................................................................................... 7
Never Events ........................................................................................................................................................................................................................... 8
Serious HCAI Incidents ............................................................................................................................................................................................................ 8
Pressure Ulcer Incidents – Potentially Avoidable Grade 3 and Grade 4 ................................................................................................................................... 9
Physical Violence to Staff Incidents .......................................................................................................................................................................................... 9
Use of Restraint ..................................................................................................................................................................................................................... 10
Suicide (Reported as a Serious Incident) ............................................................................................................................................................................... 10
Staffing Incidents – One or Less Qualified Staff on Duty ........................................................................................................................................................ 11
Staffing Incidents – Red Flags ............................................................................................................................................................................................... 11
Safer Staffing – Wards with over 40% hours worked by bank staff ......................................................................................................................................... 12
Safer Staffing – Wards with over 10% hours worked by agency staff ..................................................................................................................................... 12
Mortality Review – Numbers of Deaths and Reviews ............................................................................................................................................................. 13
Mortality Review – Classification of Deaths ............................................................................................................................................................................ 13
Lancashire Care NHS Foundation Trust Quality and Safety Report
Page 6 of 34
Serious Incidents - Rolling 12 Months
12
10
8
6
4
2
0
Nov Dec Jan Feb Mar Apr May Jun Jul Aug Sep Oct
Serious Incidents
A serious incident is defined as “acts or omissions in care that result in; unexpected or avoidable death, unexpected or avoidable injury resulting in serious harm - including those where the injury required treatment to prevent death or serious harm, abuse, Never Events, incidents that prevent (or threaten to prevent) the ability to continue to deliver healthcare services and incidents that cause widespread public concern resulting in a loss of confidence in healthcare services.”
The number of serious incidents fell throughout 2014-2016, however the long term reduction has now plateaued with a minor increase over the rolling 12 month period.
During October 2017, the following serious incidents were reported:
Serious self-harm (suspected attempted suicide) of a prisoner at HMP Liverpool;
Death (suspected suicide) of a patient under the care of the Assessment and Treatment Team in Chorley and South Ribble;
Concerns around the care of a patient in Podiatry in Central Lancashire – no immediate concerns for LCFT services however a patient under the care of podiatry underwent an operation at an acute Trust where the wound deteriorated resulting in an above knee amputation;
Death (suspected suicide) of a patient under the care of the Assessment and Treatment Team in Lancaster and Morecombe;
Death (suspected suicide) of a patient under the care of the Rapid Intervention and Treatment Team in Lancaster and Morecombe;
Death (suspected suicide) of a person recently seen by the Mental Health Liaison Team in Central Lancashire;
Death of a patient in an acute Trust which may have been contributed to by a pressure ulcer, where the patient was under the care of Southport and Formby District Nursing;
Death (suspected suicide) of a prisoner at HMP Liverpool;
Death of a patient under the care of the Mindsmatter Service in West Lancashire.
In all cases, a formal investigation is now underway and the incidents have been reported as required under the NHS Serious Incident Framework.
Lancashire Care NHS Foundation Trust Quality and Safety Report
Page 7 of 34
RIDDOR Incidents - Rolling 12 Months
7
6
5
4
3
2
1
0
Nov Dec Jan Feb Mar Apr May Jun Jul Aug Sep Oct
RIDDOR Incidents
The Trust is required to report certain incidents under the Reporting of Injuries, Diseases and Dangerous Occurrences Regulations 2013. These notifications are received by the Care Quality Commission and Health and Safety Executive. A RIDDOR incident is defined as an incident were someone has died or has been injured because of a work-related accident including specified injuries to workers (certain fractures, amputations, loss of sight, crush injury to head or torso, serious burns, loss of consciousness, etc.), injury causing absence of work for more than 7 days, injuries to non-workers requiring transfer to hospital, occupational diseases and certain dangerous occurrences.
The number of RIDDOR incidents shows a small increase during the year however improved awareness of reporting requirements is considered to be partially responsible. The predominance of incidents relate to absence of work of over 7 days and originates from violence to staff.
During October 2017, the following RIDDOR incident was reported:
Injury to a staff member’s back whilst opening a door resulting in absence for over seven
days.
Lancashire Care NHS Foundation Trust Quality and Safety Report
Page 8 of 34
Never Events - Rolling 12 Months
2
1
0
Nov Dec Jan Feb Mar Apr May Jun Jul Aug Sep Oct
Never Events
Never events are serious incidents that are entirely preventable as guidance, or safety recommendations providing strong systemic protective barriers, are available at a national level, and should have been implemented by all healthcare providers. Each never event type has the potential to cause serious patient harm or death. However, serious harm or death is not required to have happened as a result of a specific incident occurrence for that incident to be categorised as a never event.
The Trust reported one Never Event in September 2017, which related to an incident in May 2017. This related to an overdose of methotrexate in rheumatology services. The report is due for completion
HCAI Incidents - Rolling 12 Months
5
4
3
2
1
0
Nov Dec Jan Feb Mar Apr May Jun Jul Aug Sep Oct
Serious HCAI Incidents
A serious HCAI incident is considered to be an avoidable incident of Clostridium Difficile (C.Diff), Meticillin-Resistant Staphylococcus Aureus (MRSA), Methicillin-Susceptible Staphylococcus Aureus (MSSA), Gram-negative bacteria, Carbapenemase-Producing Enterobacteriaceae (CPE), or another infection control incident resulting in a ward closure.
The number of HCAI incidents remains low with no exceptions to report. The Infection Prevention and Control Team continue to drive improvements in reporting and compliance with the Essential Steps Hand Hygiene Audit and to drive forward the annual staff flu vaccination campaign.
Lancashire Care NHS Foundation Trust Quality and Safety Report
Page 9 of 34
Potentially Avoidable G3 and G4 Pressure Ulcer Incidents - Rolling 12
Months
6
5
4
3
2
1
0
Nov Dec Jan Feb Mar Apr May Jun Jul Aug Sep Oct
Pressure Ulcer Incidents – Potentially Avoidable Grade 3 and Grade 4
Pressure ulcers are injuries to the skin and underlying tissue, primarily caused by prolonged pressure on the skin. Pressure ulcers can affect any part of the body that's put under pressure. They're most common on bony parts of the body and often develop gradually, but can sometimes form in a few hours. In a grade three pressure ulcer, skin loss occurs throughout the entire thickness of the skin and the underlying tissue is also damaged. The underlying muscles and bone are not damaged. A grade four pressure ulcer is the most severe type of ulcer. The skin is severely damaged and the surrounding tissue begins to die (tissue necrosis). The underlying muscles, or bone, may also be damaged. People with grade four pressure ulcers have a high risk of developing a life-threatening infection
The number of pressure ulcer incidents increased over the summer period but has declined over the last two months. Pressure ulcer prevention is a priority for 2017/18 in the Quality Plan and work so far has included revising the policy, introducing safety huddles, a safety senate and the safety cross. Localities where these initiatives have been piloted have shown a reduction incidents.
Physical Violence to Staff Incidents - Rolling 12 Months
300
250
200
150
100
50
0
Nov Dec Jan Feb Mar Apr May Jun Jul Aug Sep Oct
Physical Violence to Staff Incidents
Physical violence to staff includes any degree of harm, including near miss incidents, where staff are physical assaulted. Incidents are recorded by staff on the Trust’s quality governance system (Datix).
The number of incidents of physical violence to staff increased notably in 2014 and remained increased since, with a further increase during 2017/18 which appears to have levelled during the last few months. Hot spots have been identified in older adult wards and psychiatric intensive care units (PICUs). A deep dive into the data for PICUs was presented to the Quality and Safety Sub- committee in October, with a deep dive into older adults planned for December 2017. Targeted improvement work is taking place in older adult wards focused on reducing violence from personal care activities. Ongoing support and training to clinical teams continues to be provided by the Violence Reduction Team.
Lancashire Care NHS Foundation Trust Quality and Safety Report
Page 10 of 34
Use of Restraint - Rolling 12 Months
500
450
400
350
300
250
200
150
100
50
0
Nov Dec Jan Feb Mar Apr May Jun Jul Aug Sep Oct
Use of Restraint
The use of restraint shows a notable increase. This is closely linked to the increase in violence and the work to address violence includes restraint reduction as an outcome measure. The hot spot areas mirror those for violence and aggression mentioned earlier in the report.
Suicide (Reported as a Serious Incident) - Rolling 12 Months
7
6
5
4
3
2
1
0
Nov Dec Jan Feb Mar Apr May Jun Jul Aug Sep Oct
Suicide (Reported as a Serious Incident)
The overall rate of suicide incidents (deemed to meet the criteria for a serious incident) show a noticeable increase over the rolling 12 months with October 2017 seeing the second highest reported number over that period. No emerging risks have been identified for this sudden increase and serious incident investigations are underway.
Lancashire Care NHS Foundation Trust Quality and Safety Report
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Staffing Incidents – One or Less Qualified Staff on Duty
Instances of one qualified staff on duty are reported and escalated in accordance with the Staffing for Quality and Safety Escalation Procedure. This allows managers to put into place mitigations by moving staff, supporting the area with senior nurses or using bank and agency staff.
Wards which reported more than 10 instances of this are:
Marshaw
Marshaw Ward reported more than 10 instances in the last reporting period.
Red Flags - Rolling 12 Months
350
300
250
200
150
100
50
0
Nov Dec Jan Feb Mar Apr May Jun Jul Aug Sep Oct
Staffing Incidents – Red Flags
All staff are encouraged to use the Red Flag facility on the eRostering Safe Care system to alert managers to staffing incidents such as low staffing numbers, missed breaks, etc.
The majority of Ref Flag incidents relates to the above issue of one or fewer qualified staff on duty.
One or Less Qualified Staff on Duty -
Rolling 12 Months 250
200
150
100
50
0
Nov Dec Jan Feb Mar Apr May Jun Jul Aug Sep Oct
Lancashire Care NHS Foundation Trust Quality and Safety Report
Page 12 of 34
Wards with over 40% hours worked by bank staff
Townley CSU
Marshaw
Bleasdale
Elmridge
Byron
Bronte
Dunsop
40% 45% 50% 55% 60%
Safer Staffing – Wards with over 40% hours worked by bank staff
The services identified on the chart used bank staff for greater than 40% of hours worked.
Marshaw, Bleasdale, Elmridge, Byron and Dunsop also reported greater than 40% bank staff usage in the last reporting period. The Executive Director of Nursing and Quality is leading a task and finish group to explore and address inpatient staffing challenges.
Teams with over 10% hours worked by agency staff
HMP Liverpool
0% 5% 10% 15%
Safer Staffing – Wards with over 10% hours worked by agency staff
The following services used bank staff for greater than 40% of hours worked:
HMP Liverpool
The Clinical Director of Secure Services presented an assurance report on staffing at HMP Liverpool to the Quality and Safety Sub-committee in November 2017. Sustained recruitment has been underway and several new staff have been appointed and are awaiting prison security clearance.
Lancashire Care NHS Foundation Trust Quality and Safety Report
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Numbers of Deaths and Mortality Reviews - Rolling 12 Months
80
60
40
20
0
Nov Dec Jan Feb Mar Apr May Jun Jul Aug Sep Oct
SCJ Reviews SI Reviews Deaths
Mortality Review – Numbers of Deaths and Reviews
The Trust is required to declare how many deaths were deemed as avoidable.
Deaths are reviewed through two processes: the serious incident (SI) process and the structured case judgement (SCJ) process. The SI process determines whether a death was predictable and/or preventable. The SCJ process determines whether a death was due to a problem in care. Neither of these terms are legal terms or formal causes of death.
Since April 2017, one death reviewed through the serious incident process was deemed predictable and preventable. No structured case judgement reviews have taken place – a cohort of reviewers have been recruited and the process will commence in January 2018.
The Trust is engaged in the Learning Disability Mortality Review Programme (LeDeR) however at this stage it is unclear how this programme will return feedback into the Trust and this is being explored with NHS England.
Classification of Deaths - Rolling 12 Months (data available from July
2017)
40
20
0
Jul Aug Sep Oct
Expected Natural Expected Unnatural
Unexpected Natural Unexpected Unnatural
Not Yet Known
Mortality Review – Classification of Deaths
The Trust records deaths as incidents, where appropriate and in accordance with the Incident Procedure. A daily review process, supported by a weekly review panel, determines which deaths meet the threshold for a serious incident and (when established) which deaths will be subject to a structured case judgement review.
Deaths are recorded against one of four categories: Expected Natural (i.e. terminal illness), Expected Unnatural (i.e. drug misuse), Unexpected Natural (i.e. sudden cardiac condition) and Unexpected Unnatural (i.e. suicide). This framework was developed by Mazars in their investigation into deaths at Southern Health NHS Foundation Trust and helps determine which deaths require further review.
Lancashire Care NHS Foundation Trust Quality and Safety Report
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Effective
This section of the report looks at the domain of effectiveness – that care, treatment and support achieves good outcomes, helps people to maintain quality of
life and is based on the best available evidence. The following indicators are covered in the report:
Mental Health Harm Free Care ........................................................................................................................................................................................... 15
Physical Health Harm Free Care ........................................................................................................................................................................................ 15
Local Clinical Audit ............................................................................................................................................................................................................. 16
National Clinical Audit ......................................................................................................................................................................................................... 17
Clinical Audit Summary Report ........................................................................................................................................................................................... 18
Lancashire Care NHS Foundation Trust Quality and Safety Report
Page 15 of 34
Mental Health Ham Free Care - Rolling 12 Months
92%
90%
88%
86%
84%
82%
80%
78%
76%
74%
Nov Dec Jan Feb Mar Apr May Jun Jul Aug Sep Oct
Mental Health Harm Free Care
The Mental Health Harm Free Care rate remains below the aspirational goal of 90%. The overall rate is made up of several individual measures. The area’s most impacting the overall measure includes violence, restraint, medication safety and feeling safe.
Physical Health Harm Free Care - Rolling 12 Months
97%
96%
95%
94%
93%
92%
91%
Nov Dec Jan Feb Mar Apr May Jun Jul Aug Sep Oct
Physical Health Harm Free Care
The Physical Health Harm Free Care rate has achieved the target in 7 of the last 12 months with an improving picture seen over recent months. The overall rate is made up of several individual measures.
Lancashire Care NHS Foundation Trust Quality and Safety Report
Page 16 of 34
Local Clinical Audit
Clinical Audits N/L/R* Network Compliance (%) Date
Prevention of Dehydration L MHN 54% Sep-17
Absent Without Leave L MHN 55% Oct-17
Nursing Management of Clozaril R MHN 60% Oct-17
Diabetes R MHN 65% Sep-17
Carers R CYPWN 54% Oct-17
Cerebral Palsy in under 25's (NICE) L CYPWN 82%
Risk Assessments L CYPWN 83%
Clozapine L CYPWN 80%
Nutrition L CYPWN 77%
Consent to Treatment R MHN 94%
Completion of Waterlow risk assessments L CWN 85%
Wound assessment documentation L CWN 70%
Care of Dying L CWN 79%
Learning Disability L CWN 85%
Acupuncture - Rheumatology & Physiotherapy
R CWN 97%
Antibiotics in dentistry R CWN 94%
Use of restrictive practices within LD R CWN 93%
Lancashire Care NHS Foundation Trust Quality and Safety Report
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National Clinical Audit
Audit Start Quarter End Quarter 2016/17 Compliance
2017/18 Compliance
National Audit of Anxiety and Depression Q4 2017/18
National Audit of Intermediate Care (NAIC) Q1 2017/18 Q4 2017/18
National Audit of Psychosis Q4 2016/17 Q4 2017/18
National Chronic Obstructive Pulmonary Disease (COPD) audit programme Q1 2017/18 Q4 2017/18 90%
National Diabetes Foot care Audit - Adults Q1 2017/18 Q4 2017/18 81%
Sentinel Stroke National Audit programme (SSNAP) Q1 2017/18 Q4 2017/18 LCFT were above national average in a total of 6 out of 16 indicators
UK Parkinson’s Audit Q1 2017/18 Q4 2017/18
National Audit of Inpatient Falls Q1 2017/18 Q4 2017/18
POMHUK High Dose and Combination Antipsychotic Prescribing Q4 2016/17 Q2 2017/18 14/ 57
POMHUK Use of depot and Long acting antipsychotic injections Q1 2017/18 Q4 2017/18
POMHUK Prescribing for bipolar disorder (use of sodium valproate) Q1 2017/18 Q4 2017/18
POMHUK Assessment of the side effects of depot antipsychotics Q1 2017/18 Q4 2017/18
POMHUK Rapid Tranquillisation Audit Q4 2016/17 Q2 2017/18 41/58 - 41%
Lancashire Care NHS Foundation Trust Quality and Safety Report
Page 18 of 34
Clinical Audit Summary Report
POMHUK Rapid Tranquillisation Audit
An action plan has been devised to ensure patients receive the necessary monitoring following use of rapid tranquillisation. Progress has been made as follows:
An alert has been added to the relevant medication templates on EPMA so nursing staff are prompted to monitor the patient if medication for rapid tranquillisation is administered.
A flowchart has been devised to support staff in undertaking the required monitoring and this is due to be ratified at the November Drugs and Therapeutics Committee.
Discussions are progressing to consider how Nerve Centre may be used to prompt physical health monitoring following use of rapid tranquillisation.
A template will also be devised for the new electronic patient record to support high standards of clinical care following use of rapid tranquillisation
POMHUK Audit: High Dose and Combination Antipsychotic Prescribing
This audit assessed the following three standards:
1. The dose of an individual antipsychotic should be within its SPC/BNF limits
2. Individuals receive only one antipsychotic at a time
3. Where high dose antipsychotics are prescribed, there should be a clear plan for regular clinical review including safety monitoring
331 patients were audited across 36 teams in LCFT. 22 patients medication regimen met the criteria for high dose prescribing. Eight of these patients were
on an adult ward or PICU and fourteen patients on forensic wards
Upper quartile performance was achieved by adult wards and PICUs. Forensic services performed higher that the national average for Standards One and Two.
Considering each standard individually, the trust achieved upper quartile performance for Standards One and Two. Upper quartile performance was not achieved for Standard Three, a newly introduced audit standard
Overall the Trust is upper quartile of Trust nationally.
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Caring
This section of the report looks at the domain of caring – that staff involve and treat people with compassion, kindness, dignity and respect. The following
indicators are covered in the report:
Friends and Family Test – Results .................................................................................................................................................................................. 20
Friends and Family Test – Submissions .......................................................................................................................................................................... 20
Compliments ................................................................................................................................................................................................................... 21
CQC Community Mental Health Survey .......................................................................................................................................................................... 21
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Friends and Family Test Results - Rolling 12 Months
100%
95%
90%
85%
80%
75%
Oct Nov Dec Jan Feb Mar Apr May Jun Jul Aug Sep
Friends and Family Test – Results
A key part of the Trust’s real time feedback process is the Friends and Family Test (FFT). The Friends and Family Test is a tool that supports the fundamental principle that people who use NHS services should have the opportunity to provide feedback on their experience. It asks people if they would recommend the services they have used and offers a range of responses. When combined with supplementary follow-up questions, the FFT provides a mechanism to highlight both good and poor patient experience.
The Friends and Family Test overall response rate has been at or above the target of 95% for 10 of the last 12 months with the target achieved and maintained since January 2017.
Friends and Family Test Submissions - Rolling 12 Months
4000
3000
2000
1000
0
Oct Nov Dec Jan Feb Mar Apr May Jun Jul Aug Sep
Friends and Family Test – Submissions
The number of submissions has notably reduced over the 12 months, however has remained broadly consistent during the last 10 months. There are a number of reasons for this including changes to how the data is captured (such as reducing multiple collection points).
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Compliments - Rolling 12 Months
1200
1000
800
600
400
200
0
Nov Dec Jan Feb Mar Apr May Jun Jul Aug Sep Oct
Compliments
The number of compliments has had a marginal decrease during the last 12 months.
CQC Community Mental Health Survey
Workers
Overall 9 Organising care experience
7
5 Overall views Planning care
3
1 Support and
Reviewing care wellbeing
Treatments Staff changes
Crisis care
CQC Community Mental Health Survey
The CQC use national surveys to find out about the experience of service users receiving care and treatment from healthcare organisations and mental healthcare providers. CQC asked people to answer questions about different aspects of their care and treatment. Based on their responses, CQC gave each NHS Trust a score out of 10 for each question (the higher the score the better). Each trust also received a rating of ‘About the same’, ‘Better’ or ‘Worse’.
Responses were received from 172 people who use services of the Trust.
The Trust was rated as “about the same” for all ten questions and each of their sub-questions.
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Responsive
This section of the report looks at the domain of responsiveness – that services are organised so that they meet people’s needs. The following indicators are
covered in the report:
Complaints .................................................................................................................................................................................................................. 23
Mixed Sex Breaches .................................................................................................................................................................................................... 23
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Complaints - Rolling 12 Months
200
150
100
50
0
Nov Dec Jan Feb Mar Apr May Jun Jul Aug Sep Oct
Complaints Upheld Complaints
Complaints
The number of complaints has noticeably increased over the 12 months. This reflects a national picture. The predominant theme is in relation to access to treatment or drugs (22%), admission and discharge (17.5%), communication (14%), appointments including delays and cancellations (10%) and clinical treatment (9%).
Despite the overall increase, the number of upheld or partially upheld complaints remains consistent although there is a noticeable increase in the last month which will be closely monitored.
Mixed Sex Breaches - Rolling 12 Months
1
0
Nov Dec Jan Feb Mar Apr May Jun Jul Aug Sep Oct
Mixed Sex Breaches
There have been zero mixed sex breaches over the rolling 12 month period.
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Well Led
This section of the report looks at the domain of well les – that the leadership, management and governance of the organisation make sure it's providing high-
quality care that's based around individual needs, that it encourages learning and innovation, and that it promotes an open and fair culture. The following
indicators are covered in the report:
Care Quality Commission (CQC) Rating) ................................................................................................................................................................. 25
Core Skills................................................................................................................................................................................................................ 25
Overdue Incident Reviews ....................................................................................................................................................................................... 26
Accreditations .......................................................................................................................................................................................................... 26
Concerns Raised ..................................................................................................................................................................................................... 27
Quality Plan Dashboard ........................................................................................................................................................................................... 28
Quality Plan Exception Report ................................................................................................................................................................................. 28
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Care Quality Commission (CQC) Rating)
The Trust was last inspected in September 2016 and the overall rating was Good. Two core services were rated as Requires Improvement – community inpatient services and community health services.
The CQC inspected healthcare services at HMP Liverpool in September 2017 in a process separate from the main Trust inspection. The draft report is now being check for factual accuracy.
Core Skills - Rolling 12 Months
95%
90%
85%
80%
75%
70%
Nov Dec Jan Feb Mar Apr May Jun Jul Aug Sep Oct
Core Skills
The overall core skills rate is above the Trust target of 85% however performance remains below target in:
Manual Handling Level 2
Manual Handling Level 3
Basic Life Support
Intermediate Life Support
Safeguarding Children Level 3
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Overdue Incident Reports - Rolling 12 Months (data available from Feb
2017)
2500
2000
1500
1000
500
0
Feb Mar Apr May Jun Jul Aug Sep Oct
7 Day Reviews 3 Day Reviews
Overdue Incident Reviews
The number of overdue incident reports, particularly 7 Day Reviews for incidents categorised as Level 1, 2 or 3 remains high with no improvement over the last 12 months. Targeted work has taken place within the Networks and has seen improvement in the Community and Wellbeing Network in particular. The Mental Health Network accounts for the vast predominance of overdue incidents.
Accreditations
This section is currently under development.
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Concerns Raised - Rolling 12 Months (data available from April 2017)
20
10
0
Apr May Jun Jul Aug Sep Oct
Concerns Raised
During October 2017, the following concerns were reported through the various mechanisms including the Raising Concerns Guardian and through Dear David:
The proposed installation of baths in initial designs for the Chorley inpatient unit;
Staff smoking on the road outside Sceptre Way;
High caseload and demand in Community Mental Health Teams;
Staff attack alarms not available to staff when entering wards at the Harbour at the start of their shift;
Lack of commissioned services for people suffering with Autistic spectrum disorder and behavioural difficulties;
High caseloads in Community Mental Health Teams;
Caseloads, lack of management support and supervision Community Mental Health Teams;
Culture and clinical practice at the Harbour;
Staff suffering with stress in Community Mental Health Teams.
In all cases a review of proportionate scale has been commissioned. The findings from each review are individually fed back to the person raising the concern if they have provided their name. The findings from every concern is summarised in the Quality Matters bulletin.
The themes from concerns over the year to date are management culture and conduct, demand, staffing and violence.
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Quality Plan Dashboard Key: Off Track On Track Complete Data Not Provided
Priority Lead QI Plan CQC Requirements
Process Measures
Outcome Measures
Balancing Measures
Mental Health Clinical Risk Assessment and Management Helen Lilley Holistic Care Planning Patsy Probert Standards of Record Keeping Patsy Probert Staffing for Quality and Safety Paula Flint Seclusion Julie Seed End of Life Care Michaela Toms Supporting Staff following Adverse Events Caroline Waterworth Reduction in Violence and Aggression Caroline Waterworth Pressure Ulcers Michaela Toms Medication Safety Sonia Ramdour Physical Healthcare in Mental Health In-patient Services Debra Wilson Appraisals Damian Gallagher Core Skills Deborah Cox Supervision Gita Bhutani New Professional Roles Patsy Probert
Mental Health Law Matthew Joyes
Quality Plan Exception Report
Improvement plans for all priorities are now in place. The priority of violence reduction is underperforming in the outcome measures as described in the safety section above. The priorities of appraisals and core skills are underperforming and information is detailed above for core skills and in the quarterly workforce report for both. The HR Directorate are assisting services with reporting and other support to improve compliance. Of particular note, both these areas are Requirement Notices from the last CQC inspection. The priority of new professional roles is progressed in respect of planning however the actual implementation of new professional roles is behind plan. Work is underway across all professional groups to address this. The priority of mental health law is well progressed in respect of new systems and processes however the outcomes are behind plan particularly in relation to ensuring patients are given their verbal Section 132 rights. This is being closely monitored as the new systems and processes are embedded.
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Appendix 1 – Extracts from the Quality and Safety Surveillance Report and Mental Health Law Surveillance Report
The Quality and Safety Surveillance Report is designed to provide the Committees and Subcommittee of the Trust Board with a range of indicators that provide
assurance and/or early warning escalation of risk. Risk indicators are used to draw attention to areas of focus. Green flags indicate a measure that is on target
or where performance is in-line with accepted levels. Yellow flags indicate a measure for close watch (perhaps because of a worsening position) or where a
measure is off target but has no immediate risk. Red flags indicate a measure that presents an immediate and/or high level risk. The Quality and Safety Tile, in
the front of this report, is a headline summary of key indicators.
In addition, a Mental Health Law Surveillance Report is produced alongside Network-level Quality Surveillance Report.
The data tables from the Trust Quality and Safety Surveillance Report (monthly) and Mental Health Law Surveillance Report (quarterly) are included in this
Quality and Safety Report for additional information and context.
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Domain
Indicator
Target
Nov
Dec
Jan
Feb
Mar
Apr
May
Jun
Jul
Aug
Sep
Oct 12 months
total
12 months
average
Sparkline
Risk
Incidents
Incidents n/a 1867 2094 2345 2358 2168 2090 2329 15251 2178.7
Incidents with harm n/a 404 436 487 547 437 473 535 3319 474.1
STEIS-reportable serious
incidents n/a 6 6 7 9 4 9 8 10 4 11 8 10 92 7.7
RIDDOR incidents n/a 2 6 2 0 3 4 5 2 6 1 6 1 38 3.2
Never Events 0 0 0 0 0 0 0 1 0 0 0 0 0 1 0.1
Medication incidents n/a 127 149 177 150 148 183 186 1120 160.0
Infection control Serious HCAI incidents 0 1 4 1 0 1 1 0 1 0 0 1 0 10 0.8
Patient safety
Use of restraint n/a 349 252 189 263 308 329 300 400 461 335 346 398 3930 327.5
Use of seclusion n/a 85 65 73 68 66 64 65 486 69.4
Safeguarding alerts n/a 100 158 138 129 130 95 152 902 128.9
Potentially avoidable grade 3
and 4 pressure ulcers n/a 0 0 0 2 0 2 0 5 1 2 0 1 13 1.1
Staffing
Number of instances of 1 or less
qualified on duty (inpatients) 0 244 207 192 170 145 139 197 140 132 177 132 84 1959 163.3
Number of red flag incidents
(inpatients only) n/a 316 261 260 268 221 195 270 227 228 258 228 137 2869 239.1
Staff safety Physical violence to staff from
patients n/a 162 137 140 129 151 155 150 218 268 220 223 219 2172 181.0
Legal Regulation 28 Notices received n/a 0 0 0 0 1 0 0 1 1 0 0 0 3 0.3
QUALITY AND SAFETY SURVEILLANCE - Safe
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QUALITY AND SAFETY SURVEILLANCE - Effective
Clinical Audits N/L/R* Network Compliance (%) Date Prevention of Dehydration L MHN 54% Sep-17
Absent Without Leave L MHN 55% Oct-17
Nursing Management of Clozaril R MHN 60% Oct-17
Diabetes R MHN 65% Sep-17
Carers R CYPWN 54% Oct-17
Cerebral Palsy in under 25's (NICE) L CYPWN 82% Risk Assessments L CYPWN 83% Clozapine L CYPWN 80% Nutrition L CYPWN 77% Consent to Treatment R MHN 94% Completion of Waterlow risk assessments L CWN 85% Wound assessment documentation L CWN 70% Care of Dying L CWN 79% Learning Disability L CWN 85% Acupuncture - Rheumatology & Physiotherapy R CWN 97% Antibiotics in dentistry R CWN 94% Use of restrictive practices within LD R CWN 93%
Domain
Indicator
Target
Nov
Dec
Jan
Feb
Mar
Apr
May
Jun
Jul
Aug
Sep
Oct 12 months
average
Sparkline
Risk
Physical Health
Harm Free Care
Pressure ulcers (%) - 4.61% 3.96% 2.72% 2.91% 5.27% 3.45% 3.45% 4.04% 3.05% 3.12% 2.55% 2.72% 3.5%
Falls with harm (%) - 1.76% 1.29% 1.28% 1.64% 1.55% 1.55% 0.60% 0.75% 1.21% 0.64% 0.93% 0.53% 1.1%
Catheter and UTI (%) - 0.29% 0.18% 0.64% 0.27% 0.26% 0.43% 0.45% 0.27% 0.21% 0.07% 0.23% 0.15% 0.3%
VTE (%) - 0.59% 0.55% 0.08% 0.36% 0.35% 0.35% 0.15% 0.69% 0.43% 0.43% 0.93% 0.38% 0.4%
Physical Health HFC Rate (%) 95% 93% 94% 95% 95% 93% 94% 96% 94% 95% 96% 96% 96% 94.7%
Mental Health
Harm Free Care
Self harm (%) - 3.69% 3.35% 4.04% 3.55% 3.43% 3.56% 3.76% 3.75% 4.37% 4.63% 3.71% 3.59% 3.8%
Victim of violence (%) - 2.87% 1.89% 1.62% 2.71% 1.07% 2.30% 1.46% 2.50% 1.66% 1.89% 1.75% 3.17% 2.1%
Feel safe (%) - 10.86% 9.22% 6.26% 8.35% 9.01% 9.62% 10.65% 7.08% 7.90% 10.53% 8.08% 11.21% 9.1%
Omission of medication (%) - 15.57% 18.87% 13.74% 16.08% 17.17% 17.99% 18.37% 23.54% 20.37% 19.79% 20.09% 24.10% 18.8%
Restraint (%) - 5.74% 6.29% 4.65% 4.80% 3.65% 5.23% 5.43% 7.08% 6.86% 7.16% 5.68% 4.86% 5.6%
Mental Health HFC Rate (%) 90% 82% 83% 86% 84% 85% 83% 83% 84% 81% 80% 84% 80% 82.9%
NICE Baseline Assessments Network Compliance Date
NG73 Endometriosis CYPWN 100% 7.11.17
NG6 Mental Health of Adults in contact with
the criminal justice system MHN 66% 7.11.17
NG71 Parkinsons Disease CWB 100% 7.11.17
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Domain
Indicator
Target
Nov
Dec
Jan
Feb
Mar
Apr
May
Jun
Jul
Aug
Sep
Oct 12 months
total
12 months
average
Sparkline
Risk
Friends & Family -
Patients
F&F Test 95% 85% 87% 96% 96% 96% 96% 97% 95% 97% 97% 97% - 94.40%
F&F Test - Response Rate n/a 3371 1744 1659 2042 1562 1263 1815 1218 1241 1652 923 18490 1680.9
Compliments Compliments n/a 719 529 678 1031 788 593 987 697 774 819 537 549 8701 725.1
QUALITY AND SAFETY SURVEILLANCE - Caring
The Friends and Family Test real time reporting is locked and nationally reported on the 19th of each month and will therefore be reported in arrears most months
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Domain
Indicator
Target
Nov
Dec
Jan
Feb
Mar
Apr
May
Jun
Jul
Aug
Sep
Oct 12 months
total
12 months
average
Sparkline
Risk
Complaints
Complaints n/a 134 150 114 111 167 95 108 152 134 173 149 145 1632 136.0
Upheld/partially upheld
complaints n/a 42 26 22 21 31 26 23 19 24 22 21 43 320 26.7
Completed within agreed
timeframe (%) n/a 54.0% 54.0% 54.0%
Reopened complaints n/a 3 3 3 4 2 4 4 7 5 0 0 3 38 3.2
PHSO complaints n/a 0 0 1 2 3 1 3 1 0 1 0 0 12 1.0
MP enquiries n/a 8 7 13 9 15 7 8 5 9 11 5 12 109 9.1
Environment Mixed Sex Breaches 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0.0
QUALITY AND SAFETY SURVEILLANCE - Responsive
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Domain Indicator Target Nov Dec Jan Feb Mar Apr May Jun Jul Aug Sep Oct 12 months
total
12 months
average Sparkline Risk
Regulatory
Trust CQC rating Good RI RI Good Good Good Good Good Good Good Good Good Good Good
Regulatory inspections/visits n/a 4 5 4 3 4 3 2 1 2 1 29 2.9
CQC notifications n/a
People
Core Skills (%) 85% 87.72% 88.24% 89.07% 89.41% 90.68% 90.33% 89.26% 91.06% 91.55% 90.81% 90.87% 91.64% - 90.05%
Supervision (%) n/a
Appraisals (%) n/a
Learning and
candour
Overdue 3 day reviews 0 1652 1305 1176 1267 1295 1695 1349 1573 2192 13504 1500.44
Overdue 7 day reviews 0 105 80 71 65 77 82 74 59 97 710 78.89
Overdue incident actions 0 94 - 94
Duty of candour breaches 0 0 0 0 0 0 0 0 1 0 0 0 1 9.09%
Assurance
Overdue safety alerts 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0.00%
Concerns raised n/a 9 9 9
Quality Plan priorities off track 0 0 0 0 0 - 0.00%
Quality assurance visits n/a 1 0 0 0 2 3 0.6
QUALITY AND SAFETY SURVEILLANCE - Well Led
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