Monthly Performance Report

Transcription

1 Monthly Performance Report Month 12 - Period to end of March 216 Report Issued: 26 th April 216

2 Table of Contents Dashboard overview summary of key indicators.. 3 Quality and safety performance summary. Workforce performance summary..6 Service delivery performance summary 8 Social Inclusion performance summary 12 Finance performance summary 13 Regulatory standards and requirements.. 1 2

3 STANDARDS, QUALITY & RISK Key - thresholds to be developed Strategic Qualtiy and Risk Key Performance Indicators: Status - Performance is on or above target Frequency Proposed Target Current Position Status Change Goal Ref's Further details in See Dashboard on page 2 monthly 2 Quality & Risk Dashboard summary Status - Performance is not meeting target HUMAN RESOURCES Status - Performance potentially of concern Workforce Key Performance Indicators: Frequency Proposed Target Current Position Status Change Strategic Goal Ref's Further details in Trend - Performance has improved over period Sickness absences monthly <5.1% 6.62% 1, Human Resources Dashboard summary Trend - Performance maintained over period Temporary staffing expenditure monthly 882,191 1, Human Resources Dashboard summary or remains in line with plan Turnover monthly 3-13% 16.3% 1, Human Resources Dashboard summary Trend - Performance has declined over period SERVICE DELIVERY N/A - Not Applicable or appropriate Quality of Care - Performance Indicators: Frequency Target Current Position Status Change Strategic Goal Ref's Further details in Access to Home Treatment (1,22 episodes per year) monthly 122 YTD 1,18 2 Service Delivery Dashboard summary Gatekeeping - Acute admissions assessed for HT monthly > 9% of admissions 97.3% 2 Service Delivery Dashboard summary Adult Acute inpatient occupancy levels monthly 95% - 1% 96.7% 2 Service Delivery Dashboard summary Out of area for acute admission due to local capacity monthly Nil - for Acute inpatient care 2 Service Delivery Dashboard summary Delayed discharges monthly < 7.5% of patients delayed 9.8% 2 Service Delivery Dashboard summary 7 Day follow up following discharge monthly 95% of CPA Discharges 95.6% 2 Service Delivery Dashboard summary Access to Early Intervention Services monthly 75 New cases YTD Service Delivery Dashboard summary Access to services - Waiting times within 18 weeks monthly > 95% of clients referred 98.8% 2 Service Delivery Dashboard summary Access to IAPT - new clients accepted monthly 12 new clients YTD 12,77 2 Service Delivery Dashboard summary Acess to IAPT - treatment in 6 weeks (at start of treatment) monthly 75% 82.5% Acess to IAPT - treatment in 18 weeks (at start of treatment) monthly 85% 99.5% CPA - Annual Review monthly 95% 95.1% 2 Service Delivery Dashboard summary Primary Care - Smoking Cessation monthly various - see dashboard various n/a 2 Primary Care Services Dashboard summary Primary Care - Obesity monthly various - see dashboard 71.5% 2 Primary Care Services Dashboard summary Primary Care - Hypertension monthly various - see dashboard various n/a 2 Primary Care Services Dashboard summary Primary Care - CHD & Stroke monthly various - see dashboard various n/a 2 Primary Care Services Dashboard summary Primary Care - Diabetes monthly various - see dashboard various n/a 2 Primary Care Services Dashboard summary Primary Care - COPD monthly various - see dashboard various n/a 2 Primary Care Services Dashboard summary Primary Care - Palliative Care / End of Life Care monthly various - see dashboard various n/a 2 Primary Care Services Dashboard summary Data Quality - Client Identifier indicators x 6 quarterly 97% Q3-99.8% 2 Service Delivery Dashboard summary Data Quality - Client Outcome indicators x 3 quarterly 5% Q3-85.1% 2 Service Delivery Dashboard summary SOCIAL INCLUSION Trust Board Performance Dashboard - key indicators for period to March 216 Social Inclusion - Performance Indicators: Frequency Target at month end Current Position Status Change Further details in Employment rates of people on CPA monthly na Q = 5.2% 6 Social Inclusion Dashboard summary Proportion of people on CPA in settled accommodation monthly na Q = 82.5% 6 Social Inclusion Dashboard summary Trust Membership - Recruitment against plan monthly 12,62 12,631 6 Social Inclusion Dashboard summary FINANCE Financial Key Performance Indicators: Frequency Target Current Position Status Change Strategic Goal Ref's Further details in Risk Rating monthly 1 Finance Dashboard summary Cash available ( ') monthly 25, 612m 25, 711m 1 Finance Dashboard summary CIP delivery against plan ( ') monthly.51m.178m 1 Finance Dashboard summary 3

4 Self Harm Safety Dashboard - Period to Mar data recorded as at 8 April 216 Falls - Service Users Missing Persons Restraints 1 Service User Falls Missing Persons Service User Falls Falls that resulted in injury All service user falls recorded on the system, the red line shows how many of those falls resulted in an injury. 91% of all falls recorded were graded as 'negligible' 7% of all falls were graded as 'minor' 1% of all falls were graded as 'moderate' A single fall (out of 236 shown within the graph above) was graded as 'Major' 2% of falls were reported from Woodland View 15% of falls were reported from Birch Avenue 12% of falls were reported from Hurlfield View 9% of falls were reported from G1 5% of falls were reported from Dovedale A report on the work of the Falls Steering Group was presented to the Service User Safety Group in February Self Harm Incidences All Self Harm Incidents No of Self-Harm Patients Missing Patient - Low Missing Patient - Medium Missing Patient - High All 'Missing Person' incidents recorded on the system together with the category of the patient. 25% of all missing person incidents relate to Burbage Ward 16% of all missing person incidents relate to Stanage Ward 15% of all missing person incidents relate to Maple Ward 15% of all missing person incidents relate to Rowan Ward 6% of all missing person incidents relate to ITS/Endcliffe Breakdown of Service User Status and Incident Type Section Number Breakdown of Detained Service User 2 79 Incidents % relate to absconsion from the ward 5(2) 6 29% relate to failing to return from leave % relate to absconsion from escorted 37/1 11 leave 37 (Notional) A detailed report on missing patients was Informal 138 discussed at the Service User Safety Group Total 8 in February and EDG in March of the 2 individuals who went missing account for 16 (2%) of all the above reported missing patient incidents. 155 service users have been missing on 1 or 2 occasions, during this reporting period Medication Incidents All Restrictive Practices Incidents (physical, chemical and mechanical) All restraints Seclusions Number of Patients Restrained All recorded restraint incidents on Safeguard (since April 215 also includes Mechanical and Chemical Restraints) Electronic recording of restraint incidents w as introduced to all areas w ho are already recording incidents electronically on 1st April 215. The above clearly show s that this has had an impact on the number of restraint incidents being reported. There w ere 335 service users involved in the restraints show n, w ith a total of 1212 restraints in the period w hich averages 3.6 restraints per service user. 2 service users w ere restrained 86 and 7 times respectively over the tw o year period, both being restrained on four different wards throughout this period. 216 service users had 1 or 2 incidences of restraint during the period shown. 3% of all recorded restraint incidents occur on ITS/Endcliffe 18% of all recorded restraint incidents occur on Row an Ward w ith a further 1% occurring on Burbage Ward. A recent NHS Benchmarking Netw ork event suggests that SHSC is below the average for the number of restraints reported (based on restraints per 1 beds across the Trust) All Seclusion Incidents vs. Number of Patients Secluded The above data is showing actual self harm, Potential Self Harm has been excluded from the data. Incidences of Self Harm as opposed to unique incidents is also used now. 72% of all self harm incidents recorded w ere graded as either 'near miss' or 'negligible' harm 23% of self harm incidents were graded as 'minor' harm % of self harm incidents were graded as 'moderate' harm 1% (8 incidences) w ere graded as 'major' harm w ith 2 x catastrophic incidents (fatalities) throughout the reporting period show n above. 22% of all self harm incidents recorded w ere from Row an Ward 1% of all self harm incidents recorded w ere from Maple Ward 11% of all self harm incidents recorded w ere from Stanage Ward 11% of all self harm incidents recorded w ere from ITS/Endcliffe 7% of all self harm incidents recorded w ere from CERT Tw o service users accounted for 12% (127) of self harm incidents over the period, there w ere 238 service users and 19 incidences of self harm in the above data. 17 service users had 1 or 2 incidences of self harm during this reporting period. = Near-Miss 1 = Negligible 2 = Minor 3 = Moderate = Major All recorded medication incidents broken down by Actual Impact. 5% of all medication incidents reported are rated 'Near Miss' 77% of all medication incidents reported in the time period above are 'Negligible' graded incidents 17% of the incidents reported above are graded as 'Minor' incidents, w ith 1% (13 ) graded as 'Moderate'. There w ere tw o x 'Major' medication incidents over the tw o year period and both of them occured in the last tw o months (Feb 16 and Mar 16). 8% of all medication incidents reported above relate to Woodland View 8% of all medication incidents reported above relate to Rowan Ward 6% of all medication incidents reported above relate to Burbage Ward 6% of all medication incidents reported above relate to Stanage Ward 6% of incidents recorded above relate to the Pharmacy Department All Seclusions All recorded seclusion incidents on Safeguard. Number of Patients Secluded 3% of all seclusions recorded above relate to ITS (latterly Endcliffe). 22% of all seclusions recorded above relate to Maple Ward, w ith a further 1% relating to Row an Ward and 12% on Burbage Ward. G1 has had 13 x recorded seclusions for the above time period (w ith 11 of those being recorded from Oct 15 onw ards). 5 (2%) of the 227 people w ho w ere secluded accounted for 129 (21%) of the incidences of seclusion. 138 service users had 1 or 2 incidences of seclusion recorded w ithin the above time period. Mar 216 total is the low est for seclusion incidences over the tw o year period at 11 x seclusions.

5 Total No of Incidents Safety Dashboard Part 2 - Period to Mar data reported as at 8 April 216 Incidents & Incidents with Harm Infection Control Verbal, Physical Assault & Intimidation - Patients All Incidents Incidents & Incidents with Harm All recorded incidents on the system are defined as 'Incidents'. Incidents with Harm is all recorded incidents on the system where an injury has been assigned. Serious Incidents Incidents With Harm 77% of all reported incidents are graded as 'negligible' impact 16% of all reported incidents are graded as 'minor' impact % of all reported incidents are graded as 'moderate' impact Just over 1% of all reported incidents are graded as 'major' or 'catastrophic' Between March and June 21, electronic incident reporting was rolled out to all inpatient areas. Some high reporting residential settings were brought onto electronic reporting in October 21, thus resulting in an increase in the number of incidents reported. Woodland View is the highest reporter of incidents accounting for 1% of all reported incidents, Rowan ward is the second highest reporter accounting for 9% of all incidents All Serious Incidents All recorded incidents that require a Level 2 investigation. Serious Incidents Median Classification of Serious Incidents The criteria for a 'serious incident' has changed and now only includes incidents where a Level 2 investigation has been (or is being) carried out. This excludes incidents like some deaths where the incident is Catastrophic in its impact but the initial screening of care records, suggest it does not warrant a full investigation (e.g. death was from natural causes). The South West Home Treatment team reported the most Level 2 incidents over the period with. South East Recovery and West Recovery are joint second highest reporters with 3. There are 1 x Level 2 incidents for this period, the Community Directorate acccounts for 26 (63%) of all those. The Specialist directorate accounts for 2% (8) of the 1 in total A detailed report covering all of Quarter 215/16 data for infection control incidents will be presented to May's Quality Assurance Committee. During the colder months of 21/15 (Q3 & Q) there were 61 D&V/Norovirus/Rotavirus incidents, the same period in 215/16 has seen that number reduce from 61 to UTI (no catheter) Soft tissue infections Intravenous Drug Users (current or ex) Q1 21/15 Q2 21/15 Q3 21/15 Q 21/15 Chest Infections D&V/ Norovirus/ Rotavirus BBV Q1 215/16 Q2 215/16 Q3 215/16 Q 215/16 Oral/ dental SCABIES/ HEADLICE SHINGLES/ Chicken pox MRSA (Col /inf) C.DIFF Tuberculosis UTI (catheter) Other Rest of Infections Top 6 Infections Q1 21/15 Q2 21/15 Q3 21/15 Q 21/15 Q1 215/16 Q2 215/16 Q3 215/16 Q 215/16 A detailed report covering all of Quarter 215/16 data for infection control incidents will be presented to May's Quality Assurance Committee. Deaths Outcome 213/1 21/15 215/16 Awaiting Coroners Inquest Closed Conclusion - Accidental Conclusion - Alcohol/Drug Related Conclusion - Misadventure 3 6 Conclusion - Narrative Conclusion - Natural Causes Conclusion - Open Conclusion - Suicide Natural Causes - No Inquest Ongoing* Grand Total All patient deaths recorded on the Safeguard system including the outcome of that death. *Ongoing - This incident is a suspected homicide of an individual whereby it is alleged that the perpetrator is an SHSC service user. All Verbal/Assaults on Patients All Abuse/Intimidation All Abuse/Intimidation with Harm All recorded verbal/physical abuse or intimidation incidents against service users. This does not include sexual abuse, racial abuse or 'other' abuse incidents. Harm is defined as an incident with an injury assigned to it. 9% of all the above incidents reported are graded as 'negligible' 8% of the above incidents are graded as 'minor' and 2% were graded as 'Moderate'. 7 incidents (.1%) were graded as 'Major' and no 'Catastrophic' incidents have been reported during the period shown. - Highest reporter of patient abuse is Woodland View with 1% of all the incidents above - Joint second highest reporters are ITS (latterly Endcliffe) and Rowan each with 9% - Joint third highest reporters each with 6% of the above incidents are Maple, Burbage and G1 All Verbal/Assaults on Staff One service user had 153 incidents over this period which is 3% of all such incidents Verbal & Physical Assault & Intimidation - Staff All Abuse/Intimidation All Abuse/Intimidation with Harm All recorded verbal/physical abuse or intimidation incidents against staff. This does not include sexual abuse, racial abuse or 'other' abuse incidents. Harm is defined as an incident with an injury assigned to it. 89% of all the above reported incidents are graded as 'negligible' 8% of all the above reported incidents are graded as 'minor' 3 x incidents have been graded as 'Major' over the reporting period shown above, with no 'Catastrophic' graded incidents. - Highest reporter of staff abuse is ITS /Endcliffe which accounts for 1% of all the above incidents -Second highest reporters is Rowan Ward accounting for 9% of all the above incidents - Third highest reporteris Woodland View with 8% of all the above incidents All Verbal/Assaults with Harm Abuse Incidents with Harm on staff 5

6 Human Resources - Period to March 216. Please Note: Sickness reporting is 1 month in arrears. Overall Sickness Absence 7.5% Overall Absence Rate Year on Year (13/1 to 15/16) 7.% 6.5% 6.% 5.5% 5.%.5%.% Apr May Jun Jul Aug Sep Oct Nov Dec Jan Feb Mar Current Year 5.31% 5.22% 5.3% 5.6% 5.65% 5.73% 5.93% 6.35% 6.53% 6.7% 6.17% 6.62% Last Year 5.% 5.3% 5.52% 5.5% 5.83% 5.77% 6.21% 6.53% 6.59% 6.9% 6.53% 6.9% Previous Year 5.35% 5.31% 5.2% 5.2% 5.1% 5.28% 5.96% 5.98% 5.73% 6.23% 6.2% 5.28% Current Year Last Year Previous Year Long Term Sickness Absence Headcount and FTE have decreased this month by 8 and 9.85 respectively. 5. Long Term Absence (proportion of Sickness Rate) (13/1 to 15/16) Apr Apr May Jun Jul Aug Sep Oct Nov Dec Jan Feb Current Year Last Year Prev. Year Current Year Last Year Prev. Year The Overall Sickness Absence rate for the Trust has increased to 6.62%. An element of caution should be taken when looking at March's sickness figures as all data may not have been recorded against employees records. Long Term sickness has increased in March to 33.93% of the overall sickness rate. As above, an element of caution should be taken when comparing the February Long Term / Short Term comparison, as not all data has been recorded against employees records. 6

7 Human Resources - Period to March 216. Staff in Post (Headcount & FTE) Staff in Post Headcount & FTE (215/16) Trust PDR Compliance as at March Headcount FTE Total (FTE+B&Non- NHS) % 93% Valid Not Valid Headcount FT E Total (FT E+B &Non-NHS) Directorate PDR Valid PDR Outstanding The above graph shows the monthly Headcount & FTE figures for the Trust. Community 87% 13% Inpatient 9% 6% The Green line is a notional Bank & Non-NHS Pay Headcount to the FTE and is based on the average Trust LDS 91% 9% Salary ( 27K) Medical 9% 1% The headcount has decreased by 18 this month and FTE has seen a decrease of 13. The loss of service within LDS in particular has had an effect on the Turnover rate and which has seen a spike in January due to the loss of Wensley ST - a total of 39 employees. The underlying Turnover Rate (excluding TUPE and Junior Doctors) Non Med Support Primary Care Specialist 95% 97% 95% 5% 3% 5% remains at approximately 1.68% (Quarter 3 figure). Further analysis of Trust staff turnover will be completed shortly. Below is the Trust Turnover Rate for the 12 month period ending March Month Turnover % All Staff Exc. Bank 17.8% 17.% 17.% 16.6% 16.2% 15.8% 15.% 15.% 1.6% 1.2% 13.8% 13.% 13.% 12.6% 12.2% 11.8% 11.% 11.% Apr- May Jun- Jul- Aug- Sep- Oct- Nov- Dec- Jan- Feb- Mar Month Turnover % All Staff Exc. Bank 12.1% 13.7% 1.8% 1.86% 15.16% 1.88% 15.1% 15.16% 15.1% 16.58% 17.2% 16.29% The PDR Focal Point Window is 1 April to 3 June 215. As at 31 March 216 the % rate of PDR's completed is 93%. The rate has remained static this month and is above the Trust target completion rate of 9%. The PDR steering Group is already making plans for the 216 Focal Point Window. 7

8 SERVICE DELIVERY - PERIOD TO MARCH 216 Crisis Resolution - Home Treatment Episodes Gate Keeping - Access To Home Treatment Bed Occupancy Levels Apr-1 May-1 Jun-1 Crisis Resolution And Number of Home Treatment Episodes HOME TREATMENT Jul-1 Aug-1 Sep-1 Oct-1 Nov-1 Dec-1 Percentage of Admissions 1.% 98.% 96.% 9.% 92.% 9.% Apr-1 Gatekeeping Of Acute Admissions (Excluding Admissions From Other Psychiatric Hospitals) May-1 Jun-1 Jul-1 Aug-1 Sep-1 Oct-1 Nov-1 Dec-1 12.% 11.% 1.% 9.% 8.% 7.% 6.% 5.%.% 3.% 2.% 1.%.% Apr-1 May-1 Jun-1 Jul-1 Inpatient Services - Bed Occupancy Levels (%) Aug-1 Sep-1 Oct-1 Nov-1 Dec-1 Home Treatment Episodes Per Month Home Treatment Target Per Month % Gatekept Gatekeeping Target % Adult Acute % Functional Illness % Dementia Management % Annual Target Target To Date YTD Status (YTD) Target Month Actual YTD Status (In Mth) Occupancy Levels Month Target Month Actual YTD Status (In Mth) Episodes Of Home Treatment 1,22 1,22 1,18 Acute Admissions Assessed 95.% 97.3% 99.51% Acute 95.% 83.92% 96.7% For Home Treatment Functional Illness 95.% 12.33% 97.11% Dementia Management 95.% 86.38% 81.92% AIM: to provide home treatment to people experiencing a mental health crisis as an alternative to AIM: to ensure all people admitted for acute inpatient care are considered and assessed (gate kept) for AIM: to support safe and effective care through 95% occupancy hospital admission. home treatment prior to decision to admit. During 211/12 the Trust achieved 12% of target, 118% in 212/13, 118% in 213/1 and 19% in 21/15. Over Quarter 1 the Trust achieved 122% of the projected target, over Quarter 2 117% of target and during Quarter 3 12% of target. The above information includes all appropriate home treatment interventions provided across a range of Trust services,. The annual position for 211/12 was 99.%, for 212/13 it was 99.5%, for 213/1 it was 99.8% and for 21/15 it was 99.8%. Over Quarter 1 the Trust's position was 99.%, over Quarter % and over Quarter 3 it was 1%. 1% Gatekeeping has been maintained for the majority of the previous 12 months. Adult Services: By the end of March 215 bed numbers had reduced from 2 per ward to 18 per ward (including 5 substance misuse beds and 1 place of safety bed) and occupancy rates from April 215 onwards are reported against the reduced bed numbers. The service was over 1% occupancy on the reduced bed numbers since April 215 as the service experiences bed pressures against the reduced bed numbers. This was managed through temporary re-opening of mothballed beds as the system adjusted. Since October 215 occupancy rates have been below 1%. Older Adults: FMI Wards: Following gradual and sustained reductions in bed occupancy during bed numbers had reduced from beds to 2 beds by March 215. Occupancy rates from April 215 onwards are reported on the reduced numbers, and from 18 beds from the end of April onwards. G1: Increased occupancy rates are noted during Quarter 2, particularly influenced by high rates of delayed discharges on G1 over that period. Out Of Town Admissions Delayed Discharges CPA 7 Day Follow Up - Post Discharge Apr-1 May-1 Jun-1 Out Of Town Admissions - Acute And Pychiatric Intensive Care OUT OF TOWN Jul-1 Aug-1 Sep-1 Oct-1 Nov-1 Dec-1 Acute PICU DTOCs as a % of OBN's 12% 1% 8% 6% % 2% % Health DTOC's All DTOC's Threshold % DTOCs - (April 1 to date) Week No. 1.% 9.% 8.% 7.% 6.% 5.% Seven Day Follow Up Rate -For CPA Clients Discharged From Inpatient Care Apr-1 May-1 Jun-1 Jul-1 Aug-1 Sep-1 Oct-1 Nov-1 Dec-1 % All People On CPA Followed Up In 7 Days Acute Out of Town Admissions PICU Out of Town Admissions Monthly Target Month Actual YTD Status (YTD) Monthly Target Month Actual YTD Status (Mth) Follow Up Rate Target Month Actual YTD Status (In Mth) 1-2 % of health delays under 7.5%.8% 3.% 7 Day Follow Up - Rate Post 95.% 95.65% 98.32% % of all delays under 7.5% 9.8% 7.6% Discharge AIM: to ensure people do not have to leave Sheffield when they need inpatient care. AIM: to ensure people are discharged when they are ready to do so. The annual performance for 212/13 was.7% for all delays, 6% for 213/1 and % for 21/15. AIM: to deliver safe care through ensuring people on CPA are seen within 7 days of being discharged. Acute Since July 21 no-one has needed to be sent out of Sheffield to access acute inpatient care due to no beds being available locally. This is a positive position in light of national challenges in this area. The annual position for 211/12 was 96.8%, 212/13 it was 95%, 213/1 it was 96.1% and for 21/15 it was 96.%. PICU Since November 21 one or two people have been sent out of town each month to access PICU level inpatient care due to lack of beds within Sheffield. The exception in March 215 has been reviewed and reported previously. 3 people were sent out of town in October 215, 2 of them returning within a week and the third in 3 weeks. The average time away from Sheffield before they were able to return to a local ward was 11 days.. The new and expanded unit planned to open in November 215 opened in January 216 and provides an extra two beds. Since February 215 increased rates of delays are noted. The main changes have been Adult acute inpatient services: in respect of awaiting access to the right housing provision, funding approval for housing provision or awaiting finalisation of SDS support packages. Older Adult wards: significant delays in accessing social care assessment support over the last 3- months. Ward G1 has experienced delays in the region of 6-7% during Quarter 2, which have reduced into Q3 and up to February 216. During March 216 high levels of delays are again reported. Revised escalation processes are being implemented. The Trust has failed this target in Q1 (8.6%) & Q2 (8.1%). Improvements are reported from September. The Q3 position is 6.8% and the Q position is 6.6%. The service failed to achieve the standard over Quarter 2 of 21/15. The circumstances behind this have been reported to the Board and the CCG (October 1). The target has been achieved each month since October 21. Exception reports for individuals not followed up have been provided separately. The position over Quarter 1 was 1%, Quarter 2 was 98.6% and Quarter 3 was 95.8% Two people were not followed up in December. The outcomes from the review was reported to the January Board meeting. 8

9 Access - Numbers Entering IAPT Services SERVICE DELIVERY - PERIOD TO APRIL 216 Access - Early Intervention in Psychosis Services Social Care - Assessment and Support 1,6 1, 1,2 1, Apr-1 May-1 Jun-1 IAPT - New Cases (Number Of People Accessing Services) Jul-1 Aug-1 Sep-1 Oct-1 Nov-1 Dec-1 IAPT New Cases IAPT New Cases - Monthly Target Apr-1 May-1 Jun-1 Early Intervention in Psychosis Services - Numbers Entering Service ACCESS TO EIS Jul-1 Aug-1 Sep-1 Oct-1 Nov-1 Dec-1 Number of New EIP Cases New EIP Case Target Self Directed Support & Direct Payments Total in receipt of a personal budget Number waiting to complete support plans Care purchasing No. of new purchased care packages in the quarter No. of people receiving purchased placement Q Q1 Q2 Q Number Of People Access Service Annual Target YTD Target YTD Actual Status (YTD) Annual Target YTD Target YTD Status (YTD) No. of above who are eligible to free after-care , 12, 12,77 Number Cases Per Year under section 117 Overall Caseload No. of people receiving purchased packages of care following assessment under duties within National Assistance Act 198 (NAA). Data Quality AIM: to improve access to psychological therapies for people with common mental health problems AIM: to ensure access to services for people experiencing their first episode of psychosis Last year the Service saw 13,535 clients against a target of 1,8. The service continues to have very positive outcomes in respect of supporting clients to leave benefits/ return to work. From April 215 onwards a revised target was agreed for new people entering the service, reflecting the historical over achievement of the service over the previous 2-3 years. Annual performance for was 17 new cases, for 213/1 it was 16 new cases and for 21/15 it was 17 new cases which was 232% of target. Activity over the last year has increased as new pathway arrangements have been put in place to improve triage and initial assessment of referrals and to improve the retention of clients on the EIS pathway. During 215/16 the focus of performance reporting for the EIS pathway will change to reflect the new national standards relating to access to treatment within 2 weeks of referral. Personal Identifiers Outcomes CPA - Employment Status CPA - Settled Acc. Status CPA - HoNOS Outcomes Target Q Q1 Q2 Q3 97.% 99.8% 99.8% 99.9% 99.8% 5.% 87.% 87.% 85.9% 85.1% 85.% 85.% 82.% 82.% 8.% 8.% 82.21% 92.% 92.% 92.% 93.15% 93.15% Access - Waiting Times IAPT Waiting Times Care Co-ordination - Annual CPA Reviews Waiting Times For External Referrals - Trust Wide Averages 3, 2,5 2, ACCESS WAITING TIMES 1,5 1, 5 Wait <6 Wait 6<12 Wait 12<18 Wait 18+ Not Known % 18+ weeks AIM: to ensure timely access to services.5%.% 3.5% 3.% 2.5% 2.% 1.5% 1.%.5%.% 1.% 9.% 8.% 7.% 6.% 5.% IAPT Waiting Time - To Start of Treatment (Started in Period) Treatment Within 6 Weeks (Started in Period) Treatment Within 18 Weeks (Started in Period) Treatment Within 6 Weeks (Ended in Period) Treatment Within 18 Weeks (Ended in Period) AIM: to ensure timely access to evidence based treatment % Starting Treatment in 6 Weeks 6 Week Target % % Starting Treatment in 18 Weeks 18 Week Target % Month Target Month Actual Status (YTD) Target Month Actual Status (In Mth) 75.% 82.51% Formal Review In Last % 95.7% 95.% 99.57% Months 75.% 75.99% 95.% 97.82% 98.% 97.% 96.% 95.% 9.% 93.% 92.% 91.% 9.% 89.% Apr-1 CPA -Formal Review Of Care Within Previous 12 months For People On CPA May-1 Jun-1 Jul-1 Aug-1 Sep-1 Oct-1 Nov-1 Dec-1 Total - % CPA Reviewed AIM: to ensure people managed under CPA receive a review of their care and on-going treatment Target % For CPA Reviewed 2,571 new referrals were removed from waiting lists in March. 79.6% of those had waited less than 6 weeks and.1% had waited more than 18 weeks. Of those waiting more than 18 weeks, Memory Management Services, Porterbrook/ Relationship services - account for c.85-9% of those who had waited longer than 18 weeks. Over the last quarter waiting times for access to memory Services have reduced. Nationally new Access Standards have been introduced for IAPT services during Providers will be required to ensure 75% of patients start treatment within 6 weeks of their referral and 95% of patients start treatment within 18 weeks. Reporting to Monitor on performance commenced in Q3 of this year. The Trust, with the support of its main Commissioner through the CQUIN programme, has prioritised a range of successful quality improvement programmes over the last 2 years targeted at addressing areas of long waits. The Trust is achieving the standards for access to IAPT services. The Trust position for Q3 was 82% commenced treatment in 6 weeks of referral, and 98.3% within 18 weeks. Performance during January was down due to delays in making appointments over the Christmas period with clients not wanting to start a programme of treatment prior to Christmas. At the time of report production the actual month end position is slightly under represented. As more data is processed following reviews completed during the end of the month the actual review rate will be slightly higher than the position reported here. This has been updated retrospectively for the period March 15 onwards. The position at the end of Quarter 1 was 95.%, Quarter 2 was 95.1% and Quarter 3 was 95.3%. The position for the month of March 216 will improve once final reports have been run at the end of April. 9

10 Key Performance Targets PRIMARY CARE SERVICES - AS AT 31 MARCH 216 Achievement per apms indicator (* not audited electronically) ary KPI performance targets are year end targets to be achieved by the end of Quarter. Not Acceptable Acceptable Excellent Excellent target Acceptable target It should be noted that these targets were set out and agreed as part of the current Clover APMS contract, with a financial value 1.% 9.% 8.% of just under k. The recent re-procurement exercise for a new APMS contract for Clover does not have KPIs attached to it, therefore there will be no KPIs from April 216 onwards. 7.% 6.% 5.%.% The service and staff have worked incredibly hard to achieve the targets in this financial year in order to maintain the current level of income for 215/16. 3.% 2.% 1.% The reported performance shows how the service has achieved the year end position of Excellent targets across all the KPIs..% PMS1a. PMS1b. PMS2a. PMS3a. PMS3b. PMS3c. PMSa. PMSc. PMSd. PMS5a. PMS5b. * PMS5c. PMS6a. PMS6b. PMS6c. PMS7a. PMS7b. * PMS7c. * PMS8a. * PMS8b. * PMS8c. * PMS9a. * PMS9b. PMS1a. * PMS1b. * PMS1c. Indicator The service will define its revised performance framework to ensure the necessary review of performance can continue. The revised framework will be informed by the new contractual arrangements, national targets and local agendas Indicator Descriptors as they relate to quality and quality improvement. Ind. No LAST MONTH THIS MONTH TARGET Smoking Cessation 1a Percentage of Patients aged 1 - record of smoking status 82.9% 85.2% 7.% 1b Percentage of smokers aged over 35 - spirometry recorded 17.38% 18.12% 1.% Obesity 2a Patients aged 15 and over who have had a BMI recorded. 7.6% 71.7% 5.% Hypertension 3a Patients aged 35 to 7 with hypertension in the last five years who have a record of CVD risk assessment 89.36% 93.9% 85.% 3b Patients aged 3-7yrs with hypertension with blood glucose or diabetes assessment 95.33% 95.56% 75.% 3c Target Patients over the age of 35 who have had recommended BP check % 95.68% 85.% CHD & Stroke a Target Patients > 65 yrs who have had a pulse rhythm check 82.5% 85.7% 65.% c Target Patients with an annual pulse rhythm check unless on existing AF register % 9.98% 75.% d Target Patients with AF having a record of CHADS2 score. 87.5% 1.% 8.% Diabetes 5a Patients with a BMI >35 in the last 3 years with a glucose or HbA1c test % 87.33% 6.% 5b Target Patients with an annual review in the last 12 months including a FBG test. 8.3% 88.61% 7.% COPD 6a Percentage of patients with a diagnosis of COPD with a classification of severity 52.28% 86.5% 65.% 6b Target Patients with COPD offered pulmonary rehabilitation in last 12 mths % 72.83% 6.% 6c Target Patients with COPD offered pulse oximetry within the past 12 months % 97.22% 7.% Palliative Care / End of Life Care 7a Target Patients who have been recorded with a palliative care register code % 27.33% 2.% 7b Target Patients with a preferred place of care code. 8.9% 76.6% 2.% IM&T Systems 1a Electronic summarisation of patient records. 85.1% 85.67% 7.% 1

11 SUBSTANCE MISUSE SERVICES - PERIOD ENDING MARCH 216 Access to Treatment (Drugs & Alcohol) Effectiveness of Treatment Oct-1 Nov-1 Drugs - Prescribing (New): New service users entering the Drug Prescribing Service Dec-1 Alcohol (Secondary Care): Compretensive assessments undertaken by the secondary care alcohol team SEAP (Triage Assessment): Initial triage assessments undertaken by the SEAP (Open Access) Team 1% of service users are retained in drug treatment for at least 12 weeks Threshold is 9%+ 73% of discharges from inpatient detoxification should be successful completions 62% of exits from Residential Rehabilitation placements should be successful completions 9% 1% 7% no exits 9% 1% 8% 1% 83% 1% 9% 1% 5% 1% 1% 1% 67% 5% 75% 75% Target Thresholds Month actual YTD Actual YTD 67% 5% Drug Drug Target Alcohol Alcohol Target SEAP SEAP Target 62 pm; 756 pa 199 pm; 2 pa Green = 9%+ Amber 8%+ Green = 9%+ Amber 8%+ 75 assessments per month Green Red Retention in Treatment Inpatient Detoxification Residential Rehab 86% 5% 9% % Recovery (Treatment Exits Drug Free) Number of exits from the service (and entire treatment system) 'treatment complete drug free' per month 89% tbc YTD (or 6 month to contract end) 95% 82% 1% Access to treatment targets set by commissioners Sheffield DACT(Drug & Alcohol Co-ordination Team) in relation to contracts for Secondary Care (Alcohol) and SEAP (Alcohol). Contracts in place from 1 April 21, with the exception of SEAP, where contract started 1 September 211. Current contracts for alcohol extended to end March 216. The chart above also shows previous targets in place up to September 21 for previous Secondary Care Prescribing (Drugs). Thistarget ceased to exist on 1 October 21 as SHSC took over the new Opiates contract Access to Treatment - Caseload (Drugs) Previous targets monitored access to treatment (caseload) target requiring the service to treat 95 Opiate/CrackUser (OCU) individuals in a 12 month period, of which 3 should be new presentations(see above). These figures are monitored through submissions to the National Drug Treatment Monitoring System (NDTMS), and based on Glasgow prevalance data. Data is shown above for the 6 months of the FY for which this target was applicable. Changes to contracts from 1 October 21 mean this target will need to be reviewed. Sec Drug Sec Drug Target Prim Drug Target Prim Drug AllEffectiveness targets willbe reviewed in light of new contracts for Drug services in Sheffield provided by SHSC. Inpatient detoxification figures for drug & alcohol detox provided, based on admission and discharge from detox beds on Burbage Ward and subject to ongoing discussions re commissioning of Inpatient Detoxification in Sheffield. Substance Misuse Residential Rehab placements currently managed by SHSC as per delegated budget from Sheffield City Council, and in line with Fair Access to Care criteria. Health Promotion & Harm Reduction 9% of new presentations YTD offered Hep B vaccinations 9% of new presentations YTD w ho accepted offer commencing Hep B vaccinations 9% of new presentations YTD (previous or current injectors) have a recorded Hep C status 9% of new presentations YTD (previous or current injectors) offered a Hep C test YTD 75% of new presentations w ho start a Hep B vaccination course to complete the course. 13/1 Q1 98% 97% 96% 92% 7% (1/15) 13/1 Q2 99% 92% 93% 1% % (1/32) 13/1 Q3 98% 9% 93% 98% 66% (58/86) 13/1 Q 99% 1% 97% 1% 7% (81/19) 1/15 Q1 1% 78% 98% 1% 55% 1/15 Q2 1/15 Q3 1/15 Q 96% 87% 99% 99% The Harm Reduction Service was commissioned to deliver services across the entire treatment system for drugs in the city. Sheffield DACT report figures back to SHSC for these targets, but with significant delay between periods. hover time in previous contracts the DACT and PHE have changed the targets for harm reduction interventions. Shown above for 21/15 is data relating to clients in specialist prescribing (drugs) with SHSC. The 5th target is shown for all clientsin treatment across the city as we have access to those figures from our own systems. 8% 1 October 21 -Harm reduction Services are now commissioned as part of the Opiates Drug Service, not as separate contracts and have different targets. Targets and reporting to be reviewed. 11

12 Employment (updated each quarter) Social Inclusion - Period to March 216 Membership Recruitment % Employment -% of clients in employment MH Scheduled Care & Employed MH CPA and Employed LD CPA and Employed Figures are a monthly average Actual Target Q Q1 Q2 Q3 Q Number of Members 12,631 12,62 Scheduled Care - Number of clients Scheduled Care - Number in employment Number of members deleted during March: 89 Scheduled Care - % in employment 1.% 1.8% 1.3% 1.% 1.8% Target Actual MH CPA - Number of clients MH CPA - Number in employment MH CPA - % in employment 5.2% 5.8% 6.3% 6.3% 5.2% Learning Disability CPA - Number of clients Learning Disability CPA - Number in employment Learning Disability CPA - % in employment.8% 5.1% 5.3% 5.1% 5.3% Settled Accommodation - clients receiving mental health services Axis Title Settled accommodation -% of CPA mental health clients in employment CPA and Settled Accommodation Figures are a monthly average Q Q1 Q2 Q3 Q3 MH CPA - Number of clients MH CPA - Number in Settled Accomm MH CPA - % in Settled Accomm. 83.5% 83.8% 83.9% 8.1% 82.5% Governors and Engagement Governor Matters We are now in the midst of Governor Elections; the nomination deadline was 17th March. There will be elections in the following constituencies: Service User Carer Public South West Staff Nursing Staff Psychology Results will be declared on Friday 29th April 216. The following have been appointed, unopposed Young Service User Michael Thomas Public North East Mohammed Khawja Ziauddin Public North West John Buston Membership Matters Membership stands at which is above target. March has seen a high level of membership engagement and recruitment activity including: -Visiting the Careers and Volunteers Fair at Longley Sixth Form College with governors from Sheffield Teaching Hospitals. As well as holding a stall at the event, we were invited to speak to various Health and Social Care classes about the importance of getting involved in NHS services and how becoming a member can benefit studies. This was extremely successful when engaging with younger people, and we will be looking at doing more of this over the next few months. -Holding a stall at Sheffield Hallam University as part of the National University Mental Health and Wellbeing Day. This was attended with governors from Sheffield Teaching Hospitals. -A health event for members was held at the Northern General Hospital as part of Nutrition and Hydration Week. The event focused on talking about the advantages of a healthy diet for those living with dementia. It was attended by over 7 members. These events resulted in 135 new members;133 Public, 1 Service User and 1 Young Service User 12

13 Financial Overview as at 31st March 216 Key Ratios Payment of Suppliers Cash Current Month s YTD Plan YTD Actual FOT Plan FOT Actual Liquidity days Green Debt service cover Continuity of Service Risk Rating Green Green Financial Sustainability Risk Rating Green Trade Creditor Days for March are 39.1 days. BPPC (YTD by number) BPPC (YTD by value) Trade NHS Target 91.68% 85.6% 95.% 9.37% 9.25% 95.% Better Payment Policy Compliance (>95%=Green;>9%<95%=Amber;<9%=Red) Red Amber (See Appendix 7 & 7A) Cash balance 25,612 Plan Actual Variance 25, Green.62% Cash Monitoring Variance (>1.15%<.85%=Red;>1.5%<.95%=Amber; Within 5%=Green) Income and Expenditure s Income Received Within Planned Days Net Working Capital Position to date Plan Achieved Variance I&E Surplus/(Deficit) 1,23 (139) (1,373) Red EBITDA 5,385 5,332 (53) Amber Under-Spend Deficit Deficit Forecast Year-end Plan Achieved Variance I&E Surplus/(Deficit) 1,23 (139) (1,373) Red EBITDA 5,385 5,332 (53) Amber Under-Spend Deficit Deficit Apr May Jun Jul Aug Sep Oct Nov Dec Jan Feb Mar 6,5 Total debtor days Debtor days (incl. accruals) Plan Target Number of Days Actual to Date Number of Days See Appendix 7 for an outline of the main six debtors of the Trust Debtor Days Red Red Plan Actual 33, 3, 27, 2, 21, 18, 15, 12, 9, 6, 3, - - 3, - 6, - 9, - 12, - 15, s M1 The Last 12 months Net Working Capital Movements M2 M3 M M5 Provisions Inventory Net Working Capital (excluding cash) Net Working Capital (including cash) M6 M7 M8 Payables Receivables Cash M9 M1 M11 M12 s 5,5,5 3,5 2,5 1, /16 Plan 213/1 Actual 21/15 Actual 215/16 Actual Overall Net Working Capital is 25, lower than plan compared to last month s 1,83, lower than plan, an in-month improvement. Key drivers of this position against plan in month include: Receivables 2,23, higher than plan; 2,55, higher than plan; a worsening of last month s position of 2,55, higher than plan despite excellent progress in month s to clear old debts. The 1,26, expected from Sheffield City Council in March was, however, received in April. More details in section d below and at Appendix 8. Payables 636, higher than plan; an increase on last month s 162, higher than plan, partly compensating for the high receivables to aid cash balances. More details in section e below. Provisions 97, higher than plan; an increase on last month s 779, higher than plan position, and also aiding cash balances. Details in section f below. The closing March 216 cash position is a balance of 25,771, ( 27,32, for February) which is 159, above the planned balance. This compares to a favourable variance against plan of 9, last month (See Appendices A - D) Full Year Target CIP Target To Date,51 Achieved,178 Variance from Plan of which Non-Recurrent Disinvestments Non-Recurrent Recurrent Combined Position Target to Date 215/16 Cost Improvement Programme s CIP Achievement Dis Achievement All figures in s Amber 1% 1% CIP delivery to date is 178 against a plan of 51 2,15 Target To Date 5,86 Achieved 5,718 Variance from Plan of w hich % Recurrent 2, % 759,959 1,32 Achieved 9,896 Variance from Plan 2 of w hich 96% Non-Recurrent 2,86 Recurrent 7,32 9% 8% 7% 6% 5% % 3% 2% 1% % 9% 8% 7% 6% 5% % 3% 2% 1% % Disinvestment delivery to date equates to 5718 against a plan of 586 Overall the Trust has achieved combined CIP and disinvestments to the value of 9896 against a plan of 132 In percentage terms this is 96% The CIP position includes major underdelivery of savings in Inpatient ( 623) and Community ( 838) mitigated by a 1,2 release of risk reserves. Capital Position to Date Plan Actual Variance In-month spend 1,29 1,29 () Green Cumulative spend 7,163 6,19 (1,1) Red Capital expenditure is <85% or >115% of plan for year to date Capital Forecast Outturn Plan Actual Variance Cumulative spend 7,163 6,19 (1,1) Red Capital expenditure is <85% or >115% of plan for year to date Capital spend outturn was 16% from plan. The in-month position was breakeven versus plan. The Forest Close development which was brought forward in light of the Phase II ACR delay is in progress with contingencies currently remaining and with expected completion early in quarter 1. The PICU Scheme is now complete, the final vat review completed, and the build revalued as part of the 31st March 216 revaluation exercise. The value of the Longley site following the capitalisation of the works was an impairment of 2,878,, of which 1,527, is not covered by revaluation reserve and therefore is an in year expenses to SOCI. Directorates have been asked to nominate a directorate representative to assess directorate equipment needs for future capital planning. Further detail can be found at Appendix 6. Capital Spend s Red Red s Capital Spend Against Plan and 15% Variance Target Cumulative Plan 85% Cumulative Plan Cumulative Plan 115% YTD Actual & Projected FOT 13

14 Regulatory Framework CQC - Annual Surveys (Care Quality Commission) CQC - Compliance Reviews (Care Quality Commission) HSE (Health and Safety Executive) Area or section Review or Assessment Date REGULATION/COMPLIANCE DASHBOARD Compliance or Rating Patient survey Green Staff survey Green All Healthcare Dec 1 Amber All Social Care Amber All primary care sites Intelligence Monitoring Progress s The 215 results show that SHSC is About the same as other trusts in all but one of the ten sections. We were considered Worse than most other trusts in the section entitled Crisis Care, specifically the question on Do you know who to contact out of hours if you have a crisis? Data collection for the 216 survey is currently underway. Results from the 215 staff survey are now published. Staff experiencing stress has reduced, however staff experiencing bullying and harassment has increased. Staff motivation at work and making use of patient feedback is worse than average. A full report on the findings will be presented to the Board of Directors in April 216. Final reports published 9 June 215. Trust's rating for 'health' services is Requires Improvement. Copies of the reports can be found here: Action plans are in place for all elements identified within the CQC report and status of compliance with action plans is reported monthly to the Board via the EDG and QAC. Final reports published 9 June 215. Trust's rating for 'social care' services is Requires Improvement. Copies of the reports can be found here: CQC commencing social care inspections for 216. Woodland View and Longley Meadows inspected in February 216. Draft reports show require improvement, final reports yet to be received. Compliant 5 GP practices yet to be inspected. Risks, Elevated Risks Ratings removed Feb 216 Mental Health Act Amber Safeguarding Adults and Children Green Latest report published February 216 shows risks and elevated risks. Details contained within CQC update to Quality Assurance Committee in February 216. Risks relate to proportion of days sick for non-clinical staff, not knowing who to contact in a crisis (CMH survey), complaints referred to the Ombudsman and proportion of emergency admissions. No risk flagged in February s Intelligence Monitoring Report. Number of issues picked up during regular MHA inspections. Pinecroft ward received inspection report without need for improvement. Details of MHA inspections included in monthly update to Quality Assurance Committee. Quarterly safeguarding reports presented to Quality Assurance Committee re adults and children. Concerns around safeguarding training. A Sheffield citywide Looked After Children review took place in October 215. The report, together with resulting action plan, was presented to EDG and assurance provided to QAC in January 216. All sites Compliant No HSE Improvement notices received. 1

15 Regulatory Framework Area or section Review or Assessment Date Compliance or Rating Progress s Fire Service Visits All sites Compliant As of 9 th April 216 there are no Fire Authority Enforcement notices NHSLA (NHS Litigation Authority) Claim History Red Provider Licence Compliant Continuity of Services Rating Apr-16 Score = 3 Annual RAG rating given by NHSLA based on number of claims and settlement figures. Rating shown is December 215. No update expected until approximately Dec 216. Compliance with conditions of Provider Licence monitoring to be established. The scores opposite relate to the Trust s position as at 11 th April 216, as published on Monitor s website. Monitor Green - no evident concerns Continuity of Services is rated from 1- with being the lowest risk. Governance Rating Apr-16 Quality indicators: DTOC, 7 day follow up & CPA reviews, Crisis access, EIS, Data Completeness, Self Cert Access Learning Disabilities, Delayed Transfers of Care Performance was below threshold for Delayed Transfers of Care, with failure on this experienced in Q1 and Q2. The overall Governance rating continues to be Green for Q. Patient Led Assessments of the Care Environment (PLACE) National Average = 97.57% Cleanliness 99.11% National Average = 88.9% Food and Hydration 92.8% National Average = 86.3% Privacy, Dignity and Wellbeing 92.98% National Average = 9.11% Condition, Appearance & Maintenance 96.% National Average = 7.51% Dementia (new assessment for 215) 95.71% SHSC scored significantly higher than national average on all indicators, including the new dementia indicator. An in-depth report on the 215 PLACE assessment was presented to the Quality Assurance Committee in October 215. PLACE assessments for 216 are ongoing. Professional Body Inspections or Reviews Royal College of Pharmaceuticals Nursing and Midwifery Council (NMC) Oct 15 Dec 15 Green (No major concerns) Green (No major concerns) RCP undertook an inspection of Pharmacy systems in Oct 215. Final report was discussed at QAC in December 215. Review of nurse training and mentoring arrangements in Sheffield took place in December 215. Verbal feedback received seems positive overall. This will be updated as and when the final report is received. Accountable Officer - Controlled Drugs Latest quarterly report Green (No major concerns) No major concerns noted in last report presented to Quality Assurance Committee in March 216. Information Governance IG toolkit - Level 2 on all items Score 67% (Satisfactory) A rise of 1% from last year, 67% equates to a Satisfactory rating. Equality Duties Equality Act 21 Reporting Accessible Information Standard Workforce Race Equality Standard Compliant The Trust Equality Objectives will need to be reviewed by April 216. Plans being taken forward. Compliant Implementation plan in progress Compliant Deadline for publishing the 215 WRES report is 1 st July 216. This year data will need to be uploaded to Unify2 by the same deadline. Current action plan proceeding. 15