Report to: Board of Directors (Public) Paper number: 3.2 Report authors: Mr Karthik ... ·...

Report to: Board of Directors (Public)

Paper number: 3.2

Report for: Information / Discussion

Date: 30 January 2020

Report authors: Mr Karthik Chinnasamy, Interim Head of Performance & Information

Mr Andrew Rogers, Chief Operating Officer

Mr Dean Howells, Director of Nursing & Quality

Ms Sally Quinn, Director of HR & OD

Mr David Wragg, Finance Director

Report of: Mr Jeff Boateng, Director of Clinical Information Management

FoI status:

Report can be made public

Strategic priorities supported:

Early and effective Intervention / Helping people to live well / Research and innovation / Keeping our service users, carers and staff

Cultural pillars supported:

We value each other / We are empowered / We keep things simple / We are connected

Title: Integrated Board Performance Report December 2019 – Month 9, 2019/20

Executive Summary

The Camden & Islington (C&I) NHS Foundation Trust Integrated Board Performance Report is aimed at providing a monthly update on the performance of the Trust based on the latest information available and reporting on actions being taken to address any issues and concerns with progress to date.

The contents of the report are defined by the Trust’s priorities which are informed by nationally defined objectives for providers - the NHS Constitution, the NHS Long Term Plan, Oversight Framework for Mental Health Providers and the Commissioning for Quality and Innovation (CQUIN) Payment Framework.

The report provides an update on the Trust’s operational, quality and safety, workforce, finance and use resources performance against national and local standards.

This includes performance against access and waiting time standards, inpatient services, number of incidents by harm, complaints, the friends and family test for patients and staff, staffing and vacancy levels, staff sickness levels and trust financial performance against plan.

Where possible and appropriate the report measures and reviews performance using Statistical Process Control (SPC). An overview of SPC can be found on the last page of this report.

Recommendation to the Board

The Board of Directors is requested to:

RECEIVE, CONSIDER and ACCEPT this report.

Camden and Islington NHS Foundation Trust

Integrated Board Performance Report

Period to December 2019 – Month 9 2019/20

1

Introduction to the report

The Camden & Islington (C&I) NHS Foundation Trust Integrated Board Performance Report is aimed at providing a monthly update

on the performance of the Trust based on the latest information available and reporting on actions being taken to address any

issues and concerns with progress to date.

The contents of the report are defined by the Trust‟s priorities which are informed by nationally defined objectives for providers - the

NHS Constitution, the NHS Long Term Plan, the Oversight Framework for Mental Health Providers and the Commissioning for

Quality and Innovation (CQUIN) Payment Framework.

The report provides an update on the Trust‟s operational, quality and safety, workforce, finance and use of resources performance

against national and local standards.

This includes performance against access and waiting time standards, inpatient services, incidents by harm, complaints, the friends

and family test for patients and staff, staffing and vacancy levels, staff sickness levels and trust financial performance against plan.

Where possible and appropriate the report measures and reviews performance using Statistical Process Control (SPC). An

overview of SPC can be found towards the end of the Finance slides. The methodology of how each operational Oversight

Framework metric is calculated is detailed on the last two pages of this report.

A performance overview of key points is included on the next page followed by the Trust‟s performance against the key mental

health targets in the Oversight Framework.

2

3

Performance Overview – Key Points

Operational

•Performance levels have broadly maintained from previous months with a slight seasonal reduction in demand seen in some areas.

•Resources Committee undertook its first Deep Dive review this month. This was focussed on the CDAT service. More detail in the CDAT slide of the report. Early Intervention in Psychosis Services has been identified for the February Committee.

•Out of area occupied bed days numbers have reduced from 200 in October to 108 in November and 28 in December. To support continued progress, the Patient Flow Project Plan refreshed for 2020 with aim to reduce occupancy to 90%.

•58% less trolley breaches in December 2019 compared to November 2019.

•Personality Disorder caseload continues to show improvement due to the patient flow and reducing avoidable admissions projects.

•Recovery rates across all 3 IAPT services have been above the target of 50% for the last 3 months.

•SMS - In both Islington and Kingston boroughs, we are exceeding our target for opiate successful completions, whereas Camden is achieving the target in alcohol and non-opiates.

Quality and Safety

•The Trust is maintaining a steady rate of incident reporting while simultaneously demonstrating a decrease in the number of incidents resulting in harm.

•The proportion of incidents resulting in harm has decreased and this is one of the Trust‟s priority objectives.

•There has been a decrease of complaints completed in time during Q3. Complaints policy has been amended to ensure divisional leads have direct oversight of any delays in investigators completing responses.

•The appointment of a least restrictive practice lead will have a further positive impact on reducing the number of physical restraints within services.

Workforce

•Use of temporary staff has fallen from 10.5% in November to 10.2% in December, just above our target of 10%.

•Sickness rate has fallen from 4.4% in November to 4.1% in December and is now back within the range of normal expectations.

•The twelve-month turnover rate has fallen to 13.7% from 14.1% in November and 14.4% in October, remaining below our 16% target.

•Vacancy rate has fallen by 1.3% to 7.1%. Core skills compliance is now at 90.3% against a target of 80%.

•Overall workforce successes include continued progress on Core Skills compliance (88.5% against an 80% target).

Finance

•The Trust submitted a plan to NHS Improvement (NHSI) based on a full year control total of £2,718k deficit. If the Trust achieves this control total, it will be awarded an additional income (Provider Sustainability Fund, PSF, and Financial Recovery Fund, FRF) of £2,718k to enable an overall breakeven position.

•The Trust has a CIP requirement of £5,600k, for 2019/20, which initially included an unidentified element of £582k. This has reduced to £295k, at month 9, after subsequent identification of £287k.

•At month 9, the Trust is reporting an underlying year to date deficit of £1,898k. This position is £161k ahead of the planned normalised deficit of £2,059k. The Use of Resources rating has now stands at a „2‟.

4

Oversight Framework

*Local Authority Target

The above table shows Oversight Framework (OF) indicators in the Care Quality Commission (CQC) domains. The Trust is achieving all

national OF targets except for the Data Quality Maturity Index (DQMI), Employment and settled accommodation status. The DQMI

methodology has changed recently to incorporate additional data items – the Trust is addressing this change through its Data Quality

Improvement Group with an aim to achieve compliance in-year. The table is continued overleaf.

Domain Measure Target 18/19

M4 M5 M6 Q2 M7 M8 M9 Q3

(19/20) (19/20) (19/20) (19/20) (19/20) (19/20) (19/20) (19/20)

Caring

Mental health scores from Friends and Family Test – % positive NA 89% 85.5% 81.5% 93.1% 86.7% 96.2% 93.3% 97.2% 95.6%

Staff Friends and Family Test % recommended – care NA 63.1% N/A N/A N/A N/A N/A N/A N/A N/A

% Responded to within agreed timeframe (closed in month) -

Complaints 80% 63% 73% 71% 82% 75% 64% 57% 42% 54%

Effective

% clients in employment 6%* 5.7% 6.6% 6.5% 6.4% 6.4% 6.4% 6.5% 5.5% 6.1%

% clients in settled accommodation 90%* 69.9% 69.1% 68.5% 62.5% 62.9% 62.5% 70.2% 70.5% 67.7%

Care programme approach (CPA) follow-up – proportion of

discharges from hospital followed up within seven days 95% 96.9% 97.4% 100% 100% 98.5% 94.2% 95.6% 100% 97.0%

Data Quality Maturity Index (DQMI) – MHSDS dataset score 95% 95.5% 87.2% 88.8% 92.1% 89.4% 94.5% Not

Published Not

Published Not

Published

Responsive

Improving Access to Psychological Therapies / talking therapies

50% 51.2% 54.4% 49.5% 50.6% 51.7% 52.3% 51.9% 52.2% 52.2% a. proportion of people completing treatment who move to

recovery

Improving Access to Psychological Therapies / talking therapies 75% 87.9% 78.7% 78.8% 77.5% 78.4% 76.5% 82.8% 79.0% 79.3%

b. i. waiting time to begin treatment within 6 weeks

Improving Access to Psychological Therapies / talking therapies 95% 98.6% 99.3% 98.7% 98.2% 98.8% 98.4% 98.6% 97.4% 98.2%

b. ii. waiting time to begin treatment within 18 weeks

Inappropriate out-of-area placements for adult mental health

services N/A 2095 172 254 271 697 204 108 28 340

People with a first episode of psychosis begin treatment with a

NICE recommended care package within two weeks of referral 56% 75.2% 86.7% 86.7% 94.1% 89.4% 93.8% 88.9%

Not Published

Not Published

5

Oversight Framework

Domain Measure Target 18/19

M4

(19/20)

M5

(19/20)

M6

(19/20)

Q2

(19/20)

M7

(19/20)

M8

(19/20)

M9

(19/20)

Q3

(19/20)

Safe

Occurrence of any Never Event 0 0 0.0% 0.0% 0.0% 0.0% 0.0% 0.0% 0.0% 0.0%

Patient Safety Alerts not completed by deadline 0 0.0% 0.0% 0.0% 0.0% 0.0% 0.0% 0.0% 0.0% 0.0%

CQC community mental health survey (overall

experience)

2018-

69% 2019 - 70%

NHS Staff Survey (Staff recommending

organisation as a place to work or receive

treatment)**

Not

Published

Not

Published

Proportion of temporary staff 2.06% 2.4% 2.4% 2.6% 2.5% 2.5% 2.4% 2.4% 2.3% 2.4%

Staff sickness 3% 3.4% 2.8% 3.2% 3.4% 3.4% 4.0% 4.4% 4.1% 4.1%

Staff turnover 16% 15.5% 15.5% 15.1% 14.4% 15.0% 14.4% 14.1% 13.7% 14.1%

Well-led

Finance Metrics (Use of Resources) Lower to Higher Threshold

Capital Service Capacity 2.5 to

1.75 1.9 1.9 1.9 1.9 1.9 2.0 2.0 2.0

Liquidity (days) 0 to n/a 107 109 104 104 104 102 107 104

Income & Expenditure (I&E) margin -1% to 0 -0.6% -0.5% -0.6% 0.4% -0.4% -0.2% -0.1% -0.2%

Distance from Financial Plan 0 to n/a -0.2% 0.2% 0.2% 0.1% 0.1% 0.1% 0.1% 0.1%

Agency Spend 25% to 0 22.0% 24.5% 20.4% 20.4% 16.3% 14.6% 13.1% 14.7%

**Expected to be published in February 2020

ORGANISATIONAL THEMES

- Operational Performance

- Quality & Safety

- Workforce

- Finance & Use of Resources

6

Recovery rates across all 3 IAPT services have been above the target of 50% for the last 3 months. In Camden, the work with voluntary sector

partner organizations has been successful and has had the expected impact on recovery rates. 18-week wait targets have been met by all 3

services. The 6-week wait to enter treatment target has been met by Kingston and Camden – but there have been continuing difficulties in Islington.

This relates to ongoing problems with administrative support following a large increase in referrals over the last year and staffing problems (sickness

/retention). The service has increased the administrative resource and has been implementing an action plan to catch up with the backlog. Even

when the immediate pressures are resolved, there will continue to be an impact on the reported waiting times for some months because the data is

reported in the month the patient is discharged (so people who are unable to access treatment now will have their data reported when the leave the

service which could be in several months‟ time).We suspect this may also have an impact on 18-week waits at some point over the next few months.

Operational Performance: IAPT

7

Performance

Indicator Target Area Source Jan-19 Feb-19 Mar-19 Apr-19 May-19 Jun-19 Jul-19 Aug-19 Sep-19 Oct-19 Nov-19 Dec-19

Waiting time to begin

treatment within 6

weeks of referral

75%

Camden Local 86% 80% 73% 74% 76% 77% 81% 80% 82% 80% 86% 78%

NHSD 84% 80% 72% 72% 76% 75% 80% 80% 83% 80%

Islington Local 90% 82% 78% 77% 77% 75% 67% 69% 65% 66% 69% 68%

NHSD 90% 82% 78% 77% 77% 74% 66% 67% 66% 66%

Kingston Local 97% 94% 97% 96% 92% 95% 92% 89% 89% 91% 95% 93%

NHSD 97% 94% 97% 96% 92% 95% 92% 89% 90% 91%

Waiting time to begin

treatment within 18

weeks of referral

95%

Camden Local 98% 99% 99% 98% 98% 99% 100% 98% 98% 98% 99% 96%

NHSD 97% 97% 97% 96% 97% 98% 99% 97% 97% 98%

Islington Local 100% 99% 98% 99% 100% 100% 99% 99% 99% 99% 98% 97%

NHSD 100% 99% 98% 99% 100% 100% 98% 98% 99% 99%

Kingston Local 99% 97% 99% 100% 99% 99% 99% 100% 98% 98% 99% 99%

NHSD 99% 97% 99% 100% 99% 99% 99% 100% 98% 98%

Proportion of people

completing treatment

who move to

recovery

50%

Camden Local 46% 50% 51% 50% 47% 48% 52% 48% 50% 51% 51% 50%

NHSD 45% 49% 49% 48% 45% 47% 52% 48% 50% 51%

Islington Local 50% 44% 59% 53% 54% 55% 56% 49% 47% 50% 51% 51%

NHSD 49% 43% 57% 54% 54% 54% 55% 48% 46% 50%

Kingston Local 61% 56% 55% 58% 51% 64% 57% 52% 57% 60% 54% 56%

NHSD 60% 56% 55% 55% 50% 64% 57% 51% 57% 58%

Operational Performance: Community Mental Health Division Referrals

8

The Camden Primary Care Mental Health service and the Islington Practice Based Mental Health services both noted a drop in referrals in

November and December- The services attribute this to:

•An increased in advice and consultancy consultations in both boroughs but particularly in Islington . The effect of advice is that potential referrals are

„headed off‟ rather than progressing.

•The effect of festive season bank holidays and referrer annual leave.

Camden PCMH has been working on a project to use EMIS as the primary EPR system; this is integral to the model of care as this is the system GP

partners use. Islington is working on a similar EMIS project with a focus on extracting useful reports from the system.

Mean

Lower process limit

Upper process limit

0

200

400

600

800

1,000

1,200

1,400

AAT/Camden PCMH Referrals

Mean

Lower process limit

Upper process limit

0

100

200

300

400

500

600

700

800

Islington PBMH Referrals

Operational Performance: Community Mental Health Division Caseloads

9

Despite on-going focused work to manage the CDAT services caseload (the impact of which was attributed to activities like assertive discharge

meetings, consultant caseload reviews, data cleanses, etc.,) the total figure has increased in months 8 and 9. The CDAT „deep dive‟ heard that:

• Balancing capacity and demand has always been a challenge for CDAT

• The medical pathway has seen a particularly notable increase in cases (Case manager caseload numbers are reasonably constant but with

increased acuity).

• The issues identified were having an impact on staff morale is an issue, as indicated by the staff survey.

• The service continues to review the way CDAT data is structured and recorded to improve analysis in the future.

• An appropriate solution would need to include resourcing

• There are opportunities out of the emerging Clinical Strategy and forthcoming financial investment that will help the issues identified.

Resources Committee asked to be kept informed of progress

The Personality Disorder service caseload has stabilised but remains under review with a plan to replicate some of the CDAT deep dive measures to

better understand the case mix and ensure service access thresholds are not increasing.

Mean

Lower process limit

Upper process limit

700

750

800

850

900

950

1,000

1,050

1,100

CDAT-End of month caseload (Snapshot)

Mean

Lower process limit

Upper process limit

280

300

320

340

360

380

400

PD Community Team - End of month caseload (Snapshot)

Operational Performance: Referrals for Recovery and Rehabilitation Teams - Camden

10

Referrals to the R&R Teams in Camden have remained consistent throughout this period with spikes in activity seen in July and a decrease in

referrals in spring and approaching Christmas. This pattern mirrors that of referrals for admission to hospital.

Mean, 20

UCL

LCL

0

5

10

15

20

25

30

35

40

45

Camden R and R Community Teams - Referrals

Operational Performance: Discharges for Recovery and Rehabilitation Teams - Camden

11

Discharges from the Camden R&R Teams appear to be linked to an increasing emphasis on supporting move on from the teams combined with a

change in Consultant medical staff which occurred in November 2018. From November 2018 to April 2019, the impact of the 2 new Consultants is

evident in the increasing discharges as they reviewed and discharged patients particularly from Outpatients. This increase in discharges has now

stabilised but remains higher than in 2018. This improvement is being supported by a QI project aimed at improving discharges from the South

Camden Recovery Team.

Mean, 28

UCL

LCL

0

10

20

30

40

50

60

Camden R and R Community Teams - Discharges

Operational Performance: Referrals for Recovery and Rehabilitation Teams - Islington

12

In Islington referrals appear to have decreased in December. This may be partly seasonal and mirrors a similar dip in December 28. Teams are

working to ensure referrals from EIS are prioritised, to support flow through EIS, where patients have been with EIS for over 3 years (The EIS

Service is intended to be time limited to 3 years).

Mean, 17

UCL

LCL

0

5

10

15

20

25

30

35

40Islington R&R Community Teams - Referrals

Operational Performance: Discharges for Recovery and Rehabilitation Teams - Islington

13

Islington discharges have declined in December which may be related to reduced activity over Christmas. The teams are continuing to transfer

service users to primary care and the Cornwallis Team in Islington have taken on a project to identify service users who are ready for step down from

the Mental Health Supported Housing Pathway.

Mean, 19

UCL

LCL

0

5

10

15

20

25

30

35

40 Islington R&R Community Teams - Discharges

Camden and Islington have maintained their position as

having among the highest dementia diagnosis

prevalence rates in London. The rates of diagnosis

within 6 weeks of referral have been maintained in

Camden.

The memory service in Islington is currently under re-

organisation as it merged with the Dementia Navigator

Service. A QI project is in place in Islington to address

the timeline to diagnosis. Some of this data has been

affected by data entry issues which are being resolved.

The average waiting time to receive a diagnosis in

Islington is 7.3 weeks which is just outside the target.

Operational Performance: Services for Ageing & Perinatal Mental Health

14

Mean, 74%

Lower process limit

Upper process limit

0%

20%

40%

60%

80%

100%

120%

140%Camden Memory Service - % Diagnosed within 6wks of referral

Mean, 68%

Lower process limit

Upper process limit

0%

20%

40%

60%

80%

100%

120%

Islington Memory Service - % diagnosed within 6wks of Referral

Operational Performance: Services for Ageing & Perinatal Mental Health (SAMH) / Delayed Transfers of Care (DTOC)

15

Following the high number of older patients

admitted earlier in the year, admissions have

now return to the long term average. This

resulted in November in a further reduction in

the number of older people in hospital.

At the end of November the Trust had 6 delayed

patients - 3 in Camden and 3 in Islington. 5 of

these patients are waiting for a care home

placement the 6th for housing. 0

5

10

15

20

25

30

SAMH ACP BED USED

Beds used SAMH ACP if we had no Dtocs Log. (Beds used SAMH ACP)

Mean, 221

Lower process limit

Upper process limit

0

50

100

150

200

250

300

350

400

Trust number of DTOC occupied bed days (OBD)

Mean, 3.3%

Lower process limit

Upper process limit

Target, 2.5%

0%

1%

2%

3%

4%

5%

6%

7%

8% Trust porportion of DTOC occupied bed days (OBD)

Operational Performance: Referrals for Inpatient Beds and Inpatient Occupancy

Current Methodology and Definitions for Occupancy:

Data Source - Bed State Dashboard. Beds included assessment

beds, adult and older adult treatment beds (excludes PICU and R&R

beds). Occupancy excludes leave.

During Quarter 3 the number of referrals have been decreasing in

November and December, although November remained above the

mean. Occupancy in November is 94.5% and 95% in December.

SAMH occupancy has been 91% in November and 85% in December.

The Patient Flow Meeting has refreshed objectives including 90%

occupancy with a view to meeting NHSE expectations around zero

OOA placements by April 2020. The target line will shift from January

2020.

Mean, 96.4%

Lower process limit

Upper process limit

Target, 95%

88%

90%

92%

94%

96%

98%

100%

102%Bed Occupancy

Mean, 151

UCL

LCL

96

116

136

156

176

196

216 Referrals for Inpatient Beds

Operational Performance: Patients with a current Length of Stay 50 days and over

17

The number of over 50 day patients is 70, as at the 25th December, this

breaks down as 40 Acutely Unwell patients and 30 other barriers to

discharge. There has been a steady rise in the number since early

November 2019.

C&I has seen an increase of those patients referred to rehab for

assessment and those awaiting rehab, currently 17, with 8 patients

accepted and waiting for a rehab bed. The R&R division are working on

the rehab patient flow via Rehab Move on Groups.

C&I have also seen an increase in those patients with No Fixed Abode

(NFA) - Currently 13. Community clinicians will be identifying individual

patient‟s reasons for NFA status and together C&I will work with CCGs

and LAs to identify appropriate accommodation.

Mean, 68

UCL

LCL

50

55

60

65

70

75

80Total No. of 50+ Day Stayers

Mean, 45

UCL

LCL

30

35

40

45

50

55

6050+ Day Stayers (Acutely Unwell)

Mean, 24

UCL

LCL

10

15

20

25

30

35 50+ Day Stayers (Other)

Operational Performance: Out of Area Placements (OAPs)

18

Out of area occupied bed days numbers in November and December have reduced from 200 in October to 28 in December. The majority of OBDs

are for male PICU – 112 in October, 86 in November and 28 in December. December OAP figures are provisional.

Male PICU LOS will have a daily focus to ensure timely referral to High Dependency Rehab, forensic placement or other specialist placements.

Mean, 200

UCL

LCL

-10

90

190

290

390

490

590

690

790

890

990

Total OAP OBDs

Operational Performance: Inpatient Length of Stay

19

The Acute Divisional Director will be reviewing the effectiveness and

management of the Discharge Facilitation Team resources.

New Senior CRT Nursing resource is now established in in-reach to

wards to promote timely discharge and data is being reviewed.

There has been an identified bottleneck in the rehab pathway that is

being addressed by acute & R&R leads.

The SAMH length of stay (LOS) in December was impacted by one

patient who had been with us for an extended period sadly passing

away, thus impacting on overall figures.

Mean, 45.3

Lower process limit

Upper process limit

0

10

20

30

40

50

60

70

80

Ap

r-1

8

May

-18

Jun

-18

Jul-

18

Au

g-1

8

Sep

-18

Oct

-18

No

v-1

8

De

c-1

8

Jan

-19

Feb

-19

Mar

-19

Ap

r-1

9

May

-19

Jun

-19

Jul-

19

Au

g-1

9

Sep

-19

Oct

-19

No

v-1

9

De

c-1

9

Acute - ALOS excl leave based on discharges

Mean, 85.3

Lower process limit

Upper process limit

Internal Target, 65.00

-100

-50

0

50

100

150

200

250

SAMH - ALOS excl leave based on discharges

Mean, 573

Lower process limit

Upper process limit

Internal Target, 365

-1,000

-500

0

500

1,000

1,500

2,000

2,500

R&R - ALOS excl leave based on discharges

Operational Performance: Whittington MHLT A&E Referrals and 12 hour trolley breaches/ A&E and Medical Ward Waits

There were 7 formal 12-hour trolley breaches in November (2 C&I, 4 BEH, 1 SLAM), whereas in December there were 2 (2 C&I). In November. there

were no patients on medical wards who waited over 48 hours for admission. In December there were 4 - Of these 3 were as a result of high numbers

of referrals (>36) in the week of referral. The numbers waiting >12 hours from the point of referral to Bed Management is noted as slightly different

from 12-hr trolley breach numbers based on Decision to Admit. Key actions to improve performance include (1) direction to the Liaison Team to

improve their adherence to escalation processes to avoid 12-hr breaches and (2) increased pace within refreshed Patient Flow work streams to

reach and routinely maintain 90% occupancy. 20

1

5

9 7 7

5

1

2

1

4

3

2

2 0

2

4

6

8

10

12

Whittington 12 hr trolley breaches 2019/20

Other Trust C&I

0

5

10

15

20

25

30

35

Whittington ED waits for a C&I bed

Less than 4 hours Between 4 and 12 hours Over 12 hours

0

1

2

3

4

5

6

7

8

Whittington medical ward waits for a C&I bed

Less than 48 hours More than 48 hours

Mean, 223

Lower process limit

Upper process limit

100

150

200

250

300

350Whittington ED Referral Rate

Operational Performance: UCLH MHLT A&E Attendances and 12 hour trolley breaches / A&E and Medical Ward Waits

21

There were 7 formal 12-hour trolley breaches in November (3 C&I, 2 BEH, 1 Kent & Medway and 1 South Devon and Torbay). In December, there

was one (Bangor/Wales). There were 2 patients who waited more than 48 hours for admission in November; all were as a result of high number of

referrals (>36) in the week of referral. In December, there were 5 - these did not occur in high referral weeks. In December the level of discharges

was lower than required which resulted in a longer wait than normal for patients on medical beds. Key actions to improve performance include (1)

direction to the Liaison Teams to improve their adherence to escalation processes to avoid 12-hr breaches and (2) increased pace within refreshed

Patient Flow work streams to reach and routinely maintain 90% occupancy.

3 3 3 5 5 4

1

3 3

0

2

4

6

8

10

Apr-19 May-19 Jun-19 Jul-19 Aug-19 Sep-19 Oct-19 Nov-19 Dec-19

UCLH 12 hr trolley breaches 2019/20

Other Trust C&I

0

5

10

15

20

25

30

UCLH ED waits for a C&I bed


0123456789

UCLH medical ward waits for a C&I bed


Mean, 222 Lower process

limit

Upper process limit

100

150

200

250

300

350UCLH ED Referral Rate

Operational Performance: Royal Free MHLT A&E Referrals and 12 hour trolley breaches / A&E and Medical Ward Waits

22

There were 12 formal 12-hour trolley breaches in November (6 C&I, 2 BEH, 2 CNWL, 1 West Sussex and 1 Waltham Forest). In December there

were 8 (2 BEH, 3 CNWL, 1 SLAM, 1 C&I, 1 ELFT). There was 1 medical bed transfer delay in November as a result of high numbers of referrals

(>36) in the week of referral. Plan to connect with the Brent Director (CNWL) to review actions to avoid breaches. Key actions to improve

performance include (1) direction to the Liaison Team to improve their adherence to escalation processes to avoid 12-hr breaches and (2) increased

pace within refreshed Patient Flow work streams to reach and routinely maintain 90% occupancy.

Mean, 204

Upper process limit

100

150

200

250

300

350Royal Free ED Referral Rate

1

5

10

3 6 6 7

3

3

3 6

1

0

2

4

6

8

10

12

14


Royal Free 12 hr trolley breaches 2019/20

Other Trust C&I

0

5

10

15

20

25

30

35

Royal Free ED waits for a C&I bed


0

1

2

3

4

5

6

Royal Free medical ward waits for a C&I bed


Successful completions are one of the key Public Health England (PHE) indicators used to measure recovery. It is defined as the number of clients

successfully exiting treatment as a proportion of all clients in treatment. The indicator is reported as a rolling twelve month figure broken down into

four drug groups; Opiates, Non-Opiates, Alcohol and Non-Opiates and Alcohol.

Opiates

C&I are the lead provider for the whole treatment pathway with third sector sub-contracts in both Islington and Kingston. In these boroughs we are

exceeding our targets for opiate successful completions. Camden remains a challenge as C&I are only commissioned to deliver treatment to the

most complex cohort with the third sector delivering treatment to the non-complex cohort. As the Camden contract has run its course the caseload

has become more complex, particularly in the north of the borough where we have a large number on our caseload who are stable in their treatment,

but have multiple long-term physical and mental health conditions linked to longer “drug careers” in earlier life. Generally the work with these service

users is much more long-term but we are still working to a recovery focused model with this cohort.

Non-opiates

Camden is exceeding the target in this area. This is largely due to 3 factors – a more realistic target of 28%, the long established GRIP Clinic which

specifically targets non-opiate clients and the longer established BOWS service in Camden running now for 2½ years which was extended to

Islington one year ago. In Islington we have now created a new GRIP post which will target this group and in Kingston we have also created a post to

specifically work in this area. Both post-holders will shadow the specialist GRIP worker in Camden to bring the learning on working with this cohort

back to their respective boroughs. This will all run alongside a QI project across the Division looking at improving performance around this measure.

Operational Performance: SMS Successful Completions

23

Performance Indicator Target Borough Apr-19 May-19 Jun-19 Jul-19 Aug-19 Sep-19 Oct-19 Nov-19 Dec-19

Successful

Completions Opiate

8% Camden 4.0% 4.0% 5.0% 5.0% 5.4% 5.5% 5.2% 6.0% 6.2%

8% Camden Partnership 5.5% 5.3% 5.6% 5.6% 5.9% 6.2% 6.0% NDTMS Report

Unreleased

NDTMS Report

Unreleased

8% Islington 6.3% 7.7% 7.3% 7.5% 7.5% 8.1% 8.8% 9.3% 9.2%

8.5% Kingston 7.9% 10.0% 9.8% 10.0% 9.2% 8.0% 8.7% 8.2% 9.2%

Successful

Completions Non

Opiate

28% Camden 22.0% 24.7% 24.7% 23.0% 28.3% 35.3% 37.3% 39.4% 37.4%


Unreleased

NDTMS Report

Unreleased

55% Islington 23.0% 26.4% 24.7% 29.4% 33.3% 37.5% 39.0% 41.7% 37.9%

52% Kingston 32.0% 33.9% 33.9% 37.7% 34.9% 36.9% 34.9% 42.2% 36.4%

Successful Completion

Alcohol and Non

Opiate

28% Camden 25.7% 22.9% 26.5% 29.7% 27.0% 32.4% 30.6% 28.1% 28.6%


Unreleased

NDTMS Report

Unreleased

45% Islington 18.3% 20.9% 24.3% 25.8% 26.4% 26.7% 29.1% 30.5% 30.6%

44% Kingston 28.7% 26.6% 26.2% 26.3% 25.7% 28.4% 31.4% 37.6% 37.4%

Successful

Completions Alcohol

Only

38% Islington 29.3% 31.1% 33.8% 36.9% 37.1% 42.3% 44.2% 44.6% 42.8%

39% Kingston 39.7% 39.0% 43.8% 47.2% 47.6% 49.8% 46.9% 48.1% 47.8%

Alcohol and non-opiates

All three boroughs have comparable performance in this measure; however, again there is a substantial difference in the targets in Kingston and

Islington compared with Camden, where we are meeting the target. This target was renegotiated to a more realistic target during the life of the

Camden contract. We forecast an increase in performance through the additional specialist worker in Islington and Kingston as well the staff QI

initiative for non-opiate clients who also use alcohol. Additionally, there are on-going reviews to ensure the accuracy in the data coding used to

identify the drug groups. This could potentially increase numbers.

Alcohol

We are exceeding targets in both boroughs in this measure where we are the lead provider for alcohol services.

Operational Performance: SMS Successful Completions

24

Operational Performance: Percentage (%) of Clients in Settled Accommodation (Local Authority Target – 90%)

25

Work needs to be undertaken to ensure care co-ordinators are correctly recorded on care notes. In Islington there is a piece of work being

undertaken by the Community Rehab Team and Cornwallis to improve move on rates from the 24 hour Mental Health Pathway. This is expected to

benefit the wider mental health system given the demand in inpatient care for service users who need supported accommodation.

During 2019 in Camden we redesigned the services within the Accommodation Pathway to make a clearer and more accessible pathway to support

people in their accommodation and to support recovery. The newly designed pathway was established in September 2019 and we anticipate a

continued improvement in those in settled accommodation.

69

.6%

68

.7%

69

.9%

66

.2%

68

.3%

70

.0%

69

.1%

68

.5%

62

.5%

62

.5%

70

.2%

70

.5%

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

Q3(2018/19)

Q4(2018/19)

2018/19 Apr-19 May-19 Jun-19 Jul-19 Aug-19 Sep-19 Oct-19 Nov-19 Dec-19

Target

% in Settled Accommodation

Operational Performance: Percentage (%) of Clients in Employment (Local Authority Target – 6%)

26

We have just started the 4 IPS workers in Islington all of whom will be based in CIFT teams and will have access to Care Notes. This should

improve employment outcomes and also recording of employment. There is a need to improve how staff record these and we may need to

consider some communication so staff are clear how and when to record employment and accommodation device. Initial reports are that there

have been a high number of referrals to the IPS workers.

During 2019 in Camden we redesigned the services within the Accommodation Pathway to make a clearer and more accessible pathway to

support people in their accommodation and to support recovery. The newly designed pathway was established in September 2019 and we

anticipate a continued improvement in those in settled accommodation.

5.9

%

6.0

%

5.7

%

5.9

%

6.2

%

6.4

%

6.6

%

6.5

%

6.4

%

6.4

%

6.5

%

5.5

%

0%

1%

2%

3%

4%

5%

6%

7%

Q3(2018/19)

Q4(2018/19)

2018/19 Apr-19 May-19 Jun-19 Jul-19 Aug-19 Sep-19 Oct-19 Nov-19 Dec-19

% in Employment

Target

Operational Performance: Data Quality Maturity Index – MHSDS Dataset Score (Target 95%)

27

Trust DQMI performance continues to improve from 85.3% in April to 94.5% in October (latest published figure). Several fixes have been made

over the past few months and this figure is expected to improve above target. The number of DQ issues pertaining to MHSDS submission has

decreased from more than 10,000 to around 2,000 in the last 3 months.

Informatics team is working closely with Trust‟s data warehouse team and performance team to reduce the number of remaining data quality and

validation errors. Several data quality reports are being developed to improve the recording of information within CareNotes.

89

.6%

90

.3%

88

.5%

85

.3%

85

.6%

86

.3%

87

.2%

88

.8%

92

.1%

94

.5%

70%

75%

80%

85%

90%

95%

100%

Jan-19 Feb-19 Mar-19 Apr-19 May-19 Jun-19 Jul-19 Aug-19 Sep-19 Oct-19

Target

DQMI - MHSDS score

Quality & Safety: Incidents by Harm

28

• The data above shows that the Trust is maintaining a steady rate of

incident reporting while simultaneously demonstrating a decrease

in the numbers of incidents resulting in harm.

• The first chart above indicates that the Trust‟s incident reporting

rate remains steadily within process limits.

• By contrast, the second chart demonstrates that the number of

incidents resulting in harm shows a statistically significant reduction

over the past 17 months.

• 14% of incidents occurring in December resulted in harm. The

proportion of incidents resulting in harm has decreased from 22%

during 2017-18 to 17% during 2018-19, and the downward trend

continues in 2019-20 at 13% (YTD).

• There was one incident resulting in severe harm in December. It

relates to the death of a service user from the Acute Community

division and has been confirmed as a Level 1 SI investigation.

Mean, 464

Lower process limit

Upper process limit

0

100

200

300

400

500

600

700

Apr-17 May-17 Jun-17 Jul-17 Aug-17 Sep-17 Oct-17 Nov-17 Dec-17 Jan-18 Feb-18 Mar-18 Apr-18 May-18 Jun-18 Jul-18 Aug-18 Sep-18 Oct-18 Nov-18 Dec-18 Jan-19 Feb-19 Mar-19 Apr-19 May-19 Jun-19 Jul-19 Aug-19 Sep-19 Oct-19 Nov-19 Dec-19

Incident Reporting Rate

Mean, 83

Lower process limit

Upper process limit

0

50

100

150

200


Incidents all categories resulting in harm (sum of low, moderate and severe harm/death)

0

5

10

15

20

25

30

35

Violence &Agg.

Ill Health Falls Health &Safety

Estates &Facilities

Self Harm Occ.Health

Death InfectionControl

Incidents with harm by category (Dec 19)

Low Harm Moderate Harm Severe Harm or Death

Quality & Safety: Falls

29

• As part of the monthly falls audit in December 93% of those

audited had a FALLSTOP Falls Screen completed.

• All those identified as at risk of falls (17 people) had a full

FALLSTOP Falls Assessment completed, giving an assessment

completion rate of 100%.

• 82% of people had their assessment completed within 24 hrs of

admission (target 90%). 3 assessments were not completed

within 24 hours of admission however, all relate to people in

residential settings (not wards) who had been resident for at

least 2 years so the data does not relate to recent practice.

• Falls assessment completion continues to be monitored by the

Falls Lead and advice and training provided to wards. All

reported falls are also tracked to monitor how soon after

admission they occur and to ensure that the April 2019 change

in assessment timescales does not adversely affect patient

safety.

• Pearl ward (older adults) is undertaking a QI project looking at

how to improve falls prevention on the ward.

0

2

4

6

8

10

12

14

16

18

20

Number of falls incidents by harm

(Trust 24 Hour Bedded Units & Day Centres)

No Harm Low Harm Moderate Harm Severe Harm or Death

Mean, 69%

Lower process limit

Upper process limit

Target, 90%

0%

20%

40%

60%

80%

100%

120%

140%% Falls assessments completed within deadline

Deadline for completing falls assessments changed from 'within 4 hours of admission' to 'within 24 hours of admission'

Quality & Safety: Medication Incidents

30

• The number of medication incidents

reported shows a statically significant

increase since April 2019.

• This increase in reporting coincides with

the appointment of the Lead Pharmacist

who is also the Medicines Safety Officer,

and who has been working to identify

gasps in incident reporting and to

encourage an open culture with regard to

reporting medication errors. To date the

reporting of Dispensing errors has

already improved and work continues to

encourage reporting of Prescribing and

Administration errors.

• The Lead Pharmacist continues to run

monthly feedback sessions to teams on

medication incidents with opportunities to

discuss examples of incidents and share

learning lessons.

• The levels of harm from medication

incidents are very low overall and none of

the medication incidents reported in

December resulted in harm.

Mean, 5%

Lower process limit

Upper process limit

0%

1%

2%

3%

4%

5%

6%

7%

8%

9%% Medication Incidents

0

10

20

30

40

Medication incidents by harm level

No Harm Low Harm Moderate Harm Severe Harm or Death

0

5

10

15

Medication Incidents by type

Prescribing Dispensing Administration

Quality & Safety: Violence & Aggression

31

• Incidents of Violence & Aggression continue to make up approximately 30% of the total number of incidents reported in the Trust each month. The

data above shows that the rate of reporting for this type of incident remains consistent while simultaneously demonstrating a decrease in the

numbers of incidents resulting in harm.

• The first chart above indicates that the rate of reporting for incidents of Violence & Aggression remains steadily within process limits.

• By contrast, the second chart demonstrates that the numbers of this type of incident resulting in harm shows a statistically significant reduction

over the past 17 months. There is a wide programme of work ongoing in the Trust to reduce V&A which is contributing to this reduction in harm

associated with this type of incident.

• Reducing Violence against staff is a Trust top priority. The numbers of violent incidents reported against staff remains steadily within process

limits however as described above for all incidents of V&A, the pattern of reduction in harm over the past year is also reflected in the sub set of

incidents directly affecting staff.

Mean, 139

Lower process limit

Upper process limit

0

50

100

150

200

250


All Incidents of Violence & Agression

Ruby Ward opened (women's PICU)

Mean, 36

Lower process limit

Upper process limit

0

20

40

60

80


All Incidents of Violence & Agression resulting in harm


Mean, 77

Lower process limit

Upper process limit

0

50

100

150


All Incidents of Violence & Aggression against staff


• The total number of

service users

absent while under

section (AWOL)

showed a

statistically

significant decrease

between Feb 19

and Aug 19.

• Levels of harm

resulting from

AWOL incidents is

consistently low

Quality & Safety: AWOL / Self Harm

32

0

5

10

15

20

25

30

35

40

AWOLs (Absence without leave) incidents

Absent following authorised leave Absent following escorted leave Absent whilst under section

0

5

10

15

20

25

30

35

40

Self Harm incidents (All harms)

Inpatient Ward Community

Self-harming incidents

reported remains

steadily within process

limits.

• There were 42 restraints in total

during December compared to 58 in

October and 52 in November. Twenty

Five service users in total were

restrained.

• Seven service users were restrained

on more than one occasion. One

service user was restrained 7 times,

another 5 times and a third was

restrained 4 times in the month.

• The wards with the most restraints

were Coral with 10 restraints and

Sapphire with 8.

• The use of seclusion continues to be

reviewed and monitored by the

Positive & Practice Care Group.

Quality & Safety: Restraints / Use of Seclusion

33

0

10

20

30

40

50

60

70

Restraints, prone restraints & planned prone restraints

Restraints Prone Restraints Planned Prone Restraints

0%

2%

4%

6%

8%

10%

12%

14%

16%

18%

20%

Proportion of prone restraints (excluding seclusion) (cumulative 12 month period)

Target <16%

Mean, 95

Mean, 83

Mean, 62 Lower process limit

Upper process limit

20

40

60

80

100

120

140

Sep

-16

Oct

-16

No

v-16

Dec

-16

Jan

-17

Feb

-17

Mar

-17

Ap

r-1

7

May

-17

Jun

-17

Jul-

17

Au

g-17

Sep

-17

Oct

-17

No

v-17

Dec

-17

Jan

-18

Feb

-18

Mar

-18

Ap

r-1

8

May

-18

Jun

-18

Jul-

18

Au

g-18

Sep

-18

Oct

-18

No

v-18

Dec

-18

Jan

-19

Feb

-19

Mar

-19

Ap

r-1

9

May

-19

Jun

-19

Jul-

19

Au

g-19

Sep

-19

Oct

-19

No

v-19

Dec

-19

Number of times Seclusion was used (each data point represents a 12 mth rolling total)

New Ward Manager

Safe Wards

Quality & Safety: Unexpected Deaths / Serious Incident Investigations / Prevention of Future Deaths

34

• There were 17 unexpected deaths in December, 2 are

confirmed unexpected unnatural, 1 confirmed as natural

causes and 14 are still being assessed by the Mortality Review

Group (MRG) before they can be coded.

• MRG carry out case reviews on all deaths weekly. All deaths

are graded using MAZARs categories. At the time of reporting

it is not always possible to define a death as unexpected,

natural or unnatural until more information is available, often

from inquests.

• A detailed Learning from Deaths report is completed quarterly

where longer term trends are reviewed.

• In December there was 1 new serious incident investigations

relating to the death of a service user from the Acute

Community Division. A cross divisional quarterly workshop is

to be established in the next few weeks to enable divisional

leaders and the clinical executive to discuss and share

learning from deaths. The outcome of the workshop will be

reported quarterly with the first outcome report to be included

in the Q4 learning from deaths report due in April 2020.

• There were no in-patient deaths in December 2019.

Unexpected Death Jan-19 Feb-19 Mar-19 Apr-19 May-19 Jun-19 Jul-19 Aug-19 Sep-19 Oct-19 Nov-19 Dec-19

Total Unexpected Deaths 21 7 7 4 11 8 6 7 9 8 13 17

(unexpected unnatural deaths (UU)) 7 2 4 0 5 2 3 2 4 3 1 2

(unexpected natural deaths (UN)) 10 2 2 0 2 0 1 0 1 2 3 1

(unexpected but not yet coded) 4 3 1 4 4 6 2 5 4 3 9 14

72 Hour Report 14 6 6 3 6 5 5 5 7 6 6 4

Investigated as an SI 7 2 2 0 2 3 1 1 3 1 1 1

Learning Disability patients 0 0 0 0 0 0 0 0 0 1 0 0

Inpatient Death Jan-19 Feb-19 Mar-19 Apr-19 May-19 Jun-19 Jul-19 Aug-19 Sep-19 Oct-19 Nov-19 Dec-19

Coral Ward 0 1 0 0 0 0 0 0 0 0 0 0

Dunkley Ward 1 0 0 0 0 0 0 0 0 0 0 0

Garnet Ward 0 1 0 0 0 0 0 0 0 0 0 0

Laffan Ward 0 1 0 0 0 0 0 0 0 1 0 0

Opal Ward 0 0 0 0 0 0 0 0 0 0 1 0

Ruby Ward 1 0 0 0 0 0 0 0 0 0 0 0

Sapphire Ward 0 0 0 0 0 0 0 0 1 0 0 0

Topaz Ward 1 0 0 0 0 0 0 0 0 0 0 0

Coroner Prevention of Future Deaths Jan-19 Feb-19 Mar-19 Apr-19 May-19 Jun-19 Jul-19 Aug-19 Sep-19 Oct-19 Nov-19 Dec-19

Number of new inquests 11 11 6 5 5 6 7 14 8 7 11 4

Number of PFDs 0 0 0 0 0 1 0 0 0 0 1 0

Mean, 8.36

Lower process limit

Upper process limit

-5

0

5

10

15

20

25

Total Unexpected Deaths

35

• There were three Estates and Facilities alerts closed overdue in December. One of these alerts was not applicable to the Trust but there was a

delay in the Professional Lead feeding back this information in order to close the alert. The actions relating to the other two alerts were not

carried out in time to meet their deadlines. The delays were associated with the generic performance issues experienced with ISS since

January 19 and which are being addressed with oversight by Trust Board and Resources Committee.

• There were no patients waiting over 12 hours in police custody for a bed and the Trust‟s new 136 Place of Safety service successfully opened

on the 20th January 2020. Activity is reviewed and monitored at the Acute Quality Forum and in conjunction with the bed management team

aim to reduce waits where possible.

Quality & Safety: Infection Control / Central Alerting System (CAS) alerts / Police Access to Beds

Infection Control Jan-19 Feb-19 Mar-19 Apr-19 May-19 Jun-19 Jul-19 Aug-19 Sep-19 Oct-19 Nov-19 Dec-19

Methicillin-resistant Staphylococcus

aureus (MRSA) 0 0 0 0 0 0 0 0 0 0 0 0

Clostridium Difficle (C.Diff) 0 0 0 0 0 0 0 0 0 0 0 0

Central Alerting System (CAS Alerts)

(alerts closed in month) Jan-19 Feb-19 Mar-19 Apr-19 May-19 Jun-19 Jul-19 Aug-19 Sep-19 Oct-19 Nov-19 Dec-19

Central alerting system (CAS) alerts

numbers non-compliant within

specified date (partial compliance is

non-compliance)

2 1 0 1 0 1 0 1 0 1 3 0

MHRA alerts numbers non-compliant

within specified date (partial

compliance is non-compliance)

2 1 0 0 0 0 0 0 0 0 0 0

Police Access to beds control Jan-19 Feb-19 Mar-19 Apr-19 May-19 Jun-19 Jul-19 Aug-19 Sep-19 Oct-19 Nov-19 Dec-19

Numbers of patients in police custody

requiring a bed with waits over 12

hours (receiving organisation)

(Camden & Islington Patients only)

0 1 3 4 1 2 1 1 3 1 2 0

Quality & Safety: Complaints / Care Indicators

• It is concerning to note that in December the number of complaints completed in time fell for the third month running. A review of the

complaints which were late showed delays at various stages of the process. In order to address this, in early January the complaints team met

with divisional leads to discuss the challenges and agree a way forward. As a result of this, regular meetings have been set up with

responsible managers to ensure focus and prompt action in regard to any issues arising. There will also be a change made to the complaints

policy to ensure that divisional leads have direct oversight of any delays in investigators completing responses. This change will be actioned

with immediate effect with the revision of the policy to be completed by the end of February 2020. It is recommended that complaints

performance data is reported monthly to the Quality and Safety programme Board to provide oversight for improvement.

• It is noted that between November and December the number of complaints open for more than 90 days fell from 7 to 2.

• To sustain and support improvement the open complaints tracker continues to be circulated weekly and contains additional information to

assist in monitoring milestones within the process. Focused support is also being provided by the complaints team to investigators particularly

for those who are new to the process.

36

Care Indicators Jan-19 Feb-19 Mar-19 Apr-19 May-19 Jun-19 Jul-19 Aug-19 Sep-19 Oct-19 Nov-19 Dec-19

Mixed sex accommodation breach

numbers 0 0 0 0 0 0 0 0 0 0 0 0

Numbers of Patient Transfers after

10pm and before 7am 0 0 0 0 0 0 0 0 0 0 0 0

Trust Aquired grade 3 or 4 Pressure

Ulcers (Older people) 0 0 0 0 0 0 0 0 0 0 0 0

Complaints Indicators Jan-19 Feb-19 Mar-19 Apr-19 May-19 Jun-19 Jul-19 Aug-19 Sep-19 Oct-19 Nov-19 Dec-19

New formal complaints received 13 9 7 16 10 8 16 8 7 12 16 11

Acknowledged in 3 working days 8 9 7 12 9 7 14 7 6 7 14 9

% Responded to within agreed

timeframe (closed in month) 20%

(5)

75%

(16)

50%

(16)

40%

(5)

57%

(7)

93%

(15)

73%

(11)

71%

(7)

82%

(11)

64%

(11)

57%

(7)

42%

(12)

Complaints open more than 90 days 5 4 2 0 0 2 4 4 5 5 7 2

Serious Incident Investigations Jan-19 Feb-19 Mar-19 Apr-19 May-19 Jun-19 Jul-19 Aug-19 Sep-19 Oct-19 Nov-19 Dec-19

Level 1 9 2 3 0 4 4 3 2 3 4 3 1

Level 2 0 1 0 0 0 0 0 0 1 0 0 0

Quality & Safety: Friends & Family Test and patient feedback

37

Following a drop in response rate in

June 2019 which was attributed to

technical issues with WiFi, the response

rate subsequently recovered in July and

was maintained until Dec 2019 when it

went below the 20% target.

The percentage patients recommending

their service remains above the 80%

target.

0%

20%

40%

60%

80%

100%

120%

Family and Friends Test (FFT) - Trust wide

% Recommend Response Rate % Recommend Target Response Rate Target

194 234

283

298

310

280

284

229

169

243

155

265

245

358

472

279

178

312 340

219

160

166

150

206

198

202

141

318

271

291

210

199

106

0

200

400

600

FFT Responses by month

Quality & Safety: Safe Staffing

38

Analysis5 wards at the Highgate Mental Health Centre. The purpose of this meeting is to review patient safety, level of enhanced

• Total fill at 106.6% remains above average for a 9th consecutive month and remains an area of focus. This represents continued levels of

increased clinical acuity across some wards resulting in additional duties being created to provide cover, mainly at night. This is reflected in the

table above where wards are staffing above 100% to meet safety standards and clinical need.

• The daily RN fill rates continue to improve significantly which is due to increased successful recruitment across divisions. Coral, Sapphire, Ruby

and Opal wards continue to demonstrate sustained improvement. December tends to present additional staffing challenges therefore it is

assuring to see increased fill rate trend for both day and night cover.

• On occasions where wards fall below 2 RN, local management plans have been invoked which would have included moving staff from other

wards, support from matrons, using professional judgement and reviewing the skill mix on the ward to ensure that safe care continues to be

delivered to service users.

Actual vs. Planned Hours shows the percentage of Nursing & Care staff who

worked (including Bank) as a percentage of all planned care hours in month.

The National Quality Board recommendations are the parameters should be

between 90% - 110%.

Name Total Fill % Day Reg Fill Rate Day Unreg Fill Rate Night Reg Fill Rate Night Unreg Fill Rate

Amber Ward 98% 93% 98% 99% 104%

Coral Ward 116% 93% 137% 97% 131%

Dunkley Ward 103% 100% 104% 100% 113%

Emerald Ward 109% 94% 116% 103% 135%

Garnet Ward 105% 99% 102% 100% 118%

Jade Ward 111% 98% 107% 100% 167%

Laffan Ward 102% 105% 100% 100% 104%

Malachite Ward 96% 98% 89% 100% 100%

Montague Ward 109% 97% 155% 100% 100%

Opal Ward 101% 98% 105% 95% 106%

Pearl Ward 105% 95% 111% 98% 129%

Rosewood Ward 111% 91% 118% 98% 158%

Ruby Ward 114% 108% 113% 103% 137%

Sapphire Ward 103% 109% 96% 95% 113%

Topaz Ward 111% 83% 126% 97% 160%

Dec 2019 - Actual vs Planned Hours

Quality & Safety – Complaints Responded to within agreed timeframe (closed in month) - (Target – 80%)

39

40

% 57

%

93

%

73

%

71

%

82

%

64

%

57

%

42

%

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%


Complaints - % Responded to within agreed timeframe

Target

Engagement visits with CMH and R&R have started (Complaints manager and Divisional Directors) to agree a plan to reduce overdue

complaint responses. Regular meeting with the divisions and complaints manager taking forward are to be arranged. Some of the

complaints are very complex and require negotiated timeframes which could be used in these circumstances more.

Quality and Safety Report being submitted to Q&S Programme Board - commenced 22/01/2020 for quality monitoring and oversight.

The new quality dashboard will include complaints metrics to enable greater oversight and monitoring of performance improvements.

Workforce: Staffing and Vacancies

40

Analysis

• In December our substantive staff in post stood at 1583 WTEs. This is an increase of 11 WTEs from November.

• Bank staffing stood at 163 WTEs (level this month) and agency at 17 WTEs (5 down on November).

• Our current vacancy rate (Establishment vs. Substantive staff) as at December 2019 is 8% (138 WTEs). It is below our 10% target. The increase

in net vacant posts this month is solely due to increases in establishments, for example +15 WTEs for the Suite 136 (Health Based Place of

Safety) development and +15.5 WTEs in Research & Development. As mentioned above our staff in post figure actually rose.

Key Issues

• Nursing recruitment remains a challenge and recruitment initiatives are in place to attract and retain staff. Focused attention is on Acute wards,

e.g. Coral where need for recruitment of band 5 nurses is critical. 11 staff have moved from Acute wards to the new Health Based Place of Safety

Suite.

• There are a number of hotspot areas for vacancy which include Coral, Aberdeen Park & Highview, Hanley Gardens, and ICT.

• Crisis Teams have been experiencing ongoing challenges of recruiting band 6 nurses. To support addressing this, workshops have been held to

explore an alternative skills mix which could include Pharmacy Technicians who are able to prescribe.

• The recruitment freeze at Hanley Gardens, Aberdeen Park & Parkview has been lifted and vacant posts are now in the recruitment pipeline. A

review is currently on-going in ICT to establish a structure fit for purpose prior to recruitment.

• Recruiting into the two Pharmacy Technician posts has been challenging. In addition to on-going local recruitment, we will now be exploring the

option of skills mixed review, taking into account the rotational programme commencing in Feb with 3 students. A clear career pathway is also

being developed to improve retention of staff.

Workforce: Turnover

41

Analysis

Turnover fell to 13.7% in December (234 headcount leavers from voluntary resignations Jan 19 – Dec 19), which is below the Trust target of 16%.

Turnover in the twelve months to December was highest in the Acute division (18.4%) with 81 voluntary resignations in the last twelve months.

The percentage of leavers due to voluntary resignation with less than twelve months service during the past year is now at 23.5% (55 headcount

leavers <12m Jan 19 – Dec 19), however this represents a relatively small number of actual leavers – only 3 in November and 3 in December.

Key Issues

The breakdown of leavers shows individual hotspot areas as; Camden Crisis Team (10 voluntary resignations in 12m), Occupational therapy(11),

Kingston IAPT (9) and Coral Ward (8).

The increased turnover in Kingston IAPT is due to Psychological Wellbeing Practitioners leaving to undertake further training.

Recruitment campaigns are ongoing to address vacancy issues on Coral Ward and plans are in place to improve staff retention.

Crisis Teams remains the area with the highest turnover especially within the non-registered band 4 staff group. Exit interview analysis has identified

that this is mainly due to a lack of development opportunities; the management team introduced a career pathway framework for non-registered staff

to enhance opportunities to progress within the team up to management level. The impact of this will be accessed on an on-going basis.

Workforce: Recruitment / Our Staff First

42

Analysis

Average time to hire is now 48 days, 31 lower than September‟s peak of 79 days and just below average. There will always be variations in Time to

Hire due to the nature of the recruitment process, but it is statistically unlikely that we will be able to consistently achieve our 40 day target

consistently based on current trends. September‟s higher level was attributable to the mass recruitment activity and there was a reduced level of

resource due to leavers in the resourcing team.

Update

• The resourcing team issued contracts to all 30 Trainee Mental Health Workers due to start on 6th January, 6 Trainee Nursing Associates started

in post on 2nd December; 3 were internal and 3 external. Work has started with the perinatal service to support recruitment for the expansion of

the perinatal service. Contract management of the OH service has been tightened to support addressing a number of issues impacting timely

referrals for staff to Occ Health and time to hire. We are exploring the possibility of implementing their „fit4jobs‟ service to help improve service

delivery by streamlining processes in keeping with our aim to „keep things simple‟.

• The HR support team have continued to run the Disclosure and Barring Service (DBS) renewal clinics and the team is investigating the possibility

of making use of the DBS update service more effectively to eliminate the need for staff to continue to require DBS renewals.

• In December the trust appointed a total of 19 BME staff (internal and external) into roles across bands 3-7, most of these 73% were in bands 3-5.

• We are continuing to work with Microsoft to support the Equality Champions process and have organised Equality Champion training in Jan, Feb,

and Mar. To further develop our retention strategies, we will be providing support to facilitate career progression for internal staff through access

to e-learning packages, face to face interview coaching, and shadowing colleagues working in similar vacancies.

Workforce: Sickness

43

Analysis

Sickness rates are at 4.1% in December, having fallen from 4.4% in November but still marginally above the 4% recorded in October. National

average sickness rates for MH Trusts are above 4.5% and those for London MH Trusts average around 4%. Long term sickness continues to be the

major factor contributing to our above average sickness rates.

Key Issues

• The hotspot areas for sickness include Ruby, Sapphire, New Laffan, Montagu and Hanley Gardens, all Inpatient Wards with the exception of

Hanley Gardens. During December, Whittington MH Liaison had a sickness rate of 11% sickness; A team building initiative is being planned to

address issues within the team.

• The three top reasons for sickness absence reported include; Stress/Anxiety, Musculo-Skeletal and Endocrine/glandular problems.

• To address long term sickness absence, specifically around work related Stress/Anxiety, the Employee Relations and Business Partner teams

are assisting managers through the provision of action plans to support timely progression of cases. Examples include:- Early Referral to

Occupational Health, regular review meetings, and determining appropriate reasonable adjustments to support a return to work in some capacity.

• To address the short term & intermittent sickness absence in R&R, a targeted approach is now being applied to specific teams to ensure that

managers requiring additional support, are coached through the process to build capability and therefore effect improved management of staff

absence. A bespoke information sharing piece is also being developed and will be delivered at team briefs to raise awareness of health and

wellbeing initiatives and the impact short term intermittent absences can have on other staff and delivery of effective patient care.

Workforce: Temporary Staffing

44

Analysis

• Agency usage at 16.7 WTE is below the long term average in December. Lime Tree Gardens has been successful at recruiting into its Band 6

vacancy which is currently being backfilled by Agency with a commencement in post in January 2020. Pharmacy agency use has fallen from 5.9

WTEs in October to 2.6 WTEs in December as a result of migration of staff from agency.

• Bank usage (162 WTE in both November and December 2019) remained below the long term average of 176 WTEs. The proportion of total

staffing provided through temporary staff has fallen by 0.1% to 11.0%, and is still above our Trust target of 10%. The NHS Professionals (NHSP)

fill rate for December 2019 is 96.9%.

Key Issues

• Acute is a temporary staffing hotspot. Efforts are being made to recruit and to facilitate a managed return for staff on sick leave. Currently,

temporary staff usage in Acute Community is 27 WTE in month; this was bank to fill vacancies (23 WTE), therefore spend is not a significant cost

pressure, however quality issues are being reviewed. Temporary staff usage in Acute Wards is currently 71 WTE due to vacancies, staff

sickness, seasonal pressures, extra staff (above budgeted) for service users with complex needs, plus known issues in Coral.

• Temporary use in R&R is currently 43 WTE mostly due to backfill for vacancy and sickness absence in the 24 hour housing services and ward.

• A total of 48 WTE vacancies are at the different stages of the recruitment pipeline, with 5.3 WTE starting in post between Jan and April 2020.

• Total vacancy is at 32.6 WTE and therefore evens out a significant part of the temporary spend. The vacancies are also due to increased budget

on Malachite ward.

• The staff issue at Hanley Gardens has now been resolved and sickness absences are being managed to facilitate return to work.

• Remaining Agency use in Pharmacy is due to backfill for Pharmacy Technician posts which are proving challenging to fill. In addition to local

recruitment campaigns, a skills mix review is being explored as a possible solution.

Workforce: Core Skills

45

Analysis

Our current overall Core Skills compliance stands at 88.5%, well above our target of 80%. The slight downward trend is due to a high number of staff

coming out of compliance in November as a reflection of increased activity preceding previous CQC visits.

Four Core Skills are currently below target: Information Governance (91% in December with a target compliance of 95%), Intermediate Life Support

(76% in December with a target compliance of 80%), CPR (79% in December with a target compliance of 80%) and Mental Capacity Act training

(78% in December with a target compliance of 80%).

Key Issues

Information Governance (IG) compliance continues to be a focus with the IG team identifying and targeting those who are out of compliance.

Steps are being taken to address all other core skill areas below target. The number of classroom based training courses has been increased to

provide enough places to achieve at least 80% compliance in all these areas. Subject Matter Experts have been asked to target staff who require

such training or who are coming out of compliance. The volume of staff coming out of compliance at the end of March is likely to have a serious

impact on the compliance rate if not addressed.

All other Core Skills continue to be actively monitored by the responsible Subject Matter Experts in the Trust who take proactive steps to prevent

them falling below compliance targets.

Workforce: Equality and Diversity

Finance: Financial Position As At Month 9

47

At month 9, the Trust returned a YTD normalised deficit of £1,898k. The key features are:

• Month 9 has shown a marginally improved position from month 8, with a reduction in outplacement costs offset by an increase in pay

costs.

• The Trust is broadly on plan, and the position is an overall positive result. However, the headroom above plan, despite improving

during month 9, is still relatively small.

• The Trust still expects to achieve its full year control total, and has indicated to the local STP that it will attempt to deliver a modest

surplus of about £300k against plan in order to help support the wider NCL position.

• The Trust has received two large unplanned receipts in recent months – i) additional income of £351k in 2019/20 to cover the cost

pressure of the new Agenda for Change pay award for staff employed in services funded by local authorities. This improves the

position by £263k YTD, and ii) a rates rebate, relating to prior years, of £117k, accounted for fully in month 4.. Without these receipts,

totalling £380k YTD, the Trust would be behind plan.

• As the position is better than control total by £161k, PSF and FRF income is accounted for.

Line Ref Business Unit

Annual

Budget Budget Actual

Variance

(fav) / adv

A B C D=C-B

£'000 £'000 £'000 £'000

1 NON DEVOLVED INCOME (145,598) (109,368) (109,218) 150

2 Subtotal Direct Services 104,015 78,265 81,645 3,380

3 Subtotal Central Services & Reserves 34,839 26,063 22,452 (3,611)

4 SUBTOTAL EXPENDITURE 138,853 104,328 104,097 (231)

5 EBITDA (6,745) (5,040) (5,121) (81)

EBITDA Margin 4.4% 4.4% 4.5% 0.1%

6 Depreciation 4,999 3,749 3,749 0

7 Dividend Payment 4,656 3,492 3,492 0

8 Interest (192) (143) (222) (80)

9 NORMALISED (SURPLUS) / DEFICIT 2,718 2,059 1,898 (161)

Normalised I&E Surplus Margin -1.8% -1.8% -1.7% 0.1%

10 PSF / FRF (2,718) (1,767) (1,767) 0

11 RETAINED (SURPLUS) / DEFICIT (0) 292 131 (161)

Retained I&E Surplus Margin 0.0% -0.3% -0.1% 0.1%

Finance: Operational Divisions – Expenditure As At Month 9

48

• During the last week of month 6, the Trust took the decision to close the WPICU and re-open the ward temporarily as an acute ward in order to

bring outplacements back in house. The impact of this this change has been a noticeable fall in outplacement costs, with month 9 also showing

an increase in WPICU income with levels now just below budget.

• Overall Outplacements and WPICU Income showed a combined month 9 improvement of £64k, however, poor financial results earlier in the

year have meant that, at month 9, the Outplacement (incl. WPICU Income) budget is £1,129k behind target (£836k relating to outplacements

and £293k as a result of reduced income generation).

• The Trust has identified and planned for a CIP requirement of £5,600k. Initially £582k was unidentified, however, during month 7, the Trust

finalised and recognised variations to the ISS contract of £287k relating to the Hoo and Stacey St, reducing the unidentified amount to £295k

(£221k YTD).

• Operational Divisions are overspent by £2,717k (£2,322k at month 8). Overall pay costs have increased across Operational Divisions during

month 9.

• Appendix B shows a breakdown of the respective divisional positions, with material overspends on Acute, Outplacements (incl WPICU Income)

and R&R being offset by underspends across all other divisions.

• The overspends in Acute and R&R are predominantly due to pay cost pressures in Inpatient areas and unidentified CIP targets. A YTD increase

in continuing care placements is also contributing to the R&R pressure.

• After discussion with the division, additional pay budget has been applied to the R&R wards in month 7 to ensure that they are funded to the

level the division has stated is necessary. These additional budgets total £294k. However it is pertinent that the current in-month spend, despite

falling during month 9, is still £7k higher than the new monthly budget, and this run rate will still need to be addressed.

Line Ref Operational Service Annual Budget Budget Actual

Variance

(favourable) /

adverse

A B C D=C-B

£'000 £'000 £'000 £'000

1 Acute Services 23,113 17,226 18,830 1,604

2 Outplacements (incl. WPICU Income) (732) (549) 580 1,129

3 Community Mental Health 18,084 13,583 13,369 (214)

4 Rehabilitation & Recovery 15,172 11,427 12,360 933

5 Services for Ageing & Mental Health 8,140 6,144 5,896 (247)

6 Substance Misuse 7,783 5,821 5,692 (129)

7 Operational Services Management 2,533 1,970 1,611 (359)

8 TOTAL OPERATIONAL SERVICES 74,093 55,621 58,338 2,717

Finance: Temporary Staffing As At Month 9

49

• The amount of spend on temporary (bank and agency) staffing in month 9 was £816k.

• Agency spend to month 9 was £187k, which is broadly in line with the in-month ceiling.

• The YTD ceiling is currently being breached by £216k (13%). Future monthly spend must now average £114k if the full year ceiling is not to be

breached, which is materially lower than levels the Trust has previously been able to achieve, and at current levels, it is expected that the full

year ceiling will be breached in February.

0

100,000

200,000

300,000

400,000

500,000

600,000

700,000

800,000

900,000

1,000,000

1,100,000

Bank and Agency Expenditure 18/19 and 19/20

Agency(£) Bank (£) Plan Agency Target

Finance: CIP As At Month 9

50

At month 9, the following are the key points to report:

• At month 9, material savings have been made regarding outplacement savings but the total level is short of the required amount by £836k. It is

doubtful whether the CIP will be fully delivered in year.

• The TFM contract re-tender was successful and the new contract started on 2nd of January 2019.

• The sale of Stacey St was originally planned for September 2019. The Trust is progressing this disposal, but, after discussions with the STP, the

Trust has agreed the sale will be completed in the next financial year.

• Holloway Rd is now expected to be retained as a future, decant space to facilitate the redevelopment of SPH and the community hubs.

• Additional variations to the ISS contract relating to the vacation of the Hoo and Stacey St have now been agreed. These amount to £287k over

the full year and have reduced the unidentified element of CIP to £295k. A further variation relating to Holloway Rd has been agreed, but as it is

not recurrent, it cannot be considered as CIP delivery.

• The start date for the new service at 154 Camden Rd was originally assumed to be October 2019. However, the tendering process was

unsuccessful and this CIP is no longer expected to deliver savings in 2019/20

• A trial of technology designed to improve staff safety and enable a potential reduction in temporary staff usage will commence during 2019/20.

• Currently only £57k of the £250k Corporate CIP target is identified. It is now assumed that there will be some slippage on the full year

unidentified amount. Work on identifying corporate savings needs is being progressed, and the themes expected to contribute towards

improving efficiency include a planned review of (non ISS) budgets in Estates; a review of HR structures as part of the strategic alliance with

BEH considering how closer working can improve processes; an admin review within THQ which is commencing; and engagement with an STP

process regarding the use of robotics/AI processes.

0

1,000

2,000

3,000

4,000

5,000

6,000

£k

CIP delivery against plan 2019/20

Plan excl Profit

Delivered CIP

Finance: Use Of Resources Rating

51

Note: The Use of Resources metrics take into account the impact of Provider Sustainability Funding received in March 2019

NHSI rates Trust‟s on a Use of Resources rating. The scoring system ranks from „1‟ (low risk/best score) to „4‟ (high risk/worst score). The above

table shows the Trust‟s Use of Resources rating for month 9:

• The Trust‟s overall rating is now a „2‟.

• The Trust submitted a plan which had an overall risk rating of „1‟ for 2019/20, but, primarily due to the profiling of PSF/FRF, planned for a score

of „2‟ at month 9. As the month 9 position is in line with plan, the risk rating score achieved is a „2‟ but this is expected to improve, in line with the

plan, as the year progresses.

• The Trust continues to score highly on the Liquidity metric.

Finance: Cash

52

At the end of month 9, the Trust held cash balances totalling £50,539k, which is ahead of plan.

• The Trust has, in 2019/20, been paid PSF/FRF income relating to 2018/19 of £4,008k, and a further £952k relating to quarters 1 and 2, 2019/20,

while the first instalment of the PDC dividend was paid by the Trust in month 6.

• As at the end of November, the rate of interest available from depositing with the National Loans Fund was unfavourable compared to the rate

the Trust receives within its current account, and as a result the Trust did not have any cash on deposit.

• As has been previously reported, liquidity levels continue to fluctuate, with volatility around cash flow timings, caused by the impact of the wider

NHS financial position. It would not be unexpected if cash levels were liable to further short term volatility over the remainder of the financial

year, and as a result, the Finance department is closely monitoring cash flow.

0.0

10.0

20.0

30.0

40.0

50.0

60.0

70.0

Apr

-18

May

-18

Jun

-18

Jul-

18

Aug

-18

Sep

-18

Oct

-18

No

v-1

8

De

c-18

Jan

-19

Feb

-19

Mar

-19

Apr

-19

May

-19

Jun

-19

Jul-

19

Aug

-19

Sep

-19

Oct

-19

No

v-1

9

De

c-19

Jan

-20

Feb

-20

Mar

-20

£m

Cash Balances 2018/19 - 2019/20

Plan

Actual

Statistical Process Control

Measurement for Improvement

Statistical process control (SPC) is an analytical technique – underpinned by science and statistics – that plots data over time. It helps us

understand variation and in so doing guides us to take the most appropriate action. SPC is one approach that we should increasingly use when

considering our performance and operational data.

These are the reasons why:

• SPC alerts us to a situation that may be deteriorating

• SPC shows us if a situation is improving

• SPC shows us how capable a system is of delivering a standard or target

• SPC shows us if a process that we depend on is reliable and in control.

A key is used throughout this report to help readers quickly identify when an SPC chart has shown special cause variation meaning closer

monitoring or more investigation is required.

53

Special-cause variation Common-cause variations

New, unanticipated, emergent or previously

neglected phenomena within the system.

Variation inherently unpredictable, even

probabilistically.

Variation outside the historical experience

base.

Evidence of some inherent change in the

system or our knowledge of it.

Phenomena constantly active within the

system.

Variation predictable probabilistically.

Irregular variation within a historical

experience base.

Lack of significance in individual high or low

values.

Special-cause variation always arrives as a

surprise. It is the signal within a system.

The outcomes of a perfectly balanced roulette

wheel are a good example of common-cause

variation. Common-cause variation is the noise

within the system.

Oversight Framework Methodology

54

Measure Description / Calculation Numerator Denominator

Written complaints – rate Count of written complaints/count of whole time

equivalent staff

Count of written complaints Count of whole time equivalent staff

Staff Friends and Family Test % recommended –

care

Count of those categorised as extremely likely or likely to

recommend/count of all responders

Count of those categorised as extremely likely or

likely to recommend

Count of all responders

Occurrence of any Never Event Count of Never Events in rolling six month period NA NA

Patient Safety Alerts not completed by deadline Number of NHS England or NHS Improvement patient

safety alerts outstanding in most recent monthly

snapshot

NA NA

CQC community mental health survey Findings from the CQC survey which gathered information

from people who received community mental health

services

NA NA

Mental health scores from Friends and Family Test

– % positive

Count of those categorised as extremely likely or likely to

recommend/Count of all responders

Count of those categorised as extremely likely or

likely to recommend

Count of all responders

Admissions to adult facilities of patients under 16

years old

Number of Under 16 bed days on adult wards NA NA

Care programme approach (CPA) follow-up –

proportion of discharges from hospital followed

up within seven days

Proportion of discharges from hospital followed up within

7 days

Count of CPA patients followed up within 7 days

of discharge

Count of all CPA patients who were

discharged during the reporting period

% clients in settled accommodation Percentage of people aged 18 to 69 in contact with

mental health services in settled accommodation

Count of patients on CPA with recorded as in

settled accommodation

Count of patients on CPA

% clients in employment Percentage of people aged 18 to 69 period in contact

with mental health services in employment

Count of patients on CPA recorded as employed Count of patients on CPA

People with a first episode of psychosis begin

treatment with a NICE recommended care

package within two weeks of referral

Percentage of people with a first episode of psychosis

beginning treatment with a NICE-recommended care

package within two weeks of referral

Count of patients who entered treatment within

2 weeks of referral in the reporting period

Count of all patients who entered

treatment in the reporting period

Oversight Framework Methodology

55

Measure Description / Calculation Numerator Denominator

Improving Access to Psychological Therapies /

talking therapies

a. proportion of people completing treatment

who move to recovery

a. Percentage of people completing a course of IAPT

treatment moving to recovery

The number of people who have completed

treatment having attended at least two

treatment contacts and are moving to recovery

(those who at initial assessment achieved

"caseness” and at final session did not).

The number of people who have completed

treatment within the reporting quarter,

having attended at least two treatment

contacts) minus (The number of people

who have completed treatment not at

clinical caseness at initial assessment)


talking therapies

b. i. waiting time to begin treatment within 6

weeks

b. Percentage of people waiting

i) six weeks or less from referral to entering a course of

talking treatment under Improving Access to

Psychological Therapies (IAPT)

The number of ended referrals that finish a

course of treatment in the reporting period who

received their first treatment appointment within

6 weeks of referral.


course of treatment in the reporting period.


talking therapies

b. ii. waiting time to begin treatment within 18

weeks

b. Percentage of people waiting

ii) 18 weeks or less from referral to entering a course of

talking treatment under IAPT


course of treatment in the reporting period who

received their first treatment appointment within

18 weeks of referral


course of treatment in the reporting period.

Inappropriate out-of-area placements for adult

mental health services

Total number of inappropriate bed days patients have

spent out of area in last quarter

NA NA

Staff sickness Level of staff absenteeism through illness in the period

Numerator = number of days sickness reporting within the

month. Denominator = number of days available within

the month

Number of days sickness reporting within the

month

Number of days available within the month

Staff turnover Number of Staff leavers reported within the period /

Average of number of Total Employees at end of the

month and Total Employees at end of the month for

previous 12 month period

Numerator = number of leavers within the report period.

Denominator = staff in post at the start of the reporting

period

Number of Staff leavers reported within the

period

Staff in post at the start of the reporting

period

NHS Staff Survey (Staff recommending

organisation as a place to work or receive

treatment)

Staff recommendation of the organisation as a place to

work or receive treatment

NA NA

Proportion of temporary staff Agency staff costs (as defined in measuring performance

against the provider's cap) as a proportion of total staff

costs.

Calculated by dividing total agency spend over total pay

bill.

Total agency spend Total pay bill

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