merseycare.nhs.ukmerseycare.nhs.uk/media/2676/care-at-a-glance-m9-2015-16... · 2016-03-07 · The...

EC agenda item: B2PIC agenda item: B1

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Recommendations

The Trust Board is asked to:

Note the assessment of performance contained within this report and the performance improvement actions detailed in the performance escalation sections and supplementary reports.

Note the content of the safer staffing report.

Note that the executive committee was asked to approve the definitive clinical team lists.

Trust board to approve four changes to the existing capital programme.

Note the content of the out of area treatment report.

B2 (EC15/16/439)Executive Committee: Trust Board: C2 (TB15/16/177)

The trust continues to perform well in respect of external assessments and financial performance. The trust is compliant with CQC registration requirements (achieving “Good” in the recent Chief Inspector of Hospitals inspection). Performance improvement plans are in place for PACE, staff sickness, Talk Liverpool and physical health KPIs. Quality reporting for the trust is under review and a new system is anticipated to be in place by July 2016.

Care at a Glance Month 9 2015/16

Period ending 31 December 2015

EC agenda item: B2TB agenda item: C2

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Mersey Care NHS Trust at a glance

Objective Reporting Frequency

Previous Data

Period 2

Previous Data

Period 1

Current Data

Period Actual

Forecast next data

periodKite-mark

Safe Q

Timely Q

Effective Q

Equitable Q

Person-Centred Q

Triangle of Care Q

Safer staffing levels M

Link to Quality Dashboard (Attachment 1)

Link to Definitive Clinical Team Lists (Attachment 2)

Link to Safer Staffing Report (Attachment 3)

QUALITY AND SAFETY OF SERVICES (QUALITY DASHBOARD)

Safer staffing: In line with the National Quality Board expectations of openness and transparency and the actions required by NHS England and the Trust Development Authority regarding publishing of staffing data, the trust has submitted data relating to inpatient staffing levels to the Department of Health. In December 2015, the secure division reported that there were 576 occasions (n=1,1953) when they had less staff than they clinically required. The local division reported that on 470 occasions (n=1,865) they had less staff than they clinically required. A deterioration observed in the number of occasions that the correct staffing levels were in place within both divisions. The RAG rating detailed above is based on the position against clinical requirement 94.5% (Amber) (>=100% green; >=90% amber, <90% red). This is a deterioration when compared with November 2015 when the fill rate was 97.7%. The safer staffing report also includes information on perceived impacts on safety, service user and staff experience. The trust is also reporting against budgeted planned establishment as advised by the NHS Trust Development Authority. In December 2015, the trust achieved a fill rate of 101.3% against the budgeted planned establishment. Further information is provided in the safe staffing report (Attachment 3).

Quality dashboard 2015/16: The position reported relates to Q3 2015/16. • Safe: The amber rating for safest mental health provider reflects that the proportion of incidents that result in death or severe harm is above the benchmark: this was also the case for all of 2014/15. • Timely: 97.24% of patients referred by their GP were seen by a member of the multidisciplinary team within 6 weeks of referral (or clock start) year to date. • Effective: The trust continues to underperform against a number of physical health indicators, including those detailed within the quality dashboard. The clinical divisions have established and are implementing performance improvement plans. An update on the delivery of these plans and physical health indicator performance is provided in escalation section 1.• Equitable: Analysis by protected characteristic (significance testing) of the patient experience scores for 1 July 2014 to 30 June 2015 has been completed and is detailed in the quality dashboard. The key improvement areas for inpatients are: BME, Muslims and under 34 year olds. The key improvement areas for community are: BME and under 34 year olds. The key areas identified were approved by the Equality Steering Group in September 2015. • Person-Centred: Patient experience scores have remained consistent across all themes for inpatients services at a trust level. A decrease in the aggregate "overall care score" has been observed this quarter and the target of 95 set as part of the strategic initiative outcomes measures has not been achieved 93.22); the local division score was 91.75 (amber) and secure was 95.91 (green).• Triangle of Care: The green rating for triangle of care reflects that the overall trust score for inpatients and community has improved when compared with Q2 2015/16.Further information is provided in Attachment 1.

Quality Reporting and Definitive Clinical Team Lists - Local and Secure Divisions

Quality reporting for the organisation is under review and the new approach will be implemented by July 2016. To support the delivery of efficient and effective performance and quality reporting, the divisions were asked to establish a definitive clinical team list. The definitive clinical team lists will enable alignment of data between the various clinical and business systems used within the trust. Further information and the definitive clinical team lists are provided in Attachment 2. The executive committee is asked to approve the definitive clinical team lists.

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Reporting Frequency

Previous Data Period 2

Previous Data Period

1

Current Data

Period Actual

Forecast next data

periodKite-mark

Contracts (Attachment 4) M

CQC registration M

Commissioning for Quality and Innovation (CQUIN) (Attachment 5) Q

High Secure (Licence, Annual prison service audit, Social Care Standards) A

Information Governance Toolkit A

Monitor - Governance Risk Rating (Attachment 6) M

Trust Development Authority (TDA) - Accountability Framework (Attachment 7) M

EXTERNAL

Contracts: The trust continues to meet with Liverpool CCG and South Sefton CCG commissioners to review progress in relation to improving A&E waiting times at Aintree Hospital. There has been a further deterioration in performance of the key indicators for the Talk Liverpool service in month nine. The trust has received confirmation from Liverpool CCG that sanctions will be imposed in month 11 for two key indicators, numbers accessing the service and recovery. The sanctions will be £0.008m for each KPI per month. The additional funding granted by NHS England is also being withheld until the trust can demonstrate a reduction in the number of patients waiting for step three treatment. Contract negotiations for 2016/17 have begun with Liverpool CCG and with South Sefton CCG and Associates. Planning guidance for 2016/17 was published by NHS England on 22 December. The trust is expecting a contract uplift of 1.1% in 2016/17 across all contracts. The national deadline for contract sign-off is 31 March 2016. Draft commissioning intentions have been received from Sefton commissioners, and Liverpool CCG have given a verbal update on their plans for 2016/17. Both commissioners are considering increased funding for Early Intervention in Psychosis, in order to meet the new national access standards which come into operation in April 2016. However, commissioners have advised that they would be looking to increase funding on an invest to save basis. The trust continues to perform well against the majority of the 537 local and secure division contract performance and quality indicators. Activity for month nine is currently forecasting a small over performance of 0.6% at month 12. Further information is provided in Attachment 4.

Improving Access to Psychological Therapies (IAPT) September 2015 Data: The trust was advised on 13 January 2016 that the appointments table in the refreshed IAPT data file for September 2015 submitted to the HSCIC was not populated. The HSCIC have advised that we are unable to resubmit the data and they are unable to use the complete data submitted by the trust in the primary data file. The implications are that data published nationally will show:• exaggerated waiting times for those patients whose first treatment appointment took place during September. • Some patients may not be included in the recovery calculation and there may also be an impact on the number of people recovering and showing reliable improvement over the next few months.• There were no patients who “entered treatment” in September. Any patients who had their first treatment appointment in September who also attend a treatment appointment in October will be counted as entering treatment in October. This will mean an increase in the numbers reported as entering treatment in October and this is expected to return to close to normal in November. The HSCIC have agreed to publish a data quality notice on their website advising of the issue so that anyone planning on using the data are aware of this. Commissioners will continue to receive locally produced data in respect of performance against the key IAPT contract indicators and this is used as the basis for reporting in Care at a Glance. The position reported locally will differ from that produced nationally by the HSCIC. A root cause analysis into the incident is underway and recommendations for improvements in process will be developed and implemented.

CQUIN: Q2 CQUIN performance has been confirmed by commissioners. All Q2 milestones were achieved, apart from the Local Division’s National Physical Health CQUIN Part 2 - (Communication with GPs) indicator. The trust is due to report Q3 performance to commissioners by 29 January 2016.Areas of risk for Q3 and Q4 are detailed below and all relate to the local division.- National Physical Health CQUIN: Part 1 - (Cardio Metabolic Assessment for Patients with Schizophrenia) (Q4)- Local Physical Health CQUIN (Q3 and Q4) - Advancing Quality (AQ) Early Intervention in Psychosis (Q4)Recent negotiations with South Sefton CCG and Associates have resulted in the financial allocation for Early Interventions being split against AQ requirements and additional milestones relating to the introduction of waiting and access standards, therefore the maximum financial impact relating to the psychosis CQUIN has reduced from the £0.12m reported previously. This amendment is to be formally ‘signed off’ at the Sefton Clinical Quality and Performance Group (CQPG) in February 2016.Attachment 5 provides further information.

Monitor / TDA: The trust has achieved the CPA reviews in 12 months indicator as at 31 December 2015 (96.08%, a slight deterioration from last month). There continue to be differences between local performance data and that published nationally, an action plan has been developed in response to this and will be shared with the next Audit Committee. The new cases of early intervention in psychosis target is now being achieved. The underperformance in month 8 was investigated and the results are detailed in the Monitor Governance Risk Rating report (Attachment 6). An update has been received from the Information Commissioner Officer in relation to the data breach reported in July 2015 when nine bags of confidential waste was left in Oak House. The incident has been closed by the Information Commissioner Officer without further action, however, they have advised that should a further incident occur of this nature action will be taken by them. The third party concern reported in September 2015 regarding the contract performance notices is ongoing. We are now reporting the quality data that the TDA use within their oversight and escalation discussions with the trust rather than an internal assessment of performance. The latest oversight and escalation position for quality is 4 and the overall oversight and escalation score is 4 (data used is October 2015). Based on the quality data provided by the TDA, the following indicators are underperforming: Service users on CPA have had a HONOS completed in the last 12 months, Service users have had a CPA review in the last 12 months; Potential under-reporting of patient safety incidents resulting in death or severe harm and Staff sickness. The TDA have confirmed that there is no evidence of the trust under-reporting incident data so the low levels of incidents resulting in death or severe harm should be viewed as a positive outcome. Further details of performance against the Monitor and TDA indicators are provided in Attachment 6 and Attachment 7.

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Indicator Reporting Frequency

Previous Data

Period 2

Previous Data

Period 1

Current Data

Period Actual

Forecast next data

periodKite-mark

Objective 1 (Workforce): Corporate induction M

Objective 1 (Workforce): Mandatory Training M

Objective 1 (Workforce): Actual bank and agency utilisation versus required (NEW) M

Objective 1 (Workforce): Monitoring of WTE against workforce plans M

Objective 1 (Workforce): Staff turnover M

Objective 2 (Health and Wellbeing): Staff sickness (in month) M

Objective 3 (Reward and Recognise): Completion of personal achievement and contribution evaluation (PACE)

M

Objective 3 (Reward and Recognise): Medical staff appraisal in line with revalidation standards Annual

Objective 3 (Reward and Recognise): Well structured personal development review (Quarterly staff survey)

Q

Objective 4 (Staff satisfaction and engagement): Percentage of staff that would recommend the trust as a place to work (Quarterly staff survey)

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Objective 4 (Staff satisfaction and engagement): Percentage of staff that would recommend the trust as a place to receive treatment (Quarterly staff survey)

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Link to Workforce Performance Report (Attachment 9)

Continued areas that require performance improvement include the achievement of the bank and agency utilisation against requirement, PACE, corporate induction, workforce against plan and staff sickness (both in-month and rolling twelve months have deteriorated when compared with last month). Further information relating to staff sickness (to the end of December 2015) is provided in performance escalation section 3.

The trust position as at 31 December 2015 for PACE completion was 85.19%. This is a deterioration on month eight when the trust achieved 85.85%.

There has been an improvement in corporate induction performance this month with the trust achieving 77.08% (red). There were ten members of staff who did not complete the full corporate induction. The main reason for this was due to the corporate essential mandatory training not been completed within the three month timescale.

It is noted that staff turnover continues to increase (the trend has been observed since August 2015). The workforce team have implemented an "exit questionnaire" to help to understand staff reasons for leaving the trust and inform strategies for retention.

The workforce performance report also includes an updated assessment for Q3 2015/16 against the Workforce Race Equality Standards. The assessment (which has included statistical significance testing) shows that:

a. BME staff are less likely to be in Bands 8-9 and VSM (including executive Board members and senior medical staff) compared with the percentage of BME staff in the overall workforce.b. BME staff are less likely to be appointed following shortlisted than white staff.c. BME staff are more likely to experience harassment, bullying or abuse from patients, relatives or members of the public than white staff.d. BME staff are less likely to believe that trust provides equal opportunities for career progression or promotion. e. There are currently no voting Board members reported as BME. Whilst the number of board members is too small to enable statistical significance testing, this would not seem to be representative of the population served.

Further information can be found in the workforce report in Attachment 9.

WORKFORCE

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Indicator Reporting Frequency

Previous Data Period 2

Previous Data Period

1

Current Data

Period Actual

Forecast next data

periodKite-mark

Better payments practice code (cumulative) M

Capital cost absorption A

Capital resource limit A

External financing limit A

Financial position (breakeven duty) M

Strategic financial plan M

Monitor - Continuity of Services Risk Rating M

TDA - Finance (Attachment 7) M

Link to Finance Dashboard (Attachment 8)

FINANCE

As at the end of December, the trust is on target to achieve all statutory financial duties. The trust has a £4.021m surplus. The secure division is breakeven and Informatics Merseyside (IM), the local division and the corporate division are underspent. The trust has achieved a Monitor financial sustainability risk rating of 4 and the Trust Development Authority (TDA) indicators are all green. An assessment of overall trust financial performance agreed with the TDA has identified no financial concerns. The planned surplus for 2015/16 is £5.415m and is shown in Appendix 1. Division forecast outturn positions remain unchanged. The local division forecast outturn is a £1.000m underspend and IM is a £0.218m underspend. The corporate and secure divisions forecast outturn position is breakeven. The planned surplus includes a technical surplus of £0.763m in respect of accounting for Clock View. The trust has uncommitted contingency reserves of £1.000m and £1.400m following confirmation by HM Treasury of the discount rate which effects the trust's provision for permanent injury benefits and early retirements. This uncommitted resource could be used to support schemes that were not funded at budget setting, other pressures including MARS or to increase the trust surplus position. The use of this resource will be prioritised by the Executive Team and reported to the board. Within the local division, overspends on out of area treatments and bank and agency costs covering vacancies and sickness in inpatient areas and locum medical costs are being supported by underspends in the management and community areas. Within the secure division, overspends on additional staffing costs related to observations, sickness cover and leave of absence cover are being supported by underspends from vacancies. The 2015/16 CIP target is £8.416m. As at 31 December 2015 all divisions are on target and £6.308m has been delivered. The strategic financial plan is amber. Detailed service, workforce and financial plans have been produced. Detailed CIP plans have been submitted and assessed for the impact on quality by the Medical Director and the Executive Director of Nursing. A summarised position was presented to the Quality Assurance Committee (QAC) in January. The QAC has requested further information on the quality impact assessments before approving the plans. This will be presented at the March QAC meeting. The Capital Resource Limit (CRL) is £13.498m. The trust board is asked to approve four changes to the existing capital programme. A reduction of £0.187m to fire safety as the work at Windsor Clinic is not required, a reduction of £0.063m to fire safety at Rathbone as this will be done by the landlord, a reduction of £0.060m to the CCTV scheme on Poplar ward and a £0.021m increase for the Wavertree bungalow extension. The changes were agreed by the Capital Investment Group in December 2015 and January 2016.The trust is on plan to achieve the cash target of £14.697m by the end of the year. A summary cash position is shown in the statement of financial position in Appendix 3. The full year cash position is detailed in Appendix 4 and a forecast cash balance for the next 13 weeks is shown in Appendix 5.The trust has been notified by the TDA that we should be reporting on only qualified agency nursing, not total agency nursing. To the end of December, the trusts expenditure on qualified agency nursing was 0.4% of all qualified nurse staffing expenditure, against a target of 3.0%.A detailed financial position paper is being presented to the private session of the January board for approval. In future, a detailed financial position paper will be taken to the Performance and Investment Committee (PIC).

Further details of financial performance and appendixs are provided in the finance dashboard (Attachment 8).

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Link to Strategy Delivery Report (Attachment 10)Link to Strategy Measures Report (Attachment 11)

STRATEGY

Strategic Framework

At the end of M9 2015/16, a number of the strategic programmes are rated as amber, for further details please refer to Attachment 10.

Analysis of the outcome measures attached to the strategy shows opportunities for improvement in all four aims. It should be noted that the data being reported relates to M9 2015/16 (or in some cases M8 2015/16). Improvements in the number of strategy measures achieved have been observed in the following areas: Our people - supportive managers and effective team; Our services - safe (improved position in relation to reduced suicides, however overall, safe domain remains amber), Our people - working side by side with service users; Our future - grow our service and Our resources - save time and money (improved position in relation to delivery against workforce plan, however overall, save time and money remains amber). Work continues to implement information flows for a small number of the measures. Attachment 11 provides further detail.




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Link to Out of Area Treatment Report (Attachment 12)

INTELLIGENCEBusiness development update: The business development team have reported that they are completing a prequalifying questionnaire for Southport and Formby Community Services and an invite to tender for Sefton Council - Medically Managed Residential Inpatient Detox. The trust was successful on the framework for Blackpool Tier 4 Inpatient Detoxification Services and are on the reserve list as the price was over the threshold indicated by the Council.

Trust wide performance against Performance Assurance Framework (PAF) indicators: The graph below shows the proportion of key performance indicators in the PAF rated red, amber and green each month since April 2014. The current (M9 position) is 70.53% green,8.46% amber and 21.63% red. This is an improvement on M8 2015/16.

Out of area treatments: Attachment 12 provides the board and its committees with an overview of the out of area treatments in place for service users who would ordinarily be admitted to a Mersey Care NHS Trust bed (on the basis of their commissioning locality). The inclusion of out of area treatment information in board reporting will support requirements 8.6 and 8.7 from the NHS Trust Development Authority’s planning checklist for 2015/16. Following the review of OATs data with the North of England Specialised Commissioning Team, the OATs data for the secure division has been finalised and the revised position is below. Further information can be found in the secure division section. The total number of out of area treatments (planned and unplanned) for the trust for December 2015 is 144; 111 of these relate to the secure services division (60 relate to specialist services) and 33 relate to the local services division (17 relate to specialist services). Digital Maturity Assessment: The digital maturity assessment for NHS England has been completed by key stakeholders at the Digital Board. The assessment has been submitted to NHS England and will be reviewed by the Digital Board in February 2016. NHS Benchmarking Mental Health Project 2014/15: The final report and toolkit for the NHS benchmarking mental health project 2014/15 was received by the Quality Assurance Committee in January 2016 and the recommendations were accepted.

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Apr-14 May-14 Jun-14 Jul-14 Aug-14 Sep-14 Oct-14 Nov-14 Dec-14 Jan-15 Feb-15 Mar-15 Apr-15 May-15 Jun-15 Jul-15 Aug-15 Sep-15 Oct-15 Nov-15 Dec-15

Trust Wide RAG rating summary April 2014 - December 2015

Not achieved Underachieved Achieved



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Performance Escalation Section 1

PREVQuality Physical healthKey Performance Indicator

Reference Key Performance Indicator Target/Description ReportingFrequency Target/Thresholds Trust Wide Trend Movement Local Services

Division Trend Movement Secure Services Division Trend Movement Latest Data

PHYSCOM21

All smokers to be offered brief intervention advice within seven days of admission (if a person is unable to or

does not want to talk about smoking, note this in their records and ask about their smoking status at the first available opportunity) and first available opportunity in

the outpatients settings. (NICE PH48, Rec 3). Applied to patients on CPA only.

Quarterly (In Quarter) >=95% green; <95% red. 92.85% 92.75% Quarter 3 2015/16

PHYSCOM22All Smokers to be offered referral to an intensive Stop Smoking Specialist Service which provides at least 4 weeks of treatment. Applied to patients on CPA only.

Quarterly (In Quarter) >=50% green; <50% red. 64.01% 63.60% Quarter 3 2015/16

PHYSCOM23All appropriate (includes CPA and non CPA) service

users to be offered brief intervention advice as per the 'Every Contact Counts' training received by frontline staff

Quarterly (In Quarter) >= 90% green; <90% red 45.74% 45.74% Quarter 3 2015/16

PHYSCOM24

Improving Physical Healthcare to Reduce Premature Mortality in People with Severe Mental Illness (SMI) (National CQUIN): Cardiometabolic assessment and treatment for patients with psychoses (inpatients)

Quarterly (In Quarter)

By Q4 2015/16 >=90% green; >=50% amber; <50% red. For Q2 to Q3 2015/16, to report On track = green;

concerns identified one division = amber; concerns identified both divisions =

red.

Amber Amber Amber Quarter 3 2015/16

PHYSCOM28Percentage of diabetic patients who have had diabetic retinopathy screening in the last 15 months (QOF DM

21).Quarterly (In Quarter) >=100% green; <100% red 100.00% 100.00% Quarter 2 2015/16

PHYSCOM29Percentage of asthma patients who have had asthma

review in the last 15 months (QOF Asthma 6). Quarterly (In Quarter) >=100% green; <100% red 100.00% 100.00% Quarter 2 2015/16

PHYSCOM30Percentage of patients with hypertension who had blood

pressure recorded in previous 9 months which was 150/90 or less (QOF BP 9).

Quarterly (In Quarter) >=100% green; <100% red 94.12% 94.12% Quarter 2 2015/16

PHYSCOM31Percentage of patients offered a dental examination

within three months of the date determined / indicated by the dentist.


PHYSCOM32Percentage of patients with coronary heart disease who

had blood pressure recorded in previous 15 months which was 150/90 or less (QOF CHD 6).


PHYSCOM34Smoking Status recorded for all patients on CPA for first

face -to-face contact (Local division only) Quarterly (In Quarter)>=95% green; <95% red.

(Sefton require >=90% green; <90% red)

85.78% 85.78% Quarter 3 2015/16

PHYSCOM35Adult in-patients screened for malnutrition on admission

using the MUST tool Quarterly (In Quarter) >=95% green; <95% red 97.06% 97.06% Quarter 3 2015/16

PHYSCOM36Patients with a score of 2 or more (MUST) to receive an

appropriate care plan Quarterly (In Quarter) >=100% green; <100% red 100.00% 100.00% Quarter 3 2015/16

PHYSCOM37Patients with a score of 2 or more (MUST) are referred

to dietician Quarterly (In Quarter) >=100% green; <100% red 50.00% 50.00% Quarter 2 2015/16

PHYSCOM6Number of patients who did not have a physical health

check within 24 hours of admission. Quarterly (In Quarter) 0 green; >0 red 0 0 Quarter 2 2015/16

PHYSCOM7Number of patients who have not had a physical health

check within the last 12 months. Quarterly (In Quarter) 0 green; >0 red 0 0 Quarter 2 2015/16

PHYSLOC1

Percentage of long term inpatients who have had their physical health needs assessed in line with locally

agreed standards as reflected in the Trust's Physical Health Policy

Quarterly (In Quarter)>=95% green; >90% amber;

<90% red 99.34% 85.71% 100.00% Quarter 3 2015/16

PHYSLOC2 Percentage of patients admitted for whom addiction status has been recorded (Local services only).

Quarterly (In Quarter) >=95% green; >=90% amber; <90% red 96.80% 96.80% Quarter 3 2015/16

PHYSLOC3

Percentage of community patients on a CPA for whom an annual health check has been completed (either by primary care or by Trust staff) in line with the Trust's

Physical Health Policy.

Quarterly (In Quarter)>=95% green; >90% amber;

<90% red 86.62% 86.63% 90.24% Quarter 3 2015/16

PHYSLOC4 Percentage of patients admitted for whom BMI has been recorded (includes High Secure).

Quarterly (In Quarter) >=95% green; >90% amber; <90% red 96.44% 96.35% 100.00% Quarter 3 2015/16

PHYSLOC5Percentage of community service users on CPA

reviewed during the reporting period to have addiction status recorded (local services only).

Quarterly (In Quarter)>=95% green; >=90%

amber; <90% red 99.87% 99.87% Quarter 3 2015/16

PHYSLOC6Percentage of community service users on CPA reviewed during the reporting period to have BMI

recorded (local services only).Quarterly (In Quarter)

>=95% green; >=90% amber; <90% red 83.86% 83.86% Quarter 3 2015/16

PHYSLOC7Standard 37: smoking cessation support-proportion of new admissions offered smoking cessation within 24

hours - High SecureQuarterly (In Quarter)

>= 95% green; >=90% and <95% amber; <90% red 100.00% 100.00% Quarter 2 2015/16

PHYSCOM40Improving physical health - Supporting improvements in physical health for Addictions service users. (Liverpool

Public Health CQUIN)Quarterly (In Quarter)

Achieve quarterly milestones to Commissioner satisfaction = green; quarterly milestones

not achieved to Commissioner satisfaction =

red

Achieved Achieved Quarter 2 2015/16

PHYSCOM41Physical Health Care of all Mental Health and Learning

Disability Services Users across Mersey Care NHS Trust


Achieve quarterly milestones to Commissioner satisfaction = green; milestones on target

= amber, quarterly milestones not achieved to

Commissioner satisfaction = red

on target on target Quarter 2 2015/16

PHYSCOM42Supporting service users in secure services to stop

smoking: Low and Medium Secure (CQUIN) Biannual

Achieve biannual milestones to commissioner satisfaction

= green; milestones not achieved to commissioner

satisfaction = red.

Achieved Achieved 30/09/15

PHYSCOM43Health lifestyles: nutritional monitoring of the patients'

shop, high secure services (CQUIN) Quarterly (In Quarter)

Achieve quarterly milestones to Commissioner satisfaction = green; quarterly milestones

not achieved to Commissioner satisfaction =

red

green green Quarter 3 2015/16

PHYSCOM39

Improving Physical Healthcare to Reduce Premature Mortality in People with Severe Mental Illness (SMI)

(National CQUIN): Communication with General Practitioners (Local Division Only)

AnnualBy Q2 2015/16 >=90% = green; >=50% = amber;

<50% = red 0.00% 0.00% 30/09/15

PHYSCOM44

Improving Physical Healthcare to Reduce Premature Mortality in People with Severe Mental Illness (SMI) (National CQUIN): Cardiometabolic assessment and

treatment for patients with psychoses (community EIP)


By Q4 2015/16 >=80% green; >=40% amber; <40% red. For Q2 to Q3 2015/16, to report. On track = green; concerns identified = red.

green green green Quarter 2 2015/16


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Performance Escalation Section 1 (cont/d…)

A trust wide physical health improvement plan continues to be taken forward by the trust’s physical health forum and divisional physical health groups. Both clinical divisions have reviewed their performance data and developed performance improvement plans and trajectories.

The local division improvement plan includes:- Support by dietetics re: MUST assessment and care planning.- Access to EMIS being rolled out across the division. Issues have been identified with hardware compatibility.- Senior accountability for the delivery of the standards.- Implementation of a new physical health pathway on ePEX (including awareness raising).- Increased resources to support audit of physical health pathway compliance and delivery of CQUIN requirements.- Awareness raising through various meetings and forums.- Review of local division physical health nurses job descriptions.- A guidance document to support staff to ensure accurate completion of the physical health screens.- Direct contact with Lead Consultant and ward manager for each ward outlining accountability for incomplete physical health pathways/under performance- Review physical health nurses role in the Division. Ensure robust supervision framework in situ, CPD and clear role description, aligned to performance targets. - A local division physical health group has been established to take forward the actions above and will also review data recording and reporting.

In relation to PHYSCOM23, work is ongoing to add the relevant fields to the new inpatient physical health form. The impact was anticipated to be observed in Quarter 3, however work is ongoing in relation to this in line with the local division's physical health group work plan.

The performance improvement deep dive session identified five primary drivers that affect the trust's ability to achieve improvements in physical health for our service users and achieve the requirements of the physical health key performance indicators. These related to policy, staff, clinical information system, indicator design / reporting and resources.

The table above shows performance against the physical health indicators as at 31 December 2015 or Quarter 3 2015/16 (unless otherwise indicated).

The trust-wide position has shown improvement in nine of the indicators and a deterioration in four of the indicators. Further work is required to achieve a number of the measures, however this is an improvement on Q2 2015/16.

In relation to PHYSCOM23 (service users to be offered brief intervention advice as per “every contact counts” training), the brief intervention for weight management was not included within the new inpatient physical health form on ePEX, this has led to a deterioration in performance for Quarter 2 and continued deterioration in performance for Quarter 3.

The only remaining area of underperformance for the secure division as at Quarter 2 is for PHYSCOM30 (hypertension / blood pressure monitoring). The division have advised that this underperformance relates to patient refusals to have screening completed.

The secure divisions' physical health indicators will be updated in the month 10 report due to commissioning timescales.

What is driving the reported under performance? What actions have we taken / do we plan to take to improve performance?


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PREVExternal CONTRACTS - TALK LIVERPOOL

What is driving the reported under performance? What actions have we taken / do we plan to take to improve performance?The trust received a performance improvement notice from Liverpool CCG in relation to continued under performance in the Talk Liverpool service and a formal meeting took place on 9 October 2015. A data quality issue has been identified which was having an impact on the waiting time figures as well as the number of patients accessing the service. Work to resolve this is still on-going, however a large proportion of the work was completed before the meeting.

The local division have identified 13 areas of concern that affect the trust's ability to achieve the Talk Liverpool indicators. These related to waiting times, centralised booking system, access/entering treatment, staff training and development, complex care referrals, capacity and demand modelling and system development, data analyst, recruitment, marketing and promotion, hub and spoke utilisation, data quality, HSCIC reporting and IAPT Analyst Network.

The table above shows performance against the Talk Liverpool indicators as at 31 December 2015. There are three Talk Liverpool indicators that do not have the information flows finalised and work is on-going in relation to this.

From the 13 indicators reported above, eight are not being achieved and five are being achieved. In December, two of the eight indicators not being achieved have improved, three have deteriorated and three have remained consistent. The new national referral to treatment indicators for IAPT services (WAITNAT2 and WAITNAT3) have been achieved in Q3 2015/16.

There has been a deterioration in performance of the key indicators for the Talk Liverpool service in month nine. The trust has received confirmation from Liverpool CCG that sanctions will be imposed in month 11 for two key KPIs, numbers accessing the service and recovery. The sanctions will be £0.008m for each KPI per month. The additional funding granted by NHS England is also being withheld until the trust can demonstrate a reduction in the number of patients waiting for step three treatment.

A remedial action plan has been produced as a key performance monitoring tool. This will:

- assist Mersey Care and Liverpool CCG in ensuring continued improved performance in relation to access, waiting times and recovery targets for the Talk Liverpool Service.- aid discussion in contract monitoring meetings between Mersey Care and Liverpool CCG.- ensure there is a live document which can be updated regularly, which provides an auditable record of progress made and key issues to be resolved.

The action plan includes:

- Development of a capacity and demand modelling tool.- Sub contract to be developed and agreed with Listening Ear which facilitates the removal of 240 service users from the waiting list over a 20 week period commencing first week in November.- Gateway assessment process to be monitored to ensure adherence to service specification.- A piece of work to be undertaken during October 2015 to establish feasibility of administration staff entering appointments onto the system at the point of entry into each modality.- Staff training and development programme in place to ensure staff are competent and supported to facilitate groups in an effective manner.- Service leads continue to work to ensure a reduction in inappropriate referrals.- Recruitment plan in place.- Marketing and Promotion plan in place.- Data cleansing to be complete by 23 October 2015.- Business Intelligence Lead Officer to liaise with HSCIC with regards to data.- Attendance at IAPT Analyst Network.

Progress against agreed actions will be monitored by the Talk Liverpool contract review meetings.

Key Performance Indicator

Reference

Key Performance Indicator Target/Description

ReportingFrequency Target/Thresholds Nov-15 Dec-15 Trend Movement

WAITNAT2

Improving access to psychological therapies (IAPT): People with common mental health conditions referred to the IAPT programme will be treated within 6

weeks of referral (Monitor)

Monthly (In quarter)

>=75% green; <75% red. Performance to be

reported from Q3 2015/16.94.69% 89.43%

WAITNAT3

Improving access to psychological therapies (IAPT): People with common mental health conditions referred to the

IAPT programme will be treated within 18 weeks of referral (Monitor)

Monthly (In quarter)

>=95% green; <95% red. Performance to be

reported from Q3 2015/16.99.82% 99.19%

FOLLCOM4

Talk Liverpool - The average number of treatment sessions received after

assessment by step 2.Monthly (In

Month) =6 green; <>6 red 4.00 4.00

RECOCOM1

Talk Liverpool - The number of people who are "moving to recovery" (of those who

have completed treatment, those who at initial assessment achieved "caseness" and at final session did not) during the

reporting quarter.

Monthly (In Month)

>50% green; <=50% red 32.00% 32.00%

CANCCOM3Talk Liverpool - The number of booked

appointments that are cancelled (Total) expressed as a percentage.

Monthly (In Month) <10% green; >=10% red 19.00% 19.00%

DNACOM4Talk Liverpool - The number of booked

appointments that are DNA'd expressed as a percentage.

Monthly (In month) <10% green; >=10% red 16.00% 17.00%

ACCECOM1

Talk Liverpool - The number of people who have entered psychological therapies (at

the end of the reporting quarter) as a proportion of prevalence.

Monthly (In Month)

Annual target is 16% (13650 people). Monthly target will be issued by

commissioners.

75.00% 73.00% WAITCOM19

Talk Liverpool - The number of referrals that have been waiting more than 28 days

from referral to treatment.

Monthly (In Month) <5% green; >=5% red 12.00% 19.00%

WAITCOM20Talk Liverpool - The number of days from

referral to entering treatment.Monthly (In

Month)<28 days green; >=28

days red 9.00 11.00 WAITCOM21

Talk Liverpool - The number of days from referral to entering treatment in Step 2.

Monthly (In Month)

<28 days green; >=28 days red 11.00 12.00

WAITCOM22Talk Liverpool - The number of days from step up to starting treatment in Step 3. Monthly (In

Month)<28 days green; >=28

days red 123 95 WAITCOM23

Talk Liverpool - The number of days most people wait for treatment.

Monthly (In Month)

<28 days green; >=28 days red 7.00 7.00

FOLLCOM5

Talk Liverpool - The average number of treatment sessions received after

assessment by step 3.Monthly (In

Month)=6 green; <>6 red 7.00 8.00


of 12


PREV

Green

<=4.8%

Staff sickness year to dateWorkforce

What is driving the reported performance? What actions have we taken / do we plan to take to improve performance?

Amanda Oates Feb-16

Next update to performance and investment committee / boardExpected date to meet standardForecast signed off

by:

TBC

Forecast (next data period "in

month")

Red6.48% 6.04%

Rolling twelve months

Latest performance (in month)

Internal

Indicator Source

Actions include:The in month absence rate of 6.48% is equivalent to 233.60 WTE staff off sick at any point in time (168.54 WTE long term and 65.06 WTE short term). The rolling 12 month absence rate of 6.04% is equivalent to 210.58 WTE staff off sick at any point in time (143.79 WTE long term and 66.78 WTE short term). The highest levels of staff sickness are observed within inpatient settings. Analysis of the data shows that long-term absence drives the majority of sickness within the organisation.

The cost of sickness for December 2015 (month 9) was not available at the time of writing.

A further graph can be found in the workforce report which highlights the benchmark for sickness absence against all mental health trusts and demonstrates comparative positions for the North West.

The workforce paper accompanying this report provides further detail.

Improved timescales for inputting sickness absence into ESR.

Benchmark and improve compliance rates for completion of return to work interviews.

RAG rate completion of sickness reviews .

Increased uptake of staff support / physiotherapy services through early communication with staff.

Provision of monthly sickness activity reports.

Continue to robustly manage sickness absence in line with the trust’s management of attendance policy.

Achieve and maintain Trust's sickness absence target.

Further details are provided in the workforce paper accompanying this report.

0%

1%

2%

3%

4%

5%

6%

7%

8%

0 50,000 100,000 150,000 200,000 250,000

Perc

enta

ge s

ickn

ess

rate

FTE Days Available

Sickness absence rate for mental health trusts, October 2014 to September 2015 (iView)

Overall sickness rate Lower control limit Upper control limit

Lower alert limit Upper alert limit Percentage sickness rate

MCT

1

2

3

4

5

6

7

8

9Ap

r-13

May-

13

Jun-

13

Jul-1

3

Aug-

13

Sep-

13

Oct-1

3

Nov-

13

Dec-

13

Jan-

14

Feb-

14

Mar-1

4

Apr-1

4

May-

14

Jun-

14

Jul-1

4

Aug-

14

Sep-

14

Oct-1

4

Nov-

14

Dec-

14

Jan-

15

Feb-

15

Mar-1

5

Apr-1

5

May-

15

Jun-

15

Jul-1

5

Aug-

15

Sep-

15

Oct-1

5

Nov-

15

Dec-

15

Perc

enta

ge si

ckne

ss ra

te

Staff Sickness - April 2013 to December 2015 (Trust Wide)


of 12

Escalation Status

NEW New Escalation

PREV Update on previousescalation

Reporting Frequency

M MonthlyQ QuarterlyA Annual

Care at a Glance Legend

Legend / key Forecasts

Graph Legend

R A G

Shows whether next month position will meet the standard

Data Quality Indicator (Kite mark)

Insufficient

Sufficient

Not yet assessed

Trend Movement Arrows - Performance Escalation Tables and Supplementary Reports

Performance Improving

Performance Deteriorating

Performance Maintained

Trend Movement Arrows - Summary Sheet

Performance improved (arrow colour indicates performance level achieved)

Performance maintained (arrow colour indicates performance level achieved)

Performance deteriorated (arrow colour indicates performance level achieved)

Relevance

Timeliness

Monitoring

Completeness

Validation

Audit

Reliability

Performance and Investment Committee:

Executive Committee:

Quality Area Sep-14 Dec-14 Mar-15 Jun-15 Sep-15

Safe A A A A A

Timely G G G G G

Effective R A A A A

Equitable A A A A A

Person-Centred A A A A A

Triangle of Care G G A G R

B1 / Attachment 1

Note: The RAG rating used above is an aggregate position reflecting performance against the individual

indicators used for each objective. For "equitable" the amber rating reflects the fact that individuals from

different groups (based on the protected characteristics) appear to have varying levels of experience of our

services.

Delivering Perfect Care

September 2015

Mersey Care NHS Trust - Quality Dashboard

B2 / Attachment 1

Summary Sheet Page 1 of 14

Return to summary sheet

0%

20%

40%

60%

80%

100%

Percentage of community patients on a CPA for whom an annual health check has been completed (Target 95%)

Local Secure (LM&OH only) Target (95%)

No secure patients to

which indicator

applicable in Q1 2013/14

0%10%20%30%40%50%60%70%80%90%

100%

Percentage of long term inpatients who have had their physical health needs assessed in line with locally agreed standards as reflected in the Trust's Physical Health Policy

(Target 95%)

Local Secure Target (95%)

30

35

40

45

50

55

Q1 2

013

/14

Q2 2

013

/14

Q3

20

13

/14

Q4

20

13

/14

Q1

20

14

/15

Q2

20

14

/15

Q3 2

014

/15

Q4

20

14

/15

Q1

20

15

/16

Q2

20

15

/16

Incident Reporting Rates Inpatients - Number of incidents per 1000 occupied bed days

Trust Wide Target (40 in 2013/14, 43 in 2014/15 and 2015/16)

92%

93%

94%

95%

96%

97%

98%

99%

100%

Dec-13 Mar-14 Jun-14 Sep-14 Dec-14 Mar-15 Jun-15 Sep-15

Proportion of patients referred by their GP to be seen by a member of the multidisciplinary team within 6 weeks of

referral (or clock start) year to date expressed as a percentage of GP referrals - Local Services Only (Target

95%)

Local Target (95%)

0

1

2

3

4

5

6

7

8

9

Q1 2

014

/15

Q2

20

14

/15

Q3

20

14

/15

Q4 2

014

/15

Q1

20

15

/16

Q2

20

15

/16

Incident Reporting Rates Community - Number of incidents per 1000 face to face community contacts

Trust Wide Target (2.92 in 2014/15, 3.92 in 2015/16)

40%

50%

60%

70%

80%

90%

100%

Nov12

Jun13

Aug13

Sep13

Oct13

Nov13

Dec13

Mar14

Jun14

Sep14

Dec14

Mar15

Jun15

Sep15

Triangle of Care Inpatients (Goal to increase compliance from March 2014 baseline figure towards 100% aspiration)

Local Services Division Secure Division

Trust Wide Goal

40%

50%

60%

70%

80%

90%

100%

Sep13

Oct13

Nov13

Dec13

Mar14

Jun14

Sep14

Dec14

Mar15

Jun15

Sep15

Triangle of Care Community (Goal to increase compliance from March 2014 baseline figure towards 100% aspiration)

Local Services Division Secure Division

Trust Wide Goal

20%

40%

60%

80%

100%

Proportion of incidents resulting in no harm

Percentage of incidents resulting in no harm

Target (75.60% 2013/14, 80.21% 2014/15)

80.0082.0084.0086.0088.0090.0092.0094.0096.0098.00

100.00

January toMarch 2014(baseline)

April to June2014

July toSeptember

2014

October toDecember

2014

January toMarch 2015

April to June2015

July toSeptember

2015

Aggregate overall score from both inpatient and community survey. (Target 95%)

Local Services Secure Services

Trust Wide Target by 31 March 2015 (95%)

Dashboard Page 2 of 14

Return to summary sheet Return to dashboard sheet

Safe

Number of

incidents

Number of occupied

bed daysTrust Wide

Target (40 in

2013/14, 43 in

2014/15 and

2015/16)

Q1 2013/14 2,196 55,441 39.61 40.00

Q2 2013/14 2,257 54,609 41.33 40.00

Q3 2013/14 2,307 56,355 40.94 40.00

Q4 2013/14 2,230 53,781 41.46 40.00

Q1 2014/15 2,448 53,132 46.07 43.00

Q2 2014/15 2,565 54,416 47.14 43.00

Q3 2014/15 2,553 52,821 48.33 43.00

Q4 2014/15 2,490 51,144 48.69 43.00

Q1 2015/16 2,716 52,395 51.84 43.00

Q2 2015/16 2,800 54,948 50.96 43.00

Number of

incidents

Number of face to

face community

contacts

Trust Wide

Target (2.92 in

2014/15, 3.92 in

2015/16)

Q1 2014/15 498 100,065 4.98 2.92

Q2 2014/15 532 99,282 5.36 2.92

Q3 2014/15 530 98,358 5.39 2.92

Q4 2014/15 732 96,489 7.59 2.92

Q1 2015/16 734 95,062 7.72 3.92

Q2 2015/16 652 98,865 7.72 3.92



30

35

40

45

50

55

Q12013/14

Q22013/14

Q32013/14

Q42013/14

Q12014/15

Q22014/15

Q32014/15

Q42014/15

Q12015/16

Q22015/16


Trust Wide Target (40 in 2013/14, 43 in 2014/15 and 2015/16)

0

1

2

3

4

5

6

7

8

9

Q1 2014/15 Q2 2014/15 Q3 2014/15 Q4 2014/15 Q1 2015/16 Q2 2015/16


Trust Wide Target (2.92 in 2014/15, 3.92 in 2015/16)

Safe Page 3 of 14

Percentage

of incidents

resulting in

no harm

Target (75.60%

2013/14, 80.21%

2014/15)

April 2010 to September 2010 36.30% 75.60%

October 2010 to March 2011 58.70% 75.60%


October 2011 to March 2012 93.30% 75.60%


October 2012 to March 2013 79.28% 75.60%

January 2013 to June 2013 74.05% 75.60%


October 2013 to December 2013 78.21% 75.60%

January 2014 to March 2014 80.89% 75.60%

April 2014 to June 2014 85.23% 80.21%

July 2014 to September 2014 85.40% 80.21%

October 2014 to December 2014 85.50% 80.21%

January 2015 to March 2015 86.88% 80.21%

April 2015 to June 2015 89.26% 80.21%

July 2015 to September 2015 89.05% 80.21%

Trust Total - Level of Harm Q1 2014/15 Q2 2014/15 Q3 2014/15 Q4 2014/15 Q1 2015/16 Q2 2015/16

Benchmark

(NRLS 1

April to 30

September

2013)

Notes re:

benchmark

Death (Caused by incident) 0.35% 0.47% 0.35% 0.42% 0.26% 0.23% <0.2% Bottom 10%

Severe Harm 0.18% 0.13% 0.22% 0.18% 0.46% 0.41% <0.0% Bottom 10%

Moderate Harm 0.49% 0.35% 0.38% 0.39% 0.38% 0.46% <1.3% Bottom 10%

Low Harm 13.76% 13.66% 13.55% 12.12% 9.64% 9.85% <18.6% Bottom 10%

No Harm 85.23% 85.40% 85.50% 86.88% 89.26% 89.05% >=80.21% Top 5%


Breakdown of by harm level compared against NRLS benchmark (mental health trusts for 1 April to 30 September 2013), all quarters refreshed

20%

40%

60%

80%

100%


Percentage of incidents resulting in no harm Target (75.60% 2013/14, 80.21% 2014/15)

Safe Page 4 of 14


Local Target (95%)

Dec-13 99.84% 95%

Mar-14 99.51% 95%

Jun-14 99.21% 95%

Sep-14 99.06% 95%

Dec-14 99.22% 95%

Mar-15 99.29% 95%

Jun-15 100.00% 95%

Sep-15 100.00% 95%

Proportion of patients referred by their GP to be seen by a member of the multidisciplinary team within 6 weeks of referral (or clock start) year to date

expressed as a percentage of GP referrals - Local Services Only (Target 95%)

Timely

92%

93%

94%

95%

96%

97%

98%

99%

100%

Dec-13 Mar-14 Jun-14 Sep-14 Dec-14 Mar-15 Jun-15 Sep-15

Proportion of patients referred by their GP to be seen by a member of the multidisciplinary team within 6 weeks of referral (or clock start) year to date expressed as a percentage of GP referrals - Local Services Only

(Target 95%)

Local Target (95%)

Timely Page 5 of 14



Jun-13 17.54% #N/A 95%

Sep-13 16.53% 50.00% 95%

Dec-13 49.13% 38.89% 95%

Mar-14 69.25% 49.15% 95%

Jun-14 70.30% 65.08% 95%

Sep-14 71.48% 80.77% 95%

Dec-14 78.65% 92.19% 95%

Mar-15 83.09% 94.23% 95%

Jun-15 81.61% 93.62% 95%

Sep-15 85.53% 97.83% 95%


Jun-13 63.89% 64.00% 95%

Sep-13 54.05% 95.71% 95%

Dec-13 91.20% 90.20% 95%

Mar-14 95.00% 99.16% 95%

Jun-14 90.91% 97.94% 95%

Sep-14 87.50% 76.92% 95%

Dec-14 100.00% 98.06% 95%

Mar-15 97.56% 100.00% 95%

Jun-15 95.12% 100.00% 95%

Sep-15 87.76% 97.76% 95%

Percentage of long term inpatients who have had their physical health needs assessed in line with locally agreed standards as reflected in the Trust's

Physical Health Policy (Target 95%)


Effective

0%10%20%30%40%50%60%70%80%90%

100%

Percentage of long term inpatients who have had their physical health needs assessed in line with locally agreed standards as reflected in the Trust's Physical Health Policy

(Target 95%)


0%

20%

40%

60%

80%

100%



No secure patients to

which indicator

applicable in Q1 2013/14

Effective Page 6 of 14


Inpatients

Number of

responsesOverall score Care Plan

Friends and

Family

Privacy and

Dignity Safety

All service users who responded 2614 92.04 90.38 82.02 96.28 95.57

Not known (inc. decline to answer) 97 95.27 95.55 84.72 96.91 98.96

Under 25 269 92.83 92.76 80.15 96.22 95.15

25-34 725 91.71 90.06 78.04 96.90 96.01

35-49 912 90.87 88.95 81.75 95.15 94.60

50-65 421 92.39 89.82 85.67 96.84 95.72

Over 65 190 95.39 93.74 92.41 97.89 97.11


Female 694 93.53 91.24 89.25 97.41 95.04

Male 1822 91.43 89.93 79.18 95.96 95.78

Transgender 6 62.04 60.42 66.67 66.67 50.00


Heterosexual 2187 92.45 90.74 82.08 96.82 96.19

Bisexual 68 90.11 88.00 83.82 94.42 91.91

Gay 40 91.24 90.76 78.97 94.58 95.00

Lesbian 15 70.89 63.33 61.33 78.89 86.67


Buddhist 16 88.74 87.50 69.33 97.92 84.38

Christian 1597 93.12 91.55 84.08 97.04 96.25

Hindu 6 73.00 71.43 66.67 76.47 75.00

Jewish 4 71.94 75.00 60.00 70.83 75.00

Sikh 4 52.78 50.00 75.00 50.00 50.00

Other 196 89.44 85.92 79.57 96.00 93.66

No religion 489 90.92 88.70 78.50 96.32 95.81


White British 2061 93.39 90.25 82.39 96.59 96.12

White Other 124 95.11 93.14 80.52 95.96 95.16

Mixed Race 108 93.36 90.60 80.19 95.68 96.30

Asian British 29 92.22 90.09 67.59 91.95 96.55

Asian Other 10 94.67 86.25 86.00 96.67 100.00

Black British 49 85.85 80.90 76.73 94.00 83.00

Black Other 9 97.78 100.00 76.00 91.38 85.00

Other Ethnic Group 26 98.21 86.54 80.77 91.67 84.62


Single 1771 91.87 90.27 80.41 96.50 95.54

Married/civil partnership 299 93.20 91.32 87.17 96.44 96.50

Separated 94 92.16 88.77 86.15 97.39 95.79

Divorced 152 90.57 87.66 82.94 95.20 95.42

Widowed 103 92.82 91.16 88.91 95.66 94.71


Declared Disability 1524 91.36 89.60 80.88 95.89 95.06

None 795 93.39 91.80 84.22 97.19 96.74

Analysis of variance in patient experience scores for protected characteristics (inpatients 1 July 2014 to 30 June 2015).

Equitable

Marital status

Disability

Ethnicity

Age

Gender

Sexual orientation

Religion

Equitable Page 7 of 14

Community

Number of

responsesOverall score Care Plan

Day to day

living

Family and

friends

Privacy and

dignity

All service users who responded 2027 93.42 93.55 91.09 89.53 97.62


Under 25 118 92.79 92.63 92.48 83.90 96.33

25-34 317 92.39 92.64 90.21 87.76 96.70

35-49 615 94.44 94.95 92.43 90.11 98.05

50-65 531 92.85 93.69 88.83 90.54 97.90

Over 65 342 92.99 91.54 90.07 90.88 98.44


Female 948 93.28 93.54 90.58 89.83 97.66

Male 960 93.37 93.54 90.69 89.54 97.92

Transgender 4 96.82 91.67 100.00 90.00 100.00


Heterosexual 1640 93.61 93.97 90.79 90.15 98.03

Bisexual 25 90.42 86.00 89.89 88.80 96.00

Gay 25 89.51 90.00 82.42 86.40 98.67

Lesbian 18 95.33 99.07 93.15 90.00 96.30


Buddhist 11 94.72 91.67 96.23 89.09 96.97

Christian 1252 93.57 93.94 90.25 90.85 98.29

Hindu 6 97.26 100.00 93.55 100.00 100.00

Jewish 19 90.79 87.96 86.67 92.63 97.32

Sikh 1 98.00 100.00 100.00 80.00 100.00

Other 106 91.47 91.72 89.87 84.57 95.79

No religion 325 93.74 93.56 92.44 87.80 97.61


White British 1644 93.62 93.86 90.81 90.14 98.13

White Other 82 93.62 93.50 93.09 88.43 96.18

Mixed Race 64 92.70 92.93 92.00 85.31 95.83

Asian British 14 85.63 85.71 80.00 84.29 94.05

Asian Other 5 98.65 100.00 100.00 96.00 96.67

Black British 26 84.80 85.26 75.00 87.69 97.44

Black Other 7 83.56 95.24 71.05 88.57 92.86

Other Ethnic Group 14 93.65 95.24 93.44 81.43 96.43


Single 1018 93.81 93.94 91.84 88.51 98.01

Married/civil partnership 488 92.12 92.46 87.33 92.51 97.44

Separated 101 94.76 93.93 94.24 87.84 98.69

Divorced 128 93.14 95.80 87.65 91.02 98.29

Widowed 99 93.98 94.22 91.69 90.10 97.64


Declared Disability 1273 93.63 94.43 90.91 89.86 97.73

None 526 93.27 92.32 90.86 89.83 98.16

Inpatients:

Community:

The results from the community patient experience questionnaires for 1 July 2014 to 30 June 2015 have been analysed using the level of positive responses

for four key areas in each patient experience questionnaire. This analysis has been conducted to identify any statistically significant differences in the

responses in relation to the seven protected characteristics. A report was produced to identify all areas of statistical significance. Following analysis and

discussion of this report with Meryl Cuzak, Equality and Human Rights Lead, the key inpatient areas of focus for quality reporting are; BME and under 34 years

olds. Further analysis will be undertaken to identify if any gender difference exists within the under 34 years old. This will identify whether the improvement

work needs to focus with one particular group i.e. female or male. The keys areas identified have been approved by the Equality Steering Group held in

September 2015.

Sexual orientation

Gender

Religion

Age

The results from the inpatient patient experience questionnaires for 1 July 2014 to 30 June 2015 have been analysed using the level of positive responses for

four key areas in each patient experience questionnaire. This analysis has been conducted to identify any statistically significant differences in the responses

in relation to the seven protected characteristics. A report was produced to identify all areas of statistical significance. Following analysis and discussion of

this report with Meryl Cuzak, Equality and Human Rights Lead; the key inpatient areas of focus for quality reporting are; BME, Muslims and under 34 years

olds. Further analysis will be undertaken to identify if any gender difference exists within the under 34 years old. This will identify whether the improvement

work needs to focus with one particular group i.e. female or male. The keys areas identified have been approved by the Equality Steering Group held in

September 2015.

Ethnicity

Marital status

Disability

Equitable Page 8 of 14


Person-Centred

Patient Experience Inpatient July to September 2015Adult Mental

HealthComplex Care

Specialist

Services

Local

ServicesLow Secure

Medium

SecureHSS Secure Services All Services

Number of responses 183 43 61 287 24 53 170 247 534

Target number of responses 426 174 279 705

% of responses target achieved 67% 98% 89% 76%

Adult Mental

HealthComplex Care

Specialist

Services

Local

ServicesLow Secure

Medium


OVERALL SCORE (Excluding Carers & Friends and Family) 93.35 96.05 86.88 92.37 97.04 98.43 94.20 95.39 93.77

Access / Contact 92.84 99.07 86.07 92.33 96.67 99.43 94.76 95.95 94.01

Activities 92.90 97.67 85.66 92.07 100.00 97.64 94.71 95.85 93.82

Care and Treatment / Diagnosis 93.44 93.79 86.27 91.97 98.44 98.94 95.44 96.48 94.06

Care Plan 92.20 93.60 76.64 89.07 94.79 98.82 91.24 93.21 90.99

Carers 76.78 79.07 63.11 74.22 77.08 91.51 68.82 74.49 74.34

Cleanliness 87.25 93.80 90.71 88.97 79.17 82.39 88.04 85.97 87.58

Effective Care 96.17 97.67 95.08 96.17 95.83 100.00 92.35 94.33 95.32

Friends and Family 88.31 89.30 94.43 89.76 83.33 79.62 78.12 78.95 84.76

Medication 92.23 94.17 88.10 91.67 100.00 98.73 93.65 95.40 93.42

Other 92.49 96.51 86.48 91.81 96.87 98.11 89.41 92.00 91.90

Privacy and Dignity 97.45 98.84 92.35 96.57 97.22 99.06 98.04 98.18 97.32

Safety 95.36 97.67 96.72 95.99 97.92 100.00 94.12 95.75 95.88

Single Sex 94.48 100.00 98.36 96.14 100.00 100.00 100.00 100.00 97.93

Inpatient patient experience survey results (Target 90% for all except single sex accommodation for which the target is 100%)

Theme

Score (Out of 100, 100 being positive)

105

23%

Person-Centred Page 9 of 14

Adult Mental

HealthComplex Care

Specialist

Services

Local

ServicesLow Secure

Medium


OVERALL SCORE (Excluding Carers) -2.80 -0.50 -2.80 -2.45 3.85 3.39 2.10 2.38 -0.17

Access / Contact -2.99 0.57 -5.50 -2.93 2.38 2.17 1.23 1.31 -0.95

Activities -1.97 3.92 -1.65 -1.06 7.14 4.83 2.26 3.27 0.96

Care and Treatment / Diagnosis -3.28 -1.48 -5.21 -3.45 4.09 4.60 2.52 3.06 -0.40

Care Plan -3.92 -0.46 -5.14 -3.75 5.50 6.26 1.98 3.02 -0.56

Carers

Cleanliness 0.74 -2.03 3.94 1.23 -0.20 -3.33 2.45 0.78 1.07

Effective Care -0.50 -2.33 -0.51 -0.69 0.59 2.38 -0.88 -0.28 -0.45

Friends and Family 0.41 -6.70 1.78 -0.18 4.28 9.38 -0.11 2.92 1.54

Medication -5.27 -1.59 2.16 -3.16 1.59 3.10 4.82 3.88 0.20

Other -2.75 -0.36 0.92 -1.58 15.92 4.66 0.09 2.10 0.20

Privacy and Dignity -0.01 -0.33 -0.79 -0.18 0.39 1.04 3.51 2.50 1.09

Safety -1.07 -2.33 -0.34 -1.02 0.30 1.79 0.11 0.30 -0.38

Single Sex -4.09 0.00 -1.64 -2.91 0.00 0.00 0.00 0.00 -1.58

Theme Local Services Secure Services All Services

Number of responses 287 247 534

Target number of responses 426 279 705

% of responses target achieved 67% 89% 76%

OVERALL SCORE (Excluding Carers) 92.37 95.39 93.77 90.00

Access / Contact 92.33 95.95 94.01 90.00

Activities 92.07 95.85 93.82 90.00

Care and Treatment / Diagnosis 91.97 96.48 94.06 90.00

Care Plan 89.07 93.21 90.99 90.00

Carers 74.22 74.49 74.34 N/A

Cleanliness 88.97 85.97 87.58 90.00

Effective Care 96.17 94.33 95.32 90.00

Friends and Family 89.76 78.95 84.76 90.00

Medication 91.67 95.40 93.42 90.00

Other 91.81 92.00 91.90 90.00

Privacy and Dignity 96.57 98.18 97.32 90.00

Safety 95.99 95.75 95.88 90.00

Single Sex 96.14 100.00 97.93 100.00

Theme

Improvement / Deterioration since April to June 2015 position (Movement arrows show improvements / deterioration above 5 points)

Inpatient Score (out of 100, 100 being positive)

Target


Patient Experience Community July to September 2015Adult Mental

HealthComplex Care

Specialist

Services

Local

Services

Low Secure,

Medium Secure

and Offender

Health

Secure

ServicesAll Services

Number of responses 122 32 87 241 0 0 241

Target number of responses 156 18 18 192

% of responses target achieved #DIV/0! #DIV/0! #DIV/0! 154% 0% 0% 126%

Adult Mental

HealthComplex Care

Specialist

Services

Local

Services

Low Secure,

Medium Secure

and Offender

Health

Secure


OVERALL SCORE (Excluding Carers) 90.73 92.27 95.46 92.58 92.58

Access / contact 91.89 93.44 97.00 93.93 93.93

Care and treatment / diagnosis 90.98 88.36 94.81 92.02 92.02

Care plan 88.80 93.23 95.40 91.77 91.77

Carers (Not RAG rated) 68.44 73.44 70.69 69.92 69.92

Day to Day Living 85.66 96.43 89.92 88.30 88.30

Effective Care 90.16 93.75 95.40 92.53 92.53

Friends and Family Test 87.54 91.25 94.25 90.46 90.46

Medication 94.65 97.47 97.57 95.94 95.94

Other 82.58 87.50 95.06 87.71 87.71

Privacy and Dignity 98.63 95.83 99.23 98.48 98.48

Adult Mental

HealthComplex Care

Specialist

Services

Local

Services

Low Secure,

Medium Secure

and Offender

Health

Secure


OVERALL SCORE (Excluding Carers) -1.82 -1.91

Access / Contact -0.83 -0.99

Care and Treatment / Diagnosis -1.79 -1.86

Care Plan -2.67 -2.72

Carers

Day to Day Living -5.32 -5.58

Effective Care -2.71 -2.85

Friends and Family 0.38 0.69

Medication 1.58 1.38

Other -2.37 -2.10

Privacy and Dignity -0.86 -0.88

Community patient experience survey results (Target 90%)

Theme

Theme

Score (Out of 100, 100 being positive)

Improvement / Deterioration since April to June 2015 position (Movement arrows show improvements / deterioration above 5 points)


Theme Local Services Secure Services All Services

Number of responses 241 241

Target number of responses 156 192

% of responses target achieved 154% 126%

OVERALL SCORE (Excluding Carers) 92.58 92.58 90.00

Access / Contact 93.93 93.93 90.00

Care and Treatment / Diagnosis 92.02 92.02 90.00

Care Plan 91.77 91.77 90.00

Carers 69.92 69.92 N/A

Day to Day Living 88.30 88.30 90.00

Effective Care 92.53 92.53 90.00

Friends and Family 90.46 90.46 90.00

Medication 95.94 95.94 90.00

Other 87.71 87.71 90.00

Privacy and Dignity 98.48 98.48 90.00

Local Services Secure Services Trust Wide

Target by

31 March

2015

(95%)

January to March 2014 (baseline) 90.94 87.02 90.10 95.00

April to June 2014 93.39 91.06 92.88 95.00

July to September 2014 92.78 92.02 92.64 95.00

October to December 2014 93.19 94.20 93.43 95.00

January to March 2015 93.41 91.41 92.89 95.00

April to June 2015 94.70 93.07 94.04 95.00

July to September 2015 92.47 95.39 93.40 95.00

To be rated as green need to hit the 95% target, amber demonstrates a position above or equal to 90% and red anything below 90%.

Target


Community Score (out of 100, 100 being positive)

80.00

82.00

84.00

86.00

88.00

90.00

92.00

94.00

96.00

98.00

100.00

January toMarch 2014(baseline)

April to June2014

July toSeptember 2014

October toDecember 2014

January toMarch 2015

April to June2015

July toSeptember 2015


Local Services Secure Services Trust Wide Target by 31 March 2015 (95%)



Local

Services

Division

Secure DivisionTrust

WideGoal

Nov 12 51% 66% 55% 100%

Jun 13 62% 74% 67% 100%

Aug 13 68% 69% 68% 100%

Sep 13 69% 78% 72% 100%

Oct 13 69% 79% 73% 100%

Nov 13 75% 82% 77% 100%

Dec 13 76% 77% 76% 100%

Mar 14 79% 84% 81% 100%

Jun 14 77% 86% 80% 100%

Sep 14 78% 88% 80% 100%

Dec 14 79% 86% 81% 100%

Mar 15 79% 89% 82% 100%

Jun 15 82% 93% 85% 100%

Sep 15 82% 90% 85% 100%

Local

Services

Division

Secure DivisionTrust

WideGoal

Sep 13 49% 76% 51% 100%

Oct 13 55% 76% 56% 100%

Nov 13 61% 76% 62% 100%

Dec 13 67% 76% 68% 100%

Mar 14 68% 79% 69% 100%

Jun 14 71% 79% 72% 100%

Sep 14 73% 79% 73% 100%

Dec 14 74% 92% 75% 100%

Mar 15 72% 92% 72% 100%

Jun 15 77% 92% 77% 100%

Sep 15 76% 92% 77% 100%

RAG rating from June 2014: If increase or maintenance observed then RAG will be green; otherwise it

will be red.

RAG rating from June 2014: If increase or maintenance observed then RAG will be green; otherwise it

will be red.

Triangle of Care Inpatients (Goal to increase compliance from March 2014 baseline figure towards 100%

aspiration)

Triangle of Care Community (Goal to increase compliance from March 2014 baseline figure towards 100%

aspiration)

Triangle of Care Page 13 of 14

40%

50%

60%

70%

80%

90%

100%

Nov12

Jun13

Aug13

Sep13

Oct13

Nov13

Dec13

Mar14

Jun14

Sep14

Dec14

Mar15

Jun15

Sep15

Triangle of Care Inpatients (Goal to increase compliance from March 2014 baseline figure towards 100% aspiration)

Local Services Division Secure DivisionTrust Wide Goal

40%

50%

60%

70%

80%

90%

100%

Sep13

Oct 13 Nov13

Dec13

Mar14

Jun 14 Sep14

Dec14

Mar15

Jun 15 Sep15

Triangle of Care Community (Goal to increase compliance from March 2014 baseline figure towards 100% aspiration)

Local Services Division Secure DivisionTrust Wide Goal

Triangle of Care Page 14 of 14

Performance and Investment Committee B1 / Attachment 2

Executive Committee: B2 / Attachment 2

Page 1

Report provided (check necessary boxes): Paper No: Care at a glance supporting paper

To Note: ☒ For Assurance: ☒ Report to: Executive Committee

For Decision: ☐ For Consent: ☐ Meeting Date: 17 December 2015

Safer Staffing Report

Accountable Director(s): Ray Walker, Executive Director of Nursing Report Author(s): Helena McCourt, Deputy Director of Nursing/Director of Infection

Prevention Control

Alignment to the Trust’s Strategic Objectives: (listed by the 4 Strategic Aims)

Our Services

☒ Safe care ☒ Timely care ☒ Effective care

☒ Equitable care ☒ Person-centred care

Our People ☐ Supportive and effective teams ☐ A productive workforce with

the right skills ☐ Working side by side with service users and users

Our Resources ☒ Save time and money ☐ Buildings that work for us ☐ Technology that helps us

provide better care

Our Future ☐ Work effectively with primary care and other organisations ☐

Deliver the benefits of research and innovation in patient care

☐ Grow our services

Purpose of Report:

• The purpose of this report is to provide a briefing to the executive committee on the nursing inpatient staffing levels for the month of November 2015.

Summary of Key Issues:

• This paper provides details of inpatient staffing level fill rates during November 2015.

• The Secure Division reports an improvement in the number of occasions when there was less staff than clinically required. The Local Division report a slight deterioration in their position.

• The paper highlights the main reasons for variance and impact on safety and experience.

• Divisional action plans are in place and are subject to scrutiny at quality surveillance groups and stand up Thursday forums.

Recommendation:

The committee is asked to: 1) Discuss the Trust’s approach to safe staffing 2) Note that staffing levels reports will be discussed in the

divisions at team level and at governance board level on a monthly basis.

3) Note that both divisions have action plans to address reasons for shortfall.

Next Steps: (Subject to recommendation being accepted)

A review of the standards for safe wards has commenced and will inform the revised self assessment framework.



Page 2

Previously Presented to:

Committee Name Date (Ref) Title of Report Outcome / Action

Do the action(s) outlined in this paper impact on any of the following issues? Area Yes None If ‘Yes’, outline the consequence(s) (providing further detail in the report)

Patient Safety ☒ ☐

Clinical Effectiveness ☒ ☐ There is a risk that there may be a delay to inpatients

achieving their goals/having needs met in a timely manner

Patient Experience ☒ ☐ There is a risk that patient experience will be adversely

affected

Operational Performance ☐ ☐

CQC Compliance ☐ ☐

NHS TDA Ratings ☐ ☐

Legal / Requirements ☐ ☐

Resource Implications (financial or staffing) ☐ ☐

Equality and Human Rights Analysis Yes No N/A

Do the issue(s) identified in this document affect one of the protected group(s) less or more favourably than any other? ☐ ☒ ☐

Are there any valid legal / regulatory reason(s) for discriminatory practice? ☐ ☐ ☒ If answered ‘YES’ to either question, please include a section in the report explaining why

Does this paper provide assurance in respect of delivery of our Equality Delivery System goals and objectives (if it does please click the appropriate ones below)

EDS 1.2 - Individual people’s health needs are assessed and met in appropriate ways ☐

EDS 1.4 – When people use NHS services their safety is prioritised and they are free from mistakes, mistreatment and abuse

☐

EDS 2.2 – People are informed and supported to be as involved as they wish to be in decisions about their care

☐ EDS 2.3 – People report positive experiences of the NHS ☐

Does this paper provide assurance in respect of a new / existing risk (if appropriate)

Area New Existing N/A If new or existing, please indicate where the risk is described

Type of Risk ☐ ☒ ☐ Board Assurance & Escalation Framework ☐ Organisational

Risk Register ☐ Divisional Risk Register ☒

Risk Reference / Description: (only include reference to the highest level framework / register)

There is a risk that when staffing is below that expected, not all aspects of care will be met. This may result in a suboptimal experience and delays in achieving identified goals. There is a risk to staff development/supervision with potential impact on staff performance and wellbeing.



Page 3

MERSEY CARE NHS TRUST

Safer Staffing Report PURPOSE 1. The purpose of this report is to provide a briefing to the committee on the nursing

inpatient staffing levels for the month of November 2015.

2. This paper provides assurance that we are regularly reviewing and monitoring our inpatient staffing levels.

WARD REPORTING 3. Each of the 41 wards across the trust has a planned number of registered and

unregistered nurses. The budgeted planned number of staff is reviewed every six months with agreement from clinical managers on the required numbers.

4. From April 2015 we have been mapping our actual levels against budgeted planned levels as requested by the Trust Development Authority and NHS England. This is to support appropriate national benchmarking. Table 1 refers. Table 1: Summary of BUDGETED PLANNED VERSUS ACTUAL

DAY

NIGHT

Month Average fill

rate percentage

REGISTERED

Average fill rate

percentage UNREGISTERED

Average fill rate

percentage REGISTERED

Average fill rate percentage

UNREGISTERED Trust Total

Sept 95.7% 101.1% 93.7% 115.1% 101.42%

Oct 97.7% 103.5% 96.8% 116.9% 103.8%

Nov 97.4% 105.5% 93.9% 119.6% 104.7%

5. As a Trust we agreed to continue to report on our actual staffing levels against

clinically required staffing levels as this provides more transparency and highlights the requirement to support unplanned care. Table 2 overleaf refers.



Page 4

Table 2: Summary of CLINICALLY REQUIRED VERSUS ACTUAL

DAY

NIGHT

Month Average fill

rate percentage

REGISTERED

Average fill rate

percentage UNREGISTERED

Average fill rate

percentage REGISTERED

Average fill rate percentage

UNREGISTERED Trust Total

Sept 90.8% 95.0% 90.6% 99.6% 94.4%

Oct 95.0% 98.8% 94.1% 104.7% 98.5%

Nov 95.1% 98.4% 91.7% 102.5% 97.7%

6. As requested by divisions the percentage of occasions when less staff than clinically

required is presented in table 3.

Table 3 - Percentage of occasions

Less staff than clinically required

% Trend

LOCAL September 22.45%

October 13.27%

November 16%

SECURE

September 39.74%

October 24.06%

November 21%



Page 5

7. The following graphs highlight the main reasons for shortfall and the impact on experience. REASONS FOR SHORTFALL

8. Both divisions have recruitment plans in place and are in the process of filling all vacant posts. The Local Division reports an improved position in the bank meeting staffing requirements (unfilled shifts) and in the number of staff suspended. Staff sickness continues to increase in both divisions. The Secure Division reports a decrease in the bank meeting staffing requirements (unfilled shifts) and an increase in sickness and staff suspensions. Their recent recruitment strategies have addressed their vacancy levels.

* % Sickness is the average of each wards sickness percentage ** Staff suspensions is the number of staff suspensions

-5

5

15

25

35

45

Apr May Jun Jul Aug Sept Oct Nov Dec Jan Feb Mar

% o

r num

ber

Reason - Local Division % Vacancies % Unfilled shifts% Sickness* Staff Suspensions **



Page 6

* % Sickness is the average of each wards sickness percentage ** Staff suspensions is the number of staff suspensions

9. The graphs below highlight the reasons for requesting additional staff from the bank. For the local division there is a reported reduction in meeting vacancy requirements and an increase in sickness and additional observations. The Secure division reports an improvement in all areas.

-5

5

15

25

35

45


% o

r num

ber

Reason - Secure Division % Vacancies % Unfilled shifts% Sickness* Staff Suspensions **

0

100

200

300

400

500

600

700

800

May Jun Jul Aug Sep Oct Nov

No.

Shi

fts C

over

ed

Extract of bank shifts filled by reason Local Division

Sickness Additional observations Escorts Vacancies



Page 7

0

100

200

300

400

500

600

700

800

May Jun Jul Aug Sep Oct Nov

No.

Shi

fts C

over

ed

Extract of bank shifts filled by reason Secure Division

Sickness Additional observations Escorts Vacancies



Page 8

10. The following graphs highlight the percentage of complaints relating to staffing and the percentage of incidents which resulted in harm. The Local Division reports an increase in complaints relating to staffing and a decrease in the percentage of incidents where harm was caused. The Secure Division reports a decrease in complaints relating to staffing and slight increase in incidents where harm was caused.

-5

5

15

25

35

45

55


%

Impact - Local Division % Complaints relating to staffing% Incidents where harm caused

-5

5

15

25

35

45

55


%

Impact - Secure Division % Complaints relating to staffing% Incidents where harm caused



Page 9

11. The Patient tracker system captures the experience of service uses on a monthly basis. The following graph highlights access to staff, access to activities and overall perception of safety. These results continue to indicate a relatively consistent score of over 90% and within the threshold identified for a RAG rated green for both divisions.

Assumption made that all of the data has been produced consistently and for ward nurse staffing only.

80

85

90

95

100


%

% Patient experience - Local Division % Access / contact % Activities % Safety

80

85

90

95

100


%

% Patient experience - Secure Division % Access / contact % Activities % Safety



Page 10

STAFF EXPERIENCE

12. The SharePoint system for the capture of fill rates has also allowed for the recording of data specific to staff experience. The nurse in charge records the total number of occasions when staff shortage impacted on staff experience. This is the professional judgment of the nurse in charge of each shift and is confirmed by the ward manager. The reported impact on staff experience shows an improved position in all areas with the exception of mentorship in both divisions and breaks cancelled in the secure division. Table 4 - Reported impact on Staff experience

Breaks

cancelled

Trend PACE

Reviews deferred

Trend

Student mentor-

ship affected

Trend Supervision cancelled Trend

LOCAL

September 91 17 3 41

October 66 9 3 27

November 61 7 6 25

SECURE

September 74 68 8 131

October 53 33 29 131

November 61 19 50 108

MONITORING

13. Staff shortages are actively discussed at many levels of the organisation, in addition to the Executive, Performance and Investment and Quality Assurance Committees, safe staffing is regularly reviewed at the divisions operational forums; in particular: a) The weekly quality surveillance group continues to receive a monthly report and

provides further scrutiny in response to any concerns. b) Staffing issues have been presented at the Stand up Thursday executive meeting

which further scrutinises staffing concerns. c) Both divisions hold a weekly quality surveillance group and report on all staffing

levels issues. d) The quality review visits continue to monitor staffing levels and requirements on

clinical areas at each review.



Page 11

ACTIONS IN TRAIN

14. Both Divisions have a detailed action plan and are addressing impact and reasons for

shortfall.

15. The local division continues to recruit to vacancies and both divisions to the additional staffing required for the divisional staffing pools.

16. A deep dive has commenced to confirm the number of starters and leavers and

consequences for staffing levels.

17. The safer staffing steering group has set terms of reference to outline future work in relation to continuously refining approaches to mapping and reporting staffing levels and developing a system to support mapping indicators for safe wards. RECOMMENDATION

18. The Committee is asked to:

a) Discuss the Trust’s approach to safe staffing b) Note that staffing level reports will be discussed in the divisions at team level and

at governance board level on a monthly basis. c) Note that both divisions have action plans to address reasons for shortfall.

RAY WALKER EXECUTIVE DIRECTOR OF NURSING 0151 473 2965



Page 12

Appendix A

Clinically required against actual November 2015

Rag Rating >=100% Green >=90% Amber <90% Red

DAY Night

Ward name

Average fill rate -

registered nurses/

midwives (%)

Average fill rate -

care staff (%)

Average fill rate -

registered nurses/

midwives (%)

Average fill rate -

care staff (%)

SECU

RE

Arnold 82.50% 106.31% 70.16% 148.19%

Allerton 70.69% 117.61% 172.65% 82.80%

Childwall 95.69% 94.12% 56.83% 155.17%

Blake 92.89% 100.98% 73.25% 176.64%

Carlyle 107.70% 93.10% 100.00% 107.10%

Dickens 107.44% 88.72% 98.58% 102.24%

Forster 102.19% 78.45% 100.00% 89.69%

Gibbon 96.55% 96.55% 103.55% 101.77%

Johnson 71.55% 112.74% 73.91% 156.70%

Keats 81.57% 105.72% 81.00% 129.91%

Lawrence 81.44% 103.08% 74.07% 145.16%

Macaulay 81.61% 102.96% 100.00% 113.87%

Ruskin 115.52% 84.89% 100.00% 100.00%

Shelley 113.79% 91.38% 77.62% 120.97%

Tennyson 82.76% 105.84% 87.92% 107.10%

Hawthorn 101.72% 104.00% 113.81% 131.60%

Ivy 115.00% 108.68% 74.93% 139.32%

Myrtle 89.17% 103.85% 103.20% 98.27%

Olive 95.83% 102.54% 116.53% 91.60%

Poplar 93.97% 105.28% 94.80% 102.17%

Reed Lodge 131.56% 108.77% 106.91% 100.00%

Secure Total 91.97% 100.73% 89.13% 114.74%



Page 13

Ward name

Average fill rate -

registered nurses/

midwives (%)

Average fill rate -

care staff (%)

Average fill rate -

registered nurses/

midwives (%)

Average fill rate -

care staff (%)

Loca

l

Boothroyd 100.00% 94.51% 100.00% 96.00%

Albert 100.00% 93.40% 100.00% 94.86%

Brunswick 100.00% 96.49% 100.00% 98.45%

Harrington 100.00% 95.97% 100.00% 96.61%

Alt 100.00% 97.65% 100.00% 98.87%

Dee 100.78% 89.91% 96.52% 90.94%

Irwell 94.27% 95.20% 100.00% 93.26%

Morris 106.51% 92.31% 100.00% 96.43%

Newton 96.72% 95.19% 56.67% 97.20%

Park/Rowbotham 96.55% 91.57% 100.00% 86.94%

Heys Court 83.62% 105.17% 103.59% 100.00%

Kevin White Unit 100.00% 100.00% 100.00% 100.00%

Acorn Ward 93.22% 97.48% 100.00% 100.00%

Brain Injury Unit 128.33% 98.83% 100.00% 100.00%

Oak Ward 116.94% 86.75% 100.00% 93.10%

STAR Unit 79.69% 109.21% 100.00% 110.76% Rehabilitation

Centre 95.66% 98.22% 96.69% 96.60%

Wavertree Bungalow 115.52% 91.38% 100.00% 100.00%

Windsor Clinic 100.00% 100.00% 100.00% 100.00%

Windsor House 100.00% 95.26% 100.00% 98.25%

Local Total 99.37% 95.80% 95.41% 96.57%

Trust Total 95.10% 98.41% 91.73% 102.51%

Overall Total 97.72%

of 4

Performance and Investment Committee: B1 / Attachment 3


Contracts Update – M8 2015/16 (30 November 2015)

Contract Issues

1. The trust continues to meet on a monthly basis with Liverpool CCG and South Sefton CCG commissioners to review progress in relation to improving A&E waiting times at Aintree Hospital. The most recent meeting took place on 19 November 2015. Commissioners were satisfied with progress to date against the trust’s remedial action plan (RAP). The next meeting has been arranged for 21 December 2015.

2. The RAP relating to Talk Liverpool under performance is also being updated and discussed on a monthly basis via the contract meetings with Liverpool CCG. There has been a deterioration in performance of the key indicators for the Talk Liverpool service in month eight. The trust expects this to result in commissioners imposing financial sanctions as per the conditions in the contract.

The trust can therefore expect sanctions of £31,200 for November’s under performance, but monthly sanctions will continue until performance improves. A full list of red and amber indicators can be found in Appendix 1, and a breakdown of expected sanctions is found in Appendix 2.

3. The trust has completed an exercise to rebase activity plans on a cluster basis, in line with national guidance. The rebased plans have been shared with local commissioners and further discussions are taking place. The local division has completed initial data cleansing work and identified actions are expected to be completed by the end of February 2016.

4. The trust has not yet signed its contract with NHS Wales for High Secure Services; this is still awaited from commissioners. The Contracts Team is continuing to chase up the documentation however payment is being received for the service. NHS Wales have advised that the delay is due to administrative issues rather than any problem with the contract itself.

Contracts Update

5. Contract negotiations for 2016/17 have begun with Liverpool CCG and with South Sefton CCG and Associates. Planning guidance for 2016/17 is awaited from NHS England, however the trust and commissioners are planning on the basis of contract sign-off by 28 February 2016.

6. Commissioning intentions have not yet been published by local commissioners, however Sefton CCGs have indicated that the Aspergers service will be formally commissioned. The service is currently being provided as a pilot. Street triage, also a pilot, is expected to be commissioned by Sefton in 2016/17.

Commissioner Performance Reporting Update

7. The trust continues to perform well against the majority of the 537 local and secure division contract performance and quality indicators. The exceptions for the most recent reports are included in Appendix 1, these all relate to the local services division, secure services reporting is completed on a quarterly basis. Month 8 performance against quality standards is not yet available.

of 4

CQUIN

8. A full update on quarter two CQUIN performance can be found in Attachment 4 to the Care at a Glance report.

Activity Plan – Month 8 2015/16

9. Activity for month eight is currently unavailable due to issues with data extraction. This is expected by 18th December 2015.

Neil Smith Executive Director of Finance

of 4

Appendix 1

Contract KPIs: Exceptions at Month 8 Local Service Division Contract Key Performance Indicators

Indicator Reference

Performance Area

Performance indicator description Data Period

Target Actual

Local Services KPI 07

Out-Patient Appointments & DNA Rates

Out Patient DNA rates . Percentage of outpatient appointments where the patient DNA a follow up appointment

M8 11% 12.0%


Psychotherapy Psychotherapy. Treatment commencing within 18 weeks of referrals.

M8 95% 27.0%


Eating Disorder Service

Eating Disorder Service. Treatment commencing within 18 weeks of referrals.

M8 95% 89.6%

IAPT KPI 3

Waiting The number of referrals that have been waiting more than 28 days from referral to treatment.

M8 <5% 12%

IAPT KPI 4

Entering Treatment

The number of people who have entered psychological therapies (at the end of the reporting quarter) as a proportion of prevalence.

M8 1118 842

IAPT KPI 6

Recovery

The number of people who are "moving to recovery" (of those who have completed treatment, those who at initial assessment achieved "caseness" and at final session did not) during the reporting quarter.

M8 >50% 32%

IAPT KPI 13

Waiting The number of days from step up to starting treatment in Step 3.

M8 <28 Days 123 Days

IAPT KPI 19

DNA The number of booked appointments that are DNAd

M8 10% 16%

IAPT KPI 20

Cancellations The number of booked appointments that are cancelled (Total)

M8 10% 19%

IAPT KPI 25a

Follow ups The number of treatment sessions received after assessment - step 2

M8 Overall = 6 4

IAPT KPI 25b

Follow ups The number of treatment sessions received after assessment - step 3

M8 Overall = 6 7

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Appendix 2 IAPT KPIs: Expected Financial Sanctions for Under Performance Trigger Sanction Limit Month 8

Performance Expected Sanction Month 8 (£)

Failure to achieve target: 95% of referrals to wait less than 28 days from referral to treatment.

2% of the actual monthly value or £200 in respect of each excess breach above 5% threshold, whichever is the lesser.

£200 per breach per month

36 breaches above 5% threshold

£7,200

Failure to achieve annual target of 13,650 people (based on 16% of prevalence) entering psychological therapies as a proportion of prevalence.

2% of actual monthly value to be withheld of monthly performance is below target, monies will be retained if annual target is not met

2% of actual monthly value for duration of breach

842 in m8 against phased target of 1118

£8,000

Failure to achieve target of 50% of people who are "moving to recovery" during the reporting quarter.



32% against target of 50%

£8,000

Failure to achieve target: people to wait less than 28 days from step up to starting treatment in Step 3.



Mean wait of 123 days against target of 28 days

£8,000

Expected Financial Sanction for Month 8 £31,200

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CQUIN PERFORMANCE UPDATE Q3 2015/16

(November 2015) OVERVIEW OF 2015/16 CQUIN 1. In 2015/16 the trust has five main contracts, each of which has its own CQUIN scheme(s). In addition,

Liverpool CCG has a separate IAPT contract which also includes a CQUIN. The total available CQUIN funding for 2015/16 is £4,418,112. The financial breakdown of the 2015/16 CQUIN schemes is shown in Table 1:

Table 1 - 2015/16 CQUIN Schemes

Scheme 2015/16 Goals

2015/16 full allocation £

Q1 allocation profile £




Local Services (Liverpool CCG) Incl. IAPT 7 1,577,329 331,668 360,813 408,906 475,942

Local Services (South Sefton CCG and Associates)

7 778,883 114,495 139,421 161,229 363,738

Addictions Services 4 111,657 27,913 27,914 27,915 27,915 High Secure Services* 4 935,232 233,808 233,808 233,808 233,808 Medium and Low Secure Services 4 1,015,011 54,134 189,468 54,134 717,275

Overall 26 4,418,112 762,018 951,424 885,992 1,818,678 *NHS Wales' financial values, included under High Secure Services above, are still awaiting confirmation from commissioners.

QUARTER 2 CONFIRMED PERFORMANCE

2. Quarter 2 (Q2) CQUIN performance has now been confirmed by commissioners. Across the trust, all Q2 milestones were achieved, apart from the Local Division’s National Physical Health CQUIN Part 2 - (Communication with GPs) - indicator, which failed to achieve the set target for the audit carried out in Q2. The financial implication is that £44,725 will need to be returned to Local Commissioners, (£29,147 to Liverpool CCG and £15,578 to South Sefton CCG and Associates).

3. An outline of the financial values attached to each aspect of the Trusts 2015/16 CQUIN schemes is highlighted in Appendix 1 for reference.

QUARTER 3 FORECASTED PERFORMANCE 4. The trust is due to report Q3 performance to commissioners in January 2016. Based on a current

assessment by the CQUIN leads, the Q3 forecast position and potential financial impact is summarised below in Tables 2 and 3. The Q1 and Q2 ratings are also included for ease of reference:

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Table 2 – Secure Division CQUIN Schemes: Forecasted Performance for Quarter 3 Financial Milestones

Scheme

Q1 RAG Rating (& total

schemes involved)


schemes involved)

Q3 RAG Rating at

15.12.2015 (& total

schemes involved)

High Secure Q3 allocation

£

Low and Medium

Secure Q3 allocation

£

Q3 total allocation

£

2015/16 full allocation

£

National Physical Health 1 1 1 54,134 54,134 270,670

Collaborative Risk Assessment 1 1 1 0 0 406,005

Supporting Carer Involvement 1 1 1 0 0 270,670

Supporting Service Users to Stop Smoking 1 1 1 0 0 67,667

Supportive Observations 1 1 1 58,452 58,452 233,808

Long Term Segregation 1 1 1 58,452 58,452 233,808

Healthy Lifestyles – Patients Shop 1 1 1 58,452 58,452 233,808

Carer Involvement 1 1 1 58,452 58,452 233,808

Overall 8 8 8 233,808 54,134 287,942 1,950,244 Table 3 – Local Division CQUIN Schemes: Forecasted Performance for Quarter 3 Financial Milestones

Scheme


schemes involved)


schemes involved)

Q3 RAG Rating as

at 15.12.2015

(& total schemes involved)

Liverpool CCG Q3

allocation £

Sefton CCG Q3

allocation £

Q3 total allocation

£

2015/16 full allocation

£

National Physical Health 2 2 2 23,317 12,462 35,779 223,621

National Urgent Care 2 2 2 72,866 38,945 111,811 447,242

Improving Youth Mental Health & Learning Disabilities Services (CAMHS)

2 2 2 43,720 19,472 63,192 252,767

Collaborative Working 2 2 2 139,904 74,773 214,677 715,587

Local Physical Health (Liverpool only) 1 1 1 58,293 58,293 233,173

Digital Maturity (Liverpool only) 1 1 1 40,805 40,805 145,733

IAPT – Accreditation Programme for Psychological Therapies (ATTPS) (Liverpool only)

1 1 1 30,000 30,000 120,000

Liverpool Public Health (Addictions) 4 4 4 27,915 27,915 111,658

Mental Health Tariff Cluster Specifications (PbR) (Sefton only)

1 1 1 15,578 15,578 62,311

Advancing Quality (Sefton only) No milestones in Q1

No milestones in Q2

No milestones in Q3 0 0 155,776

Overall 16 16 16 436,728 161,230 598,050 2,467,868

5. National Physical Health CQUIN: Part 1 - (Cardio Metabolic Assessment for Patients with Schizophrenia): The local division has identified issues with data recording which may mean that it is unable to meet the end of the year target for the National Royal College of Schizophrenia (RCPsych) audit. The financial impact, based on a sliding scale of payment, is that a maximum of £107,388 would

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need to be returned to local commissioners for Q4 performance should we fail to achieve the minimum requirement. A physical health action plan has been put in place by the local division to resolve the identified issues.

6. Local Physical Health CQUIN – The local division in Liverpool has highlighted concerns regarding data recording, which may mean that Q3 and Q4 targets may not be met. The physical health CQUIN lead and project team are meeting regularly in order to resolve the issues and are meeting with local commissioners to discuss a change in reporting requirements. The financial impact for underachievement would be that a maximum of £58,293 may need to be returned to Liverpool CCG for Q3 and a further £58,293 for Q4.

7. Advancing Quality (AQ) Early Intervention in Psychosis:

Appropriate Care Score (ACS) - There is a time lag in reporting performance due to the upload of population data into the AQ reporting tool. New measures are also coming into effect from October 2015 in relation to Psychological Needs Assessment. Processes are currently being identified with trust psychological leads, to identify populations early and highlight any area of concern, to ensure solutions are put in place within the required time frames to resolve issues going forward. Data Completeness – Data completeness (which does not affect the ACS), relating to the outcome measure may also be an issue, due to problems establishing this within the trust initially. Systems are now established within the teams and performance has since improved. However due to the initial problems, it is unlikely that the 95% completion rate will be achieved for this measure by the end of Q4.

In addition to the above concerns, AQuA have recently confirmed psychosis measures will cease being collected at the end of this fiscal year, therefore the final data collection will take place in January 2016. This will result in a two month gap at the end of the year, making achievement of the target more difficult. Discussions are being held with AQuA to clarify achievement based on a revised, shortened reporting year, and commissioners have been advised. There are no financial implications during Q3, as full payment is allocated against Q4 reporting. Should the trust fail to achieve Q4 milestones, the maximum financial impact is that £124,621 would need to be returned to South Sefton CCG and Associates.

8. More detailed information is shared with the local and secure divisional boards. Within the local division, monthly CQUIN performance meetings are taking place in order to monitor any issues.

Donna Porter Acting CQUIN Co-ordinator 15 December 2015

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Appendix 1 Back to Section 3 Local Division 2015/16 CQUIN Schemes: M8 Update

Scheme: Aspect: 2015/16 Full allocation £

Q1 allocation £

Q2 allocation £

*Q3 allocation £

Q4 allocation £

L'pool Sefton TOTAL L'pool Sefton TOTAL L'pool Sefton TOTAL L'pool Sefton TOTAL L'pool Sefton TOTAL

National Physical Health (£223,621)

Cardio Metabolic Assessment 116,586 62,310 178,896 23,317 12,462 35,779

Not applicable

Not applicable 0 23,317 12,462 35,779 69,952 37,386 107,338

GP Communication 29,147 15,578 44,725 Not

applicable Not applicable 0 29,147 15,578 44,725 Not

applicable Not applicable 0 Not

applicable

Not applicable

0

Urgent Care (£447,242)

Reducing A&E Attendance 174,880 93,466 268,346 43,720 23,367 67,087 43,720 23,367 67,087 43,720 23,367 67,087 43,720 23,367 67,087

Working with Acute Trusts 116,586 62,310 178,896 29,147 15,577 44,724 29,146 15,578 44,724 29,147 15,577 44,724 29,146 15,578 44,724

Collaborative Working 466,345 249,242 715,587 69,952 37,386 107,338 93,269 49,848 143,117 139,904 74,773 214,677 163,220 87,235 250,455 Transitions (CAMHS) 174,879 77,888 252,767 43,720 19,472 63,192 43,720 19,472 63,192 43,720 19,472 63,192 43,719 19,472 63,191 Local Physical Health 233,173 233,173 58,294 58,294 58,293 58,293 58,293 58,293 58,293 58,293

Digital Maturity (£145,733)

Assessment 29,147 29,147 4,372

4,372 4,372 4,372 11,659 11,659 8,744 8,744 LETs 58,293 58,293 14,573 14,573 14,573 14,573 14,573 14,573 14,574 14,574 Interoperability 58,293 58,293 14,573 14,573 14,573 14,573 14,573 14,573 14,574 14,574

IAPT - Accreditation Programme for Psychological Therapies (ATTPS)

120,000 120,000 30,000 30,000 30,000 30,000 30,000 30,000 30,000 30,000

Liverpool Public Health (LCC) (Addictions) (£111,658)

Improving Physical Health 27,915 27,915 6,978 6,978 6,979 6,979 6,979 6,979 6,979 6,979

Dual Diagnosis 44,663 44,663 11,165 11,165 11,166 11,166 11,166 11,166 11,166 11,166

Service User Experience 27,915 27,915 6,978 6,978 6,979 6,979 6,979 6,979 6,979 6,979

Performance & Outcome Measures

11,165 11,165 2,792 2,792 2,791 2,791 2,791 2,791 2,791 2,791

Advancing Quality (£155,776)

Dementia 31,155 31,155 Not applicable 0 Not

applicable 0 Not applicable 0 31,155 31,155

Early Intervention 124,621 124,621 Not applicable 0 Not

applicable 0 Not applicable 0 124,621 124,621

Mental Health Tariff Cluster Specifications (PbR) 62,311 62,311 6,231 6,231 15,578 15,578 15,578 15,578 24,924 24,924

TOTALS 1,688,987 778,881 2,467,868 359,581 114,495 474,076 388,728 139,421 528,149 436,821 161,229 598,050 503,857 363,738 867,595

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Appendix 1 (Cont’d…)

Secure Division 2015/16 CQUIN Schemes: M8 Update

Scheme: Aspect: 2015/16 Full allocation £

Q1 allocation £

Q2 allocation £

*Q3 allocation £

Q4 allocation £

HSS M&LSU TOTAL HSS M&LSU TOTAL HSS M&LSU TOTAL HSS M&LSU TOTAL HSS M&LSU TOTAL

National Physical Health 270,670 270,670 54,134 54,134 Not applicable 0 54,134 54,134 162,402 162,402

Collaborative Risk Assessment 406,005 406,005 Not applicable 0 101,501 101,501 Not

applicable 0 304,504 304,504

Supporting Carer Involvement 270,670 270,670 Not applicable 0 67,666 67,667 Not

applicable 0 203,003 203,003

Supporting Service Users to Stop Smoking (£67,667)

Smoke Free 13,533 13,533 Not applicable 0 6,767 6,767 Not

applicable 0 6,766 6,766

NICE Guidance 27,067 27,067 Not applicable 0 6,767 6,767 Not

applicable 0 20,300 20,300

Continues Cessation 27,067 27,067 Not

applicable 0 6,767 6,767 Not applicable 0 20,300 20,300

Supportive Observations 233,808 233,808 58,452 58,452 58,452 58,452 58,452 58,452 58,452 58,452 Long Term Segregation 233,808 233,808 58,452 58,452 58,452 58,452 58,452 58,452 58,452 58,452 Healthy Lifestyles – Patients Shop 233,808 233,808 58,452 58,452 58,452 58,452 58,452 58,452 58,452 58,452

Carer Involvement 233,808 233,808 58,452 58,452 58,452 58,452 58,452 58,452 58,452 58,452 TOTALS 935,232 1,015,011 1,950,244 233,808 54,134 287,942 233,808 189,468 423,277 233,808 54,134 287,942 233,808 717,275 951,083

TRUST WIDE

2015/16 Full allocation £

Q1 allocation £

Q2 allocation £

*Q3 allocation £

Q4 allocation £

4,418,112 762,018 951,424 885,992 1,818,678

NB: *The Quarter 3 position shown in the above table is the forecasted position and subject to confirmation from commissioners

Access and Outcomes Page 1 of 4

Indicator Construction Target Weighting Q1 2015/16 Q2 2015/16 Q3 2015/16October

Q3 2015/16November

Q3 2015/16 Score Further information

receiving follow-up contact within seven days of discharge

Numerator: the number of people under adult mental illness specialties on CPA who were followed up (either by face-to-face contact or by phone discussion) within seven days of discharge from psychiatric inpatient care. Denominator: the total number of people under adult mental illness specialties on CPA who were discharged from psychiatric inpatient care. Agreed exemptions are detailed in the Risk Assessment Framework.

>=95% 98.21% 98.01% 100.00% 98.81%

having a formal review within 12 months

Numerator: the number of adults in the denominator who have had at least one formal review in the last 12 months. Denominator: the total number of adults who have received secondary mental health services and who had been on CPA for at least 12 months at the end of the reporting period

>=95% 95.93% 96.22% 96.66% 96.01%

This indicator applies only to admissions to the foundation trust’s mental health psychiatric inpatient care. The indicator applies to users of working age (16-65) only, unless otherwise contracted. An admission has been gate-kept by a crisis resolution team if they have assessed the service user before admission and if they were involved in the decision-making process, which resulted in admission. Agreed exemptions are detailed in the Risk Assessment Framework.

>=95% 1.0 98.90% 99.24% 100.00% 97.14% 0.0

Quarterly performance against commissioner contract year to date. Threshold represents a minimum level of performance against contract performance, rounded down.

95% 1.0 97.44% 98.72% 98.90% 94.23% 1.0

Reasons for underperformance are being investigated with the information team and service.

Methodology to be confirmed. >=50% 1.0 Not due Not due Not due Not due Not due

People with common mental health conditions referred to the IAPT programme will be treated within 6 weeks of referral

Numerator and Denominator: To be reported in line with the latest technical guidance issued by NHS England and the HSCIC

>=75% 1.0 Not due Not due 91.84% 94.69%



>=95% 1.0 Not due Not due 99.21% 99.82%

Numerator: the number of non-acute patients (aged 18 and over on admission) per day under consultant and non-consultant-led care whose transfer of care was delayed during the quarter. For example, one patient delayed for five days counts as five.Denominator: the total number of occupied bed days (consultant-led and non-consultant-led) during the quarter.Delayed transfers of care attributable to social care services are included.

<=7.5% 1.0 1.02% 1.42% 2.59% 2.92% 0.0

Data completeness is assessed for each constituent part: NHS number, Date of Birth, Postcode (normal residence), Gender, Registered General Medical Practice Organisation Code, Commissioner Organisation Code.

>=97% 1.0 99.02% 99.22% 99.28% 99.25% 0.0

Aggregate performance based on average of each constituent part: Employment Status, Settled Accommodation Status and HoNOS assessment.

>=50% 1.0 87.83% 86.14% 88.22% 87.78% 0.0

Meeting the six criteria for meeting the needs of people with a learning disability, based on recommendations set out in Healthcare for All (DH, 2008)

Fully compliant 1.0 Fully

CompliantFully

CompliantFully

CompliantFully

Compliant 0.0

0.0 0.0 0.0 1.0 1.0

Key:GreenRed


B1 / Attachment 5Performance and Investment Committee:

Score

AC

CES

SO

UTC

OM

ES

Improving access to psychological therapies (IAPT). To be reported on from Quarter 3 2015/2016

Early intervention in Psychosis (EIP): People experiencing a first episode of psychosis treated with a NICE approved care package within two weeks of referral. To be reported on from Quarter 4 2015/16

Score >=4.0 OR one or more indicators has underperformed for three consecutive quarters.Score <4.0 AND no single indicator has underperformed for three consecutive quarters.

Monitor Risk Assessment Framework - Governance: Access and Outcome Metrics

Service Performance Indicators

Self Certification on access to healthcare for people with LD

1.0

Data Completeness: outcomes (MHLDDS)

Care Programme Approach (CPA) patients, comprising either:

Admissions to inpatient services had access to crisis resolution home treatment teams

New cases of EI (100% against contract requirements YTD)

0.0

Data Completeness: identifiers (MHLDDS)

Minimising Delayed Transfers of Care

0.0

Organisational Health Page 2 of 4

Q1 2015/16 Q2 2015/16 Q3 2015/16October

Q3 2015/16November

No No No No

No No No No

Third party reports Yes Yes Yes Yes

No No No No

No No No No

No No No No

No No No No

12.65% 12.96% 13.18% 13.41%

No No No No

4.11% 4.14% 4.14% 4.14%

No No No No

Q2 2015/16 position is based the rolling twelve months position of 6.03% (1 December 2015 to 30 November 2015)

In month November 2015 value = 10.87%. Year to date = 10.76%.

CQC judgementGovernance concern triggered by CQC warning notice issued.

Governance concern triggered by civil and / or criminal action initiated.

Material increase in proportion of temporary staff (benchmark 2014/15 - 11.13% based on percentage of paybill spent on agency and bank).

Quality governance

Material reduction in patient satisfaction based on "overall" section score (annual community mental health service user survey)

High executive team turnover

Material reduction in staff satisfaction (annual national staff survey)

Material increase in staff sickness / absence rate (compared to previous financial year - 5.63% for 2013/14 used for reporting in 2014/15, revised benchmark is 5.64% in 2015/16)

Material increase in staff turnover (benchmark 2013/14 - 12.65% based on FTE (used for reporting in 2014/15), revised benchmark 11.22% for 2014/15 based on FTE)

Monitor Risk Assessment Framework - Governance: Organisational Health Indicators

There has been one new "third party concern" reported in November 2015 in relation to a confidentiality breach. A list containing service user data was posted onto a ward notice board by a member of the nursing team within the secure division. A complaint was made by a service user that this was a breach of confidentiality. The notice was subsequently removed. This incident was reported to the Information Commissioner Officer on 25 November 2015. The incident was closed on 27 November 2015 by the Information Commissioner Officer with no further action required. The third party concern reported in September 2015 regarding the contract performance notices is ongoing.

Element Indicator Further information

Adhoc reports from GMC, the Ombudsman, Commissioners, Healthwatch England, Auditor Reports, Health and Safety Executive, Patient Groups, Complaints, Whistleblowers, Medical Royal Colleges etc.

The increase in staff turnover in Q1 2015/16 is as a result of delayed MARS and the transfer of HMP Liverpool staff to Lancashire Care. The workforce directorate have been asked to review the reasons for the continuing increases in turnover.

Performance in the 2014/15 annual national staff survey was broadly consistent with the previous year's results. Next update due March 2016.

Figure quoted is year to date actual (November 2015). Aggressive cost reduction plans (i.e. in excess of 5% in any given year)

Continuity of services risk rating Breach of any continuity of services licence condition as a result of governance

At the start of 2015, a questionnaire was sent to 850 people who received community mental health services. Responses were received from 230 people at Mersey Care NHS Trust. Overall there has been no material deterioration in our scores between 2014 and 2015 with them all remaining at either "maintained" or "improved". Next update is due October 2016.

Data Completeness - Breakdown Page 3 of 4

Data Completeness Identifiers

Indicator Indicator Construction Q1 2015/16 Q2 2015/16

Q3 2015/16October

Q3 2015/16November

GP practice complete Numerator: count of valid entries Denominator: total number of entries. 97.89% 97.78% 98.09% 97.95%

Post code complete Numerator: count of valid entries Denominator: total number of entries. 98.84% 98.83% 98.88% 98.85%

DOB complete Numerator: count of valid entries Denominator: total number of entries. 100.00% 100.00% 100.00% 100.00%

Gender complete Numerator: count of valid entries Denominator: total number of entries. 100.00% 100.00% 100.00% 100.00%

Organisation code of commissioner complete Numerator: count of valid entries Denominator: total number of entries. 98.95% 98.94% 98.98% 98.96%

NHS Number Complete Numerator: count of valid entries Denominator: total number of entries. 98.42% 99.78% 99.76% 99.76%

http://www.hscic.gov.uk/mhldsmonthly

Data Completeness Outcomes

Indicator Indicator Construction Q1 2015/16 Q2 2015/16 Q3 2015/16October

Q3 2015/16November

Employment Status

Numerator: the number of adults in the denominator whose employment status was recorded in the previous 12 months. Denominator: the total number of adults (aged 18-69) who have received secondary mental health services and who were on the CPA at the end of the reporting period

85.60% 85.49% 85.31% 84.38%

Accommodation Status

Numerator: the number of adults in the denominator whose accommodation status (ie, settled or non-settled accommodation) was recorded in the previous 12 months. Denominator: the total number of adults (aged 18-69) who have received secondary mental health services and who were on the CPA at the end of the reporting period.

83.84% 83.03% 83.05% 82.34%

Having a Health of the Nation Outcome Scales (HoNOS) assessment in the past 12 months:

Numerator: The number of adults in the denominator who have had at least one HoNOS assessment in the past 12 months. Denominator: The total number of adults who have received secondary mental health services and who were on the CPA at the end of the reporting period.

93.21% 96.00% 95.29% 95.53%

Note: Information reported for MHLDDS Identifiers is the data published by Open Exeter MHMDS v4 diagnostic reports and data tables. The information provided for MHLDDS Outcomes is based on an internal assessment of performance following published Health and Social Care Information Centre methodology.

For details of how data items are classified as VALID please refer to the data quality constructions available on the Health and Social Care Information Centre’s website:

Patient Experience - Breakdown Page 4 of 4

National Community Mental Health Service User Survey - Section ResultsRAG ratings are based on comparison with national average for MHTsTo be deemed a material improvement or deterioration a +/- 0.5 rule has been applied

2015 2014 2013 Difference in score

Improvement / Maintained / Deterioration

*2015 scores compared with other trusts

Health and social care workers 8.0 8.1 8.9 -0.1 Maintained About the sameOrganising care 9.0 8.9 8.1 0.1 Maintained BetterPlanning care 7.6 7.5 6.7 0.1 Maintained BetterReviewing care 8.2 8.2 7.2 0.0 Maintained BetterChanges in who people see 6.8 6.1 0.7 Improved About the sameCrisis care 6.8 6.9 7.1 -0.1 Maintained About the sameTreatments 7.9 7.7 7.7 0.2 Maintained BetterOther areas of life 5.8 5.6 5.0 0.2 Maintained BetterOverall views of care and services 7.7 7.5 7.0 0.2 Maintained About the sameOverall experience 7.3 N/A About the same

Overall there has been no material deterioration in our scores between 2014 and 2015 with them all remaining at either "maintained" or "improved".

The "National Annual Patient Survey Findings" were considered by the Trust Board on 25 November 2015.

Section

Note: At the start of 2015, a questionnaire was sent to 850 people who received community mental health services. Responses were received from 230 people at Mersey Care NHS Trust.

Access and Outcomes Page 1 of 4

Indicator Construction Target Weighting Q1 2015/16 Q2 2015/16 Q3 2015/16October

Q3 2015/16November

Q3 2015/16 Score Further information

receiving follow-up contact within seven days of discharge

Numerator: the number of people under adult mental illness specialties on CPA who were followed up (either by face-to-face contact or by phone discussion) within seven days of discharge from psychiatric inpatient care. Denominator: the total number of people under adult mental illness specialties on CPA who were discharged from psychiatric inpatient care. Agreed exemptions are detailed in the Risk Assessment Framework.

>=95% 98.21% 98.01% 100.00% 98.81%

having a formal review within 12 months

Numerator: the number of adults in the denominator who have had at least one formal review in the last 12 months. Denominator: the total number of adults who have received secondary mental health services and who had been on CPA for at least 12 months at the end of the reporting period

>=95% 95.93% 96.22% 96.66% 96.23%

This indicator applies only to admissions to the foundation trust’s mental health psychiatric inpatient care. The indicator applies to users of working age (16-65) only, unless otherwise contracted. An admission has been gate-kept by a crisis resolution team if they have assessed the service user before admission and if they were involved in the decision-making process, which resulted in admission. Agreed exemptions are detailed in the Risk Assessment Framework.

>=95% 1.0 98.90% 99.24% 100.00% 97.14% 0.0

Quarterly performance against commissioner contract year to date. Threshold represents a minimum level of performance against contract performance, rounded down.

95% 1.0 97.44% 98.72% 98.90% 94.23% 1.0

Reasons for underperformance are being investigated with the information team and service.

Methodology to be confirmed. >=50% 1.0 Not due Not due Not due Not due Not due



>=75% 1.0 Not due Not due 91.84% 94.69%



>=95% 1.0 Not due Not due 99.21% 99.82%

Numerator: the number of non-acute patients (aged 18 and over on admission) per day under consultant and non-consultant-led care whose transfer of care was delayed during the quarter. For example, one patient delayed for five days counts as five.Denominator: the total number of occupied bed days (consultant-led and non-consultant-led) during the quarter.Delayed transfers of care attributable to social care services are included.

<=7.5% 1.0 1.02% 1.42% 2.59% 2.92% 0.0

Data completeness is assessed for each constituent part: NHS number, Date of Birth, Postcode (normal residence), Gender, Registered General Medical Practice Organisation Code, Commissioner Organisation Code.

>=97% 1.0 99.02% 99.22% 99.28% 99.25% 0.0

Aggregate performance based on average of each constituent part: Employment Status, Settled Accommodation Status and HoNOS assessment.

>=50% 1.0 87.83% 86.14% 88.22% 87.78% 0.0

Meeting the six criteria for meeting the needs of people with a learning disability, based on recommendations set out in Healthcare for All (DH, 2008)

Fully compliant 1.0 Fully

CompliantFully

CompliantFully

CompliantFully

Compliant 0.0

0.0 0.0 0.0 1.0 1.0

Key:GreenRed Score >=4.0 OR one or more indicators has underperformed for three consecutive quarters.

Score <4.0 AND no single indicator has underperformed for three consecutive quarters.

Monitor Risk Assessment Framework - Governance: Access and Outcome Metrics

Service Performance Indicators

Self Certification on access to healthcare for people with LD

1.0

Data Completeness: outcomes (MHLDDS)

Care Programme Approach (CPA) patients, comprising either:

Admissions to inpatient services had access to crisis resolution home treatment teams

New cases of EI (100% against contract requirements YTD)

0.0

Data Completeness: identifiers (MHLDDS)

Minimising Delayed Transfers of Care

0.0


B1 / Attachment 5Performance and Investment Committee:

Score

AC

CES

SO

UTC

OM

ES

Improving access to psychological therapies (IAPT). To be reported on from Quarter 3 2015/2016

Early intervention in Psychosis (EIP): People experiencing a first episode of psychosis treated with a NICE approved care package within two weeks of referral. To be reported on from Quarter 4 2015/16

Organisational Health Page 2 of 4

Q1 2015/16 Q2 2015/16 Q3 2015/16October

Q3 2015/16November

No No No No

No No No No

Third party reports Yes Yes Yes Yes

No No No No

No No No No

No No No No

No No No No

12.65% 12.96% 13.18% 13.41%

No No No No

4.11% 4.14% 4.14% 4.14%

No No No No

Monitor Risk Assessment Framework - Governance: Organisational Health Indicators


Element Indicator Further information

Adhoc reports from GMC, the Ombudsman, Commissioners, Healthwatch England, Auditor Reports, Health and Safety Executive, Patient Groups, Complaints, Whistleblowers, Medical Royal Colleges etc.

The increase in staff turnover in Q1 2015/16 is as a result of delayed MARS and the transfer of HMP Liverpool staff to Lancashire Care. The workforce directorate have been asked to review the reasons for the continuing increases in turnover.

Performance in the 2014/15 annual national staff survey was broadly consistent with the previous year's results. Next update due March 2016.

Figure quoted is year to date actual (November 2015). Aggressive cost reduction plans (i.e. in excess of 5% in any given year)

Continuity of services risk rating Breach of any continuity of services licence condition as a result of governance

At the start of 2015, a questionnaire was sent to 850 people who received community mental health services. Responses were received from 230 people at Mersey Care NHS Trust. Overall there has been no material deterioration in our scores between 2014 and 2015 with them all remaining at either "maintained" or "improved". Next update is due October 2016.

Q2 2015/16 position is based the rolling twelve months position of 6.03% (1 December 2015 to 30 November 2015)

In month November 2015 value = 10.87%. Year to date = 10.76%.

CQC judgementGovernance concern triggered by CQC warning notice issued.

Governance concern triggered by civil and / or criminal action initiated.

Material increase in proportion of temporary staff (benchmark 2014/15 - 11.13% based on percentage of paybill spent on agency and bank).

Quality governance

Material reduction in patient satisfaction based on "overall" section score (annual community mental health service user survey)

High executive team turnover

Material reduction in staff satisfaction (annual national staff survey)

Material increase in staff sickness / absence rate (compared to previous financial year - 5.63% for 2013/14 used for reporting in 2014/15, revised benchmark is 5.64% in 2015/16)

Material increase in staff turnover (benchmark 2013/14 - 12.65% based on FTE (used for reporting in 2014/15), revised benchmark 11.22% for 2014/15 based on FTE)

Data Completeness - Breakdown Page 3 of 4

Data Completeness Identifiers

Indicator Indicator Construction Q1 2015/16 Q2 2015/16

Q3 2015/16October

Q3 2015/16November

GP practice complete Numerator: count of valid entries Denominator: total number of entries. 97.89% 97.78% 98.09% 97.95%

Post code complete Numerator: count of valid entries Denominator: total number of entries. 98.84% 98.83% 98.88% 98.85%

DOB complete Numerator: count of valid entries Denominator: total number of entries. 100.00% 100.00% 100.00% 100.00%

Gender complete Numerator: count of valid entries Denominator: total number of entries. 100.00% 100.00% 100.00% 100.00%

Organisation code of commissioner complete Numerator: count of valid entries Denominator: total number of entries. 98.95% 98.94% 98.98% 98.96%

NHS Number Complete Numerator: count of valid entries Denominator: total number of entries. 98.42% 99.78% 99.76% 99.76%

http://www.hscic.gov.uk/mhldsmonthly

Data Completeness Outcomes

Indicator Indicator Construction Q1 2015/16 Q2 2015/16 Q3 2015/16October

Q3 2015/16November

Employment Status

Numerator: the number of adults in the denominator whose employment status was recorded in the previous 12 months. Denominator: the total number of adults (aged 18-69) who have received secondary mental health services and who were on the CPA at the end of the reporting period

85.60% 85.49% 85.31% 84.38%

Accommodation Status

Numerator: the number of adults in the denominator whose accommodation status (ie, settled or non-settled accommodation) was recorded in the previous 12 months. Denominator: the total number of adults (aged 18-69) who have received secondary mental health services and who were on the CPA at the end of the reporting period.

83.84% 83.03% 83.05% 82.34%

Having a Health of the Nation Outcome Scales (HoNOS) assessment in the past 12 months:

Numerator: The number of adults in the denominator who have had at least one HoNOS assessment in the past 12 months. Denominator: The total number of adults who have received secondary mental health services and who were on the CPA at the end of the reporting period.

93.21% 96.00% 95.29% 95.62%

Note: Information reported for MHLDDS Identifiers is the data published by Open Exeter MHMDS v4 diagnostic reports and data tables. The information provided for MHLDDS Outcomes is based on an internal assessment of performance following published Health and Social Care Information Centre methodology.

For details of how data items are classified as VALID please refer to the data quality constructions available on the Health and Social Care Information Centre’s website:

Patient Experience - Breakdown Page 4 of 4

National Community Mental Health Service User Survey - Section ResultsRAG ratings are based on comparison with national average for MHTsTo be deemed a material improvement or deterioration a +/- 0.5 rule has been applied

2015 2014 2013 Difference in score

Improvement / Maintained / Deterioration

*2015 scores compared with other trusts

Health and social care workers 8.0 8.1 8.9 -0.1 Maintained About the sameOrganising care 9.0 8.9 8.1 0.1 Maintained BetterPlanning care 7.6 7.5 6.7 0.1 Maintained BetterReviewing care 8.2 8.2 7.2 0.0 Maintained BetterChanges in who people see 6.8 6.1 0.7 Improved About the sameCrisis care 6.8 6.9 7.1 -0.1 Maintained About the sameTreatments 7.9 7.7 7.7 0.2 Maintained BetterOther areas of life 5.8 5.6 5.0 0.2 Maintained BetterOverall views of care and services 7.7 7.5 7.0 0.2 Maintained About the sameOverall experience 7.3 N/A About the same

Overall there has been no material deterioration in our scores between 2014 and 2015 with them all remaining at either "maintained" or "improved".

The "National Annual Patient Survey Findings" were considered by the Trust Board on 25 November 2015.

Section

Note: At the start of 2015, a questionnaire was sent to 850 people who received community mental health services. Responses were received from 230 people at Mersey Care NHS Trust.

Performance and Investment Committee: B1 / Attachment 6Executive Committee: B2 / Attachment 6

30 November 2015Trust Development Authority (TDA) Accountability Framework

Element ScoreQuality score 4Finance RAG assessment GreenSustainability score * Not availableModeration issues YesOverall escalation 4

* The sustainability scoring mechanism has not been defined by the TDA so is currently feeding into the moderation element of the oversight and escalation framework.

The Trust will remain at level 4 until the TDA have considered the outcome of the Chief Inspector of Hospitals inspection for which the trust achieved "Good".

Financial Page 2 of 10

Financial Indicators 30 November 2015

Financial Risk Rating at 30 November 2015

FS Risk Score at 30 November 2015 RAG rating

Liquidity days 26 days 4 GreenCapital services capacity 2 3 GreenI&E Margin 2% 4 GreenI&E Margin Variance (based on original plan) 99% 4 GreenOverall Financial Sustainability Risk Score 4 Green

RAG ratingRevised Plan 5,415 Actual 5,415 Revised Plan 3,238 Year to date actual 3,239 Plan 8,416 Forecast 8,416 Plan 5,610 Year to date actual 5,610 Plan 8,821 Actual 8,821 Plan 13,498 Year to date actual 13,498

Is the Trust forecasting permanent PDC forliquidity purposes? Green

Green

Monitor risk assessment framework - Continuity of Services

Indicator

I&E position – Forecast

I&E position – Actual

Measures of in-year financial delivery

Green

Green

GreenCIP - Forecast

Green

Green

Green

Overall RAG rating

CIP - Actual

Forecast underlying surplus

Capital Resource Limit

No

Quality Page 3 of 10

Quality

Oversight and escalation information supplied by TDA on 24 October 2015 - Oversight and Escalation Period: September 2015

Oversight and Escalation Score Score Colour(Level 1) - Special Measures >0 - <=35%(Level 2) - Intervention >35 - <=50%(Level 3) - Intervention >50 - <=65%(Level 4) - Standard Oversight >65 - <=80% (Level 5) - Standard Oversight >80 - 100%

No mental health trust override rules have been triggered this month.

Metric_ID Indicator description Domain OE_Month Data_Period Numerator description Numerator Denominator description Denominator Performance Scoring Criteria Standard_Range Lower_Confidence_Limit

Upper_Confidence_Limit

Oversight and Escalation Score

MH_CR Admissions to inpatient services who had access to Crisis Resolution Responsive 01/09/2015 Q1 2015/2016 Gate Admissions 267 Total Admissions 270 98.89 >= Standard 95

DTOC Delayed Transfers of Care Responsive 01/09/2015 01/09/2015 Delayed Transfers of Care 3.93 Beddays 558 0.7 <= Standard 7.5

MH_FR12

The proportion of those on Care Programme Approach (CPA) who have had a HoNOS assessment in the last 12 months

Responsive 01/09/2015 01/07/2015 People on CPA with HoNOS recorded 3740 Total People on CPA 4315 86.67 >= Standard 90

MH_CPA_12

The proportion of those on Care Programme Approach for at least 12 months who have had a CPA review within the last 12 months

Responsive 01/09/2015 01/07/2015 People on CPA for 12 months with review 2720 Total People on CPA for 12

months 3130 86.9 >= Standard 95

MH_CIE % clients in employment Effective 01/09/2015 01/07/2015 People aged 18-69 on CPA in employment 125 People on CPA aged 18-69 4105 3.0451 >= Lower Decile 3.6887 11.5177

MH_CSA % clients in settled accommodation Effective 01/09/2015 01/07/2015 People aged 18-69 on CPA in settled accommodation 2635 People on CPA aged 18-69 4105 64.19 >= Lower Decile 39.9626 82.7306

MH_7_DISCHCPA follow up - Proportion of discharges from hospital followed up within 7 days - MHMDS

Effective 01/09/2015 Q1 2015/2016

The number of people under adult mental illness specialties on Care Programme Approach receiving follow up (by phone or face to face contact) within seven days of discharge from psychiatric in-patient care

274

The number of people under adult mental illness specialties on Care Programme Approach discharged from psychiatric in-patient care

279 98.21 >= Standard 95

RKECDIFF_act Clostridium Difficile - infection rate Safe 01/09/2015 01/09/2015Count of trust apportioned C-difficile infections in patients aged 2 years and over

0 Occupied bed days 191327 0 For Information

ME_Rate Medication errors causing serious harm Safe 01/09/2015 01/12/2014 Number of Medication errors causing serious harm 0

The denominator is set dependent on the type of organisation: per bed days for acute, per patient contacts for MH, per calls for Ambulance and per patient surveyed for Community (all per 1000).

36105 0>= Lower Decile

and <= Upper Decile

0 0

HFC Percentage of Harm Free Care Safe 01/09/2015 01/10/2015 Number patients surveyed with a harm 154 Number of patients surveyed 154 100 >= Standard 95

MH_U16 Admissions to adult facilities of patients who are under 16 years of age Safe 01/09/2015 01/07/2015 N/A 0 N/A 0 0 = Standard 0

NRLS Proportion of reported patient safety incidents that are harmful Safe 01/09/2015 01/08/2015

Count severe harm and death NRLS incidents (based on incident month)

4 Count total NRLS incidents (based on incident month) 421 0.9501

>= Lower Decile and

<= Upper Decile0 2.3005

SI_Rate Serious Incidents rate Safe 01/09/2015 01/07/2015 Count of Serious Incidents 24


39250 0.6115>= Lower Decile

and <= Upper Decile

0.0741 1.1065

NE Never events - indicents rate Safe 01/09/2015 01/07/2015 Count of Never Events 0


441150 0 <= Upper Decile 0 0

FF_MH_REC Mental Health Scores from Friends and Family Test - % positive Caring 01/09/2015 01/09/2015

Count of those categorised as extremely likely or likely to recommend

207 Count of all responders 224 92.4107 >= Lowest Decile 78.6889 96.0291

FF_STF_CR Staff FFT Percentage Recommended - Care Caring 01/09/2015 Q1 2015/2016 Count of those categorised as

extremely likely or likely to 546 Count of all responders 775 70.4516 >= Lowest Decile 58.8723 81.0689Complaints Written Complaints - rate Caring 01/09/2015 2013/2014 Written Complaints 371 Beddays 28721.1666 12.9173 <= Upper Decile 6.9127 27.1608MSA Mixed Sex Accommodation Breaches Caring 01/09/2015 01/10/2015 N/A 0 N/A 0 0 0 0

FF_STF_WR Staff FFT Percentage Recommended - Work Well led 01/09/2015 Q1 2015/2016 Number of responses 459 Number of eligible responses 773 59.379 > Lower Decile 43.4583 69.5619

FF_STF_SE Staff FFT response rate Well led 01/09/2015 Q1 2015/2016 Total number of responders 776 Total number of staff 3746 20.7154 > Lower Decile 3.6603 34.3573

WKF_SICK Staff sickness Well led 01/09/2015 01/09/2015 Number of Staff sickness days reported. 6777 Total WTE days available / 12

months 107113 6.327 < Upper Decile 4.1467 5.0945

30 November 2015

2

4

5

5


Oversight and escalation information supplied by TDA on 24 October 2015 - Oversight and Escalation Period: September 2015

WKF_TO Staff turnover Well led 01/09/2015 01/09/2015 Number of Staff Staff leavers reported within the period 448.53

Average of number of Total Employees at end of the month and Total Employees at end of the month for previous 12 month period.

3500.36 12.8138>= Lower Decile

and <= Upper Decile

12.1828 17.8606

Safe Stf Overall safe staffing fill rate Well led 01/09/2015 01/09/2015 Number of overall actuals 160995 Number of overall plan 158734 101.4244 > Lower Decile 97.8481 132.3229

Overall Quality Score 4

5


Oversight and escalation information supplied by TDA on 24 October 2015 - Oversight and Escalation Period: September 2015Override Rules Applicable to Mental Health Trusts in relation to Quality Metrics

Metric Override Rule Domain Domain Score Affected

Maximum Domain Score

AchievableQuality Score Affected Maximum Quality

Score Achievable Maximum Escalation

Level Achievable

Receiving follow-up contact within 7 days of discharge

Below 95% Responsive Yes 3 No N/A N/A

Admissions to adult facilities of patients who are under 16 years of age

>0 Safe Yes 2 No N/A N/A

Sustainability 30 November 2015

Following assessment of the five year plans by the TDA, a score will be developed which in turnwill feed through to the overall escalation level for the trust.

Until then, the sustainability of the trust will feed into the escalation scoring system through the moderation process.

The assessment of the credibility of trust five year plans will focus on five broad areas of assurance.

Clinical and workforce strategyFinancial and business strategyFuture commissioning and service strategySecuring a sustainable organisational formLeadership capability and capacity.

Moderation information 30 November 2015

Yes / No If yes (details of issue, actions and expected date of resolution)No

Third party report Yes


No

YesAny moderation issues

Any sustainability concerns

CQC rating warning notices

Board statements 30 November 2015

For each statement the Board is asked to confirm the following:

For CLINICAL QUALITY, that Response

1

The board is satisfied that, to the best of its knowledge and using its own processes and having had regard to the TDA’s oversight (supported by Care Quality Commission information, its own information on serious incidents, patterns of complaints, and including any further metrics it chooses to adopt), the trust has, and will keep in place, effective arrangements for the purpose of monitoring and continually improving the quality of healthcare provided to its patients.

Yes

2 The board is satisfied that plans in place are sufficient to ensure ongoing compliance with the Care Quality Commission’s registration requirements. Yes

3The board is satisfied that processes and procedures are in place to ensure all medical practitioners providing care on behalf of the trust have met the relevant registration and revalidation requirements.

Yes

For FINANCE, that Response

4 The board is satisfied that the trust shall at all times remain a going concern, as defined by relevant accounting standards in force from time to time. Yes

For GOVERNANCE, that Response

5 The board will ensure that the trust remains at all times compliant with has regard to the NHS Constitution. Yes

6All current key risks have been identified (raised either internally or by external audit and assessment bodies) and addressed – or there are appropriate action plans in place to address the issues – in a timely manner.

Yes

7The board has considered all likely future risks and has reviewed appropriate evidence regarding the level of severity, likelihood of it occurring and the plans for mitigation of these risks.

Yes

8

The necessary planning, performance management and corporate and clinical risk management processes and mitigation plans are in place to deliver the annual operating plan, including that all audit committee recommendations accepted by the board are implemented satisfactorily.

Yes

9

An Annual Governance Statement is in place, and the trust is compliant with the risk management and assurance framework requirements that support the Statement pursuant to the most up to date guidance from HM Treasury (www.hm-treasury.gov.uk).

Yes

10

The board is satisfied that plans in place are sufficient to ensure ongoing compliance with all existing targets (after the application of thresholds) as set out in the relevant GRR; and a commitment to comply with all known targets going forwards.

Yes

11 The trust has achieved a minimum of Level 2 performance against the requirements of the Information Governance Toolkit. Yes

12

The board will ensure that the trust will at all times operate effectively. This includes maintaining its register of interests, ensuring that there are no material conflicts of interest in the board of directors; and that all board positions are filled, or plans are in place to fill any vacancies.

Yes

13

The board is satisfied that all executive and non-executive directors have the appropriate qualifications, experience and skills to discharge their functions effectively, including setting strategy, monitoring and managing performance and risks, and ensuring management capacity and capability.

Yes

14The board is satisfied that: the management team has the capacity, capability and experience necessary to deliver the annual operating plan; and the management structure in place is adequate to deliver the annual operating plan.

Yes

Signed on behalf of the Trust: Print Name DateCEOChair

Timeline Page 9 of 10

Timeline toward achievement of FT status 30 November 2015

Milestone (including delivered achieved) Milestone DateComment where milestones are not delivered or where a risk to delivery has been identified

1 TDA observation of Audit Committee 18-Feb-15 As part of well led - to be confirmed if this needs to be repeated for FT -

2 TDA observation of PIC 27-Feb-15 As part of well led - to be confirmed if this needs to be repeated for FT -

3 TDA observation of QAC 18-Mar-15 As part of well led - to be confirmed if this needs to be repeated for FT -

4 TDA observation of Trust Board 25-Mar-15 As part of well led - to be confirmed if this needs to be repeated for FT -

5 TDA observation of Executive Committee TBC To be confirmed.

6 TDA board interviews 25,30,31-Mar-15 As part of well led - to be confirmed if this needs to be repeated for FT -

7 Submit Draft 1 year operational plans to TDA 07-Apr-15 Reflected in year 1 of IBP

8 QGF external reviewIncorporated into the Good Governance Institute Review of quality governance and risk

9 Submit Final 1 year operational plans to TDA 14-May-1510 Chief Inspector of Hospitals Visit 01-Jun-15 Date of visit confirmed as 1 June 201511 CQC Quality Summit 09-Oct-1512 Submit IBP/LTFM 30-Jun-1513 Submit revised IBP/LTFM 31-Jul-1514 Mock board to board 09-Oct-1515 Submit refreshed IBP/LTFM 19-Oct-1516 HDD 02-Nov-1517 TDA board to board 29-Oct-15 TDA Corporate Board18 National TDA board 19-Nov-15 Decision to refer Mersey Care to Monitor19 Monitor Stage 01-Dec-15 to 28-Feb-16 Monitor with Mersey Care20 Council of governors elections 30-Jan-16 Post TDA referral to Monitor21 IFR 30-Jan-1622 Monitor Board to Board meeting Mar-1623 Potential authorisation 01-Apr-16

Compliance with Monitor licence requirements for NHS Trusts 30 November 2015

Compliance Comment where non-compliant or at risk of non-compliance

1Condition G4 – Fit and proper persons as Governors and Directors (also applicable to those performing equivalent or similar functions)

Yes

2 Condition G7 – Registration with the Care Quality Commission Yes

3 Condition G8 – Patient eligibility and selection criteria Yes

4 Condition P1 – Recording of information Yes5 Condition P2 – Provision of information Yes

6 Condition P3 – Assurance report on submissions to Monitor Yes

7 Condition P4 – Compliance with the National Tariff Yes

8 Condition P5 – Constructive engagement concerning local tariff modifications Yes

9 Condition C1 – The right of patients to make choices Yes

10 Condition C2 – Competition oversight Yes

11 Condition IC1 – Provision of integrated care Yes

Licence Condition

B1 / Attachment 7

B2 / Attachment 7

ClickLink

Below

Dashboard 1 Breakeven, Better Payment Practice Code, Monitor/TDA Reporting

Dashboard 2 Capital Programme, Cash, Aged Debt

Dashboard 3 Procurement

Appendix 1 Statement of Comprehensive Income

Appendix 2 Financial Sustainability Risk Rating and Accountability Framework and Operating Plan

Appendix 3 Statement of Financial Position

Appendix 4 2014/15 Cash Flow

Performance and Investment Committee

Executive Committee:

As at the end of November, the trust is on target to achieve all statutory financial duties. The trust has a £3.239m surplus. The secure division is breakeven and Informatics Merseyside (IM), the local division and the corporate division are underspent. The trust has achieved a Monitor financial sustainability risk rating of 4 and the Trust Development Authority (TDA) indicators are all green. An assessment of overall trust financial performance agreed with the TDA has identified no financial concerns. The planned surplus for 2015/16 is £5.415m and is shown in Appendix 1. Division forecast outturn positions remain unchanged. The local division forecast outturn is a £1.000m underspend and IM is a £0.218m underspend. The corporate and secure divisions forecast outturn position is breakeven. The planned surplus includes a technical surplus of £0.763m in respect of accounting for Clock View. The trust has uncommitted contingency reserves of £1.000m. A further review of forecast outturn positions will be undertaken at month 9. Following the review, this contingency could be used to support schemes that were not funded at budget setting or other pressures. This will be prioritised by the Executive Committee. The surplus position also includes anticipated costs of approx. £1.200m in respect of a change in the discount rate for trust provisions. This would be available, together with the contingency reserve, if HM Treasury do not change the rate in December 2015. The 2015/16 CIP target is £8.416m. As at 30th November 2015 all divisions are on target and £5.610m has been delivered. The strategic financial plan is amber. Detailed service, workforce and financial plans have been produced. Detailed CIP plans have been submitted and assessed for the impact on quality by the Medical Director and the Executive Director of Nursing and will be summarised in a paper to the Quality Assurance Committee (QAC) in January.The Capital Resource Limit (CRL) is £13.498m. The trust board will be asked to approve two changes to the existing capital programme. A reduction of £0.165m to fire safety as the work at Windsor Clinic is not required and £0.015m increase for the Wavertree bungalow extension. Both changes were agreed by the Capital Investment Group in December 2015.The trust has been notified by the TDA that we should be reporting on only qualified agency nursing, not total agency nursing. To the end of November, the trusts expenditure on qualified agency nursing was 0.56% of all qualified nurse staffing expenditure, against a target of 3.0%.

Finance DashboardMonth 8 - 2015/16

-1

0

1

2

3

4

5

6

Apr

May Jun Jul

Aug

Sept Oct

Nov De

c

Jan

Feb

Mar

£ m

Financial Position - Break Even Duty Actual Performance Statutory Duty Plan Revised Plan

0

10

20

30

40

50

60

70

80

90

Local Secure Corporate IM Reserves & Other

£ m

Summary Financial Position Annual Plan Cumulative Plan Cumulative Actual

The trust's revised planned 2015/16 surplus is £5.415m. This reflects the request from the TDA for all trusts to improve their financial positions. As at 30th November 2015 the surplus is £3.239m. The statement of comprehensive income is shown in Appendix 1.

As at 30th November 2015, the secure division is breakeven, IM is £0.155m underspent, the local division is £0.675m underspent and the corporate division is £0.013m underspent. The forecast outturn position for the secure and corporate divisions is breakeven. The local division and IM position is £1.000m and £0.218m underspend respectively.

The 2015/16 CIP target is £8.416m. As at 30th November 2015 all divisions are on target and £5.610m has been delivered.

The surplus, cash and CIP position for the 6 year period from 2015/16 to 2020/21 is shown in the graph. This represents the Long Term Financial Model (LTFM) included in the October integrated business plan submission. Detailed transformation plans have been produced. Detailed CIP plans have been assessed for the impact on quality by the Medical and Nursing Directors.

The Better Payments Practice Code (BPPC) requires the trust to pay 95% of all valid invoices within 30 days of receipt of goods. In November 2015 the trust achieved 97.09% and 97.10% cumulative to date.

As at 30th November 2015 the Monitor financial sustainability risk rating was 4. This now includes 2 additional measures for I&E Margin. The trust has scored 4 for both these measures. The financial indicators are used by the TDA to monitor financial performance. The detail is shown in Appendix 2.

Income, Expenditure, Cost Improvement Plans and Financial Plan

0.0

0.5

1.0

1.5

2.0

2.5

3.0

3.5

4.0

Local Secure Corporate Strategic

£ m

Cost Improvement Plans (CIP) Annual Plan Cumulative Plan Cumulative Actual

0

5

10

15

20

25

30

35

2015/16 2016/17 2017/18 2018/19 2019/20 2020/21

£m

Surplus, CIPs and Cash 2014/15 - 2020/21 Surplus CIPs Cash

Approved by Executive Director of Finance/Deputy Chief Executive £m Clock View Newton Ward Enabling 0.014

Requiring Board Approval £m Fire Safety Works * (0.165) Local Wavertree Bungalow Extension 0.015

(0.150)

* Works at Windsor Clinic no longer required. The service at Windsor Clinic will be moving to the Kevin White Unit in 2016.

Changes to Capital Programme

0.0

5.0

10.0

15.0

20.0

25.0

30.0


£ m

Cash Balance 2015/16

Actual Plan Revised Plan

0.0

5.0

10.0

15.0

20.0

25.0

30.0

Nov Dec Jan Feb Mar Apr May June July Aug Sep Oct

£ m

12 Month Rolling Cash Flow

Actual Plan

0.0

5.0

10.0

15.0

20.0

25.0


£ m

Capital Expenditure 2015/16

Actual Capital Expenditure Planned Capital Expenditure Revised Plan

The trust has reviewed its capital expenditure plan for 2015/16 and has agreed with the TDA to reduce the CRL by £6.500m. The revised plan is £13.498m. As at 30th November 2015 capital expenditure is £7.380m. This is £0.827m under the revised plan due to the rescheduling of strategic schemes.

The 31st March 2016 cash target is £14.697m. The trust is on plan to achieve the target. The cash balance at 30th November 2015 is £28.149m. The cash position is shown in the statement of financial position in Appendix 3 and a detailed cash flow statement is shown in Appendix 4.

The trust forecasts cash on a rolling 12 month basis. The trust remains in a healthy position and has a liquidity ratio of 4. The cash reduces in 2015/16 due to expenditure on the capital programme. The cash increase in 2016/17 is due to receiving a loan for the strategic capital programme.

As at 30th November 2015 total trade payables is £2.824m. The majority of the aged payables include invoices which will be paid within 0-30 days.

Capital Programme, Cash, Aged Debt, Aged Payables

The revised CRL is £13.498m which the trust is forecast to achieve. The Executive Director of Finance has approved changes of £0.014m. The trust board will be asked to approve changes of £0.150m to the capital programme.

0.0

1.0

2.0

0-30 days 30 - 60 Days 60-90 Days Over 90 Days

£ m

Aged Receivables as at 30 November 2015

Receivables NHS Receivables Non NHS

As at 30th November 2015 total trade receivables is £3.021m of which £1.116m is over 90 days old. Included in the debt over 90 days is: £0.434m Liverpool CCG for winter resilience, £0.271m LHC a late SLA payment for IM, £0.183m South Sefton CCG disputed shared care prescribing costs and £0.104m managed debt. It is anticipated these will be resolved by month 11. 0.0

1.0

2.0

3.0

0-30 days 30-60 days 60-90 days Over 90 days

£ m

Aged Payables as at 30 November 2015

Payables NHS Payables Non NHS

71.0% 0.5%

5.8%

22.7%

Percentage of Purchase / Non Purchase Order Invoices 2015/16

Purchase Order

Non Purchase Order

Out of scope

Contract

Procurement Indicators

0.0

1.0

2.0

3.0

4.0

5.0

6.0

13/14 14/15 15/16 YTD 15/16 FOT 16/17 FOT

£m

Catalogue Ordering

Projected Actual

Rolled out in 2014, catalogue ordering is at the heart of delivering a customer focused service. It allows a simple search and ordering of standardised products which are pre-populated with the correct product code, description, price, subjective code and image to reduce transactional processing. By 2016/17 the trust plans to have £5.500m of products and services processed through catalogue ordering. As at 30th November, the Trust has achieved £4.6m against a projected current year end target of £3.6m.

The procurement department has a savings target of £0.500m. Savings plans will be delivered from the procurement work plan. As at 30 November 2015, savings of £1.252m have been made on the building, engineering and grounds maintenance contract, catering trolleys, dairy products and Occupational Health Physician Services.

0

200

400

600

800

1,000

1,200

1,400

2015/16

£000

's

Savings Target 2015/16

Savings target

Savings

Standards of Procurement have been developed to support and measure continual improvement of NHS procurement. The standards are organised into four domains: People; Leadership; Partnership and Process with each containing a number of measurable standards of Level 1 (Building), Level 2 (Achieving) and Level 3 (Excelling) The trust is the first mental health trust in the North West to achieve Level 1 and is now working towards Level 2. Progress will be recorded and reported monthly on this dashboard.

The majority of spend is influenced by procurement professionals by contract or purchase order. The out of scope expenditure includes payroll deductions, patient expenditure, visitors travel, rent and legal payments.

The graph shows our top ten suppliers in terms of total purchase order spend for 2015/16. The top ten suppliers account for approximately 38% of total purchase order spend.

29.21 0.19

2.37

9.36

Value (£m) of Purchase / Non Purchase Order Invoices 2015/16

Purchase Order

Non Purchase Order

Out of scope

Contract

0500

1,0001,5002,0002,5003,0003,5004,000

£000

's

Top 10 Suppliers by Purchase Order

0

2

4

6

8

10

12

14

16

18

20

Leadership Process Partnership People

Leve

l

NHS Standards of Procurement

Maximum Actual Aspirant (Level 2)

Appendix 1 - Statement of Comprehensive Income for the period ending 30 November 2015

Full Year Plan

£000

Year to Date Plan £000

Year to Date Actual £000

Year to Date Variance

£000Contract Income 198,079 129,893 129,893 0Informatics Merseyside Income 8,632 5,732 6,251 519Operational Income 1,894 1,387 2,617 1,230Total Income 208,605 137,012 138,761 1,749Costs (191,213) (125,286) (127,035) (1,749)EBITDA (Earnings before Interest, Tax, Depreciation and Amortisation) 17,392 11,726 11,726 0

EBITDA Margin % 8.34% 8.56% 8.45%

Capital Charges (9,945) (6,999) (6,999) 0Provisions Unwinding of Discount (274) (274) (274) 0Interest Payable (2,433) (1,635) (1,635) 0Interest Receivable 72 72 72 0Carbon Credits (160) (160) (160) 0I&E Surplus (before technical adjustments) 4,652 2,730 2,730 0IFRIC 12 Adjustment (Clockview) 763 509 509 0Adjusted Retained I&E Surplus (before technical adjustments) 5,415 3,239 3,239 0

I&E Surplus Margin % 2.60% 2.36% 2.33%Reverse IFRIC 12 Adjustment (763) (509) (509) 0Capital Impairment (15,362) (13,150) (12,473) 677

Net I&E Surplus / (Deficit) (10,710) (10,420) (9,743) 677

Appendix 2 - Financial Sustainability Risk Rating and Accountability Framework and Operating Plan

Financial Risk Rating at 30 November 2015

FS Risk Score at 30 November

2015RAG rating

Liquidity days 26 4 Green

Capital services capacity 2 3 Green

I&E Margin 2 4 Green

I&E Margin Variance (based on original plan) 99% 4 Green

Overall Financial Sustainability Risk Rating 4 Green

Indicator £000s RAG rating

Revised Plan 5,415

Actual 5,415

Revised Plan 3,238

Year to date actual 3,239

Plan 8,416

Forecast 8,416

Plan 5,610


Plan 8,821

Actual 8,821

Plan 13,498


Is the Trust forecasting permanent PDC forliquidity purposes? Green

Green

Indicator %

April to November 2015

RAG rating

Target 3.00

Actual 0.56

Monitor risk assessment framework - Financial Sustainability Risk Rating

I&E position – Actual Green

Capital Resource Limit Green

I&E position – Forecast Green

Measures of in-year financial delivery

Forecast underlying surplus Green

CIP - Forecast Green

CIP - Actual Green

Agency nursing expenditure

Qualified agency nursing expenditure as a percentage of all qualified nurse staffing expenditure

Green

No

Overall RAG rating

Appendix 3 - Statement of Financial Position as at 30 November 2015

Year to 2015/16 2014/15Date FOT Year End£000 £000 £000

NON-CURRENT ASSETS 180,745 182,162 190,904

CURRENT ASSETS

Inventories 375 375 382Trade Receivables 3,021 3,000 3,078Other Receivables 3,507 2,600 4,331Cash and Cash Equivalents 28,149 14,697 24,306TOTAL CURRENT ASSETS 35,052 20,672 32,097

CURRENT LIABILITIES

Trade and Other Payables (19,328) (6,881) (16,246)Provisions (1,513) (1,681) (1,705)Borrowings (580) (600) (465)TOTAL CURRENT LIABILITIES (21,421) (9,162) (18,416)NET CURRENT ASSETS (LIABILITIES) 13,631 11,510 13,681TOTAL ASSETS LESS CURRENT LIABILITIES 194,376 193,672 204,585

NON-CURRENT LIABILITIES

Provisions (21,047) (20,908) (21,830)Borrowings (30,473) (30,232) (30,834)

TOTAL ASSETS EMPLOYED 142,856 142,532 151,921

FINANCED BY:TAXPAYERS' EQUITYPublic dividend capital 58,349 60,149 58,349Retained Earnings (23,210) (24,099) (21,359)Revaluation Reserve 47,810 46,575 55,024Other reserves 59,907 59,907 59,907

TOTAL TAXPAYERS' EQUITY 142,856 142,532 151,921

Appendix 4 - 2015/16 Cash Flow

Statement of Cash Flows (CF) April May June July August September October November December January February March£000s £000s £000s £000s £000s £000s £000s £000s £000s £000s £000s £000s

CASH FLOWS FROM OPERATING ACTIVITIES

Operating Surplus/(Deficit) (6,465) 293 (2,038) (71) 405 1,387 809 738 (1,655) 843 866 36Depreciation and Amortisation 536 533 528 522 514 517 523 522 522 522 522 583Impairments and Reversals 7,259 818 2,973 1,033 390 0 0 0 2,992 0 0 1,107Interest Paid (37) (103) 0 (181) (264) (208) (162) (162) (634) (208) (209) (208)Dividend Paid 0 0 0 0 0 (2,224) 0 0 0 0 0 (2,076)Losses(Increase)/Decrease in Inventories 52 (29) 38 (39) (13) 37 (35) (4) (18) (18) 27 (5)

(Increase)/Decrease in Trade and Other Receivables (8,453) 7,382 (828) 2,152 363 (1,746) 945 997 (368) 1,182 136 (32)

Increase/(Decrease) in Trade and Other Payables 466 (1,765) 3,152 (1,212) 623 160 (657) 1,092 1,901 510 (304) (12,687)

Increase/(Decrease) in Other Current Liabilities 0 0 0 0 0 0 0 0 0 0 0 0Provisions Utilised (322) (8) (4) (339) (16) (149) (358) 0 (41) (354) (41) (29)Increase/(Decrease) in Movement in non cash Provisions (685) 14 14 1 14 491 83 14 117 87 34 254

Net Cash Inflow/(Outflow) from Operating Activities (7,649) 7,135 3,835 1,866 2,016 (1,735) 1,148 3,197 2,816 2,564 1,031 (13,057)

CASH FLOWS FROM INVESTING ACTIVITIES

Interest received 7 6 9 10 9 11 9 11 10 9 10 9(Payments) for Property, Plant and Equipment (840) (433) (338) (1,017) (667) (599) (995) (722) (2,088) (2,121) (2,000) (2,178)(Payments) for Intangible Assets 0 0 0 0 0 0 (160) 0 0 0 0 0

Proceeds of disposal of assets held for sale (PPE) 0 0 0 0 0 0 0 0 0 0 0 0

Net Cash Inflow/(Outflow)from Investing Activities (833) (427) (329) (1,007) (658) (588) (1,146) (711) (2,078) (2,112) (1,990) (2,169)

NET CASH INFLOW/(OUTFLOW) BEFORE FINANCING (8,482) 6,708 3,506 859 1,358 (2,323) 2 2,486 738 452 (959) (15,226)

CASH FLOWS FROM FINANCING ACTIVITIES

New Public Dividend Capital 0 0 0 0 0 0 0 0 0 0 0 1,800Loans received from DH - New Capital Investment LoansOther Capital Receipts 0 0 0 0 0 0 0 0 0 0 0 0Capital Element of Finance Leases and PFI (24) (35) 0 (90) (38) (28) (28) (27) (120) (46) (46) (45)

Net Cash Inflow/(Outflow)from Financing (24) (35) 0 (90) (38) (28) (28) (27) (120) (46) (46) 1,755

Net Increase/(Decrease) in Cash (8,507) 6,673 3,506 769 1,320 (2,351) (26) 2,459 618 406 (1,005) (13,471)

Cash at the Beginning of the Period 24,306 15,799 22,472 25,978 26,747 28,067 25,716 25,690 28,149 28,767 29,173 28,168

Cash at the End of the Financial Period 15,799 22,472 25,978 26,747 28,067 25,716 25,690 28,149 28,767 29,173 28,168 14,697

ForecastActual

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Performance and Investment Committee: B1 / Attachment 8 Executive Committee: B2 / Attachment 8

Workforce Performance Report – M8 2015/16

(30 November 2015) Workforce plan 1. The staff in post whole time equivalent (WTE) figures as at the end of November

2015 compared with the budgeted WTE for year end 2015/16 are provided in the tables below. Please note that a minus figure demonstrates that the current position of WTE is below the figure planned for year-end.

2. iMerseyside has highlighted that the nature of their business requires flexibility in terms of covering vacancies with agency staff.

Staff sickness 3. The sickness absence target for 2015/16 is 4.8% i.e. no change from 2014/15.

4. The “in month” staff sickness rate (November 2015) was 6.34%, a deterioration on

the October 2015 position. The in month absence rate is equivalent to 221.02 WTE staff off sick at any point in time (152.18 WTE long term and 68.84 WTE short term).

5. For the period 1 December 2014 to 30 November 2015 (i.e. rolling 12 months), the

sickness absence rate was 6.03%; performance has deteriorated when compared with the position reported for 1 November 2014 to 31 October 2015 (5.95%). The

DivisionStaff in post at 30 November 2015 (WTE)

Planned budget at 30 November

2015 (WTE)

Difference (%)

Local Division 1,611.12 1,738.58 -7.33Secure Division 1,179.39 1,244.34 -5.22Corporate Division 538.53 585.20 -7.98iMerseyside 211.14 225.07 -6.19Grand Total 3,540.18 3,793.19 -6.67

Long Term Financial Model Staff Group

Staff in post at 30 November 2015 (WTE)

Planned budget at 30 November

2015 (WTE)

Difference (%)

Consultant 65.30 72.24 -9.61Junior medical 81.95 91.50 -10.44Nursing, midwifery and health visitors 1,793.84 1,857.46 -3.43Scientific, therapeutic & technical 358.09 403.34 -11.22Other clinical staff 129.00 139.72 -7.67Non clinical staff 1,112.00 1,228.93 -9.51Grand Total 3,540.18 3,793.19 -6.67

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rolling 12 month absence rate is equivalent to 209.74 WTE staff off sick at any point in time (142.12 WTE long term and 67.61 WTE short term).

6. The rolling twelve months position for the period 1 December 2014 to 30 November 2015 is equivalent to approximately 14.04 working days per WTE employee off sick each year (based on an indicative total of 233 working days per WTE1). If the target attendance rate target was being achieved the number of working days lost due to sickness absence would be 11.2.

7. The cost of sickness for November 2015 was not available at the time of writing.

8. The trust’s sickness absence rate is higher than that of the other two high secure provider trusts at 5.90% (equivalent to 13.75 days off sick per WTE) compared with 5.09% at Nottinghamshire Healthcare NHS Trust and 4.67% at West London Mental Health Trust (equivalent to 11.86 days and 10.88 days off sick per WTE respectively) (H&SCIC iView, data period 1 September 2014 to 31 August 2015).

9. The graph below highlights the sickness absence rates from 1 September 2014 to 31

August 2015 for all mental health trusts within England. Mersey Care NHS Trust is highlighted in orange and mental health trusts within the North West are highlighted in green. The trust is within the highest five of all mental health trusts within England and is the fourth highest within the North West.

10. Performance escalation section 3 of the M8 2015/16 Care at a Glance report to the

trust board and executive committee provides further information on staff sickness.

11. Appendix 1 provides details of all teams across the trust where the “rolling 12 month” sickness rate is greater than the target.

1 260 potential working days per WTE employee per year minus 29 days for annual leave minus 8 days for bank holidays = 233 working days per WTE employee per year.

1.0%

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Sickness Absence Rates - Mental Health Trusts (England) 1 September 2014 to 31 August 2015

% Sickness Lower Quartile Median Upper Quartile

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12. The “in month” staff sickness rate for inpatient wards at trust level was 8.59% in

November 2015. For the local division the rate was 6.99% and for the secure division the rate was 9.81%.

13. The “rolling 12 month” staff sickness rate for inpatient wards at trust level was 8.82%

for 1 December 2014 to 30 November 2015. For the local division the rate was 7.37% and for the secure division the rate was 9.95%.

14. The graph on page 4 highlights the trust inpatient wards’ “in month” staff sickness

rates since April 2015. The graphs in Appendix 2 provide the breakdown for the local division and secure division.

Workforce – performance improvement plans 15. Appendix 3 provides updated details of key performance improvement actions and

trajectories for performance improvement for the following areas:

a. Sickness absence b. Mandatory training c. HR systems review d. Personal Achievement and Contribution Evaluation, PACE e. Induction

Workforce key performance indicator overview

16. The table on page 10 provides details of performance against key workforce

performance indicators at the end of November 2015.

17. iMerseyside has highlighted that their high turnover rates is as a result of a TUPE transfer in the last 12 months.

18. Offender Health has highlighted that their high turnover rate is as a result of the HMP Liverpool staff transfer to Lancashire Care NHS Foundation Trust.

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19. The workforce directorate has been asked to review reasons for the ongoing

increases in turnover rates.

20. Performance against the additional staffing indicator is detailed in the table on page 5. The position reported relates to October 2015 as a timelag of one month is built into the process to enable timesheets to be supplied to additional staffing and entered onto the system (giving the “Actual hours” position, item C). This indicator enables the trust to identify the extent to which additional staffing usage is ensuring safe staffing levels within inpatient settings but also supports monitoring of potential over-use. The thresholds are as follows:

a. Green: The percentage of bank and agency usage is between 98% and 102% of that required.

b. Amber: The percentage of bank and agency usage is between 95% to 98% OR between 102% and 105% of that required.

c. Red: The percentage of bank and agency usage is less than 95% of that required OR more than 105% of that required.

21. The number of shifts filled by bank and agency against requirement improved during

October when compared with the figure reported for September 2015 (75.88%).

22. Performance against the doctor job plans indicator is detailed in the table below. An agreed job plan ensures the most effective / productive use of medical resource. Job plans outline the programmed activities of medical staff and help to ensure the organisation has the right number of doctors to meet the needs of our service users. Performance is detailed in the table below. The performance thresholds are: >=95% green; >=85% amber; <= 85% red with the target of 95%.

Doctor Job Plans Reviewed and Signed Off in the last 12 months – Month 8 2015/16

23. Improvements have been achieved for the following indicators:

a. Mandatory training b. Completion of PACE c. Actual bank and agency utilisation

Number of hours covered -

safe staffing

Number of hours required -

safe staffing

Number of hours covered

by bank and agency - bank system (Actual

Hours)

Number of hours covered

by core staff (A - C)

Number of hours bank and

agency required(B - D)

Variance between bank

and agency required and used (R - C)

% bank and agency used versus that

required (C/R)Division A B C D R X %Trust Wide (Clinical divisions only) 167779 170261 28684 139096 31166 2482 92.04%Local 80849 81821 15796 65053 16768 972 94.20%Secure 86930 88440 12888 74042 14398 1510 89.51%

Divisional positions Numerator Denominator % Indicator value MovementLocal 40 64 62.50%

Secure 20 25 80.00%

Corporate 1 1 100.00%

Total 61 90 67.78%

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d. Staff sickness (in-month) e. Well structured personal development review

24. Performance against the safeguarding training indicators is reported quarterly.

Compliance rates for Q2 2015/16 are detailed in the table on page 6.

25. To ensure compliance with safeguarding training within the secure division an action

plan has been produced.

26. In summary, high secure services have implemented level 1 training on secure induction to cover high secure specific policy requirements (additional to corporate level 1 e-learning), level 2 e-learning and level 3 face to face safeguarding training for eligible practitioners. Two further training sessions for Level 3 Adults/Children have been identified for 2015 to capture the non compliance of current staff and new staff band 6 and above who have been employed by HSS. Two adhoc level 2 and level 3 safeguarding adult/children training sessions have taken place in May 2015 for the medium secure services. Training dates for level 2 and level 3 for medium, low and offender health secure services have been arranged up until December 2015.

Key Performance Indicator

Reference

Key Performance Indicator Target/Description

ReportingFrequency Target/Thresholds Trust Wide Trend Movement Local Services

Division Trend Movement Secure Services Division Trend Movement

WTRACOM10

Percentage of all identified staff who have received Level 2 adult safeguarding

training within the past three years (local services).


Commissioner target: >=80% green; <80% red. 80.16% 80.16%

WTRACOM11

Percentage of all identified staff who have received Level 3 adult safeguarding




WTRACOM12Percentage of all staff who have received Level 1 child safeguarding training within

the past three years (local services).


Commissioner target: >=90% green; <90% red 96.14% 96.14%

WTRACOM13

Percentage of all identified staff who have received Level 2 child safeguarding




WTRACOM14

Percentage of all identified staff who have received Level 3 child safeguarding




WTRACOM16

Percentage of all identified staff (in line with training needs analysis and policy) who have completed Prevent Awareness raising training in the past three years

(local services).


Commissioner target: >=90% green by Q4 2015/16; <90% red. 53.26% 53.26%

WTRACOM18Percentage of all staff who have received Level 1 adult safeguarding training within the past three years (secure services).


>=90% green; <90% red. 97.42% 97.42% WTRACOM19

Percentage of all staff who have received Level 1 child safeguarding training within the past three years (secure services).



Percentage of all identified staff who have received Level 2 adult safeguarding training within the past three years

(secure services).



Percentage of all identified staff who have received Level 2 child safeguarding training within the past three years

(secure services).



Percentage of all identified staff who have received Level 3 adult safeguarding training within the past three years

(secure services). Only applicable to ML&OH staff.

Quarterly (In Quarter) >=90% green; <90% red. 91.69% 91.69%

WTRACOM23

Percentage of all identified staff who have received Level 3 child safeguarding training within the past three years

(secure services).



Percentage of all staff who have received Level 1 adult safeguarding training within

the past three years (local services).


Commissioner target: >=90% green; <90% red 96.19% 96.19%

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27. It is expected that medium, low and offender health secure services will achieve the target of 95% by 20 November 2015. Further information can be found in Appendix 4.

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Employee Relations Activity 28. The charts below summarise employee relations activity, Quarter 2 2015/16.

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Top Reasons for Disciplinary – Q2 2015/16

Local

• Theft / Fraud / Misrepresentation - 5 • Negligent in performance of duties - 2 • Verbal abuse / inappropriate language – staff - 1 • Confidentiality - 1 • Relationship / boundary issues - 1 • Medication error – 1

Secure

• Relationship / boundary issues – 2 • Failure to comply with a reasonable request – 2 • Other breach of Trust policy - 2 • Verbal abuse / inappropriate language – staff - 1 • Threatening / menacing / inappropriate behaviour – staff - 1 • Threatening / menacing / inappropriate behaviour - patient(s) - 1 • Smoking / alcohol / substance misuse – 1

Corporate

• Other breach of Trust policy - 2 • Negligent in performance of duties – 1

Disciplinary Hearing Outcomes – Q2 2015/16 Outcomes Q2 2015/16 No case to answer 2 No further bank shifts offered 1 Informal process agreed 1 First written warning 3 Dismissal 5 Total 12 Staff Friends and Family Test Indicator Q2 2015/16 Benchmarking

29. The table below provides an overview of the trust’s and divisions’ performance in

comparison with the national Q2 2015/16 results for mental health/ learning disability trusts and the national data for England for the Q2 2015/16 staff friends and family test following the publication of this data by NHS England.

30. The data for the mental health/ learning disability trusts does not include the Isle of Wight NHS Trust or Taunton and Somerset NHS Foundation Trust as the data for these trusts do not separately identify the mental health sector.

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Organisation

Percentage

Recommended (place to work)

Percentage Not Recommended (place to work)

Percentage Recommended (receive care)

Percentage Not Recommended (receive care)

Mersey Care NHS Trust 56% 25% 70% 13%

Local Division Services 50% 28% 66% 17%

Secure Division Services 49% 34% 68% 14%

Corporate Services 63% 18% 77% 7%

iMerseyside 89% 6% 81% 3%

MH / LD maximum 86% 44% 87% 26% MH / LD upper quartile 66% 27% 77% 14%

MH / LD median average 58% 22% 71% 9%

MH / LD mean average 59% 23% 71% 11%

MH / LD lower quartile 51% 18% 66% 7%

MH / LD minimum 36% 7% 48% 0% England maximum 90% 61% 100% 27% England upper quartile 70% 25% 86% 10%

England median average 63% 18% 80% 6%

England mean average

62% 20% 78% 7%

England lower quartile 54% 13% 70% 3%

England minimum 21% 3% 48% 0% 31. The trust’s results for the percentage of staff who would recommend the trust as a

place to work and as a place to receive care has deteriorated when compared with Q1 2015/16 results.

32. The trust is below the national average (median) of all mental health/ learning disability trusts for the percentage of staff who would recommend the trust as a place to work. This is a deterioration when compared with Q1 2015/16 benchmarking comparisons.

33. The trust is slightly below the national average (median) of all mental health/ learning disability trusts for the percentage of staff who would recommend the trust as a place to receive care. This is consistent when compared with Q1 2015/16 benchmarking comparisons.

34. The trust is below the England average (median) for the percentage of staff who would recommend the trust as a place to work and as a place to receive care. The

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England data in the table relates to all trusts regardless of type. This remains consistent when compared with Q1 2015/16 benchmarking comparisons.

35. The table below provides a direct comparison between the trust and the other

providers of high secure services. The trust is ranked second when compared with the other high secure providers in relation to both elements.

Organisation Percentage

Recommended - Work

Percentage Not

Recommended - Work

Percentage Recommended

- Care

Percentage Not

Recommended - Care

Mersey Care NHS Trust 56% 25% 70% 13%

Nottinghamshire Healthcare NHS Trust

66% 16% 74% 7%

West London Mental Health NHS Trust 47% 32% 48% 22%

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Summary of key workforce performance indicators – November 2015

Head of Performance Improvement and Customer Relationship Management Wendy Copeland-Blair

Staff Plan Objective Indicator Target Trust Wide Trust Wide Movement Local Division

Local Division

Movement Secure Division Secure Division

Movement Corporate Division

Corporate Division

Movement iMerseyside iMerseyside

Movement

Corporate induction (within three months of start date)

Q1 >=75% green; <75% red. Q2 >=80% green; <80% red. Q3 >=85% green; <85% red. Q4 >=90% green;

<90% red. 73.08% 20.00% 50.00% 100.00% 75.00%

Mandatory training

Internal: >=95% green; <95% red. Low secure and Medium secure: 100% green; >=85% amber; <85% red. Secure division (quality schedule): >=95% green; <95%

red.

96.30% 96.21% 96.35% 95.56% 99.53%

Actual bank and agency utilisation versus required based on staffing levels on wards and demand (defined by levels of observations and escorts).

Green: The percentage of bank and agency usage is between 98% and 102% of that required. Amber: The

percentage of bank and agency usage is between 95% to 98% OR between 102% and 105% of that required.

Red: The percentage of bank and agency usage is less than 95% of that required OR more than 105% of that

required.

92.04% 94.20% 89.51%

Monitoring of WTE against workforce plans

Variance from plan is within 5% (positive or negative) = green; Variance from plan is between 5% and 10%

(positive or negative) = amber; Variance from plan is greater than 10% = red.

-6.67% -7.33% -5.22% -7.98% -6.19%

Staff turnover 8% -12% green; 5% - 8% or 12% - 15% amber; <5% or >15% red 13.41% 13.53% 13.15% 14.51% 11.39%

Objective 2: Health and Wellbeing Staff sickness (in month) <=4.8% green; <=5.8% amber; >5.8% red 6.34% 6.52% 7.12% 3.77% 2.02%

Completion of PACE

Low and Medium Secure: 100% green; >=85% amber; <85% red. High Secure: >=90% green; <90% red.

Local targets: Q1 (April-June) Corporate, iMerseyside and Secure Divisions: >=95% green <95% red. Local Division: >=80% green; <80% red. Trust wide: >=89% green <89% red. Q2 (July to September) trust; >=95%

green <95% red

85.85% 78.13% 89.72% 91.89% 100.00%

Medical staff appraisal in line with revalidation standards (2013/14) >=95% green; >=85% and <95% amber; <85% red 100.00% 100.00% 100.00% 100.00%

Well structured PACE >=47 green; >=41 amber; <41 red 56.59 53.78 48 69.49 73.44

Percentage of staff who would recommend the trust as a place to work

Green >=67% (upper quartile); Amber >=56% (median average for England MH/LD) ; Red <56%. 56.18% 49.75% 48.62% 62.64% 88.89%

Percentage of staff who would recommend the trust as a place to receive treatment

Green >=77% (upper quartile); Amber >=70% (median average for England MH/LD); Red <70%. 70.34% 65.82% 67.57% 77.14% 80.56%

Notes:

Additional staffing performance as at 30 November 2015 was 100%.iMerseyside has highlighted that the nature of their business requires flexibility in terms of covering vacancies with agency staff.

Objective 1: Workforce

Objective 4: Staff satisfaction and engagement

Objective 3: Reward and Recognise

In respect of the completion of PACE indicator; if additional staffing was not included in the figures then the trust's position would be 84.95% and the corporate division position would be 88.64%.

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Appendix 1 – Team Level Sickness Absence Exceptions

Division Service Line Team

FTE in year (FTE Days Available /

365)

Long term rolling twelve

months

Short term rolling twelve

months

Total rolling twelve months

Corporate Services 350 L3 Clinical Governance, Quality & Innovation (CORCQI) 350 L9 Clinical Audit (AHB855) 2.10 18.43% 2.88% 21.31%Corporate Services 350 L3 Clinical Governance, Quality & Innovation (CORCQI) 350 L9 Equality & Diversity (AHC360) 2.11 0.00 7.58% 7.58%Corporate Services 350 L3 Clinical Governance, Quality & Innovation (CORCQI) 350 L9 Medical Training (AHP440) 1.73 9.08% 0.00 9.08%Corporate Services 350 L3 Corporate Governance & Business Development (CORGDB) 350 L9 Business Development (A3NN20) 4.39 3.87% 2.44% 6.31%Corporate Services 350 L3 Corporate Governance & Business Development (CORGDB) 350 L9 Communications (AHG200) 6.66 6.75% 0.82% 7.57%Corporate Services 350 L3 Corporate Governance & Business Development (CORGDB) 350 L9 FTE Membership (AHG205) 1.00 41.64% 5.75% 47.40%Corporate Services 350 L3 Estates & Facilities (CORFES) 350 L9 Administration Management (AHB550) 2.85 26.32% 2.02% 28.34%Corporate Services 350 L3 Estates & Facilities (CORFES) 350 L9 Catering Broadoak (Z2BD30) 2.03 0.00 5.07% 5.07%Corporate Services 350 L3 Estates & Facilities (CORFES) 350 L9 Clock View Site Management (Z2CN70) 20.54 5.47% 2.55% 8.02%Corporate Services 350 L3 Estates & Facilities (CORFES) 350 L9 FMA's Broadoak (Z2BA30) 14.72 8.54% 3.33% 11.87%Corporate Services 350 L3 Estates & Facilities (CORFES) 350 L9 FMA's Mossley Hill (Z2BA20) 25.70 5.81% 1.89% 7.70%Corporate Services 350 L3 Estates & Facilities (CORFES) 350 L9 FMA's Norris Green (Z1SH15) 1.84 35.87% 4.08% 39.95%Corporate Services 350 L3 Estates & Facilities (CORFES) 350 L9 FMA's Southport (Z2CN65) 11.86 6.88% 2.53% 9.41%Corporate Services 350 L3 Estates & Facilities (CORFES) 350 L9 General Estates (AHB700) 3.91 8.19% 1.12% 9.31%Corporate Services 350 L3 Estates & Facilities (CORFES) 350 L9 Hospital Assistants Rathbone (Z2BA40) 14.85 3.74% 2.56% 6.30%Corporate Services 350 L3 Estates & Facilities (CORFES) 350 L9 Mossley Hill Site Management (Z2GA30) 2.00 6.16% 4.52% 10.68%Corporate Services 350 L3 Estates & Facilities (CORFES) 350 L9 Switchboard (AHB510) 6.67 5.57% 1.40% 6.97%Corporate Services 350 L3 Informatics & Performance Improvement (CORIPI) 350 L9 IT Systems (AHB253) 6.64 4.33% 0.52% 4.85%Corporate Services 350 L3 Informatics & Performance Improvement (CORIPI) 350 L9 Project Managment Office (AHB405) 6.42 4.01% 1.84% 5.85%Corporate Services 350 L3 Workforce (CORWKF) 350 L9 E-Rostering (AEB205) 3.67 7.02% 1.63% 8.65%Corporate Services 350 L3 Workforce (CORWKF) 350 L9 Health & Wellbeing (ALB400) 6.23 11.12% 2.55% 13.67%Corporate Services 350 L3 Workforce (CORWKF) 350 L9 Resus/ECT (AEB440) 0.67 54.10% 8.20% 62.30%Informatics Merseyside 350 L3 IM 350 L9 IM DALLAS QIPP (HIS975) 3.73 17.59% 2.16% 19.75%Informatics Merseyside 350 L3 IM 350 L9 IM PPM (HIS650) 17.23 3.50% 1.35% 4.85%Informatics Merseyside 350 L3 IM 350 L9 IM Training (HIS700) 11.77 4.60% 2.89% 7.50%Informatics Merseyside 350 L3 IM 350 L9 IM Web Development (HIS675) 4.82 5.34% 2.61% 7.96%Informatics Merseyside 350 L3 IM 350 L9 Primary Care Facilitators (HIS660) 1.98 8.54% 4.93% 13.48%Local Services 1.Assessment Services 350 L9 Criminal Justice Liaison Team (Z1AF95) 24.90 6.67% 1.29% 7.96%Local Services 1.Assessment Services 350 L9 Ect Broadoak (Z1AF60) 1.46 34.30% 4.87% 39.17%Local Services 1.Assessment Services 350 L9 Hospital Liaison (Z1AB70) 3.56 14.00% 2.15% 16.15%Local Services 1.Assessment Services 350 L9 Mental Health Team (Z1AH10) 31.45 5.75% 4.24% 9.99%Local Services 2.Specialist Services 350 L9 19a Olive Lane (Z1FY74) 2.57 11.31% 2.30% 13.61%Local Services 2.Specialist Services 350 L9 22 The Oaks (Z1FY89) 5.29 3.69% 1.41% 5.09%Local Services 2.Specialist Services 350 L9 53a Borrowdale Road (Z1FY67) 2.62 41.81% 0.00 41.81%Local Services 2.Specialist Services 350 L9 Addictions Management (Z1LK50) 7.72 2.27% 2.77% 5.04%Local Services 2.Specialist Services 350 L9 Biu Senior Medical Staff (Z1BK10) 1.71 10.56% 0.00 10.56%Local Services 2.Specialist Services 350 L9 Brain Injury Support (Z1BK90) 25.93 3.62% 2.13% 5.76%Local Services 2.Specialist Services 350 L9 Brook Place (Z1HJ10) 16.97 6.40% 1.21% 7.60%Local Services 2.Specialist Services 350 L9 Care Pack Infrastructure (Z1FY62) 2.56 6.52% 3.42% 9.94%

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365)


months


months


Local Services 2.Specialist Services 350 L9 Central Liverpool (Z1FA10) 8.56 4.10% 2.02% 6.12%Local Services 2.Specialist Services 350 L9 D.A.R.T. (Z1LK46) 17.38 5.85% 2.60% 8.45%Local Services 2.Specialist Services 350 L9 DRR Green Lane (Z1LK54) 3.88 6.92% 0.78% 7.69%Local Services 2.Specialist Services 350 L9 Liverpool Community Alcohol Service (Z1AB91) 11.99 7.31% 2.42% 9.73%Local Services 2.Specialist Services 350 L9 Morley Road (Z1NW22) 8.87 6.99% 1.98% 8.96%Local Services 2.Specialist Services 350 L9 Moss Lane (Z1NW57) 6.67 2.42% 3.90% 6.32%Local Services 2.Specialist Services 350 L9 Neuropsychiatry Trauma Pathway (Z1BK11) 0.67 0.00 8.20% 8.20%Local Services 2.Specialist Services 350 L9 Rathbone Rehab Centre (Z1BG11) 31.71 6.90% 4.13% 11.04%Local Services 2.Specialist Services 350 L9 Speech Therapy Learning Dis. (Z2AA30) 1.59 14.99% 4.36% 19.35%Local Services 2.Specialist Services 350 L9 Star Unit Mossley Hill (Z1FY30) 27.85 7.52% 3.97% 11.49%Local Services 2.Specialist Services 350 L9 Support Team Ns (Z1NW63) 11.60 6.43% 0.80% 7.23%Local Services 2.Specialist Services 350 L9 Windsor Clinic (Z1AB77) 23.67 4.69% 1.18% 5.87%Local Services 2.Specialist Services 350 L9 Windsor Community Team (Z1AB83) 4.08 18.26% 0.00 18.26%Local Services 3.Adult Mental Health Services 350 L9 64 Wadham Road (Z1BN75) 3.63 3.81% 6.39% 10.21%Local Services 3.Adult Mental Health Services 350 L9 Albert Ward (Z1AB11) 25.84 10.50% 2.53% 13.03%Local Services 3.Adult Mental Health Services 350 L9 Alt Ward (Z1AB71) 25.06 5.04% 2.42% 7.46%Local Services 3.Adult Mental Health Services 350 L9 Arundel Cmht (Z1AH28) 34.45 6.12% 2.09% 8.20%Local Services 3.Adult Mental Health Services 350 L9 Assertive Outreach Team (Z1AD24) 7.13 4.69% 0.77% 5.46%Local Services 3.Adult Mental Health Services 350 L9 Brunswick Ward (Z1AE11) 28.17 4.91% 3.01% 7.92%Local Services 3.Adult Mental Health Services 350 L9 Cavendish Road (Z1BN55) 3.48 10.24% 4.96% 15.20%Local Services 3.Adult Mental Health Services 350 L9 Cmht Nrth Liverpool & Kirkby (Z1AD18) 12.90 5.18% 2.25% 7.43%Local Services 3.Adult Mental Health Services 350 L9 Community Clinic Team (Z1AD10) 2.00 30.27% 0.41% 30.68%Local Services 3.Adult Mental Health Services 350 L9 Dee Ward (Z1AB74) 20.13 4.64% 3.65% 8.29%Local Services 3.Adult Mental Health Services 350 L9 Glenwyllin Road (Z1BN60) 3.11 2.99% 2.87% 5.86%Local Services 3.Adult Mental Health Services 350 L9 Haigh Road Cmht (Z1AH26) 15.72 7.76% 2.34% 10.10%Local Services 3.Adult Mental Health Services 350 L9 Harrington Ward (Z1AD11) 30.33 5.99% 4.26% 10.25%Local Services 3.Adult Mental Health Services 350 L9 Health & Wellbeing Centre (Z1AF93) 2.92 10.59% 3.19% 13.77%Local Services 3.Adult Mental Health Services 350 L9 Ld Aspergers Team (Z1FA05) 6.00 14.52% 2.83% 17.35%Local Services 3.Adult Mental Health Services 350 L9 Liverpool Acute Services Manager (Z1WA14) 8.18 3.99% 2.11% 6.10%Local Services 3.Adult Mental Health Services 350 L9 Liverpool Operational (Z1AF90) 7.74 12.96% 3.78% 16.74%Local Services 3.Adult Mental Health Services 350 L9 Moorgate Avenue (Z1BN70) 4.00 21.58% 2.05% 23.63%Local Services 3.Adult Mental Health Services 350 L9 Morris Ward (Z1AB73) 27.01 5.02% 2.33% 7.35%Local Services 3.Adult Mental Health Services 350 L9 PAC Office (Z1AA45) 6.14 0.47% 5.76% 6.23%Local Services 3.Adult Mental Health Services 350 L9 Psychotherapy (Z1EH90) 11.15 4.73% 0.40% 5.12%Local Services 3.Adult Mental Health Services 350 L9 Rathbone Dir.Support (Z1BG90) 5.46 10.44% 2.36% 12.80%Local Services 3.Adult Mental Health Services 350 L9 Regent Road Crosby (Z1BN65) 3.27 9.56% 0.00 9.56%Local Services 3.Adult Mental Health Services 350 L9 Windsor Cmht (Z1AH32) 22.24 4.23% 1.24% 5.47%Local Services 3.Adult Mental Health Services 350 L9 Windsor House (Z1AA11) 29.60 5.86% 2.31% 8.16%

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365)


months


months


Local Services 4.Complex Care Services 350 L9 Boothroyd Ward SGI (Z1NW33) 22.66 2.53% 2.83% 5.36%Local Services 4.Complex Care Services 350 L9 Heys Court (Z1CH75) 25.04 5.13% 3.25% 8.38%Local Services 4.Complex Care Services 350 L9 Irwell Ward (Z1AB31) 27.20 5.12% 2.24% 7.37%Local Services 4.Complex Care Services 350 L9 Medical North Sefton Older Persons (Z1NW85) 3.00 6.68% 0.27% 6.96%Local Services 4.Complex Care Services 350 L9 Mossley Hill Oak Ward (Z1CH21) 26.18 4.76% 2.58% 7.34%Secure Services 350 L3 High Secure Services Directorate (SECHSS) 350 L9 Arnold Ward (AEB981) 35.98 9.12% 3.84% 12.96%Secure Services 350 L3 High Secure Services Directorate (SECHSS) 350 L9 Blake Ward (AEB301) 38.63 9.47% 2.78% 12.26%Secure Services 350 L3 High Secure Services Directorate (SECHSS) 350 L9 Carlyle Ward 2008 (AEB661) 30.18 12.38% 2.96% 15.34%Secure Services 350 L3 High Secure Services Directorate (SECHSS) 350 L9 Central Clerical Services (AEB510) 25.81 3.64% 1.62% 5.26%Secure Services 350 L3 High Secure Services Directorate (SECHSS) 350 L9 Clinical Support Office (AEB161) 11.20 3.72% 2.47% 6.19%Secure Services 350 L3 High Secure Services Directorate (SECHSS) 350 L9 Dickens Ward General (AEB351) 26.18 8.55% 2.53% 11.08%Secure Services 350 L3 High Secure Services Directorate (SECHSS) 350 L9 Forster Ward General (AEB871) 29.19 6.19% 3.37% 9.57%Secure Services 350 L3 High Secure Services Directorate (SECHSS) 350 L9 Gibbon Ward General (AEB371) 31.76 10.08% 2.42% 12.50%Secure Services 350 L3 High Secure Services Directorate (SECHSS) 350 L9 Hazlitt Ward General (AEB851) 4.42 17.69% 3.91% 21.59%Secure Services 350 L3 High Secure Services Directorate (SECHSS) 350 L9 Health Centre (AEB420) 10.91 4.67% 3.46% 8.14%Secure Services 350 L3 High Secure Services Directorate (SECHSS) 350 L9 Health and Fitness (AEG805) 11.25 3.17% 1.97% 5.14%Secure Services 350 L3 High Secure Services Directorate (SECHSS) 350 L9 High Secure Catering (AGA500) 17.38 7.28% 2.18% 9.46%Secure Services 350 L3 High Secure Services Directorate (SECHSS) 350 L9 High Secure Domestic Services (AKA500) 33.49 7.58% 1.63% 9.20%Secure Services 350 L3 High Secure Services Directorate (SECHSS) 350 L9 Johnson Ward General (AEB331) 35.30 5.33% 2.66% 7.99%Secure Services 350 L3 High Secure Services Directorate (SECHSS) 350 L9 Keats Ward General (AEB831) 38.33 4.27% 2.55% 6.82%Secure Services 350 L3 High Secure Services Directorate (SECHSS) 350 L9 Lawrence Ward (AEB941) 36.98 5.91% 1.60% 7.51%Secure Services 350 L3 High Secure Services Directorate (SECHSS) 350 L9 Owen Ward General (AEB881) 32.05 6.58% 3.09% 9.68%Secure Services 350 L3 High Secure Services Directorate (SECHSS) 350 L9 Patients Education (AEH300) 3.91 8.61% 5.81% 14.42%Secure Services 350 L3 High Secure Services Directorate (SECHSS) 350 L9 Rec & Leisure (AGF720) 7.67 3.93% 1.79% 5.72%Secure Services 350 L3 High Secure Services Directorate (SECHSS) 350 L9 Ruskin Ward General (AEB841) 26.10 2.08% 3.00% 5.08%Secure Services 350 L3 High Secure Services Directorate (SECHSS) 350 L9 Security Reception (AEB608) 44.07 4.03% 2.38% 6.40%Secure Services 350 L3 High Secure Services Directorate (SECHSS) 350 L9 Security Training (AEB615) 3.30 9.97% 0.00 9.97%Secure Services 350 L3 High Secure Services Directorate (SECHSS) 350 L9 Shelley Ward General (AEB811) 26.62 5.28% 2.76% 8.04%Secure Services 350 L3 High Secure Services Directorate (SECHSS) 350 L9 Tennyson Ward General (AEB311) 40.73 5.41% 3.38% 8.79%Secure Services 350 L3 High Secure Services Directorate (SECHSS) 350 L9 Therapy Suite Escorts (AFP555) 4.44 13.34% 0.86% 14.21%Secure Services 350 L3 High Secure Services Directorate (SECHSS) 350 L9 Tilt Work Escorts (APA890) 1.00 67.12% 0.00 67.12%Secure Services 350 L3 High Secure Services Directorate (SECHSS) 350 L9 Union (AEB577) 1.67 27.26% 0.00 27.26%Secure Services 350 L3 High Secure Services Directorate (SECHSS) 350 L9 Vocational Training Centre (AEG809) 10.93 6.00% 1.06% 7.06%Secure Services 350 LOW SECURE UNIT 350 L9 Low Secure Unit Allerton Ward (Z1BG51) 28.01 9.25% 2.74% 11.99%Secure Services 350 LOW SECURE UNIT 350 L9 Low Secure Unit Childwall Ward (Z1BG61) 28.93 8.31% 4.14% 12.46%Secure Services 350 LOW SECURE UNIT 350 L9 Low Secure Unit O.T. Rathbone (Z2AE60) 2.41 13.76% 3.03% 16.79%Secure Services 350 MEDIUM SECURE UNIT 350 L9 Hawthorne Ward (SCF300) 23.98 3.54% 2.22% 5.75%Secure Services 350 MEDIUM SECURE UNIT 350 L9 Ivy Ward (SCF200) 30.77 5.11% 3.33% 8.44%Secure Services 350 MEDIUM SECURE UNIT 350 L9 Medium Secure Unit Sc Administration (SCFA00) 11.46 5.84% 2.47% 8.31%

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365)


months


months


Secure Services 350 MEDIUM SECURE UNIT 350 L9 Myrtle Ward (SCF400) 23.23 12.02% 2.37% 14.39%Secure Services 350 MEDIUM SECURE UNIT 350 L9 Olive Ward (SCF500) 25.46 8.64% 2.78% 11.42%Secure Services 350 MEDIUM SECURE UNIT 350 L9 Poplar Ward (SCF510) 33.38 11.20% 3.06% 14.26%Secure Services 350 MEDIUM SECURE UNIT 350 L9 Safe Cquin (SCF655) 2.64 3.43% 2.49% 5.92%Secure Services 350 MEDIUM SECURE UNIT 350 L9 Sc Control Room & Portering (SCFD00) 5.12 5.24% 0.32% 5.56%Secure Services 350 MEDIUM SECURE UNIT 350 L9 Sc Facilities Managment (SCFB00) 12.11 7.57% 1.33% 8.90%

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Appendix 2 – Local Division and Secure Inpatient Ward Graphs since April 2015

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Appendix 3 – Performance Improvement Plans Sickness absence Plan Action to date Action Required Timescale Progress and Update as at 16

November 2015 Improve timescales for inputting sickness absence into ESR

Initial benchmark review undertaken on 14/04/15 for period 01/12/14 to 31/01/15. 1:1 sessions to educate managers.

Continue to educate managers. Undertake additional review on a bi-monthly basis.

Ongoing June 2015

Di Hutton, Sickness Absence Advisor undertook a further review on 14 August 2015 for the period 01/02/2015 to 30/06/2015. This showed a compliance rate of 95% (+17.5% on benchmark).

Benchmark and improve compliance rates for completion of Return to Work interviews

Requested all Managers to send copies of Return to Work forms to Sickness Team for uploading onto central database for audit purposes.

Undertake initial benchmark review for month of March 2015. Undertake additional review on a bi-monthly basis.

May 2015 July 2015

This is reviewed on a monthly basis and July 2015 saw an improvement on the benchmark. Local division showed +9% on benchmark and secure division showed +22%.

RAG rate completion of Sickness Reviews (LTS & UA)

Sickness Team logs date review(s) due and the date they are undertaken. Outstanding actions are turned “red” after 14 days.

Continue to undertake 1:1 sessions with Managers to educate them on the monitoring process. Set thresholds for RAG rating. Create league tables in relation to Managers’ compliance.

Ongoing May 2015 July 2015

The unsatisfactory attendance reviews are continuing to be turned “red” after 14 days and “league tables” have been developed for the local division. The secure division has had no red actions for five consecutive months. Training sessions for all new managers are continuing.

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Plan Action to date Action Required Timescale Progress and Update as at 16 November 2015

Increase uptake of Staff Support / Physiotherapy services through early communication with staff

Sickness Team sends staff support and / or physiotherapy letters to relevant staff on “Day One” of their sickness absence. A log is kept of all support letters sent to staff.

Correlate Sickness Team’s log with Occupational Health’s records to establish the level of increase in uptake of staff support services.

September 2015

The sickness team continue to send letters to relevant staff on “day one”. Correlation with occupational health records needs to be undertaken. Di Hutton, Sickness Absence Advisor is meeting with Michelle Cunneelly, Trust Physiotherapist at the beginning of December 2015 to discuss the uptake of physio sessions.

Achieve and maintain Trust’s sickness absence target

Introduction of centralised sickness co-ordination team across two clinical divisions. Trust Target achieved as at 31/03/15.

Provide monthly sickness activity reports. Continue to robustly manage sickness absence in line with the Trust’s Management of Attendance Policy.

Monthly March 2016

Monthly and ad hoc sickness reports continue to be provided. Management of attendance continues to be robustly co-ordinated and is reflected in the 150% increase in staff on unsatisfactory attendance monitoring.

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Mandatory Training Actions to be taken include: • Quarter 1 - The attachment of mandatory training competencies to position level. • Quarter 2 - Ability to report from ESR on all organisational mandatory training. • Quarter 3 - Managers Self Service Access, providing managers with the ability to see and check their own and their staff’s level of training compliance. • Quarter 4 - Self Service to employee level, providing staff with the ability to see and check their own training records. A CEMT paper was presented to Board 22 October. It was agreed that from December 15th all the CEMT will be divided into nine Statutory subjects (HENW core skills framework) and seven that are locally driven mandatory subjects. We will continue to report nine statutory subjects to Team Managers through Divisional Boards monthly by exception (red) only and using inclusion and exclusion criteria for staff that are absent or have left the organisation. These subjects should remain at a 95% compliance over a period of 3 months post induction (not 28 days) and then at the required refresher period as stipulated by subject experts. Raw compliance data reporting will cease. We shall continue to report outstanding statutory training to the Board monthly as a percentage in terms of compliance through Care at a Glance. Statutory subjects are: 1. Fire Safety (face to face or e learning) 2. Manual Handling of Patients(clinical and secure) or manual handling of loads (non clinical) (all levels) (face to face and e learning) 3. Conflict resolution i.e. Managing Violence and Aggression – PSS modules for divisions (Face to face) 4. Equality and Diversity/ Human Rights (face to face or e learning) 5. Health and Safety (face to face or e learning) 6. Infection Control and prevention (face to face or e learning) 7. Safeguarding Adults and Children’s (face to face or e learning) 8. Information Governance – e learning only 9. Resuscitation i.e. Basic Life support/ First Aid (BLS) and Immediate Life Support –Role dependent (ILS) (Face to face only) Mandatory subjects will be reported monthly to the Board as a percentage completion rate. For the seven subjects staff will have a twelve month period to complete this training then ongoing compliance against the refresher period stipulated by subject specialists. There will be an annual review by the Board of a mandatory subject which the Board requires staff to complete within a specified time frame. Subject for 2015-2016 is suicide prevention training. Once launched, staff will have a six month period within which to complete. Reporting mandatory and Divisional Specific training to Divisional Boards will continue monthly to support supervision and to coincide with PACE reviews and at a compliance completion rate of 95%.

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Current mandatory subjects are: 1. Suicide Prevention – All staff priority completion within 6 months of launch and within 6 months of employment for all new starters. 2. Introduction to Dementia – All staff 3. Very Brief Advice on Smoking – All clinical staff 4. Carer Awareness – All staff 5. Fraud Awareness – All staff 6. Complaints Handling – All staff 7. Adverse Incidents – All staff We will report fully, annually to the Board compliance of the statutory, mandatory and divisional specific subjects which are specific within the organisations TNA plan and operational arrangements. We shall include a question relating to statutory and mandatory compliance within the PACE preparation questions. An ongoing review is being undertaken to align job/ role positions in ESR against the levels within statutory and mandatory training delivery, with a review of the methods of delivery of that learning across the Training Needs Analysis subjects. This will ensure a true blended learning approach to facilitate continuous improvement of staff skills and knowledge in these subjects.

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HR Systems Review Actions to be taken include:

• Quarter 1 – Map the Learning Management system to Trust TNA ensuring all training is captured within OLM, set training requirments against position, produce compliance reports down to individual by Department/Ward level.

• Quarter 2 – Establishment Control, input budgeted establishment from Finance for all

Divisions.

• Quarter 3 – Implement Establishment Control maintainence and refresh process and enable accurate vacancy reporting to support Values Based Recruitment direct from ESR.

• Quarter 4 – Refresh and cleanse OLM, realign to TNA/Prospectus. Implement Bank

Staff Roster module, expand roster use to include the whole Trust.

• Quarter 1 2016/17 – Continue Roster expansion, commence set up work for Self Service hierarchy

• Quarter 2 2016/17 – Continue Self Service set up work

• Quarter 3 2016/17 – ESR enhanced go live, Self Serv go live, project close

• Quarter 4 2016/17 – Lessons learnt, official project close documentation

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Personal Achievement and Contribution Evaluation (PACE) Quarter 1:

• Implement PACE version 2 (April). • Achieve performance trajectories completion (June):

o 95% compliance in Corporate and Secure Divisions o 80% compliance Local Division

Quarter 2:

• Achieve performance trajectories for completion (September): o 95% compliance Local Division o 95 % compliance whole Trust

Quarter 3:

• Evaluation of annual performance, process, system improvements. • Produce improvement plan 2016/17. • Conduct annual training needs analysis. • Produce learning and development plan.

Quarter 4:

• Implementation of improvement plan for development and preparation for PACE version 3.

Overall Trust compliance for October 2015 is 85.75% Secure Division – 88.08% Local Division – 78.44% Corporate Division – 89.20% Additional staffing – 100% iMerseyside – 100% In September the Diretor of Workforce sent letters to the Divisional Leads to remind them that all PACE reviews needed to be completed. A break down of their division’s compliance was provided by ward/department to enable the leads to target areas of concern. Throughout October and November the OE&L team have been contacting the managers and providing regular updates on team’s compliance. Support has continued for staff undertaking preparation, work with members of the OE&L team going to the various sites to provide this support. As at the 9th November, 665 staff had completed the PACE evaluation.

Questions % answered yes

% answered no

% did not answer

Do you feel valued after having your PACE and that your contribution to Perfect Care has been recognised?

77% 21% 2%

Do you understand your role and how it impacts Perfect Care?

95% 3% 2%

Do you understand how your behaviour can impact on patients, service users, carers and families?

98% 1% 1%

Do you feel supported in your role? 83% 16% 1% Do you feel confident in raising concerns? 89% 10% 1%

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This information will be used to inform the PACE training for 2016, eg. an emphasis will be placed on supporting reviewers to acknowledge the contribution that staff have made to Perfect Care and to help them understand how they can make their reviewees feel more valued during their PACE reviews. An improvement plan for PACE 2016 has been developed and will be presented to the IM&T committee in November 2015. This includes feedback taken from the system evaluation that was sent to all staff (63 responses). Information from the PDP section of the PACE has been collated to support the develoment of the annual Training Needs Analysis (TNA). This information is being used to identify training needs for the Trust and enable the production of the Learning and Development plan and prospectus. Work will continue with all teams to support them in achieving the 95% trajectory.

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Induction Actions to be taken include:

• Quarter 1: o Agree new process for the administration of passwords and email accounts for

new starters. o Create new starter lists on a monthly basis to escalate non completion prior to

non-compliance date.

Performance improvement trajectories:

• Quarter 1 - 75% • Quarter 2 - 80% • Quarter 3 - 85% • Quarter 4 - 95%

Work has be on-going throughout the year to improve the quality of the administration process for all new starters on their induction pathway.

• It has been agreed and implemented that all new starters will be issued with an email account through resourcing to allow for the allocation of the CEMT e-learning on completion of the 1 day Corporate Induction day.

• The process for the allocation of CEMT and confirmation of attendance on the induction has been updated. All attendees are recorded on ESR the week prior to their induction training date. They are recorded as completed following attendance or the reason for DNA. This will allow for accurate recording of data for reasons of non-attendance.

• Work is being carried out to improve the process of the SharePoint system between the resourcing and induction links. Phase 2 of the SharePoint system is currently in development. Meetings are taking place with other facilitators and key stakeholders to ensure that phase 2 of the system improves communication and the sharing of information of new starters. This is to ensure high quality recruitment and introduction to Mersey Care as a leading employer.

• An escalation process has been established.

Phase 1 – (21 days) email sent to new starter and their manager as a reminder to complete their CEMT and local induction paperwork via the SharePoint system within 1 week of starting employment.

Phase 2 – (28 days) a further reminder e-mail sent to comply with CEMT and Local paperwork within 5 working days.

Following a review Phase 3 has now been amended (40 days) is escalated to the L&D Facilitators and the L&D Manager. L&D facilitators will now offer individual information & support to the new starter / manager to aid completion.

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Performance Improvement Trajectories to date: The L&D Facilitators working within the Divisions will support new starters to complete the outstanding elements within the 90 day timeframe. This will be implemented from December 2015.

• Quarter 1 – target – 75% Achieved (Average score): Corporate Induction 1 day: 78.66% CEMT: 72.16%

• Quarter 2 – target – 80% Achieved (Average score): Corporate Induction 1 day: 95.04%

CEMT: 71.99%

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Appendix 4 – Secure Division Safeguarding In the Secure Division, the Head of Forensic Social Care/Nominated Officer for Safeguarding has operational responsibility to deliver effective safeguarding arrangements for adults detained in the Trust’s Secure Service’s. In High Secure Services this is in line with the established performance arrangements with commissioners. Training arrangements have been established within High Secure Services in conjunction with Sefton Local Authority. Training for Medium, Low and Offender Health is provided by the corporate Safeguarding Team in line with their partner Local Authorities. High Secure Services have implemented L1 training on Secure induction to cover specific policy HSS 34, (additional to corporate L1 e-learning), L2 e-learning and L3 face to face Safeguarding Training for eligible Practitioners. Two further training sessions for Level 3 Adults/Children have been identified for 2015 to capture the non compliance of current staff and new staff band 6 and above who have been employed by HSS. Training Compliance as at 31 May 2015

Training Compliance as at 30 September 2015

For non compliance of Medium Secure Services 95% target two adhoc Level 2 and 3 Safeguarding Adult/Children have taken place in May 2015. The offender Health non compliance is 1 member of staff who is committed to training in July. Training Dates for levels 2 and 3 are in place for Medium/Low and Offender Health up until December 2015. The present training provision is being reviewed with a Trust wide level 2 e-learning package (either the present one amended or the “Skills for Health” Package) to be used and level 3 training to be adapted to ensure all areas of the Trust are covered in the corporately provided training.

Level 1 96.00% 81.74% 100.00% 95.28%Level 2 94.00% 88.52% 98.53% 91.11%Level 3 100.00% 87.50% 97.06% 90.91%

Commissioners Target 95% Current % Compliant

High Secure Services

Medium Secure

ServicesLow Secure

Services

Offender Health (Garth)

Level 1 98.90% 92.31% 96.34% 95.83%Level 2 96.83% 88.89% 92.86% 82.61%Level 3 95.04% 88.94% 95.71% 82.61%

Commissioners Target 95% Current % Compliant

High Secure Services

Medium Secure

ServicesLow Secure

Services

Offender Health (Garth)

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Secure Division new employees are required to complete appropriate levels of training for their job role. This is reflected upon commencement of employment on the Electronic Staffing Roster (ESR). There has recently been an influx of 91 new starters across the secure division which have had an impact on our training compliance figures.

Key Issues • HSS 34, The Policy & Procedure for Safeguarding Adults, applies to all staff in High Secure Services • The Policy covers all contact with adults at risk. • The Policy should be read in conjunction with the Mersey Care Trust Policy for Safeguarding Vulnerable Adults from Abuse (SD17), May 2015 and Sefton Borough Council Safeguarding Adults Policy.

Associated Trust Policies and Procedures: • Protection of vulnerable adults (SD17) to be read and applied in conjunction with Local Authority Safeguarding Procedures • Concerns at work about patient care or matters of business misconduct (whistle blowing) HR06 • Guidelines on referral to the police and related disclosure of service user Information HSS 9 • Patients Complaints SA 06



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Report provided (check necessary boxes): Paper No: Care at a Glance Supporting Paper

To Note: ☐ For Assurance: ☒ Report to: Executive Committee

For Decision: ☐ For Consent: ☒ Meeting Date: December 2015

Update on Strategic Initiatives

Accountable Director(s): Jim Hughes, Director of Informatics & Performance Improvement

Report Author(s): Justine Maher

Alignment to the Trust’s Strategic Objectives: (listed by the 4 Strategic Aims)

Our Services

☐ Safe care ☐ Timely care ☒ Effective care

☐ Equitable care ☐ Person-centred care

Our People ☐ Supportive and effective teams ☐ A productive workforce with

the right skills ☐ Working side by side with service users and users

Our Resources ☐ Save time and money ☐ Buildings that work for us ☐ Technology that helps us

provide better care

Our Future ☐ Work effectively with primary care and other organisations ☐


☐ Grow our services

Purpose of Report:

• To provide an overview of the transformation programme across the three divisions and its ability to deliver the Strategic Framework.

• To provide the highlight reports from each of the programmes to allow the Executive Committee to understand the progress on each programme and summary risks and issues to date.

Summary of Key Issues:

• Local Division – Recruitment to the transformation programme continues with appointments having been made in the previous month and interviews for a role during December to ensure programme resources meet needs. The division's cost pressure paper was combined with the corporate and secure transformation programme and submitted at the end of November. Further development of the Local Division Transformation plan has taken place and v 2.0 has been produced, the plan is being further scrutinied in line with the development of a benefits plan and critical path analysis. The Community, Inpatient and Specialist redesign projects each contain a number of work streams, in Appendix A, a summary of the RAG status for each can be found. The highlight reports and milestone plan in Appendix B have informed the overall RAG status and the Trust strategy plan in Appendix C.

• Secure Division – Progress on the secure campus development continues with the current plan to deliver a paper to be used as an internal SoC to Trust Board in January. The schedule of accommodation has been prepared, an initial costing has been provided and a workforce plan is being reviewed for it's fitness for purpose under the potential addition of LD MSU beds to the project. The review of therapeutic interventions is currently rated as



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RED due the uncertainty around the review of psychological services and the ability for the potntial workforce model to deliver the interventions described in the review. The reconfiguration of Admission, HDU and rehab are all currently being developed with a new lead being appointed to the reconfiguration of HSS rehabilitation. The review of observations is complete and a paper has been compiled.

• Corporate Division – The ten corporate projects this month

report as two projects being rated green and eight as amber. Projects are generally progressing in line with milestones and plans declared in the reporting process. The recent grouping of projects for reporting purposes seems to be working well with the projects showing similar levels of compliance against their milestones and plans.

• Outcome Measures –

Recommendation:

The Committee is asked to: 1) Review the highlight reports and milestone plans to understand

progress so far and the next steps required 2) Provide a Trust wide view on risks and issues raised by the

programmes 3) Question the ability to deliver the strategic programme and

associated CIP targets

Next Steps: (Subject to recommendation being accepted)

The Programme management office will continue to monitor the progress of the transition plans and provide support as necessary, as well as providing assurance reports to this committee.

Previously Presented to:

Committee Name Date (Ref) Title of Report Outcome / Action

Do the action(s) outlined in this paper impact on any of the following issues? Area Yes None If ‘Yes’, outline the consequence(s) (providing further detail in the report)

Patient Safety ☐ ☒

Clinical Effectiveness ☐ ☒

Patient Experience ☐ ☒

Operational Performance ☐ ☒

CQC Compliance ☐ ☒

NHS TDA Ratings ☐ ☒

Legal / Requirements ☐ ☒

Resource Implications ☐ ☒



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(financial or staffing)

Equality and Human Rights Analysis Yes No N/A

Do the issue(s) identified in this document affect one of the protected group(s) less or more favourably than any other? ☐ ☒ ☐

Are there any valid legal / regulatory reason(s) for discriminatory practice? ☐ ☒ ☒ If answered ‘YES’ to either question, please include a section in the report explaining why

Does this paper provide assurance in respect of delivery of our Equality Delivery System goals and objectives (if it does please click the appropriate ones below)

EDS 1.2 - Individual people’s health needs are assessed and met in appropriate ways ☐

EDS 1.4 – When people use NHS services their safety is prioritised and they are free from mistakes, mistreatment and abuse

☒

EDS 2.2 – People are informed and supported to be as involved as they wish to be in decisions about their care

☐ EDS 2.3 – People report positive experiences of the NHS ☐

Does this paper provide assurance in respect of a new / existing risk (if appropriate) Area New Existing N/A If new or existing, please indicate where the risk is described

Type of Risk ☐ ☐ ☒ Board Assurance & Escalation Framework ☐ Organisational

Risk Register ☐ Divisional Risk Register ☐

Risk Reference / Description: (only include reference to the highest level framework / register)



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MERSEY CARE NHS TRUST

Update on Strategic Initiatives

PURPOSE

1. To provide an overview of the transformation programme across the three divisions.

2. To provide updates from each of the programmes to allow the Executive Committee to understand the progress on each programme and summary risks and issues to date.

BACKGROUND

3. The Strategic Framework for 2015/16 for the Trust was agreed by the Trust board in January 2015. The initiatives which underpin the delivery of the framework make up the programmes of work for the divisions.

4. Each of the divisions has aligned their programmes to the framework. The governance arrangements for reporting and monitoring these programmes were agreed in April 2015.

5. Each of the programmes leads also reports on progress via monthly highlight reports to their respective programme boards. A summary of the highlight reports by division is included for information in appendix A along with the reporting process overview. Full highlight reports for all the programmes can be found on the strategic framework 2015-16 SharePoint site. The milestone plan is attached in appendix B, and the strategic wheel performance against outcome measures is shown in appendix C

6. UPDATE ON PROGRAMMES

7. Local Division - Overall RAG status AMBER

8. Recruitment against the requisite resource plan is ongoing as roles remain unfilled however roles have now been released to external advertisement and interviews for the band 6 role are taking place in December.

9. The division transformation programme cost pressure paper was combined with those of the corporate and secure transformation programmes and submitted together at the end of November 2015.

10. Transformation Programme Delivery Plan version 2.0 has now been developed based on comments from key groups and key lead officers. Further analysis is planned against the 2.0 plan and benefits plans are to be developed informed by this.

11. CIP's associated with the transformation programme were presented to the Wider Executive Team on the 12th October. They were then completed in detail for 2016/17 and submitted to the Trust within timescale of the end of October. High level plans for



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remaining years have also been submitted. Work on detailed plans for 2017/18 is underway and will be completed by end of December in line with Trust timelines.

12. The Community, Inpatient and Specialist redesign projects each contain a number of work streams, in Appendix A, a summary of the RAG status for each can be found. The highlight reports and milestone plan in Appendix B have informed the overall RAG status and the Trust strategy plan in Appendix C.

13. Secure Division – Overall RAG status AMBER

14. The Secure Transformation consists of 6 projects; four have been reported in November as amber, one as red and one as green. More detail can be found in the summary highlight report in Appendix B.

15. The development of an internal SoC for MSU has continued and the project is currently working to two plans, one including Calderstones and one to reprovide the MSU at Maghull.

16. The remaining projects continue to deliver against their milestones, there is however indication that milestones may be moving and this could potentially result in projects exceeding the tolerances of their project delivery.

17. The review of therapeutic interventions is rated red for the second month running due to the anticipated risks relating to the review of the psychological workforce to a model. It is perceived that this could result in very experienced team members leaving the Trust and possibly compromising patient care. The suggested model increases use of 8a psychologists who are known to have a higher rate of turnover against on a yearly basis against more established, higher banded psychologists. The concern is that loss of experience and increased psychological staff turnover will not reduce waiting lists for psychological interventions; will reduce the ability of the Trust to deliver psychologically informed therapeutic environments and significantly reduce stability for very demanding patient groups.

18. Corporate Division - Overall RAG status AMBER

19. Of the 10 programmes noted 8 are marked as amber and 2 as green. A number of the programmes which were reported separately continue to be reported under the one heading with a single RAG rating for a second month. The decision to group these projects has proven to be appropriate due to the groups remaining consistent in the delivery of their projects.

20. The projects are progressing against plan although there is some concern (as with Local and Secure divisions) that this may have the potential to create a spurious impression of the projects progress against their outcomes and initially scoped deadlines. It is however felt that with ongoing support some projects could move into a green RAG status subject to the production of plans and the creation of other project’s plans may reveal the requisite mitigation to assure the board of delivery of those projects perceived to having moved milestones.

21. Outcome Measures –



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22. CONSEQUENCES OF NOT TAKING ACTION

23. Failure of alignment in the delivery of the programmes will lead to failure to deliver effectively and on time, reducing the benefits of the overall. It is also likely that duplication of effort and roles across the divisions will occur. In turn the intended realisation of CIPs as project benefits may change the Trust’s financial status and eventually result in a deficit.

24. RECOMMENDATION

25. The Committee is asked to:

a. review the highlight reports and plans to understand progress so far and the next steps required

b. provide a Trust wide view on alignment issues and risks raised by the programmes

c. question the ability to deliver the strategic programme and associated CIP targets

Jim Hughes Director of Informatics and Performance Improvement & Corporate Division COO / Director of Strategy

September 2015

Appendix A

PMO Summary Highlight Report Strategic Framework 2015/16

PMO Lead

Justine Maher

Report Author

Andy Greene

Period Covered

November 2015

Status RAG Rating

Reporting on Track



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Budget RAG Rating

No Budget attached to reporting element of Framework

PURPOSE OF REPORT

1. The purpose of the report is to feedback to the executive committee the progress

made within the Divisions in all aspects of the strategic framework.

BACKGROUND

2. This report summarises the highlight reports received from the divisions in relation to the strategic framework delivery for the Trust.

DELIVERABLES COMPLETED DURING THE PERIOD 3. Each project contains a number of work streams along with the milestone plan in

Appendix B the overall RAG status on the Trust strategy plan in Appendix C.

4. LOCAL DIVISION – overall rating AMBER

26. The resource plan for the whole Division Transformation Plan resulted in the appointment of band 8a clinical change manager posts for RIO and the Transformation Programme. A new band 6 OE support post has been recruited to, the band 6 project support officer post interviews take place on 9th December and the remaining 8a post has now gone to external advertisement. These steps further support the workforce capacity to deliver the programme and minimise risk to delivery.

27. The development of the Transformation Programme Delivery Plan 2.0 has facilitated further detailed project planning in the current reporting period and the development towards a project GANT view to support the identification of interdependencies and provide some critical path analysis.

28. The development of the 2.0 plan does however raise some questions as to variance within the delivery of the project. Projects are currently being monitored against plans rather than defined project products and as such present as Amber where a case could be made for them to measure against outcomes which could more accurately show the impact of delivery against the programmes benefits and impact on CIPs.

29. Whilst the development of the latest plan has been on-going there have been continued activities within each of the projects in order to enable the implementation of the plan and support programme delivery. Notably caseload reviews have been underway within the remit of each project, informed by new pathway design.

30. Benefits realisation planning has taken place with a plan to be developed in draft for the programme in December along with firm identification of metrics to support the measurement of the effectiveness of the programme.



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31. The final Workforce Plan presented to the Trust Board in September and this will now form the basis of ensuring we have the right staff, in the right roles, in the right areas to achieve transformed services. This will be regularly reviewed as a live document integral to the transformation programme delivery plan. A planning meeting took place on the 2nd December in relation to the establishment of a new divisional sub group of the transformation programme board specifically to look at the workforce plan and ensuring this is a key enabler to transform services. This group will ensure delivery of all aspects of the divisional workforce plan.

32. Community redesign programme - AMBER.

33. Communication activities identified in the previous month as being relevant to the community project continue in order to ensure there is appropriate support within CCG’s and other primary care providers to support service users who are discharged from our community services. The stakeholder list is being developed and stakeholder interviews have taken place in November and will continue into December 2015.

34. Care pathway design is being finalised to deliver the fully articulated Care Pathway in terms of the function clinical pathway, the interventions provided to support the pathway and the workforce plan to deliver the aforementioned clinical pathway and interventions.

35. A Caseload review tool has been agreed for the review of clusters 1, 2, 3, 11 and 18 and is being used to review CMHT caseloads currently. The work commenced in September 2015 and all CMHT's across the division have been reviewing their caseloads from September and continue this work.

36. The Kaizen launch of community project took place on the 19th October. Individual

project plans for the 3 month caseload review and discharge pathway being developed. KPI identification and data gathering has commenced.

37. The Discharge and recovery pathway in development will be finalised by the end of

January and will be tested out with service users in two areas of the division in December. This will include brief interventions outlined in a robust care plan.

38. Inpatient redesign programme – AMBER

39. The Delivery Plan was discussed during the project team meeting in August and objectives for inpatient and assessment services redesign were updated/condensed. The work streams have been updated from the delivery plan and the work streams established x 4. The 4 work streams have now met and have a schedule of regular meetings, agreed TOR etc. In November we have now developed a project plan outlining the key work activities to be undertaken over the next 12 months. The work streams have been updated from the delivery plan and the work streams established have been increased from three to four. The four work streams have now met and have a schedule of regular meetings, agreed TOR etc.



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40. Prenton Suite opened 24/7 on the 9th November. The unit is already seeing an impact on the length of stay for service users who would have normally waited in AED's and on reducing inpatient stays.

41. Detailed CIP plans for 2016/17 have been developed and submitted to the Trust within timescale and target in October. High level plans for 2017/18 and 2020/21 have also been submitted. Work on development of detailed plans for 2017/18 is underway. Cost pressure bids have been produced in collaboration with corporate and secure divisions and submitted in November. CIP Plans will be discussed in a divisional meeting with Monitor on the 9th December. CIP plans have all been impact assessed.

42. A draft benefits plan is being developed in December

43. Specialist redesign programme – AMBER

44. The Specialist Services Programme covers both the review of Addictions Services and Learning Disabilities Services.

45. The project could possibly be rated as RED due to the loss of the Liverpool Addiction Services tender to Addaction. The loss of the addictions tender as a constituent element of the transformation results in a significant risk to project going forward due to the loss of revenue. The risk can be mitigated by winning newly commissioned business for either area in the specialist service project.

46. Capital business case completed and agreed by the division and Performance Investment Committee to the value of £3 million. Bidder interviews for construction companies proposing to undertake the new build have taken place and Gilling Dodd have been awarded the contract. Draft plans for the new inpatient facility have been drawn up and been discussed in the addictions redesign project team for further amendments to be made.

47. The model of care for the new inpatient facility has been developed and key communication activities will take place with key stakeholders regarding service changes. A briefing report has been developed regarding the transformation of inpatient services for commissioners and local Overview & Scrutiny Committees (LA). Clinical and managerial leads will meet with Sefton and St Helens commissioners during week of 2nd November 2015.

48. Work continues in relation to the tendering of inpatient services with St Helens and Blackpool tender still on-going. As mentioned earlier in this report the tendering process for Liverpool (community) completed on the 2nd November and the tender was not successful, with the contract being awarded to Addaction. St Helens and Blackpool tenders have been submitted and we are awaiting the outcome. Sefton will advertise their ITT on 11th December

49. CIP plans associated with the LD and Addictions work streams for 2016/17 have now been developed, in line with the care delivery model, agreed and submitted to the Trust within timescale of end of October 2015.



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50. SECURE DIVISION - overall rating AMBER

51. The Secure Transformation consists of 6 projects; one project has reported a RAG status of green, four projects have again been reported as amber for November and one project as red.

52. Similarly to the Local Division’s projects the RAG ratings for secure division are determined against project plans. Due to the fluid nature of project planning and the recent changes to the scope of the projects, some projects report more favourably than they will perform against the project product specification (i.e. being delivered in time, within a cost envelope).

53. The model of care is under discussion and has milestones but no formal plan; as such the project is rated amber. Whilst activity is on-going around the model of care, its importance as a prerequisite to the Secure Campus FBC means that assurance on its delivery is critical to the secure programme of work. Based on the current state of the model of care project and the new requirement to address the needs of patients with learning difficulties, the project should be considered a greater risk.

54. The model of care will now be required to address secure LD patient needs and is dependant on strengthening relationships with Calderstones Trust. A thorough plan may be able to articulate the steps to address this need and provide assurance that the model can be delivered in line with the scope of the project delivery timescale. As it stands the project is amber because it is rated against its sole milestone as on target but without a plan. Under the constraint of these measurements it is difficult to assure a project against its scope.

55. The review of therapeutic interventions in secure remains rated red due to the perceived risk of the psychology workforce review. The risks of the workforce review highlighted in the Review of therapeutic interventions in secure have the potential to cascade across the model of care due to the possible impact on the psychology workforce skills mix required to service the model.

56. Medium Secure Unit, Low Secure Unit and Community Forensic Model of Care – Amber

57. The project team reviewed the following documents. 1. "Building the right support 2015" 2. "Supporting people with a learning disability and or autism who display behaviour which challenges including those with a mental health condition 2015" 3. "Forensic care pathways for adults with intellectual disability involved with the criminal justice system 2014" 4. "Equal access equal care 2015". To begin some familiarisation with likely patient profiles to consider in an amalgamated model of care that is innovative in treating LD and MI patients side by side according to need, function and risk in the least restrictive environment, provided by effective processes and infrastructure.

58. The project team visited the MSU at Calderstones on 20th November and met with a range of clinicians to discuss service delivery, patient need, staffing levels and consider options for ward configuration. On the 27th November there was a further



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meeting with Calderstones staff at Scott Clinic to discuss the model of care and begin investigating considerations for workforce planning.

59. Transforming the Secure Pathway (Previously secure Campus) - Green

60. Scope of the project has changed and will now include learning disability MSU beds. The schedule of accommodation has been completed and the MSU will comprise of 106 beds, 56 existing MSU beds, 40 LD patients and 10 modular rooms that will be able to flex to meet additional patient capacity.

61. An internal SOC is to be produced and submitted to the Trust Board in January 2016 which will seek approval to progress to Full Business Case.

62. The SoC development is on-going albeit in a revised internal format. Discreet workstreams and small working groups have been established and begun meeting. The workstreams will contribute to the internal SOC, which is intended to be delivered to Project Board in December, PIC in January and Trust Board in February

63. The Project plan has been created although the new Scope (due to significant change), PID and Brief are yet to be produced.

64. The Secure Campus has the potential to exceed revenue gained in revenue cost. Should the new build fail to deliver additional uncommissioned beds that can be sold to meet the cost of borrowing to build a new MSU the cost of the borrowing will exceed the revenue generated under our currently commissioned bed scheme.

65. The Secure Campus project is also likely to exceed the ambition of NHS England for the deadline to relocate Calderstones MSU LD patients to a new state of the art site. Due to the project having a plan and being within the tolerances of that plan it is rated as green this month even though the plan exceeds the desired delivery timescale in 2018.

66. Reconfigure Admission & HDU in High Secure Services – Amber

67. SGB agreed the further development of the reconfiguration of Admission and HDU for HSS in November; the next step is to convene a multi-disciplinary project team that reports to Secure Transformational Group to consider the options available and to progress with developing internal options appraisal.

68. Reconfigure Rehabilitation Services in High Secure Services – Amber

69. Similarly to the reconfiguration of Admission and HDU for HSS, Rehabilitation will convene a project board. In order to address competing priorities and release the project lead, a new project lead has been assigned and is currently familiarising themselves with the project.

70. Review of Therapeutic Interventions in Secure Division – RED

71. There is a risk to the delivery of the on-going pilot as a result of the pending psychological services review. The proposed review of psychological services will



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result in the loss of clinical posts directly involved in the delivery of this project. The proposed structure is due to go out to consultation. It is imperative that the division consider the impact of changes to the existing workforce structure will have on the continued delivery of this project. The proposed model envisages delivery of this project through assistant psychology posts rather than through the existing nurse therapists. The assistant psychology workforce is by its nature a temporary workforce, the use of which will not guarantee continuity, and stability in clinical delivery.

72. Review of observations patient practice across all inpatient areas – Amber

73. The report relating to the project has now been produced and was shared in November with QAC and is awaiting recommendations to take forward.

74. The 3rd Round of the Delphi study will continue and is now due to be completed by the end of January 2016.

CORPORATE DIVISION _ Overall Rating Amber

75. The corporate division’s 10 projects in November have been rated as follows, two projects are green against plans and eight are rated as amber.

76. As noted in for both Local and Secure division the projects are measured against milestones and plans that are open to some degree of change. Again this leaves the projects open to ratings that could be perceived as more favourable than their position against the project product.

77. The projects showing a green RAG rating this month are Implement new e-prescribing system and Workforce Projects Centralised sickness coordination team, Workforce redesign and better use of new roles (workforce Planning). The workforce plan has been delivered and centralised sickness and e-prescribing are progressing in line with their plans.

78. The remaining amber rated projects are mainly rated as amber due to no formal plans being in place even though progress is underway with tasks to deliver the projects. It is perceived that some projects may be able to be rated as green subject to plans being generated whereas others that have neither plans nor milestones can’t be adequately evaluated against the outputs they are intended to deliver.

79. Centre for perfect care and wellbeing R & D and Innovation programme – Amber

80. The database established to review returned questionnaires and identify areas of interests is now fully operational and being used to identify clinicians in particular areas and to promote training opportunities.

81. The team are awaiting a date to move to Indigo, once agreed promotional materials will be produced to advertise the services offered.

82. Key risk identified is a lack of engagement with service users and staff.

83. Centre for Perfect Care Quality improvement - Physical Health - Amber



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84. The initial RCP findings have been considered, and dietetic and nursing resources have been made available for the pilot wards. A cardiac needs audit has been completed on Broad Oak, and discussions are underway regarding the project roll out on to other wards.

85. Key Risk identified is the staffing capacity to complete the work.

86. Centre for Perfect Care Quality improvement – Suicide – Amber

87. Training has been arranged for January for staff involved in the Living Life to the Full programmes and safety planning. There is a six month evaluation of the self harm clinical in A&E and a new process has been established in Aintree and Southport regarding the frequent attendance at AED.

88. The second stake holder meeting took plans for innovate depression in November with short medium and long term actions agreed.

89. Indicators for measuring the progress have now been agreed with WCB, and will be reported on from January.

90. No key risks have been identified on the highlight reports

91. People Participation Programmes - Develop recovery college programme, Develop peer support programme and Volunteering Programme – Amber

92. The contractors have taken on the Walton library site and are in the process of preparing it for redesign, full works to start on site in January 2016.

93. Participants have been recruited to the governance posts and the volunteering and participation programme targets are on track

94. A re launch of the recovery colleges has taken place and all courses were approved by SMT. Sefton learners contract has commenced

95. Key identified risks include the possibility that Walton library will not be completed on time.

96. Deployment of PACIS clinical system into Medium and Low Secure Services to replace ePEX – Amber

97. Matrix of process mapping activities developed across both EPMA and PACIS to communicate progress to the team; process maps printed and discussions held with Training Lead in order to add definition to training materials. The following areas were process mapped as planned: Rathbone, Rathbone flats and Security.

98. Functionality requested by MSU/ LSU reviewed in the first of two key meetings with Andy Osborne; this review will contribute to the accurate estimation of product development required from Bankside, Product Supplier



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99. The banner stands were signed off and are currently ready for printing. A significant proportion of this time period has been spent with the Project Manager ensuring the intranet site content accurately reflects the background and current progress of the PACIS deployment. Communications Lead leaves the project 04/12; Identification of future communications support will be undertaken by the Programme Manager.

100. Implement new clinical information system – Amber

101. Exception report to Project Board confirming the project will not achieve the planned 16th March 2016 Go Live for complex care. Project Board agreed plan to work to a March go live. The Risk Strategy was tabled at the Project Board on the 30th November. However due to time constraints the Strategy will be discussed at the next board. Review of Build and Configuration Work stream progress is underway.

102. The Project manager is Scoping alternative options for a Phase 1 "Go Live" and they have Started completing a Configuration Management Strategy

103. Clinical Business Change Manager has taken up post and is leading the Clinical

Reference Group. The TOR has been updated and ready to be agreed at the next group meeting.

104. The project has commenced process mapping with support from the Servelec RiO Product expert.

105. A meeting was held with the trusts key stakeholders on 30th November to agree on an approach to service management in order to support key systems and new Rio system once go live is achieved in March.

106. Key risk identified: Project Off Plan will not achieve 16th March 2016 Go Live for Complex Care.

107. Implement new e-prescribing system – Green

108. Process queries being addressed with Pharmacy Team and Clinical Business Change manager. Captivate licences have been requested from Programme Manager in order to develop eLearning guides. Training Room at Ashworth has been allocated and equipment is being arranged by Technical Infrastructure Lead; this has been block booked from January – July 2016. Support is being given by the Clinical Support Office regarding the procedure for booking staff onto training sessions.

109. A matrix of process mapping activities developed across both EPMA and PACIS to communicate progress to the team; process maps printed and discussions held with Training Lead in order to add definition to training materials. Clinical Reference Group being developed with Clinical Pharmacist (Sarah Rafferty, Chair); Names have been suggested form both Local, Corporate and Secure to capture all key areas and with people with the authority for change. Statement of Planned Benefits in the form of a



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Benefits Tracker has been completed by the Project Manager in conjunction with Business Change and Lee Knowles for NHSE.

110. Key risks identified: The EPMA system if installed with one locality will allow all users to access all patients’ prescription details, no matter what service they are linked to. So if a staff in local services logs on to EPMA they can access any patient in High, Medium and Low and visa a versa. Highest level of security appears to be ward-based only.

111. Review of quality according to Protected Characteristics – Amber

112. A Meeting was held with Community development worker to support the Trust activities re SA arranged on the 13th November

113. A meeting re equality analysis of local division transformational change was held, awaiting information on leads to be identified.

114. A new system for online translation and interpretation moving forward. Invoicing process to be agreed by local division and finance.

115. Meeting has been arranged with Health watch, patient experience lead and quality account lead to report activities together at engagement session in Feb

116. Key risk identified :- EDS progress not being met if local division does not support the agenda and put processes in place

117. Workforce Projects Centralised sickness coordination team, Workforce redesign and better use of new roles (workforce Planning) – Green

118. A System has been developed, and processes have been developed and rolled out to team managers in all clinical divisions.

119. Workforce have met up with the team managers and set the process in place. Training has been delivered and continues to be available on an ad hoc basis to newly appointed Managers and those requiring additional support.

120. They are currently working through the 6 monthly review feedback and developing an action plan.

121. Workforce has undertaken an evaluation questionnaire to ascertain Manager's views in relation to the benefits of the centralised sickness absence team. Feedback will be available in the new year

122. Key risk identified - Fixed term funding until March 2016

123. OE Programme: Aston University Model - Support to clinical teams, Support to PACE process and improvements to electronic system & Leadership programme – Amber

124. Support has been offered to all areas with low compliance of PACE - provided in work areas where needed. The OE&L team are actively monitoring reviews completed as



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recorded in PACE online and via the BiT. Managers have been contacted directly with lists of staff names that still require a PACE review, support offered.

125. The final evaluation has now been completed for the Health and Wellbeing survey at the end of the PACE review.

126. Work has commenced on EDHR analysis on those staff who have not received a PACE will be completed by the end of December 2015.

127. System enhancement requests have been formalised and presented to share point team manager for consideration of costings and timeframes.

128. Discussions have commenced with BiT team to ensure all PACE data is correct within the BiT

129. Key risks identified:- Non compliance of completions of PACE reviews will result in untrue TNA data



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Appendix B

Milestone Plan



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Page 19 of 22



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Process for reporting strategic framework



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REPORTING PROCESS

130. The current programmes will continue to be reported on via a RAG rating against the strategic wheel. Each programme’s deliverables will be identified against outcome measures linked to the strategic framework. The overall status of each programme will be shown in a graphical format and the underlying highlight reports showing the detail of the programmes will continue to be monitored through the programme boards

131. Each programme produce a highlight report monthly, which is RAG rated against time, cost and quality, providing the data to update the plan on a page report. To ensure consistency RAG thresholds have been developed.

132. Green - To be green a project must be within tolerance to the agreed plan, within the agreed budget, and on track to deliver the agreed benefits and any CIP plans associated with the project.

133. Amber – If the planned timeline is delayed but still deliverable, if the budget is exceeded but is using an agreed contingency then this should be Amber. If there is no agreed plan, or budget but there are milestones in place, or the project is in the scoping phase then at most a project can be Amber.

134. Red – If a plan is on hold or an issue has prevented any further work. If the budget is exceeded with no agreed contingency, or if the CIP plans are not going to be delivered. If a project does not have a plan, milestones, or budget agreed then it will automatically be classified as red.

135. The process will then generate RAG status reports alongside the measurable outcomes for the full strategic framework for the monthly executive committee.



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of 4

Strategy Measures 2015/16 - Summary

Strategic Aim Strategic Objective R (0) A (2) G (3) Maximum Score

Actual Score

% Achievement (Actual /

Maximum)

RAG (100% green; >=50% amber; <50% red)

R (0) A (2) G (3) Maximum Score Actual Score

% Achievement (Actual /

Maximum)

RAG (100% green; >=50% amber; <50% red)

Our Services Safe 1 0 1 6 3 50% A 0 1 1 6 5 83% A Improved

Our Services Timely 0 0 2 6 6 100% G 0 0 2 6 6 100% G Maintained

Our Services Effective 1 0 1 6 3 50% A 1 0 1 6 3 50% A Maintained

Our Services Equitable 0 0 1 3 3 100% G 1 0 0 3 0 0% R Deteriorated

Our Services Person-Centred Care 0 1 1 6 5 83% A 0 1 1 6 5 83% A Maintained

Our People Supportive Managers and Effective Teams 1 0 0 3 0 0% R 0 1 0 3 2 67% A Improved

Our People A productive workforce with the right skills 0 1 1 6 5 83% A 1 0 1 6 3 50% A Deteriorated

Our People Working side by side with service users 2 0 0 6 0 0% R 0 0 2 6 6 100% G Improved

Our Future Work effectively with primary care and other organisations 2 0 0 6 0 0% R 2 0 0 6 0 0% R Maintained

Our Future Deliver the benefits of research and innovation in patient care 0 0 2 6 6 100% G 0 0 2 6 6 100% G Maintained

Our Future Grow our service 1 0 0 3 0 0% R 0 0 1 3 3 100% G Improved

Our Resources Save time and money 1 0 1 6 3 50% A 0 1 1 6 5 83% A Improved

Our Resources Buildings that work for us 0 0 2 6 6 100% G 0 0 2 6 6 100% G Maintained

Our Resources Technology that helps us to provide better care 0 0 2 6 6 100% G 0 0 2 6 6 100% G Maintained

Nov-15Baseline (Q3 2014/15)

Executive Committee: B2 / Attachment 10Performance and Investment Committee: B1 / Attachment 10

of 4

Strategy Measures 2015/16 - Detail

Strategic Aim

Strategic Objective Measure name Description Numerator Denominator Proposed Thresholds Q3 baseline RAG baseline Nov-15 RAG rating

November 2015

Strategic Outcome Measure

Comments

Our Services Safe Reduced levels of harm

Reduction in the proportion of incidents that result in harm (classified as low, moderate, severe or death) from the Q3 2014/15

Number of incidents that result in harm in the reporting period.

Number of incidents in the reporting period.

<14.45% green; <19.79% amber; >=19.79% red. 14.45% G 10.70% G Y Latest data is November 2015. Quarterly figures taken

directly from Quality Dashboard.

Our Services Safe Reduced suicides

Reduction in the rolling twelve month average of suicide incidents by 25% year on year from a 2013/14 baseline.

Number of incidents of suicide per month for the last twelve months

Number of months in a year (12) <=12 green; <=24 amber; >24 red 27 R 24 A Y Latest data is November 2015. Quarterly figures taken directly from Quality Dashboard.

Our Services TimelyImproved access to psychological therapies

Percentage of patients seen within six week of referral to IAPT services.

Number of patients seen within six weeks of referral.

Number of patients referred to IAPT services >=75% green; <75% red. Not available G 91.84% G Y

Data flow established in July 2015. New PAF indicator 2015-16 ref. WAITNAT2

Latest data is October 2015

Our Services TimelyAccess to treatment for first episode of psychosis.

Percentage of patients experiencing a first episode of psychosis will be treated with a NICE approved care package within two weeks of referral.

Number of first episode of psychosis patients referred who receive a NICE concordant care package within two weeks of referral.

Number of first episode of psychosis patients referred >=50% green; <50% red. Not available G Not available G Y Data flows being established in line with Monitor

timeframes. New PAF indicator 2015-16 ref. WAITNAT1

Our Services Effective

Increase in % annual health checks recorded on ePEX / PACIS

Percentage of community service users on a CPA who receive an annual physical health check

Number of patients from the denominator for whom an annual health check has been completed (either by primary care or by Trust staff) in line with the Trust's Physical Health Policy

Number of community patients who are on a CPA on caseload for more than 12 months.

>=95% green; >90% amber; <90% red 78.99% R 86.67% R Y Latest data November 2015

Our Services EffectiveCompletion of mandatory training (CEMT+)

% of staff up to date with extended corporate essential mandatory training as defined by their job role.

Number of staff in post for whom all relevant CEMT (including extended requirements per the trust's Training Matrix) has been completed and is in date.

Number of staff in post (head count) minus any agreed exemptions.

>=95% green; <95% red Not available G 96.30% G Y

Will initially be reporting upon standard CEMT training completion and will then review to extend to CEMT+ upon establishment of reporting processes.

Latest data November 2015

Our Services Equitable Reduction of detention by protected characteristic

Analysis of detention under the Mental Health Act by each protected characteristic

Admissions under the Mental Health Act as a proportion of all admissions analysed by each protected characteristic and assessed for any significant differences.

Percentage of all patients admitted to the trust who are admitted under the Mental Health Act.

No significant difference = green; Significant difference = red. Not available G Significant difference R Y

Analysis of 12 months data to November 2015 shows that the following categories of service users are statistically more likely to be detained under the MHA.

A) BME service users with white service usersB) service users aged under 25 with service uses aged between 25 and 65.C) service users aged between 25 and 34 with service users aged between 35 and 65.D) service users aged between 50 and 65 with service users aged between 35 and 49E) service users aged over 65 with service users aged between 25 and 65.

Our ServicesPerson-Centred Care

Patient Experience - Friends and Family Test

Aggregated friends and family test position from patient experience questionnaires (rolling quarter)

(Friends and family question score from inpatients survey x number of respondents)+(Friends and family question score from community survey x number of respondents)

Number of respondents to inpatients survey + Number of respondents to community survey

>=90 green; >=75 amber; <75 red 85.78 A 88.09 A Y Latest data rolling quarter September to November 2015

Our ServicesPerson-Centred Care

Patient Experience - Involvement in Development of Care Plan

Aggregated position for question relating to involvement in the development of care plans from patient experience questionnaires (rolling quarter)

(Involvement in Care Plan Development question score from inpatients survey x number of respondents)+(Involvement in Care Plan Development question score from community survey x number of respondents

Number of respondents to inpatients survey + Number of respondents to community survey

>=90 green; >=75 amber; <75 red 97.32 G 93.43 G Y Latest data rolling quarter September to November 2015

Our People

Supportive Managers and Effective Teams

Increase in PDR / PACE completion

Percentage of staff for whom PDR / PACE has been completed in the last twelve months.

Number of staff in post for whom PDR / PACE has been completed in the last twelve months.

Number of staff in post for whom PDR / PACE is required (minus agreed exemptions).

Q1 2015/16: >=90% green; >=85% amber; <85% red. Q2 2015/16 onwards: >=95% green; >=90% amber; <90% red.

83.70% R 85.75% A Y Latest data October 2015

Our People

A productive workforce with the right skills

Delivery of workforce component of CIP plans

Percentage achievement of CIP plans.

Monetary value of CIPs delivered year to date.

Monetary value of planned CIPs year to date. 100% green; <100% red. Not Due G 100% G Y Latest data M7 2015/16 position.

Our People

A productive workforce with the right skills

Reduced sickness absence

Percentage sickness absence rate (rolling twelve months)

Number of FTE days available lost to sickness absence (long term + short term)

Number of FTE days available <=4.8% green; <=5.8% amber; >5.8% red 5.75% A 5.95% R Y Latest data October 2015

of 4


Strategic Aim


November 2015


Comments

Our PeopleWorking side by side with service users

Increase in the number of recovery college students

Increase the number of recovery college contacts (monthly average over the academic term) from the baseline 2014/15 target of 145 per month.

Number of contacts year to date (academic year)

Number of months to date in academic year

>=10% increase on baseline green; <10% increase on baseline amber; no increase on baseline observed red.

131 R 167.22 G Y Latest data - monthly average September 2015 to October 2015

Our PeopleWorking side by side with service users

Increase in the number of peer support workers

Number of peer support workers employed by the trust (WTE) increase on baseline

Actual WTE peer suppport workers

Baseline WTE peer support workers


0 R 14 G Y

Latest data October 2015

- reported figures include 7 peer support workers and 7 peer tutors in post since April 2015

Our Resources

Save time and money Delivery of CIP plans Percentage achievement of CIP

plans.Monetary value of CIPs delivered year to date.

Monetary value of planned CIPs year to date. 100% green; <100% red. Not Due G 100% G Y Latest data M7 (October) 2015/16 position.

Our Resources

Save time and money

Delivery against workforce plan

Variance from expected workforce plan levels (analysis by overall WTE against budget bottom line and also against staff group)

Any areas outside of tolerance at service line / divisional level and / or by staff group. If any "red" then position reported needs to be "red" otherwise report "amber" if any area "amber"

N/A

Allowable tolerances are: Variance from plan is within 5% (positive or negative) = green; Variance from plan is between 5% and 10% (positive or negative) = amber; Variance from plan is greater than 10% = red.

R R A A Y Reporting M7 (October) 2015/16 position.

Our Resources

Buildings that work for us

Achievement of the agreed capital resource limit

Achievement of the agreed capital resource limit

Actual capital expenditure (forecast to year end)

Agreed Capital Resource Limit (CRL) for financial year

Capital expenditure is less than or equal to the agreed Capital Resource Limit = green; Capital expenditure is greater than the agreed Capital Resource Limit = red.

Not Due G G G Y Reporting M7 (October) 2015/16 position.

Our Resources

Buildings that work for us

Increase in single en-suite and Category B accommodation

Proportion of estate at category B quality compared to plan for financial year in line with approved capital programme.

Actual amount of estate at category B quality.

Planned amount of estate planned to be at category B quality.

Monthly assurance statement received showing on track to achieve estates framework assessment - Green; Monthly assurance statement shows that plans are not on track - Red.

Not Due G On track to achieve G Y

E-mail from Alison Jordan 11 May 2015 stating that the objective as laid out in the estates framework is for "condition B for all refurbs and A for new builds with the rest of estates being brought up to B via Backlog maintenance programmes by 2020. " Monthly assurance statement that this is on track to be provided by Estates and Facilities.

Latest data available October 2015 (update 04/11/2015)

Our Resources

Technology that helps us to provide better care

Digital maturity score Digital maturity score Digital maturity score current N/A

On track to achieve planned Digital maturity score by 31 March 2016 - Green; On track to achieve improved Digital maturity score but not to planned level - Amber; No improvement to Digital Maturity Score Anticipated.

Not available G On track to achieve G Y

Update from Sarah Barr:

We are working with the ILinks transformation Board across the Health Economy to improve our digital maturity as an organisation. Q1 & Q2 we will be baselineing ourselves against national Targets. We will be working closely with the CIAG group across the health economy to agree locally defined digital maturity models. In Q3 we will take the assessment in Q4 we will produce an action plan. Sharing agreement: The sharing agreement has been signed across the Health Economy (June 2015). By the end of 2015 we will have implemented economy wide sharing agreement for tier 1 data. Life enhancing technologies (LETs): Q1 we will be addressing what LETs are useful for Mersey care. Q2 and Q3 we will work on developing the plan for LETs within MCT. We will implement agreed LETs in Q4. OUR staff- In September 2015 we have been accredited by the ISD for Informatics

Latest update October 2015

Our Resources

Technology that helps us to provide better care

Delivery of CIP plans Percentage achievement of CIP plans.

Monetary value of CIPs delivered year to date.

Monetary value of planned CIPs year to date. 100% green; <100% red. Not Due G 100% G Y Latest data M7 (October) 2015/16 position.

Our Future

Work effectively with primary care and other organisations

Increased identification and treatment of physical health needs of people with SMI in primary care.




>=95% green; >90% amber; <90% red 78.99% R 86.67% R Y Latest data M8 (November 2015)

of 4


Strategic Aim


November 2015


Comments

Our Future

Work effectively with primary care and other organisations

Increase in physical health checks for people with SMI




>=95% green; >90% amber; <90% red 78.99% R 86.67% R Y Latest data M8 (November 2015)

Our Future


Increase in the number of products and services brought to market

Increase in the income from products and services brought to market compared with 2014/15 baseline

Income from products and services brought to market in 2015/16 (extrapolated for full year position).

Income from products and services brought to market in 2014/15


Not due G Not available G Y Information flow to be established

Our Future


Increase in externally funded research projects / programmes.

Increase in the income from research projects and programmes compared with 2014/15 baseline

Income from research projects and programmes in 2015/16 (extrapolated for full year position).

Income from research projects and programmes in 2014/15


Not due G Not available G Y Information flow to be established

Our Future Grow our service

Increase in overall income

Proportion of tenders for new or existing business won during the financial year.

Number of successful tenders for new or existing business in the financial year (business development)

Total number of tenders submitted (with outcome decision) for new or existing business in financial year

Increase in tender success rate in line with trust plans

>=50%= green; >12.5% = amber; <=12.5% = red.

12.5%(2014/15) R 56% G Y

October 2015:In the absence of a published business development strategy with required income and growth targets, it has been agreed that 'tender success rate' for new or existing business will be used to monitor this measure for the remainder of the financial year.

Latest data is November 2015

Performance and Investment Committee: B1/ Attachment 11

Executive Committee: B2/ Attachment 11

Page 1 of 15

Effective Care: Out of Area Treatments (OATs) M8 2015-16

Contents INTRODUCTION AND EXECUTIVE SUMMARY ....................................................................... 2 REPORTING DEVELOPMENTS ................................................................................................ 3 DIVISIONAL ACTION PLANS .................................................................................................... 4 Local Division Action Plan .......................................................................................................... 4 Secure Division Action Plan ........................................................................................................ 4 CURRENT POSITION ................................................................................................................ 5 Trust Wide .................................................................................................................................. 5 Local Division.............................................................................................................................. 5 Local Division – Adult Acute Services ......................................................................................... 5 Local Division – Specialist Services ............................................................................................ 7 Secure Division ........................................................................................................................... 8 Secure Division – Low Secure Unit ............................................................................................. 8 Secure Division – Medium Secure Unit .................................................................................... 10 FINANCIAL IMPACT ................................................................................................................ 13 UNDER 18 ADMISSIONS – LOCAL SERVICES DIVISION ..................................................... 14 CONSEQUENCES OF NOT TAKING ACTION ........................................................................ 15



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INTRODUCTION AND EXECUTIVE SUMMARY This report provides the board and its committees with an overview of the out of area treatments in place for service users who would ordinarily be admitted to a Mersey Care NHS Trust bed (on the basis of their commissioning locality). The report also includes information in relation to the number of service users aged under 18 who have been admitted to a Mersey Care NHS Trust bed as the trust is not commissioned to provide inpatient services for this age group. The inclusion of out of area treatment information in board reporting will support requirements 8.6 and 8.7 from the NHS Trust Development Authority’s planning checklist for 2015/16. Scrutiny of out of area data will:

• Support the trust in gaining a sense of the position with regards to out of area treatments to support service planning.

• Support the trust in identification of potential service and business developments.

• Support operational management in considering strategies to reduce both the number of out of area treatments and the financial impact of this, for the trust and commissioners.

• Support the management of beds within both clinical divisions and contribute to our

understanding of the efficacy of this process.

• Enable forecasting of any potential increase in the number of “unplanned” out of area treatments and highlight this to the clinical divisions.

• Identify between “planned” and “unplanned” out of area treatments. This will allow for the

“unplanned” out of area treatments to be discussed within the clinical divisions, who will then devise a performance improvement plan with the aid of the performance improvement business partners.

The summary statistics on out of area treatments are shared with the local division commissioners on a monthly basis. For the secure division, all potential out of area treatments are discussed and agreed with commissioners prior to placement.



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Definitions: “Planned” out of area treatments are when the commissioners have to agree funding and placement and the reason for the out of area treatment is because the trust is not commissioned to provide the service required. “Unplanned” out of area treatments are when a bed of the type that Mersey Care NHS Trust is commissioned to provide is required but not available; therefore the service line (local division) or commissioner (secure division) has to identify an appropriate placement elsewhere. REPORTING DEVELOPMENTS 1. Currently, the out of area treatment data for each division is provided by the service lines, in

the form of an excel spreadsheet. This is how each service line keeps abreast of their out of area treatments. This is sent to the performance analyst on a monthly basis.

2. To ensure consistency in how the data is being captured, it was agreed that an out of area

treatment ePEX project screen would be created for each service line. This will allow for real-time monitoring of out of area treatments within the clinical information system and through BiT.

3. The ePEX project screen for the out of area treatments for the secure division has been

completed and went live on the 1 August 2015. The secure division had been requested to input all current out of area treatments by 30 November 2015, however, due to the identification of further out of area treatments and missing data this has been extended to 31 January 2016.

4. The ePEX project screen for the out of area treatments for the adult acute service is

finalised and went live on the 15 August 2015. The adult acute service have inputted all out of area treatments from this date forward.

5. The ePEX project screen for the out of area treatments for the specialist services has now

been finalised and is awaiting to be created within epex. It is hoped this will be live in January 2016.

6. Work is on going with the Business Intelligence Team in relation to out of area treatments

being reported upon via the BiT. The timescale for this to be live has been extended to January 2016 due to the identification of further out of area treatments within the secure division, this will allow data validation to take place between the automated BiT reports and the monthly report provided by the service lines.



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DIVISIONAL ACTION PLANS 7. As requested in the month 4 out of area treatment report, the clinical divisions were asked

to provide a response to the report to identify any barriers and issues in relation to bed management and if so, what actions could be taken to support and alleviate the barriers.

Local Division Action Plan 8. On 13 August 2015, a bed management review was undertaken within the local division by

Matty Byrne, Professional Project Manager. The identified issues and actions include:

• There were shortfalls in the completion of discharge plans at the point of admission. The division has implemented a 72 hour review for all admissions. The 72 hour review will identify the plan for discharge and any accommodation and financial issues that could potentially lead to discharge being delayed.

• The 30 day review was not being routinely completed for all service users who have remained an inpatient for 30 days plus. The 30 day review will therefore be re-introduced and will review and update the discharge plan and identify any actions that will support discharge in a timely manner.

• All clinical staff have been reminded of the importance of always considering the least

restrictive environment e.g. through the provision of stepped up care as an alternative to admission.

• A review of all complex care out of area treatments is being undertaken by Jon Gillespie,

Capacity and Flow Manager.

• A review of admissions and length of stay by consultant / community teams has been completed to identify any unwarranted variation in practice.

• Jayne Johnson has commenced in her role as Outliers Co-ordinator.

Secure Division Action Plan 9. Dr Melanie Higgins, Associate Medical Director for the secure division has developed an

action plan in relation to the secure division OATs. This will be provided in the month 9 report.



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CURRENT POSITION Trust Wide 10. Following the review of OATs data with the North of England Specialised Commissioning

Team, the OATs data for the secure division has been finalised and the revised position is below. Further information can be found in the secure division section.

11. The total number of out of area treatments (panned and unplanned) for the trust for November 2015 is 143; 111 of these relate to the secure services division and 32 relate to the local services division.

12. It is worth noting that out of the 111 OATs for the secure division, 60 of these relate to OATs that are in specialist services not provided by the trust (planned OATs) and further information relating to these can be found in the secure division section.

Local Division 13. The number of out of area treatments for the local division that spent part of November

2015 in an OAT bed is 32. 44% (n=14) of these relate to inpatient specialist services, 6% (n=2) of these relate to community treatment specialist services and 50% (n=16) relate to adult acute services.

Local Division – Adult Acute Services

14. As at the 30 November 2015, seven of the 16 adult acute OATs had been transferred back to an MCT bed, five had been discharged home, two had transferred to a non-MCT area of residence and two remained in OAT beds. The two service users that remained in as OATs at the end of November were transferred back to a MCT bed on 1 December 2015. As at 15 December 2015 there is one adult acute OAT; this service user was admitted on 2 December 2015. The reason for this was that there were no local NHS beds, therefore the service user has been admitted to a private unit.

15. The total number of out of area treatment occupied bed days for acute services was 1,990 for the period April 2015 – November 2015. The number of occupied bed days for acute services was 186 for November 2015 (in-month). The comparison between the number of out of area treatments and the number of occupied bed days can be seen below for adult acute services.



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16. The reasons for out of area treatments within the adult acute services were:

I.

II. III. IV.

17. The number and distribution of out of area placements for acute services was:

OAT Reason Number of OATs Local NHS Bed not available (unplanned)

11

Other trust admitted (unplanned) 4 Trust employee (planned) 1

OAT Placement Number of OATs Bury 3 Priory Cheadle Royal 3 Ablett Unit, Glan Clwyd Hospital 1 Cygnet Harrogate 1 Five Boroughs 1 Priory Altrincham 1 Priory Darlington 1 Sheffield 1 Whiston 1 Worcester 1 Wrexham 1 Wyke 1



Page 7 of 15

18. The number of out of area treatments by CCG for acute services was:

CCG Number of OATs Liverpool 13 Liverpool/South Worcestershire 1 South Sefton 1 South Sefton/Sheffield 1

Local Division – Specialist Services

19. As at the 30 November 2015, one of the 14 specialist services OATs had been discharged.

20. The total number of out of area treatment occupied bed days for specialist services 2,999

for the period April 2015 – November 2015. The number of occupied bed days for specialist services was 350 for the period of November 2015 (in-month). The comparison between the number of out of area treatments and the number of occupied bed days can be seen below for specialist services (inpatients).

21. The compliance level for care co-ordinator contact with the service user within the last 12

months for specialist services is at 83% for November 2015. 22. The assumption has been taken that all specialist services out of area treatments are

“planned” i.e. Mersey Care NHS Trust is not commissioned to provide the service type that is required. This will be tested once the ePEX project screen is live and reporting commences from the BiT.



Page 8 of 15

23. The provider for the two out of area treatments receiving community psychology treatment are:

Secure Division

24. Following the review of OATs data with the North of England Specialised Commissioning

Team, the OATs data for the secure division has been finalised and the revised position is below.

25. The number of “unplanned” out of area treatments for the secure services division that spent part of November 2015 is 51. 15 of these relate to low secure and 36 relate to medium secure. The number of “unplanned” out of area treatments for the secure services division that spent part of November 2015 (51) compared with the reported figure for October 2015 (26) has increased. This is due to the OAT data for the secure division being reviewed with the North of England Specialised Commissioning Team.

26. The number of “planned” out of area treatments for the secure services division that spent part of November 2015 is 60. 14 of these relate to low secure and 46 relate to medium secure. The number of “planned” out of area treatments for the secure division that spent part of November 2015 (60) compared with the reported figure for October 2015 (20) has increased. This is due to the OAT data for the secure division being reviewed with the North of England Specialised Commissioning Team. These OATs would not be expected to return back to services within the trust.

27. The secure division have provided assurances that the out of area treatment paperwork will

be completed for all out of area treatment cases. Secure Division – Low Secure Unit 28. Following the review of OATs data with the North of England Specialised Commissioning

Team, the OATs data for the Low Secure Unit has been finalised. The number of out of area treatments for the low secure unit that spent part of November 2015 in an OAT bed is 29 (unplanned and planned). There were no new admissions during November 2015. There was one discharge in November 2015 into the community under Southport CMHT.

29. The reasons for out of area treatments for the low secure unit were:

Reason for OATs Number of OATs No MCT bed available (unplanned) 15

Psychology Provider Counselling Initiative View Psychology



Page 9 of 15

Reason for OATs Number of OATs Specialist Service Required - Acquired Brain Injury Low Secure Services (planned)

6

Specialist Service Required – Long-term Low Secure Services (planned) 3

Specialist Service Required –Deaf Low Secure Services (planned) 2

Locality Issues Low Secure Services (planned) 2

Service user choice Low Secure Services (planned) 1

30. At a meeting with the North of England Low Secure Specialised Commissioner, low secure

unit and secure division performance improvement business partner on the 19 November 2015, the OATs were discussed in terms of their potential for repatriation to a MCT low secure bed and out of the 15 unplanned OATs, four OATs were agreed as potential repatriations to a MCT low secure bed.

31. The number of out of area treatments by CCG for the Low Secure Unit is:

CCG Number of OATs Liverpool 24 South Sefton 3 Knowsley 1 Southport and Formby 1

32. A breakdown of the category of diagnosis for the out of area treatments for low secure is

provided below:

Category of Diagnosis Number of OATs Mental illness 15 Acquired Brain Injury 6 Mental illness and personality disorder 3 Autistic spectrum disorder 2 Dementia 1 Multiple personality disorders and mental illness 1 Personality disorder 1



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33. The number of out of area placements for the low secure unit was:

OAT Placement Number of OATs Alpha Hospital 7 The Spinney 6 Guild Lodge 5 Kemple View 4 Marlowe Unit 2 St Mary’s Hospital 2 Tatton Unit 2 Saddlebridge 1

34. The number of out of area treatment occupied bed days for the low secure unit in-month

position (November 2015) was 852. 35. The comparison between the number of out of area treatments and the number of occupied

bed days can be seen below for the low secure unit. The graph has been amended to reflect the finalised list of OATs. From April 2015 to October 2015, one OAT has been omitted due to the admission date for this OAT being incomplete. The OAT has been included in November 2015 as the finalised list was compiled at the end of the October, thus definitely being an OAT in November 2015. Once this data is complete, the graph will be rectified to reflect this.

Secure Division – Medium Secure Unit 36. Following the review of OATs data with the North of England Specialised Commissioning

Team, the OATs data for the Medium Secure Unit has been finalised. Due to the number of

780

800

820

840

860

880

26

26.5

27

27.5

28

28.5

29

29.5

Apr-15 May-15 Jun-15 Jul-15 Aug-15 Sep-15 Oct-15 Nov-15

Occu

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Bed

Day

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Num

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Number of Out of Area Treatments and Occupied Bed Days (In-Month) - Low Secure Unit Apr 15 - November 15

Number of out of area treatments Occupied bed days



Page 11 of 15

out of area treatments for the medium secure these have been split into the following reasons for out of area treatments:

Reason for OATs Total Number

of OATs No. of Male

No. of Female

No MCT bed available (unplanned)

36 26 10

Specialist Service Required – Long-term Medium Secure Services (planned)

23 23 -

Specialist Service Required – Personality Disorder Medium Secure Services (planned)

15 15 -

Specialist Service Required – Acquired Brain Injury Medium Secure Services (planned)

4 4 -

Specialist Service Required – Learning Disability Medium Secure Services (planned)

2 - 2

Specialist Service Required – Therapeutically Enhanced Medium Secure Services (planned)

2 - 2

37. There were no new admissions or discharges during the month of November 2015.

38. Work is ongoing in relation to the data completeness of the planned OATs and it is planned

that this information will be updated and available from February 2016. Therefore the data below represents the unplanned OATs only.

39. The number of out of area treatments (unplanned) by CCG for the medium secure unit is:

CCG Number of OATs Liverpool 11 South Cheshire 7 Warrington 5 West Cheshire 3 South Sefton 2 St Helens 2 Wirral 2 Eastern Cheshire 1 Knowsley 1 Unknown 1 Vale Royal 1



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40. A breakdown of the category of diagnosis for the out of area treatments (unplanned) for the

medium secure unit is provided below:

Category of Diagnosis Number of OATs Mental illness 34 Personality Disorder 2

41. The number of out of area (unplanned) placements for the medium secure unit was:

OAT Placement Number of OATs Alpha Hospital 13 The Spinney 8 Edenfield 7 Arbury Court 5 Calverton Hill 2 Stockton Hall 1

42. The number of out of area treatment occupied bed days for the medium secure unit in-

month position (November 2015) was 1080. 43. The comparison between the number of out of area treatments and the number of occupied

bed days can be seen below for the medium secure unit. The graph has been amended to reflect the finalised list of OATs. From April 2015 to October 2015, twelve OATs have been omitted due to the admission date for these OATs being incomplete. The OATs have been included in November 2015 as the finalised list was compiled at the end of the October, thus definitely being OATs in November 2015. Once this data is complete, the graph will be rectified to reflect this.

0

200

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800

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1200

05

10152025303540

Apr-15 May-15 Jun-15 Jul-15 Aug-15 Sep-15 Oct-15 Nov-15

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Number of Out of Area Treatments and Occupied Bed Days (In-Month) - Medium Secure Unit Apr 15 - November 15

Number of out of area treatments Occupied bed days



Page 13 of 15

FINANCIAL IMPACT 44. The trust expenditure for 2014/15 for out of area treatments was £388,527. This cost

relates to the adult acute beds (“unplanned”) within the local division. 45. The clinical commissioning group expenditure for 2014/15 for out of area treatments was

£1,036,780. This cost relates to the specialist service beds (“planned”) within the local division.

46. The total expenditure for 2014/15 for out of area treatments was £1,425,307. 47. The trust expenditure for April 2015 to November 2015 for out of area treatments was

£946,719. This cost relates to the adult acute beds (“unplanned”) within the local division. 48. The clinical commissioning group expenditure for April 2015 to November 2015 for out of

area treatments was £1,430,974. This cost relates to the specialist service beds (“planned”) within the local division.

49. The total expenditure for April 2015 to November 2015 for out of area treatments was

£2,377,693. 50. The forecasted trust expenditure for 2015/16 for out of area treatments is £1,000,079. This

figure has been forecasted based on the actions being taken to reduce the usage of out of area beds in the latter half of the year. This cost relates to adult acute beds (“unplanned”) within the local division.

51. The forecasted clinical commissioning group expenditure for 2015/16 for out of area

treatments is £2,585,000. This cost relates to specialist service beds (“planned”).

52. The total forecast for out of area treatments for 2015/2016 is £3,585,079. This could represent an increase of over 100% on the financial year 2014/15.

53. The monthly expenditure breakdown by trust and clinical commissioning group can be seen

in the table on page 14.



Page 14 of 15

UNDER 18 ADMISSIONS – LOCAL SERVICES DIVISION 54. The executive director of nursing has recommended that through this paper, we also report

upon admissions to Mersey Care NHS Trust for service users aged under 18 as we are not commissioned to provide inpatient services for this age group.

55. The data below relates to patients aged under 18 on the day of admission to the trust.

Ordinarily these service users should be admitted to Cheshire and Wirral Partnerships NHS Foundation Trust under 18 unit.

56. There were no new under 18 admissions during November 2015.

RAG Rating:Decrease in expenditure compared to previous monthIncrease in expenditure compared to previous month

Total ExpenditureMonth Trust Funded CCG Funded Total Apr-14 460 460 May-14 14,962 14,962 Jun-14 1,208 1,208 Jul-14 55,012 55,012 Aug-14 44,613 44,613 Sep-14 14,898 165,429 180,327 Oct-14 16,884- 165,428 148,544 Nov-14 14,737- 165,428 150,691 Dec-14 20,434 165,429 185,863 Jan-15 151,457 118,590 270,047 Feb-15 18,450 134,004 152,454 Mar-15 98,654 122,472 221,126 Apr-15 43,720 102,147 145,867 May-15 31,858 227,970 259,828 Jun-15 111,093 374,204 485,297 Jul-15 71,795 224,711 296,506 Aug-15 285,789 65,540 351,329 Sep-15 117,406 171,265 288,671 Oct-15 252,016 193,191 445,207 Nov-15 33,042 71,946 104,988

1,335,246 2,467,754 3,803,000

£



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57. In addition to the indicative cost above, in order to facilitate one of the admissions in May

and ensure safety of the service user we had to close a further bed in the Rowbotham Unit. The admission to the Rowbotham Unit did not result in a full occupied bed day as the service user was discharged 17 ½ hours after admission.

CONSEQUENCES OF NOT TAKING ACTION 58. The consequences of not taking action would potentially mean that the requirements of 8.6

and 8.7 are not met from the NHS Trust Development Authority’s planning checklist for 2015/16.

59. The “unplanned” out of area treatments could put the trust at financial risk. 60. A deterioration in clinical effectiveness and patient experience, should service users

continue to be admitted to inpatient units away from home in an “unplanned” way. Wendy Copeland-Blair Head of Performance Improvement and Customer Relationship Management Jennifer Billingsley Performance Analyst 15 December 2015

1 April to 30 November 2015Number of admissions 2Number of occupied bed days 2.73Unit cost per bed day 343.00£ Additional cost per bed day for 1:1 (Band 3) 263.76£ Total indicative cost per bed day for under 18 admission 606.76£ Indicative cost of U18 admissions to the trust 1,655.95£

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