Dudley & Walsall Mental Health Partnership NHS Trust Board

Transcription

1 Dudley & Walsall Mental Health Partnership NHS Trust Board Date of Board Meeting: 29 th July 2 Subject: Performance Corporate Dashboard Month 3 Trust Board Lead: Jacky O Sullivan, Director of Performance & Strategy Presented by: Jacky O Sullivan, Director of Performance & Strategy Aim of the report: To brief Trust Board on Performance against key indicators for the month of June 2 To brief Trust Board on Care Quality Commission s (CQC) method of assessment for 28/ and 2/ Key points: The Corporate Dashboard predominantly reflects performance for the month of June: any exceptions to this are noted within the narrative. Reporting is by exception. Recommendation: The Board is asked to receive this report on Trust performance for June 2 for assurance Board action required (please tick) Information Approval Discussion Assurance Other (please state) Key Standard(s) for Better Health: C1, C5, C14, D7 Financial: HR/Personnel: Community/user: Equality & Diversity: Implications: None None None None 1

2 1. Introduction This report presents the following information: - Corporate Dashboard June 2 Trajectories Performance against Monitor indicators CQC method of assessment 28/ CQC method of assessment 2/ 2. Corporate Dashboard The Corporate Dashboard is presented at appendix 1 and provides a visual summary of Trust performance against key performance indicators for the month of June 2. This is not meant to replace or duplicate reports the Board will receive from other service areas where more detailed information will be provided e.g. monthly finance reports, integrated governance reports. The corporate dashboard is populated from extraction routines that interrogate the trust s four main patient information systems, together with extracts from the Electronic Staff Records, the finance ledger and the HALO substance misuse system. The information is presented as pan-trust activity except where specific locality information is required. The dashboard, where appropriate, presents data aggregated from the beginning of the financial year. This month the dashboard has been modified to reflect changes to the Care Quality Commission (CQC) Key Performance Indicators (KPIs) that have recently been published. Specifically CQC have now introduced a new indicator Access to Healthcare for People with a Learning Disability. The indicator will not be included in the assessment process for 2/. However, trusts will be expected to provide the requisite information and CQC will publish this indicator alongside the results of the review to ensure visibility of performance in this area. Additionally CQC are reviewing the construction of indicators Completeness of the Mental Health Minimum Data Set (MHMDS), Patterns of Care from the Mental Health Minimum Data Set (MHMDS) and Best Practice in Mental Health Service for People with learning Difficulties. As a consequence of this review CQC have currently removed the construction for these indicators from its national guidance. The PALs indicator has been relabelled to reflect the actual activity presented. 2.1 Care Quality Commission (CQC) Indicators CQC calculate delayed transfer of care in terms of occupied bed days. In May this was 4.99% for the Trust but this has deteriorated to 7.29% for June and has now been rated as red. The period of assessment for this indicator by CQC is April to August 2. The Directorate of Operations have been asked for an action plan which will be considered by the Finance and Performance Committee in August. The highest number of delays was experienced on Ambleside Ward at Dorothy Pattison Hospital with the reason for delay being awaiting completion of assessment. The second area of highest delays was Clent Ward at Bushey Fields Hospital with the reason being Housing patients not covered by NHS and Community Care Act. 2

3 While the construction for Best Practice in Mental Health Service for People with Learning Difficulties is being developed our Trust will continue to work on compliance with the Green Light Toolkit to improve performance against the indicator. Performance against the Experience of Patients indicator is determined by the results of the national inpatient survey. Whilst we have now received the results of the survey, they remain embargoed by the CQC. An action plan will need to be developed following a full analysis of the results. The NHS staff satisfaction survey was undertaken just as the Trust was being established and asked employees to reflect upon the previous year s employment. As this was within employees respective PCT s, it does not provide the Trust with its own baseline, and as a result the Finance and Performance Committee agreed not to self rate this indicator this year. 2.2 Local Authority Indicators Performance Assessment Framework (PAF) Indicators are presented for each Local Authority. The performance of these indicators for Walsall Council is derived from data from trust information systems and supplied monthly to Walsall Council. In Dudley Social Care staff record on Council systems (SWIFT) and information is supplemented by Trust data, thus making it difficult for the Trust to monitor or performance manage. Low levels remain for people taking up direct payments in Walsall with higher levels recorded in Dudley. 2.3 Finance Indicators As at Month 2 the Trust had a small surplus of 47k and remains on track to meet its forecast outturn target of k. The cost improvement programme over achieved in month 2 however the longer term challenge remains with regard to delivering recurrent rather than non recurrent savings. The Public Sector Payment Policy is slightly below the 9% limit however the on average the Trust pays suppliers within 19 days of receipt of a valid invoice. Analysis has started to determine if a small number of high value disputed invoices are the cause of the current amber performance. It is intended that some of the key trends (variance against forecast, outstanding debt, bank and locum spend) will be reported on a graphical basis from month 3. The actual month 2 figures with regard to these areas are provided for information presently. The External Financing Limit can only be calculated on a Quarterly basis and as such this value will be presented next month. 2.4 Workforce Indicators In May 2 the health staff sickness and absence rate increased marginally to 5.85% from 5.26%. Similarly May has seen an increase in sickness levels for Dudley Local Authority staff. However in Walsall, Local Authority data for June 2 shows a significant drop in sickness to 3.9% from 4.7% in May. The Board are asked to note that Walsall Local Authority supplies this data by month but on a quarterly basis. 3

4 The data presented on the dashboard for appraisal and Personal Development Plans (PDP) is a refresh of Quarter 4 data for 28/. Quarter 1 data 2/ will be available for the August dashboard. It has been agreed at the Finance and Performance Committee that the staff satisfaction survey will not be RAG rated this year. The survey took place just as the Trust was formed and responses related to the previous 12 months of employment which would have been in employees respective PCTs. Therefore our Trust has no comparator. 2.5 Efficiency Indicators While waiting times for Clinical Psychology Services remain a cause for concern, this month patients waiting more than 18 weeks have decreased by 12. Of those Patients waiting over 18 weeks all are attributable to the Walsall locality, 175 patients waiting for Primary Care Psychology and 1 in Older Adults. Both Assertive Outreach Teams have developed exception report action plans to achieve their team caseloads and whilst Dudley have improved slightly this month, Walsall have shown no change in their position. Dudley Early Intervention Team has increased its caseload from 131 in May to 137 in June and is on target to achieve their trajectory of 143 in August as per their exception report action plan. While there has been an increase in the rate of new cases taken onto the caseload, this falls just short of the planned target. Walsall Early Intervention Team also has an exception report action plan in place and has increased the number of patients on their caseload from 96 in May to 3 in June against a target of 137. They have also improved performance for the number of new users onto the team caseload and this is now rated as green. Readmissions within 28 Days, again remains green this month with performance improving from 8.99% in May to 6.42% in June. A further breakdown of efficiency indicators against trajectories is available in Appendix Clinical Quality Indicators While the performance of the Drug Action Team (DAT) Partnership will be assessed across all services it is important that the Trust can understand and assess its own contribution to this partnership. Work is therefore progressing to interrogate the Halo Information System in relation to Walsall Substance Misuse Service, to make the trust less dependent on the National Treatment Agency for compiled performance data. The Primary Care Prescribing data is unavailable at this time After further discussion with Dudley DAT it was felt that the indicator relating to Quarterly Treatment Outcome Profile (TOP) Reviews was the most relevant indicator to the Trust Substance Misuse Services in Dudley. 4

5 When considering the contribution the trust makes to the performance of the DAT (Drug Action Team) partnership, the potential is just over 6% and therefore the trust will make only a minor impact on the overall DAT performance indicators. The Retention & Care Planned indicator for Dudley has therefore been removed. 3. Data Warehouse and Performance Software Contracts have been signed with Stalis, the successful supplier of the Data Warehouse solution and the server equipment has been ordered. It is anticipated that the initial software installation will take place at the end of July. An initial scoping meeting between Stalis and the Performance and Information teams has taken place where final queries relating to the Project Initiation Plan (PID) were tabled. The final PID agreement and a technical workshop are both planned for mid July. 4. Monitor indicators It can be seen from the table in Appendix 3 that the Trust is achieving 7 of the 8 indicators that are assessed within Monitor s Governance Framework. Over the first quarter of this year there has been a steady rise in delayed discharges which this month has taken the quarterly performance over the 7.5% target threshold. Standards for Better Health Core Standards are included in the framework. At year end the Trust had insufficient assurance on 8 of the Core Standards. One of these has now been verified this month: Patient Focus Information on Patient access to complaint (C14a) If the Trust were being assessed by Monitor at this point in time we would have a score of 3.8 for quarter 1 which would be a red rating. 5. CQC method of assessment 28/ The Care Quality Commission have published a document Reviews in 2/ that clarifies how trusts will be assessed this year and the coming year. In October 2 CQC will publish the results of assessments of performance in 28/ which they inherited from the Healthcare Commission. When doing so, they will: - Award NHS trusts a rating that comprises two scores for their quality of services and for their quality of financial management. The quality of services score is an aggregation of scores for performance against the Government s national priorities, existing commitments, and assurance of compliance with core standards. 6. CQC method of assessment 2/ 2/ is a transitional year between the previous system of the annual health check and CQC s systems of registration and periodic review. The CQC review will have three components of assessment: 5

6 Trust assurance of compliance with core standards Performance against the Government s national priorities and existing commitments Quality of financial management The core standards assessment will be based on a mid-year declaration and will not be linked directly to a programme of inspections. The Trust will be required to make a declaration in November 2 on our performance against core standards in the first seven months of the year. The declaration will be a re-fresh of our declarations made for 28/ and we will need to include a statement on our progress against action plans outstanding from 28/. Declarations will not include standards related to healthcare-associated infection as they will be covered by registration in 2/. Summary scores will be derived based on declarations, including any changes CQC make, and published in autumn 2. CQC will combine the results of assessment of core standards with the results of the assessment of performance against indicators to provide the score for quality of services. CQC will use the work of Monitor and the Audit Commission to reach their assessment of the quality of financial management. 7. Recommendations The Board is asked to note performance against indicators for June 2 and to receive this report for assurance. 6

7 Appendix 1 7

8 Appendix 2 The charts below will give an historical view of key indicators on the corporate dashboard as the year progresses. Compliments & Complaints Compliments Formal Complaints Complaint Response time 5 Serious Untoward Incidents(SUI) Incidents Reported Readmission Within 28 Days.% 9.% 8.% 7.% 6.% 5.% 4.% 3.% 2.% 1.%.% 8

9 Dudley Assertive Outreach Caseload Walsall Assertive Outreach Caseload AOT Caseload AOT Target AOT Caseload AOT Target Dudley Early Intervention Caseload Walsall Early Intervention Caseload 12 8 EIS Caseload EIS Target 12 8 EIS Caseload EIS Target Dudley Early Intervention New Cases (Year to date) Walsall Early Intervention New Cases (Year to date) EIS New Cases New Case Target EIS New Cases New Case Target Dudley CR/HT Caseload Against Target 7 Walsall CR/HT Caseload Against Target 5 No of unique HT Patients CR/HT Target 6 5 No of unique HT Patients HTT Episode Target

10 Appendix 3 Monitor's Governance Declaration framework Reporting Period June 2 submission MONITOR Compliance Framework YTD Score Target RAG Apr May Jun Jul Aug Sep % Followed up on enhanced CPA 97.46%. 95.% G 98.8% 95.24% 98.17% % of occupied bed days with delays 7.63% % R 4.5% 8.48%.2% % CRHT Gate Keeping 99.6%. 9.% G 98.78% % % No. of CRHT teams in place 4. 4 G Medical 18 Week Waits (Inpatient) %. 9% G % % % Medical 18 Week Wait (Outpatient) %. 95% G % % % MSRA Infections. G Clostridium Difficile Infections. G National Core Standards R Insufficient evidence on 7 rated at.4 Green = Less than 1. Amber = From1. to 2.9 Red = 3. or more Overall Weighted Score = 3.8 which is rated as RED for Quarter 1