Care at a Glance...will be delivered to the quality assurance committee in September 2016. The new...

Key Performance Issues

Recommendations

The committee 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.

The committee is asked to note the assessment of performance contained within the Calderstones Partnerships NHS

Foundation Trust corporate dashboard report.

Trust Board C2 (TB/16/17/027)

Physical Health (Escalation Section 1)

Patient Experience - Local Division

Safer staffing - fill rates against clinical requirement

Contract Performance - Talk Liverpool (Escalation Section 2)

Early Intervention In Psychosis Waiting Times - NHS Improvement

Bed Management - Unplanned out of area treatments and delayed discharges (Escalation Section 3)

Sickness Absence (Escalation Section 4)

The report provides assurance against a number of strategically significant risks and these are detailed within the

relevant sections.

B2 (EC/16/17/579)Executive Committee

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 most recent Chief Inspector of Hospitals inspection). Performance improvement plans

are in place for key areas of underperformance. Phase 1 of the new quality reporting system has been implemented and a demonstration

will be delivered to the quality assurance committee in September 2016. The new indicators will be reported from Q2 2016/17.

Care at a Glance

Month 3 2016/17

Period ending 30 June 2016

TB Agenda Item: C2

EC Agenda Item: B2 of 15

Mersey Care NHS Trust at a glance

ObjectiveReporting

Frequency

Previous

Data

Period 2

Previous

Data

Period 1

Current

Data

Period

Actual

Forecast

next data

period

Kite-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 Safer Staffing Report (Attachment 2)

QUALITY AND SAFETY OF SERVICES (QUALITY DASHBOARD)

Quality dashboard: The position reported relates to Q1 2016/17 with the exception of equitable which

relates to Q4 2015/16. Key issues:

• Safe: The proportion of incidents that result in death or severe harm is above the benchmark.

• Effective: The trust continues to underperform against a number of physical health indicators, including

those detailed within the quality dashboard. Improvement plans are in place. An update on the delivery of

these plans and physical health indicator performance is provided in escalation section 1.

• Equitable: 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.

• Person-Centred: An increase in the aggregate "overall care score" has been observed for both divisions

this quarter however the target of 95 set as part of the strategic initiative outcomes measures has not been

achieved 92.43); the local division score was 90.86 (amber) and secure was 95.75 (green).

•Triangle of Care: The trust wide performance for triangle of care for both community and inpatients has

increased this quarter.

Further information is provided in Attachment 1.

Phase 1 of the quality reporting system has been implemented and a demonstration will be delivered to the

quality assurance committee in September 2016. The new indicators will be reported from Q2 2016/17.

Safer staffing: In June 2016, the secure division reported that there were 565 occasions (n=1,890) when

they had less staff than they clinically required (a deterioration on May 2016). The local division reported that

on 302 occasions (n=1,834) they had less staff than they clinically required (an improvement on May 2016).

The RAG rating detailed above is based on the position against clinical requirement of 96.97% (Amber)

(>=100% green; >=90% amber, <90% red). This is an improvement when compared with May 2016 when

the fill rate was 96.92%. The fill rate against clinical requirement has continued to be below target for some

months and is subject of a piece of performance improvement work sponsored by the Executive Director of

Nursing and supported by the Head of Performance Improvement and Customer Relationship Management.

In June 2016, the trust achieved a fill rate of 104% against the budgeted planned establishment. Further

information is provided in the safe staffing report (Attachment 2).

Strategically significant risks associated with this domain are:

Cleanliness: The clinical divisions undertake cleanliness audits in line with the national standards for

cleanliness on a thirteen week basis (for non-clinical areas the frequency is reduced to six monthly or

annually). The latest data shows that for the secure division the median average score for clinical areas was

98.00% (based on June’s data for high secure services and April’s data for the low and medium secure

units). For the local division, the median average for clinical areas was 96.00% and for non-clinical areas

92.09% (the data reported was the latest available and reflected the outcomes of audits undertaken between

29/06/2015 and 24/06/2016; all clinical areas have had an audit undertaken during Q1 2016/17 with the

exception of Windsor Clinic for whom the results relate to 16/03/2016). Both divisions are achieving the

standards required to achieve a green rating in both clinical and non-clinical areas.


SRR.64 - Risk that the trust will be unable to provide safe staffing on wards (Safe-staffing).

SRR.60 - Risk that the focus on the drivers for financial sustainability and quality improvement become out of

balance.

A

A

A

A

G

G

G

TB Agenda Item: C2


gropen://appendices/Attachment 1.pdf



Reporting

Frequency

Previous

Data

Period 2

Previous

Data

Period 1

Current

Data

Period

Actual

Forecast

next data

period

Kite-

mark

Contracts (Attachment 3) M

CQC registration M

Commissioning for Quality and

Innovation (CQUIN) (Attachment 4)Q

High Secure (Licence, Annual prison

service audit, Social Care Standards)A

Information Governance Toolkit A

NHS Improvement - Governance

Risk Rating (Attachment 5)M

Contracts:

CQUIN:

Performance against the NHS Improvement indicators is provided in Attachment 5.


LOC.095 - LCCG support for Addiction services.

LOC.081 - Talk Liverpool (IAPT) Performance (Contract).

SRR.63 - Risk that due to the block contract we experience an increase in demand for services (Contract).

The third party concerns - In June there were no third party concerns reported.

In the month of June 2016 there were two 12 hour A&E breaches reported. Both of these were in the Adult Mental

Health Liaison Service RLUH and were reported via DATIX.

The early intervention indictor requiring patients to be seen within two weeks with a NICE approved packed of care has

been missed in month three. This has been due to a number of reasons including delays in referrals being received

from single point of access and inpatient services. These issues have been addressed by the services though weekly

meetings with single point of access teams and the service planning are also an event to discuss near misses in the

future. There has also been work within the triage and allocation system to ensure there is greater flexibility to ensure

that if a service user DNAs or cancels, there is still sufficient time to allow them to be assessed within the two weeks.

Further details including details of all the 2016/17 CQUIN schemes are provided in Attachment 4.

NHS Improvement - Governance Risk Rating:

The percentage of delayed discharges has increased since Q4 2015/16 and is 8.45% for the period 1 April to 30 June

2016 (equivalent to an average of 32.3 delayed service users per day). The main reason for the increase since Q4

2015/16 is the reporting of a number of new delayed discharges in the secure division. An Investment Adjustment has

been agreed with NHS Improvement, which is a mechanism designed to facilitate NHS Foundation Trusts to undertake

major transactions without impacting negatively on NHSI’s risk ratings. NHSI have agreed that an adjusted level of

performance (15%) is considered appropriate for a period of 12 months following the Acquisition of Calderstones. The

trust will need to engage with NHS Improvement prior to submission of Q1 2016/17 access and outcomes data to

advise of the increased levels of delays and the anticipated impact of these on our modelling and the investment

adjustment request. A number of actions are in train across the both divisions and further information is provided in

Performance Escalation Section 3.

The local division has now achieved the new cases for early interventions in psychosis indicator following reported

underperformance in Q4 2015/16 and for the period 1 April 2016 to 31 May 2016. This will continue to be closely

monitored by the performance improvement team and the local division to mitigate any risks to future

underachievement.

The trust has identified issues which may mean the Local Services Division may not be able to achieve the national

milestones with regards to the recording of physical health interventions relating to the Cardio Metabolic Assessments

for Patients with Schizophrenia. The physical health leads are working closely with the RiO implementation team to

look at ways of recording interventions in RiO. The maximum financial impact is £0.08m which may need to be

returned to commissioners. The audit is not due to take place until quarter two with results available in quarter four.

There is a sliding scale of payment, however the maximum financial impact is that £0.08m may need to be returned to

commissioners.

The CQUIN leads have raised concern that the temporary nature of the new posts required to deliver the new service

model agreed with the CCGs may compromise the overall delivery of the Primary Care Liaison CQUIN. However they

have confirmed that the quarter one milestones will be met. A meeting is due to take place in July to discuss the risks

of delivery for the remaining three quarters.

EXTERNAL

The business case for A&E Liaison Services is to be submitted to Liverpool CCG by 8 August 2016.

Transitions CQUIN for the CAMHS service has been agreed by LCCG and Alder Hey. A meeting to ensure formal

agreement is made has been scheduled.

Further details including all underperforming quality and performance indicators are provided in Attachment 3.

All CQUINs for 2016/17 have been assigned to trust leads, however a medical Physical Health Lead is yet to be

identified. This will be raised with the local division to resolve.

The trust is meeting weekly with Liverpool City Council and Liverpool CCG on the redesign of addictions services within

affordability levels. The group met 14 July to consider the preferred savings plans and the impact on the wider health

economy.

The proposal from Sefton CCGs of an £0.170m investment in a Dementia Pilot scheme is currently being reviewed by

the trust.

The trust has provided two pricing options to Liverpool and Sefton commissioners for the Brain Injuries Unit. The first

is a block and the second option is a spot purchase price with additional service payments if required.

The services provided in the Walton Centre have been extended until the end of 2016/17, however the trust has been

advised that these will go out to tender in 2017/18

G

G

G

G

A

A

TB Agenda Item: C2








IndicatorReporting

Frequency

Previous

Data Period

2

Previous

Data

Period 1

Current

Data

Period

Actual

Forecast

next data

period

Kite-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

NHS Improvement - Financial

Sustainability Risk RatingM

Link to Finance Dashboard (Attachment 6)

The trust plans to achieve all financial performance targets in 2016/17. As at the end of June, the trust has a £2.284m

surplus before technical adjustments. The secure division is breakeven. The local division, corporate division and

Informatics Merseyside (IM) are £0.125m, £0.002m and £0.051m underspent respectively. The trust has achieved an

NHS Improvement (NHSi) financial sustainability risk rating of 4.

The 2016/17 CIP target is £12.770m. At the end of June, the trust's rephased target is £2.647m of which £2.614m has

been delivered. The undelivered scheme of £0.033m is in corporate division. If no action is taken the 2016/17 CIP

target will be underachieved by £1.115m. The underachieved includes £0.446m CIP from the addictions community

services redesign scheme, a service which is subject to a loss of commissioner income in 2016/17. Divisions are

required to review these CIP plans and the delivery profile for the remainder of the financial year. If following review,

alternative plans are required; those plans must be approved by the agreed process. An update will be provided each

month to the Board and PIC.

FINANCE

Further details of financial performance and appendices are provided in the finance dashboard (Attachment 6).

The trust is still awaiting guidance on the capital regime for 2016/17. At the end of June capital expenditure is

£1.027m.

In 2015/16, as a consequence of slippage on the capital programme, the trust agreed with the TDA a repayment of

Public Dividend Capital (PDC) of £6.000m. The repayment of PDC, supported the national financial position. In

2016/17 the trust will receive £6.000m PDC in August. The trust has been notified that it will receive £1.280m

Sustainability and Transformation funding in 2016/17, as a result the 31 March 2017 cash target has increased to

£11.036m. 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.

To the end of June, the trusts expenditure on qualified agency nursing was 0.05% of all qualified nurse staffing

expenditure, against a target of 3.0%. In 2016/17 a price cap on all agency expenditure was introduced. The price cap

for the trust is £4.659m. At the end of June the price cap is £1.165m and the trust has spent £1.929m. If this continues

the agency price cap will not be delivered. An action plan has been requested to ensure this is delivered.

The planned surplus has increased from £8.000m to £8.425m due to a stretch target agreed with NHSi. This is as a

result of the trust receiving additional STP funding of £1.280m. The planned surplus for 2016/17 is shown in Appendix

1. The local division forecast outturn is £0.500m underspent and IM forecast outturn is £0.200m underspent. The

secure and corporate division forecast outturn position is breakeven. The local division forecast may change as posts

are recruited and non pay costs increase to achieve the targets. The planned surplus no longer includes a technical

adjustment of £0.855m in respect of accounting for Clock View. This technical adjustment is not applicable under the

NHSi (previously Monitor) finance regime.

Within the local division there are overspends in medical budgets due to high locum medical costs, nurse bank and

agency costs (covering vacancies and sickness in inpatient areas), acute out of area treatments. The division and

finance are working on an action plan to address the medical budget overspend. The division will need to continue to

monitor the Liverpool IAPT contract and budget as failure to reduce waiting list may result in financial penalties. Within

the secure division, overspends in medium secure services are being supported by underspends in high secure, low

secure and offender health services.

G

4

G

G

G

G

A

TB Agenda Item: C2




IndicatorReporting

Frequency

Previous

Data Period

2

Previous

Data Period

1

Current Data

Period

Actual

Forecast

next data

period

Kite-

mark

Objective 1 (Workforce): Corporate induction M

Objective 1 (Workforce): Statutory 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 standardsAnnual

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)

Q

Objective 4 (Staff satisfaction and engagement):

Percentage of staff that would recommend the trust as a

place to receive treatment (Quarterly staff survey)

Q

Link to Workforce Performance Report (Attachment 7)

Continued areas that require performance improvement include corporate induction, achievement of the bank and agency utilisation against

requirement, statutory training, and PACE which have mostly deteriorated when compared with last month. Staff sickness has seen a

deterioration in the in-month position. Further information relating to staff sickness (to the end of June 2016) is provided in performance

escalation section 4.

The trust position as at 30 June 2016 for PACE completion was 61.62%. This is a deterioration on month 2 when the trust achieved 73.31%.

There has been a deterioration in corporate induction performance this month with the trust achieving 77.14% (red).


SRR.56 - Risk that the People Plan including WFP, H&WB Plan and Engagement Plan will not be implemented effectively.

CS-Project-W02 - Retention of staff to ensure safe wards and effective workforce planning.

LOC098 - Long Term Consultant Vacancy at Windsor CMHT (Baird House)

CS-Programme17 - Insufficient qualified/unqualified staff retained at Calderstones

WORKFORCE

R

A

R

G

A

A

R

G

R

A

A

TB Agenda Item: C2



STRATEGY

Local Division

All three transformational projects report as green for Local Services. A brief overview for each of the three projects

is provided below:

Community Redesign

Progress:

• Baseline caseload profile review and overarching action plan complete.

• High level discharge and recovery pathway developed and agreed with transfer of care group established to

engage partners in discharge pathways.

• Recruitment of discharge and recovery support staff completed with start dates September 2016.

• Community care pathways developed and ratified and on track to implement pathways in all community services by

August 2016.

• Work progressing in line with plan regarding integrated working with primary care.

• Enhanced case management and day support in place for personality disorder pathway.

Issues or risks:

• Capital monies are not available for further development of Haigh Road to support implementation of crisis

component of the PD pathway/model. Revised plans have been developed in year to provide crisis support, with

ability to also provide support into AEDs. Review of approach once capital monies available.

Assessment and Inpatient Redesign

Progress:

• Kaizan 2 project underway, with 30 day report due end July 2016.

• On track to produce standard access and assessment operating procedures by end July 2016.

• Recruitment of staff required to implement psychological approaches on inpatient wards complete with

commencement in post anticipated within required timescales.

• Psychology formulation levels 1,2,3 finalised.

• Other actions in relation to psychological approaches on track.

• Stepped up care policy and SOP development on track.

Issues or risks:

• Work to develop and implement inpatient model of care including standard operating procedures delayed by one

month. To be completed by end August 2016

Specialist Redesign

Progress:

• Review of LD services within division complete. Implementation of findings on track.

• Review of inpatient and community model for addictions completed. Options appraisal undertaken in light of loss

of commissioning income.

• Work to decant Kevin White Unit into Windsor Clinic has commenced (due to complete 25 July 2016) prior to

refurbishment.

• Organisations change process commenced.

Issues or risks:

• Addictions contract funding reduction remains a key issue and risk for the Trust which is being managed with

support from division and trust personnel.

• Planning permission not yet received for Kevin White Unit development (submitted February 2016).

Secure Division

For Secure Division there are four projects reported as amber and 1 project reported as green. A brief overview for

each project is given below:

Effective Secure Pathway

Progress:

• Admissions panel established at Scott Clinic with the Chair of the High Secure Admissions Panel supporting the

process.

• The new standard of 2 weeks for the assessment of all new referrals and 3 weeks for a decision to be made has

been implemented at Scott Clinic.

Issues or risks:

• Issues with the availability of nursing staff to undertake and complete assessment reports within the time period.

This is due to their shift patterns, allocation of role to undertake leave duties or because of holidays, vacancies and

sickness.

• The Matrons have reviewed this and initial feedback is that it is starting to improve.

TB Agenda Item: C2


Link to Strategy Delivery Report (Attachment 8)

Further details are provided in the update summaries on key transformational areas paper to the executive

committee.

Strategically significant risks associated with strategy delivery are:

SRR.61 - Risk that the large scale transformational programmes are not managed effectively.

SRR.62 - Risk that the Trust approaches to Perfect Care will not be implemented effectively.

SRR.54 - Risk that the Trust will not embrace its appetite for risk in the areas of growth.

SRR.50 - There is a risk that the Trust will not embrace its appetite for risk in innovation.

SRR.55 - Risk that we will fail to engage effectively with primary and social care and we will not formally agree a

pathway approach to integrated care.

SRR.68 - There is a risk that robust planning will not be put in place to manage the transition arrangements with

Calderstones (subject to the Board agreeing the acquisition).

SRR.58 - Risk that we fail to deliver sustainable redesign plans.

SRR.59 - Risk that we fail to deliver our enabling plans (digital, financial, people, and estates).

SRR.69 - Possible delay in CQC Registration for Calderstones.

CS-Programme16 - Target number of transfers of secure Service Users on the Calderstones site into community

care programmes is not possible to achieve, within the three year implementation period.

CS-Programme19 - Insufficient capital funding will be available to secure the restructuring of clinical services.

SHP.027 - Affordability of the development of the Medium Secure Unit.

SD 092 - Proposed reconfiguration of admission/high dependency service in high secure is not funded

SRR.53 - Risk that the trust Research and Development agenda is not aligned to Perfect Care

Psychology Review

Progress:

• Psychology review has been completed to offer an improved service to patients, align the provision across the

Division and improve efficiencies through a single management structure. The revised model has been consulted

upon.

• Some staff have been slotted into posts as per the planned process, but due to a joint grievance by some staff the

slotting in process has been paused.

• The new psychological services model will result in additional band 8a psychologists working with ward teams. To

ensure this is in place as soon as possible recruitment for additional 8a posts has commenced.

Issues or risks:

• The benefits that were identified for improved service provision will not be realised until the full scheme is

completed. There is an additional risk that further delay to completing the review will impact on the provision of

psychological services to patients.

• It is not envisaged that the slotting in process will be completed before September 2016. Efficiency savings from

this scheme have been identified for 2017/18, therefore, this will not impact on 2016/17 CIPs.

Secure Campus

Progress:

• The Division has worked up the model of care and the workforce plan for the full business case.

• Work is on-going with the external project team to design the new building. The design of the new building is in

place and the layout of rooms has been agreed. The 1:200 design have been signed off by the Project Board and

reviewed by the Design Champion.

• An update paper and presentation was provided to the PIC Meeting on 1 July 2016 which was well received

• The Trust acquired Calderstones Foundation NHS Trust on the 1st July 2016.

Issues or risks:

• The key risks still remain around securing capital and the timing of the build to be open by the end of April 2019.

Redesign of Rehabilitation Services

Progress:

• The initial redesign plan, agreed in September 2015, required significant enabling costs which were not secured.

• As a result a new plan was developed that negated the need for enabling costs but only achieved £800k of the

£1,000k CIP savings required. The new plan was accepted by the Secure Governance Board in June 2016.

• Prior to commencing the formal organisational change process an informal process has been initiated. This has

included asking for 19 volunteers from the rehabilitation service to move to the new ward based activity role.

Issues or risks:

• The Division has to formulate additional plans to achieve the £200k CIP shortfall. Plans are in the early stages and

the Division is confident it can realise those savings.

STRATEGY (cont/d…)

TB Agenda Item: C2



Link to CPFT Corporate Dashboard Report - Month 3 2016/17 (Attachment 9)

INTELLIGENCE

Performance Assurance Framework 2016/17: The trust’s performance assurance framework has been reviewed. This review takes

account of the acquisition of Calderstones Partnerships NHS Foundation Trust on 1 July 2016; to include reference to the agreed quality

reporting and strategy measures; and to reflect known changes to commissioner and regulatory requirements. A paper summarising

these changes will accompany the month 4 care at a glance report to the performance and investment committee. Work is underway to

establish reporting mechanisms (and where relevant, data capture) for all agreed measures. Whilst it has been possible to remove a

small number of indicators, there is an overall significant increase in the number of measures to be reported within the framework and

further work is necessary over the course of the financial year to assess whether any further rationalisation of the number of measures is

possible.

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 2015. The current (M3 position) is 67.17%

green, 9.12% amber and 23.71% red. Overall, this is a deterioration on M2.

Out of area treatments: An update is not available in this report and will be circulated in a separate document.

Calderstones Partnerships NHS Foundation Trust corporate dashboard report: The month 3 corporate dashboard report for

Calderstones Partnerships NHS Foundation Trust is provided in Attachment 9 for reference by committee members. Combined reporting

for the enlarged organisation will commence August 2016.

TB Agenda Item: C2



Performance Escalation Section 1

PREVQuality Physical health

Key Performance

Indicator

Reference

Key Performance Indicator

Target/Description

Reporting

FrequencyTarget/Thresholds Trust Wide Trend Movement

Local Services

DivisionTrend Movement

Secure Services

DivisionTrend 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. 95.76% q 95.70% q

Quarter 1 2016/17

PHYSCOM22

All 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. 69.69% p 69.35% p

Quarter 1 2016/17

PHYSCOM23

All 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 50.47% p 50.47% p

Quarter 1 2016/17

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.

ambertu

ambertu

Greentu

Quarter 3 2015/16

PHYSCOM28

Percentage 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% tu 100.00% tuQuarter 4 2015/16

PHYSCOM29

Percentage 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% tu 100.00% tuQuarter 4 2015/16

PHYSCOM30

Percentage 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 0.00% q 0.00% qQuarter 4 2015/16

PHYSCOM31

Percentage of patients offered a dental

examination within three months of the

date determined / indicated by the

dentist.

Quarterly (In

Quarter)

>=100% green; <100%

red 100.00% tu 100.00% tuQuarter 4 2015/16

PHYSCOM32

Percentage of patients with coronary

heart disease who had blood pressure

recorded in previous 15 months which

was 150/90 or less (QOF CHD 6).

Quarterly (In

Quarter)

>=100% green; <100%

red 100.00% tu 100.00% pQuarter 4 2015/16

PHYSCOM34

Smoking 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)87.55% p 87.55% p

Quarter 1 2016/17

PHYSCOM35Adult in-patients screened for malnutrition

on admission using the MUST tool

Quarterly (In

Quarter)>=95% green; <95% red 97.60% q 97.60% q

Quarter 1 2016/17

PHYSCOM36Patients with a score of 2 or more (MUST)

to receive an appropriate care plan

Quarterly (In

Quarter)

>=100% green; <100%

red 97.03% q 97.03% qQuarter 1 2016/17

PHYSCOM37Patients with a score of 2 or more (MUST)

are referred to dietician

Quarterly (In

Quarter)

>=100% green; <100%

red 62.14% p 62.14% pQuarter 1 2016/17

PHYSCOM6

Number of patients who did not have a

physical health check within 24 hours of

admission.

Quarterly (In

Quarter)0 green; >0 red 0 tu 0 tu

Quarter 4 2015/16

PHYSCOM7

Number of patients who have not had a

physical health check within the last 12

months.

Quarterly (In

Quarter)0 green; >0 red 0 tu 0 tu

Quarter 4 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 92.86% q 92.86% p 100.00% tuQuarter 1 2016/17

PHYSLOC2

Percentage of patients admitted for whom

addiction status has been recorded (Local

services only).

Quarterly (In

Quarter)

>=95% green; >=90%

amber; <90% red 96.56% q 96.56% qQuarter 1 2016/17

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 89.50% q 89.39% p 97.37% pQuarter 1 2016/17

PHYSLOC4

Percentage of patients admitted for whom

BMI has been recorded (includes High

Secure).

Quarterly (In

Quarter)

>=95% green; >90%

amber; <90% red 97.95% q 98.51% p 71.43% qQuarter 1 2016/17

PHYSLOC5

Percentage 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 99.80% q 99.80% qQuarter 1 2016/17

PHYSLOC6

Percentage 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 89.11% p 89.11% pQuarter 1 2016/17

PHYSLOC7

Standard 37: smoking cessation support-

proportion of new admissions offered

smoking cessation within 24 hours - High

Secure

Quarterly (In

Quarter)

>= 95% green; >=90%

and <95% amber; <90%

red100.00% tu 100.00% tu

Quarter 4 2015/16

PHYSCOM40

Improving 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

tu tuQuarter 4 2015/16

PHYSCOM41

Physical Health Care of all Mental Health

and Learning Disability Services Users

across Mersey Care NHS Trust

Quarterly (In

Quarter)

Achieve quarterly

milestones to


= green; quarterly


to Commissioner

satisfaction = red

Achievedtu

Achievedtu

Quarter 4 2015/16

PHYSCOM42

Supporting 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.

Achievedtu

Achievedtu

31/03/16

MEWSLOC1Percentage of short form audit standards

achieved for audited patients.

Monthly (In

Month)

Green 100%; Amber

>=90%; Red <90% 94.16% pNot available

tu 94.16% p30/06/16

PHYSLOC8

% of new admissions who have had

physical health screening completed

(NAS Standard)

Monthly (In

Month)>=95% green; <95% red Not available

tuNot available

tuNot available

tu

PHYSCOM43

Health lifestyles: nutritional monitoring of

the patients' shop, high secure services

(CQUIN)

Quarterly (In

Quarter)

Achieve quarterly

milestones to


= green; quarterly


to Commissioner

satisfaction = red

greenp

greenp

Quarter 4 2015/16

PHYSCOM39




Communication with General Practitioners

(Local Division Only)

Annual

By Q2 2015/16 >=90% =

green; >=50% = amber;

<50% = red. On track =

green; concerns identified

= red.

58.00% tu 58.00% tu31/03/16

PHYSCOM44




Cardiometabolic assessment and

treatment for patients with psychoses

(community EIP)

Quarterly (In

Quarter)

By Q4 2015/16 >=80%

green; >=40% amber;

<40% red. For Q2 to Q3

2015/16, to report. On

track = green; concerns

identified = red.

greenp

greenp

greenp

Quarter 4 2015/16

TB Agenda Item: C2


Performance Escalation Section 1 (cont/d…)

PREVQuality Physical health

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

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 30 June 2016 or Quarter

1 2016/17 (unless otherwise indicated).

Based on the data currently available, the trust-wide position has shown improvement in seven of the

indicators and a deterioration in six of the indicators. Further work is required to achieve a number of the

measures.

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. An improvement has been observed in Q1 2016/17 (50.47% red),

however, this will continue to be monitored throughout 2016/17.

A new indicator was added to the framework in 2015/16 auditing the compliance with our Early Warning

System for physical health observations (MEWSLOC1). Performance for month 3 2016/17 continues to

improve when compared to month 2 but remains under target. This will continue to be monitored. Data

completeness has significantly improved since implementation. There was no auditable data for month 3

within the Local Division.

Secure division

MEWSLOC1 continues to be monitored monthly with this month showing more improvement achieving

100% compliance and an overall achievement of 94.1% .

There are plans to change the way in which the audit is completed, with the responsibility changing to

Physical Care department on a quarterly basis. This is due to commence in September.

Dr Feelwell continues to be used across the division as part of the health and well being agenda. A

workshop displaying the works of Dr Feelwell with be delivered at the 3 hospitals conference due to take

place in Cardiff in November.

Initial meetings have taken place to look at the issue of refusals in relation to accessing physical health care

/ monthly well man checks.

Baseline data has been gathered for patients refusing to attend the Health Centre for physical health

interventions.

Local division

The local division's physical health policy is being amended following a review of the inpatient pathway; the

date for ratification is yet to be confirmed. The division are now undertaking a review of the community

physical health pathway and this will inform a further iteration of the division's physical health policy later

this financial year (December 2016). Additional monies have been secured around physical health; job

descriptions for a modern matron and data quality and performance roles have been put together. The job

description for the Modern Matrons role has been ratified through agenda for change. We are currently in

the process of recruiting to the Modern Matron and Performance posts. A strategic physical health meeting

has been established to lead on the physical health agenda for the trust. There will also be additional

physical health posts for support to community and inpatient teams. Design of the service model for

physical health is underway. Weekly compliance monitoring of completion of physical health checks within

inpatient settings has identified some issues around junior medical staff completion (partially as a result of

availability). The lead consultant has put an aide-memoir together to support out of hours doctors around

their requirements. Issues around access to investigation results have been raised with CCGs and with the

trust's medical director. Discussions are underway around finding a technological solution. The dietitians

continue to support inpatient wards with completion of the relevant fields within the physical health

observations form around MUST, nutritional care planning and referral to dietitians. A BiT report is in place

to support ongoing monitoring. There is training available to staff on MUST and nutrition (which is also

being delivered directly to wards due to issues in releasing staff to attend, staff shortages). The dietitians

are working with learning and development and the local division (via the divisions quality meeting) to agree

solutions.

TB Agenda Item: C2



PREVExternal CONTRACTS - TALK LIVERPOOL

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

performance?

In 2015/16 the trust received a performance improvement

notice from Liverpool CCG in relation to continued under

performance in the Talk Liverpool service. A number of

actions remain outstanding and these will continue to be

monitored during 2016/17 through the service development

improvement plan and in CQPG meetings between the trust

and commissioners.

The local division have identified 14 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 , IAPT Analyst

Network and Recovery Rate.

The table above shows performance against the Talk

Liverpool indicators as at 30 June 2016. 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 11 indicators reported above, eight are not being

achieved and three are being achieved. In June 2016, four of

the eight indicators not being achieved have improved, four

have stayed the same and three have deteriorated when

compared to the previous month.

The national referral to treatment indicators for IAPT services

(WAITNAT2 and WAITNAT3) have been achieved.

The updated action plan as at 13 July 2016 includes:

- Waiting times. The internal waiting list has increased to

3,132 reflecting the increase in numbers entering treatment to

897 in June from 742 in May.

- Development of a capacity and demand modelling tool.

NHS England's IAPT Intensive Support Team have requested

a range of information and data prior to their visit to the servie

on 21 July.

- Further roll out ensuring equitable access to therapies for

both new clients and long waiters to following discussion with

IAPT Improvement Team.

- Work is ongoing through clinical supervisors and case

managers to maximise adherence to NICE/IAPT protocols

and pathways following workshop with senior staff and

supervisors.

- Recruitment is on-going in relation to permanent and

temporary positions. Two PWP positions have been

advertised (closing date 17 July with interviews week

commencing 1 August). Agency interviews for PWPs

continue weekly. Due to the lack of resource within the step 2

leadership, Nick Nool, IAPT Course Lead, Chester University

will be providing 1 day per week case management/clinical

supervision from 18 August. 2 fixed term HITs have been

recruited to cover maternity leave.

- A draft GP newsletter has been produced for review by the

the CCG before circulation.

Key Performance

Indicator

Reference


Target/Description

Reporting


FOLLCOM4

Talk Liverpool - The average number of

treatment sessions received after

assessment by step 2.

Monthly (In

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

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 month.

Monthly (In

Month)>50% green; <=50% red 36.00% p

CANCCOM3

Talk Liverpool - The number of booked

appointments that are cancelled (Total)

expressed as a percentage.

Monthly (In

Month)<10% green; >=10% red 20.00% q

DNACOM4

Talk Liverpool - The number of booked

appointments that are DNA'd expressed

as a percentage.

Monthly (In

month)<10% green; >=10% red 12.00% q

ACCECOM1

Talk Liverpool - The number of people who

have entered psychological therapies (AU

the end of the reporting month) as a

proportion of prevalence.

Monthly (In

Month)

Annual target is 16%

(13650 people). Monthly

target has been issued by

commissioners.

78.82% p

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 16.00% p

WAITCOM20Talk Liverpool - The number of days from

receipt of referral to entering treatment.

Monthly (In

Month)

<28 days green; >=28

days red 9.00 tu

WAITCOM21

Talk Liverpool - The number of days from

receipt of referral to entering treatment in

Step 2.

Monthly (In

Month)


days red 12.00 p

WAITCOM22Talk Liverpool - The number of days from

step up to starting treatment in Step 3.

Monthly (In

Month)


days red 120 q

WAITCOM23Talk Liverpool - The number of days most

people wait for treatment.

Monthly (In

Month)


days red 7.00 tu

FOLLCOM5

Talk Liverpool - The average number of

treatment sessions received after

assessment by step 3.

Monthly (In

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

TB Agenda Item: C2



External Delayed transfers of Care PREV

Green

<=7.5%

* Following the approval of the acquisition Calderstones Partnerships NHS Foundation Trust (CPFT), the trust anticipated

increased levels of delayed discharges. An Investment Adjustment has been agreed with NHS Improvement, which is a

mechanism designed to facilitate NHS Foundation Trusts to undertake major transactions without impacting negatively on NHSI’s

risk ratings. NHSI have agreed that an adjusted level of performance (15%) is considered appropriate for a period of 12 months

following the Acquisition of Calderstones. The trust's worst case scenario modelling expected a return to below 7.5% in Q3

2017/18. The best case scenario modelling shows a return to below 7.5% occurring in Q2 2017/18. This modelling was

undertaken assuming the position reported for Mersey Care NHS Foundation Trust in April 2016 continued (5.90%).

If the modelling including the specialist learning disability beds is undertaken using the Mersey Care NHS Foundation Trust (secure

and low secure division) position reported for 1 April to 30 June 2016, then neither the best case nor worst case scenarios show a

return to below 7.5% in the modelling period (Q1 2016/17 to Q4 2018/19). This scenario is unlikely to occur as the trust is putting

actions in train (as detailed below) to reduce the number of delays to below 7.5%. In the worst case scenario, the percentage of

delays would rise to 15.47% in Q4 2016/17 and Q1 2017/18. This would place the trust's performance above the 15% level agreed

with NHS Improvement through the Investment Adjustment process.

Mersey Care NHS Foundation Trust data (secure and local division) as at 11 July 2016 indicates that the number of delayed

discharges was 28 (equivalent to 7.32% of beds occupied by delays). When the number of delayed discharges for the local and

secure division as at 11 July 2016 is fed into the modelling including specialist learning disability beds from the beginning of Q2

2016/17, the best case scenario shows achievement of the 7.5% target in Q4 2018/19. Prior to this, combined performance is

expected to be above 9% from Q2 2016/17 through Q1 2017/18. In Q2 2017/18, the percentage reduces to 7.64% and remains

above 7.5% until Q4 2018/19 when the target is expected to be achieved. The worst case scenario also shows achievement of the

7.5% target in Q4 2018/19. Between Q2 2016/17 and Q2 2017/18 the expected performance is between 12.91% and 14.49%. In

Q3 2017/18, the percentage reduces to 7.71% but remains above 7.5% until Q4 2018/19.

Indicator

Source

Latest

performance

Expected date to

meet standard

National 8.45% Q2 2016/17 *

Next update to

performance and

investment committee

/ board

August 2016

Data period

1 April to 30 June 2016

Forecast (next

data period "in

quarter")

Green

TB Agenda Item: C2


Performance Escalation Section 3 (cont/d…)

What is driving the reported performance? What actions have we taken / do we plan to take to improve performance?For the period 1 April 2016 to 30 June 2016, the local division had (on average) 23.1

beds occupied by delayed discharges, equating to 8.05% of occupied bed days. The

secure division (low and medium secure) had an average of 9.2 beds occupied by

delayed discharges, equating to 9.66% of occupied bed days.

The trust is required to report delays using reasons defined by the department of

health.

For the local division, the main reasons (based on occupied bed days) were: Nursing

Home, Disputes, Housing (non NHS), Funding and Residential Home.

For the secure division, the main reasons for delays (based on occupied bed days)

were: Assessment, Non Acute NHS Care and Disputes. The division has reported

difficulties in obtaining placements for some medium and low secure service users

due to the complexity of their cases and ongoing needs.

In addition to the above, the secure division reported five delayed discharges within

high secure services as at the end of June 2016. The shortage of medium secure

beds nationally has now started to impact on the ability of high secure services to

promptly move people on (historically the average number of delayed discharges is

reported as two at any one time).

Based on the actions in train, the local and secure divisions are confident that they can

return to a position of below 7.5% by Q2 2016/17. This forecast assumes:

• Appropriate engagement by external agencies in discussions regarding service

users for whom discharge is clinically indicated and agreed by the multi-disciplinary

team.

• Timely assessment where care packages or alternative provision is required upon

discharge.

• Timely agreement of funding.

• Appropriate care packages / placements in place to which the service user can be

discharged.

Actions include:

Secure division

The process for monitoring delayed discharges within the secure

division has been reviewed and updated to minimise delays.

Increased contact with commissioners in relation to potential and

actual delayed discharges has been implemented.

Work is underway to systematically capture data for and officially

report upon delayed discharges within high secure services via

Unify2. Once high secure delays are officially reported upon and the

denominator for the indicator extended to include the high secure

service; this is expected to positively impact on the overall

percentage of occupied bed days associated with delayed

discharges. Work will be undertaken during Q2 2016/17 to support

this; with official reporting of high secure delays commencing from 1

October 2016.

Local division

• The introduction of a number of processes to aid recording and

reporting of delayed discharges.

• Each week Sefton and Liverpool have local radar meetings. These

are attended by inpatient community staff to update on the recorded

delays and possible new delays for the coming week.

• Each week (Thursday), the division has an overarching delayed

discharge meeting with the Local Division Social Care Lead and

representatives from Liverpool. Within the meeting every patient is

discussed and the meeting is action orientated.

• Since this system was introduced in February, the division can

confidently predict the number of delays and has reduced the

number from 45 to the current average figure of 23.

• The division has historically encountered some difficulties in

consistently capturing the required information on Epex. The Local

Division Social Care Lead has attended ward managers meetings to

explain the system and the Division Capacity and Flow manager

sends reminders to the ward managers on coding when errors

occur.

• The division has held a series of Multi Agency Discharge Events

(MADE) as follows: North Liverpool and South Sefton on the 27 April

2016; Liverpool on 22 June 2016; North Sefton on the 15 July 2016.

TB Agenda Item: C2



PREV

Green

<=4.8%

The workforce paper accompanying this report provides further detail.

Total

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.

Corporate Services 3.41% 0.141

iMerseyside 3.82% 0.078

Internal

Indicator Source

Actions include:

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.

The graph above shows that in 2015/16, the trust saw a step change in the

levels of sickness absence which resulted in a move from an average “amber”

position to “red”.

The in month absence rate of 5.60% is equivalent to 192.27 WTE staff off sick at

any point in time (129.25 WTE long term and 63.02WTE short term). The rolling

12 month absence rate of 6.17% is equivalent to 217.37 WTE staff off sick at

any point in time (148.97 WTE long term and 68.39 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 sickness rate and direct of cost of sickness for the period

1 April 2016 to 30 June 2016 split by division is set out in the table below.

DivisionSick Days as a %

of Available Days

Estimated YTD Cost of

Sickness (£m)

Local Services 5.94% 0.957

Secure Services 6.52% 0.781

5.66% 1.957

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 01/08/2016

Next update to performance and

investment committee / boardExpected date to meet standard

Forecast signed

off by:

TBC

Forecast

(next data

period "in

Amber5.60% 6.17%

Rolling twelve

months

Latest

performance (in

month)

0%

1%

2%

3%

4%

5%

6%

7%

8%

0 50,000 100,000 150,000 200,000 250,000 300,000

Pe

rcen

tag

e s

ick

ne

ss r

ate

FTE Days Available

Sickness absence rate for mental health trusts, April 2015 to March 2016 (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

9

Apr

-14

May

-14

Jun-

14

Jul-1

4

Aug

-14

Sep

-14

Oct

-14

Nov

-14

Dec

-14

Jan-

15

Feb

-15

Mar

-15

Apr

-15

May

-15

Jun-

15

Jul-1

5

Aug

-15

Sep

-15

Oct

-15

Nov

-15

Dec

-15

Jan-

16

Feb

-16

Mar

-16

Apr

-16

May

-16

Jun-

16

Per

cent

age

sick

ness

rat

e

Staff Sickness - April 2014 to June 2016 (Trust Wide)

TB Agenda Item: C2


Escalation Status

NEW New Escalation

PREV Update on previous

escalation

Reporting Frequency

M Monthly

Q Quarterly

A 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

pPerformance Improving

qPerformance Deteriorating

tuPerformance Maintained

Trend Movement Arrows - Summary Sheet

Performance improved (arrow

colour indicates performance level

achieved)

Performance maintained (arrow


achieved)

Performance deteriorated (arrow


achieved)

Relevance

Timeliness

Monitoring

Completeness

Validation

Audit

Reliability

TB Agenda Item: C2


Trust Board

Executive Committee:

Quality Area Dec-14 Mar-15 Jun-15 Sep-15 Dec-15 Mar-16 Jun-16

Safe A A A A A A G

Timely G G G G G G G

Effective A A A A A A A

Equitable A A A A A A A

Person-Centred A A A A A A A

Triangle of Care G A G R G A G

C2 / 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

June 2016

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

60

Q1 2

013

/14

Q2

20

13

/14

Q3 2

013

/14

Q4

20

13

/14

Q1 2

014

/15

Q2

20

14

/15

Q3

20

14

/15

Q4

20

14

/15

Q1

20

15

/16

Q2 2

015

/16

Q3

20

15

/16

Q4 2

015

/16

Q1

20

16

/17

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)

0123456789

10

Q1

20

14

/15

Q2 2

014

/15

Q3

20

14

/15

Q4

20

14

/15

Q1

20

15

/16

Q2 2

015

/16

Q3

20

15

/16

Q4

20

15

/16

Q1

20

16

/17

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%

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%

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, 2015/16 and 2016/17)

80

85

90

95

100

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

Local Services Secure Services Trust Wide Target

92%

93%

94%

95%

96%

97%

98%

99%

100%

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%)

Dashboard Page 2 of 14

Return to summary sheet Return to dashboard sheet

Safe

Number of

incidents

Number of

occupied bed

days

Trust 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 2,724 53,568 50.85 43.00

Q2 2015/16 2,824 55,593 50.80 43.00

Q3 2015/16 2,726 55,487 49.13 43.00

Q4 2015/16 2,897 52,911 54.75 43.00

Q1 2016/17 3,143 54,495 57.68 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 2015/16 806 94,144 8.56 3.92

Q2 2015/16 709 96,988 7.31 3.92

Q3 2015/16 787 93,825 8.39 3.92

Q4 2015/16 820 91,467 8.96 3.92

Q1 2016/17 748 91,173 8.20 3.92



30

35

40

45

50

55

60


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

0

1

2

3

4

5

6

7

8

9

10

Q12014/15

Q22014/15

Q32014/15

Q42014/15

Q12015/16

Q22015/16

Q32015/16

Q42015/16

Q12016/17


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,

2015/16 and

2016/17)

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%


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%


January 2016 to March 2016 90.40% 80.21%

April 2016 to June 2016 86.97% 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 Q3 2015/16 Q4 2015/16 Q1 2016/17

Benchmark

(NRLS 1

April to 30

September

2013)

Notes re:

benchmark

Death (Caused by incident) 0.13% 0.47% 0.38% 0.47% 0.28% 0.23% 0.42% 0.29% 0.23% <0.7% Bottom 10%

Severe Harm 0.20% 0.13% 0.22% 0.21% 0.54% 0.40% 0.42% 0.29% 0.28% <0.3% Bottom 10%

Moderate Harm 0.86% 0.35% 0.38% 0.39% 0.37% 0.48% 0.54% 0.42% 0.41% <6.1% Bottom 10%

Low Harm 15.88% 13.66% 13.52% 12.00% 9.75% 9.81% 9.17% 8.90% 12.10% <34.0% Bottom 10%

No Harm 82.92% 85.40% 85.51% 86.93% 89.06% 89.09% 89.44% 90.10% 86.97% >=62.1% Top 5%

Note new benchmarks have been applied to Q1 2016/17


Breakdown of by harm level compared against latest NRLS benchmark (mental health trusts for 1 April 2015 to 30 September 2015)

20%

40%

60%

80%

100%


Percentage of incidents resulting in no harm

Target (75.60% 2013/14, 80.21% 2014/15, 2015/16 and 2016/17)

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%

Dec-15 97.24% 95%

Mar-16 97.45% 95%

Jun-16 96.18% 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 Dec-15 Mar-16 Jun-16

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%

Dec-15 86.63% 90.24% 95%

Mar-16 89.49% 97.22% 95%

Jun-16 89.39% 97.37% 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%

Dec-15 85.71% 100.00% 95%

Mar-16 85.71% 100.00% 95%

Jun-16 92.86% 100.00% 95%

Note: Secure position still relates to Q4 2015/16.

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 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

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

Equitable Page 8 of 14


Person-Centred

Patient Experience Inpatient April to June 2016Adult Mental

HealthComplex Care

Specialist

ServicesLocal Services Low Secure

Medium

SecureHSS Secure Services All Services

Number of responses 172 41 65 278 20 64 183 267 545

Target number of responses 426 174 279 705

% of responses target achieved 65% 105% 96% 77%

Adult Mental

HealthComplex Care

Specialist


Medium


OVERALL SCORE (Excluding Carers & Friends and Family) 90.83 97.09 92.48 92.14 97.61 97.05 95.10 95.75 93.91

Access / Contact 92.05 97.80 94.75 93.53 98.50 98.28 95.63 96.48 94.98

Activities 90.23 99.39 89.23 91.35 100.00 96.46 91.23 93.14 92.23

Care and Treatment / Diagnosis 90.87 94.94 93.85 92.17 96.25 97.36 96.10 96.41 94.25

Care Plan 87.20 95.09 85.77 88.03 97.50 96.68 93.85 94.80 91.37

Carers 71.51 79.27 71.54 72.66 75.00 89.84 77.60 80.34 76.42

Cleanliness 86.82 95.94 90.77 89.09 88.33 84.38 87.80 87.02 88.07

Effective Care 95.91 100.00 93.85 96.03 100.00 98.44 97.81 98.13 97.06

Friends and Family 90.47 93.17 95.38 92.01 83.00 79.69 83.83 82.77 87.49

Medication 86.32 100.00 88.95 88.89 100.00 99.48 94.10 95.88 92.33

Other 86.05 97.56 90.00 88.67 93.75 94.88 93.29 93.70 91.13

Privacy and Dignity 97.09 99.59 98.21 97.72 99.17 96.61 97.63 97.50 97.61

Safety 93.60 100.00 94.62 94.78 100.00 99.22 95.63 96.82 95.78

Single Sex 100.00 92.68 100.00 98.92 100.00 98.44 100.00 99.63 99.27

105

80%

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)

Person-Centred Page 9 of 14

Adult Mental

HealthComplex Care

Specialist


Medium


OVERALL SCORE (Excluding Carers) 2.14 -0.53 -0.66 1.28 0.52 0.09 1.36 0.88 1.06

Access / Contact 0.09 -1.17 0.31 0.07 1.00 -0.94 0.49 0.04 0.04

Activities 2.02 0.67 3.52 2.22 0.00 0.03 -0.48 -0.48 0.88

Care and Treatment / Diagnosis 2.86 -2.32 -1.77 1.28 -0.63 1.02 2.81 2.02 1.63

Care Plan 4.05 0.57 -1.31 2.44 3.83 -0.06 -0.27 -0.02 1.17

Carers

Cleanliness 0.22 0.21 0.21 0.40 -11.67 -0.90 -0.97 -1.59 -0.58

Effective Care 5.10 0.00 -6.15 2.02 0.00 -1.56 4.99 2.81 2.40

Friends and Family 4.20 -2.73 0.05 2.50 -8.00 2.85 3.72 2.77 2.68

Medication 0.02 0.88 -5.40 -0.88 1.67 2.96 0.84 1.32 0.20

Other 1.45 4.70 3.33 2.50 5.00 -0.57 2.82 1.97 2.20

Privacy and Dignity 4.40 -0.41 1.54 3.18 -0.83 -1.64 1.68 0.63 1.92

Safety 0.43 1.28 1.29 0.81 0.00 0.52 1.98 1.32 1.05

Single Sex 1.08 -7.32 0.00 -0.38 0.00 -1.56 0.00 -0.37 -0.37

Theme Local Services Secure Services All Services

Number of responses 278 267 545

Target number of responses 426 279 705

% of responses target achieved 65% 96% 77%

OVERALL SCORE (Excluding Carers) 92.14 95.75 93.91 90.00

Access / Contact 93.53 96.48 94.98 90.00

Activities 91.35 93.14 92.23 90.00

Care and Treatment / Diagnosis 92.17 96.41 94.25 90.00

Care Plan 88.03 94.80 91.37 90.00

Carers 72.66 80.34 76.42 N/A

Cleanliness 89.09 87.02 88.07 90.00

Effective Care 96.03 98.13 97.06 90.00

Friends and Family 92.01 82.77 87.49 90.00

Medication 88.89 95.88 92.33 90.00

Other 88.67 93.70 91.13 90.00

Privacy and Dignity 97.72 97.50 97.61 90.00

Safety 94.78 96.82 95.78 90.00

Single Sex 98.92 99.63 99.27 100.00

Inpatient Score (out of 100, 100 being positive)

Target

Theme

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


Patient Experience Community April to June 2016Adult Mental

HealthComplex Care

Specialist

Services

Assessment

ServicesLocal Services

Low Secure,

Medium

Secure and

Offender

Health

Secure Services All Services

Number of responses 135 43 20 87 285 0 0 285

Target number of responses 156 18 18 174

% of responses target achieved #DIV/0! #DIV/0! #DIV/0! 183% 0% 0% 164%

Adult Mental

HealthComplex Care

Specialist

Services

Assessment


Low Secure,

Medium

Secure and

Offender

Health


OVERALL SCORE (Excluding Carers) 88.56 89.71 96.34 89.61 89.61

Access / contact 91.63 90.93 94.50 91.81 91.81

Care and treatment / diagnosis 89.67 85.58 97.00 89.56 89.56

Care plan 88.32 92.58 97.50 90.29 90.29

Carers (Not RAG rated) 65.19 70.93 62.50 66.00 66.00

Day to Day Living 77.12 91.85 91.80 80.91 80.91

Effective Care 93.33 95.35 100.00 94.50 94.50

Friends and Family Test 87.46 90.95 90.59 88.00 88.00

Medication 91.75 94.02 100.00 92.98 92.98

Other 81.85 77.33 93.75 82.00 82.00

Privacy and Dignity 96.42 98.84 98.33 97.17 97.17

Adult Mental

HealthComplex Care

Specialist

Services

Assessment


Low Secure,

Medium

Secure and

Offender

Health


OVERALL SCORE (Excluding Carers) -0.30 -2.79 2.02 89.61 -0.48

Access / Contact 2.07 -4.07 -0.85 91.81 0.66

Care and Treatment / Diagnosis 1.07 -6.42 2.00 89.56 -0.41

Care Plan -1.75 2.58 5.83 90.29 0.02

Carers

Day to Day Living -9.31 1.42 1.00 80.91 -6.52

Effective Care 4.68 2.02 0.00 94.50 3.64

Friends and Family 1.83 0.28 -7.87 88.00 -0.08

Medication 0.29 -0.57 5.36 92.98 0.76

Other 5.96 -9.96 3.37 82.00 2.46

Privacy and Dignity -0.29 2.73 0.89 97.17 0.46

Community patient experience survey results (Target 90%)

Theme

Theme

Score (Out of 100, 100 being positive)

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


Theme Local Services Secure Services All Services

Number of responses 285 0 285

Target number of responses 156 18 174

% of responses target achieved 183% 0% 164%

OVERALL SCORE (Excluding Carers) 89.61 89.61 90.00

Access / Contact 91.81 91.81 90.00

Care and Treatment / Diagnosis 89.56 89.56 90.00

Care Plan 90.29 90.29 90.00

Carers 66.00 66.00 N/A

Day to Day Living 80.91 80.91 90.00

Effective Care 94.50 94.50 90.00

Friends and Family 88.00 88.00 90.00

Medication 92.98 92.98 90.00

Other 82.00 82.00 90.00

Privacy and Dignity 97.17 97.17 90.00


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

October to December 2015 91.75 95.91 93.22 95.00

January to March 2016 90.54 94.87 92.13 95.00

April to June 2016 90.86 95.75 92.43 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 toJune 2014

July toSeptember

2014

October toDecember

2014

January toMarch 2015

April toJune 2015

July toSeptember

2015

October toDecember

2015

January toMarch 2016

April toJune 2016





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%

Dec-15 85% 90% 86% 100%

Mar-16 85% 99% 89% 100%

Jun-16 89% 99% 92% 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%

Dec-15 77% 87% 77% 100%

Mar-16 76% 87% 76% 100%

Jun-16 77% 90% 78% 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%

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%

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

Trust Board C2 / Attachment 2

Executive Committee: B2 / Attachment 2

Page 1 of 11

Report provided (check necessary boxes): Paper No: C2/B2 Attachment 2

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

For Decision: ☐ For Consent: ☐ Meeting Date: 21 July 2016

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 June 2016.

Summary of Key Issues:

This paper provides details of inpatient staffing level fill rates during June 2016.

The local division report an improved position. The secure division report a deterioration.

The paper highlights the main reasons for any variance and the 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.

Recommendations:

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.

Next Steps: (Subject to recommendation being accepted)

1) Future reports will reflect the position for the Specialist Learning Disability Division.

2) The Quality Dashboard, launched in July 2016, will support future reports.



Page 2 of 11

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 of 11

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 June 2016.

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


Average fill rate percentage

UNREGISTERED

Trust Total

Apr 91% 109% 98.6% 117.5% 104.7%

May 97% 108% 100% 118% 106%

Jun 95% 106% 96% 117% 104%

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 of 11

Table 2: Summary of CLINICALLY REQUIRED VERSUS ACTUAL

DAY

NIGHT

Month

Average fill rate


Average fill rate

percentage UNREGISTERED

Average fill rate


Average fill rate percentage

UNREGISTERED

Trust Total

Apr 90.7% 96.8% 94.7% 101.3% 96.0%

May 96% 96% 97% 100% 97%

Jun 93% 97% 93% 100% 97%

6. As requested by divisions the percentage of occasions when less staff than clinically required is presented in table 3. Both divisions report an improved position. Table 3 - Percentage of occasions

Less staff than clinically required

% Trend

LOCAL

April 21%

May 20%

June 16%

SECURE

April 32%

May 28%

June 30%

7. The following graphs highlight the main reasons for shortfall and the impact on service

user and staff experience. REASONS FOR SHORTFALL

8. Both divisions continue to report an improvement in the bank filling shift requests.

9. Sickness data was not available at the time of the report.

10. Both divisions report difficulty recruiting to vacancies and have robust recruitment plans in place to support recruitment to the staffing pools.



Page 5 of 11

* % Sickness data not available at the time of the report. **Staff suspensions is the number of staff.

* % Sickness data not available at the time of the report. **Staff suspensions is the number of staff.



Page 6 of 11

11. The graph below highlights the reasons for requesting additional staff from the bank.

12. The following graphs highlight the percentage of complaints relating to staffing and the percentage of incidents which resulted in harm. The local division reports no change from previous month. The secure division reports an increase in complaints relating to staffing.



Page 7 of 11

13. The Patient tracker system captures the experience of service uses on a monthly basis. The following graphs highlights access to staff, access to users’ activities and overall perception of safety. The local division report an improved position in relation to safety and a deterioration in the access domains of patient experience. The secure division report an improvement in patients’ access to staff and deterioration in safety and activities.

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

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



Page 8 of 11

STAFF EXPERIENCE

14. 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.

15. A deterioration is noted for all areas in the local division.

16. The secure division report improvement in access to supervision and breaks with a deterioration in other areas of staff experience.

Table 4 - Reported impact on staff experience

Breaks

Cancelled

Trend

PACE Reviews Deferred

Trend

Student mentor-

ship affected

Trend Supervision

Deferred Trend

LOCAL

April 51

11

0

18

May 64 18

10 24

June 75

52

13

66

SECURE

April 76

60

11

74

May 51

82

17

55

June 63 101

24

53

MONITORING

17. 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) Staffing issues have been presented at the Stand up Thursday executive

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

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

clinical areas at each review.

ACTIONS IN TRAIN 18. Both Divisions have a detailed action plan and are addressing impact and reasons for

shortfall.

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



Page 9 of 11

20. The workforce team has commenced a review to confirm the number of starters and

leavers and consequences for staffing levels

21. 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.

RECOMMENDATIONS 22. 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.

RAY WALKER

EXECUTIVE DIRECTOR OF NURSING

July 2016



Page 10 of 11

Appendix A

Clinically required against actual June 2016

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 (%)

SEC

UR

E

Arnold 79.31% 115.96% 84.54% 96.77%

Allerton 103.33% 106.67% 156.53% 89.96%

Childwall 105.00% 111.67% 71.60% 158.06%

Blake 76.62% 106.93% 97.83% 105.86%

Carlyle 105.78% 84.17% 103.43% 103.43%

Dickens 105.17% 96.74% 125.65% 113.87%

Forster 106.40% 78.68% 98.97% 100.00%

Gibbon 114.11% 84.81% 67.32% 183.49%

Johnson 74.56% 101.24% 94.70% 98.47%

Keats 89.26% 94.68% 84.91% 106.54%

Lawrence 80.36% 106.31% 86.63% 100.00%

Owen 80.00% 102.50% 100.00% 83.07%

Ruskin 110.78% 81.06% 113.40% 86.60%

Shelley 110.00% 81.67% 73.25% 116.82%

Tennyson 75.83% 104.31% 93.08% 80.06%

Hawthorn 101.67% 98.37% 103.20% 102.27%

Ivy 99.14% 97.84% 67.17% 125.09%

Myrtle 81.03% 114.12% 100.00% 101.60%

Olive 102.59% 93.68% 110.50% 93.10%

Poplar 100.83% 107.76% 101.83% 110.86%

Reed Lodge 100.00% 91.67% 100.00% 100.00%

Secure Total 91.60% 98.68% 93.20% 107.22%



Page 11 of 11

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 83.55% 91.72% 100.00% 96.08%

Albert 98.56% 89.66% 100.00% 85.50%

Brunswick 99.12% 98.87% 100.00% 100.86%

Harrington 100.00% 94.05% 100.00% 99.16%

Alt 82.40% 109.86% 89.79% 94.30%

Dee 100.00% 100.00% 96.70% 100.00%

Irwell 93.33% 95.78% 100.00% 100.00%

Morris 103.45% 94.95% 100.00% 100.00%

Newton 93.97% 94.33% 62.07% 94.32%

Park/Rowbotham 101.63% 93.02% 103.43% 93.47%

Heys Court 103.25% 96.61% 100.00% 98.27%

Kevin White Unit 100.00% 100.00% 100.00% 100.00%

Acorn Ward 92.80% 94.10% 100.00% 94.52%

Brain Injury Unit 106.90% 99.49% 100.00% 100.00%

Oak Ward 103.42% 95.89% 100.00% 104.40%

STAR Unit 83.33% 100.67% 100.00% 99.30%

Rehabilitation Centre

97.55% 97.95% 100.00% 98.84%

Wavertree Bungalow

105.66% 97.17% 100.00% 100.00%

Windsor Clinic 100.00% 97.80% 100.00% 96.66%

Windsor House 97.81% 93.78% 100.00% 100.00%

Local Total 97.03% 96.43% 95.78% 97.32%

Trust Total 93.87% 97.63% 94.26% 100.69%

Overall Total 96.97%

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Performance and Investment Committee C2 / Attachment 3 Executive Committee: B2 / Attachment 3

Contracts Update – M3 2016/17

2016/17 CONTRACTS

1. The trust is meeting weekly with Liverpool City Council and Liverpool CCG on the redesign of Addictions services within affordability levels. The Strategic Steering Group met on 14th July to consider the preferred savings plans and the impact on the wider health economy.

2. The trust agreed to a further three months funding for A&E Liaison Services for the period July - September 2016. The trust is preparing a business case to be submitted to the CCG by the 8 August 2016.

3. Transitions CQUIN for the CAHMS service has been agreed by LCCG and Alder Hey FT. A meeting has been scheduled to ensure we have a formal agreement that is documented and agreed by both trusts.

4. Sefton CCG are proposing to invest £0.170m (full year, non-recurrent) in a Dementia Pilot scheme. The proposal is currently being reviewed by the trust.

5. The trust has provided two pricing options to Liverpool and Sefton CCG for the Brain Injury Unit. The first is a block contract for the four additional beds and the second option is a spot price with additional service payments if required. The trust is awaiting confirmation from the CCG’s on the preferred option.

6. The trust is not meeting the IAPT contacts targets and LCCG is looking at all contract levers, including contract sanctions. A capacity and demand deep dive is being arranged by LCCG and the service.

7. An IAPT workshop took place on the 6 July 2106 where a range of internal stakeholders attended. The key issues were discussed and a recovery plan is being drawn up. The group will meet on a regular basis to support this plan.

8. The trust has three separate contracts to provide services to The Walton Centre FT. The total contract value was £0.592m in 2015/16. The contracts have been extended for 2016/17, however the trust has been advised that the services will go out to tender for 2017/18.

9. Liverpool and Sefton CCGs have now agreed the activity plan for 2016/17.

10. The trust continues to perform well against the majority of the 537 local and secure division contract performance and quality indicators. The local division exceptions are listed in Appendix 1. The secure division exceptions are reported on a quarterly basis and will be reported in next month’s report. All areas of under performance are notified to the divisions and the feedback received is included in reports to commissioners.

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11. The main areas of under performance in month three relate to physical health and

Talk Liverpool. The Talk Liverpool service has again missed the targets for the key indicators under which Liverpool CCG issued performance notices in 2015/16. 897 patients accessed the service in month which is up from 742 in month 2, but still below the 1,138 target. Recovery also improved and is up to 36% against a target of 50%. Smoking and Every Contact Counts indicators remained below target in month three.

12. In month three there were 15 KPI breaches, compared with 12 in month two. There are more indicators reported quarterly than there are monthly. In general most breaches have improved in month three and the trend of each KPI can be found in Appendix 1.

13. An update on 2016/17 CQUIN can be found in Attachment 4 of the Care at a Glance report.

COSTING AND ACTIVITY

14. The currency development meetings have continued with commissioners and there has been a verbal agreement to use the year of care / episode of care approach rather than a capitated approach.

15. Liverpool and Sefton CCG have informed the trust they wish to carry out an external audit of the trusts costing methodology. The trust will work with the CCGs to prepare the specification for the audit.

16. There is an audit of cluster activity being carried out by Capita which is due to be finalised in September 2016. The objectives of the audit are to look at the accuracy of cluster allocations, including the underpinning HoNOS scores, and to see if the data recorded by the trust reflects the national clustering guidance and local reporting agreement. The results of the audit will be shared internally as well as with commissioners.

17. NHS Improvement have confirmed that forthcoming tariff engagement documents and guidance are expected to be published by mid to late July 2016. Policy proposals for 2017/18 will be outlined in this guidance.

18. The costing team will be meeting with services to validate the draft reference costs during July prior to submission by the end of July.

Neil Smith Executive Director of Finance

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Appendix 1

Contract KPIs: Provisional Exceptions at Month 3 Local Service Division Contract Key Performance and Quality Indicators

Indicator Reference

Performance Area

Performance indicator description

Data Period Target Actual Trend

Local Services KPI 01

Smoking

Smoking Status recorded for all patients on CPA

Q1

95% 87.6%


All Smokers to be offered Smoking intervention Advice within 7 days of admission for in-patients (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.

95% 94.5%


Out-Patient Appointments & DNA Rates

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

M3 11% 13.0% Local Services KPI 10

Keeping Nourished

Patients with a score of 2 or more to receive an appropriate care plan

Q1 100% 95.8%


Every Contact Counts

All 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

Q1 90% 50.0%


Psychotherapy Psychotherapy. Treatment commencing within 18 weeks of referrals.

M3 95% 19.6%

Local Services NR 06

Early Intervention

Early Intervention in Psychosis programmes: the percentage of Service Users experiencing a first episode of psychosis who commenced a NICE-concordant package of care within two weeks of referral.

M3 50% 36.8%

IAPT KPI 3 Waiting

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

M3 <5% 16.0%

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Indicator Reference

Performance Area

Performance indicator description

Data Period Target Actual Trend

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.

M3 1138 897

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.

M3 >50% 36.0%

IAPT KPI 13 Waiting

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

M3 <28 Days

120 Days

IAPT KPI 19 DNA

The number of booked appointments that are DNAd

M3 10% 12.0% IAPT KPI 20 Cancellations

The number of booked appointments that are cancelled (Total)

M3 10% 20.0% IAPT KPI 25a

Follow ups

The number of treatment sessions received after assessment - step 2

M3 Overall

= 6

4 IAPT KPI 25b

The number of treatment sessions received after assessment - step 3

M3 7

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Trust Board C2 / Attachment 4 Executive Committee: B2 / Attachment 4

CQUIN Performance Update M3 2016/17

2016/17 CQUIN Schemes

1. In 2016/17 the trust has five main contracts, each of which attracts its own CQUIN scheme(s).

Liverpool CCG has a separate IAPT contract which also includes a CQUIN. CQUIN schemes amount to 2.5% of contract income. The total available CQUIN funding for 2016/17 is £4.445m. Each CQUIN scheme contains a number of different indicators intended to deliver demonstrable quality improvements. The contracts and CQUIN schemes are shown in Table 1 below.

Table 1 Contract CQUIN Schemes NHS England High Secure Low and Medium Secure

NHS Wales High Secure (contribution to NHS England CQUIN)

Liverpool CCG Local Services Addictions

Liverpool CCG IAPT

South Sefton CCG (lead commissioner for Sefton, Knowsley and other Associates)

Local Services

The number of schemes and the financial breakdown of the 2016/17 CQUIN schemes are shown in table 2. Table 2

CQUIN Scheme 2016/17 No. Of

Schemes

2016/17 Full

Allocation £

Local Services (South Sefton CCG and Associates) 4 781,286 Local Services (Liverpool CCG incl. IAPT) 5 1,575,485 High Secure Services 4 1,113,899 Low and Medium Secure Services 4 861,898 Addictions Services 1 112,886 Overall 18 4,445,454

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2. An overview of the trust’s 2016/17 CQUIN schemes can be found in Appendix 1. 3. CQUIN schemes have been agreed by Corporate, Secure and Local divisions. Quarter one

performance will be reported to commissioners on the 29th July and will be included in the month four CQUIN performance update.

4. Following a Physical Health Summit on 29 June, the local division are still to identify a medical Physical Health Lead. This will be raised with the local division clinical director to resolve.

5. National Physical Health CQUIN - Cardiometabolic Assessment for Patients with Schizophrenia. The trust has identified issues with regards to the recording of physical health interventions. The physical health leads are working closely with the RIO implementation team to look at ways of recording interventions in RIO. The audit of performance is not due to take place until quarter two with results available in quarter four. There is a sliding scale of payment, however the maximum financial impact is that £0.08m may need to be returned to commissioners.

6. Primary Care Liaison service CQUIN - The CQUIN leads have raised concern that the temporary nature of the new posts required to deliver the new service model agreed with the CCG’s may compromise the overall delivery of the CQUIN. However they have confirmed that the quarter one milestones will be met. A meeting is due to take please in July to discuss the risks of delivery for the remaining three quarters. An update will be included in next month’s report.

7. Monthly updates and performance against schemes are reported to Divisional Boards and included within the Care at a Glance Report.

Vicky Ivens CQUIN Co-ordinator

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Mersey Care CQUIN Schemes 2016/17 Appendix 1

Local Services (Liverpool CCG):

CQUIN Indicator Summary: Lead:

National Staff Health & Wellbeing

1a. Introduction of health and wellbeing initiatives 1b. Healthy food for NHS staff, visitors and patients 1c. Improving the uptake of flu vaccinations for front line staff within Providers

1a. Amanda Smith 1b. Michelle McGee

1c Joanne Scoltock

National Physical Health

2a. Improving Physical healthcare to reduce premature mortality in people with SMI: Cardio Metabolic Assessment and treatment for Patients with Psychoses 2b. Communication with General Practitioners

TBC

Primary Care Liaison Service Improving collaborative working between Primary and Secondary Mental Health Care.

Jimmy Cousineau

Physical Health Training Training and Education package for diabetes, wound care and catheter care.

Jean Perkins

Local Digital Maturity

All Trusts across the Health Economy will be asked to progress Digital Maturity requirements.

Sarah Barr

IAPT- Access to psychological Therapies for Older Adults

Increase the percentage of older people who experience depression and / or specific anxiety condition and enter psychological treatment

Jacqui Howard

Local Services (South Sefton CCG and Associates):




1a. Amanda Smith 1b. Michelle McGee 1c Joanne Scoltock



TBC

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Primary Care Liaison Service

Improving collaborative working between Primary and Secondary Mental Health Care.

Alex Henderson

CAMHS Transition Continuation of work from previous years to improve mental health pathways for young people

Nicky Fearon

Addictions Services:


Addictions To improve the services to patients within Addictions services

Dawn Hayes

High Secure Services: Inc NHS Wales




Lisa Rens



Implementing Sense of Community in High Secure Wards

Developing a Sense of Community across high secure wards to improve inpatient wellbeing

Recovery College for Medium and low secure patients

Education and training programmes to support recovery

Reducing Restrictive Practices within Adult Secure Services

The development, implementation and evaluation of a framework for the reduction of restrictive practices within adult secure services, in order to improve service user experience whilst maintaining safe services.

Indicator Construction Target Weighting Q1 2016/17 Q1 2016/17 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-facecontact 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% One patient had a follow up but it was outside of 7 days, therefore this patient breached the 7 day follow up target. The Performance Improvement Business Partner is aware of this.

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% 95.03%

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% 1.0 100.00% 0.0

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

95% 1.0 117.95% 0.0

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

>=50% 1.0 45.65% 1.0

The team have actively been reflecting on near misses where the service has not met the 2 week

target to improve systems. A few areas have emerged for on‐going development. There can be

delays in triage from Single Points of Access to EIP, which delay EIP referral. We are addressing this

through weekly meetings with the SPA teams, and planning a reflective event around near misses.

There have been delays when a service user presents in crisis and is admitted to hospital, in terms of

delay of EIP referral from acute services, though in these cases people have been receiving

appropriate care in hospital. In addition we are reviewing EIP triage and allocation system to ensure

there is greater flexibility, to ensure that if a service user DNAs or cancels, there is sufficient time to

allow them to be assessed within the 2 weeks. We are still awaiting additional investment from

commissioners and are currently working significantly under capacity to deliver all aspects of better

access targets. Sefton have agreed funding and we are recruiting. Liverpool decision is awaited in

September.

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


>=75% 1.0 93.29%

People with common mental health conditions referred to the IAPT programme will be treated within 18 weeks of referral


>=95% 1.0 99.58%

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 8.45% 1.0

The percentage of delayed discharges had slight decrease during June 2016 and is now 8.45% (equivalent to an average of 23 delayed service users per day). The trustinpatient units are undertaking regular reviews of all inpatients to support earlier identification of potential delays and are engaging with appropriate agencies to mitigate any risks well ahead of planned discharge dates.

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 99.44% 0.0

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

>=50% 1.0 86.08% 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

Compliant 0.0

1.0 2.0

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.

NHS Improvement - 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


C2 / Attachment 5Trust Board

Score

OU

TCO

MES

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

AC

CES

S

Access and Outcomes Page 1 of 4

Q1 2016/17

No

No

Third party reports No

No

No

No

No

12.50%

No

5.02%

NHS Improvement - 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.

There has been no material increase in Staff turnover for June 2016 based on the revised benchmark. Staff turnover has only slightly deteriorated in June 2016, this will continue to be monitored. The workforce team have implemented an "exit questionnaire" to help to understand staff reasons for leaving the trust and inform strategies for retention.

Performance in the 2015/16 annual national staff survey was broadly consistent with the previous year's results. Next update due March 2017.

Figure quoted is year to date actual (June 2016).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.

Q1 2016/17 June position is based the rolling twelve months position of 6.17% (1 July 2015 to 30 June 2016)

In month June 2016 value = 10.81%.

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 11.22% for 2014/15 based on FTE, revised benchmark 12.61% for 2015/16 based on FTE)

Organisational Health Page 2 of 4

Data Completeness Identifiers

Indicator Indicator Construction Q1 2016/17

GP practice complete Numerator: count of valid entries Denominator: total number of entries. 97.77%

Post code complete Numerator: count of valid entries Denominator: total number of entries. 99.66%

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

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

Organisation code of commissioner complete Numerator: count of valid entries Denominator: total number of entries. 99.98%

NHS Number Complete Numerator: count of valid entries Denominator: total number of entries. 98.54%

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

Data Completeness Outcomes

Indicator Indicator Construction Q1 2016/17

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

82.84%

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.

80.51%

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.

94.19%

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:

Data Completeness - Breakdown Page 3 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.

Patient Experience - Breakdown Page 4 of 4

C2 / Attachment 6B2 / Attachment 6

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 2015/16 Cash Flow

Appendix 5 Thirteen week cash flow forecast

The 2016/17 CIP target is £12.770m. At the end of June, the trust's rephased target is £2.647m of which £2.614m has been delivered. The undelivered scheme of £0.033m is in Corporate division. If no action is taken the 2016/17 CIP target will be underachieved by £1.115m. The underachieved includes £0.446m CIP from the addictions community services redesign scheme, a service which is subject to a loss of commissioner income in 2016/17. Divisions are required to review these CIP plans and the delivery profile for the remainder of the financial year. If following review, alternative plans are required; those plans must be approved by the agreed process. An update will be provided each month to the Board and PIC. The trust is still awaiting guidance on the capital regime for 2016/17. At the end of June capital expenditure is £1.027m. In 2015/16, as a consequence of slippage on the capital programme, the trust agreed with the TDA a repayment of Public Dividend Capital (PDC) of £6.000m. The repayment of PDC, supported the national financial position. In 2016/17 the trust will receive £6.000m PDC in August. The trust has been notified that it will receive £1.280m Sustainability and Transformation funding in 2016/17, as a result the 31 March 2017 cash target has increased to £11.036m. 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. To the end of June, the trusts expenditure on qualified agency nursing was 0.05% of all qualified nurse staffing expenditure, against a target of 3.0%. In 2016/17 a price cap on all agency expenditure was introduced. The price cap for the trust is £4.659m. At the end of June the price cap is £1.165m and the trust has spent £1.929m. If this continues the agency price cap will not be delivered. An action plan has been requested to ensure this is delivered.

Trust Board:Executive Committee:

The trust plans to achieve all financial performance targets in 2016/17. As at the end of June, the trust has a £2.284m surplus before technical adjustments. The secure division is breakeven. The local division, corporate division and Informatics Merseyside (IM) are £0.125m, £0.002m and £0.051m underspent respectively. The trust has achieved an NHS Improvement (NHSi) financial sustainability risk rating of 4.

The planned surplus has increased from £8.000m to £8.425m due to a stretch target agreed with NHSi. This is as a result of the trust receiving additional STP funding of £1.280m. The planned surplus for 2016/17 is shown in Appendix 1. The local division forecast outturn is £0.500m underspent and IM forecast outturn is £0.200m underspent. The secure and corporate division forecast outturn position is breakeven. The local division forecast may change as posts are recruited and non pay costs increase to achieve the targets. The planned surplus no longer includes a technical adjustment of £0.855m in respect of accounting for Clock View. This technical adjustment is not applicable under the NHSi (previously Monitor) finance regime. Within the local division there are overspends in medical budgets due to high locum medical costs, nurse bank and agency costs (covering vacancies and sickness in inpatient areas), acute out of area treatments. The division and finance are working on an action plan to address the medical budget overspend. The division will need to continue to monitor the Liverpool IAPT contract and budget as failure to reduce waiting list may result in financial penalties. Within the secure division, overspends in medium secure services are being supported by underspends in high secure, low secure and offender health services.

Finance DashboardMonth 3 - 2016/17

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£ m

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Local Secure Corporate IM Reserves & Other

£ m

Summary Financial PositionAnnual Plan Cumulative Plan Cumulative Actual

The trust's planned 2016/17 surplus is £8.425m. As at 30th June 2016 the surplus is £2.284m against the revised plan reported to NHSi £2.284m.

The trust is forecast to achieve the £8.425m surplus.

The statement of comprehensive income is shown in Appendix 1.

As at 30th June 2016, the local division is £0.125m underspent, corporate division is £0.002m underspent, secure are breakeven and IM is £0.051m underspent.

The forecast outturn position for the secure and corporate divisions is breakeven. The local division forecast is £0.500m underspent and IM is £0.200m underspend.

As at 30th June 2016, the Trust's target is £2.647m and £2.614m has been delivered. The variance is due to slippage in a corporate scheme £0.033m Informatics.

If no action is taken the 2016/17 CIP target will be underachieved by £1.115m.*Secure schemes

£0.271m in high secure rehab, medium and low secure and*Local schemes

£0.843m merger of Kevin White and addictions community

The current surplus, cash and CIP position (before the Calderstones acquisition) for the 6 year period to 2020/21 is shown in the graph. This represents the Long Term Financial Model (LTFM) included in the October IBP 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 June 2016 the trust achieved 97.05% and 97.16% cumulative to date.

As at 30th June 2016 the NHSi financial sustainability risk ratingwas 4.

The NHSi (previously TDA) indicators are amber due to undelivered CIP schemes. The forecast for the year is green.

The detail is shown in Appendix 2.

Income, Expenditure, Cost Improvement Plans and Financial Plan

0.0

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£ m

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

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35

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

£m

Surplus, CIPs and Cash 2015/16 ‐ 2020/21Surplus CIPs Cash

Changes to the Capital Programme

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30.0

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

£ m

Cash Balance 2016/17

Actual Plan Revised Plan

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

£ m

12 Month Rolling Cash Flow

Actual Plan Revised Plan

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25.0

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35.0


£ m

Gross Capital Expenditure Planned 2016/17

Actual Capital Expenditure Planned Capital Expenditure

The monthly profile for 2016/17 is shown in the 'Gross Capital Expenditure Planned 2016/17' graph. As at 30th June 2016 capital expenditure is £1.027m. This is £1.432m under the plan.

The trust is still awaiting guidance on the capital regime for 2016/17.

The 31st March 2017 cash target has increased by £1.280m to £11.036m followingnotification that the trust will received Sustainability and Transformation Funding.

The trust is on plan to achieve the target.The 30th June balance is £19.871m.

More information is provided in Appendix 3,

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 increase in 2016/17 is due to receiving £6m PDC and a loan for the strategic capital programme.

Capital Programme, Cash, Aged Debt, Aged Payables

There are no changes to the capital programme.

0.0

1.0

2.0

3.0

0‐30 days 30 ‐ 60 Days 60‐90 Days Over 90 Days

£ m

Aged Receivables as at 30 June 2016

Receivables NHS Receivables Non NHS

At 30th June 2016 total trade receivables is £3.327m. The over 90 days is £0.161m and includes:

* £0.017m due from Lancashire Care for salary recharges.

* £0.019m due from South Sefton CCG for EPACT drug recharges.

* £0.115m managed debt.

0.0

1.0

2.0

0‐30 days 30‐60 days 60‐90 days Over 90 days

£ m

Aged Payables as at 30 June 2016

Payables NHS Payables Non NHS

At 30th June 2016 total trade payables is £1.470m.

Total trade payables are made up of invoices authorised and awaiting payment and invoices awaiting authorisation for payment.

47.3%

0.1%

37.0%

15.6%

Percentage of Purchase / Non Purchase Order Invoices 2016/17

Purchase Order

Non Purchase Order

Out of scope

Contract

Procurement Indicators

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3.0

4.0

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7.0

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13/14 14/15 15/16 16/17 YTD 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 June 2016, the Trust has achieved £7.2m against a projected current year end target of £5.5m.

The procurement department has a savings target of £0.500m. Savings plans will be delivered from the procurement work plan.

As at 30th June 2016, savings of £0.036m have been made on the supply of fresh fruit &veg and managed print rebate

0

100

200

300

400

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600

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£000's

Savings Target 2016/17

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 andProcess 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 2016/17.

The top ten suppliers account for approximately 37% of total purchase order spend.

9.69

0.01

7.58

3.21

Value (£m) of Purchase / Non Purchase Order Invoices 2016/17

Purchase Order

Non Purchase Order

Out of scope

Contract

0100200300400500600700800900

1,000

£000's

Top 10 Suppliers by Purchase Order

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NHS Standards of Procurement

Maximum Actual Aspirant (Level 2)

Appendix 1 - Statement of Comprehensive Income for the period ending 30 June 2016

Full Year Plan

£000

Year to Date Plan £000

Year to Date Actual £000

Year to Date Variance

£000Contract Income 197,128 49,970 49,970 0STP Funding 1,280 0 0 0Informatics Merseyside Income 8,221 2,079 2,186 107Operational Income 2,452 692 961 269Total Income 209,081 52,741 53,117 376Costs (186,585) (47,217) (47,593) (376)EBITDA (Earnings before Interest, Tax, Depreciation and Amortisation) 22,496 5,524 5,524 0

EBITDA Margin % 10.76% 10.47% 10.40%Capital Charges (11,110) (2,638) (2,638) 0Provisions Unwinding of Discount (442) 0 0 0Interest Payable (2,403) (618) (618) 0Interest Receivable 60 16 16 0Carbon Credits (176) 0 0 0I&E Surplus (before technical adjustments) 8,425 2,284 2,284 0

Adjusted Retained I&E Surplus (before technical adjustments) 8,425 2,284 2,284 0

I&E Surplus Margin % 4.03% 4.33% 4.30%

Capital Impairment (10,154) 0 0 0Net I&E Surplus / (Deficit) (1,729) 2,284 2,284 0

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

Financial Risk Rating at 30 June 2016

FS Risk Score at 30 June 2016 RAG rating

Liquidity days 18 4 Green

Capital services capacity 3 4 Green

I&E Margin 4 4 Green

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

Overall Financial Sustainability Risk Rating 4 Green

Indicator Position to 30 June 2016

Target (%) 3.00

Actual (%) 0.05

Target (£000s) 1,165

Actual (£000s) 1,817

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

Total agency expenditure ceiling compared to expenditure

Agency

NHSi risk assessment framework - Financial Sustainability Risk Rating

Appendix 3 - Statement of Financial Position as at 31 May 2016

Year to 2016/17 2015/16Date FOT Year End£000 £000 £000

NON-CURRENT ASSETS 179,522 192,444 180,291

CURRENT ASSETS

Inventories 333 333 333Trade Receivables 3,327 3,000 3,524Other Receivables 5,000 2,600 4,964Cash and Cash Equivalents 19,871 11,036 10,665TOTAL CURRENT ASSETS 28,531 16,969 19,486

CURRENT LIABILITIES

Trade and Other Payables (15,828) (7,335) (9,367)Provisions (1,865) (1,706) (2,181)Borrowings (608) (652) (509)DH Capital Investment Loan 0 (360) 0TOTAL CURRENT LIABILITIES (18,301) (10,053) (12,057)NET CURRENT ASSETS (LIABILITIES) 10,230 6,916 7,429TOTAL ASSETS LESS CURRENT LIABILITIES 189,752 199,360 187,720

NON-CURRENT LIABILITIES

Provisions (20,849) (20,456) (20,982)Borrowings (30,114) (29,581) (30,233)DH Capital Investment Loan 0 (8,547) 0

TOTAL ASSETS EMPLOYED 138,789 140,776 136,505

FINANCED BY:TAXPAYERS' EQUITYPublic dividend capital 54,149 60,149 54,149Retained Earnings (24,289) (24,502) (26,807)Revaluation Reserve 49,022 45,222 49,256Other reserves 59,907 59,907 59,907

TOTAL TAXPAYERS' EQUITY 138,789 140,776 136,505

Appendix 4 - 2016/17 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) 1,110 1,269 1,536 289 1,299 699 1,278 1,277 378 1,269 1,269 (6,381)Depreciation and Amortisation 536 536 537 548 548 548 565 565 565 574 574 574Impairments and Reversals 0 0 0 1,000 0 600 0 0 900 0 0 7,654Interest Paid 0 0 (137) (685) (205) (206) (205) (206) (205) (206) (205) (276)Dividend Paid 0 0 0 0 0 (1,798) 0 0 0 0 0 (2,058)Losses(Increase)/Decrease in Inventories (25) (11) 36 (19) 8 57 (35) (4) 6 (18) 20 (15)(Increase)/Decrease in Trade and Other Receivables (5,633) 5,191 586 1,655 (133) (2,507) 962 996 (3,161) 1,999 962 (620)

Increase/(Decrease) in Trade and Other Payables 4,430 366 204 (1,136) 703 2,603 (1,000) 746 354 1,076 (1,834) (6,056)

Increase/(Decrease) in Other Current Liabilities 0 0 0 0 0 0 0 0 0 0 0 0Provisions Utilised (493) 0 0 (268) (20) (494) (340) (20) (20) (428) (28) (29)Increase/(Decrease) in Movement in non cash Provisions 15 14 15 14 14 638 14 91 14 (202) 14 254

Net Cash Inflow/(Outflow) from Operating Activities (60) 7,365 2,777 1,398 2,214 140 1,239 3,445 (1,169) 4,064 772 (6,953)

CASH FLOWS FROM INVESTING ACTIVITIES

Interest received 5 4 7 8 8 8 8 8 7 7 7 7(Payments) for Property, Plant and Equipment 67 (439) (499) (1,691) (1,855) (4,868) (2,132) (3,143) (3,011) (2,487) (2,584) (4,047)(Payments) for Intangible Assets 0 0 0 0 (300) (378) (476) (300) (300) (300) (300) (300)

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 72 (435) (492) (1,683) (2,147) (5,238) (2,600) (3,435) (3,304) (2,780) (2,877) (4,340)

NET CASH INFLOW/(OUTFLOW) BEFORE FINANCING 12 6,930 2,285 (285) 67 (5,098) (1,361) 10 (4,473) 1,284 (2,105) (11,293)

CASH FLOWS FROM FINANCING ACTIVITIES

New Public Dividend Capital 0 0 0 0 6,000 0 0 0 0 0 0 0Loans received from DH - New Capital Investment Loans 0 0 0 0 0 0 2,000 0 3,000 0 0 4,000

Public Dividend Capital repaid in year 0 0 0 0 0 0 0 0 0 0 0 0Other Capital Receipts 0 0 0 0 0 0 0 0 0 0 0 0Loans repaid to DH - Capital Investment Loans Repayment of Principal 0 0 0 0 0 0 0 0 0 0 0 (93)

Capital Element of Finance Leases and PFI 0 0 (21) (87) (52) (49) (50) (50) (50) (50) (50) (50)Net Cash Inflow/(Outflow)from Financing 0 0 (21) (87) 5,948 (49) 1,950 (50) 2,950 (50) (50) 3,857

Net Increase/(Decrease) in Cash 12 6,930 2,264 (372) 6,015 (5,147) 589 (40) (1,523) 1,234 (2,155) (7,436)

Cash at the Beginning of the Period 10,665 10,677 17,607 19,871 19,499 25,514 20,367 20,956 20,916 19,393 20,627 18,472

Cash at the End of the Financial Period 10,677 17,607 19,871 19,499 25,514 20,367 20,956 20,916 19,393 20,627 18,472 11,036

ForecastActual

Appendix 5 - Thirteen Week Cash Flow Forecast

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Thirteen Week Cash Balance

Cash Balance

The large increases in the cash balance relateto the receipt of monthly block income from our Commissioners. The trust currently anticipates receipt of £6m PDC on 15 August 2016.

The large reductions to cash relate to the payment of monthly salaries.

The remaining adjustments relate to working capital adjustments in payables and receivables.

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Trust Board: C2/ Attachment 7


Workforce Performance Report – M3 2016/17

(30 June 2016)

Workforce plan

1. The staff in post whole time equivalent (WTE) figures as at the end of June 2016 compared with the budgeted WTE for the same period 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 2016/17 is 4.8% i.e. no change from 2015/16.

4. The “in month” staff sickness rate (June 2016) was 5.60%, a deterioration on May

2016. The in month absence rate is equivalent to 192.27 WTE staff off sick at any point in time (129.25 WTE long term and 63.02 WTE short term).

DivisionStaff in post at 30

June 2016 (WTE)

Planned budget at

30 June 2016

(WTE)

Difference

(%)

Local Division 1,612.79 1,698.55 -5.05

Secure Division 1,145.00 1,206.68 -5.11

Corporate Division 542.96 611.11 -11.15

iMerseyside 187.32 215.03 -12.89

Grand Total 3,488.07 3,731.37 -6.52

Long Term Financial Model

Staff Group

Staff in post at 30

June 2016 (WTE)

Planned budget at

30 June 2016

(WTE)

Difference

(%)

Consultant 64.50 69.98 -7.83

Junior medical 78.75 88.86 -11.38

Nursing, midwifery and health visitors 1,800.69 1,926.84 -6.55

Scientific, therapeutic & technical 364.93 413.79 -11.81

Other clinical staff 125.60 146.90 -14.50

Non clinical staff 1,053.60 1,085.00 -2.89

Grand Total 3,488.07 3,731.37 -6.52

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5. For the period 1 July 2015 to 30 June 2016 (i.e. rolling 12 months), the sickness absence rate was 6.17%; performance has remained the same when compared with

the position reported for 1 June 2015 to 31 May 2016 (6.19%). The rolling 12 month absence rate is equivalent to 217.37 WTE staff off sick at any point in time (148.97 WTE long term and 68.39 WTE short term).

6. The rolling twelve months position for the period 1 July 2015 to 30 June 2016 is

equivalent to approximately 15.41 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 was being achieved, the number of working days lost due to

sickness absence would be 11.2.

7. The target level of sickness for the trust is 4.8%. The actual level of sickness during 2016/17 is 5.66% which has produced a cost £0.305m over target, extrapolated this would equate to a cost of £1.22m over target at month 12. A breakdown of staff

sickness and estimated costs by division is provided in the table below.

8. The trust’s sickness absence rate is higher than that of the other two high secure

provider trusts at 6.16% (equivalent to 14.35 days off sick per WTE) compared with 4.99% at Nottinghamshire Healthcare NHS Trust and 4.73% at West London Mental Health Trust (equivalent to 11.63 days and 11.02 days off sick per WTE respectively)

(H&SCIC iView, data period 1 April 2015 to 31 March 2016).

9. The graph below highlights the sickness absence rates from 1 April 2015 to 31 March 2016 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 sixth highest within the North West.

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.

DivisionSick Days as a %

of Available Days

EstimatedYear

to Date Cost of

Sickness (£m)

Local Services 5.94% 0.957

Secure Services 6.52% 0.781

Corporate Services 3.41% 0.141

iMerseyside 3.82% 0.078

Total 5.66% 1.957

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10. Performance escalation section 3 of the M3 2016/17 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” and “in-month” sickness rate is greater than the target.

12. The “in month” staff sickness rate for inpatient wards at trust level was 8.16% in June 2016, an improvement on May 2016 (8.60%). The local division rate was 8.70% an

improvement on May 2016 (9.81%) and for the secure division the rate was 7.72%, a deterioration on May 2016 (7.63%).

13. The “rolling 12 month” staff sickness rate for inpatient wards at trust level was 9.40% for 1 July 2015 to 30 June 2016. For the local division the rate was 8.68% and for the

secure division the rate was 9.96%. 14. The graph below 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.

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rds

hir

e F

Cu

mb

ria

Pa

rtn

ers

F

Av

on

& W

ilts

MH

Bir

min

gh

am

& S

oli

MH

F

Do

rset

He

alt

hc

are

Un

i F

No

rth

Sta

ffo

rds

hir

e C

om

bin

ed

Su

sse

x P

art

ne

rs F

No

rth

Ea

st

Lo

nd

on

F

So

uth

We

st

Lo

nd

on

& G

eo

rge

's M

H

No

rth

Es

se

x M

H F

Ox

lea

s F

Ox

ford

He

alt

h F

Ea

st

Lo

nd

on

F

Ke

nt

& M

ed

wa

y P

art

ne

rs

Be

rks

hir

e H

ea

lth

F

Su

rre

y B

ord

ers

Pa

rtn

ers

F

So

uth

Lo

nd

on

& M

au

ds

ley

F

Ce

ntr

al &

No

rth

We

st

Lo

nd

on

F

Sickness Absence Rates - Mental Health Trusts (England) 1 April 2015 to 31 March 2016

% Sickness Lower Quartile Median Upper Quartile

of 26

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 – updated February 2016. b. Mandatory training – updated March 2016.

c. HR systems review – updated February 2016. d. Personal Achievement and Contribution Evaluation, PACE - updated March

2016. e. Induction - updated March 2016.

Workforce key performance indicator overview

16. The table on page 11 provides details of performance against key workforce performance indicators at the end of June 2016.

17. The trust and division position for statutory training is provided within the table on page 11 as this is a key workforce performance indicator.

18. At the 30 June 2016, the trust and divisions’ compliance for information governance and mandatory training is as follows:

Information Governance (IG) Mandatory Training*

Trust-wide 18% 27%

Local Division 15% 28%

Secure Division 17% 23%

Corporate Division 23% 21%

Informatics Merseyside 26% 85%

* Mandatory training consists of the following modules: Adverse incidents, carer

awareness, complaints, dementia awareness, fraud awareness and smoking advice.

2

3

4

5

6

7

8

9

10

11

12

Ap

r-15

Ma

y-1

5

Ju

n-1

5

Ju

l-15

Au

g-1

5

Sep

-15

Oct-

15

No

v-1

5

De

c-1

5

Jan

-16

Fe

b-1

6

Ma

r-1

6

Ap

r-16

Ma

y-1

6

Ju

n-1

6

Perc

en

tag

e s

ickn

ess r

ate

Inpatient Wards Staff Sickness - April 2015 to June 2016 (Trust Wide)

of 26

The launch for mandatory training began in April 2015. Work is ongoing with the divisions to agree trajectories for the achievement of mandatory training targets.

The thresholds for mandatory training are; >= 95% Green, <95% Amber, <85% Red.

IG Training is an annual target and the trust must attain a 95% compliance status by 31 March 2017 to provide evidence for the Annual Information Governance Toolkit. As at the 30 June 2016, the Trust was showing very low rates of compliance, this is

due to the fact that very few people will have not, as yet, completed their training for the year 2016/17. This figure will increase as the year continues.

19. Staff turnover has slightly decreased for June 2016 but this will continue to be

monitored. The workforce team have implemented an "exit questionnaire" to help to

understand staff reasons for leaving the trust and inform strategies for retention.

20. Performance against the additional staffing indicator is detailed in the table below. The position reported relates to May 2016 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 May 2016 when compared with April 2016 (77.96%).

22. Performance against the doctor job plans indicator is detailed in the table on page 6.

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.

The performance thresholds are: >=95% green; >=85% amber; <= 85% red with the target of 95%.

of 26

Doctor Job Plans Reviewed and Signed Off in the last 12 months – Month 3 2016/17

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

Compliance rates for Q1 2016/17 are detailed below.

24. The secure division have developed an action plan in relation to safeguarding training. This can be found in Appendix 4.

Divisional positions Numerator Denominator % Indicator value Movement

Local 52 59 88.14% p

Secure 25 25 100.00% tu

Corporate 1 1 100.00% tu

Total 78 85 91.76% p

Key Performance

Indicator

Reference


Target/Description

Reporting


Local Services

DivisionTrend Movement

Secure Services

DivisionTrend Movement Latest Data

WTRACOM10

Percentage of all identified staff who have

received Level 2 adult safeguarding

training within the past three years (local

services).

Quarterly (In

Quarter)

Commissioner target: >=80%

green; <80% red. 73.78% q 73.93% qQuarter 1 2016/17

WTRACOM11




services).

Quarterly (In

Quarter)



WTRACOM12

Percentage of all staff who have received

Level 1 child safeguarding training within

the past three years (local services).

Quarterly (In

Quarter)


green; <90% red 90.13% q 88.28% qQuarter 1 2016/17

WTRACOM13


received Level 2 child safeguarding


services).

Quarterly (In

Quarter)



WTRACOM14




services).

Quarterly (In

Quarter)



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).

Quarterly (In

Quarter)


green by Q4 2015/16; <90%

red. 61.69% p 60.96% p

Quarter 1 2016/17

WTRACOM18


Level 1 adult safeguarding training within

the past three years (secure services).

Quarterly (In


Quarter 1 2016/17

WTRACOM19


Level 1 child safeguarding training within

the past three years (secure services).

Quarterly (In


Quarter 1 2016/17

WTRACOM20



training within the past three years

(secure services).

Quarterly (In


Quarter 1 2016/17

WTRACOM21




(secure services).

Quarterly (In


Quarter 1 2016/17

WTRACOM22




(secure services). Only applicable to

ML&OH staff.

Quarterly (In


Quarter 1 2016/17

WTRACOM23




(secure services).

Quarterly (In


Quarter 1 2016/17

WTRACOM9


Level 1 adult safeguarding training within

the past three years (local services).

Quarterly (In

Quarter)


green; <90% red 89.96% q 87.74% qQuarter 1 2016/17

of 26

Employee Relations Activity

25. The charts below summarise employee relations activity, Quarter 1 2016/17.

of 26

All Q1 Closed ER Cases Local Secure Corporate IM Total

DAW 0 0 0 0 0

Grievance 0 0 0 0 0

Whistleblowing 1 0 0 0 1

Capability 0 0 0 0 0

ET 0 0 0 0 0

All Q1 ER Live Cases Local Secure Corporate IM Total

DAW 1 0 0 0 1

Grievance 0 2 2 0 4

Whistleblowing 2 0 1 0 3

Capability 0 0 0 0 0

ET 1 2 0 0 3

Fast Track Cases Q1 Local Secure Corporate IM Total

April 3 0 0 0 3

May 5 1 0 0 6

June 0 1 0 0 1

Total 8 2 0 0 10

Q1 Top 3 Allegations/ Reasons Local Secure Corporate IM Total

Negligent in performance of duties 5 1 0 0 6

Medication error 2 0 0 0 2

Patient Assault 2 0 0 0 2

Q4 Hearing Outcomes Local Secure Corporate IM Total

Dismissal 2 1 0 0 3

First Written Warning 1 2 0 0 3

No Case to Answer/Insufficient Evidence 0 0 1 0 1

of 26

Staff Friends and Family Test Indicator Q4 2015/16 Benchmarking

26. The table below provides an overview of the trust’s and divisions’ performance in comparison with the national Q4 2015/16 results for mental health/ learning disability

trusts and the national data for England for the Q4 2015/16 staff friends and family test following the publication of this data by NHS England.

27. 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.

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

57% 24% 71% 11%

Local Division Services

52% 26% 65% 12%

Secure Division Services

46% 32% 61% 14%

Corporate Services

63% 18% 74% 9%

iMerseyside 80% 5% 78% 5%

MH / LD maximum 81% 52% 93% 27%

MH / LD upper quartile

67% 25% 79% 13%

MH / LD median average

62% 19% 72% 10%

MH / LD mean

average 60% 21% 72% 11%

MH / LD lower

quartile 53% 14% 67% 6%

MH / LD minimum 30% 9% 52% 2%

England maximum 87% 60% 100% 27%

England upper

quartile 69% 24% 87% 11%

England median

average 63% 18% 78% 7%

England mean average 61% 20% 78% 8%

England lower

quartile 55% 14% 71% 4%

England minimum 27% 4% 51% 0%

28. 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 improved slightly when compared

with Q2 2015/16 results.

of 26

29. 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 an improvement when compared with Q2 2015/16 benchmarking comparisons.

30. 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 Q2 2015/16 benchmarking comparisons.

31. 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

decreased slightly. The England data in the table relates to all trusts regardless of type.

32. 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 57% 24% 71% 11%

Nottinghamshire Healthcare NHS

Trust

63% 20% 75% 8%

West London Mental Health NHS Trust

50% 25% 52% 21%

of 26

Summary of key workforce performance indicators – June 2016

Wendy Copeland-Blair

Staff Plan Objective Indicator Target Trust WideTrust Wide

Movement Local Division

Local

Division

Movement

Secure DivisionSecure 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.

77.14% q 75.00% q 71.43% q 81.25% qNot

Applicable tu

Statutory 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.

88.44% q 86.33% q 90.73% q 88.53% q 92.08% q

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.

84.12% q 81.18% q 88.37% q

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.

-6.52% q -5.05% q -5.11% q -11.15% q -12.89% q

Staff turnover8% -12% green; 5% - 8% or 12% - 15% amber; <5% or

>15% red12.50% q 13.68% q 10.23% p 13.64% p 13.84% q

Objective 2: Health and

WellbeingStaff sickness (in month) <=4.8% green; <=5.8% amber; >5.8% red 5.60% q 5.99% q 6.37% q 3.09% q 4.16% q

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

65.38% q 49.97% q 65.24% q 87.22% p 100.00% tu

Medical staff appraisal in line with

revalidation standards (2013/14)>=95% green; >=85% and <95% amber; <85% red 96.34% q 98.28% q 91.30% q 100.00% tu

Well structured PACE >=47 green; >=41 amber; <41 red 56.59 p 56.86 p 48 q 59.24 p 73.44 p

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%.57.45% q 45.53% q 56.76% q 66.83% q 74.07% p

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%.70.78% q 68.38% q 69.13% p 76.44% q 62.96% p

Objective 1: Workforce

Objective 4: Staff

satisfaction and

engagement

Objective 3: Reward and

Recognise

of 26

Head of Performance Improvement and Customer Relationship Management

Appendix 1 – Team Level Sickness Absence Exceptions

of 26

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

0

1

2

3

4

5

6

7

8

9

10

11

12

Ap

r-15

Ma

y-1

5

Ju

n-1

5

Ju

l-15

Au

g-1

5

Sep

-15

Oct-

15

No

v-1

5

De

c-1

5

Jan

-16

Fe

b-1

6

Ma

r-1

6

Ap

r-16

Ma

y-1

6

Ju

n-1

6

Pe

rce

nta

ge

sic

kn

es

s r

ate

Inpatient Wards Staff Sickness - April 2015 to June 2016 (Local Services)

2

3

4

5

6

7

8

9

10

11

12

13

Ap

r-15

Ma

y-1

5

Ju

n-1

5

Ju

l-15

Au

g-1

5

Sep

-15

Oct-

15

No

v-1

5

De

c-1

5

Jan

-16

Feb

-16

Ma

r-1

6

Ap

r-16

Ma

y-1

6

Ju

n-1

6

Pe

rce

nta

ge

sic

kn

es

s r

ate

Inpatient Wards Staff Sickness - April 2015 to June 2016 (Secure Services)

of 26

Appendix 3 – Performance Improvement Plans

Sickness absence

Plan Action to date Action Required Timescale Progress and Update – February 2016

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).

A further review was undertaken on 26/01/16 for the period 01/07/15 to 31/12/15, and showed a compliance

rate of 94%.

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%. The most recent review of Return to

Work interviews related to all staff who had returned from a period of sick leave

in November 2015. Local Division recorded a 74% compliance rate (+7% on benchmark) and Secure Division

recorded a 67% compliance rate (+14% on benchmark).

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.

Ongoing

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.

of 26

Plan Action to date Action Required Timescale Progress and Update – February

2016

Set thresholds for RAG rating.

Create league tables in relation to Managers’

compliance.

May 2015

July 2015

Training sessions for all new managers are continuing.

The Divisions are actively encouraging Managers to undertake sickness

actions in a timely manner. The Sickness Team is providing Senior Managers with monthly performance

charts in relation to outstanding actions.

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 met

Michelle Cunneelly, Trust Physiotherapist at the beginning of

December 2015 to discuss the uptake of physio sessions and to identify hot spots to ensure that targeted

interventions are delivered to the relevant areas/wards.

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. As at 31/12/15 the Trust has 1049 staff

on Unsatisfactory Attendance monitoring and 181 staff on LTS

monitoring.

of 26

Statutory Training

Actions from quarter one

Within ESR we continue to attach new mandatory training competencies (for example

suicide prevention) to the position levels of relevant staff for training that is e learning or face to face for all staff groups. Actions from quarter two

Within ESR/OLM there is a data cleanse under way to ensure existing courses are aligned

to the correct positions to ensure completion rates and reporting are correct for all staff groups. Actions from quarter three

There is on going work to align all course delivery to the national Core Skills Framework

(CSF) positions with Skills for Health. New subject titles from CSF project group are to come on line over the coming months for dementia and mental health. We are working with subject leads to ensure our course

learning outcomes are compliant and map to the CSF.

The new e learning module on suicide prevention has now been launched. This has to be completed by all staff August 2016 and will be reported separately in the monthly compliance figures.

Additional support for divisions to complete Core Statutory and Mandatory Training (CSMT)

The Learning and Development Facilitators are developing a 12 month training plan to

break down each staff groups statutory and mandatory training priorities over the 12 month period into a visual chart to make planning within the teams more manageable. It will be piloted in Secure division locally and will then be introduced to Local divisions post

evaluation in Secure.

The Trust Statutory training compliance as at 22nd March 2016 is 94.74%. For Mandatory training it has been identified that some staff have more than one training

account which is potentially affecting the figures. A piece of work has now commenced to amalgamate duplicate accounts and new processes have been requested for the teams

involved in managing employee accounts. In addition there appears to have been some confusion around which courses staff are meant to complete, work is currently underway to clarify this for staff and to ensure positions are correct on ESR/OLM to reflect this.

Mandatory training compliance at 22nd March 2016:

Adverse Incidents – 63%

Carer Awareness – 56%

Complaints – 54%

Fraud Awareness – 50% - there was a glitch with this module which has now been

resolved

Smoking Advice – 59%

Dementia Awareness – 25% - this module was removed from the platform by Health Education England in December 2015 which has also affected compliance

figures. It was rolled back out early January 2016 but staff who completed all other modules prior to this have not yet completed the new dementia module.

Regular updates are sent to Managers and support offered for staff on an on going basis.

of 26

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 Service go live, project close

Quarter 4 2016/17 – Lessons learnt, official project close documentation

Appendix 3 – Performance Improvement Plans

Sickness absence

Plan Action to date Action Required Timescale Progress and Update – February 2016

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.

Continue to educate managers.

Undertake

additional review on a

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

of 26


2016

1:1 sessions to educate managers.

bi-monthly basis. benchmark). A further review was undertaken on 26/01/16 for the period 01/07/15 to

31/12/15, and showed a compliance rate of 94%.

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%.

The most recent review of Return to Work interviews related to all staff who

had returned from a period of sick leave in November 2015. Local Division recorded a 74% compliance rate (+7%

on benchmark) and Secure Division recorded a 67% compliance rate (+14%

on benchmark).

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.

The Divisions are actively encouraging Managers to undertake sickness

actions in a timely manner. The Sickness Team is providing Senior

Managers with monthly performance charts in relation to outstanding actions.

of 26


2016

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 met Michelle Cunneelly, Trust

Physiotherapist at the beginning of December 2015 to discuss the uptake of physio sessions and to identify hot

spots to ensure that targeted interventions are delivered to the

relevant areas/wards.

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.

As at 31/12/15 the Trust has 1049 staff on Unsatisfactory Attendance

monitoring and 181 staff on LTS monitoring.

of 26

Statutory Training

Actions from quarter one

Within ESR we continue to attach new mandatory training competencies (for example

suicide prevention) to the position levels of relevant staff for training that is e learning or face to face for all staff groups. Actions from quarter two

Within ESR/OLM there is a data cleanse under way to ensure existing courses are aligned

to the correct positions to ensure completion rates and reporting are correct for all staff groups. Actions from quarter three

There is on going work to align all course delivery to the national Core Skills Framework

(CSF) positions with Skills for Health. New subject titles from CSF project group are to come on line over the coming months for dementia and mental health. We are working with subject leads to ensure our course

learning outcomes are compliant and map to the CSF.

The new e learning module on suicide prevention has now been launched. This has to be completed by all staff September 2016 and will be reported separately in the monthly compliance figures.

Additional support for divisions to complete Core Statutory and Mandatory Training (CSMT)

The Learning and Development Facilitators are developing a 12 month training plan to

break down each staff groups statutory and mandatory training priorities over the 12 month period into a visual chart to make planning within the teams more manageable. It will be piloted in Secure division locally and will then be introduced to Local divisions post

evaluation in Secure.

The Trust Statutory training compliance as at 22nd March 2016 is 94.74%.

of 26

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.

Work has now commenced on the improvements to the PACE system in readiness for the new PACE window to open on the 1st April 2016. The share point development team were

unable to approve the majority of the enhancement requests due to other priorities; therefore changes to the system will be minimal this year.

Staff will be asked to add their qualifications to the learning log section of the PACE system to enable us to capture and store this information – this will support the work around

ensuring the right skill mix within teams and maximising potential. Action plans have been developed for each area and these will be sent to managers to

support them with their PACE planning during the window. Reviewers guidance packs have been developed and these will be issued to all reviewers listed from last year to assist them

in undertaking a meaningful conversation with their staff. A real focus will be placed on the importance and benefits of a good quality PACE review

and communications will be sent to all managers detailing this. Areas that did not achieve 95% completion in 2015/16 will be targeted initially to ensure

they have the support in place to reach their target this year. The OE&L teams will support both reviewers and staff with their preparation.

Preparation is key to enable the constructive and meaningful review. Some staff had not completed their preparation work last year so close monitoring will be in place to ensure that

all preparation is completed and managers will be informed if not. The current list of preparation questions has been reviewed and updated to support this.

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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 been on-going throughout the year to improve the quality of the administration process for all new starters on their induction pathway.

A review of the allocation of the CSMT e-learning modules has been undertaken, this

highlighted that the majority of staff were not receiving e-learning passwords until after attending Corporate Induction. Some staff do not attend Induction on their commencement date so are not receiving their e-learning passwords until a month after they’ve started. The

OE&L team will now commence a new process:

A new starters list will be downloaded every Friday

All new starters will be issued with e-learning user names and passwords

Reporting will be taken from the date they were sent their password to ensure they are given the full 12 weeks to complete

Weekly monitoring has commenced – e-mail reminders will be sent to those staff who have not completed and managers will be copied into these e-mails.

.

Work is continuing 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.

The L&D Facilitators working within the Divisions will continue to support new starters to complete the outstanding elements within the 90 day timeframe.

As at the end of February 2016 the overall Induction completion rate was 84.44%

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Appendix 4 – Secure Division Safeguarding Action Plan Return to Paragraph 24

In the Secure Division, the Head of Forensic Social Care/Nominated Officer had operational responsibility to deliver effective safeguarding arrangements for adults detained in the

Secure Division. Following the review of safeguarding services the Nominated Officer has reduced responsibility for High Secure Services and from 1.4.16, corporate services have responsibility for all training, operational issues for Forensic Outreach, Medium, Low and

Offender Health Secure services. Training arrangements were 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. Following the Trust wide review of safeguarding arrangements the corporate division has taken responsibility for all safeguarding training and reporting.

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. All training apart from the local induction and enhanced child supervisor training for High secure services will be provided by the

corporate division.

Training Compliance as at 30 June 2016 Quarter 1

For non compliance of Medium, Low Secure Services and Offender Health 95% target ten

face to face sessions of Level 2 and 3 Safeguarding Adult/Children are available throughout quarter 4 2015/2016.

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.

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).

Level 1 94% 89% 94% 96%

Level 2 96% 81% 84% 87%

Level 3 96% 82% 84% 87%

Commissioners Target 95%

Current % Compliant

High Secure

Services

Medium

Secure

Services

Low Secure

Services

Offender

Health

(Garth)

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

Trust Board: C2 / Attachment 8


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Report provided (check necessary boxes): Paper No: EC16/17/579

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

For Decision: ☐ For Consent: ☐ Meeting Date: July 2016

Update on Key Transformational Areas

Accountable Director(s): Louise Edwards, Director of Strategy Report Author(s): Helen Bennett, Deputy Director of Strategic Planning and

Intelligence

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:

• This report provides an update to Executive Committee on progress in delivery of the key transformational areas and strategic deliverables for 2016/17 from our Strategy and outlined in our operational plan. The update is drawn from highlight reports provided by project/ programme leads, performance against strategy measures and month 2 financial reporting.

Summary of Key Issues:

• A small number of key measures have been identified to assess delivery of the transformation plans in local and secure services and the project and programme leads for each of the deliverables in our operational plan have produced a set of clear milestones for 2016/17.

• The report focuses on focus on the identification of risk associated with the delivery of the transformation programmes in local and secure services and other key deliverables from our operational plan. This report considers delivery to the end of quarter one.

• Key risks identified at the end of quarter one in relation to our strategic deliverables for 2016/17 are identified.

• Achievement of a number of our cost improvement plans is dependent upon delivery of transformation programmes across our divisions. Therefore, in order to present a more rounded view of transformation delivery, information is drawn from month 2 financial reporting.

Recommendation:

The Committee is asked to: 1) Note the revised process for reporting on delivery of our

operational plan and strategic deliverables. 2) Review the delivery report and key risks identified to inform the

assurance discussion in the Executive Committee meeting.



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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 ☒ ☐ The report outlines areas of operational performance that

impact upon the delivery of the strategic plan.

CQC Compliance ☐ ☒

NHS Provider Licence Compliance ☐ ☒

Legal / Requirements ☐ ☒

Resource Implications (financial or staffing) ☒ ☐ Delivery of CIP targets is considered within the report.

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 Framework ☐ Risk Register ☐

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



Page 3 of 20

MERSEY CARE NHS FOUNDATION TRUST

Update on Key Transformational Areas

PURPOSE

1. This report provides an update to Executive Committee on progress in delivery of the key transformational areas and strategic deliverables for 2016/17 from our Strategy and outlined in our operational plan. The update is drawn from highlight reports provided by project/ programme leads, performance against strategy measures and month 2 financial reporting.

BACKGROUND

2. As was reported to the Executive Committee in January 2015, in order to meet and deliver the challenge of the critical next two years of our transformation plan, it is essential that we hold each other to account for delivery and continually target resources to support areas of under performance. Therefore, the focus of the Executive Committee has been adjusted on a quarterly basis to oversee delivery, adopting the principles from the ‘stand up’ sessions, allowing scrutiny and accountability for delivery at programme and/or Divisional level. July 2016 is the first of these sessions.

3. Outcome measures were previously identified in relation to our strategic objectives and reported through the Care at a Glance report on a monthly basis. These measures have been reviewed to ensure that they adequately allow assurance in relation to delivery. From these, a small number of key measures have been identified to assess delivery of the transformation plans in local and secure services. The development of the data capture and reporting arrangements for some of these measures is on-going and therefore the content of this report will be ameliorated throughout the year. In some cases, trust-level data is available for reporting and work will take place to split this to divisional level going forward.

4. The project and programme leads for each of the deliverables in our operational

plan have produced a set of clear milestones for 2016/17. The highlight reporting approach used to monitor delivery has been reviewed jointly with project/ programme leads and the PMO to simplify content and ensure a focus on delivery of milestones and risks associated with this.

UPDATE ON PROGRAMMES

5. In order to ensure that this report is impactful and allows decision-making where required by the Executive Committee, it will focus on the identification of risk



Page 4 of 20

associated with the delivery of the transformation programmes in local and secure services and other key deliverables from our operational plan. This report considers delivery to the end of quarter one.

6. Appendix 1 summarises the self assessment by project/ programme leads in relation to their deliverables at the end of quarter one.

7. Key risks identified at the end of quarter one in relation to our strategic

deliverables for 2016/17 are summarised below. a. Capacity in local services to deliver significant workplan identified for

August 2016, in relation to discharge and recovery menu, implementing community pathways, and completing inpatient, learning disabilities and addiction pathways.

b. Impact of lack of capital to support Haigh Road developments on personality disorder pathway.

c. Delay in refurbishment to Kevin White Unit caused by lack of receipt of planning permission and associated slippage in CIP scheme (c£350k in 2016/17).

d. Ability to cover £200k shortfall in secure CIP (targeted from rehabilitation review) through other schemes.

e. Impact on service users of delay in implementing new psychology model in secure services.

f. Risk of difficulties in securing capital for planned development works across the Trust.

g. Inability to go-live with RiO and PACIS deployment if interpendencies and hardware upgrade issues are not addressed and funded.

h. Lack of clarity regarding accountabilities and responsibilities in relation to physical health care deliverables and associated risk to delivery of CQUIN schemes.

i. Failure to deliver PACE target across the Trust and lack of solution to forthcoming closure of face to face training venue at Mossley Hill.

j. Impact of competing demands upon clinical teams resulting from improvement initiatives including engagement in carer champion roles, Aston team and leadership development and Perfect Care initiatives.

k. Failure to focus appropriate resources and expertise on creating a high quality bid for Liverpool Community Health services.

CLINICAL DIVISION TRANSFORMATION PROGRAMMES

8. The following section outlines progress with in relation to the deliverables of the transformation programmes in local and secure services.



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Community Redesign (Local Services)

Overall Status – self assessment

Deliverables • Caseload review • Managed transition of caseload in clusters 1-3 back to primary care • Integrated working with primary care • Implement standard pathways for community services • Implement personality disorder pathway phase 1 and 2 • Develop alternatives to outpatient model • Reduce DNAs in outpatient clinics Highlight report and milestones by exception Progress: • Baseline caseload profile review and overarching action plan complete. • High level discharge and recovery pathway developed and agreed with transfer of care group

established to engage partners in discharge pathways. • Recruitment of discharge and recovery support staff completed with start dates September 2016. • Community care pathways developed and ratified and on track to implement pathways in all

community services by August 2016. • Work progressing in line with plan regarding integrated working with primary care. • Enhanced case management and day support in place for personality disorder pathway. Issues or risks: • Capital monies are not available for further development of Haigh Road to support

implementation of crisis component of the PD pathway/model. Revised plans have been developed in year to provide crisis support, with ability to also provide support into AEDs. Review of approach once capital monies available.

Next steps: • Complete team level case load review action plans by 15 July. • Complete discharge and recovery menu of activities (including recovery college) by August 2016. • Implement community services care pathways in all settings by August 2016. • Complete inpatient, learning disabilities and addictions pathways by August 2016. Escalation to Executives for resolution: • None Key Measures Baseline/ Target Latest position Percentage of community service users on a CPA who receive a physical health check once a year.

>=95% green; <95% red

45.61%

Reduce the percentage of service users on clusters 1, 2, 3 and 11 by 60% by 31 March 2017 from the baseline position as at 31 March 2016.

Baseline = 21.72% 20.92%

Number and percentage of new service users offered a formulation based assessment within 6 weeks of referral / presentation.

Data capture and reporting processes to be established

Financial performance



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At end May 2016, local division is underspent and has delivered £0.805m CIP against May target of £1.002m. Assessment and Inpatient Redesign (Local Services)


Deliverables • Enhance A&E liaison service • Roll-out of standardised access and assessment operating procedures • Implement bed management system • Increase psychological approaches on inpatient wards

Highlight report and milestones by exception Progress: • Kaizan 2 project underway, with 30 day report due end July 2016. • On track to produce standard access and assessment operating procedures by end July 2016. • Recruitment of staff required to implement psychological approaches on inpatient wards

complete with commencement in post anticipated within required timescales. • Psychology formulation levels 1,2,3 finalised. • Other actions in relation to psychological approaches on track. • Stepped up care policy and SOP development on track.

Issues or risks: • Work to develop and implement inpatient model of care including standard operating procedures

delayed by one month. To be completed by end August 2016.

Next steps: • Finalise standard access and assessment operating procedures by end July. • Develop and implement inpatient model of care and SOPs to all inpatient wards by August 2016. • Roll our new stepped up care policy and SOP by end August 2016. Escalation to Executives for resolution: • None Key Measures Baseline/ Target Latest position Reduction in the average length of stay for current inpatients from the baseline of 31 March 2016.


Readmission Rates - 30 days <10.58% green; >=10.58% red

1.9% (local division)

Number of unplanned out of area placements within agreed time period (local division – acute adult mental health only)

0 = green; >0 red 11

Financial performance At end May 2016, local division is underspent and has delivered £0.805m CIP against May target of £1.002m.



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Specialist Redesign (Local Services)


Deliverables • Deliver Transforming Care programme locally with commissioners • Agree way forward with supported living service • Review provision at Wavertree Bungalow • Review community LD teams and STAR unit • Work with Calderstones NHSFT to develop community packages of care for secure LD • Develop community model for addictions with 3rd sector providers Highlight report and milestones by exception Progress: • Review of LD services within division complete. Implementation of findings on track. • Review of inpatient and community model for addictions completed. Options appraisal

undertaken in light of loss of commissioning income. • Work to decant Kevin White Unit into Windsor Clinic has commenced (due to complete 25 July

2016) prior to refurbishment. • Organisations change process commenced. Issues or risks: • Addictions contract funding reduction remains a key issue and risk for the Trust which is being

managed with support from division and trust personnel. • Planning permission not yet received for Kevin White Unit development (submitted February

2016). Next steps: • Implementation of finding from review of LD services in community services, respite, inpatient

and SLS services. Escalation to Executives for resolution: • Management of loss of addiction services income already being supported by Executives. Key Measures Baseline/ Target Latest position Reduction in the number of service users for whom at least one admission to a mental health bed or learning disability bed occurs during the year from the 2015/16 baseline.


Reduction in the average length of stay for current inpatients from the baseline of 31 March 2016.


Financial performance At end May 2016, local division is underspent and has delivered £0.805m CIP against May target of £1.002m.



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CIP scheme in respect of the merger of the Kevin White Unit and Windsor Clinic has slipped and an estimated £353k of the target £750k is now forecast to be achieved in year, with the balance being delivered in 20017/18. An alternative CIP plan to meet the shortfall is required. Effective Secure Pathway (Secure Division)


Deliverables Implement standard assessment, bed management and discharge system across the Division Highlight report and milestones by exception Progress: • Admissions panel established at Scott Clinic with the Chair of the High Secure Admissions Panel

supporting the process. • The new standard of 2 weeks for the assessment of all new referrals and 3 weeks for a decision to

be made has been implemented at Scott Clinic. Issues or risks: • Issues with the availability of nursing staff to undertake and complete assessment reports within

the time period. This is due to their shift patterns, allocation of role to undertake leave duties or because of holidays, vacancies and sickness.

• The Matrons have reviewed this and initial feedback is that it is starting to improve.

Next steps: • By end July a review undertake review of the new panel at Scott Clinic and the revised standards

for processing referrals. • Workshop planned for August 2016 to explore how the proposed clinical overview panel will

operate. Escalation to Executives: • None Key Measures Baseline/ Target Latest position Delayed discharges (i.e. those waiting 12 weeks or more) in the reporting period (HSS only)

<=5% of resident population green; >5% red

0

Reduction in the average length of stay for current inpatients from the baseline of 31 March 2016.


Reduced time taken to agree and implement interservice transfers within the division.


Financial performance At end May 2016, secure division is breakeven and has delivered £0.623m CIP against May target of £0.834m.



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Redesign of rehabilitation services (Secure Division)


Deliverables Implement new integrated ward-based and off-ward based model of rehabilitation, which provides an improved more efficient service for patients. Highlight report and milestones by exception Progress: • The initial redesign plan, agreed in September 2015, required significant enabling costs which

were not secured. • As a result a new plan was developed that negated the need for enabling costs but only achieved

£800k of the £1,000k CIP savings required. The new plan was accepted by the Secure Governance Board in June 2016.

• Prior to commencing the formal organisational change process an informal process has been initiated. This has included asking for 19 volunteers from the rehabilitation service to move to the new ward based activity role.

Issues or risks: • The Division has to formulate additional plans to achieve the £200k CIP shortfall. Plans are in the

early stages and the Division is confident it can realise those savings.

Next steps: • Finalise plans to achieve £200k CIP shortfall and realise those savings by the end of August 2016. Escalation to Executives:

• None Key Measures Baseline/ Target Latest position Overall patient experience score measure >=95% green; >=90%

amber; <90% red 95.75%

Percentage of service users undertaking a minimum of 25 hours of meaningful activity per week.


Attendance rate of patients taking part in planned rehabilitation activities both on and off wards


Financial performance At end May 2016, secure division is breakeven and has delivered £0.623m CIP against May target of £0.834m. There is a CIP shortfall of £200k from rehabilitation review. Plans are being finalised to recover this shortfall.



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Psychology Review (Secure Division)


Deliverables Implement new model of psychological approaches following pilot evaluation Highlight report and milestones by exception Progress: • Psychology review has been completed to offer an improved service to patients, align the

provision across the Division and improve efficiencies through a single management structure. The revised model has been consulted upon.

• Some staff have been slotted into posts as per the planned process, but due to a joint grievance by some staff the slotting in process has been paused.

• The new psychological services model will result in additional band 8a psychologists working with ward teams. To ensure this is in place as soon as possible recruitment for additional 8a posts has commenced.

Issues or risks: • The benefits that were identified for improved service provision will not be realised until the full

scheme is completed. There is an additional risk that further delay to completing the review will impact on the provision of psychological services to patients.

• It is not envisaged that the slotting in process will be completed before September 2016. Efficiency savings from this scheme have been identified for 2017/18, therefore, this will not impact on 2016/17 CIPs.

Next steps: • Complete the recruitment of 8a psychology staff to support the wards. • Continue with the grievance process trying to agree a resolution as soon as possible. • Continue to monitor the impact of the review being delayed on provision of psychological

support for patients. Escalation to Executives: • The joint grievance by some senior psychological services staff is on-going. Key Measures Baseline/ Target Latest position Psychological assessment completed within three months of admission.


Agreed programme of psychological treatment to commence within 18 weeks of the completion of assessment.


Reduce the number of patients waiting for a group or individual programme once accepted.





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Secure Campus (Secure division)


Deliverables • Secure campus business case approval by Trust Board • Consultation on secure campus care model and movement of services Highlight report and milestones by exception Progress: • The Division has worked up the model of care and the workforce plan for the full business case. • Work is on-going with the external project team to design the new building. The design of the

new building is in place and the layout of rooms has been agreed. The 1:200 design have been signed off by the Project Board and reviewed by the Design Champion.

• An update paper and presentation was provided to the PIC Meeting on 1 July 2016 which was well received

• The Trust acquired Calderstones Foundation NHS Trust on the 1st July 2016.

Issues or risks: • The key risks still remain around securing capital and the timing of the build to be open by the

end of April 2019.

Next steps: • Sessions for clinicians and managers to work up the 1:50 scale designs. • The full business case will go to the board in September 2016 for approval. Advice received by

external consultants that this delay will have no impact on the external approval process timescale by NHS Improvements and the Treasury and no detrimental impact on the overall programme

• To support workforce plan for new MSU, discussions with Edge Hill University regarding dual mental health and LD training.

Escalation to Executives for resolution:

• None Key Measures Baseline/ Target Latest position Reduction in the average length of stay for current inpatients from the baseline of 31 March 2016.


Reduced time taken to agree and implement interservice transfers within the division.





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9. Progress against other deliverables from the operational plan is grouped in relation to their project or programme accountabilities.

Centre for Perfect Care

10. A Physical Health Strategy Programme Board has been created with revised governance arrangements to ensure support for physical health throughout the organisation. Community pathway work commenced as part of the local division transformation programme. Risks identified in relation to clarity of responsibilities between corporate and clinical divisions and delivery of CQUIN schemes. A plan and accountability framework relating to metabolic screening is in development but not yet complete.

Key Measures Baseline/ Target Latest position Percentage of community service users on a CPA who receive a physical health check once a year.

>=95% green; <95% red

45.61%

11. The roll-out of No Force First is experiencing delay in relation to analysis and discussion of trend data per ward (restraints, medication led restraints, incidents of aggression) and agreement of targets with ward managers. This is being managed by the project team.

Key Measures Baseline/ Target Latest position By 31 March 2017, the use of restrictive practice across the trust will be reduced by 20% based on the position for 1 April 2015 to 31 March 2016 (for all wards). Report on a rolling twelve months position.

Green = expected reductions observed; Amber = reduction observed but not to expected level; Red = increase on baseline observed

-0.80%

12. Full implementation of the zero suicide is progressing to plan, with the exception

that some timescales for the stages of implementation are yet to be agreed with local services. This is being managed by the project team.

Key Measures Baseline/ Target Latest position Number of people who commit suicide whilst an inpatient and 3 day post-discharge. (Trust wide, rolling 12 months)

0 0

Number of people who commit suicide within seven days of discharge from inpatient services. (Trust wide, rolling 12 months)

0 0



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13. Work with pilot wards to implement a design based solution to reduce self-harm is underway, with all wards at differing stages in the insight and solutions identification. Whilst there is some slippage, the project team report that this does not impact on the roll out design based thinking approach to self harm across all in-patient wards by March 2017.

14. The ethics process associated with work to develop a ‘suicide app’ is delayed due to the extended development stage with Stanford and the project team are reviewing the milestones in light of this. The app was due to be developed for implementation across the Trust by March 2017.

15. No risks are identified with regard to the development of costed capital plans for new 'centre of excellence' at Maghull. Provision plans have been developed and a design thinking day to inform revised plans is scheduled.

16. The project to commercialise opportunities identified through Innovate Depression programme is progressing to plan. Currently in the discovery phase, proposal for Mersey Care's version of ''my health locker' is due to be approved in December 2016.

17. Further work is required in order to clarify the work programmes and accountabilities in relation to falls prevention and equitable care insight at service line level in order that delivery in these areas can be reported comprehensively.

Key Measures Baseline/ Target Latest position Reduction in the proportion of falls that result in harm (classified as low, moderate, severe or death) from the Q4 2015/16 baseline (20% reduction by 31 March 2017).

Green = expected reductions observed; Amber = reduction observed but not to expected level; Red = increase on baseline observed

8.0% (Q4 = 93 Q1 =101 8% increase at Trust level)

Supported managers and teams

18. Achievement of the trust target for 95% completion of PACE across all divisions by end August 2016 is at high risk. The position as at end of June 2016 is:

Preparation complete PACE fully complete Local 33% 18% Secure 57% 33% Corporate 91% 82%



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19. In addition, a significant risk has been identified with regard to a suitable venue for statutory face to face training in Resuscitation, Manual Handling and Personal safety once the Mossley Hill site closes. Estates have been asked to seek a suitable alternative venue.

20. Twenty-eight clinical frontline teams are engaged with Aston (compared with a target of 39 at end of September). Availability of coaches to support Aston team based working is the greatest risk area with only 20 of 35 trained coaches currently active. Additional coach training is planned along with increased training opportunities for leaders to become Aston tool familiar therefore increasing capabilities and reducing reliance on coaches for full Aston support.

21. The KPIs selected for the ‘teamness score’ have been validated and further work is now required regarding data availability and system readiness. Once this is concluded, further milestones will be required for this project.

22. The delivery of management and leadership programmes across the organisation is progressing to plan, and core attendance is 80%, however, management programmes are experiencing a 40% dropout rate which is making some courses unviable.

23. The planned milestones aligned to reducing staff sickness are being delivered

and a detailed update paper was presented to PIC in July. Roll out of Sickness Absence Team to start incorporating Calderstones absence is planned as is design thinking methodology using two pilot wards.

Key Measures Baseline/ Target Latest position % staff sickness rate rolling twelve months (month 2 data)

6.21% (Trust baseline) <=4.8% green; <=5.8% amber; >5.8% red

6.19% (Trust wide)

Working side by side with service users and carers

24. No risks are identified with regard to the operationalizing of the Life Rooms. The development of a marketing strategy and network of partner organisations is underway. Evaluation research is reported to have commenced. A business case for Life Rooms 2 is due in March 2017.

25. Establishing Carer Champions in each service and Carer Mentor Volunteers to support Triangle of Care is at risk due to difficulties in securing engagement from services. A programme of carer awareness training for staff is scheduled from



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July-December, however, competing staff training priorities may challenge engagement with this.

Key Measures Baseline/ Target Latest position Percentage of triangle of care elements RAG rated green – inpatients (Trust)

89.47% >90% green; >=80% amber; <80% red

92.23%

Percentage of triangle of care elements RAG rated green – community (Trust)

76.44% >90% green; >=80% amber; <80% red

77.92%

Grow our Services

26. Delivery is as planned in relation to the growth and innovation components of Grow our Services (including work regarding addictions, young people’s mental health, A&E liaison and secure services). CQUIN monies for young people’s mental health have been retained by Alder Hey and alternative options are being considered.

27. With regard to protecting existing service lines, clarification is awaited from NHS England as to whether medium and low secure services will go to tender for our region, particularly given the Calderstones acquisition. Six service lines identified for review in local services are awaiting ratification from the division.

28. Bid submission in relation to Liverpool Community Health services is due on 31

August. Support is required from the Executive team and local division senior management team in the final preparation and review of the bids and in supporting resource requirements when requested to minimise risks associated with achieving a high quality submission.

Key Measures Baseline/ Target Latest position Proportion of tenders for new or existing business won during the financial year.

54% >=50%= green; >12.5% = amber; <=12.5% = red.

50% (one out of two tenders were won in May 16)

Technology that works for us

29. There are a number of risks associated with the deployment of RIO into local services division. Most notably, additional funding is required by end July 2016 to replace the existing computers in Local Division that fall short of the minimum hardware specifications for the RiO Clinical Information System. In light of the



Page 16 of 20

impact for users and patients, the Project group will make the recommendation not to ‘go live’ with RiO in February 2017 until this hardware has been replaced.

30. In response to concern that it may not be possible to migrate all the agreed data to RiO from ePEX, dedicated resource has been identified to address this with engagement of key stakeholders to develop clinically acceptable solutions.

31. A number of significant dependencies are being managed regarding deployment

of PACIS in secure services by February 2017, including HL7 Compliance, interoperability with RIO, compliance with National Reporting Requirements and Outpatient/ Community activity module and true sharing of real time data between RiO and PACIS. Without resolution of these issues ‘go-live’ will not be possible.

32. The EPMA project is progressing to plan with risks and mitigations being

managed by the project team.

Buildings that work for us

33. The Liverpool 2 inpatient facility and Southport projects are progressing in line with their project plans and the Strategic Outline Cases for both schemes are scheduled to be considered by the Board of Directors in July 2016. Risks and issues relating to securing the required funding for the build are being managed by the project team.

Key Measures Baseline/ Target Latest position Proportion of estate at category B quality compared to plan for financial year in line with approved capital programme.

Achieved Achieved

FINANCIAL PERFORMANCE

34. Achievement of a number of our cost improvement plans is dependent upon delivery of transformation programmes across our divisions. Therefore, in order to present a more rounded view of transformation delivery, information is drawn from month 2 financial reporting.

35. Detail is provided in this report only in relation to those CIP programmes which are explicitly delivered through the defined transformation programmes outlined in our operational plan.



Page 17 of 20

36. The trust 2016/17 CIP target is £12.770m. At 31st May £1.661m has been delivered against a target of £2.129m. If no action is taken, the CIP target will underachieve by £0.712m in 2016/17.

37. The local Division 2016/17 CIP target is £6.013m. At the 31st May, £0.805m has

been delivered against the May target of £1.002m. The CIP scheme in respect of the merger of the Kevin White Unit and Windsor Clinic (delivered through the specialist redesign programme) has slipped and will only be partially achieved during 2016/17 (estimated £0.350m) due to delays in building work. The CIP has been phased to the last six months of the year. An alternative CIP plan is required to meet the shortfall.

38. At end May 2016, secure division has delivered £0.623m CIP against May target

of £0.834m. The rehabilitation redesign plan in secure services required significant enabling costs which were not secured. As a result an alternative redesign plan has been developed, however this revised plan has a shortfall in the region of £0.200m. The secure division are formulating a plan to meet this shortfall.

39. The corporate division 2016/17 CIP target is £1.756m. The plan in May is £0.291m, of which £0.231m has been achieved.

40. CIP delivery should be viewed in the context of overall financial performance. At month 2, the local division was underspent and secure and corporate divisions are breakeven.

CONSEQUENCES OF NOT TAKING ACTION

41. Lack of effective management of delivery of the operational plan for 2016/17 puts the delivery of our Strategy for Perfect Care at risk. Delivery of our CIPs for 2016/17 and our aspiration for high quality care are dependent upon delivery of our transformation and supporting programmes and therefore robust performance management of delivery is required.

RECOMMENDATION

42. The Committee is asked to:

a. Note the revised process for reporting on delivery of our operational plan and strategic deliverables.

b. Review the delivery report and key risks identified to inform the assurance discussion in the Executive Committee meeting.

Louise Edwards



Page 18 of 20

Director of Strategy July 2016

Appendix One

Self assessed project/ programme status – June 2016

Deliverable RAG

Com

mun

ity

Community Redesign Project

Implement Talk Liverpool action plan Implement improvements to community services ‘flow’ Caseload review Managed transition of caseload in clusters 1-3 back to primary care

Integrated working with primary care Implement standard pathways for community services Develop alternatives to outpatient model Implement personality disorder pathway phase 1 and 2 Reduce DNAs in outpatient clinics Implement new model of psychological approaches following pilot evaluation

Caseload review

Inpa

tient

Inpatient and Assessment Redesign

Project

Implement improvements to inpatient services ‘flow’ Implement bed management system Increase psychological approaches on inpatient wards Develop alternatives to inpatient admission Enhance A&E liaison service Develop and implement an Inpatient Model of Care including clear SOP. Roll-out of standardised access and assessment operating procedures

Spec

ialis

t

Specialist Redesign Project (LD)

Agree way forward with supported living service Review provision at Wavertree Bungalow Deliver Transforming Care programme locally with commissioners

Review community LD teams and STAR unit

Reha

b Redesign rehabilitation services (High Secure)

Implement new ward-based model of rehabilitation

Psyc

holo

gy

Psychology Review Improve access to specialist psychological therapies (medium secure)

Effe

ctiv

e Pa

thw

ay

Effective Secure Pathway

Implement standard assessment, bed management and discharge system across the Division

Est

ate s Southport Build New Southport mental Health facility to include



Page 19 of 20

community services

Liverpool New Liverpool 2 Inpatient facility New MSU Integrating MI and LD Unit New MSU (part of secure campus development)

Kevin White Re-provision of addictions service facility (Kevin White)

OE

& H

R

Leadership Plan Implement leadership plan Aston Targetted Aston team development Teamness Score Implement a teamness score PACE Implement team objectives through PACE PDR

Targeted sickness absence reduction Targetted sickness absence reduction

Cent

re F

or P

erfe

ct C

are

Zero Suicide Fully implement zero suicide strategy Roll-out zero restraint approach to all wards

Stanford

By December 2016 a ‘zero suicide app’ will be developed for implementation across the Trust (in conjunction with Stanford University).

Develop an innovation pipeline based on 'design thinking' and Innovence Pulse

By December 2016 four pilot wards will have implemented a design based solution to reduce self-harm. This will be rolled out across all in-patient wards by March 2017.

No Force First

By July 2016 individualised performance outcomes and targets will be developed for each in patient area

By July 2016 a guide of strategies for implementing No Force First will be developed and roll out commenced

By July 2016 a research project will commence to evaluate the impact of on ward safety, staff and service user satisfaction and workforce metrics

By September 2016 a policy on reducing restrictive practice will be developed

By March 2017 there will be a further 20% reduction in restraint across all wards

Improvements in Physical Health

Pathways

Improve physical health care for service users (local) Improve physical health care for service users (secure) By December 2016 100% of inpatients will have metabolic screening completed in line with the National Audit of Schizophrenia standards

By March 2017 all inpatients screened as smokers will have prescribed nicotine replacement therapy on admission

Centre of Excellence at Maghull

Develop costed capital plans for new 'centre of excellence' at Maghull

Locktons Implement a clinical enterprise risk management and safety system

Innovate Depression Commercialise opportunities identified through Innovate Depression programme

Wor

king

sid

e by

side

w

ith se

rvic

e us

ers a

nd

care

rs Peer-run service user

and carer support group

Develop peer-run service user and carer support groups at service level

Achieve 90% compliance with Triangle of Care self assessment



Page 20 of 20

LIFE Rooms Operationalize Life Rooms

Recovery College

Evaluate the recovery college

Increase recovery college students integrate the recovery college in to community services Embed recovery college to support discharge

Peer Support Workers Increase service user and carer peer support workers

Busin

ess D

evel

opm

ent

Strategic Acquisition Complete acquisition of Calderstones Partnerships NHS Foundation Trust

Strategic Acquisition Acquire service lines from LCH in Liverpool and Sefton

Growth & Innovation Develop community model for addictions with 3rd sector providers

Growth & Innovation

Attract commissioner investment in youth mental health model

Attract commissioner investment in enhanced A&E liaison service in Liverpool and Sefton

Retain & Grow: Engage with contracts to forward plan for contracts ending between now and 31st March 2017

Secure Business Development Strategy

Protect & Defend

Secure: Succeed in winning tender to provide medium and low secure services

Local: end to end service reviews to be undertaken across a number of areas

Clin

ical

In

form

atio

n

Clinical Information Systems

Rio, Develop and Roll out in Local Services PACIS, Develop and Roll out in Secure Services EPMA, Develop and Roll out in Secure and Local Services



SUBJECT:

ACTION REQUIRED:

AUTHOR(S):

For Assurance

Kate Chapman, Andrea Bolton & Jo Twist

Calderstones Partnership NHS Foundation Trust Corporate Performance

Report - M3 2016/17

EXECUTIVE SUMMARY

(KEY ISSUES):

SUMMARY:

Quality:

Performance has slightly deteriorated for 'Actual staffing levels' for

Support Staff and have improved for Registered Staff.

Workforce:

Forensic & High Support services (F&HSS) sickness has slightly

improved during June, with corporate sickness remaining the same.

Sickness has been an ongoing issue in the F&HSS area for the past 3

years, and has rarely been below 7%. Corporate sickness continues to

fluctuate and is impacted on by the current organisational change

process. Vacancy rates remain consistent.

Weekly staffing meetings with human resources (HR) and operations

continue to review staffing levels; sickness, recruitment and mandatory

training trajectories against plan.

Performance:

All targets are being met and there have been no issues, assessments

are closely monitored and robust systems are in place to ensure they are

completed and regularly reviewed.

Finance:

The net deficit at month 3 was £1.0m against a plan of £1.2m. EBITDA

was £0.2m deficit (-2.1%) against a plan of £0.4m (-3.8%) with an FSRR

of 2 against a plan of 2. Additional income from contracts has been

received in month but is offset by overspending in pay areas, especially

on bank and agency which has been an ongoing issue for the past 18

months.

Workforce

Finance

Quality

Risk Profile Reviews

Centre Circle Key:

3 or above Greens = 2 Greens =

Performance

I get 25hrs activity

Risk of Choking

Assessments

Integrated Care Plan

I am supported to make

choices in my life

Actual Staffing Levels

I am confident that my

Treatment & Care will help

me move on

The overall performance to date is ahead of plan with a

net deficit of £1.0m against a plan of £1.2m. The position

is due to the overachievement of income (ESS Contract)

and underspending on non pay areas offset by an

overspend on pay areas.

The use of agency and back to cover vacancies,

sickness and increased clinical observations is the main

driver behind the pay position to date. Management

continue to monitor and plan for reductions in pay

spends and have formulated contraction plans to reduce

establishments in areas where this can be done safely

and in line with planned discharges. Staffing will be

redeployed to areas were clinical need is greatest.

The position of Actual against Planned positions for both

registered nurses and support staff continues to remain

green.

Support Staff - June 2016 position indicates notable

improvement compared with the 12 month comparator

(June '15). The previous month (May '16) comparator

indicates a very marginal deterioration but still notably

above target. The trajectory is one of continued

improvement. The recruitment of Support staff is not

problematic.

With reference to Registered Nurses the vacancy

position continues to deteriorate slightly. Planned

discharge forecasts and service bed contraction should

ameliorate the situation over the coming months. Safe

staffing levels continue to be maintained.

Performance remains in target on the three critical

indicators for choking screen assessments, integrated

care plans and risk reviews.

% Sickness Rate

% Vacancy Rate

% Mandatory

Training

Director Lead

Performance Finance

L Taylor Director Lead N Smith

FSRR Score

Pay Variance

1 Green or below =

Red

Sickness has improved this month for F&HSS and

remained the same for corporate areas. F&HSS from

9.27% in May 16 to 9.14 % in June 16 above a target of

6.5%. Corporate Services has remained the same at

3.73% and still remains over the target of 2.5%. Case

conferences with occupational health (OH) continue this

month to discuss all staff on long term sick . Mandatory

training continues to perform well there are slight

deteriorations in some areas but all remain above target

apart from MVA which has an action plan in place.

There has been a significant improvement in Life

support, MH Act and Mental Capacity Act training this

month. Vacancy rate continues to improve despite the

pending large scale organisational change and

uncertainty.

EBITDA Variance

Director Lead J Smith J Twist

Workforce

Director Lead

Quality

Green Amber

Critical Key Performance Indicator Summary:

Workforce

Finance

Quality

Performance

Performance Graphs

Key:

KPI Descriptions

<=6.5%

F&HSSTrust Jun-16 8.40 p

9.14

(Denominator:

19,657.60 hrs)

q 9.27 9.00 Red Red Red Red

<=2.5% Other Trust Jun-16 2.45 p

3.73

(Denominator:

5,027.60 hrs)

tu 3.73 3.60 Red Red Amber Green

7.03 Vacancy <=8% Trust Jun-16 8.31 p 11.84 q 12.97 12.50 Red Amber Amber Green

Mandatory Training (1 indicator broken down for clarity of viewing)

6.01Information

Governance>=95% Trust Jun-16 92.12 p 96.45 p 95.99 95.80 Green Green Green Green

6.02Appraisal - Band 7 /

Above>=90% Trust Jun-16 74.75 p 82.28 p 80.00 82.43 Amber Green Green Green

6.03Appraisal - Band 6 /

Below>=90% Trust Jun-16 62.49 p 88.63 q 89.70 88.82 Amber Green Green Green

Target for

period

Workforce:

Sickness (E- Rostering) 7.06

Set by

Forecast

Reporting

Period Next

monthYear End

Jun-15 May-16 YTD

Trend

direction from

last reporting

period

Jun-16

Trend direction

from same time

previous yearNext

month +1

Next

month +

2

0.00

2.00

4.00

6.00

8.00

10.00

12.00

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

0.00

1.00

2.00

3.00

4.00

5.00


0.00

5.00

10.00

15.00

20.00


88.00

90.00

92.00

94.00

96.00

98.00


60.00

70.00

80.00

90.00

100.00


60.00

70.00

80.00

90.00

100.00


Performance Graphs

Key:

KPI No: Descriptions

6.04 Fire >=90% Trust Jun-16 86.25 p 94.43 q 95.04 94.58 Green Green Green Green

6.05

Positive Management

of Violence &

Aggression

>=90% Trust Jun-16 80.66 p 88.18 p 88.13 87.43 Amber Green Green Green

6.06 Infection Control >=90% Trust Jun-16 83.13 p 94.26 q 95.00 94.45 Green Green Green Green

6.07 Food Hygiene >=90% Trust Jun-16 81.85 p 94.14 q 94.90 94.33 Green Green Green Green

6.08 Moving/Handling >=90% Trust Jun-16 83.75 p 93.25 q 94.33 93.75 Green Green Green Green

6.10 Equality & Diversity >=90% Trust Jun-16 83.46 p 92.77 q 92.92 92.66 Green Green Green Green

Target for

periodSet by

Reporting

Period Next

month +

2

Year EndYTD

Forecast

Next

monthMay-16Jun-16Jun-15

Trend direction

from same time

previous year

Trend

direction from

last reporting

period

Next

month +1

60.00

70.00

80.00

90.00

100.00


70.00

75.00

80.00

85.00

90.00

95.00

100.00


60.00

70.00

80.00

90.00

100.00


60.00

70.00

80.00

90.00

100.00


60.00

70.00

80.00

90.00

100.00


70.00

75.00

80.00

85.00

90.00

95.00

100.00


Performance Graphs

Key:


6.11 Safeguarding >=91% Trust Jun-16 91.20 p 93.95 q 95.02 94.55 Green Green Green Green

6.12 Life Support (ESS Only) >=90% Trust Jun-16 93.85 p 80.68 78.36 Green Green Green Green

6.12bLife Support

(Stepdown, LSU, MSU)>=90% Trust Jun-16 58.78 p 44.94 44.08 Red Amber Amber Green

6.13 Mental Health Act >=90% Trust Jun-16 69.22 p 67.44 67.90 Red Red Amber Green

6.14 Mental Capacity Act >=90% Trust Jun-16 45.47 p 39.84 40.81 Red Red Red Green

KPI

Refere

nce

Responsible Director:

7.06 L Taylor

7.06 J Twist

7.03 J Twist

6.02 J Twist

6.03 J Twist

6.05 J Twist

Risk:

F&HSS

Sickness has seen a slight improvement in performance from the

previous month however remains red.

Impact on service user experience and overall quality,

pressures on staff that remain. Higher costs to Trust

through use of bank and agency

Issue:

Vacancy rates have seen an improvement during the month with

performance remaining red.

Trend direction

from same time

previous year

Jun-16

Trend

direction from

last reporting

period

There are safety and care implications for staff if staff fail

to attend new techniques and refresher training as

required.

Appraisals for Band 7 > has seen an improvement in trend from the

previous month with 14 outstanding.

Appraisals for Band 6< has seen a slight deterioration in trend from the

previous month.

Workforce not adequately supported to develop within

their roles. Lack of investment in staff.

Workforce not adequately supported to develop within

their roles. Lack of investment in staff.

Target for

periodSet by

Reporting

Period Jun-15

Other Sickness

Sickness has stayed the same in June

PMVA remains at 88% in June

Mitigation:

Next

month +1

Next

month +

2

Year EndYTD

Impact on service user experience and overall quality,

pressures on staff that remain. Higher costs to Trust

through use of bank and agency

Forecast

Next

monthMay-16

A reminder will be issued to Heads of Service this month to continue using the existing paperwork until PACE is implemented.

As above

PMVA training is planned until March 2017. Staff requiring a refresher and new skills must attend as required.

Work continues with the Health@work team to reduce absence and also preventative work to assist staff with their wellbeing. Two sessions have

been held to help staff around their mental health whilst going through a major change - this gives coping strategies to deal with stress and anxiety

in times of change and how to look after yourself as well as your colleagues. The sessions have been very well received.

As above

The vacancy rate continues to improve with appointments of support staff and redeployment of current staff as patients are discharged and also

establishments are reviewed. Recruitment is ongoing for qualified nurses.

Risks around delivery of mandatory reports and

submissions on contract requirements

70.00

75.00

80.00

85.00

90.00

95.00

100.00

Jul Aug Sept Oct Nov Dec Jan Feb Mar Apr

60.00

70.00

80.00

90.00

100.00


0.00

20.00

40.00

60.00

80.00

100.00

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

0.00

20.00

40.00

60.00

80.00

100.00

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

0

20

40

60

80

100


0

20

40

60

80

100


6.12 L Taylor

6.13 L Taylor

6.14 L Taylor

Performance Graphs

Key:


8.03 FSRR 2 Jun-16 4 q 2 tu 2 Green Green Green Green

8.04 Pay Variance 0% Jun-16 -1.53 q -3.09 q -2.66 Amber Amber Amber Amber

8.05 EBITDA Variance 0% Jun-16 6.40 q -2.10 p -3.90 Green Green Green Green

KPI Ref Responsible Director:

8.04 N.Smith

YTD

Overspending on pay by the reliance of bank and agency is

a risk on quality of care for our service users. Not having

consistent carers and new staff having to learn our

standards and protocols requires tight supervision.

Trend direction

from same time

previous year

Weekly management meetings and investment in recruitment, induction and sickness monitoring are in place to help reduce the use of bank and

agency staffing. The introduction of recruitment and retention premiums for nurses commenced in Jan 2016, however vacancies at band 5

continue to increase - a contraction plan is being developed to address the overstretched resources and first phase was implemented from 1 July

16 with the consolidation of LSU beds in west drive.

Year EndJun-16 Next

month

Finance:

Issue: Risk: Mitigation:

Target for

periodSet by

Reporting

Period

Staff are unable to deal with emergencies in an effective

manner. Patients are put at risk

The pay variance deteriorated by £109k from month 2-3. The

cumulative pay overspend was £254k. Of the total overspend FHSS was

£367k overspent at the end of month 3, due to the continued additional

cost of agency and bank to cover vacancies, sickness and increased

observation levels (especially in LSU). Of the £8.5m spent to date on pay

costs, £1.4m (16%) relates to Bank & Agency.

Jun-15

Mental Capacity Act training has seen a slight improvement during the

month.

Life Support Training for both areas has seen a significant improvement

during June.

Trend

direction from

last reporting

period

May-16 Next

month +1

Next

month +

2

Forecast

Staff not able to demonstrate underpinning knowledge

and application commensurate with their role will impact

on care. Staff not able to demonstrate underpinning knowledge

and application commensurate with their role will impact

on care.

Further training will be offered in July for Registered Staff and Support Workers - it is making steady improvement

The change of attendance to the planned MCA update on 8 June 2016 by the Medical Team impacted on Registered Nurse compliance. A further

targeted event for nurses was offered on 28 June 2016. During July further sessions will be offered for Registered Staff and Support Workers.

Immediate Life Support and Basic Life Support training is planned in until March 2017. Operational colleagues must ensure staff attend training as

required.

Mental Health Act Training has seen a slight improvement during the

month.

-5.00

-4.00

-3.00

-2.00

-1.00

0.00


-5.00

0.00

5.00

10.00


0.00

1.00

2.00

3.00

4.00

5.00


Performance Graphs

Key:


2.02

Risk of choking

screening assessment

(every 12 months)

100% Jun-16 100.00 tu 100.00 tu 100.00 100.00 Green Green Green Green

2.03

Integrated care plan

(within 12 weeks) >=95% Jun-16 100.00 tu 100.00 tu 100.00 100.00 Green Green Green Green

2.04

Risk profile or IRMP

review (every 6

months)

>=95% Jun-16 100.00 q 98.05 q 100.00 99.35 Green Green Green Green

Performance Graphs

Key:


19.03

Actual Staffing levels

vs quality level

requirements (Support

Staff)

>=90% National Jun-16 106.23 p 118.18 q 119.29 119.05 Green Green Green Green

19.04

Actual staffing levels vs

quality level

requirements

(registered Staff)

>=90% National Jun-16 108.52 q 100.28 p 96.38 100.48 Green Green Green Green

Next

month +1

Next

month +

2

Year End

YTD

Trend direction

from same time

previous year

Jun-16

Trend

direction from

last reporting

period

May-16

Trend direction

from same time

previous year

YTD

Trend

direction from

last reporting

period

Performance

Forecast

Jun-16

Next

month

Next

month +1

Next

month +

2

Year End

Forecast

Next

monthMay-16

Target for

periodSet by

Target for

periodSet by

Reporting

Period Jun-15

Jun-15Reporting

Period

0

20

40

60

80

100

120


92

94

96

98

100

102


92

94

96

98

100

102


0

50

100

150


0

20

40

60

80

100

120


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