Monthly Performance Report

Transcription

1 Monthly Performance Report Month 2 - Period to end of May 216 Report Issued: 5 th July 216

2 Table of Contents Dashboard overview summary of key indicators.. 3 Quality and safety performance summary.4 Workforce performance summary..7 Service delivery performance summary 8 Social Inclusion performance summary 11 Finance performance summary 12 Regulatory standards and requirements

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% 5.8% 1, 4 Human Resources Dashboard summary Trend - Performance maintained over period Turnover monthly 3-13% 16.4% 1, 4 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 2 YTD Service Delivery Dashboard summary Gatekeeping - Acute admissions assessed for HT monthly > 9% of admissions 1.% 2 Service Delivery Dashboard summary Adult Acute inpatient occupancy levels monthly 95% - 1% 19.% 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 6.8% 2 Service Delivery Dashboard summary 7 Day follow up following discharge monthly 95% of CPA Discharges 1.% 2 Service Delivery Dashboard summary Access to Early Intervention Services monthly 13 New cases YTD 58 2 Service Delivery Dashboard summary Access to services - Waiting times within 18 weeks monthly > 95% of clients referred 96.7% 2 Service Delivery Dashboard summary Access to IAPT - new clients accepted monthly 2 new clients YTD 2,486 2 Service Delivery Dashboard summary Acess to IAPT - treatment in 6 weeks (at start of treatment) monthly 75% 85.4% Acess to IAPT - treatment in 18 weeks (at start of treatment) monthly 85% 99.6% CPA - Annual Review monthly 95% 92.6% 2 Service Delivery Dashboard summary Data Quality - Client Identifier indicators x 6 quarterly 97% Q4-99.9% 2 Service Delivery Dashboard summary Data Quality - Client Outcome indicators x 3 quarterly 5% Q4-87.9% 2 Service Delivery Dashboard summary SOCIAL INCLUSION Trust Board Performance Dashboard - key indicators for period to May 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 Q4 = 5.2% 6 Social Inclusion Dashboard summary Proportion of people on CPA in settled accommodation monthly na Q4 = 82.5% 6 Social Inclusion Dashboard summary Trust Membership - Recruitment against plan monthly 12,62 12,623 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 Finance Dashboard summary Cash available ( ') monthly 24,137m 24,682m 1 Finance Dashboard summary CIP delivery against plan ( ') monthly 737, 526, 1 Finance Dashboard summary 3

4 Self Harm Safety Dashboard - Period to May data recorded as at 16 Jun 216 Falls - Service Users Missing Persons Restraints Service User Falls Falls that resulted in injury UCL LCL All service user falls recorded on the system, the grey line shows the number of unique service users who fell in that month. Control limits are based on the service user falls. 92% 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 2418 shown within the graph above) was graded as 'Major' and there were no 'Catastrophic' falls over the period. 24% of falls were reported from Woodland View 14% of falls were reported from Birch Avenue 14% of falls were reported from Hurlfield View 9% of falls were reported from G1 5% of falls were reported from Dovedale Missing Patient - Low Missing Patient - Medium Missing Patient - High Upper Control Limit Lower Control Limit 26% of all missing person incidents relate to Burbage Ward 17% of all missing person incidents relate to Stanage Ward 16% 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 Percentage Breakdown of Detained Service User 2 78 (18%) Incidents 3 26 (48%) 4 1 (.2%) 66% relate to absconsion from the ward 5(2) 6 (1.4%) 28% relate to failing to return from leave 37 1 (.5%) 6% relate to absconsion from escorted 37/41 9 (2.1%) leave 37 (Notional) 1 (.2%) (.2%) Informal/Other 119 (3%) Total 422 Benchmarking - Detained Service Users The data in the chart above captures both detained and non-detained service users. Benchmarking NHS Mental Health Services has recently produced data for the year 214/15. This, however, only covers detained service users who absconded. In this dataset, SHSC is in the upper quartile of all mental health trusts in England for detained absconsions. 72 Medication All Restrictive Practice Instances (physical, chemical and mechanical) All restraint instances Number of Patients Restrained UCL LCL All recorded restraint incidents on Safeguard (since April 215 also includes Mechanical and Chemical Restraints). Control limits relate to the restrictive practice instances. Electronic recording of restraint incidents was introduced to all areas who are already recording incidents electronically on 1st April 215. The above clearly shows that this has had an impact on the number of restraint incidents being reported. There were 351 service users involved in the restraints shown, with a total of 125 restraints in the period which averages 3.6 restraints per service user. 2 service users were restrained 9 and 75 times respectively over the two year period, both being restrained on four different wards throughout this period. Benchmarking Using NHS Mental Health Services benchmarking data for , SHSC is below the mean nationally for reporting of restraints and we are the second lowest reporter in the region out of six organisations. A separate Restrictive Practices NHS Benchmarking exercise, has also recently shown SHSC in the lower half of reporters for Restraint incidences. 6 Seclusions All Seclusion Instances vs. Number of Patients Secluded Self Harm Instances Upper Control Limit No of Self-Harm Patients Lower Control Limit 12-1 Only actual self-harm instances are shown, near miss and potential self-harm are excluded. Control limits are based on the Self-Harm instances. 7% of all self harm incidents recorded were graded as 'negligible' harm 25% of self harm incidents w ere graded as 'minor' harm 4% of self harm incidents w ere graded as 'moderate' harm 1% of incidences w ere either 'Major' or 'Catastrophic (8 incidences and 2 incidences respectively). Betw een Aug 15 to date, there has a been a statistical shift of a drop in the number of self harm incidences, each month's figure w as below the mean hence it is a Special Cause Variation as opposed to Common Cause Variation (expected variation). If Control Limits w ere used from Aug 15 onw ards the upper and low er limits w ould be 46 and 19 respectively showing a low er and less variable spread of incidences. There w ere 234 unique service users who self-harmed accounting for 161 incidences. 2 of the 234 service users accounted for 622 incidences or 59% of all self-harm incidences over the period, the highest number of self-harm incidences for any service user in this data is of the 234 service users had 1 or 2 incidences of self-harm. Benchmarking Using NRLS benchmarking data, SHSC is below the national average for reporting selfharming behaviour incidents with an average rate of 14.1% against the national figure of 2.8%. = Near-Miss 1 = Negligible 2 = Minor 3 = Moderate 4 = Major UCL LCL All recorded medication incidents broken down by Actual Impact. 6% of all medication incidents reported are rated 'Near Miss' 76% 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, 1% (14 ) graded as 'Moderate'. There were two x 'Major' medication incidents over the two year period and both of them occurred in 216. Benchmarking SHSC is slightly above the mean for medication incidents reported during Of the six mental health trusts in our region SHSC was the second lowest reporter. We fall in the main quartile on a national level using Benchmarking NHS Mental Health Services data. Using the latest NRLS benchmarking data, SHSC is just below the national average reporting 8.1% as opposed the 8.6% nationally. All Seclusion instances Number of Patients Secluded UCL LCL All recorded seclusion incidents on Safeguard. The control limits are based on the seclusion instances. 3% of all seclusions recorded above relate to ITS/Endcliffe 23% of all seclusions recorded above relate to Maple Ward, with a further 15% relating to Stanage Ward and 13% on Rowan Ward. 1 of the 21 people who were secluded accounted for 18 (29%) of the incidences of seclusion. 142 service users had 1 or 2 incidences of seclusion recorded within the above time period. Benchmarking Data for shows SHSC as being the third highest reporter of seclusions at a national level, when based on incidences of seclusion per 1 bed days. Using the same criteria, SHSC is the highest reporter in the region. 4

5 Total No of Incidents Safety Dashboard Part 2 - Period to May data reported as at 17 Jun 216 Incidents & Incidents with Harm Infection Control Abuse/Intimidation to SU 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. Incidents & Incidents with Harm All Incidents Incidents With Harm UCL LCL 77% of all reported incidents are graded as 'negligible' impact 16% of all reported incidents are graded as 'minor' impact 4% 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 214, electronic incident reporting was rolled out to all inpatient areas. Some high reporting residential settings were brought onto electronic reporting in December 214, 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 8% of all incidents Serious Incidents Serious Incidents Upper Control Limit Lower Control Limit All recorded incidents that require a Level 2 investigation. 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). Benchmarking SHSC is the third lowest reporter of serious incidents at a national level, this is based on serious incidents per 1, bed days. We are the lowest reporter of serious incidents in the region. This comes with a health warning because the criteria for what constitutes a serious incident is inconsistent across organisations. Also the serious incident data from the benchmarking report is based on ward areas, the bulk of our serious incidents come from the community A detailed report covering all of Quarter 4 215/16 data for infection control incidents was presented to May's Quality Assurance Committee. During the colder months of 214/15 (Q3 & Q4) 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 214/15 Q2 214/15 Q3 214/15 Outcome Awaiting Coroners Inquest Closed Conclusion - Accidental Conclusion - Alcohol/Drug Related Conclusion - Misadventure Conclusion - Narrative Conclusion - Natural Causes Conclusion - Open Conclusion - Suicide Conclusion - Unlawful Killing Natural Causes - No Inquest Ongoing* Grand Total Q4 214/15 Q1 215/16 Chest Infections D&V/ Norovirus/ Rotavirus Q2 215/16 Q3 215/16 Oral/ dental SCABIES/ HEADLICE SHINGLES/ Chicken pox MRSA (Col /inf) C.DIFF Tuberculosis UTI (catheter) Other A detailed report covering all of Quarter 4 215/16 data for infection control incidents was presented to May's Quality Assurance Committee. Deaths All patient deaths recorded on the Safeguard system including the outcome of that death. The figures for will be updated each month. *Ongoing - This incident is a suspected homicide of an individual whereby it is alleged that the perpetrator is an SHSC service user. BBV Rest of Infections Top 6 Infections Q4 215/16 Q1 214/15 Q2 214/15 Q3 214/15 Q4 214/15 Q1 215/16 Q2 215/16 Q3 215/16 Q4 215/16 All Verbal/Assaults on Patients All Abuse/Intimidation All Abuse/Intimidation with Harm UCL LCL 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. 89% of all the above incidents reported are graded as 'Negligible' or 'Near Miss' 9% 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. Benchmarking SHSC is right on the mean line nationally for 'actual physical violence' in the Benchmarking NHS Mental Health Services Report. This dataset differs slightly from the data above as it includes verbal abuse and intimidation as well as physical violence. At a regional level, SHSC is third out of six for physical assault incidents reported. NRLS benchmarking records 'disruptive, aggressive behaviour incidents. Using this data, SHSC is slightly higher than average reporting 21.3% of these incidents against the national average of 15.3%. All Verbal/Assaults on Staff Abuse/Intimidation to Staff All Abuse/Intimidation All Abuse/Intimidation with Harm UCL LCL 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' 9% of all the above reported incidents are graded as 'minor' with 2% as 'moderate' 3 x incidents (less than.1%) have been graded as 'Major' over the reporting period shown above, with no 'Catastrophic' graded incidents. Benchmarking SHSC is above the mean and is in the upper quartile for actual assaults on staff, using NHS Mental Health Services benchmarking data for 214/15. This is based on 1, bed days and counts ward areas only. The data in the chart above records both physical violence as well as verbal abuse and intimidation. 5

6 Human Resources - Period to May 216. Please Note: Sickness reporting is 1 month in arrears. Overall Sickness Absence 7.5% Overall Absence Rate Year on Year (13/14 to 15/16) 7.% 6.5% 6.% 5.5% 5.% 4.5% 4.% Jun Jul Aug Sep Oct Nov Dec Jan Feb Mar Apr May Current Year 5.32% 5.63% 5.65% 5.73% 5.93% 6.35% 6.5% 6.47% 6.% 5.94% 5.4% 5.76% Last Year 5.52% 5.45% 5.83% 5.77% 6.21% 6.53% 6.59% 6.9% 6.53% 6.9% 5.31% 5.22% Previous Year 5.42% 5.42% 5.1% 5.28% 5.96% 5.98% 5.73% 6.23% 6.2% 5.28% 5.44% 5.34% 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) (13/14 to 15/16) Jun Jul Aug Sep Oct Nov Dec Jan Feb Mar Apr May Current Year Last Year Prev. Year Current Year Last Year Prev. Year The Overall Sickness Absence rate for the Trust has increased to 5.76%. An element of caution should be taken when looking at May's sickness figures as all data may not have been recorded against employees records. Long Term sickness has increased in May to 28.52% of the overall sickness rate. As above, an element of caution should be taken when comparing the April Long Term / Short Term comparison, as not all data has been recorded against employees records. 6

7 Human Resources - Period to May 216. Staff in Post (Headcount & FTE) Staff in Post Headcount & FTE (215/16) Trust PDR Compliance as at May Headcount FTE Total (FTE+B&Non- NHS) % 95% 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 9% 1% Inpatient 96% 4% The Green line is a notional Bank & Non-NHS Pay Headcount to the FTE and is based on the average Trust LDS 93% 7% Salary ( 27K) Medical 91% 9% The headcount has decreased by 18 this month and FTE has seen a decrease of 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) is Non Med Support Primary Care Specialist 98% 97% 96% 2% 3% 4% approximately 11.5% (Quarter 4 figure). Further analysis of Trust staff turnover will be completed shortly. Below is the Trust Turnover Rate for the 12 month period ending May Month Turnover % All Staff Exc. Bank 17.8% 17.4% 17.% 16.6% 16.2% 15.8% 15.4% 15.% 14.6% 14.2% 13.8% 13.4% 13.% 12.6% 12.2% 11.8% 11.4% 11.% Jun- Jul- Aug- Sep- Oct- Nov- Dec- Jan- Feb- Mar- Apr- May Month Turnover % All Staff Exc. Bank 14.8% 14.86% 15.16% 14.88% 15.14% 15.16% 15.1% 16.58% 17.2% 16.29% 15.7% 16.47% As at 31st May 216 the % rate of PDR's completed is 95%. The rate has remained static this month and is above the Trust target completion rate of 9%. We are now into the next Focal Point Window 1 April 216 to 3 June 216. While employees PDRs are still valid this period, it should be noted that when the Focal Point Window closes the completion rate may fall as those who have not had a PDR within this Focal Point Window, will cease to have a Valid PDR from 1 July

8 SERVICE DELIVERY - PERIOD TO MAY 216 Crisis Resolution - Home Treatment Episodes Gate Keeping - Access To Home Treatment Bed Occupancy Levels Crisis Resolution And Number of Home Treatment Episodes Percentage of Admissions 1.% 98.% 96.% 94.% 92.% 9.% Gatekeeping Of Acute Admissions (Excluding Admissions From Other Psychiatric Hospitals) 12.% 11.% 1.% 9.% 8.% 7.% 6.% 5.% 4.% 3.% 2.% 1.%.% Inpatient Services - Bed Occupancy Levels (%) 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, Acute Admissions Assessed 95.% 1.% 1.% Acute 95.% 19.26% 19.47% For Home Treatment Functional Illness 95.% 15.91% 16.56% Dementia Management 95.% 89.61% 92.81% 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 213/14, 19% in 214/15 and 118% in 215/16. The above information includes all appropriate home treatment interventions provided across a range of Trust services,. The annual position for 211/12 was 99.4%, for 212/13 it was 99.5%, for 213/14 it was 99.8%, for 214/15 it was 99.8% and for 215/16 it was 99.5%. 1% Gatekeeping has been maintained for the majority of the previous 12 months. Adult Acute Services: In April 216 Rowan Ward closed and the service consist of 3 Wards of 18 beds each, 54 beds in total (including 5 substance misuse beds and 1 place of safety bed). Occupancy rates from April 216 onwards are reported against the reduced bed numbers. The service was over 1% occupancy on the reduced bed numbers since April 216 as the service adjusts to reduced capacity along with reduced bed day activity. Older Adults: FMI Wards: Following gradual and sustained reductions in bed occupancy over the last two years the service has reduced from 44 beds across two wards to 1 ward of 18 beds from April 15 onwards. There has been an increase in occupancy as part of the broader Acute service adjustments to the Rowan Ward closure. G1: Increased occupancy rates are noted periodically in line with increased rates of delayed discharges. Out Of Town Admissions Delayed Discharges CPA 7 Day Follow Up - Post Discharge Out Of Town Admissions - Acute And Pychiatric Intensive Care DTOCs as a % of OBN's 12% 1% 8% 6% 4% 2% % % DTOCs - (April 15 to date) 1.% 9.% 8.% 7.% 6.% 5.% Seven Day Follow Up Rate -For CPA Clients Discharged From Inpatient Care Acute PICU Health DTOC's All DTOC's Threshold Week No. % 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% 3.2% 3.9% 7 Day Follow Up - Rate Post 95.% 1.% 98.8% % of all delays under 7.5% 6.8% 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. AIM: to deliver safe care through ensuring people on CPA are seen within 7 days of being discharged. The annual performance for 212/13 was 4.7% for all delays, 6% for 213/14, 4% for 214/15 and 7.6% for 215/16. Acute Since July 214 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. PICU: Endcliffe Ward During around 1 or 2 patients were sent out of town due to lack of beds in Sheffield, with occassional peaks above this range. The service's new and expanded unit opened in January 216 and provides an extra two beds, taking local capacity up to 1 beds. Reduced use of out of town beds are expected. I person was admitted out of town in April 216, and retruned to the local PICU within 5 days. During 215/16 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 Q4 position is 6.6%. During March and April increased/ high rates of delays are noted within G1, with c.1-12 patients each week being medically fit for discharge but progressing through various assessment and decision making processes in respect of after care arrangements and provision. At the end of April no system blockages were reported in respect of progress towards discharge. Rates reduced in May, with the numbers delayed on G1 reducing from 12 each week in April to 7-8 each week by the end of May. The average over the first 2 months is 7.6% and we expect to be below 7.5% over the first quarter. The annual position for 211/12 was 96.8%, 212/13 it was 95%, 213/14 it was 96.1%, 214/15 it was 96.4% and for 215/16 it was 98.3% One client was not followed up in April. Repeat efforts were made by local community team services to provide follow up support however the client has remained missing for a prolonged period. 8

9 Access - Numbers Entering IAPT Services SERVICE DELIVERY - PERIOD TO MAY 216 Access - Early Intervention in Psychosis Services Social Care - Assessment and Support 1,6 1,4 1,2 1, IAPT - New Cases (Number Of People Accessing Services) IAPT New Cases IAPT New Cases - Monthly Target Early Intervention in Psychosis Services - Numbers Entering Service ACCESS TO EIS 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 Q1 Q2 Q3 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 , 2, 2,486 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 1948 (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 12,774 clients against a target of 12,. 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 213/14 it was 16 new cases, for 214/15 it was 174 new cases and for 215/16 it was 228 which was 34% 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 216/17 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 Q1 Q2 Q3 Q4 97.% 99.8% 99.9% 99.8% 99.9% 5.% 87.% 85.9% 85.1% 87.9% 85.% 82.44% 82.% 88.% 84.% 82.21% 92.% 85.% 92.% 93.15% 93.15% 91.% Access - Waiting Times IAPT Waiting Times Care Co-ordination - Annual CPA Reviews 3, 2,5 2, 1,5 1, 5 Waiting Times For External Referrals - Trust Wide Averages 4.% 3.5% 3.% ACCESS WAITING TIMES 2.5% 2.% 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.% 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.% 85.46% Formal Review In Last % 92.95% 95.% 99.58% Months 75.% 77.46% 95.% 98.16% 98.% 97.% 96.% 95.% 94.% 93.% 92.% 91.% 9.% 89.% CPA -Formal Review Of Care Within Previous 12 months For People On CPA Total - % CPA Reviewed AIM: to ensure people managed under CPA receive a review of their care and on-going treatment Target % For CPA Reviewed 2,943 new referrals were removed from waiting lists in May. 77.1% of those had waited less than 6 weeks and 3.3% 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 Q4, agaisnt the national targets was 75.6% commenced treatment in 6 weeks of referral, and 98.1% within 18 weeks. At the time of report production the actual month end position is 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 95.4%, Quarter 2 was 95.1%, Quarter 3 was 95.3% and Quarter 4 was 95.1%. The position for the month of April/ May 216 will improve once final reports have been run at the end of June. 9

10 Access to Treatment (Drugs & Alcohol) Substance Misuse Services - period ending May 216 Effectiveness of Treatment % 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% 8% 1% 25 83% 1% 9% 1% 5% 1% 1% 1% 67% 5% 75% 75% Drug Drug Target Alcohol Alcohol Target SEAP SEAP Target 67% 5% 86% 5% Target Month actual YTD Actual YTD 9% % Drugs - Prescribing (New): New service users entering the Drug Prescribing Service 75 assessments per month 89% 33% 1% 8% Alcohol (Secondary Care): Comprehensive assessments undertaken by the secondary care alcohol team SEAP (Triage Assessment): Initial triage assessments undertaken by the SEAP (Open Access) Team 63 pm; 756 pa Green = 9%+ Amber 8%+ 2 pm; 24 pa Green = 9%+ Amber 8% Green Amber Retention in Treatment Inpatient Detoxification Residential Rehab Recovery (Treatment Exits Drug Free) Number of exits from the service (and entire treatment system) 'treatment complete drug free' per month 1% % YTD (or 6 month to 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 214 for previous Secondary Care Prescribing (Drugs). Thistarget ceased to exist on 1 October 214 as SHSC took over the new Opiates contract. 16 Access to Treatment - Caseload (Drugs) 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 13/14 Q1 98% 97% 96% 92% 7% (1/15) Sec Drug Sec Drug Target Prim Drug Target Prim Drug 13/14 Q2 99% 92% 93% 1% 44% (14/32) 13/14 Q3 98% 94% 93% 98% 66% (58/86) 13/14 Q4 99% 1% 97% 1% 74% (81/19) 14/15 Q1 1% 78% 98% 1% 55% 8 7 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 214 mean this target will need to be reviewed. 14/15 Q2 14/15 Q3 14/15 Q4 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. Over time in previous contracts the DACT and PHE have changed the targets for harm reduction interventions. Shown above for 214/15 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. 48% 1 October 214 -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. 1

11 Employment (updated each quarter) Social Inclusion - Period to May 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 Q4 Q1 Q2 Q3 Q4 Number of Members 12,623 12,62 Scheduled Care - Number of clients Scheduled Care - Number in employment Scheduled Care - % in employment 1.4% 1.8% 1.3% 1.% 1.8% Mar-17 Feb-17 Jan-17 Dec-16 Nov-16 Oct-16 Sep-16 Aug-16 Jul-16 Jun Target Actual MH CPA - Number of clients MH CPA - Number in employment MH CPA - % in employment 5.42% 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 4.8% 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 Governors & Membership Engagement A membership event was organised at the University of Sheffield s Student Union on 17 th May. Newly elected young service user/carer governor Michael Thomas was instrumental in setting this up. Together we engaged a number of third sector organisations plus services within the Trust to participate in the event which was very successful in terms of being able to signpost students to appropriate services but also in terms of recruiting over 3 new members. Together with Michael, Vin Lewin, Dorothy Cook and Sue Roe all attended and supported the event as well as governors from Sheffield Teaching Hospitals, with whom the Trust works in partnership on membership matters. Another event is planned for October/November time. Whilst not participating in person, the Trust contributedinformation to be handed out at the Heads Up! Festival held on 14th May at Hagglers Corner in Sheffield. This festival is aimed at tackling the stigma associated with mental ill health. CPA and Settled Accommodation Figures are a monthly average Q4 Q1 Q2 Q3 Q4 MH CPA - Number of clients MH CPA - Number in Settled Accomm MH CPA - % in Settled Accomm. 83.5% 83.8% 83.9% 84.1% 82.5% 11

12 Financial Overview as at 31st May 216 Key Ratios Payment of Suppliers Cash Current Month s YTD Plan YTD Actual FOT Plan FOT Actual Capital Service Cover Liquidity I&E Margin I&E Margin Variance from Plan YTD Rating Red Green Red Green Trade Creditor Days for May are 8.16 days. BPPC (YTD by number) Trade NHS Target 88.99% 95.76% 95.% Amber BPPC (YTD by value) 91.56% 97.8% 95.% Amber (See Appendix 7 & 7A) Plan Actual Variance Cash balance 24,137 24, Green 2.26% Financial Sustainability Risk Rating Amber Income and Expenditure s Position to date Plan Achieved Variance I&E Surplus/(Deficit) 1 (433) (434) Red EBITDA (444) Red Under-Spend Deficit Deficit Forecast Year-end Plan Achieved Variance I&E Surplus/(Deficit) (66) (66) Red EBITDA 4,156 4,11 (55) Amber Under-Spend Deficit Deficit Apr May Jun Jul Aug Sep Oct Nov Dec Jan Feb Mar 6,5 5,5 4,5 3,5 s 2,5 1, ,5 216/17 Actual 213/14 Actual 214/15 Actual 215/16 Actual Better Payment Policy Compliance (>95%=Green;>9%<95%=Amber;<9%=Red) Total debtor days Debtor days (incl. accruals) Income Received Within Planned Days 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 ,6, 1,4, 1,2, 1,, 8, 6, 4, 2, Debtor Days Green Green Plan Actual 12+ days overdue days overdue 61-9 days overdue 31-6 days overdue 1-3 days overdue Cash Monitoring Variance (>1.15%<.85%=Red;>1.5%<.95%=Amber; Within 5%=Green) 3, 27, 24, 21, 18, 15, 12, 9, 6, 3, - - 3, - 6, - 9, - 12, - 15, s M3 Net Working Capital The Last 12 months Net Working Capital Movements M4 M5 M6 M7 Provisions Inventory Net Working Capital (excluding cash) Net Working Capital (including cash) M8 M9 M1 Payables Receivables Cash Overall Net Working Capital is 1,38, higher than plan compared to last month s 2,218, higher than plan. The Trust planned to have 2,952, more payables than receivables and has, at month 2 3,99, more payables than receivables, a positive result for cash balances. Month 2 saw stabilisation of the working capital position after an exceptional month 1, with therefore Net Working Capital of 1,535, utilised in month 2 reversing part of the 3,821, clawed back in month 1 and giving a cumulative working capital claw-back of 2,286, ytd. i.e. we planned to reduce cash by 2,936, throughout April and May cumulatively, but only reduced it by 65,. Key drivers of this position against plan in month include: Receivables 1,474, lower than plan and positive for cash. A 73, reduction on last month. More details in section d below and at Appendix 8. Payables 191, under plan, negative for cash. This is a reduction of 893, on last month's balance. More details in section e below. Provisions are 262, lower than plan. Details in section f below. The closing May Cash balance is 24,682, ( 25,682, for April) which is 548, above the planned balance. M11 M12 M1 M2 (See Appendices 4A - 4D) Full Year Target CIP Target To Date 737 Achieved 526 Variance from Plan of which Non-Recurrent Disinvestments Non-Recurrent Recurrent Combined Position Target to Date 215/16 Cost Improvement Programme s All figures in s CIP Achievement Dis Achievement CIP delivery to date is Red 1% 1% 526 against a plan of Target To Date 1,34 Achieved 1,79 Variance from Plan of which % Recurrent % ,77 Achieved 1,65 Variance from Plan 471 of which 77% Non-Recurrent 451 Recurrent 1,154 9% 8% 7% 6% 5% 4% 3% 2% 1% % 9% 8% 7% 6% 5% 4% 3% 2% 1% % Disinvestment delivery to date equates to 179 against a plan of 134 Overall the Trust has achieved combined CIP and disinvestments to the value of 165 against a plan of 277 In percentage terms this is 77% This position includes the release of contingency and risk reserves of 1,15 to offset CIP and disinvestment gaps that identified in the financial plan. Action is being taken (including via the directorate performance management process) to identify savings to meet other gaps in savings plans. Capital Position to Date Plan Actual Variance In-month spend Green Cumulative spend (313) Red Capital expenditure is <85% or >115% of plan for year to date Capital Forecast Outturn Plan Actual Variance Cumulative spend 3,337 3,253 (85) Green Capital expenditure is <85% or >115% of plan for year to date Capital Spend s Red Green The 2 week delay in April on the Forest Close scheme affected the cashflow profile in both months 1 and 2 versus plan. This is the main cause of the high percentage variance at month 2.. However, it is anticipated that the scheme will complete within quarter 1 broadly in line with plan. Phase II ACR is proceeding to the design stage, with the tender of the design team underway. Costs are ahead of plan at month 2 due to profiling. The IT schemes planned for 16/17 were largely phased in twelfths with the exception of the potential spend on licenses anticipated in months 3 and 6 in the plan. Two schemes were brought forward into 15/16 via utilisation of unspent capital funds in the Estates fund. The forecast outturn therefore on those schemes will be zero for this year, resulting in a 145, underspend in IT to fund the delayed Estates schemes. Further detail can be found at Appendix 6. s Capital Spend Against Plan and 15% Variance Target Cumulative Plan 85% Cumulative Plan Cumulative Plan 115% YTD Actual & Projected FOT 12

13 Regulatory Framework CQC - Annual Surveys (Care Quality Commission) CQC - Compliance Reviews (Care Quality Commission) Area or section Review or Assessment Date REGULATION/COMPLIANCE DASHBOARD Compliance or Rating Patient survey Green Staff survey Green All Healthcare Amber All Social Care Amber All primary care sites Intelligence Monitoring Compliant 4 Risks, Elevated Risks Ratings removed Feb 216 Mental Health Act Amber Safeguarding Adults and Children Green 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 was presented to the Board of Directors in April 216. Trust's current rating for 'health' services is Requires Improvement. Copies of all published reports can be found at Action plans are in place for all areas of improvement identified following inspections. A monthly progress report, following the Trust s provider inspection, is provided to EDG, QAC and the Board of Directors. Focussed inspection on well-led domain took place in May 216. Formal feedback awaited. Follow-up provider inspection anticipated in late 216. Trust's current rating for 'social care' services is Requires Improvement. Copies of all published reports can be found at Woodland View and Longley Meadows rated as requires improvement following recent inspections. Wainwright Crescent inspection took place in May 216 final report and action plan will be presented to a future QAC meeting. 136 Warminster Road was also inspected in May 216. Rated as good across all domains. GP practices yet to be inspected. Recent communication suggests inspection is due imminently. Last report published February 216 shows 4 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 updates 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

14 Regulatory Framework Area or section Review or Assessment Date Compliance or Rating Progress s HSE (Health and Safety Executive) All sites Compliant No HSE Improvement notices received. Fire Service Visits All sites Compliant As of 16 th May 216 there are no Fire Authority Enforcement notices within SHSC. NHSLA (NHS Litigation Authority) Monitor Claim History Red Provider Licence Compliant Continuity of Services Rating Score = 4 Green - no evident concerns 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. Internal Audit to commence work in this area. The scores opposite relate to the Trust s position as at 9 th June 216, as published on Monitor s website. Continuity of Services is rated from 1-4 with 4 being the lowest risk. Governance Rating 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 Q4. Patient Led Assessments of the Care Environment (PLACE) National Average = 97.57% Cleanliness 99.11% National Average = 88.49% Food and Hydration 92.84% National Average = 86.3% Privacy, Dignity and Wellbeing 92.98% National Average = 9.11% Condition, Appearance & Maintenance 96.4% National Average = 74.51% 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 Mayr-16 Green (No major concerns) No major concerns noted in last report presented to Quality Assurance Committee in June 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 Jun-16 Compliant The Trust Equality Objectives will need to be reviewed by April 216. Plans being taken forward. Jun-16 Compliant Implementation plan in progress Jun-16 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. 14