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TB 179/17 Welcome and opening comments Chair Verbal
TB 180/17 Apologies for absence and confirmation of quoracy
Chair Verbal
TB 181/17 Declarations of Interest Chair Verbal
TB 182/17 Minutes of the previous meetings Chair Decision Paper
TB 183/17 Action Tracker Chair Decision Paper
SCRUTINY & ASSURANCE
TB 184/17 Finance Report Chief Finance Officer Noting Paper
TB 185/17 Performance Report Chief Operating Officer Noting Paper
TB 186/17 Trust Chair’s Report Chair Noting Paper
TB 187/17 Quality Committee Chairs Report Committee Chair Noting Paper
TB 188/17 Chief Executive’s Report Chief Executive Discussion Paper
TB 189/17 Quality Report Director of Nursing and
Quality/Medical Director Noting Paper
PART TWO (PRIVATE MEETING)
TB 190/17 Minutes of the last meeting Chair Decision Paper
TB 191/17 Chief Executive Report Chief Executive Noting Paper
TB 192/17 Public Health Initiatives in LCFT Medical Director Noting Pres.
TB 193/17 Inpatient Reconfiguration Programme
Chief Executive Decision Paper
TB 194/17 Cumbria Strategic Options Business Case
Chief Finance Officer Noting Paper &
Pres.
TB 195/17 Staffing for Safety and Quality Action Plan Update
Director of Nursing Noting Paper
TB 196/17 Any Other Business Chair Verbal
TB 197/17 Date & Time of the Next Meeting
04 January 2018, 8.30am
Chair Verbal
Declaration of Interest – Board of Directors
Date of Declaration
Surname First Name
Job Title Nature of Interest
Do you envisage a conflict of interest between outside employment and
your NHS employment?
Nil Declaration
21/02/2017 Eva David Trust Chair Employed by Union Learn as National Manager
Yes TUC funds learning in relation to apprenticeship and Trade Union representation.
06/02/2017 Tierney-Moore
Heather Chief Executive
1. Director of Lancashire Sport Partnership2. Trustee of Community Integrated Care3. Macmillan Allumni Patron4. Retained Consultant Glenview5. Patron Breakthrough Mental Health Charity
Yes Potential risk of CIC bidding to provide services in Lancashire that are also of interest to LCFT
06/09/2017 Furlong Gwynne Non-Executive Director &
SID
1. 1. Non-Executive Director of Together HousingGroup
2. 2. CEO of Regain Sports Charity3. 3. Trustee of Chorley Youth Zone4. 4. Non-Executive Director of subsidiary of
Progress Housing Group called Concert LivingLimited
No
13/02/2017 Ballard Peter Deputy Chair & Non-
Executive Director Chief Executive DSE Service No
29/03/2017 Dickinson Louise Non-Executive Director
1. Director at Talegar Limited2. Consultancy Services at Talegar Limited3. Foundation Governor and Finance Chair at
St.Vincents Primary School
No
03/02/2017 Wilson Isla Non-Executive Director
1. NED - Progress Housing Group2. Shareholder – FSquared Ltd3. Shareholder - Ruby Star Associates Ltd4. Consultancy/Advisory Work – Ruby Star
Associates5. Chair - Borough Care Stockport
No
Declaration of Interest – Board of Directors
03/02/2017 Curtis David Non-Executive Director 1. Director at Clinical and Corporate Governance
Limited2. Clinical Associate at MIAA (Advisory Section)
No
07/02/2017 Gregory Bill Chief Finance Officer
1. Trustee of Healthcare Financial ManagementAssociation
2. Governor of Stockport College3. Co-opted member of Lancaster University
Financial and General Purpose Committee.4. Director of Red Rose Corporate Services
No
02/10/2017 Possener Julia Non-Executive Director (Start date 01.02.2017)
1. Lay member of the Lancaster UniversityManagement School and Faculty of Arts andSocial Science Ethics Committee. Although theTrust and LU have a working relationship andcollaborate such matters do not fall usuallywithin these Faculties.
2. My partner's sister is the owner of a domiciliarycare business which does have contracts withThe Trust. I am including this for the sake ofcompleteness. Bluebird Lancaster and SouthLakeland Ltd. I have no formal nor informalinvolvement in that business.
No No business with the Trust or other NHS organisation or organisations providing services to NHS No unrelated faculties or formal or informal business.
13/02/2017 Roach Dee Executive Director of
Nursing & Quality
06/02/2017 Marshall Max Medical Director
06/02/2017 Moore Sue Chief Operating Officer
07/02/2017 Gallagher Damian Director of HR
BOARD OF DIRECTORS
Minutes of the Part One Board of Directors Meeting held on 02 November 2017 Training Rooms 1 & 2, the Harbour, Blackpool
PRESENT: David Eva, Trust Chair (Chair)
Heather Tierney Moore, Chief Executive Max Marshall, Medical Director Peter Ballard, Deputy Chair Bill Gregory, Chief Finance Officer Sue Moore, Chief Operating Officer Dee Roach, Director of Nursing Damian Gallagher, Director of HR Louise Dickinson, Non-Executive Director Isla Wilson, Non-Executive Director Julia Possener, Non-Executive Director David Curtis, Non-Executive Director Jo Alker, Company Secretary
IN ATTENDANCE: Darren Conway, Quality Improvement Manager accompanying service user (Agenda Item TB 159/17) Bev Howard, Head of Communications Julie-Ann Bowden, Associate Director of Risk & Assurance Viv Prentice, Deputy Company Secretary (minutes)
OBSERVERS: Lisa Knight, Insight Development Programme
Pauline Walsh, Public Governor Adnan Gharib-Omar, Staff Governor Public Member: Jinette Hindmarsh, Partner Engagement Office, MHC UK
TB 154/17 WELCOME & OPENING COMMENTS
The Chair welcomed everyone to the meeting and introductions were made.
TB 155/17 APOLOGIES FOR ABSENCE & CONFIRMATION OF QUORACY Apologies for absence were received from Non-Executive Director, Gwynne Furlong and confirmation of quoracy was provided.
TB 156/17 DECLARATIONS OF INTEREST A declaration was made by the Chief Finance Officer in relation to his position on the Red Rose Corporate Services Board.
TB 157/17 MINUTES OF THE PREVIOUS MEETING
The minutes of the previous meeting held on 05 October 2017 were approved as a true and accurate record subject to including the detail of a discussion around care co-ordinators attendance at CPA meetings that was raised by a Non-Executive Director.
TB 158/17 ACTION TRACKER The Board reviewed the action tracker and noted the updates provided. Items were closed off as necessary. The actions relating to future staffing and clinical pathways were discussed at the Finance & Recovery Group and it was agreed that a further update would be provided at the December Board. ACTION
UNCONFIRMED
TB 159/17 PATIENT STORY The Board heard a patient story from a service user who had previously used the Trust’s CAMHS inpatient service. They spoke of their experience and journey to recovery providing the Board with examples of good practice and areas they felt could be improved.
TB 160/17 TRUST CHAIR’S REPORT
The Chair presented his report which included an overview of the activity of both Non-Executive Directors and Governors. An update was provided following the Chair’s recent visit to Scarisbrick Inpatient Unit at Ormskirk Hospital which provided the Chair with the opportunity to speak with staff about some of the challenges they face. The Board noted the content of the Chair’s Report.
TB 162/17 CHIEF EXECUTIVE REPORT The Chief Executive introduced her report and confirmed that 30% of employees had now received the flu vaccination. Areas of success were highlighted which included the recent visit from HRH Prince Harry to the MyPlace project at Brockholes Nature Reserve. The MyPlace project is a partnership supported by Big Lottery Funding and is one of 31 UK projects co-ordinated through Our Bright Futures. Constitutional changes in relation to the Council of Governors constituencies had been approved at the Annual Members’ Meeting. The election process was currently underway and the Board would be kept informed of the outcome. The Medical Director provided an update following a visit undertaken with colleagues to Northumberland, Tyne & Wear NHS Foundation Trust that had been successful in applying lean methodology focusing on improving patient experience. This discussion would be picked up with the Board as part of the scheduled session in January 2018. ACTION
TB 162/17 AUDIT COMMITTEE CHAIR’S REPORT
The Chair of the Audit Committee introduced the Chair’s Report and highlighted the key areas of discussion and focus for the Committee. This included an update on the delivery of the Internal Audit Plan which was currently amber rated in terms of progress. It was noted that this was not a concern and the delay would be mitigated in quarter three. Assurance had been received that sufficient processes and mechanisms were in place for staff to raise concerns within the organisation. The Quality Report that formed part of the Board agenda would provide an overall view of the key themes and hot spots from those concerns. Assurance had been received from the Corporate Governance and Risk Management health-checks undertaken during quarter two in the Children & Young People Network and the HR Directorate. In addition, the annual assurance programme update highlighted the key pieces of work that had been undertaken within the last twelve months relating to risk assurance. The Committee considered the extension of the internal and external audit contracts and it was agreed that stakeholder feedback in relation to the internal audit contract would be obtained prior to approving a contract extension. With
regards to external audit, a recommendation would be put forward to the Council of Governors in November to extend the contract for a further two years.
The Board noted the content of the Audit Committee Chair’s Report.
TB 163/17 QUALITY COMMITTEE CHAIR’S REPORT The Chair of the Quality Committee introduced the Chair’s Report and highlighted the key areas of discussion and focus for the Committee which included recognition of the significant amount of work that had been undertaken at HMP Liverpool.
It was noted that work was currently underway to enhance the Quality & Safety Surveillance Reports and that work was being undertaken to address staffing levels as a result of the reduction in staff from the EU.
The Board noted the Trust’s achievement of 100% compliance with PREVENT training.
The Board noted the content of the Quality Committee Chair’s Report.
TB 164/17 FINANCE & PERFORMANCE COMMITTEE CHAIR’S REPORT The Chair of the Finance & Performance Committee introduced the Chair’s Report and highlighted the key areas of discussion and focus for the Committee. This included an update on the EPR programme and the work that was being undertaken to address the small amount of overpayments to staff.
In relation to the perinatal business case update, the Chief Operating Officer confirmed that the Trust was close to signing the lease for the perinatal facility and had agreed access with Lancashire Teaching Hospitals for the inpatient reconfiguration work. The Chief Finance Officer also confirmed that funding had been approved by NHS Improvement.
The Board noted the content of the Finance & Performance Chair’s Report.
TB 165/17 QUALITY & PERFORMANCE REPORT The Chief Operating Officer presented the Quality & Performance Report for month six and confirmed that the Trust was compliant with all NHS Improvement indicators with the exception of performance against the Early Intervention in Psychosis (EIS) 2 week target. The Chief Operating Officer outlined the context of the discrepancy and the actions that were being taken to address this.
It was noted that CAMHS Tier 4 was underperforming and whilst A&E was still challenged there had been a significant reduction in the number of 12 hour breaches. The Trust also remained challenged in terms of beds and occupancy.
Patients with over 180 day’s length of stay on mental health wards had increased slightly due to the patient cohort. The lead commissioner had formally been informed of the position and the financial impact of holding chronic presentations on acute mental health wards.
The Board’s attention was drawn to the Memory Assessment Service (MAS) which, with the exception of the Central Lancashire MAS team, continued to perform well against the 79% target for the six week referral to assessment standard.
Non-Executive Director, David Curtis, highlighted that the target for Care Coordinators attending CPA reviews had not been achieved again this month. Following a question from the Chair in relation to secure services, the Chief Operating Officer outlined the work that was being undertaken with the psychology associates which included looking at violence reduction and the number of wards vs number of patients.
TB 166/17 FINANCE REPORT The Chief Finance Officer presented the finance report and confirmed that the financial position in month 6 was similar to month 5 and showed a gap of £2.6m at the half year point. Whilst staffing pressures and OAPs continued to be an issue, a task force was underway to address staffing led by the Director of Nursing and Quality. In addition, the high number of PICU OAPs was being addressed with the commissioners. An update was provided on land disposals which included the conclusion of the Ridge Lea offer. In addition, it was highly likely that a VAT reclaim relating to a capital scheme would be concluded this year. Financial pressures relating to the prison contract had been discussed with the commissioners and a response was currently awaited. In addition, the Board noted that the Trust had secured a contribution to establish the Core 24 liaison service. The Chief Finance Officer confirmed that the cash position was back on plan and that progress against the capital programme was slow due to issues with the Chorley site. Work had been progressing on a revised format of the Finance Report and therefore month 6 would be re-presented in the new format for comment. ACTION
TB 167/17 QUARTERLY WORKFORCE REPORT
The Director of HR presented the workforce report for quarter two and highlighted that whilst levels of sickness absence remained the same as the previous year work was underway to address this. This included the back to basics programme. The turnover rate for quarter two had seen a slight increase, reporting 13.95% at the close of the quarter. The Director of HR confirmed that future reports would also include additional detail in respect of the breakdown of reasons for leaving. It was referenced that there had been fewer registrations from EU workers and an increase in leavers indicating a future problem. Whilst appraisal compliance was below the Trust target, this was being addressed within the Networks. Overall mandatory and statutory training compliance continued to improve, reporting an overall compliance of 89% at the close of quarter two. For those individual subjects that remained non-compliant, Networks were agreeing new trajectories to support their achievement of the Trust target by December.
Following the percentage drop in visa compliance, the Director of HR assured the Board that this related to one individual whose application was currently being processed. Non-Executive Director, Isla Wilson, took the opportunity to update the Board following her attendance at a recent Workforce Quality Standard event. A discussion ensued in relation to the importance of increasing the Trust’s awareness of diversity. Following a question in relation to the spike in sickness rate figures in the Children and Young People’s Network, the Chief Operating Officer outlined the reasons that this could be attributed to. This included the recent changes in the network and long term sickness absence. The Director of Nursing responded to a question in relation to mandatory training from a Non-Executive Director and advised that a detailed piece of work was being undertaken in respect of moving to competency based training. This would ensure that staff are able to evidence competencies around core skills.
TB 168/17 BOARD ASSURANCE FRAMEWORK
The Associate Director of Risk and Assurance presented the Board Assurance Framework (BAF) Quarter 2 Review and provided an update on BAF risks 1.1 and 4.2 that had moved in score at the end of Quarter 2. The Board’s attention was drawn to the appendices to the BAF which included a thematic summary of the operational risks scored at 12 and above. Following a question from a Non-Executive Director in relation to CIP targets, the Chief Finance Officer explained that whilst the overall position was directly related to the mental health run rate scheme he was confident it would result in a satisfactory conclusion. The Chief Operating Officer confirmed that the current position in relation to secure services transformation would be mitigated before the end of the year. The Board approved the BAF 2016/17 Risk Register at Quarter 2.
TB 169/17 MENTAL HEALTH ACT MANAGERS The Director of Nursing presented the Assurance Report on the effective discharge of duties of Hospital Managers under the Mental Health Act and confirmed that a development session was planned for the Board in relation to its responsibility in discharging the Act. A discussion followed in relation to the responsibilities of Non-Executive Directors and it was agreed that their responsibilities would be agreed following the development session in February 2018. ACTION
TB 170/17 LEARNING FROM DEATHS
The Director of Nursing presented the Learning from Deaths Assurance Report and drew the Board’s attention to the baseline assessment against the national guidance. The Board noted that the Trust was compliant with all deadlines and would achieve upcoming deadlines by Q3/Q4. The Medical Director highlighted that that this was an important development in supporting a safety culture within the NHS in the context of openness and
transparency. It was noted that there would also be potential media interest as Trusts begin to publish their reports.
TB 177/17 On behalf of the Board, the Chair thanked Non-Executive Director, Peter Ballard for his valued contribution and support following his many years’ service within the Trust adding that as a personal colleague he would be incredibly missed.
TB 178/17 DATE AND TIME OF NEXT MEETING 07 December 2017 @ 08:30a.m. Training Room 1 & 2, The Harbour
Board of Directors
Agenda Item TB 184/17 Date: 07/12/2017
Report Title Finance Report
FOIA Exemption Part Exemption
Prepared by Shannon Carroll, Financial Services Director
Presented by Bill Gregory, Chief Finance Officer
Action required Noting
Supporting Executive Director Chief Finance Officer
PURPOSE OF THE REPORT:
Report purpose To summarise and analyse actual and forecast financial performance and standing of the Trust, the implications and any proposed management action.
Strategic Objective(s) this work supports
To provide excellent value for money in a financially sustainable way
Board Assurance Framework risk 5.1 The Trust does not achieve financial performance sufficient to maintain resilience and sustainability
The cash position remains strong but shows a minor adverse variance from plan of £0.4m. The capital position continues to offset the I&E position. High debtors are placing some pressure on working capital though this is considered transient. Forecast cash is currently expected to exceed plan, a combination of an improved opening position, capital funding, and anticipated disposals. - see Cash and Liquidity for more details.
Current Out-Turn
At month 7 with CIPs of c£7.4m against a plan of c£8.4m the Trust is £1.1m behind plan, a deterioration of £0.1m on month 6 (£1.0m behind plan). The adverse variance is mainly due to a lack of performance on Run Rate Reduction Programmes on staffing pressures. Compensating schemes have, and continue to be, developed and confirmation of transactions are expected in month 8. Networks continue to create and implement measures aimed at improving the position.
Month 7 sees a year to date operating deficit of -£2.3m, excluding planned Sustainability and Transformation funding of £0.9m, against a planned surplus to date of £0.6m. This shows an improvement on month 6 and represents a small budgetary surplus in month and nearly £0.2m when excluding STF monies. The position remains driven by staffing pressures in ward and prison areas and consequential impact on cost improvement programmes (rising agency costs will also impact Use of Resources targets). Additionally OAPs expenditure continues to exceed funding - see Out Of Area Activity for more details. The forecast assumes current pressures and risks are addressed or mitigated in line with the recovery plan (see forecasting) and financial performance achieves (or exceeds) plan but the unmitigated projection indicates a gap of c£4.8m, c£6.9m without STF monies. This is represents an improvement on month 6 forecasts (£6.2m), and is driven by excess OAPs of c£0.8m (all be that significantly below last month), prisons (see also Bank and Agency section) and additional mental health pressures. Delivery of the recovery plan and financial targets will required a significant and coordinated response with robust management and oversight. After taking in to account £1.7m of disposals, which are accounted for after EBITDA, EBITDA is broadly in line with I&E Margin. The new Use of Resources (UoR) metric is rated at 3, but will rise to a 2 should the Trust meet its financial plans and targets, see below.
Capital and Financing
Use of Resources (UoR) risk ratings
Forecasting
Recovery Plan
#
Whilst it would appear that the gap can be bridged through the plan, this is not without significant risk. Delivery will only be achieved with a considerable coordinated and sustained effort across the organisation. The plan will continue to be refined and presented in more detail to the Financial Recovery Group along with the actions required.
Progress against the capital programme has been slow to date with expenditure at £1.8m against the original profile of £6.0m. The scheduling profile of many schemes was dependent on a number of tendering exercises (the last of which, Perinatal, has now been completed), agreements with third parties (now substantially resolved) and final funding approval (Inpatient schemes approval now received from NHSI, awaiting final confirmation of funds and timing from DH). Schedules for these and related/dependant schemes are now being finalised through discussions with the incumbent contractors and the Trust is pushing forward with work on the affected projects. Discussions with contractors indicate the delays will cause slippage, mainly on the Inpatients (Chorley site - c5 weeks) though a risk of slippage on the Perinatal scheme remains and is being worked on. Impacts on the respective projects have yet to be finalised and incorporated in to forecasts.
Revised year end control totals are being provided to networks in line with the recovery plan and will require:• Progress and delivery of ward staffing actions• Implementation of the recovery plan.• Agreement of OAPs mitigations with commissioners.• Progress on land sales.
Though slightly improved the current I&E position continues to give a rating of 4 and a Capital Service rating of 4 constraining the current overall UoR to a 3. Assuming current pressures and risks are addressed through the recovery plan and I&E performance achieves (or exceeds) forecast the Trust will achieve a UoR of 2 in line with the plan. However, though forecast would achieve the overall target rating, Capital Service is based on EBITDA and since part of the Trusts recovery plan is based on disposals (which are excluded from EBITDA) the Trust is not forecast to achieve planned Capital Service. The Trust is also forecast to exceed its liquidity and slip against it's planned Agency target. Should conditions persist and costs not be managed within the control total then the resulting deterioration might trigger a review of our segmentation.
Forecast ForecastYTD YTD Out-turn Out-turn
Oct 2017 Sep 2017 at Oct 2017 at Sep 20177 6 Note 12 12 Note
Plan 0.610 0.321 Plan 2.167 2.167
Major Variances Major VariancesCIP Slippage -1.054 -0.982 - See CIP section CIP Slippage 0.000 0.000 - See CIP sectionOAPs -0.773 -0.773 - See OAPs section OAPs -1.792 -1.792 - See OAPs sectionStaffing -5.471 -5.000 - See also Bank and Agency section Staffing -8.139 -8.201 - See also Bank and Agency sectionOther Bud Vars 1.708 1.791 - See Services section Other Bud Vars 1.929 0.601 - See Services sectionReserves 3.210 3.040 - See Reserves section Reserves 7.231 8.899 - See Reserves sectionIncome -0.699 -0.688 - See Reserves section Income 0.584 0.514 - See belowMinor Variances 0.000 0.000 Minor Variances 0.000 0.000
Variance -3.079 -2.612 Variance -0.187 0.021
Actual -2.469 -2.291 Actual Forecast 1.980 2.188
----
Surplus - YTD (£m) Surplus - Out-turn (£m)
This month sees an operating deficit of £2.5m, £2.3m after adjusting for impairments, £2.9m behind plan. Of this £0.9m relates to STF funding leaving a net gap from plan of £1.9m.
YTD income variance relates mainly to STF funds which are assumed in forecast along with additional funds re NCAs and R&D
Staffing variance has increased in part due to phasings of development funding in mental health, but more materially due to ward pressures.The full year projection is a surplus of £2.0m, £2.2m after adjusting for impairments. The position models an upside of c£7.0m and includes profit on disposals of c£1.7m.
Minor Variances 0.000 -0.039 Minor Variances 0.000 0.015
Variance 2.148 1.794 Variance 4.978 4.308
Actual 196.070 167.938 Actual Forecast 337.886 337.216
12
345 Major increases in the latter part of the year generated by AHSN.
Monthly Income Variances (£m) Cumulative Income Variances (£m)
Major decrease due to Southport commencing in May and not April offset by minor gains in other services including Rheumatology and District Nursing.Major increases revolve around the phasing of the Out of Area Placements expenditure, in addition to Liaison & Diversion and Eating Disorders. Major decreases in Rehabilitation Services and Hospital Liaison.Income is in line with plan at this stage. Year end variances are driven by the anticipated cessation of the HIV contract.Major decrease in respect of lower than planned activity in Sexual Health services and forecasts for Sexual Health and Offender Health later in the year.
0.000
5.000
10.000
15.000
20.000
25.000
30.000
35.000
Apr May Jun Jul Aug Sep Oct Nov Dec Jan Feb Mar
Actual/Forecast
Plan
0.000
50.000
100.000
150.000
200.000
250.000
300.000
350.000
400.000
Apr May Jun Jul Aug Sep Oct Nov Dec Jan Feb Mar
Actual/Forecast
Plan
Forecast ForecastYTD YTD Out-turn Out-turn
Oct 2017 Sep 2017 at Oct 2017 at Sep 20177 6 Note 12 12 Note
Budget 164.955 141.407 Budget 281.644 281.506
Major Variances Major VariancesMental Health -6.479 -5.654 - Note 1 Mental Health -9.257 -9.961 - Note 1Community & Wellbeing -0.216 -0.274 - Note 2 Community & Wellbeing -0.401 -0.489 - Note 2Children & Young People 0.844 0.705 - Note 3 Children & Young People 0.824 0.866 - Note 3Pharmacy 0.188 0.169 - Note 4 Pharmacy 0.260 0.265 - Note 4Property Services 0.000 0.000 - Note 5 Property Services 0.000 0.000 - Note 5Corporate 0.073 0.089 - Note 6 Corporate 0.571 -0.073 - Note 6
Variance -5.590 -4.965 -8.002 -9.392
Actual 170.545 146.372 Actual Forecast 289.646 290.898
1
23
456 Corporate services are slightly ahead of plan year to date, with overspends in IM&T currently met by underspends in Medical and Human Resources.
Mental Health in year overspend is driven more acutely by excess staffing costs, primarily on wards, (£3.9m). Actions to review the patients in inpatients setting, their appropriateness for the ward and levels of staffing associated with acuity are advanced and should furnish us with the appropriate information to discuss necessary action to recover the position, though risk remains until this is enacted. There is also significant CIP slippage, as all CIPS have been withdrawn but some schemes are still in development (c£1.9m). The Network's position is diminished further by ward overspends in Secure Services wards (c£1.2m). OAPs are now manifesting as overspends (£0.8m for the year)
Community's position is impacted by undelivered CIPs to date (£0.35m). Underspends on community teams and non-pay continue to alleviate the current position.Children and Young People have similarly been impacted by a shortfall on CIP delivery(£0.25m) and Sexual Health activity shortfall (£0.2m) but is currently being compensated for by vacancies and non-pay underspends.
YTD Service Net Expenditure Variance (£m) Forecast Service Net Expenditure Variance (£m)
Pharmacy is performing broadly in line with plan, with some underspends on staffing.Property Services are performing in line with plan and are expected to remain so.
-£7,000
-£6,000
-£5,000
-£4,000
-£3,000
-£2,000
-£1,000
£0
£1,000
£2,000Mental Health
Community &Wellbeing
Children &Young People Pharmacy
PropertyServices Corporate Total
Service Forecast Variance
-£10,000
-£8,000
-£6,000
-£4,000
-£2,000
£0
£2,000Mental Health
Community &Wellbeing
Children &Young People Pharmacy
PropertyServices Corporate Total
Service Year to Date Variance
CIP Achievement (£)Notes
Year to Date PerformanceAt month 7 with CIPs of £7.4m against a plan of £8.4m the Trust is c£1.1m behind plan, a deterioration of £0.1m on month 6 (£1.0m behind plan). The adverse variance is mainly due to the continued lack of performance on Run Rate Reduction Programmes on staffing pressures. Compensating schemes have, and continue to be, developed and network management team are being supported by to implement measures aimed at improving the position.
Schemes to be Transacted£0.9m of schemes are yet to be transacted at month 7 leading to year to date slippage of c£0.5m. There is a good degree of confidence in the delivery of these schemes.
Schemes In Process£1.5m of additional schemes identified are not yet sufficiently detailed to transact and after allowing for slippage factored into plan this results in slippage of c£0.6m. There is some confidence in the delivery of these schemes.
Schemes to be IdentifiedIncluding pipeline schemes plan totals exceed target and though not without risk forecast continues to be broadly in line with plan requirements.
ForecastThe programme is currently expected to achieve the Annual Plan however risk of slippage, particularly on mental health and community schemes, remains.
The Trust has been given a ceiling by NHS Improvement for agency spend. This target is£7.695m for the year. At the end of period 7, the Trust is -£758k, or 17% above it'strajectory. The new Use of Resources rating measures agency against target and containstrigger points. Key trigger points are a requirement for 50% and 25% or better for ratings of3 and 2 respectively. An individual rating of at least 3 is required to obtain an overall ratingof 2 (see also Use of Resources section).
Corporate Services is net of the charge levied for agency staff. Agency spend is negligible with the exceptions of Health Informatics.
Agency Costs Over Time (£'000) Bank Costs Over Time (£'000)
A high level of vacancies is supported by bank and agency, though increased levels of recruitment mean overall staffing costs remain high. Agency costs have decreased from last month as well as bank costs.Mental Health Networks bank and agency costs are primarily due to the level of acuity on inpatient wards being beyond the level established although the in month decrease in bank is almost entirely attributable to staffing on Adult and Secure wards.Children and Young Peoples temporary staffing remains relatively minor and consistent.Community and Wellbeing sees an increase in both Agency but a fall in Bank, with the major agency change being the with regard to Learning Diability, and bank recovering in Integrated Teams and Southport.
56 Provisions and Deferred Income are currently generating gains of c£1.9m over plan. Crystallisation of income and redundancy settlements are expected to reduce gains and this is
factored into forecasts.
Monthly Cash and Liquidity Variance (£m) Forecast Cash and Liquidity (£m)
Timing of settlements to suppliers are broadly in line with plan.
Reductions in capital expenditure are supporting cash more than compensating for the impact of the deficit. Forecasts assume planned revenue and capital forecasts are achieved, that PDC for the inpatients Programme is in line with expectations, and that the disposal of Westfields, Ridge Lea and Ribbleton take place in 2017/18.
Late payments by CCGs (£1.0m) and local authorities (£2.1m) coupled with outstanding CQUIN (£0.5m) have lead to a large adverse position on debtors. Late payments were largely settled in early November and the issues are being addressed accordingly (as problems over payment timing rather than disputes). CQUIN payments are a national issue and payment is expected by March.
Forecast cash is ahead of plan by c13.6m partly due to the change in opening position c2.7m, but mainly due to assumptions around disposals (net improvement c£5.75m - Westfields, Ribbleton and Ridge Lea) and the assumed external cash funding of a substantial part of the Inpatient Scheme (net improvement £4.6m). The forecast assumes that proposed management action to bring financial performance back in to line is achieved (including profit on disposals), that capital receipts are in line with expectations, and that the Trust maintains eligibility for Sustainability Funding (achieves the control total).
Cash shows an adverse variance from plan of £0.4m. The capital position continues to offset the I&E position and pressures on working capital have been reduced - see below.
Contract variations and phasing adjustments negatively impact on cash and are not included in plans.
-10.000
-5.000
0.000
5.000
10.000
15.000
Apr May Jun Jul Aug Sep Oct Nov Dec Jan Feb Mar
Opening cash balance
Financing and Other
Capital and Investment Activities
Changes to WC
Non Cash Flows
Cash flows from operating activities
0.000
5.000
10.000
15.000
20.000
25.000
30.000
Apr May Jun Jul Aug Sep Oct Nov Dec Jan Feb Mar
Forecast
Plan
YTD Plan YTD Act Annual ForecastOct 2017 Oct 2017 Variance Plan Out-turn Variance
6 The underspend largely relates to contingency and reserves. Some delays as a result of dependencies/focus on large schemes and fire safety have resulted in slippage rather than the expected pressures on contingency. Transfers between revenue and capital transacted are as required.
Note 6-
£3.5m of external cash funding was allocated for the Perinatal project, £2.5m in 2017/18. Again issues with third parties have caused some delays and whilst it was hoped this can be managed, some slippage may be likely. The impact has yet to be finalised and incorporated in to forecast.
£0.5m of external cash funding was allocated for Places of Safety. Funding currently exceeds planned work and should spend not be required this year then funding will be retained by DoH.
Capital Expenditure
Progress against the capital programme has been slow to date with expenditure at £1.8m against the original profile of £6.0m. The scheduling profile of many schemes was dependent on a number of tendering exercises (the last of which, Perinatal, has now been completed), agreements with third parties (now substantially resolved) and final funding approval (Inpatient schemes approval now received from NHSI, awaiting final confirmation of funds and timing from DH). Schedules for these and related/dependant schemes are now being finalised through discussions with the incumbent contractors and the Trust is pushing forward with work on the affected projects. Discussions with contractors indicate the delays will cause slippage, mainly on the Inpatients (Chorley site - c5 weeks) though a risk of slippage on the Perinatal scheme remains and is being worked on. Impacts on the respective projects have yet to be finalised and incorporated in to forecasts.
IT programme is expected to be delivered on forecast.External cash funding was provisionally allocated to the Inpatient project through the STP and was approved by NHSI in October. DH have requested additional information, including additional governance requirements, and final approval remains to be confirmed. Work has commenced though delays in relation to the Chorley site, primarily caused by third parties, have meant that works have started later than originally intended and whilst it was hoped this could be managed, slippage of c5 weeks now appears likely. The impact has yet to be finalised and incorporated in to forecast.
Schemes are underway and despite some delays, partly as a result of inpatient development, schemes are expected to be completed in line with planned outturns.
Use Of Resource Metric
unitsPlan
YTD ending 31-Oct-2017
Actual YTD ending 31-
Oct-2017
Variance YTD ending 31-May-17
Plan YTD ending 31-
Mar-2018
Forecast YTD ending 31-
Mar-2018
Forecast Variance
Year ending31-Mar-18
Threshold 1 2 3 4
\ Capital Service Cover 2.5 1.75 1.25 <1.25Capital Service Cover Liquidity 0 -7 -14 <-14
I&E Margin 1.00% 0.00% -1.00% <=-1%
Capital service metric 0.0x 1.803 1.208 (0.594) 1.909 1.647 (0.262) Variance from plan 0.00% -1.00% -2.00% <=-2%
Capital service rating Rating 2 4 2 3 Agency 0.00% 25.00% 50.00% >=50%
Overall rating unrounded Rating 2.80 2.00 If unrounded score ends in 0.5 Rating - -Rounded score Rating 3 2
Use Of Resources Rating before overrides Rating 3 2
4 Rating Trigger for Use Of Resources Rating Text Trigger No trigger
Use Of Resources Rating after 4 rating override Rating 3 2
Control total override - Control total accepted Text YES YES
Is the provider in Financial Special Measures? Text No No
Use Of Resources Rating after overrides Rating 3 2
Finance and use of resources is one theme of 5 in the Single Oversight Framework. Segmentation and therefore autonomy and support is dependent on performance across all themes.
Note that under the Single Oversight Framework a score of 1 is now the best rating and 4 the worst. A rating of 4 on any metric or an average rating of 3 triggers a concern and a potential support need.
Though slightly improved the current I&E position continues to give a rating of 4 and a Capital Service rating of 4 constraining the current overall UoR to a 3. Assuming current pressures and risks are addressed through the recovery plan and I&E performance achieves (or exceeds) forecast the Trust will achieve a UoR of 2 in line with the plan. However, though forecast would achieve the overall target rating, Capital Service is based on EBITDA and since part of the Trusts recovery plan is based on disposals (which are excluded from EBITDA) the Trust is not forecast to achieve planned Capital Service. The Trust is also forecast to exceed its liquidity and slip against it's planned Agency target. Should conditions persist and costs not be managed within the control total then the resulting deterioration might trigger a review of our segmentation.
• Capital Service is currently a 4 against a plan of 2, an increase in operating performance of c£0.2m would be required to increase the rating to 3.
• Liquidity is currently a 1 against a plan of 2, a deterioration in the liquidity metric of c£3.8m would be required to reduce the rating to 2.
• I&E Margin rating is currently 4 against a plan of 2, an increase in operating performance of c£0.3m would be required to increase the rating to 3 - Note that the adjusted deficit of -£2.3m is £2.9m behind the RCT (£1.9m exc STF)).
• I&E Variance from Plan is currently 3, an increase in operating performance of c£0.3m would be required to increase the rating to 2.
Reserves
Reserve Budget Actual £ Annual Projected £
To Date To Date Variance Budget Actual Variance Narrative
£'000 £'000 £'000 £'000 £'000 £'000
Capital Charges £8,966 £9,168 -£202 £15,546 £13,852 £1,694 Anticipated Profit on Disposals offset by var due to revaluation of estate
Pay Reserve £1,166 £566 £600 £1,529 £969 £559 Charge for Apprentice LevyPressures Reserve £293 £117 £176 £503 £201 £302 Funds to be applied to servicesCIP Reserve £1,028 -£47 £1,075 £1,834 -£80 £1,914 Gain on CIP to be applied to service pressuresEmerging Pressures -£315 £0 -£315 -£2,261 £0 -£2,261 Utilisation of Reserves to meet Emerging PressuresDevelopments £729 £280 £449 £934 £250 £684 Costs to be applied as incurredContracts £168 £0 £168 £227 £0 £227 Minor contract gains to be applied to servicesOrganisational Reset £1,017 £235 £782 £1,734 £573 £1,162 Funds to be returned to Networks, with some staffing chargesAgency & Direct Engagement -£350 -£343 -£7 -£600 -£612 £12 Premium for using non-contracted staffNon Clinical Development £4 £0 £4 £22 £0 £22 Premium for using non-contracted staffSavings to be Identified £0 -£2 £2 £0 -£2,420 £2,420 Additional savings required to deliver control total
Non Pay Inflation £638 £162 £477 £794 £216 £578 Funds to be applied for inflationary pressures
Total £13,346 £10,136 £3,210 £20,263 £12,949 £7,313
MATTERS
ID Meeting DatePaper Status
2017/01 Jul-17 VerbalPartial
2017/02 Jul-17 VerbalPartial
2017/03 Jul-17 VerbalPartial
2017/04 Jul-17 VerbalPartial
2017/05 Jul-17 Verbal
Excluded
2017/06 Jul-17 VerbalExcluded
2017/07 Jul-17 Verbal Excluded
2017/08 Jul-17 VerbalExcluded
The Trust is actively exploring the potential for land sales. Gains may crystallise in 17/18 dependent on timing and profits willcontribute toward the control total.
On-going Claims: The process of reclaiming VAT in relation to older developments continues. Communications with HRMC progressthough timing and amounts remain uncertain. Treatment is being discussed with external audit but initial indications are positive. Thevalue may be up to £2m, though less than half this amount is included in plans and forecasts. Our advisors are actively engaged inbringing this to a final resolution.
SubjectA number of disputes require resolution and may result in arbitration. These concern NHSE, West Lancs, and Pennine CCGs. These arebeing escalated through NHSI.
NHSI is currently clarifying the position around elements of the national contingency reserve, £0.5m of which is now outstanding.
The forecast trajectory with regard to Out of Area Placements (OAPs) is currently projected to £1.6m, with the assumption that the50% risk share applies.
Provision for charges incurred as a result of the organisational reset have been made, the process is largely complete, but somechallenges remain and these may have financial consequences.
STF monies have been included in forecasts on the assumption that the Trust will achieve its revenue control total. Should this not bethe case £2.1m of funding would be lost.The Trust is assessing the impact of recent court decisions around pay for sleepover in Learning Disabilities care placements.
The Trust has written to commissioners about the pressure caused by patients awaiting alternative placements.The Trust has opened negotiations with commissioners about the financial impact of patients inappropriately occupying our beds in excess of 180 days.
The Trust is mobilising Acute Therapy Services in Pennine and Chorley, Crisis Support Units in Preston and Blackpool, and a Crisis House in Coppull. These services have an impact on the bed trajectory and variations in timing will alter the OAPs usage accordingly.
There is a fund of c£3m for OAPs, financed 50:50 by the Trust and Lancashire CCGs. After this fund is exhausted, any additional OATs are accounted for on the basis of 50:50 split between the Trust and CCGs.
Current projection suggest there will be expenditure of £5.0m for OAPs in 2017/18., though slippage on developments takes the net impact to £4.8m as reported elsewhere.
Commissioners have asked for, and are receiving, monthly actual performance against the profile.
If the current trajectory persists this would present pressure in the order of £2.3m (net).
ForecastActuals
Board of Directors
Agenda Item TB 185/17 Date: 07/12/2017
Report Title Performance Report (QPR)
FOIA Exemption No Exemption
Prepared by Louise Corlett, Head of Business Intelligence
Presented by Sue Moore, Chief Operating Officer
Action required Noting
Supporting Executive Director Chief Operating Officer
PURPOSE OF THE REPORT:
Report purpose To appraise the Board of Directors of key elements and themes from the Month 7 QPR
Strategic Objective(s) this work supports
To provide high quality services
Board Assurance Framework risk 2.1 The Trust is unable to reposition in the marketplace to become established as a provider of choice achieving excellence
CQC domain Well-led
The Board are asked to note the QPR for month 7 with following comments below:
All NHS I metrics are compliant with the exception of the Early Intervention in Psychosis 2-week
target.
The revised Single Oversight Framework from NHS I contains changes to Operational
Performance metrics, in particular introduction of a new measure on Inappropriate Out of Area
Placements. A reduction in the number of bed days used for inappropriate OAPs is expected
against an agreed baseline and trajectory, both of which are currently being formulated in
conjunction with the STP. This will be presented in further detail at the next Trust Board.
The measures within the Board Balanced Scorecard continue to show the challenges faced by
the organisation currently in relation to our financial position and attracting the best people.
Are we SAFE? Current CQC rating is ‘requires improvement’
Progress on the 16 key priorities in the Quality plan are being monitored through the designated sub-
committee and as shown in the BBSC the current status is that we are on track with 14 priorities and 2
are off track. A detailed update was presented to Board through the Q2 update report.
In month 7, we reported one incident of a potentially avoidable pressure ulcer (grade 3 and 4) however
this is in line with the annual rolling average and is not thought to be the start of a new upward trend.
Nevertheless, a full root cause analysis of the incident is being conducted to identify any new learning
points not already in practice.
As reported last month, levels of physical violence towards staff is still tracking at higher than average in
month 6, and has remained largely static for the last 3 months at around 220 (219 this month). There are
no new areas of concern and the work into the hotspots (PICU and OAMH) continues: The report on a
deep dive review conducted on PICUs has been reported to the Quality and Safety sub-committee and
recommendations accepted which are now being implemented. In addition, the review of personal care
activities on Older Adult wards continues, alongside provision of specific training, and will identify if there
are any changes in clinical practice required. However, as reported last month, the impact of this work
on physical violence against staff is unlikely to deliver a reduction in the short term, and therefore it is
positive that incidence is not increasing.
The incidence of physical violence towards staff alongside the in-month increase in the use of restraint
has also impacted on the performance against the mental health harm free care metric, which has fallen
to 80% against the 90% target in month 7. These 2 metrics are likely to be linked, with the increase in
violence resulting in the requirement for restraint.
The number of Serious Incidents has slightly increased this month and is above the rolling 12-month
average of 7.7 at 10.
Are we CARING?
Current CQC rating is ‘Good’.
We maintain 100% compliance against mixed sex accommodation breaches.
Feedback received through the Friends and Family test is not available at the time of writing for month
7.
The number of compliments has risen slightly in month to 549, however this continues to be well below
the rolling 12 month average. There is a lag in submission of compliments in some areas therefore this
number may increase slightly.
Are we EFFECTIVE?
Current CQC rating is ‘Good’.
The improvement in readmission rate for both 30 and 90 days, across both adult and older adult services
has been retained for the fourth consecutive month in month 7. Whilst for 30d the standard of below 8.7%
was achieved, for 90d readmission the target number of 28 was met and the 15% standard exceeded by
only 0.1%. This position demonstrates the impact of maintaining the team leader reviews at
CMHT/CRHTT clinical discussion meetings and maintaining the profile of this cohort of patients at locality
governance groups.
Average Length of stay still remains just above the 31 day standard at 38.8 days. The length of stay on
adult wards includes PICU patients and it is noted that PICU length of stay has fallen slightly to 34 days.
Over the last 4 months, the positive impact of the Joint Advisory Group has been evident and whilst the
focus has been maintained on the patients with a length of stay of greater than 180 days it is inevitable
that the LOS will be variable as patients are discharged. In future months the QPR will also contain LOS
for current inpatients so that we are able to review a complete picture.
Are we RESPONSIVE?
Current CQC rating is ‘Good’.
The Trust continues to perform well against NHS I indicators, however, as reported last month an issue
has been identified regarding performance in the Early Intervention in Psychosis service against the 2
week target. Current performance falls significantly below the required 50% at 9.5%. A remedial action
plan to address the under-performance has been developed and is being monitored through a fortnightly
task group. Operationally, the requirement to enable timely access and treatment for this patient group
within 2 weeks, is being managed through a daily call with all team leaders. This daily call is enabling
current referrals to be managed in accordance with the 2 week standard, notwithstanding patient choice.
However, the impact of long waiting patient referrals on our performance throughout the remainder of Q3
will make recovery of the target challenging. A formal report was received by SLT in November and SLT
will be kept briefed on progress in achievement of the Q3 target. In addition, formal reporting against the
remedial action plan will be reported to Corporate Governance and Compliance sub-committee.
Responsiveness is also demonstrated through our achievement of the 18 week referral to treatment
(RTT) standard for AHPs and for dental waiting times. In the Community Wellbeing Network, the dental
service RTT in Liverpool prison has recovered back to 100% following the failure to meet the 95% target
in month 6. The Community Well Being Network are compliant against all contractual RTT measures.
In the Children and Young People’s Wellbeing Network, 3 out of 5 services across which we report in
month 7 against the 18 week RTT pathways are compliant, which maintains the improvement seen in
month 5 and month 6.
The Children’s Speech and Language Therapy service have achieved the RTT measure of 92% of
patients on the waiting list having waited less than 18 weeks for the third consecutive month, reporting
98% and as such are no longer required to submit an exception report.
The 2 areas of performance which remain challenged are Child Psychology and CAMHs Tier 3.
Performance in Child Psychology for month 6 has improved to 89%, a further increase on the 84%
reported in month 6 against the 95% RTT standard. In addition, the number of children on the waiting list
who have waited >18 weeks continues to reduce (from 49 in month 6 to 32 in month 7) which is a positive
indicator of the impact that the recovery plan is having and moves the service closer to being able to
achieve the 95% target once the backlog is cleared.
Conversely, performance in the CAMHS Tier 3 service has deteriorated further and the service are
reporting 57% against the 95% RTT standard for completed pathways (compared to 59% in month 6).
The Chorley and South Ribble team continue to be the main contributor to the under-performance with
264 of the 289 service users who are on the waiting list having waited greater than 18 weeks. This is a
result of capacity shortfalls caused by sickness and vacancies, an issue that is being addressed by the
appointment of a new team leader and further appointments are expected in Q3. The longest waiters
are being focussed on in month 8 with all patients waiting greater than 36 weeks being offered
appointments. Weekly meetings are being held with teams to manage the actions necessary to deliver
improvements in line with the trajectory.
In Mindsmatter, a number of measures are monitored that indicate our overall responsiveness. The
service continues to perform well against the NHS I indicators for referral to treatment in 6 and 18 RTT
weeks and percentage of patients entering recovery. Also positive is the reduction in the number of
patients on the waiting list who have waited longer than 26 weeks which has fallen this month to 14. This
will be monitored closely to ensure it drops further. Performance against
prevalence continues to be challenging at team level. Cumulative prevalence is being measured against
the current target and the trajectory required to meet the 16.8% by Q4 (for all teams except BwD). Teams
are largely on track with the current target (with exception of St Helens) but are falling short against the
increased targets for Q4. In depth monitoring and a number of interventions are underway to increase
prevalence.
The high demand for inpatient beds continues, with occupancy levels exceeding 100%, consequently,
the number of out of area placements (OAPs) continues to exceed plan. Work on reducing the number
of patients who have a length of stay of greater than 180 days continues, as identification of alternative
provision would potentially enable the resolution of the OAPs position. As reported last month STP leads
have supported the view that the financial impact of this cohort of patients is separate to the OAPs spend
and as a result the Network have secured support for the implementation of an integrated discharge team
from the end of December.
Mental health liaison teams (MHLT) are reporting an improved position in relation to the 12 hour breach
numbers with a reduction from 8 to 6 in month 7. This demonstrates the impact of the significant
operational management oversight on patient flow and ensuring patients access care in a timely manner.
Demand for the teams continues to be challenging and performance against the 1h and 4h metrics
remains below target. Improvement is expected over coming months given the early investment that has
been secured around Core 24, of which we were notified on the 1st November.
This month the number of complaints has reduced very slightly to 145 compared to 149 in month 6, but
is only marginally above the rolling average of 136 per month. The number of upheld complaints has
risen sharply in month to 43 from 21 in month 6 against an average of 26.7. Notable themes within the
upheld complaints are communication and treatment are addressed via service level action plans. The
number of re-opened complaints and those escalated to the ombudsman remains extremely positive and
may demonstrate the satisfaction of complainants with the outcome of their complaints.
Are we WELL-LED?
Current CQC rating is ‘Good’.
As reported last month, the staff engagement score for the Q2 position shows a static position with only
a decimal point increase on the Q1 position. A further update will be available after Q3.
Sickness rates have risen again to 6.88%, off track in relation to achieving a 4.5% target. The increase
is largely driven by increases in the Mental Health Network where the percentage is 8.5%. Work
continues on absence management across all areas in accordance with policy.
Summary and Recommendations
The information in the QPR provides evidence of our performance against key metrics aligned to each
CQC domains. From this, and the exception reporting against each measure, we are able to provide
information that supports the assessment of our position against each domain.
Section 2.3:- Data Quality • Data Quality Summary • Key Data Quality Exceptions
Section 3:- Finance and Contracting
Section 3.1:- Financial Activity
• UoR Risk Rating • Summary I&E Position • Summary of Clinical Services • CIPS • Capital Expenditure
Section 3.2:- Community Contract Activity • Community & Wellbeing – Network Line Totals • Community & Wellbeing – Service Line Totals • Community & Wellbeing – Total Activity Split by CCG • Community & Wellbeing – Activity Exception Reports by CCG • Children & Young People’s Wellbeing – Service Line Totals • Children & Young People’s Wellbeing – Exception Reports by
Service • Children & Young People’s Wellbeing – Total Activity Split by CCG • Mental Health – Total Activity Split by CCG • Mental Health – Activity Totals
• Quality and Safety Tile • Quality Surveillance – Safe • Quality Surveillance – Effective • Quality Surveillance – Caring • Quality Surveillance – Responsive • Quality Surveillance – Well Led • Delivering the Strategy
Section 5:- Workforce
• Actual Workforce Costs Compared to Budget • Sickness Absence Rates • Appraisals and Mandatory Training Compliance • Vacancy Management and Active Recruitment • Core Workforce Headcount • Workforce Turnover
Section 1:- Board Balanced Score Care
• Trust Strategic Priorities • Board Summary • Quality & Safety • Service Delivery • People & Leadership • Finance
We will ensure that people who use our services are at the heart of everything we do, and the people who deliver and support
delivery of services are motivated, engaged and proud to provide high quality, compassionate, continually improving care. We
will empower people to share their stories so that we know how we are doing and we will listen to learn and to improve quality
together. We will continue to strive to be the best that we can be by upholding our 8 quality commitments and the ‘I’ statements,
empowering everyone to embrace these personal pledges.
Inte
gri
ty
To deliver sustainable services
that meet the needs of local
people
We will collaborate with partners to deliver system wide transformation and we will be an active partner in delivering a bespoke
offer to a number of Accountable Care Systems by
being the prime provider of specialist, acute and community mental health services, and
a lead provider in delivering new models of integrated physical and mental health out of hospital services, and
realising the benefits of our geographical footprint to deliver system wide sustainable infrastructure solutions and
organisational vehicles for new models of care.
Whilst our principal footprint for delivery of services is Lancashire and South Cumbria, we will continue to seek opportunities
across North West STP footprints.
Te
am
wo
rk
To become recognised
for excellence
Our service users and carers will tell us that our services are of high quality. Our people will recommend us to family and
friends. We will be respected by our commissioners and other providers as a co-producing partner in shaping new service
models that deliver our aligned strategies with an emphasis on place based care.
Res
pe
ct
To employ the best
people
We will develop an organisational culture and leadership team equipped to meet its strategic intent and the needs of both its
workforce and the population it serves; in short, a culture of high performing, continually improving and compassionate care.
Staff will be motivated, engaged, high performing and proud of the service they provide. We will proactively support staff to look
after their own health and wellbeing, and to reach their full potential. We will identify and grow our future leaders. People will
want to work here.
Ac
co
un
tab
ilit
y
To provide financially
sustainable services
We will restore and maintain financial balance, and provide services that offer excellent value for money without compromising
financial sustainability. We will work with local partners to deliver system wide efficiency measures. We will actively seek
business opportunities that add value for local people.
Ex
ce
lle
nc
e
To innovate and exploit
technology to transform
care
We will develop and promote digital enabled care, and lead research and innovation to enhance patient experience, reduce
costs and/or improve quality. We will have a culture where staff are given the time, training and resources to research and
innovate. Research will validate innovations and innovations will direct research. Partnerships with third party organisations will
enable rapid execution and exploitation of innovation projects.
4
Performance Management
Research Studies
Aug Sep Oct
127 60 38
Business Gained - Lost
Aug Sep Oct
-£2,230,000 -£602,688 -£51,600
OAPS
Aug Sep Oct
23.68 26.17 24.58
NHSI Compliance
Aug Sep Oct
92.9% 92.9% 92.9%
Sickness Absence
Aug Sep Oct
6.18% 6.35% 6.88%
Agency Ceiling
Aug Sep Oct
-188,237 -222,185 -132,475
UoR
Aug Sep Oct
3 3 3
Revenue Control Total
Aug Sep Oct
-1.4% -1.4% -1.2%
CIP
Aug Sep Oct
86% 86% 88%
Liquidity
Aug Sep Oct
1 1 1
1. Board Balanced Score Card Summary
Capital Expenditure
Aug Sep Oct
33% 29% 31%
Contract Performance (MH)
Aug Sep Oct
+0.88% +0.84% -0.84%
Contract Performance (Comm)
Aug Sep Oct
-1.2% -0.4% -0.6%
Engagement Score
Q4 16-17 Q1 17-18 Q2 17-18
3.77 3.73 3.74
National COPD Audit
Programme
Report due Feb
2018
Use of depot/LA
antipsychotics for relapse
prevention – baseline audit
Report due Nov 2017
Prescribing for bipolar
disorder (use of sodium
valproate) re-audit
Report due Feb 2018
Quality Plan
17/18 objectives 16
On track Off track
12 4
Service Delivery Quality & Safety
People & Leadership Finance
5
Prescribing of high dose
antipsychotics
Acute wards & PICU rank 14/57
Secure Services 20/46
Performance Management
1. Board Balanced Score Card Quality & Safety
Quality Plan
Four Quality Priorities are currently marked as “off track” which are: violence to staff, pressure ulcers, new professional roles
and mental health law. In all cases this is due to the outcome measure not being achieved, the actual improvement projects
themselves are on track. A mid year review is planned for December to review each programme in detail.
Target: 16 objectives
On track 12 Off track 4
Research Studies
Data is subject to a 6-8 week lag as it is uploaded by research teams to a national system retrospectively. Recent recruitment
to the SSHEW clinical trial has an additional 5 weeks until randomisation, leading to significant lag in recruits appearing in
national figures. Local data shows that activity is currently forecast to meet this year’s annual target. Target: 100 participants monthly
38
6
National Audit –
National COPD Audit
Programme
The aim of the project is to audit the activity of the 2 LCFT PR programmes against BTS Quality standards for Pulmonary Rehabilitation in Adults
and compare results with the initial audit which took place in 2015.
The report is due February 2018. Target: Upper quartile nationally
National Audit –
Prescribing for bipolar disorder
(use of sodium valproate) re-
audit
The aim of this topic is to identify any improvement in practice around prescribing in bipolar since the initial audit carried out by POMH-UK.
The report will be published Feb 2018.
Target: Upper quartile nationally
National Audit –
Use of depot/LA antipsychotics
for relapse prevention –
baseline audit Data for this project has been submitted and a report is due November 2017.
Target: Upper quartile nationally
National Audit –
Prescribing of High dose
antipsychotics
A total of 3 standards were included in the audit. The results demonstrated the trust were in the upper quartile for 2 standards.
These standards assessed that the dose of an antipsychotic was within SPC/BNF limits and that only one antipsychotic should
be prescribed at a time. Upper quartile performance was not achieved for standard 3, this was a newly introduced audit
standard. However, overall across all 3 standards acute wards and PICUs were in the upper quartile nationally. Secure
Services were not in the upper quartile, this was a smaller sample than for acute wads and PICUs and an improvement plan has
been developed.
Target: Upper quartile nationally
Achieved
Performance Management
1. Board Balanced Score Card Service Delivery
Business Gained – Business
Lost
Target: 1.5% over next 12 months
(year-end)
Out of Area Placements
(OAPS) The average number of OAPs decreased slightly in October by 1.59 alongside a decrease in the OAP OBD in October with a position of 762, a
decrease of 23 from September.
The overall number of OAPs remains relatively static against an assumed fall in the trajectory.
Target: 15 contracted beds
24.58
Contract Activity - Community
Target achieved. Target: 100% (+/-10%)
-0.6%
Contract Activity – Mental
Health Following an investigation into MAS data being inflated due to ‘Notes’ being included within reporting, LCFT have removed ‘Notes’ from the
following affected services: MAS, ADHD, Eating Disorders and Hospital Liaison, which has seen the Trust overall variance against last year’s plan
fall from 0.84% to -0.84%. Target: 100% (+/-10%)
-0.84%
NHSI Compliance
All NHSI measures are compliant for M7 apart from EIP (MR13), which has been under a period of revalidation and investigation. Work within the
Network is currently ongoing and it is anticipated that performance is still achievable for Q3. Target: 100% in each quarter
92.9%
7
Performance Management
Agency Ceiling
Usage of Agency in Community, HMP Liverpool and Medics has been
consistent across the last two months, with only small deviation.
The percentage of annual leave in month has dropped considerably
and this can be seen in the reduction in Agency spend.
Target: 641,250
Not achieved
1. Board Balanced Score Card People & Leadership
Aug Sep Oct
YTD Target 641,250 641,250 641,250
YTD Actuals 829,487 863,435 773,725
Under/(Over)
Agency
Usage
-188,237 -222,185 -132,475
Engagement Score Q2 2017/18 period results :
• Recommend LCFT as a place to receive treatment (Workforce Advocacy): Yes – 71.41%, No – 10.31%, Don’t Know – 18.28%
• Recommend LCFT as a good place to work: (Workforce Involvement and Motivation): Yes – 51.75%, No – 27.35%, Don’t Know – 20.89%
Improvement Initiatives:
A Wellbeing dimension has been added to the Quarterly Staff FFT questionnaire. This supplements the 3 existing dimensions of Advocacy,
Motivation and Involvement. The first Staff FFT report to include this new dimension will be available in January 2018.
Target: Top 25% of other Trusts
Not achieved
Sickness Absence
The sickness absence rate for October has increased, reporting at 6.88%. Please refer to the relevant M7 QPR detailed slides for information
about Improvement plans and initiatives. Target: 4.5%
6.88%
8
Performance Management
1. Board Balanced Score Card Finance
Use of Resources (UoR)
The current I&E position gives a rating of 4 and delivers a Capital Service rating of 4 constraining the current overall UoR to a 3. Assuming
current pressures and risks are addressed through the recovery plan and I&E performance achieves (or exceeds) forecast the Trust will achieve
a UoR of 2 in line with the plan. Target: 2
3
Capital Expenditure Progress against the capital programme continues to be slow with year-to-date expenditure at £1.8m against the original
profile of £5.9m. A number of issues have recently been resolved which will allow the Trust to push forward with the work
required to complete its capital programme in line with its control total and funding, however given the delays, risks of slippage
remain.
Target: 85-100%
31%
Revenue Control Total A number of risks and pressures have been identified that if not addressed will compromise the Trusts ability to deliver the planned control total
for 2017/18. Whilst it would appear that the gap can be bridged through the recovery plan, this is not without significant risk. Delivery will only be
achieved with a considerable coordinated and sustained effort across the organisation. Target: ≥0%
-1.2%
Cost Improvement
Programmes (CIPs) At £7.4m in month 7 the Trust is c£1.1m behind the plan of £8.4m. The adverse variance is mainly due to a lack of performance on Run Rate
Reduction Programmes on staffing pressures. Compensating schemes have, and continue to be, developed and network management team are
being supported by to implement measures aimed at improving the position. Target: ≥100%
88%
Liquidity
Forecasts indicate that with the delivery of the planned surplus the Trust will achieve a liquidity of 1. Target: 2
1
9
*Under the Single Oversight Framework, the Trust is now managed against the Use of Resource Metrics (UoR). Under the Single Oversight Framework, a score of 1 is now the
best rating and 4 the worst. A rating of 4 on any metric or an average rating of 3 triggers a concern and a potential support need.
% of SU that have had a CPA Review in last 6 months Stretch 100% 100.0% 100.0% 100.0% 100.0% 99.3% 99.3% 98.0% 97.4% 96.1% 94.5% 97.2% 96.0% 100.0%
% of service users who have a Care Coordinator allocated within 2 weeks Stretch 100% - 60.0% 62.5% 75.0% 77.8% 75.0% 66.7% 100.0% 50.0% 66.7% 99.3% 100.0% 100.0%
% of CPA reviews attended by Local Care Coordinators Stretch 80% - 37.5% 50.0% 25.0% 42.9% 39.3% 65.2% 33.3% 51.7% 42.9% 44.0% 48.1% 43.5%
% of service users who have Cardiometabolic risk factors assessed within
% of caseload with a Local Care Coordinator allocated Stretch 100% - 89.8% 96.1% 96.0% 97.9% 100.0% 95.3% 97.0% 95.5% 100.0% 97.0% 100.0% 100.0%
% of caseload carried longer than 12 months post SMHBU discharge Stretch ≤ 20.00% - 57.1% 58.8% 72.0% 66.7% 74.0% 60.9% 60.6% 59.7% 63.5% 58.2% 60.9% 66.0%
% of CPA Reviews Attended by Local Care Coordinators / Local Teams Stretch 80% - 42.9% 50.0% 62.5% 75.0% 30.0% 33.3% 40.0% 54.5% 33.3% 50.0% 63.6% 25.0%
No of Incidents exceeding PACE Clock Commissioners 0 6 4 3 4 3 5 7 3 4 5 5 9 3
Health & Justice Business Unit - HMP Liverpool
GP Waits over 2 Weeks NHSE 0% 43.6% 52.6% 64.1% 55.0% 59.5% 64.2% 49.4% 22.8% 0.0% 18.8% 43.6% 43.1% 44.9%
Children & Young People's Allocated Patients 0 13 14 8 18 29 23 5 4 2 2 - -
Manual Overrides
Trust NHSI Manual Overrides 0 6 16 21 11 13 2
MR01 NHSI Manual Overrides 0 5 4 6 8 1 0
MR07 NHSI Manual Overrides 0 1 11 6 3 8 0
Other NHSI Manual Overrides 0 0 1 9 0 4 2
Note: Allocated patients figures are not provided for September or October as the report is offline due to a technical error. The report has been redefined and rebuilt and is
in the process of final validation.
Performance Management
2.3 Data Quality Data Quality – Manual Overrides
72
Manual Overrides:
A combination of better recording, checking and reporting has seen manual overrides greatly reduce. Meetings have been diarised
aimed at addressing those that remain.
Performance Management
73
Section 3:- Finance and Contracting
Section 3.1:- Financial Activity
• UoR Risk Rating
• Summary I&E Position
• Summary of Clinical Services
• CIPS
• Capital Expenditure
Section 3.2:- Contract Activity
• Community & Wellbeing – Network Line Totals
• Community & Wellbeing – Service Line Totals
• Community & Wellbeing – Total Activity Split by CCG
• Community & Wellbeing – Activity Exception Reports by CCG
• Children & Young People’s Wellbeing – Service Line Totals
• Children & Young People’s Wellbeing – Exception Reports by Service
• Children & Young People’s Wellbeing – Total Activity Split by CCG
• Mental Health – Total Activity Split by CCG
• Mental Health – Activity Totals
Section 3.3:- Commissioning for Quality & Innovation
• CQUIN Executive Summary
3. Finance and Contracting
Performance Management
Financial Activity
Section 3.1
74
Performance Management
Use of Resources rating (UoR)
The current I&E position gives a rating of 4 and delivers a Capital Service rating of 4 constraining the current overall UoR to
a 3. Assuming current pressures and risks are addressed through the recovery plan and I&E performance achieves (or
exceeds) forecast the Trust will achieve a UoR of 2 in line with the plan. However, though forecast would achieve the overall
target rating, Capital Service is based on EBITDA and since part of the Trusts recovery plan is based on disposals (which
are excluded from EBITDA) the Trust is not forecast to achieve planned Capital Service. The Trust is also forecast to
exceed its liquidity and slip against it's planned Agency target.
Should conditions persist and costs not be managed within the control total then the resulting deterioration might trigger a
review of our segmentation.
3.1 Financial Activity Use of Resources (UoR) Risk Rating
75
FINANCE AND USE OF RESOURCES RATING
Plan Actual Plan Forecast
Capital service cover rating 3 4 2 3
Liquidity rating 2 1 2 1
I&E margin rating 2 4 2 2
I&E margin: distance from financial plan 1 3 1 2
Agency rating 1 2 1 2
Overall 2 3 2 2
Year to Date Annual
Performance Management
Sustainability
Month 7 sees a year to date operating deficit of -£2.3m, excluding planned Sustainability and Transformation funding of
£0.9m, against a planned surplus to date of £0.6m. This represents a small budgetary surplus in month and nearly £0.2m
when excluding STF monies and indicated the position has improved in month. The position remains driven by staffing
pressures in ward and prison areas and consequential impact on cost improvement programmes (rising agency costs will
also impact Use of Resources targets). Additionally OAPs expenditure continues to exceed funding. The forecast assumes
current pressures and risks are addressed or mitigated in line with the recovery plan and financial performance achieves (or
exceeds) plan but the unmitigated projection indicates a gap of c£4.8m, c£6.9m without STF monies. This is represents an
improvement on month 6 (£6.2m), and is driven by excess OAPs of c£0.8m (all be that significantly below last month),
prisons and additional mental health pressures. Delivery of the recovery plan and financial targets will required a significant
and coordinated response with robust management and oversight.
3.1 Financial Activity Summary I&E Position
76
FUNDED WTE BUDGET DETAIL BUDGET ACTUAL £ ANNUAL PROJECTED £
EST. ACTUAL TO DATE TO DATE VARIANCE BUDGET ACTUAL VARIANCE
£'000 £'000 £'000 £'000 £'000 £'000
Healthcare Income 178,911 178,212 -699 303,991.4 304,576 584
3.2 Contract Activity – Variance to Plan Community & Wellbeing – Activity Exception Reports by CCG
Community & Wellbeing Planned Contract Activity M7
The Community & Wellbeing Network has provided the following explanations as to why certain services are underperforming by more than 10% against the baseline.
Commissioner: NHS Blackburn with Darwen CCG
Under Performance Exception Reporting:-
Adult Learning Disability Service 59%-
Current position and issues:
The ongoing work regarding data capture has provided an increase in activity for October. This is despite a reduction of staff during the month. Long term sickness for
the clinical psychologist continues and there have been a number of absences during the month.
Actions:
1. Ongoing validation of the data.
2. Monthly Performance meetings with Team Leaders, Service Manager and Care Group Manager to review performance.
Forecast:
A deep dive into the data continues so understand the full extent of the under-performance however the return from sickness and the improved data capture should start
to have a more positive impact on baseline activity.
Until these further investigations have been carried out it is difficult to propose an accurate recovery trajectory and therefore this will be proposed once the increase in
activity of the returning staff has been quantified.
3.2 Contract Activity – Variance to Plan Community & Wellbeing – Activity Exception Reports by CCG
Commissioner: NHS Blackburn with Darwen CCG
Under Performance Exception Reporting:-
Community IV Service BwD 62.5%-
Current position and issues:
In M7 the IV team became a step down service only. The service continues to work with BWDCCG and ELHT to maximise referrals. The IV team have capacity to
accept and see more referrals. In M7 the team had the highest number of contacts in this financial year.
In M7 there was a staff member on long term sickness which has had an impact upon our ongoing promotions.
The service continues to support the nursing element of IHSS to ensure all service needs and demands are delivered in a timely way to provide acute responses.
Recovery action plan:
We will continue to promote the IV service in ELHT and other acute sites and liaise with the OPAT nurse at ELHT daily regarding potential patients to try and increase
referrals to the service.
Trajectory:
From October 1st 2017 the service stopped accepting step up referrals from primary Care so this will have a further impact on referrals to the service.
Forecast:
As we will cease to receive step-up referrals this will have an impact on our proposed recovery trajectory.
The IV service continues to work with stakeholder colleagues to promote and identify patients for Community IV therapy.
The staff member who was on long term sick has now returned to work. This will increase our teams capacity and ensure further promotion work can be completed.
Community Stroke Service 16%-
Current position and issues:
The teams monthly plan was to achieve 486 contacts. For M7 this target was exceeded however previous months positions left us at 16.% negative variance. This has
been due to a number of factors. Long term sickness has impacted on our capacity for a number of months but we have also had some short term sickness. In M7 we
have had reduced staff sickness levels.
We continue reviewing the vacancies in terms of skill mix and in line with the Pennine Lancashire stroke specification which is currently being worked on. We aim to start
recruitment as soon as possible.
A locum has now been in place since the beginning of M7 to support Speech and Language Therapy until permanent staff are in place.
Forecast:
With increased staffing levels over the coming months we expect that we will be back within tolerance by M11 and the YTD Plan will be met.
We will continue to build on our working relationships and promoting the service within the acute trust to facilitate timely discharges.
Performance Management
3.2 Contract Activity – Variance to Plan Community & Wellbeing – Activity Exception Reports by CCG
Commissioner: NHS Blackburn with Darwen CCG
Under Performance Exception Reporting continued:
DESMOND (Completed Courses) 19%-
Current position and issues:
Month 7 is showing a negative variance of 19% which equates to a total of 42 contacts. This is an improvement on the previous month of 7.7%.
The service has had problems with long term sickness throughout 17/18 which has reduced the amount of courses it has been able to offer, this was particularly
challenging in months 3,4 &5 but has recovered in recent months with the past 2 months being over plan.
Recovery action plan:
An action plan has been agreed with the CCG which includes the following:
• Team to contact all patients that have been referred in by telephone to give more detail of the value and benefits of attending a DESMOND course
• Increase the number of people trained in Desmond to enable backfill when staff are off sick.
Forecast:
There are 4 courses planned for Month 8 and 2 for Month 9 which should maintain our recovery trajectory which has been set at 10% above monthly plan. If achieved our
year end position should be within our target performance tolerance.
Diabetes Specialist Nursing 27%-
Current position and issues:
The monthly plan was 515 contacts and the team achieved only 362 in M7 leaving us in a -27% negative variance. Due to unplanned levels of sickness within our
Diabetes Education Programme (DESMOND), Diabetes Specialist Nurses supported the education courses so that patients did not have to be cancelled. This however
has had a negative impact on our own Diabetes baseline figures.
Recovery action plan:
A member of staff on long term sickness had now returned to work in M8. In M8 we will expect to see an increase in number of contacts completed.
Forecast:
With the new member of staff in post and DESMOND staff returning to work in M8, we would expect to see an increase in contacts over the coming months leaving us in a
positive year-end position.
Treatment Room
Meetings are taking place in November with Commissioners to understand decreasing activity. The outcomes and subsequent action plans from the meetings will be
published in month 8 QPR.
Performance Management
3.2 Contract Activity – Variance to Plan Community & Wellbeing – Activity Exception Reports by CCG
Commissioner: NHS Blackburn with Darwen CCG
Over Performance Exception Reporting:-
Children's Learning Disability Service 54%+
Current position and issues:
There have been a number of groups running over the past 2 months which has increased our activity figures leaving us in a positive variance of 54% in M7. These
groups are set to continue throughout the year.
Community Respiratory Service 14%+
Current position and issues:
We continue to see high levels of referrals and the service responds to the demand and needs of the population.
Pulmonary Rehabilitation 26%+
Current position and issues:
The current position in maintaining activity over plan is due to the numbers of patients attending and successfully completing their course. This is due to intensive work
contacting patients, building relationships within the service/stakeholders which has resulted in more patients completing a six week course.
Tissue Viability Service 17%+
Current position and issues:
The team have noted an increase in the complexity of the patients requiring more visits. The team are now completing an increasing number of reviews due the
increased number of referrals which are more complex, including referrals from the acute, nursing homes and district nurses. The team continue to meet current
demands.
Performance Management
3.2 Contract Activity – Variance to Plan Community & Wellbeing – Activity Exception Reports by CCG
Commissioner: NHS Blackpool CCG
Over Performance Exception Reporting:-
Specialist Nurse TB 63%+
Current position and issues:
Increased numbers of referrals over several months has contributed to a positive in month variance against plan.
Commissioner: Central Lancs Locality
Under Performance Exception Reporting:-
Community Matrons 24%-
Current position and issues:
Referrals into the matron service have decreased over the last three months which has impacted on activity linked to new face to face contacts and associated reviews.
A reduction in WTE linked to vacancy and implementation of the action plan to support the CHESS service has also impacted on matron activity.
All patients referred have been seen and care plans formulated. New care pathways are being developed between matrons and specialist teams to ensure seamless care
across pathways are in place. This may see a reduction in follow up activity for matrons moving forwards as patients are managed along specialist pathways.
Forecast:
Additional vacancy from the end of November is likely to further impact on activity. It is unlikely that the service will be fully recruited to before M10 and this will further
impact on activity with a projected negative end of year variance of -22%.
Tissue Viability Service Total 90 49 50 48 53 57 53 50 360 -380 -51.4% 740
Performance Management
3.2 Contract Activity – Variance to Plan Community & Wellbeing – Activity Exception Reports by CCG
Commissioner: Central Lancs Locality
Under Performance Exception Reporting continued:-
Heart Failure Service 51%-
Current position and issues:
The existing staff are supporting the Chorley expansion until new staff in post. This has contributed to the drop in Greater Preston activity in month.
Intermediate Care ACS 27%-
Current position and issues:
Activity in Intermediate Care is to be viewed in the context of Falls and Community Therapies. These are collectively above baseline and delivered as one overall service
specification. Taking account of the overall activity of the combined Community Therapy teams overall they are over-performing. Staff are flexed across all areas within the
Integrated rehabilitation Team to respond according to clinical demand - performance of the combined team is showing well above activity taking into account the
Intermediate Care, Domiciliary Physio and Falls data.
Tissue Viability Service 51%-
Current position and issues:
The patient pathway following referral has been reviewed, and opportunities to access the multi-disciplinary team have been maximised. This supports clear case holding
responsibility and access to services in the wider neighbourhood team, most suited to the patient need (e.g. podiatry). This supports increased availability for consultation
and supervision. Referral rates remain constant.
Over Performance Exception Reporting:-
Adult Speech and Language Therapy 37%+
Current position and issues:
The service have increased their use of non face to face reviews which has had a positive impact on our activity levels. There has also been a significant increase in
referrals over the last 2 quarters of the year. New staff have commenced employment and have full caseloads.
Community Neuro Team 11%+
Current position and issues:
Team resource is flexed across the Central Lancs locality and overall the demand has increased for the service which is reflected in the increase numbers of referrals
across the locality. Overall the service is showing a positive variance.
Performance Management
3.2 Contract Activity – Variance to Plan Community & Wellbeing – Activity Exception Reports by CCG
Commissioner: Central Lancs Locality
Over Performance Exception Reporting Continued:-
Community Respiratory Service 23%+
Current position and issues:
An increase in the number of in month referrals combined with increased acuity of caseload has contributed to increased activity in month.
DESMOND (Completed Courses) 21%+
Current position and issues:
The service currently has an action plan in place to increase uptake of diabetes structured education. This is continuing to deliver improvements in attendance and
contributing to a positive variance in month against plan.
Domiciliary Physiotherapy 75%+
Current position and issues:
The Team's continued over performance reflects activity delivered to support admission avoidance. This activity should also be taken in conjunction with all other
community therapy activity (as part of one combined service specification for Central Lancs Community Rehabilitation Team). This combines Domiciliary Physiotherapy
and Falls Team data. Whilst Intermediate care is showing an underperformance, collectively the rehabilitation team is significantly overperforming on activity - as per
previous exception narrative. Note, Falls data does not include that of Steady On which is reported separately to LCC.
Falls Team 79%+
Current position and issues:
The Team's continued over performance reflects activity delivered to support admission avoidance. This activity should also be taken in conjunction with all other
community therapy activity (as part of one combined service specification for Central Lancs Community Rehabilitation Team). This combines Domiciliary Physiotherapy
and Falls Team data. Whilst Intermediate care is showing an underperformance, collectively the rehabilitation team is significantly overperforming on activity - as per
previous exception narrative. Note, Falls data does not include that of Steady On which is reported separately to LCC.
Nutrition & Dietetics 13%+
Current position and issues:
A high demand for the service combined with increasing numbers of patients requiring ongoing follow up reviews continues to place the service under pressure and
contributes to higher than planned activity.
Performance Management
3.2 Contract Activity – Variance to Plan Community & Wellbeing – Activity Exception Reports by CCG
Commissioner: NHS Chorley & South Ribble CCG
Under Performance Exception Reporting
Adult Learning Disabilities 13%-
Current position and issues:
There have been unfilled vacancies since July and also maternity leave and sickness absence With a significant amount of annual leave in October (half term) this has
contributed to lower activity levels in M7.
Over Performance Exception Reporting:-
Children's Learning Disability Service 48%+
Current position and issues:
Overactivity is due to the number of groups that the team now undertake. The additional activity within Chorley & South Ribble team to see ASD referrals has also
contributed to the increase in activity.
Rheumatology 16%+
Current position and issues:
Increasing numbers of referrals is contributing to increased activity which is both positive in month and YTD variance against plan.
Specialist Nurse TB 28%+
Current position and issues:
Increased numbers of referrals over several months has contributed to a positive in month variance against plan.
Viral Hepatitis Service 19%+
Current position and issues:
Increases in group activity continues to contribute to a positive in month variance.
3.2 Contract Activity – Variance to Plan Community & Wellbeing – Activity Exception Reports by CCG
Commissioner: NHS Fylde and Wyre CCG
Under Performance Exception Reporting:-
Adult Learning Disability Service 15%-
Current position and issues:
The revision of the baseline and the continuing validation of the data is reflected in the improving performance and the diminishing YTD variance.
Actions:
1. Ongoing validation of the data.
2. Analysis of data on a weekly basis to identify issues in advance.
3. Monthly Performance meetings with Team Leaders, Service Manager and Care Group Manager to review performance. The focus of these meetings being on
performance and contributing factors.
Forecast:
With the revised baseline and the work to improve data capture coming to fruition it is felt that we will over perform against the new monthly plans by approximately 10%
each month however this will be reviewed and adjusted accordingly once the revised activity levels have been quantified over the next few months.
This trend is expected to continue and may result in a review of baselines for 2018.
Over Performance Exception Reporting:-
Specialist Nurse TB 60%+
Current position and issues:
Increased numbers of referrals over several months has contributed to a positive in month variance against plan
3.2 Contract Activity – Variance to Plan Community & Wellbeing – Activity Exception Reports by CCG
Commissioner: NHS Greater Preston CCG
Under Performance Exception Reporting:-
CHESS 39%-
Current position and issues:
The CHESS team supports services across both GPCCG and CSRCCG. Both localities have seen reduced numbers of referrals from 29 in M4 down to only 5 in M7
which is a significant reduction and which has led to reduced activity, although activity has significantly increased in M7.
The team experienced substantial unplanned absence from June onwards which will have contributed to the reduced referrals and impacted upon activity levels over the
last 5 months. Coupled with this, there has been an increase in vacant beds in both homes over the latter months which will also have impacted on referrals to the service
and associated activity.
Recovery Actions:
LCFT have been in regular communication with the CCG and have put actions in place to address the immediate staffing issues within the CHESS service using a rotation
of senior matrons to manage the two intermediate care facilities. This is now working more smoothly and activity has increased in M7. Longer term LCFT has formulated
a business case to create a sustainable integrated frailty service able to work in an integrated and flexible manner to deliver the specifications set out in the Frailty,
CHESS and Community Matron service lines and establishing a longer term sustainable service. This business case is awaiting CCG sign off to enable full recruitment
into appropriate skill mixed roles.
Forecast:
Assuming that bed occupancy and associated referrals increases in line with the time of the year based on previous years referral activity then we would expect to see
activity increasing.
It is unlikely that we will meet the plan in year as recruitment to posts proposed in the new model will need to take place. It is estimated that it will take 3 months to
achieve full recruitment. The trajectory has been based on this and will still give a negative variance of approx -37%.
3.2 Contract Activity – Variance to Plan Community & Wellbeing – Activity Exception Reports by CCG
Commissioner: NHS Greater Preston CCG
Over Performance Exception Reporting:-
Adult Learning Disability Service 28%+
Current position and issues:
This months over performance is largely due to consistent communications with staff to record all activity they undertake for a patient. There has also been a
significant increase in referrals to this team over the last quarter resulting in increased activity in M7.
Children’s Learning Disabilities 14%+
Current position and issues:
Over activity is due to the groups that commenced in M6 'Riding the Rapids' These courses are set to continue.
Viral Hepatitis Service 65%+
Current position and issues:
Increases in group activity continues to contribute to a positive in month variance.
Commissioner: NHS Morecambe Bay CCG
Under Performance Exception Reporting:-
Adult Learning Disability Service 14%-
Current position and issues:
Sickness has contributed to targets not being met. 1 nurse on long term sick and a number of short term sickness. There has been no impact to patient care.
3.2 Contract Activity – Variance to Plan Community & Wellbeing – Activity Exception Reports by CCG
Over Performance Exception Reporting:-
Children’s Learning Disability Service 206%+
Current position and issues:
Over activity due to the significant number of groups running e.g. 'Riding the Rapids'. A re-evaluation of baselines may need to be considered in respect of the new
activity and capacity in north Lancs (ASD pathways).
Specialist Nurse TB 42%+
Current position and issues: Significant increases in referrals continues to result in a positive variance against plan.
Commissioner: NHS West Lancashire CCG
Over Performance Exception Reporting:-
Adult Learning Disability Service 74%+
Current position and issues:
This months over performance is largely due to consistent communications with staff to record all activity they undertake for a patient. There has also been a small
increase in referrals received over the last quarter which has led to an increase in activity in M7. The complexity of clients on the caseload has also increased the
numbers of contacts undertaken in month.
Specialist Nurse TB 27%+
Current position and issues:
High levels of referrals continue to contribute to a positive variance against monthly plan.
Viral Hepatitis Service 124%+
Current position and issues:
Increases in group activity continues to contribute to a positive in month variance.
Total Against Plan11,118 6,830 9,676 8,101 7,920 7,188 8,855 9,362 57,932 -14,073 -19.5% 72,005
Performance Management
3.2 Contract Activity – Variance to Plan Children & Young People’s Wellbeing – Exception Reports by Service
98
Commissioner: NHS Chorley & South Ribble CCG
Under Performance Exception Reporting:-
Children’s Occupational Therapy 23%-
Current position and issues:
October manual activity data was 204 against a baseline of 240. The current YTD total based on CITNS manual count is 1,220 -338 YTD. (Variance % -23.2%).
Based on the planned activity total, the service is required to see an extra 96 contacts in total to meet the 10% threshold.
Average staff capacity in Chorley & South Ribble OT during the 17/18 monitoring year has been at 100%.
The team continues to now meet RTT target during 17/18.
Paediatric Liaison 62%-
Current position and issues:
The service receives 100% of its referrals from the Emergency Department (ED), and have no control over the number of children attending however the activity is
lower than expected as we are currently unable to identify the activity that is deflected through the Go To Doctor service.
Commissioner: NHS East Lancashire CCG
Under Performance Exception Reporting:-
Children’s Occupational Therapy 14%-
Current position and issues:
October manual activity data was 350 against a baseline of 379. The current YTD total based on CITNS manual count is 2,155 -358 YTD. (Variance % -14%). Based
on the planned activity total, the service is required to see an extra 154 contacts in total to meet the 10% threshold.
Average staff capacity in East Lancashire OT during the 17/18 monitoring year has been at 83%.
The team continues to now meet RTT target during 17/18.
3.2 Contract Activity – Variance to Plan Children & Young People’s Wellbeing – Exception Reports by Service
99
Commissioner: NHS East Lancashire CCG
Under Performance Exception Reporting Continued:-
Children’s Speech & Language Therapy 15%-
Current position and issues:
October manual activity data was 1258 against a baseline of 1272. The current YTD total based on CITNS manual count is 6843 YTD. (Variance % -15.6%). Based
on the planned activity total, the service is required to see an extra 236 contacts in total to meet the 10% threshold.
Average staff capacity in East Lancs SLT during the 17/18 monitoring year has been at 84%.
The team continues to now meet RTT target during 17/18.
Commissioner: NHS Greater Preston CCG
Under Performance Exception Reporting:-
Children’s Occupational Therapy 26%-
Current position and issues:
October manual activity data was 212 against a baseline of 232. The current YTD total based on CITNS manual count is 1,137 -400 YTD. (Variance % -26%). Based
on the planned activity total, the service is required to see an extra 108 contacts in total to meet the 10% threshold.
Average staff capacity in Greater Preston OT during the 17/18 monitoring year has been at 83%.
The team continues to now meet RTT target during 17/18.
3.2 Contract Activity – Variance to Plan Children & Young People’s Wellbeing – Exception Reports by Service
100
Commissioner: NHS Greater Preston CCG
Under Performance Exception Reporting Continued:-
Children’s Physiotherapy 22%-
Current position and issues:
October manual activity data was 327 against a baseline of 360. The current YTD total based on CITNS manual count is 1,764, -523 YTD. (Variance % -22.9%).
Based on the planned baselines, the service is required to record an extra 155 F2F contacts by year end to meet the 10% threshold.
Staff capacity in Greater Preston Physio team during the 17/18 monitoring year has been at 83%.
The team continues to meet RTT target during 17/18.
Children’s Speech and Language Therapy 16%-
Current position and issues:
October manual activity data was 591 against a baseline of 606. The current YTD total based on CITNS manual count is 3,216 -645 YTD. (Variance % -16.7%).
Based on the planned activity total, the service is required to see an extra 259 contacts in total to meet the 10% threshold.
Average staff capacity in Greater Preston SLT team during the 17/18 monitoring year has been at 77%.
The team continues to meet RTT target during 17/18.
Children’s Paediatric Liaison 34%-
Current position and issues:
The service receives 100% of its referrals from the Emergency Department (ED), and have no control over the number of children attending however the activity is
lower than expected as we are currently unable to identify the activity that is deflected through the Go To Doctor service.
Performance Management
3.2 Contract Activity – Variance to Plan Children & Young People’s Wellbeing–Exception Reports by Service
101
Commissioner: NHS West Lancashire CCG
Under Performance Exception Reporting:-
Children’s Occupational Therapy 32%-
Current position and issues:
October manual activity data was 103 against a baseline of 166. The current YTD total based on CITNS manual count is 742 -358 YTD. (Variance % -33%). Based
on the planned activity total, the service is required to see an extra 68 contacts in total to meet the 10% threshold.
Average staff capacity in West Lancashire OT during the 17/18 monitoring year has been at 98%.
The team continues to now meet RTT target during 17/18.
Children’s Physiotherapy 25%-
Current position and issues:
October manual activity data was 155 against a baseline of 194. The current YTD total based on CITNS manual count is 909, -315 YTD. (Variance % -25.7%).
Based on the planned activity total, the service is required to see an extra 83 contacts in total to meet the 10% threshold.
Average staff capacity in West Lancashire Physio team during the 17/18 monitoring year has been at 66%.
The team continues to meet RTT target during 17/18.
Grand Total 21,924 25,423 24,424 24,385 24,474 23,479 24,019 168,128
Performance Management
104
3.2 Contract Activity – Variance to Plan Mental Health – Activity Totals
2017-18 Baseline Proposal
Last month it was reported that the MAS Contact activity has been over inflated due to the reporting of ‘Patient Notes’ and as result an investigation
was required to determine which other teams maybe affected and whether the baselines would need to be adjusted as a result.
Since then a meeting with Practitioners has been carried out to determine whether Patient/Proxy contacts are reported within ‘Patient Notes.’ The
outcome of which concluded that Practitioners have sporadically been using the ‘Notes’ contact type to record patient contacts across all services.
If we therefore take the decision to remove ‘Notes’ from the Schedule 6 reporting we would be excluding a percentage of legitimate patient contacts.
The Performance team are therefore co-ordinating an ad-hoc audit to determine the percentage of Patient/Proxy contacts recorded within ‘Notes’
against each service. The results of this audit, which we are planning to complete by the end of November, will then enable more accurate revised
baselines to be set and for the reported figures to be adjusted appropriately.
Aside from the above audit, LCFT are investigating whether other Contact Types that do not hold Patient/Proxy contacts have been misreported within
the Schedule 6 figures and the results of this investigation will also be known by the end of November.
2017-18 M7 Activity
For M7, LCFT have continued to provide the activity totals and YTD position only whilst the baselines are being finalised.
Following the initial investigation into LCFT including ‘Patient Notes’ within Schedule 6 reporting and the resulting over inflated activity of MAS contact
activity, LCFT have determined that the same error had been replicated in the following services: ADHD, Eating Disorders and Hospital Liaison, and a
decision was taken to remove ‘Patient Notes’ and refresh the activity back to April 17. This refresh has been completed for M7, however following the
Practitioner meeting it has become apparent that this will need to be amended following the aforementioned audit.
As a result of the Network Re-design historical data prior to 15 May 2017 is recorded in the four Network structure and has been aggregated in this report to provide the best available comparison.
Data provided shows the following 12 month figure (where a number) or the rolling 12 month average (where a percentage).
Physical Health HFC Rate (%) Appraisals (%)
Mental Health HFC Rate (%) Concerns raised
Good
Completed within agreed
timeframe (%)
RESPONSIVE
Complaints
Upheld/partially upheld
complaints
WELL LED
Trust CQC rating
Performance Management
4. Quality Safe
110
Domain Indicator Target Nov Dec Jan Feb Mar Apr May Jun Jul Aug Sep Oct12 months
The Friends and Family Test real time reporting is locked and nationally reported on the 19th of each month and will therefore be reported in arrears most months
Domain Indicator Target Nov Dec Jan Feb Mar Apr May Jun Jul Aug Sep Oct12 months
National Audit Data collection period Report due Compliance
National Audit of Intermediate Care
(NAIC)
May 2017 to August 2017
Participants will be asked for outturn data
April 2018
National chronic Obstructive
Pulmonary Disease (COPD) audit
programme
April 2017 to July 2017 February 2018
National Diabetes Audit – Adults April 2017 to July 2017 February 2018
Sentinel Stroke National Audit
programme (SSNAP)
April 2017 to March 2018
Collection: April to July, August to November, December to
March, April to March (annual)
January 2018
UK Parkinson’s Audit: (incorporating
Occupational Therapy
Speech and Language Therapy,
Physiotherapy
Elderly care and neurology)
1 May 2017 to 30 September 2017
May 2018
National Audit of Psychosis Autumn/Winter 2017 TBC
National Audit of Anxiety & Depression TBC TBC
Topic 17: Use of depot/LA
antipsychotics for relapse prevention
– baseline audit
May 2017 to June 2017
Sampling & Data Collection: May 2017
Online Data Submission: June 2017
Nov 2017
Topic 15: Prescribing for bipolar
disorder (use of sodium valproate) –
re-audit
September 2017 to October 2017
Sampling & Data Collection: Sept 2017
Online Data Submission: October 2017
Feb 2017
Topic 6: Assessment of side effects of
depot antipsychotic medication – 2nd
supplementary
February 2018 to March 2018
Sampling & Data Collection: February 2018
Online Data Submission: March 2018
July 2018
Performance Management
4. Quality Delivering the Strategy
116
Not currently assessed
Project Element not in place
Project Element in place but requires update or further
work
Project Element in place and fit for purpose
Project Element not required
Project Element not in place
Key
Exec SRO Sue Moore
Programme SRO Joanne Moore
Programme Manager Carly SteerReporting Period October 2017 (Month 7)
Report date 13-Nov-17
The purpose of Delivering the Strategy (DTS) is to deliver the Trust's transformation programme and the operational annual plan. The focus is on
tranformational schemes that are aligned to the STP and LDPs and on continuous improvement of quality within our services. There are 6 DTS portfolios in
2017/18 aiming to deliver a wide range of redesign programmes.
Programme Description
DTS Programme Report
Overview
Across each network portfolio, for all schemes that have been initiated, work is ongoing to develop detailed delivery plans where this is not already in place status
summarised for each scheme in Programme assurance heat maps.
Complex packages of care within C&YP is now underway for a tender submission in November and work has also started to scope out Transformation of Secure
Services, Core 24 and Core Home Treatment 24/7.
Further work required to establish benefit trackers for each programme, to enable leads to measure performance and provide robust assurance on delivery.
assignedTBC Nicola Adams Nicola Adams Michael Orchard
Project Lead assigned TBC Paul AndertonSarah Wright/Anita
DemariaCathy Allen
Clinical Lead assigned Lorna Taylor Terry Drake Julie Ross Debra Wilson
Full resource plan agreed
PROGRAMME
DOCUMENTATION
Programme initiation
document
To be reviewed
Nov/Dec 17
Programme under
review Oct/Nov 17
Not currently required –
pre tender periodMove to the Cove –
in placeTransformation work
Programme PlanUnder review –
deadline 30 Nov
Under review – deadline
30 NovHigh level – Aug 17
Risks and Issues log In place In place In place
Programme Governance In place In place In place
TOR Redrafted Redrafted Agreed
Regular meetings 1st meeting 13 June 1st meeting 13 June 1st meeting 13 June
PROJECT PERFORMANCE
On time
On cost
Benefits tracker in place Not applicable
Children & Young People's Wellbeing DTS Portfolio
QIAs drafted for
Integrated MDT offer and
Point of Access
Quality Impact Assessment
Not currently required –
quality issues addressed
within tender process
Performance Management
4. Quality Delivering the Strategy
117
PROGRAMME RESOURCE
PMO Lead assigned Dawn Killey Dawn Killey Dawn Killey Dawn Killey Dawn Killey Dawn Killey Dawn Killey
Transformation Lead
assignedSarah Neve Helena Owen Sarah Neve Sarah Neve
Natalie Hilton/Fran
RileySarah Neve Sarah Neve
Clinical Lead assigned Lorraine Chadwick Lorraine ChadwickLorraine Chadwick/Claire
BensonGuz Singh Jeremy Tudway TBC Lorraine Chadwick
Full resource plan agreed n/a currently n/a currently
PROGRAMME
DOCUMENTATIONProgramme initiation
documentScoping n/a currently
n/a In Progress
Currently Nov-17In Progress
Nov-17
Programme Governance n/a currently
In Progress
Nov-17
Regular meetings n/a Currently n/a Currently n/a currently
Benefit trackerIn progress- met
with PerformanceStarted to map benefits TBC n/a currently
n/aCurrenty
On cost
On time( from
dashboard)n/a currently 83% 30% 16% n/a n/a
S136
99% 33%
New Models of Care?
Dawn Killey
Sarah Neve
Phil Horner
Transforming Secure
Services
TOR n/a currently
Risks and Issues log
Programme Plan Scoping
Quality Impact Assessment
Signed off by Clinical
Lead, to be presented to
Network Leads on 21st
Phil Horner Bev Liddle
Richard Morgan
Scoping TBC n/a currently Update In progress
n/a currently
n/a currently
Core Home
Treatment 24/7 Core 24
Project Lead assigned Lorraine McDonald-Johnson Bev Liddle Joe Crocock Phil Horner Pauline Cullen
Crisis House eastASSURANCE CRITERIONMental Health
Access Line
Inpatient Reconfiguration
programme
Mental Health DTS Portfolio
Performance Management
4. Quality Delivering the Strategy
118
ASSURANCE CRITERION LD IAPT CPSR South Ribble Central BwD Dental CPOC
ASSURANCE CRITERION LD IAPT CPSR South Ribble Central BwD Dental CPOC
PROGRAMME RESOURCE
Programme Lead assigned Stuart Sheridan Deborah Bretherton Julie Nowell Julie Nowell Tanya Hibbert Tanya Hibbert Andy Jones
Transformation Lead
assignedDeborah Howe
Clinical Lead assigned Mahesh Odiyoor Janine Williams Tracy Cook- Scowen Tracy Cook- Scowen Sarah Procter
Full resource plan agree
PROGRAMME
DOCUMENTATIONProgramme initiation
document
Quality Impact Assessment
Programme Plan Plans to be finalisedTo be updated in line
with new governance
structure
High-level – plan in
place further detail
required.
Risks and Issues log
Programme Governance
TOR
Regular meetings Fortnightly
Benefits Tracker
PROJECT PERFORMANCE
On time
On cost
Community and Wellbeing DTS Portfolio
Mark Wardman
MCP Prime Provider
MCP
Performance Management
119
4. Quality Delivering the Strategy
Annual
Performance
Plan (£000)
Annual
Forecast
Performance
Actual (£000)
15,100
15,100
12,744 12,730
886
Risks
14
2,370 a+b+c
886 d
1,484 (a+b+c)-d
419 a+b+c
Value of schemes at Feasibility
Slippage Against Annual Performance
Gross Risk of Delivery Against Overall DTS
Baseline
Additional Programme Reporting
2017/18
Overall Target
Value of approved schemes
Mitigation
Net Risk of Delivery Against Overall DTS
Value of non-recurrent schemes
Performance Management
120
4. Quality Delivering the Strategy
Programme SRO Goal (£000) MonthTransacted
(£000)Narrative
Q2 502,634
Sep (06) 89,361
Oct (07) 89,361
Q2 2,669,787
Sep (06) 464,539
Oct (07) 464,539
Q2 853,000
Sep (06) 115,039
Oct (07) 115,039
Organisational
reset
Joanne
Moore
Savings delivered through this programme will be reported through the relevant
Network or Corporate services. Phase 2 is in development.
Mobilisation &
DemobilisationLouise Giles
Savings delivered through this programme will be reported through the relevant
Network or Corporate services.
Q2 2,102,128
Sep (06) 350,355
Oct (07) 350,355
Children &
Young PeopleSteve Tingle 2,142,770
Support
Services
£1.4m is registered on the CIP system, £1,172k approved and £254k at feasibility.
Current forecast of £1049k delivery due to £117k slippage on the continence and
dental scheme, which is a static position on last month leaving an in year gap of £962.
However, further work has progressed on the gap and pipeline schemes with current
schemes rated green to the value £392k with further pipeline schemes anticicpated to
convert. CIP plans and additional pipeline schemes are monitored weekly.
£5.4m of schemes are registered as approved leaving a gap of £2.4m. This position
includes £2.4, of schemes related to cost reduction including temporary staffing and
OAPs. This a static position on last month, with schemes worth £384k still in the
pipeline. Further recovery schemes are underway whilst expenditure reduction
schemes are being tested in order to determine the underlying recurrent position. CIP
plans, additional pipeline schemes and recovery plans are being monitored weekly.
£1.54m of schemes are registered on the system, all of which are approved leaving a
gap of £603k. Pipeline schemes to the value of £600k are in train- and if all schemes
are approved this will meet 17/18 target. This is an static position on last month. CIP
plans and additional pipeline schemes are monitored weekly.
Schemes to the value of £4.5m are registered at approved stage. In addition there is
£534k of schemes at feasibility. If delivered, this will give an over-acheivement of
£2m which is offsetting gaps elsewhere. There are £134k worth of pipeline schemes
that are being monitored weekly
Dominic
McKenna2,801,600
Community
Wellbeing
Tanya
Hibbert2,265,460
Mental HealthLisa
Moorhouse7,869,522
Performance Management
Workforce
Section 5
121
Performance Management
5. Workforce
122
Section 5:-
• Actual Workforce Costs Compared to Budget
• Sickness Absence Rates
• Appraisals and Mandatory Training Compliance
• Vacancy Management and Active Recruitment
• Core Workforce Headcount
• Workforce Turnover
Performance Management
123
Actual Workforce Costs Compared to Budget - Quarterly Trend
Peripheral Workforce Spend and Usage
5. Workforce Actual Workforce Costs Compared to Budget
Actual Workforce Costs compared to Budget:
Overall spend on peripheral labour has decreased
slightly in the month of October, when compared
to the September position. MHN and C&WBN
continue to be the highest spenders.
Actions:
Mental Health Network:
Secure Services and the Harbour are holding
weekly Bank and Agency meetings to establish
the reasons for high usage and agree how this
can be mitigated. The content of this meeting
updates the monthly Network Bank and Agency
usage meeting.
Regular reviews are being conducted by the
Care Teams to appraise the level of service
user acuity and staffing levels. Their focus is to
ensure an appropriate level of staffing is in
place to provide safe and effective care.
Community & Wellbeing Network:
Services continue to review their need for the
use of Bank and Agency and usage escalation
processes in place at Longridge have been
extended to Southport & Formby.
Performance Management
5. Workforce Sickness Absence Rates
124
Trust 12 Month, Year on Year Trend
Sickness Absence Breakdown
Sickness Absence Rates:
Sickness Absence has increased in the month of October,
reporting 6.88%. The Trust increase this month is attributable to
the increase in sickness experienced in MHN.
Actions:
Mental Health Network:
The management of sickness absence remains a top priority
for the Network’s Senior Leadership Team as is the focus on
the Back to Basics Sickness Absence Management Action
Plan.
Service Managers are working closely with HR to effectively
manage sickness absence.
Community & Wellbeing Network: Sickness absence management remains a top priority with Network
SMT and the Network continues to review its action plan alongside the Trust Back to Basics plan
Action plans are in place for significant Long Term Sickness Cases in the Network and are monitored by and discussed with Care Group managers on a monthly basis
Children & Young Persons Wellbeing Network:
Q3 & Q4 will see the HRBP’s focus the Network on the
management of Short Term repetitive Absence Management.
Network has agreed a Sickness Absence trajectory to support
its achievement of the Trust Target of 4.5% by the end of Q4.
Performance Management
5. Workforce Appraisals and Mandatory Training Compliance
125
Appraisals and Mandatory Training Compliance:
Networks continue to work closely with Quality Academy and focus on improvement in this key performance measure. Appraisal Compliance for Q3 is
calculated using the number of employees who have objectives and who have completed a PDR review.
Actions:
Mental Health Network:
The Network continue to work closely with the Quality Academy to develop and implement their Network compliance improvement plans for the training
areas that are, individually, below the compliance target.
PDR compliance is monitored on a monthly basis at the Network People Group Meeting and uses the Tier 2 monthly Network People Performance
Report.
The new Network structure has enhanced accountability and responsibility lines for ensuring that there is a quality PDR process in place across the
Network.
Community & Wellbeing Network:
• Network continue to work closely with Quality Academy to improve compliance and enhance data quality.
• PDR compliance has been monitored on a monthly basis at the Network SMT and People Group Meeting using the Tier 2 monthly Network People
Performance Report.
• The new network structure is expected to enhance accountability and reasonability lines for ensuring that Quality PDR process take place and that
compliance across the Network is improved and bi-weekly tracking will continue post reset for Q3.
• Refinement of reporting lines post reset continues to take place and systems updated to ensure alignment of staff to mangers to allow PDR completion.
Children & Families:
• The Network are currently developing a PDR achievement Trajectory and it is anticipated that this will be ready by the close of November 2017. This is
being prepared to facilitate an increase in compliance in delivering the PDR experience and process.
• The Network discuss PDR compliance, compliance recovery and delivery expectations at the monthly People and Leadership Sub-Committee and
through Q3, the Network will be refining the cascade process for recovery activity from this meeting.
Performance Management
5. Workforce Vacancy Management and Active Recruitment
126
Vacancy Management and Active Recruitment:
The Budgeted Establishment Vacancy Rate has increased slightly in October and reports a closing rate of 12.17%. The number of those vacancies
being actively recruited has also increased, moving from 48.55% in September to 57.49% in October.
Actions:
Mental Health Network:
• The new Network have amalgamated the Specialist Services and Mental Health Ongoing Recruitment Programmes, designed to target hard to fill
posts and continue to effectively manage its delivery.
Community & Wellbeing Network:
• Vacancy clarity and management continues to be high on the Network agenda.
Children & Young People’s Wellbeing Network:
• Health Visitor Vacancies, held in in light of the Universal 0-19 contract Tender exercise, will be released through Q3 and actively recruited to as the
Trust is now in receipt of the new Service Specification that we are bidding against.
• The Network continue to hold a number of vacancies across Tier 3 Services as a result of the financial variation to contract removal of the CAHMS
Grant.
Support Services:
• A refresh of the Support Services Organisational Structure has been undertaken. The ESR system updates are complete and Financial EFIN system
updates are underway. The refresh has seen a move of ‘Hosted Services’ out of the Trust main workforce information data set and the temporary non
alignment of the ESR and EFIN systems (due to update timing differences) has resulted in a reported increase in BEVR for Support Services in
Establ ishment Vacancies Vacancies in Active Recruitment
Performance Management
4. Workforce Core Workforce Headcount
147
Core Workforce
Network Headcount FTE Headcount FTE
Southport & Formby 260 204.51 260 204.75
2017 09 2017 10
Performance Management
148
4. Workforce Workforce Turnover
Board of Directors
Agenda Item TB 186/17 Date: 07/12/2017
Report Title Trust Chairs Report
FOIA Exemption No Exemption
Prepared by Umme Batan, Corporate Governance Support
Presented by David Eva, Trust Chair
Action required Noting and Decision
Supporting Executive Director Chief Executive
PURPOSE OF THE REPORT:
Report purpose The purpose of the report is to provide the Board with an overview of the activity undertaken by the Board and Non-Executive Directors in addition to the Board of Director meetings and Council of Governor meetings.
The Board of Directors is also asked to approve the appointment of the Senior Independent Director and the Deputy Chair.
Strategic Objective(s) this work supports
To become recognised for excellence
Board Assurance Framework risk 1.1 If we do not meet regulatory standards for quality and safety we will not be fit for purpose as a care provider.
CQC domain Well-led
1.0 NON-EXECUTIVE DIRECTOR ACTIVITY
The Non-Executive Directors have been attending the Board Committee meetings of which they are a member (including the Financial Recovery Group) and apologies have been given where they were unable to attend. In addition to the usual Board business, Non-Executive Directors (NEDs) have been involved in their areas of special interest during the period of October 2017 – November 2017: Gwynne Furlong
Attended the Quality Committee Attended the CoG Quality & Assurance Meeting Sat on the panel of a disciplinary hearing Met with the Property Services Director Attended the Hearing Feedback Steering Group Had an introductory meeting with the Head of Operations for the Children and Young
People’s Network Met with the Head of Communications to discuss the delivery of November Team Talk
and filmed Team Talk Attended a meeting with the Trust Chair to discuss Housing Association
Louise Dickinson Met with the Assistant Director from MIAA to discuss 18/19
planning
Met with the Company Secretary to discuss the Audit Committee Effectiveness Review
Julia Possener
Attended the Charitable Trustee Funds Committee meeting
David Curtis Chaired the monthly SI Panel Attended the Audit Committee Effectiveness Review
Met with the Deputy Company Secretary to discuss the Quality Committee agenda
Attended the Quality Committee
Attended the Opportunity Knocks event
Met with the Director of Nursing for their monthly catch up Attended the Clinical Research Unit opening event at Royal Preston Hospital
Isla Wilson
Attended the Quality Committee
Met with the Chief Executive to discuss STP
Attended the planning for the social value workshop
Sat on the panel of an appeal hearing Attended the NHS Workforce Race Equality Standard (WRES) Conference on behalf of
the Chair Met with the Director of HR to discuss WRES Attended the STP Board Development Session Met with Amanda Thornton to discuss BDRW Attended the Opportunity Knocks event
Peter Ballard
Attended the AAC Panel Attended the Council of Governors meeting in November Attended the Opportunity Knocks event Met with the Chair for an exit interview
In addition to the above:
Gwynne, Louise and Peter attended the November Council of Governors meeting Louise, Julia and Isla attended the Audit Effectiveness Review meeting which the
Company Secretary was in attendance for
2.0 CHAIR’S ACTIVITY The Chair attended the Board meetings and Council of Governors meetings. The Chair has been having weekly catch up meetings with the Chief Executive and had
monthly meetings with the Company Secretary and has met with several Board members and Senior Managers and colleagues
The Chair continues to meet with MPs Attended the Partnership Leaders Forum Met with a member of the public Attended a meeting with the Senior Independent Director to discuss Housing
Association
3.0 COUNCIL OF GOVERNORS UPDATE This section has been added to the Chair’s Report in order to keep the Board updated on Council of Governor activity, recognising that since 01 April 2017 Board members have been attending meetings on an invitation basis. Since the last Chair’s Report received on 02 November 2017, the following items have been considered by the Council of Governors: 15th November 2017
The Council of Governors approved the extension of the External Audit contract with
KPMG for a period of two years (from 1 April 2018 until 31 March 2020).
It was confirmed that Staff Governors Max Oosman and James Harper would not apply for a second term of office from December 2017 due to work commitments.
The Chief Operating Officer deputised for the Chief Executive and provided an update on the STP and the high and low points for the month
The Head of Strategy & Business Planning provided a presentation on the Annual Planning 2018/19
The Health & Wellbeing Project Manager provided the Governors with insight into the Health and Wellbeing agenda within the Trust.
4.0 USE OF THE COMMON SEAL To inform the Board that the Common Seal has been used as follows since the Board of Directors meeting on the 02 November 2017:
30/11/2017 – Licence to occupy on short term basis relating to offices at Croston House, Lancashire Business Park, Centurion Way, Leyland between LCFT and Lancashire County Developments (Property) Limited (sign only)
30/11/2017 – Renewal Lease re Friday Street, Chorley, PR6 0AA between LCFT and Bugle Inn Motor Company Limited
5.0 RAISING CONCERNS As Trust Chair I continue to oversee the Dear David process for staff to raise concerns. This
process compliments other mechanisms for staff to raise concerns such as the Raising
Concerns Guardian. During October 2017, the following concerns were raised with me through
Dear David:
Concerns over the proposed installation of baths in initial designs for the Chorley
inpatient unit;
Staff smoking on the road outside Sceptre Way;
High caseload and demand in Community Mental Health Teams;
Lack of commissioned services for people suffering with Autistic spectrum disorder and
behavioural difficulties;
High caseloads in Community Mental Health Teams;
Caseloads, lack of management support and supervision Community Mental Health
Teams;
Staff suffering with stress in Community Mental Health Teams.
The Executive Director of Nursing and Quality (as Executive Lead for Raising Concerns) and Associate Director of Safety and Quality Governance (as Raising Concerns Guardian) continue to administer the Dear David process on my behalf and they have ensured that all concerns are
being reviewed with feedback provided to those raising concerns directly, where possible, and also included in the Quality Matters electronic bulletin to staff.
6.0 DEPUTY CHAIR APPOINTMENT The Board of Directors is aware of the departure of the Deputy Chair Peter Ballard whose term of office finished on 30 November 2017. In line with NHSI requirements the Trust must nominate a Deputy Chair. The Trust Chair proposes that Gwynne Furlong is appointed as the new Deputy Chair with effect from 01 December 2017. Gwynne was re-appointed as a NED for a second term of office in 2015 and will be finishing his term of office in October 2018. Gwynne is the longest serving Non-Executive Director. The Board of Directors is asked to consider and agree with the proposal and make a recommendation to the Council of Governors.
7.0 SENIOR INDEPENDENT DIRECTOR APPOINTMENT In line with NHS Improvement requirements the Trust must nominate a Senior Independent Director, a role which Gwynne Furlong held till 30 November 2017. The Trust Chair proposes that Isla Wilson is appointed as the new Senior Independent Director with effect from 01 December 2017. The Code of Governance states that:
A.4.1. In consultation with the council of governors, the board should appoint one of the
independent non-executive directors to be the senior independent director to provide a
sounding board for the chairperson and to serve as an intermediary for the other
directors when necessary.
The Board of Directors is asked to consider and agree with the proposal and make a recommendation to the Council of Governors.
8.0 NON-EXECUTIVE DIRECTORS ROLES & COMMITTEE MEMBERSHIP On approval of the above Non-Executive Director appointments the new committee membership will be as below effective of 01 December 2017.
Non-Exec Role
David Eva Trust Chair
Gwynne Furlong Deputy Chair
Isla Wilson Senior Independent Director and
Finance & Performance Committee Chair
David Curtis Quality Committee Chair
Louise Dickinson Audit Committee Chair
Julia Possener Non-Executive Director
Board of Directors Audit Committee Quality Committee Finance and Performance Committee
Charitable Trustee Funds
Committee
David Eva
Chair
Louise Dickinson
Committee Chair
David Curtis
Committee Chair
Isla Wilson
Committee Chair
Gwynne Furlong
Committee Chair
Gwynne Furlong
Louise Dickinson
David Curtis
Isla Wilson
Julia Possener
David Curtis
Isla Wilson
Julia Possener
Gwynne Furlong
Isla Wilson
Gwynne Furlong
Louise Dickinson
Julia Possener
9.0 BOARD ACTION
The Board is asked to note the updates provided for information and make a recommendation to the Council of Governors to ratify: The appointment of Gwynne Furlong as the Deputy Chair with effect from 01 December
2017 The appointment of Isla Wilson as Senior Independent Director with effect from 01
December 2017
Board of Directors
Agenda Item TB 187/17 Date: 07/12/2017
Report Title Quality Committee Chair Report
FOIA Exemption No Exemption
Prepared by Viv Prentice, Deputy Company Secretary
Presented by David Curtis, Chair of Quality Committee
Action required Noting
Supporting Executive Director Executive Director of Nursing and Quality
PURPOSE OF THE REPORT:
Report purpose To provide an outline of the activity undertaken by the Quality Committee.
Strategic Objective(s) this work supports
To provide high quality services
Board Assurance Framework risk 1.1 The Trust does not protect services users from avoidable harm and fails to comply with the CQC standards for the quality and safety of services
1.2 The Trust does not deliver safe, appropriate and therapeutic environments to deliver high quality services
3.1 The Trust fails to deliver the benefits of being a Health and Wellbeing provider.
4.1 The Trust is unable to attract, recruit and retain high quality staff impacting on a continued dependency on temporary staffing levels, affecting quality of care and financial costs
4.2 The Trust does not deliver effective education, training and leadership opportunities resulting in a workforce who are unable to deliver high quality, safe care
7.3 The Trust does not comply with Mental Health Legislation
CQC domain Well-led
1.0 INTRODUCTION This Chair Report outlines the activity undertaken by the Quality Committee held on the 13 November 2017. 2.0 COMMITTEE ACTION
The Trust Board is asked to note the content of the Chair’s Report for assurance.
CHAIR’S REPORT
CHAIRS REPORT OF: Quality Committee
DATE OF MEETING: 13 November 2017
BOARD ASSURANCE FRAMEWORK RISKS ALIGNED TO COMMITTEE:
1.1 The Trust does not protect services users from avoidable harm and fails to comply with the CQC standards for the quality and safety of services
1.2 The Trust does not deliver safe, appropriate and therapeutic environments to deliver high quality services
3.1 The Trust fails to deliver holistic whole person care (Physical and Mental Health)
4.1 The Trust is unable to attract, recruit and retain high quality staff impacting on a continued dependency on temporary staffing levels, affecting quality of care and financial costs
4.2 The Trust does not deliver effective education, training and leadership opportunities resulting in a workforce who are unable to deliver high quality, safe care
7.3 The Trust does not comply with Mental Health Legislation
AGENDA ITEMS BAF RISK DISCUSSION, ASSURANCE, RISK OR FURTHER ACTION
Board Assurance Framework Report
1.1, 1.2, 1.3, 3.1, 4.1, 4.2
Assurance
Consideration was given to each of the assurance reports during the meeting and the Committee received assurance that there had been no significant changes to the risks in the last quarter.
Raising Concerns Bi-Annual Report
1.1 Discussion The development work that had taken place to continually promote the right culture to enable staff to raise concerns was outlined. This included engagement with the National Guardian’s office, regular communication with staff and the recruitment of Raising Concerns Advocates. Concerns are now themed against set criteria developed by the National Guardian’s office which highlighted quality and safety as the predominant theme. These concerns related in particular to violence and aggression, caseloads and feelings of stress.
An internal indicator to assess the confidence in the culture of raising concerns indicated that just over half of the staff members that raised concerns wished to remain anonymous. Assurance Significant assurance was provided in relation to the Raising Concerns process and compliance with the system. In addition, both the Audit Committee and the Council of Governors had previously received assurance in respect of the Trust’s systems and processes that are in place to enable staff to raise concerns. Following a survey of all local Guardians undertaken by the National Freedom to Speak up Guardian, the work that was being undertaken to address the three areas of improvement that had been identified were outlined. This included recruiting Raising Concerns Advocates and working closely with the Equality & Diversity Project Manager to ensure hard to reach staff groups are supported and encouraged to raise concerns. The Committee noted that 59 concerns had been raised during the last six months with the majority of concerns raised via the Trust’s ‘Dear David’ method. This clearly highlighted how well embedded this had become as a way for staff to raise concerns. Further Action The Committee agreed with the recommendation to receive future reports on a quarterly basis thereby ensuring more timely information and detail. The Committee consented to the Raising Concerns Guardian appointing a Deputy from the pool of Advocates (on a recurrent 12 month appointment basis) to ensure continuity during periods of absence.
Quality and Safety Surveillance Reports
1.1 Discussion The Committee’s attention was drawn to the lack of Southport & Formby data prior to May 2017 and noted that this was due to the non-availability of data from the previous provider. Assurance The Committee received significant assurance in respect of the Quality Surveillance systems and controls and the continued improvement of the reports, which now included a Mental Health Law Surveillance Report. There had been a decrease in the number of Grade 3 and 4 pressure ulcers and it was noted that an investigation was being undertaken following the Never Event that had occurred earlier in the year. Upheld complaints remained broadly static whilst re-opened complaints had dropped significantly and complaints to the PHSO were very low.
In relation to Mental Health Law, the number of section 136 lasting over 72 hours remained consistent. However, with the introduction of new legislation there was an expectation that this would increase. It was noted that the risk to the organisation was fairly low as the Trust would rely on some common law powers to hold people in their best interests. There had been an increase in compliance with patients having a Section 132 rights form in place at the beginning of the month. As a result of the increase in medication incidents within the Community and Wellbeing Network, there was now renewed visibility in that area. Risk The number of RIDDORs had increased which related to incidents of violence on inpatient units. The use of restraint had also increased with the highest use being reported on PICU wards and older adult wards. A deep dive would therefore be undertaken and a summary provided to the Quality & Safety Sub-Committee. The overall Mental Health Harm Free Care target remained below the Trust aspiration, although it was higher than the previous two months. Whilst overall compliance with Core Skills was above target, compliance with key modules in some subject areas remains challenged. Whilst the number of overdue incident reviews continues to be high, this remains a focus for the networks. A further quality measure has been added to look at the percentage of patients who have their rights read within 24 hours of detention as compliance with this is currently very poor. As a result of the increase in the number of complaints, work is underway to improve the approach to hearing feedback. Further Action
Following a query regarding levels of detention and if there was any data relating to ethnicity, it was noted that following development of the MH Act recording system this information should be extractable. However, the Associate Director of Safety and Quality Governance agreed to look into this further and report back to the MH Law Sub-Committee.
Quality & Safety Sub-Committee Chair’s Report
1.1, 1.2, 3.1 Assurance The Chair’s Report following the meeting held on the 25 October was presented which highlighted the approval of the Quality Assurance Framework.
The Committee were informed that the number of self-harm incidents at The Cove related to a small number of patients.
Further Action
The Executive Director of Nursing confirmed that a development session may be held upon completion of the deep dive into incidents of violence on older adult wards.
People Sub-Committee Chair’s Report
4.1, 4.2 Assurance The Chair’s Report following the meeting held on the 15 June was presented and it was noted that the outcome of the effectiveness review undertaken was positive. In addition, an in-depth discussion had been held in relation to the untapped talent project report which had been well received. The Committee had received positive assurance following the LADO Allegations Thematic Review Report, which provided strong evidence of engagement. Risk It was disappointing to note non-compliance against the core skills target. Further Action An overview of the apprenticeship levy delivery plan was provided. The Director of HR agreed to provide further assurance in respect of the delivery of the plan at the next meeting.
Quality Account 1.1 Assurance The Associate Director of Quality and Experience presented the Quality Account quarter two position and provided an update on the quality priorities reflected in the Quality Account aligned to the four domains of effectiveness, experience of care, safety and well-led. The Committee noted the good progress with the Quality Account. The work that had been undertaken in respect of each domain was outlined. This included the recent ‘thinking space’ session that had been held to drive improvement and consistency in seclusion practice. In addition, eight Always Events had been planned and the Trust were implementing the Care and Compassion programme (adopted from the Sit and See approach) to ensure that feedback informs quality improvements at the point of care. A further quality improvement had seen the launch of the Safety Cross model of reporting, providing teams with an at a glance picture of pressure ulcer prevention. The work being undertaken in partnership with AQuA to develop a ‘bite-size’ quality improvement learning programme was outlined. Small scale testing of the programme had been undertaken with further testing to be undertaken during quarter three. Plans were also being developed for the next Quality Improvement Conference which would provide the opportunity to showcase the quality improvements taking place throughout the Trust.
All NHS Improvement core indicator targets were achieved. It was noted that the data relating to the Early intervention Service (EIS) was currently being reviewed and validated and would be available within the quarter three report.
Risk Assurance 1.1, 1.2, 3.1, 4.1, 4.2, 7.3
Assurance It was agreed that following discussions throughout the meeting adequate assurance had been received and there had been no impact on the risk scores relevant to the Committee.
Board of Directors
Agenda Item TB 188/17 Date: 07/12/2017
Report Title Chief Executive’s Report – Part One
FOIA Exemption No Exemption
Prepared by Heather Tierney-Moore, Chief Executive
Presented by Heather Tierney-Moore, Chief Executive
Action required Discussion/Decision
Supporting Executive Director Chief Executive
PURPOSE OF THE REPORT:
Report purpose The purpose of this report is to provide Board members with an overall summary of the Trust position and highlight areas for further discussion.
Strategic Objective(s) this work supports
To provide high quality services
Board Assurance Framework risk 2.1 – The Trust does not receive assurance of the accuracy, timeliness and consistency of data and reporting with the potential to compromise decision making and service quality
CQC domain Well-led
Introduction This report aims to give Board members an overview of the activity undertaken since the last Board meeting, both within the Trust and externally.
QUALITY AND SAFETY
Serious Incidents
During October 2017, the following serious incidents were reported:
(brief information is provided to protect confidentiality, the term suicide is only used once a Coroner’s
Inquest has returned a verdict of suicide)
Serious self-harm (suspected attempted suicide) of a prisoner at HMP Liverpool;
Death (suspected suicide) of a patient under the care of the Assessment and Treatment Team in Chorley and South Ribble;
Concerns around the care of a patient in Podiatry in Central Lancashire – no immediate concerns for Lancashire Care Foundation Trust (LCFT) services however a patient under the care of Podiatry underwent an operation at an Acute Trust where the wound deteriorated resulting in an above knee amputation;
Death (suspected suicide) of a patient under the care of the Assessment and Treatment Team in Lancaster and Morecombe;
Death (suspected suicide) of a patient under the care of the Rapid Intervention and Treatment Team in Lancaster and Morecombe;
Death (suspected suicide) of a person recently seen by the Mental Health Liaison Team in Central Lancashire;
Death of a patient in an Acute Trust which may have been contributed to by a pressure ulcer, where the patient was under the care of Southport and Formby District Nursing;
Death (suspected suicide) of a prisoner at HMP Liverpool;
Death of a patient under the care of the Mindsmatter Service in West Lancashire.
In all cases, a formal investigation is now underway and the incidents have been reported to
commissioners, NHS England and regulators as required under the NHS Serious Incident
Framework.
Significant Health and Safety Incidents During October 2017, the following incident was reported to the Health and Safety Executive and
Care Quality Commission under the Reporting of Injuries, Diseases and Dangerous occurrences
Regulations (RIDDOR):
(brief information is provided to protect confidentiality)
Injury to a staff member’s back whilst opening a door resulting in absence for over seven days. Raising Concerns During October 2017, the following concerns were reported through the various mechanisms including the Raising Concerns Guardian and through Dear David:
The proposed installation of baths in initial designs for the Chorley Inpatient Unit;
Staff smoking on the road outside Sceptre Way;
High caseload and demand in Community Mental Health Teams;
Staff attack alarms not available to staff when entering wards at the Harbour at the start of their shift;
Lack of commissioned services for people suffering with Autistic Spectrum Disorder and behavioural difficulties;
High caseloads in Community Mental Health Teams;
Caseloads, lack of management support and supervision Community Mental Health Teams;
Culture and clinical practice at the Harbour;
Staff suffering with stress in Community Mental Health Teams. In all cases a review of proportionate scale has been commissioned. The findings from each review
are individually fed back to the person raising the concern if they have provided their name. The
findings from every concern is summarised in the Quality Matters bulletin.
Changes to the Mental Health Act The government has formally announced through regulations laid in Parliament that changes in law to
sections 135 and 136 of the Mental Health Act 1983 will come into effect on 11 December 2017. The
changes are as follows:
section 136 powers may be exercised anywhere other than in a private dwelling;
it is unlawful to use a police station as a place of safety for anyone under the age of 18 in any circumstances;
a police station can only be used as a place of safety for adults in specific circumstances, which are set out in regulations;
the previous maximum detention period of up to 72 hours will be reduced to 24 hours (unless a doctor certifies that an extension of up to 12 hours is necessary);
before exercising a section 136 power police officers must, where practicable, consult a health professional;
where a section 135 warrant has been executed, a person may be kept at their home for the purposes of an assessment rather than being removed to another place of safety (in line with what is already possible under section 136);
a new search power will allow Police Officers to search persons subject to section 135 or 136 powers for protective purposes.
The Trust has been preparing for these changes and the Lancashire-wide multi-agency protocol has
been updated. However, the estimate is that 40% of section 136s will run over the reduced period of
24 hours. Longer term developments in mental health services should reduce this over time. A further
report will go to the Mental Health Law Sub-committee in December 2017.
Modern Slavery/Human Trafficking – ‘Duty to Notify’ “Human trafficking destroys lives and its effects damage communities” (Home Office, 2011). The
Modern Slavery Act (2015) introduced measures to enhance the protection of victims of slavery and
trafficking. Section 52 of the Act refers to the ‘Duty to notify’ the Secretary of State about suspected
victims, improving identification, creating a statutory duty to notify for specified public authorities. This
raises awareness, and builds a picture of the nature and scale of modern slavery/human trafficking, to
inform the law enforcement response. It has been confirmed that health agencies do not have a ‘duty
to notify’ but are encouraged to make voluntary notifications.
The Safeguarding Team have integrated this into the Trust’s safeguarding practices which now
require LCFT practitioners to make voluntary notifications if they suspect someone may be a victim.
This is seen as good safeguarding practice which fully supporting the Trust Values, strategic priorities
and 5 year plan; to provide high quality compassionate care and protect people from harm as part of
our quality plans; doing the right thing at the right time for vulnerable people. It is also consistent with
the Trust’s safeguarding vision.
The Safeguarding Team have now implemented processes and steps to fully embed this agenda into
practice, raise awareness and undertake the ‘duty to notify’ as well as undertaking the following:
Trust Safeguarding Team representation at the Pan Lancashire Human Trafficking Group. Within this forum we were made aware of ‘Duty to notify’. It is acknowledged that this is not a statutory requirement of health organisations; however, it was identified as good practice that LCFT front line practitioners make voluntary notifications, if they suspect someone may be a victim.
Received support from NHS England to fund and deliver a conference in 2016 to raise awareness and highlight the agenda within Lancashire. The conference was fully supported by the Trust Board Chair who published a public declaration describing the Trust’s commitment to ensuring no modern slavery or human trafficking in our supply chains or in any part of our business. As part of our commitment the Trust reviewed its supply chains and will be introducing a ‘Supplier Code of Conduct’ with a view to requesting all existing and new suppliers to confirm that they are compliant with the Act.
Identification of the Safeguarding Operational Lead Nurse as a Strategic Lead to drive the agenda forward. Specific training on human trafficking was accessed and she has recently received a MSc in Safeguarding in an international Context.
Introduction of a notification pathway.
The facilitation of several workshops for staff to introduce the “duty to notify” process, regular workshops are available as part of the safeguarding training offer.
Upskilling of the Safeguarding Team to provide advice, support, information and resource for staff. This supported responses to concerns that a patient may have been trafficked and embedded the agenda into the role of the Safeguarding Team as well as staff providing care.
Updated safeguarding training to raise awareness and include information and resources on human trafficking.
Incorporated human trafficking and modern slavery into adult and child safeguarding policies and practice.
Work with Safeguarding Board partners to monitor local human trafficking trends and consider care needs arising
The steps taken have increased staff awareness significantly. In all cases, staff are encouraged to
trust and act on their instinct and if they have concerns about a child, young person or adult they are
advised to take immediate action to ask further questions to help identify victims and offer support.
The Trust is fully engaged in the multi-agency work taking place across the county, contributing to the
intelligence gathering of potential victims in order to protect vulnerable people. In October 2017 the
Operational Safeguarding Lead and Associate Director Safeguarding were invited to present the work
which the Trust has undertaken at a multi-agency conference led by Lancashire Constabulary. Our
actions were recognised by partners as excellent practice and Trust leads have since been invited to
share our process with partner organisations.
The focus of the event was how to build current partnership working practices. Police colleagues fed
back how significant it was that the Trust highlighted the importance of our role when providing care to
individuals who may present themselves either alone or with perhaps a controlling ‘other’ and take on
the role of a ‘duty to notify’ responder. This step is not yet replicated in other areas of the country and
has been praised by the ‘National Police Transformation Team’, who reported that they are
‘enlightened by LCFT’s approach to this area of work’.
Risk and Assurance The Risk and Assurance Team are continuing to build relationships with other organisations to share
best practice and learn from each other. In facilitating this approach, the Associate Director of Risk
and Assurance is co-chairing a new Governance, Assurance and Risk Network with the Deputy
Director of Governance at The Walton Centre NHS Foundation Trust in Liverpool. GARNet is aimed
at colleagues across health and social care in the north west who have an interest in these areas and
would welcome an opportunity to come together to share best practice, learn from each other and to
general promote a better system-wide understanding of governance, assurance and risk. The first
meeting is scheduled for Tuesday 12 December 2017 and is being hosted by The Walton Centre.
The meetings will be held quarterly with Lancashire Care hosting the next meeting in March 2018.
Awards
Karen Seal, Acting Clinical Lead for the Eating Disorder Service won the Mental Health Worker of the
Year Award at The Gazette Best of Health Awards in September.
The Psychosis and Bipolar Psychological Care Network won the Psychological Therapies in
Secondary Care (NHS England) Award at the National Positive Practice in Mental Health Awards in
October and The Acute Therapy Service (PDMCN) were also highly commended within this category.
Allied Health Professions Return to Practice Guidance The Framework and Mentor Guidance for Allied Health Professions (AHP) Return to Practice has
been finalised and is now in place to guide our provision of placements for these professional groups.
This is part of the recruitment and retention strategy and workforce planning. The Associate Director
for AHPs has now promoted and aligned developments within the Trust with an emerging national
piece of work led by Health Education England with LCFT being a recognised placement provider. A
local marketing campaign is due to commence in early January which will dovetail with national
marketing strategy.
Quality Improvement Showcase A showcase session focussing on areas of harm free care improvement work was co-ordinated by the
Quality Improvement Team with presentations from Nursing, AHPs and Psychology with
commissioner colleagues invited. The three key improvement themes were pressure ulcers, falls and
psychological approaches in children’s mental health. Key quality improvement projects were
presented with outcomes to date demonstrating direct impact at the point of care across the
organisation. These projects will be revisited later in the year to track continuous improvement and
sustained change achievements.
HMP Liverpool The Trust has received the draft of the HMP Liverpool joint HMIP/CQC inspection report. The report is
subject to a factual accuracy checking process before being published.
HMP Liverpool Press Enquiry The Board have been separately briefed on a comprehensive media request from the BBC regarding
the Trust’s contract to provide healthcare services at HMP Liverpool. The questions posed and the
formal response was shared with the Board and were signed off by the Chief Executive and the Chair,
as well as shared with NHS Improvement and NHS England. The Board will continue to receive
updates on when the report will be featured and any subsequent media interest generated as a result.
PEOPLE & LEADERSHIP
Head of Organisational Development Appointed Emma Dawkins joins the Trust on Monday 04 December as the new Head of Learning and
Organisational Development. Emma will report directly to Deborah Cox, Deputy Director of Human
Resources & Quality Academy. Emma has a wealth of experience working within the NHS and more
recently for the North West Leadership Academy. Emma is an experienced OD Professional with a
large amount of knowledge and experience in Leadership Development, Talent Management,
Coaching and Mentoring and Organisational Development.
STP-wide Workforce & OD Appointment Paula Roles will commence with the Trust on 4th December in the position of HR Strategic Lead for
the Healthier Lancashire and South Cumbria Sustainability and Transformation Partnership (STP).
This is a new position funded by Health Education England to strengthen workforce, leadership and
organisational development throughout the STP area. Paula is seconded from Blackpool Teaching
Hospitals where she was the acting Director of Human Resources & Organisational Development.
Paula will report to Damian Gallagher and brings with her vast experience of workforce issues,
leadership and organisational development gained through years of experience working throughout
the North West region.
FINANCE AND PERFORMANCE
Finance Report Month 7 sees a year to date operating deficit of -£2.3m, excluding planned Sustainability and
Transformation funding of £0.9m, against a planned surplus to date of £0.6m. This shows an
improvement on month 6 and represents a small budgetary surplus in month and nearly £0.2m when
excluding STF monies. The position remains driven by staffing pressures in ward and prison areas
and consequential impact on cost improvement programmes (rising agency costs will also impact Use
of Resources targets). Additionally OAPs expenditure continues to exceed funding - see Out Of Area
Activity for more details. The forecast assumes current pressures and risks are addressed or
mitigated in line with the recovery plan (see forecasting) and financial performance achieves (or
exceeds) plan but the unmitigated projection indicates a gap of c£4.8m, c£6.9m without STF monies.
This is represents an improvement on month 6 forecasts (£6.2m), and is driven by excess OAPs of
c£0.8m (all be that significantly below last month), prisons (see also Bank and Agency section) and
additional mental health pressures. Delivery of the recovery plan and financial targets will required a
significant and coordinated response with robust management and oversight. After taking in to
account £1.7m of disposals, which are accounted for after EBITDA, EBITDA is broadly in line with I&E
Margin. The new Use of Resources (UoR) metric is rated at 3, but will rise to a 2 should the Trust
meet its financial plans and targets.
Performance Report & Quality Report The Performance Report can be viewed under item TB 185/17 and the separate Quality Report can be viewed under TB 189/17. Changes to the Single Oversight Framework NHS Improvement has published the updated Single Oversight Framework (SOF) in response to an
exercise to seek feedback from providers. The organisation NHS Providers have produced a helpful
briefing which summarises the changes which have been made as a result by NHS Improvement. The
Senior Leadership Team has already considered how the changes will shape the Trust’s performance
reporting accordingly. The briefing can be accessed here.
High Value Requisition: Perinatal Unit As agreed by the Board in February 2017, the RRCS JV partnership is delivering the Trust’s Capital
Programme for 2017/18. The Board is required to provide authorisation to progress project C3:
Central Perinatal Unit following the Trust successfully winning the tender to provide this service,
awarded by NHSE on 10th April 2017. The scheme is within the financial envelope of £3.5m and the
contracted works will commence December 2017 with completion target date of July 2018. RRCS is
recommending that Board approve the attached purchase order requisition for £2,122,535.28
including VAT to enable the work package to be completed within the agreed timeframes for the
Chorley re-design work.
Autumn Budget Following the recent autumn budget statement from the Chancellor, a helpful briefing has been issued
by NHS Providers which summarises the announcements and the potential implications for the NHS
and providers. The briefing can be accessed here.
Memorandum of Understanding: Ribblesdale Partnership The Ribblesdale Community Partnership (RCP) was formed to involve organisations with looking at
ways that services can be locally developed for the Ribblesdale community. The RCP membership
includes all four Ribblesdale medical practices, which serve a population of around 38,000 people, as
well as other provider organisations including the Trust, East Lancashire Hospitals and Lancashire
County Council.
The RCP have developed a unified vision “To create a new integrated system for the management of
community services in Ribblesdale locality run in partnership by local health and care organisations,
removing organisational boundaries to deliver care pathways designed around the needs of our local
population not organisational structures.”
The vision describes similar aspirations to the development of the Chorley Integrated Community
Wellbeing Service, an initiative which is supported by a detailed Memorandum of Understanding
(MOU). As such, a more concise MOU has been developed and circulated by East Lancashire CCG
for the Ribblesdale Partnership which sets out the broad principles and objectives for working
together as part of the RCP. Work has been undertaken to understand the needs of local
communities and what they feel are the health priorities and the partnership is now seeking
agreement from all organisations to sign up to the MOU and therefore the Board are asked to sign off
the MOU which can be viewed here.
NHS Improvement Quarterly Review Follow Up In October, the Trust had its routine quarterly review meeting with NHS Improvement and received
confirmation it would be remaining within segmentation 1.
This was the first Autumn Budget, following Philip Hammond’s announcement that he was changing both
the timing and the frequency of the Government‘s “fiscal event “. The budget outlook was significantly less
optimistic about economic prospects than in March. This cut to Britain’s productivity growth has meant a
downgrading of the growth forecast and signals that the UK economy is weaker than hoped.
The NHS in England received more funding than we had expected, but less than needed. The chancellor
announced £1.6 billion extra revenue for 2018/19; £3.5 billion extra capital funded by the treasury, £0.5bn
this year and an additional £3bn over the next five years; and the government has committed to fund with
new money an increase to agenda for change staff, subject to the recommendation from the pay review
bodies. In addition, the government has committed extra capital and extra revenue for this year.
This briefing outlines the economic headlines within the Budget, key announcements for health and the
wider economy, and NHS Providers’ response.
Economic Overview
• Public sector net borrowing has
been revised down for 2016/17
by £8.4bn, relative to the
estimate published in March.
The downward revision is being
driven by higher than expected
PAYE income tax and NICs
receipts (up by £1.9bn this year),
underspending by Government
departments (down by £3.2bn),
an increase in other receipts,
such as VAT and
exercise duty (revised up by £1.3bn), and a downward revision in various annually managed
expenditure lines, such as state pensions and tax credits (down by £4.7bn).
• The deficit is expected to rise to 2.3% of GDP in 2017/18 before falling steadily over the next four years.
• Economic growth for this year (2017/18) has been revised down from 2% to 1.5%. The OBR has
downgraded the forecasts for the three subsequent years. The average annual growth rate over the
next five years is 1.4%.
NHS Providers | ON THE DAY BRIEFING | Page 2
OBR PRODUCTIVITY GROOBR PRODUCTIVITY GROOBR PRODUCTIVITY GROOBR PRODUCTIVITY GROWTH (OUTPUT PER HOURWTH (OUTPUT PER HOURWTH (OUTPUT PER HOURWTH (OUTPUT PER HOUR) ) ) ) ––––
FORECASTS AND OUTURNFORECASTS AND OUTURNFORECASTS AND OUTURNFORECASTS AND OUTURNS S S S
Productivity • The OBR has revised down its forecast growth over the coming years, based on current productivity
levels.
• Productivity growth has been
revised down by 0.7% a year.
• Employment increased by around
230,000 between the end of 2016
and the third quarter of 2017,
however average hours worked
per person remained flat, rather
than falling.
Department of Health spending profile
Overview of Department of Health spending: revenue and capital
• The Government has increased the Department
of Health’s budget by £2.8bn. This funding has
been made on an ‘exceptional’ basis, which
means it is not clear whether this will be
recurrently carried forward in to 2020/21.
• The allocation has been made directly to the
Department of Health’s budget, rather than NHS
England’s budget as we have seen in previous
years which means that this is genuinely new
funding, rather than taking additional funds
from other non-frontline services, such as
education and training budgets.
OBR GDP forecast growth: 2017/18 to 2021/22OBR GDP forecast growth: 2017/18 to 2021/22OBR GDP forecast growth: 2017/18 to 2021/22OBR GDP forecast growth: 2017/18 to 2021/22
• It is estimated that with the increase next year, the Department of Health’s budget will grow from 0.5%
to 1.4%.
• 2019/20 still looks incredibly challenging for the sector, as £665m of the additional £900m will need to
be used to fund additional NHS pension cost increases.
• The Treasury will fund £3.5 billion of capital investment between 2017/18 and2022-23, including:
• £2.6 billion for STPs to deliver transformation schemes that improve their ability to meet demand
for local services and improvements in facilities .The government has today provisionally allocated
up to 10% of this £2.6bn funding to 12 of the schemes it judges the highest quality, on the basis
of their potential to meet future demand and develop local clinical and financial accountability.
The rest of the funds will be allocated ‘in due course’. You can read which schemes have been
provisionally allocated funding here
• £700 million to support turnaround plans in the trusts facing the biggest challenges, and to tackle
the most urgent and critical maintenance issues
• £200 million to support efficiency programmes
• Other sources of capital funding will come from:
• £3.3bn from land sales
• £2.8bn is expected to come from private finance investment.
Funding for pay award • Additional funding in addition to today’s settlement will be provided for NHS staff on the Agenda for
Change contract subject to the Pay Review Body recommendation. This will be linked to productivity
improvements the Government wishes to see through the contract.
• Any pay award for doctors will not be funded by the government, but will need to be funded from
existing NHS budgets.
Increases to the Department of Health’s budgetIncreases to the Department of Health’s budgetIncreases to the Department of Health’s budgetIncreases to the Department of Health’s budget
YearYearYearYear 2017/182017/182017/182017/18 2018/192018/192018/192018/19 2019/202019/202019/202019/20 Total increase between Total increase between Total increase between Total increase between
Department of Health budgDepartment of Health budgDepartment of Health budgDepartment of Health budget: RDEL and CDELet: RDEL and CDELet: RDEL and CDELet: RDEL and CDEL
Responding to the Budget, the chief executive of NHS Providers, Chris Hopson, said:
“NHS providers needed three things from the Budget: extra revenue for day to day spending in 2018/19;
more capital funding for transformation and tackling the maintenance backlog; and fully funding the
ending of the 1 per cent pay cap.
“The NHS has been given £1.6 billion extra revenue for 2018/19; £3.5 billion extra capital funded by the
treasury; and the government has committed to fund the main NHS pay rise. In addition, the government
NHS Providers | ON THE DAY BRIEFING | Page 9
has committed extra capital and extra revenue for this year, though this has come very late to be used
with maximum impact for this winter.
“Any extra investment in the NHS is welcome given the overall economic context and the other demands
on public expenditure. It is a clear signal that the government has listened to the NHS’ definitive statement
that the existing spending review plans for 2018/19 were undeliverable.
“However it is disappointing that the government has not been able to give the NHS all that it needed to
deal with rising demand, fully recover performance targets, consistently maintain high quality patient care
and meet the NHS’s capital requirements. We also note that the extra revenue has been tied to acute
hospital performance at a point when the pressures across the rest of the health service – community,
mental health and ambulance services – are just as great.
“Tough choices are now needed and trade offs will have to be made. It is difficult to see how the NHS can
deliver everything in 2018/19, for example fully recovering performance targets. The next step is a
conversation with frontline leaders to clearly agree what can and can not be done.
“We are also still trying to live hand to mouth without a sustainable long term financial and capital
settlement for the health and care sector. This makes it impossible to plan effectively. The existing gap
between demand and funding is still scheduled to grow significantly by the end of the parliament and we
must address this underlying problem.
“Overall this new funding is less than the NHS needed but more than was expected. But, as always, NHS
trusts will do their absolute best to provide the highest quality care for patients within the funding
settlement that’s been allocated.”
Useful links
The full Budget document can be accessed here The full text of the Chancellor’s speech is accessible here OBR figures are available here
Ribblesdale Community Partnership Memorandum of Understanding V0.1 14/09/17
RVBC
Ribblesdale Community Partnership Memorandum of Understanding (MOU)
This Ribblesdale Community Partnership MOU is an understanding between Provider Organisations working in the Ribblesdale Neighbourhood to deliver on the objectives outlined in the Ribblesdale Community Partnership Strategy. Furthermore signing up to this document confirms that the Organisation you are representing supports the activities of the Community Partnership. COMMENCEMENT
1 This Memorandum of Understanding is made on the insert relevant date between Organisations’ participating in the Ribblesdale Community Partnership listed in paragraph five of this document. This agreement will be reviewed in April 2018.
RIBBLESDALE COMMUNITY PARTNERSHIP VISION AND AIMS
2 VISION
To create a new integrated system for the management of community services in Ribblesdale locality run in partnership by local health and care organisations, removing organisational boundaries to deliver care pathways designed around the needs of our local population not organisational structures.
3 AIMS/OBJECTIVES
The aims and objectives of the Ribblesdale Community Partnership are to:
Develop the Ribblesdale Community Partnership.
Develop a Ribblesdale Community Partnership Strategy and Plan.
To be the overseeing body to ensure the delivery of the agreed plan.
To test out models of delivery for health, wellbeing and care services within a locality.
To ensure that the model supports the delivery of health, wellbeing and care needs for the Ribblesdale population.
To ensure the maximisation of all available resources.
To performance monitor the impact of the Ribblesdale Community Partnership.
To continually improve the development of the Ribblesdale Community Partnership.
To support the strategic direction of the Pennine Lancashire Transformation Programme.
MEMBERSHIP Member Organisations
4 The membership of the group consists of those listed as follows:-
Sabden & Whalley Medical Practice (Whalley)
The Castle Medical Group (Clitheroe)
Pendleside Medical Practice (Clitheroe)
Slaidburn Country Practice (Slaidburn)
Ribblesdale Community Partnership Memorandum of Understanding V0.1 14/09/17
East Lancashire Hospitals Trust (ELHT)
Lancashire Care Foundation Trust (LCFT)
Lancashire County Council (LCC)
Ribble Valley Borough Council (RVBC)
Hyndburn and Ribble Valley CVS (HRVCVS)
Foundation for Ribble Valley Families (FRVF) Applications from other organisations wishing to join the partnership will be considered following application to the secretariat at the East Lancs CCG. GEOGRAPHIC AREA COVERED
5 The Ribblesdale Community Partnership will support the development of services to patients registered with its constituent practices.
GOVERNING STUCTURE AND ACCOUNTABILITY
6 The Ribblesdale Community Partnership will be accountable to each Partnership Members Organisation. Each partner will be responsible for their own arrangements for reporting progress to their Organisation.
ROLES AND RESPONSIBILITIES OF THE RIBBLESDALE COMMUNITY PARTNERSHIP REPRESENTATIVES
7 The roles and responsibilities of each partner representative is as follows:
To ensure regular attendance at meetings. Where a representative can’t attend a nominated deputy will attend.
To provide all information requested by the Strategy Group on time and ensuring involvement of their organisation.
All information must be shared honestly and transparently.
To cascade information about decisions reached and agreements made by the Board to their respective organisations.
To ensure communication is clear, concise and timely.
To make recommendations on behalf of their organisation.
To develop a communications and engagement strategy in line with the agreed Strategic Plan.
ADOPTION OF THE RIBBLESDALE COMMUNITY MEMORANDUM OF UNDERSTANDING
8 The persons whose signatures and Organisation appear at the bottom of this document are the partners named representatives and sign that on behalf of their member Organisation they shall support as appropriate and applicable the activities of the Ribblesdale Community Partnership.
Organisation
Organisation Representative / Designation
Sabden & Whalley Medical Practice (Whalley)
Ribblesdale Community Partnership Memorandum of Understanding V0.1 14/09/17
The Castle Medical Group (Clitheroe)
Pendleside Medical Practice (Clitheroe)
Slaidburn Country Practice (Slaidburn)
East Lancashire Hospital’s Trust
Foundation for Ribble Valley Families
Lancashire Care Foundation Trust
Lancashire County Council
Ribble Valley Borough Council
Hyndburn and Ribble Valley CVS
Board of Directors
Agenda Item TB 189/17 Date: 07/12/2017
Report Title Quality Report
FOIA Exemption No Exemption Not Applicable
Prepared by Matthew Joyes
Associate Director of Safety and Quality Governance
Presented by Dee Roach, Executive Director of Nursing and Quality
and
Professor Max Marshall, Medical Director
Action required Decision
Supporting Executive Director Executive Director of Nursing & Quality
PURPOSE OF THE REPORT:
Report purpose To provide the Trust Board with latest version of the Quality Report
Strategic Objective(s) this work supports
To provide high quality services
Board Assurance Framework risk 1.1 If we do not meet regulatory standards for quality and safety we will not be fit for purpose as a care provider
CQC domain Well-led
Quality and Safety Report
December 2017
(data from November 2016 to October 2017)
Prepared by: Presented to the Trust Board by:
Matthew Joyes, Associate Director of Safety and Quality Governance Dee Roach, Executive Director of Nursing and Quality
Max Marshall, Executive Medical Director
Lancashire Care NHS Foundation Trust Quality and Safety Report
Well Led .................................................................................................................................................................................................................................... 24
Appendix 1 – Extracts from the Quality and Safety Surveillance Report and Mental Health Law Surveillance Report ................................................................ 29
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QUALITY AND SAFETY TILE
SAFE
Incidents 15251
STEIS-reportable serious
incidents 92
RIDDOR incidents 38
Never Events 1
Serious HCAI incidents 10
Use of restraint 3930
Potentially avoidable grade 3 and
4 pressure ulcers 13
Number of red flag incidents
(inpatients only) 2869
Physical violence to staff from
patients 2172
CARING
F&F Test 94.40%
Compliments 8701
RESPONSIVE
Complaints 1632
Upheld/partially upheld
complaints 320
Completed within agreed
timeframe (%) 54%
WELL LED
Trust CQC rating Good
Core Skills (%) 90.05%
Appraisals (%)
Concerns raised 9
EFFECTIVE
Physical Health HFC Rate (%) 95%
Mental Health HFC Rate (%) 83%
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Executive Summary
This is the second report of the new format Quality and Safety Report.
In relation to current quality and safety performance, attention is drawn to:
The levels of physical violence to staff;
The levels of restraint;
The under-performance of the Mental Health Harm Free Care rate;
The high number of overdue incident reviews.
There is a clear correlation between violence, restraint, staffing and the performance of the Mental Health Harm Free Care rate. The Quality and Safety Sub- committee is receiving deep dive presentations into the data across inpatient services. A review of the existing programme and improvement initiatives is underway through the Positive and Safe Group.
The data shows a noticeable increase in serious incidents however this should be considered against the context of a significant reduction over the last 4 years. The number of RIDDOR incidents is noticeably low in the last month.
Mortality review data is included in this report for the first time in accordance with requirements set-out by NHS Improvement. Reporting in this area will improve over coming months as the Trust commences its programme of structured case judgement reviews however there is still an absence of nationally standardised tools and definitions in this area as they relate to mental health and community health services.
Staffing continues to be a challenge and a number of wards at Guild Lodge have high use of bank staff. As mentioned above, there is a correlation between the use of temporary staff, staffing challenges, and levels of violence and restraint on wards. The Staffing for Quality and Safety Group continues to receive Network reports to monitor action being taken locally to mitigate risk. The Executive Director of Nursing and Quality is leading a task and finish group to review and take action in relation to inpatient staffing challenges.
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Safe
This section of the report looks at the domain of safety – that services are safe, and people are protected from abuse and avoidable harm. The following
Never Events ........................................................................................................................................................................................................................... 8
Physical Violence to Staff Incidents .......................................................................................................................................................................................... 9
Use of Restraint ..................................................................................................................................................................................................................... 10
Suicide (Reported as a Serious Incident) ............................................................................................................................................................................... 10
Staffing Incidents – One or Less Qualified Staff on Duty ........................................................................................................................................................ 11
Staffing Incidents – Red Flags ............................................................................................................................................................................................... 11
Safer Staffing – Wards with over 40% hours worked by bank staff ......................................................................................................................................... 12
Safer Staffing – Wards with over 10% hours worked by agency staff ..................................................................................................................................... 12
Mortality Review – Numbers of Deaths and Reviews ............................................................................................................................................................. 13
Mortality Review – Classification of Deaths ............................................................................................................................................................................ 13
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Serious Incidents - Rolling 12 Months
12
10
8
6
4
2
0
Nov Dec Jan Feb Mar Apr May Jun Jul Aug Sep Oct
Serious Incidents
A serious incident is defined as “acts or omissions in care that result in; unexpected or avoidable death, unexpected or avoidable injury resulting in serious harm - including those where the injury required treatment to prevent death or serious harm, abuse, Never Events, incidents that prevent (or threaten to prevent) the ability to continue to deliver healthcare services and incidents that cause widespread public concern resulting in a loss of confidence in healthcare services.”
The number of serious incidents fell throughout 2014-2016, however the long term reduction has now plateaued with a minor increase over the rolling 12 month period.
During October 2017, the following serious incidents were reported:
Serious self-harm (suspected attempted suicide) of a prisoner at HMP Liverpool;
Death (suspected suicide) of a patient under the care of the Assessment and Treatment Team in Chorley and South Ribble;
Concerns around the care of a patient in Podiatry in Central Lancashire – no immediate concerns for LCFT services however a patient under the care of podiatry underwent an operation at an acute Trust where the wound deteriorated resulting in an above knee amputation;
Death (suspected suicide) of a patient under the care of the Assessment and Treatment Team in Lancaster and Morecombe;
Death (suspected suicide) of a patient under the care of the Rapid Intervention and Treatment Team in Lancaster and Morecombe;
Death (suspected suicide) of a person recently seen by the Mental Health Liaison Team in Central Lancashire;
Death of a patient in an acute Trust which may have been contributed to by a pressure ulcer, where the patient was under the care of Southport and Formby District Nursing;
Death (suspected suicide) of a prisoner at HMP Liverpool;
Death of a patient under the care of the Mindsmatter Service in West Lancashire.
In all cases, a formal investigation is now underway and the incidents have been reported as required under the NHS Serious Incident Framework.
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RIDDOR Incidents - Rolling 12 Months
7
6
5
4
3
2
1
0
Nov Dec Jan Feb Mar Apr May Jun Jul Aug Sep Oct
RIDDOR Incidents
The Trust is required to report certain incidents under the Reporting of Injuries, Diseases and Dangerous Occurrences Regulations 2013. These notifications are received by the Care Quality Commission and Health and Safety Executive. A RIDDOR incident is defined as an incident were someone has died or has been injured because of a work-related accident including specified injuries to workers (certain fractures, amputations, loss of sight, crush injury to head or torso, serious burns, loss of consciousness, etc.), injury causing absence of work for more than 7 days, injuries to non-workers requiring transfer to hospital, occupational diseases and certain dangerous occurrences.
The number of RIDDOR incidents shows a small increase during the year however improved awareness of reporting requirements is considered to be partially responsible. The predominance of incidents relate to absence of work of over 7 days and originates from violence to staff.
During October 2017, the following RIDDOR incident was reported:
Injury to a staff member’s back whilst opening a door resulting in absence for over seven
days.
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Never Events - Rolling 12 Months
2
1
0
Nov Dec Jan Feb Mar Apr May Jun Jul Aug Sep Oct
Never Events
Never events are serious incidents that are entirely preventable as guidance, or safety recommendations providing strong systemic protective barriers, are available at a national level, and should have been implemented by all healthcare providers. Each never event type has the potential to cause serious patient harm or death. However, serious harm or death is not required to have happened as a result of a specific incident occurrence for that incident to be categorised as a never event.
The Trust reported one Never Event in September 2017, which related to an incident in May 2017. This related to an overdose of methotrexate in rheumatology services. The report is due for completion
HCAI Incidents - Rolling 12 Months
5
4
3
2
1
0
Nov Dec Jan Feb Mar Apr May Jun Jul Aug Sep Oct
Serious HCAI Incidents
A serious HCAI incident is considered to be an avoidable incident of Clostridium Difficile (C.Diff), Meticillin-Resistant Staphylococcus Aureus (MRSA), Methicillin-Susceptible Staphylococcus Aureus (MSSA), Gram-negative bacteria, Carbapenemase-Producing Enterobacteriaceae (CPE), or another infection control incident resulting in a ward closure.
The number of HCAI incidents remains low with no exceptions to report. The Infection Prevention and Control Team continue to drive improvements in reporting and compliance with the Essential Steps Hand Hygiene Audit and to drive forward the annual staff flu vaccination campaign.
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Potentially Avoidable G3 and G4 Pressure Ulcer Incidents - Rolling 12
Pressure ulcers are injuries to the skin and underlying tissue, primarily caused by prolonged pressure on the skin. Pressure ulcers can affect any part of the body that's put under pressure. They're most common on bony parts of the body and often develop gradually, but can sometimes form in a few hours. In a grade three pressure ulcer, skin loss occurs throughout the entire thickness of the skin and the underlying tissue is also damaged. The underlying muscles and bone are not damaged. A grade four pressure ulcer is the most severe type of ulcer. The skin is severely damaged and the surrounding tissue begins to die (tissue necrosis). The underlying muscles, or bone, may also be damaged. People with grade four pressure ulcers have a high risk of developing a life-threatening infection
The number of pressure ulcer incidents increased over the summer period but has declined over the last two months. Pressure ulcer prevention is a priority for 2017/18 in the Quality Plan and work so far has included revising the policy, introducing safety huddles, a safety senate and the safety cross. Localities where these initiatives have been piloted have shown a reduction incidents.
Physical Violence to Staff Incidents - Rolling 12 Months
300
250
200
150
100
50
0
Nov Dec Jan Feb Mar Apr May Jun Jul Aug Sep Oct
Physical Violence to Staff Incidents
Physical violence to staff includes any degree of harm, including near miss incidents, where staff are physical assaulted. Incidents are recorded by staff on the Trust’s quality governance system (Datix).
The number of incidents of physical violence to staff increased notably in 2014 and remained increased since, with a further increase during 2017/18 which appears to have levelled during the last few months. Hot spots have been identified in older adult wards and psychiatric intensive care units (PICUs). A deep dive into the data for PICUs was presented to the Quality and Safety Sub- committee in October, with a deep dive into older adults planned for December 2017. Targeted improvement work is taking place in older adult wards focused on reducing violence from personal care activities. Ongoing support and training to clinical teams continues to be provided by the Violence Reduction Team.
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Use of Restraint - Rolling 12 Months
500
450
400
350
300
250
200
150
100
50
0
Nov Dec Jan Feb Mar Apr May Jun Jul Aug Sep Oct
Use of Restraint
The use of restraint shows a notable increase. This is closely linked to the increase in violence and the work to address violence includes restraint reduction as an outcome measure. The hot spot areas mirror those for violence and aggression mentioned earlier in the report.
Suicide (Reported as a Serious Incident) - Rolling 12 Months
7
6
5
4
3
2
1
0
Nov Dec Jan Feb Mar Apr May Jun Jul Aug Sep Oct
Suicide (Reported as a Serious Incident)
The overall rate of suicide incidents (deemed to meet the criteria for a serious incident) show a noticeable increase over the rolling 12 months with October 2017 seeing the second highest reported number over that period. No emerging risks have been identified for this sudden increase and serious incident investigations are underway.
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Staffing Incidents – One or Less Qualified Staff on Duty
Instances of one qualified staff on duty are reported and escalated in accordance with the Staffing for Quality and Safety Escalation Procedure. This allows managers to put into place mitigations by moving staff, supporting the area with senior nurses or using bank and agency staff.
Wards which reported more than 10 instances of this are:
Marshaw
Marshaw Ward reported more than 10 instances in the last reporting period.
Red Flags - Rolling 12 Months
350
300
250
200
150
100
50
0
Nov Dec Jan Feb Mar Apr May Jun Jul Aug Sep Oct
Staffing Incidents – Red Flags
All staff are encouraged to use the Red Flag facility on the eRostering Safe Care system to alert managers to staffing incidents such as low staffing numbers, missed breaks, etc.
The majority of Ref Flag incidents relates to the above issue of one or fewer qualified staff on duty.
One or Less Qualified Staff on Duty -
Rolling 12 Months 250
200
150
100
50
0
Nov Dec Jan Feb Mar Apr May Jun Jul Aug Sep Oct
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Wards with over 40% hours worked by bank staff
Townley CSU
Marshaw
Bleasdale
Elmridge
Byron
Bronte
Dunsop
40% 45% 50% 55% 60%
Safer Staffing – Wards with over 40% hours worked by bank staff
The services identified on the chart used bank staff for greater than 40% of hours worked.
Marshaw, Bleasdale, Elmridge, Byron and Dunsop also reported greater than 40% bank staff usage in the last reporting period. The Executive Director of Nursing and Quality is leading a task and finish group to explore and address inpatient staffing challenges.
Teams with over 10% hours worked by agency staff
HMP Liverpool
0% 5% 10% 15%
Safer Staffing – Wards with over 10% hours worked by agency staff
The following services used bank staff for greater than 40% of hours worked:
HMP Liverpool
The Clinical Director of Secure Services presented an assurance report on staffing at HMP Liverpool to the Quality and Safety Sub-committee in November 2017. Sustained recruitment has been underway and several new staff have been appointed and are awaiting prison security clearance.
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Numbers of Deaths and Mortality Reviews - Rolling 12 Months
80
60
40
20
0
Nov Dec Jan Feb Mar Apr May Jun Jul Aug Sep Oct
SCJ Reviews SI Reviews Deaths
Mortality Review – Numbers of Deaths and Reviews
The Trust is required to declare how many deaths were deemed as avoidable.
Deaths are reviewed through two processes: the serious incident (SI) process and the structured case judgement (SCJ) process. The SI process determines whether a death was predictable and/or preventable. The SCJ process determines whether a death was due to a problem in care. Neither of these terms are legal terms or formal causes of death.
Since April 2017, one death reviewed through the serious incident process was deemed predictable and preventable. No structured case judgement reviews have taken place – a cohort of reviewers have been recruited and the process will commence in January 2018.
The Trust is engaged in the Learning Disability Mortality Review Programme (LeDeR) however at this stage it is unclear how this programme will return feedback into the Trust and this is being explored with NHS England.
Classification of Deaths - Rolling 12 Months (data available from July
2017)
40
20
0
Jul Aug Sep Oct
Expected Natural Expected Unnatural
Unexpected Natural Unexpected Unnatural
Not Yet Known
Mortality Review – Classification of Deaths
The Trust records deaths as incidents, where appropriate and in accordance with the Incident Procedure. A daily review process, supported by a weekly review panel, determines which deaths meet the threshold for a serious incident and (when established) which deaths will be subject to a structured case judgement review.
Deaths are recorded against one of four categories: Expected Natural (i.e. terminal illness), Expected Unnatural (i.e. drug misuse), Unexpected Natural (i.e. sudden cardiac condition) and Unexpected Unnatural (i.e. suicide). This framework was developed by Mazars in their investigation into deaths at Southern Health NHS Foundation Trust and helps determine which deaths require further review.
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Effective
This section of the report looks at the domain of effectiveness – that care, treatment and support achieves good outcomes, helps people to maintain quality of
life and is based on the best available evidence. The following indicators are covered in the report:
Mental Health Harm Free Care ........................................................................................................................................................................................... 15
Physical Health Harm Free Care ........................................................................................................................................................................................ 15
Local Clinical Audit ............................................................................................................................................................................................................. 16
National Clinical Audit ......................................................................................................................................................................................................... 17
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Mental Health Ham Free Care - Rolling 12 Months
92%
90%
88%
86%
84%
82%
80%
78%
76%
74%
Nov Dec Jan Feb Mar Apr May Jun Jul Aug Sep Oct
Mental Health Harm Free Care
The Mental Health Harm Free Care rate remains below the aspirational goal of 90%. The overall rate is made up of several individual measures. The area’s most impacting the overall measure includes violence, restraint, medication safety and feeling safe.
Physical Health Harm Free Care - Rolling 12 Months
97%
96%
95%
94%
93%
92%
91%
Nov Dec Jan Feb Mar Apr May Jun Jul Aug Sep Oct
Physical Health Harm Free Care
The Physical Health Harm Free Care rate has achieved the target in 7 of the last 12 months with an improving picture seen over recent months. The overall rate is made up of several individual measures.
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Local Clinical Audit
Clinical Audits N/L/R* Network Compliance (%) Date
Prevention of Dehydration L MHN 54% Sep-17
Absent Without Leave L MHN 55% Oct-17
Nursing Management of Clozaril R MHN 60% Oct-17
Diabetes R MHN 65% Sep-17
Carers R CYPWN 54% Oct-17
Cerebral Palsy in under 25's (NICE) L CYPWN 82%
Risk Assessments L CYPWN 83%
Clozapine L CYPWN 80%
Nutrition L CYPWN 77%
Consent to Treatment R MHN 94%
Completion of Waterlow risk assessments L CWN 85%
Wound assessment documentation L CWN 70%
Care of Dying L CWN 79%
Learning Disability L CWN 85%
Acupuncture - Rheumatology & Physiotherapy
R CWN 97%
Antibiotics in dentistry R CWN 94%
Use of restrictive practices within LD R CWN 93%
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National Clinical Audit
Audit Start Quarter End Quarter 2016/17 Compliance
2017/18 Compliance
National Audit of Anxiety and Depression Q4 2017/18
National Audit of Intermediate Care (NAIC) Q1 2017/18 Q4 2017/18
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Clinical Audit Summary Report
POMHUK Rapid Tranquillisation Audit
An action plan has been devised to ensure patients receive the necessary monitoring following use of rapid tranquillisation. Progress has been made as follows:
An alert has been added to the relevant medication templates on EPMA so nursing staff are prompted to monitor the patient if medication for rapid tranquillisation is administered.
A flowchart has been devised to support staff in undertaking the required monitoring and this is due to be ratified at the November Drugs and Therapeutics Committee.
Discussions are progressing to consider how Nerve Centre may be used to prompt physical health monitoring following use of rapid tranquillisation.
A template will also be devised for the new electronic patient record to support high standards of clinical care following use of rapid tranquillisation
POMHUK Audit: High Dose and Combination Antipsychotic Prescribing
This audit assessed the following three standards:
1. The dose of an individual antipsychotic should be within its SPC/BNF limits
2. Individuals receive only one antipsychotic at a time
3. Where high dose antipsychotics are prescribed, there should be a clear plan for regular clinical review including safety monitoring
331 patients were audited across 36 teams in LCFT. 22 patients medication regimen met the criteria for high dose prescribing. Eight of these patients were
on an adult ward or PICU and fourteen patients on forensic wards
Upper quartile performance was achieved by adult wards and PICUs. Forensic services performed higher that the national average for Standards One and Two.
Considering each standard individually, the trust achieved upper quartile performance for Standards One and Two. Upper quartile performance was not achieved for Standard Three, a newly introduced audit standard
Overall the Trust is upper quartile of Trust nationally.
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Caring
This section of the report looks at the domain of caring – that staff involve and treat people with compassion, kindness, dignity and respect. The following
indicators are covered in the report:
Friends and Family Test – Results .................................................................................................................................................................................. 20
Friends and Family Test – Submissions .......................................................................................................................................................................... 20
CQC Community Mental Health Survey .......................................................................................................................................................................... 21
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Friends and Family Test Results - Rolling 12 Months
100%
95%
90%
85%
80%
75%
Oct Nov Dec Jan Feb Mar Apr May Jun Jul Aug Sep
Friends and Family Test – Results
A key part of the Trust’s real time feedback process is the Friends and Family Test (FFT). The Friends and Family Test is a tool that supports the fundamental principle that people who use NHS services should have the opportunity to provide feedback on their experience. It asks people if they would recommend the services they have used and offers a range of responses. When combined with supplementary follow-up questions, the FFT provides a mechanism to highlight both good and poor patient experience.
The Friends and Family Test overall response rate has been at or above the target of 95% for 10 of the last 12 months with the target achieved and maintained since January 2017.
Friends and Family Test Submissions - Rolling 12 Months
4000
3000
2000
1000
0
Oct Nov Dec Jan Feb Mar Apr May Jun Jul Aug Sep
Friends and Family Test – Submissions
The number of submissions has notably reduced over the 12 months, however has remained broadly consistent during the last 10 months. There are a number of reasons for this including changes to how the data is captured (such as reducing multiple collection points).
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Compliments - Rolling 12 Months
1200
1000
800
600
400
200
0
Nov Dec Jan Feb Mar Apr May Jun Jul Aug Sep Oct
Compliments
The number of compliments has had a marginal decrease during the last 12 months.
CQC Community Mental Health Survey
Workers
Overall 9 Organising care experience
7
5 Overall views Planning care
3
1 Support and
Reviewing care wellbeing
Treatments Staff changes
Crisis care
CQC Community Mental Health Survey
The CQC use national surveys to find out about the experience of service users receiving care and treatment from healthcare organisations and mental healthcare providers. CQC asked people to answer questions about different aspects of their care and treatment. Based on their responses, CQC gave each NHS Trust a score out of 10 for each question (the higher the score the better). Each trust also received a rating of ‘About the same’, ‘Better’ or ‘Worse’.
Responses were received from 172 people who use services of the Trust.
The Trust was rated as “about the same” for all ten questions and each of their sub-questions.
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Responsive
This section of the report looks at the domain of responsiveness – that services are organised so that they meet people’s needs. The following indicators are
Mixed Sex Breaches .................................................................................................................................................................................................... 23
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Complaints - Rolling 12 Months
200
150
100
50
0
Nov Dec Jan Feb Mar Apr May Jun Jul Aug Sep Oct
Complaints Upheld Complaints
Complaints
The number of complaints has noticeably increased over the 12 months. This reflects a national picture. The predominant theme is in relation to access to treatment or drugs (22%), admission and discharge (17.5%), communication (14%), appointments including delays and cancellations (10%) and clinical treatment (9%).
Despite the overall increase, the number of upheld or partially upheld complaints remains consistent although there is a noticeable increase in the last month which will be closely monitored.
Mixed Sex Breaches - Rolling 12 Months
1
0
Nov Dec Jan Feb Mar Apr May Jun Jul Aug Sep Oct
Mixed Sex Breaches
There have been zero mixed sex breaches over the rolling 12 month period.
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Well Led
This section of the report looks at the domain of well les – that the leadership, management and governance of the organisation make sure it's providing high-
quality care that's based around individual needs, that it encourages learning and innovation, and that it promotes an open and fair culture. The following
indicators are covered in the report:
Care Quality Commission (CQC) Rating) ................................................................................................................................................................. 25
Quality Plan Dashboard ........................................................................................................................................................................................... 28
Quality Plan Exception Report ................................................................................................................................................................................. 28
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Care Quality Commission (CQC) Rating)
The Trust was last inspected in September 2016 and the overall rating was Good. Two core services were rated as Requires Improvement – community inpatient services and community health services.
The CQC inspected healthcare services at HMP Liverpool in September 2017 in a process separate from the main Trust inspection. The draft report is now being check for factual accuracy.
Core Skills - Rolling 12 Months
95%
90%
85%
80%
75%
70%
Nov Dec Jan Feb Mar Apr May Jun Jul Aug Sep Oct
Core Skills
The overall core skills rate is above the Trust target of 85% however performance remains below target in:
Manual Handling Level 2
Manual Handling Level 3
Basic Life Support
Intermediate Life Support
Safeguarding Children Level 3
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Overdue Incident Reports - Rolling 12 Months (data available from Feb
2017)
2500
2000
1500
1000
500
0
Feb Mar Apr May Jun Jul Aug Sep Oct
7 Day Reviews 3 Day Reviews
Overdue Incident Reviews
The number of overdue incident reports, particularly 7 Day Reviews for incidents categorised as Level 1, 2 or 3 remains high with no improvement over the last 12 months. Targeted work has taken place within the Networks and has seen improvement in the Community and Wellbeing Network in particular. The Mental Health Network accounts for the vast predominance of overdue incidents.
Accreditations
This section is currently under development.
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Concerns Raised - Rolling 12 Months (data available from April 2017)
20
10
0
Apr May Jun Jul Aug Sep Oct
Concerns Raised
During October 2017, the following concerns were reported through the various mechanisms including the Raising Concerns Guardian and through Dear David:
The proposed installation of baths in initial designs for the Chorley inpatient unit;
Staff smoking on the road outside Sceptre Way;
High caseload and demand in Community Mental Health Teams;
Staff attack alarms not available to staff when entering wards at the Harbour at the start of their shift;
Lack of commissioned services for people suffering with Autistic spectrum disorder and behavioural difficulties;
High caseloads in Community Mental Health Teams;
Caseloads, lack of management support and supervision Community Mental Health Teams;
Culture and clinical practice at the Harbour;
Staff suffering with stress in Community Mental Health Teams.
In all cases a review of proportionate scale has been commissioned. The findings from each review are individually fed back to the person raising the concern if they have provided their name. The findings from every concern is summarised in the Quality Matters bulletin.
The themes from concerns over the year to date are management culture and conduct, demand, staffing and violence.
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Quality Plan Dashboard Key: Off Track On Track Complete Data Not Provided
Priority Lead QI Plan CQC Requirements
Process Measures
Outcome Measures
Balancing Measures
Mental Health Clinical Risk Assessment and Management Helen Lilley Holistic Care Planning Patsy Probert Standards of Record Keeping Patsy Probert Staffing for Quality and Safety Paula Flint Seclusion Julie Seed End of Life Care Michaela Toms Supporting Staff following Adverse Events Caroline Waterworth Reduction in Violence and Aggression Caroline Waterworth Pressure Ulcers Michaela Toms Medication Safety Sonia Ramdour Physical Healthcare in Mental Health In-patient Services Debra Wilson Appraisals Damian Gallagher Core Skills Deborah Cox Supervision Gita Bhutani New Professional Roles Patsy Probert
Mental Health Law Matthew Joyes
Quality Plan Exception Report
Improvement plans for all priorities are now in place. The priority of violence reduction is underperforming in the outcome measures as described in the safety section above. The priorities of appraisals and core skills are underperforming and information is detailed above for core skills and in the quarterly workforce report for both. The HR Directorate are assisting services with reporting and other support to improve compliance. Of particular note, both these areas are Requirement Notices from the last CQC inspection. The priority of new professional roles is progressed in respect of planning however the actual implementation of new professional roles is behind plan. Work is underway across all professional groups to address this. The priority of mental health law is well progressed in respect of new systems and processes however the outcomes are behind plan particularly in relation to ensuring patients are given their verbal Section 132 rights. This is being closely monitored as the new systems and processes are embedded.
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Appendix 1 – Extracts from the Quality and Safety Surveillance Report and Mental Health Law Surveillance Report
The Quality and Safety Surveillance Report is designed to provide the Committees and Subcommittee of the Trust Board with a range of indicators that provide
assurance and/or early warning escalation of risk. Risk indicators are used to draw attention to areas of focus. Green flags indicate a measure that is on target
or where performance is in-line with accepted levels. Yellow flags indicate a measure for close watch (perhaps because of a worsening position) or where a
measure is off target but has no immediate risk. Red flags indicate a measure that presents an immediate and/or high level risk. The Quality and Safety Tile, in
the front of this report, is a headline summary of key indicators.
In addition, a Mental Health Law Surveillance Report is produced alongside Network-level Quality Surveillance Report.
The data tables from the Trust Quality and Safety Surveillance Report (monthly) and Mental Health Law Surveillance Report (quarterly) are included in this
Quality and Safety Report for additional information and context.
Lancashire Care NHS Foundation Trust Quality and Safety Report
Lancashire Care NHS Foundation Trust Quality and Safety Report
Page 31 of 34
QUALITY AND SAFETY SURVEILLANCE - Effective
Clinical Audits N/L/R* Network Compliance (%) Date Prevention of Dehydration L MHN 54% Sep-17
Absent Without Leave L MHN 55% Oct-17
Nursing Management of Clozaril R MHN 60% Oct-17
Diabetes R MHN 65% Sep-17
Carers R CYPWN 54% Oct-17
Cerebral Palsy in under 25's (NICE) L CYPWN 82% Risk Assessments L CYPWN 83% Clozapine L CYPWN 80% Nutrition L CYPWN 77% Consent to Treatment R MHN 94% Completion of Waterlow risk assessments L CWN 85% Wound assessment documentation L CWN 70% Care of Dying L CWN 79% Learning Disability L CWN 85% Acupuncture - Rheumatology & Physiotherapy R CWN 97% Antibiotics in dentistry R CWN 94% Use of restrictive practices within LD R CWN 93%
The Friends and Family Test real time reporting is locked and nationally reported on the 19th of each month and will therefore be reported in arrears most months
Lancashire Care NHS Foundation Trust Quality and Safety Report