Sarah Connery, Director of Finance & Information Board action required: For Information For assurance (Yes or No): Yes. Purpose of the Report

Transcription

1 5.1 Report to: Board of Directors Date of meeting: 26 April 2018 Section: Operational Performance Report title: Integrated Performance Report Report written by: Linda Bathgate Job title: Performance Officer Lead officer: Sarah Connery, Director of Finance & Information Board action required: For Information For assurance (Yes or No): Yes Purpose of the Report To report to the Board of Directors on the main areas of performance exception at month 12 (March) of 2017/18. Key Issues, Options and Risks A review of performance against all key performance indicators is provided, based on complete data for month 12. The narrative below indicates the action that is being taken to address areas of concern or where performance is below the expected standard or target level. Executive Analysis There are ten main sections to this report. The LPFT and Divisional Scorecards provide an at a glance summary of the national and mandated indicators including those within the Single Oversight Framework. The Divisional performance summary highlights within clinical divisions areas of concern and areas that have since improved following previous exception reporting. The key areas are summarised below; 1. The Trust Level Metrics and Key Points Summary highlights the main indicators currently not being met together with Trust level reporting for Quality & Safety, Patient Experience and Safe Staffing. 2. The Divisional Integrated Performance Summaries have highlighted the areas within the Divisions where under target performance has driven action plans to address the issues and include areas of Quality, Safety and Workforce on a divisional basis. 3. The Finance report which gives the current financial position in line with the forecast plan. 4. The Early Warning Tool gives an early indication of areas that may require further attention and is not to be considered as a performance management tool. Recommendation (action required, by whom, by when) The Trust Board is asked to agree the actions arising from review of this report. Regulation, legislation and compliance CQC Impact on key lines of All enquiry: Financial Implications: Impact on financial standing if targets are not achieved. 1

2 Equality Analysis: Compliance Impact: Not applicable. NHS Improvement, NHS England, Clinical Commissioning Groups and Care Quality Commission Risk Appetite Risk assessment Completed below / Not applicable (delete as appropriate) Risk Level Avoid Minimal Cautious Open Seek Mature Key Elements Financial / VFM: G Compliance/Regulatory: Innovation/Quality: Reputation: APPETITE NONE LOW MODERATE HIGH SIGNIFICANT Explanation of variance from general (G) risk appetite The level of risk has been assessed as meeting the Trust s general risk appetite. The Board will agree whether the risk appetite differs following the paper discussion The level of risk against each element should be indicated. Where more than one option is available the level of risk of each option against each element should be indicated by numbering each option and showing numbers in the boxes. The content of this report is the property of Lincolnshire Partnership NHS Foundation Trust Document Control Version 4 November 2016 G G G 2

3 INTEGRATED PERFORMANCE REPORT BOARD OF DIRECTORS April 2018 Report 3

4 CONTENTS Section PAGE Trust Metrics Scorecard 5 Operational Metrics Tracking Table 6 Trust Quality & Safety Summary 7 9 Trust Patient Experience Summary 10 Trust Workforce Summary Trust Safe Staffing Summary Specialist Integrated Performance Summary Adult Community Mental Health Integrated Performance Summary Adult Mental Health Inpatient Integrated Performance Summary Older Adult Mental Health Integrated Performance Summary Finance Summary and Data Early Warning Tool

5 LPFT Integrated Scorecard Trust Performance Metrics Historical data Dec Final Jan Final Feb Final Decr - / Incr + % on Primary vs Final Data* Latest Data Mar '18 Same Month previous year Target 1 2 Single Oversight Framework Number of Never events MHSDS Identifier Metrics 99.5% 99.7% 99.9% 0.0% 99.9% 99.5% 95% 4 MHSDS Priority Metrics 84.9% 88.7% 88.0% 0.0% 89.0% 75.0% 85% 5 Cardio metabolic Inpatient 90% 6 Cardio metabolic Community 65% 7 Cardio metabolic Early Intervention 65% 8 Early Intervention Psychosis 2 week wait 69.6% 67.7% 84.0% 0.0% 83.3% 77.8% 50% 9 % of CPA patients receiving a follow up within 7 days of discharge 94.0% 96.6% 97.6% 0.0% 92.7% 97.8% 95% 10 Admissions to Adult facilities of patients aged 16 or under % Lincolnshire IAPT services Recovery rate 56.7% 54.0% 54.7% 56.2% 54.7% 50% 12 Lincolnshire IAPT services Wait from Referral to Treatment within 6 weeks 88.3% 87.3% 83.2% 84.5% 86.2% 75% 13 Lincolnshire IAPT services Wait from Referral to Treatment within 18 weeks 99.8% 98.6% 98.6% 99.6% 98.5% 95% 14 Friends and Family Test Recommend rate 89% 88% 90% 88% 85% 71% 15 % of Complaints as against Trust whole time equivalent staff numbers (New measue Nov 2017) 0% 1% 0% 1% Info only 16 % sickness absence 5.3% 5.1% 4.4% 0.0% 4.1% 4.7% 4.5% 17 Finance Score Agency Spend compared to Agency cap ( 000's) Info only 19 Net Income and expenditure ( 000) Cash balance ( m) 11,822 12,168 13,088 11, Non Single Oversight Framework PbR Compliance - % of eligible caseload assigned to a cluster (added April 2018) 93.1% 96% 23 PbR Compliance - % of patients in scope with an in date cluster review (added March 2018) 81.7% 82.5% 96% day Unplanned re-admissions 1.7% 3.2% 7.7% 0.0% 7.7% 2.2% <10% 25 Whistle Blowing (New Cases in the month) Info only 26 Lincolnshire IAPT services Access rate 16.1% 19.8% 17.6% 16.8% 16.8% 15% 27 Number of Serious Incidents (including suicides and never events) Info only 28 Number of suspected Suicides Info only 29 Trust waiting times compliance (Community non contractual, actual waits) - 18 weeks 97.7% 97.7% 96.2% 0.0% 97.6% 95% week RTT non-admitted incomplete pathways (Consultant led, still waiting) Incl Int Referrals 91.1% 91.2% 90.5% 0.0% 89.9% Info only week RTT non-admitted incomplete pathways (Consultant led, still waiting) Exc Int Referrals 92.8% 92.6% 92.2% 0.0% 94.5% 98.5% 92% 32 Zero tolerance RTT waits over 52 weeks % 0 0 0% 33 Delayed Transfer of Care - Trust Position 0.3% 0.2% 2.5% 0.0% 1.8% 9.9% 3.5% 34 % of CPA patients with a formal review within the last 12 months 95.7% 96.5% 95.1% 0.0% 95.4% 95.6% 95% 35 % Compliance with CQUINS (Forecast) 92% 92% 90% 90% 100% 36 % Complaints % compliance with plan 82% 90% 96% 100% 95% 90% 37 Number of Complaints Info only 38 Number of Incidents requiring Duty of Candour Info only * Please note that any + / - is due to late data entry and/or additional data validation 5

6 Operational Metrics Tracking Table Operational Metric Description Specialist Mental Health Lincolnshire CAMHS waiting times Routine % of patients seen or offered and appointment within 6 weeks Adult Community Mental Health PbR Compliance Reviewed clusters % of patients in scope with an in date cluster review Older Adult Mental Health Community Mental Health Team (CMHT) waits % of patients seen within 18 weeks Older Adult Mental Health 18-week RTT nonadmitted incomplete pathway (Consultant-led, still waiting) Older Adult Mental Health PbR Compliance Reviewed clusters % of patients in scope with an in date cluster review Actions & Tracking data All new referrals are being offered appointments within the time frame, however the current report reflects the backlog of referrals mostly in Grantham that were already breaching, this issue will continue to reflect breaches over March and April until the backlog have all been seen. The service manager is working with the Grantham team manager on the local recovery plan. Month Oct-17 Nov-17 Dec-17 Jan-18 Feb-18 Mar-18 % 66.9% 72.0% 77.0% 65.7% 83.6% 90.6% Trust target 95% 95% 95% 95% 95% 95% All Teams are sent out compliance lists for action across the Division, utilising the current PbR report. Medical colleagues are aware of the need to re-cluster and have been sent a list of any patients who require their cluster up-dating. This will be an on-going action. Month Feb-18 Mar-18 % 78.3% 80.0% Trust target 96% 96% Stamford CMHT nurses are supporting the Spalding team 3 sessions per week. Medical staff are making clinical sessions available to support new referrals and reduce delay. A new Coordinator is in post in the Grantham CMHT and is clinically reviewing all current waits and caseloads. Month Oct-17 Nov-17 Dec-17 Jan-18 Feb-18 Mar-18 % 92.0% 94.0% 94.6% 98.2% 94.6% 96.3% Trust target 95% 95% 95% 95% 95% 95% Recruitment of Consultant commencing January 2018, as is recruitment of part time staff grade. The service is receiving Intensive support by Clinical Director and Service Manager Month Oct-17 Nov-17 Dec-17 Jan-18 Feb-18 Mar-18 % 95.2% 90.1% 86.7% 87.9% 85.0% 89.4% Trust target 95% 95% 95% 95% 95% 95% All team coordinators have been requested to provide a remedial plan to support achieving target of 96% by June This is to be presented at March s Divisional Meeting for assurance that appropriate actions and monitoring are in place at local level. Month Feb-18 Mar-18 % 83.7% 83.0% Trust target 96% 96% Reporting on Progress / Completion May 2018 June 2018 May 2018 May 2018 July

7 Mar-16 Apr-16 May-16 Jun-16 Jul-16 Aug-16 Sep-16 Oct-16 Nov-16 Dec-16 Jan-17 Feb-17 Mar-17 Apr-17 May-17 Jun-17 Jul-17 Aug-17 Sep-17 Oct-17 Nov-17 Dec-17 Jan-18 Feb-18 Mar-18 Mar-16 Apr-16 May-16 Jun-16 Jul-16 Aug-16 Sep-16 Oct-16 Nov-16 Dec-16 Jan-17 Feb-17 Mar-17 Apr-17 May-17 Jun-17 Jul-17 Aug-17 Sep-17 Oct-17 Nov-17 Dec-17 Jan-18 Feb-18 Mar-18 Trust Quality & Safety Summary All aspects of quality and safety are monitored by the Quality and Safety Team to identify any themes, trends, exceptions and actions taken to address any issues highlighted. Presented below are data (c-charts) relating to 3 key safety domain areas. Violence, Abuse and Harassment (VAH) Trustwide patient to staff violence Number of incidents Mean (CL) UCL Trustwide patient to patient violence Number of incidents Mean (CL) UCL Please note the lower control limit (LCL) is zero for both graphs above. Violence both patient to patient and patient to staff are demonstrating uncontrolled variation. Actions continue, as described in last month s report, to try and generate greater understanding and control of variation. This topic was subject to a hot-spot report in the March 2018 Integrated Performance Report. 7

8 Mar- 16 May- 16 Jul-16 Sep-16 Nov-16 Jan-17 Mar- 17 May- 17 Jul-17 Sep-17 Nov-17 Jan-18 Mar- 18 Falls Trustwide falls 60 Number of falls Mean (CL) UCL LCL March 2018 Falls by Ward Langworth Ward Manthorpe Centre Brant Ward Ashley House Rochford FWU Conolly Ward Level of harm from falls in March 2018 No Harm % Low Harm % Moderate Harm 0 0 Severe harm 0 0 Total patient falls % Bespoke falls training sessions for older adult multi-disciplinary teams has been developed and delivery has commenced. This training focusses on the completion of the new assessment documentation. Training has taken place with the following areas: Langworth Brant Manthorpe Lincoln Community Mental Health team Learning Disability services Some Adult Community staff have attended the Older Adult Mental Health session at Witham Court. LPFT is increasingly linking with Lincolnshire Community Health Service (LCHS) who specialises in the Frailty Agenda of which falls is integral. There is much work to be undertaken to improve LPFT involvement with the Lincolnshire Frailty Agenda and supporting patients to access community services to minimise falls. The Older Adult Division Community Service Manager is in the process of finalising addition of the Edmonton Frailty Scale into the older adult CMHT s pathway processes as agreed with LCHS matron. 8

9 Mar-16 Apr-16 May-16 Jun-16 Jul-16 Aug-16 Sep-16 Oct-16 Nov-16 Dec-16 Jan-17 Feb-17 Mar-17 Apr-17 May-17 Jun-17 Jul-17 Aug-17 Sep-17 Oct-17 Nov-17 Dec-17 Jan-18 Feb-18 Mar-18 Trust Quality & Safety Hotspot Medication Trustwide medication errors 35 Number of errors Mean (CL) UCL LCL Bi-monthly locality medicines management meetings continue to cover Adult, Older Adult and Specialist Inpatient services. These are supported with quarterly meetings with all inpatient service nursing and pharmacy colleagues. Reviewing incidents, trends, themes and learning lessons are discussed as are new ways of working and latest developments such as the imminent introduction of an Electronic Prescribing & Medicines Administration (EPMA) with the focus on patient safety and improved patient experience within LPFT. Staff within the Adult Mental Health Inpatient Division are working closely with the Modern Matron and the Clinical Lead Pharmacist to understand the errors that are occurring and address any issues identified either with individual staff or within systems and processes. Current developments for the Adult Mental health Inpatient Division include: The quality of Datix reviews in relation to medication errors with controlled drugs has been highlighted. Recent developments to address this have involved collaborative work with the Clinical Lead Pharmacist to produce guidance for reviewers to ensure full investigation and escalation processes are completed. A bespoke refresher training package is currently being developed for Conolly Ward staff to target regularly occurring medicine management issues/ errors. The Wolds are trialling the revised self-administration of medicines policy with initial positive feedback from patients and staff. The implementation of EPMA should reduce the number of reported medication errors / issues. 9

10 Trust Patient Experience Summary In March 2018 there are no exceptions to report regarding complaints received by the Trust. The Trust wide percentage of people who would recommend our services from the Friends and Family Test (FFT) in March is 94% with an 11% response rate for community teams (all divisions combined) and a 63% response rate for inpatient wards (all divisions combined).the latest published national statistics from January 2018 for mental health trusts was 89% recommendation rate. NHS England do not set a national response rate and advocate the importance of using the free text comments to action and evidence change from this feedback mechanism. A greater focus in obtaining and understanding the FFT free text comments to generate You said, we did to improve services is being supported by the Patient Experience Team. The Trust is to trial FFT SMS text messages within the Crisis Resolution and Home Treatment service in April This trial is to see if response rates are increased within the services by using text messages to ask people to respond to the FFT question. If the trial proves successful it is hoped to widen this provision to other services. In Table 1 the complaint subjects of the 18 complaints received in March are presented as a Pareto chart based upon the K041a NHS Digital categorisation. This mandatory collection monitors complaints received by the NHS and there can be more than one subject recorded per complaint. Nationally the Single Oversight Framework (SOF) measures complaints against the number of whole time staff employed. Within the Trust medical staff numbers are calculated separately and not included in divisional staff numbers therefore the Patient Experience Lead is unable to reproduce these figures for each division, preventing comparative analysis. Table 1- Subject of Complaints March Number Percentage 10

11 Trust Workforce Summary Sickness Absence Trust overall sickness has decreased by 0.25% from 4.37% to 4.12%. There have been significant increases in days lost due to; Stress/Anxiety ( ), MSK Problems (+51.03) and Back Problems (+48.45). There have been significant decreases in days lost due to; Cold, Cough, Flu ( ), Chest & Respiratory problems (-60.64) and ENT (-13.31). Cumulative sickness has reduced from 4.96% to 4.87%. The below table demonstrates the areas where sickness is above 5% (based on rolling year). Areas in grey have less than 20 people and should be discounted. Service Number in Post Turnover Sickness Absence % Sickness Absence % Cumulative Sickness Month Cumulative Ranking Ranking # Increase / # Decrease ## Adult Inpatient Rehabilitation % 9.11% 8.61% 1 0 Less than 4.5% Specialist Learning Disabilities % 7.46% 7.20% % to under 5% Older Adult Liaison % 1.53% 7.11% 3 0 5% and above Specialist Eating Disorders % 2.74% 7.07% 4-2 Adult Community Complex & Forensic Community Service % 7.23% 6.76% 5 0 ## Adult Community Community Services IAPT % 5.68% 6.74% 6 1 Ranking Decrease Older Adult OA Inpatient % 6.06% 6.53% 7-1 No change Adult Community Therapy Services % 4.27% 6.25% 8 1 Ranking Increase Adult Community Principal Social Worker % 2.78% 6.01% 9-1 Older Adult OA Community % 5.87% 5.61% 10 3 Human Resources are fully involved and aware of sickness absence cases within the services and a full breakdown of activity was provided in March Mandatory Training The mandatory training figure has increased from 88.02% in February to 89.10% in March Appraisal The appraisal rate has increased from 80.97% in February to 82.41% in March Vacancy Rate The vacancy rate has decreased 1.05% during March from 10.08% to 9.03%; although it is anticipated that the vacancy rate may increase next month due to the start of the new financial year due to new establishments. 11

12 Apr-17 May-17 Jun-17 Jul-17 Aug-17 Sep-17 Oct-17 Nov-17 Dec-17 Jan-18 Feb-18 Mar-18 Ratio per 100 employees Turnover The overall turnover figure has decreased by 0.62% to 14.41%. The total number of leavers over the 12 month period has decreased from to Of the six divisions, four saw a reduction in turnover during February; Medical (-3.63%), Older Adult (-2.73%), Adult Community (-1.48%) and Specialist (-0.11%). Two divisions saw an increase in turnover; Corporate (+1.14%) and Adult Inpatient (+0.80%). Employee Relations (ER) Cases As at 31 March LPFT had a headcount of 1982 and the employee relation ratios continue to be low overall Ratio Report ER Cases Disciplinary Cases Bullying and Harassment Grievance Count Ratio Previous Month ER Cases Disciplinary Cases Bullying and Harassment Grievance

13 Trust Safe Staffing Summary Where ward areas Registered Nurse (RN) and Health Care Support Worker (HCSW) staff totals are less than 90% filled or greater than 115% filled this will trigger exception reporting. This enables a timely review to seek assurance; and if required take action, to ensure patient and staff safety are always prioritised. Data is obtained from Safecare (software that pulls information from the Health Roster and combines it with patient dependency). This data supports the ability to accurately forecast whether wards are safely staffed and has been referenced alongside information relating to actual staffing levels. All wards are shown in Table 1 (below) have triggered exception reporting in March 2018 as follows: Ward The Fens Ashley House The Vales Staffing level Amalgamated RN/HCSW 121.8% RN days 123.9% RN days 72.8% HCSW days 78.8% RN days 115.1% HCSW days 122.8% HCSW nights Total Monthly Planned Hours RN Total Monthly Actual Hours RN (+169) ( ) ( ) Total Monthly Planned Hours HCSW Total Monthly Actual Hours HCSW (-103) (-192) ( ) Dependency (1- lowest & 5 - highest) Bed Occupancy Dependencies 3-5 Bed fill bed fill Dependency 2-4 Dependencies 3-5 Bed fill Rationale 2 HCSW short term sick 1 HCSW long term sick 4 RN short term sick Jury service and bereavement leave Redeployment of staff to assist other wards Last two weeks of March oversubscribed with annual leave due to honouring leave for new starters and those returning from long term sickness Additional shifts used to facilitate escorted leave in order to assist early discharge for a patient 1 RN long term sick 1 HCSW long term sick 2 episodes of special leave Three weeks in the month oversubscribed on annual leave 2 patients being nursed on 1:1 observation on the ward 1 patient in LCH on 1:1 observation 2 patients on 5 min and 15 minute observations due to self-harming behaviours 5 band 5 vacancies recruitment is underway and one is due to start in April and another September. The others are out to advert 13

14 Ward 12 Ash Villa 83.9% RN nights 116.3% HCSW nights 133.7% HCSW days ( ) ( ) (+158) ( ) Dependencies 3-5 Bed fill Dependencies 3-5 Bed fill HCSW short term sick 5 RN short term sick 1 RN long term sick RN leave oversubscribed 1 band 6 vacancy which is out to advert 2.6 Band 5 vacancy, has been advertised but no applicants interviewed 2 Band 2 vacancies out to advert 1 RN who s NMC registration lapsed so worked as HCSW 1 female patient requiring 1:1 observations Building works have commenced in the female area of the ward requiring additional staff each shift expected to last around 6 weeks 1 RN short term sick 2 HCSW long term sick 2 HCSW short term sick Annual leave oversubscribed for the month 1 band 5 vacancy 1 HCSW long term sick 1 HCSW short term sick 4 RN short term sick Annual leave oversubscribed towards the end of March 2 people on 1:1 observations High levels of violence and aggression requiring additional staffing Additional staffing required for RI to administer NG feeds 14

15 What is being done about it? It is worth noting that 1 st - 4 th March 2018 there was continued inclement weather which caused some wards to have additional staffing due to staff struggling to get into their usual place of work. Staffing adjustments have been made within the Adult Mental Health Inpatient Division s rehabilitation units (Maple Lodge and Ashley House). One RN at Maple Lodge has retired. One RN at Ashley House has been redeployed to Grantham Crisis Resolution & Home Treatment Team. There have been some changes in the management structure for rehabilitation and the manager for Ashley House is now managing both Ashley House and Maple Lodge. There are no proposed changes to the staffing numbers at present due to this change. The nurse at ward 12 who was working as a HCSW has now sent off all of the revalidation paperwork and should have their NMC PIN reinstated during April The patient displaying high levels of violence and aggression at Ash Villa has now been transferred to a specialist learning disability placement. The Healthroster team are developing a KPI document that will allow each ward to see their unavailability statistics in advance of a roster being approved to reduce the risk of oversubscription of annual leave and training. Bank Staffing Unit Fill Rates for Inpatient Wards Ward fill rates are generally good. The fill rates for Charlesworth Ward and The Vales are lowest for RN bank shifts at 71% and 76% respectively. The Vales and Manthorpe Unit have the lowest fill rates for HCSW shifts at 83% and 75% respectively. Bank Staffing Unit clinical lead is planning some group clinical supervision sessions to address some of the difficulties facing bank staff in the harder to fill ward areas. Bank and Agency in the Community IAPT service continues to use some agency staff to cover their vacant RN and Psychological Wellbeing Practitioner posts. When the Bank Staffing Unit recruit RN posts they ask about community experience and where bank RN s have matching skills they are signposted to IAPT. There are RN bank shifts used to cover vacant posts in the Community Mental Health Teams and some bank RN and HCSW shifts to cover short term sickness in the Crisis Resolution and Home Treatment Teams. The Adult community teams are recruiting to their vacant posts. 15

16 Specialist Division Scorecard Divisional Performance Metrics Historical data Dec Final Jan Final Feb Final Decr - / Incr + % on Primary vs Final Data* Latest Data Mar '18 Same Month previous year Target 41 Specialist Services Scorecard 42 Operational Performance Metrics 43 Lincolnshire CAMHS waiting times (Emergency referrals seen or offered within 24 hours) 100.0% 80.0% 100.0% 0.0% 100.0% 91.3% 95% 44 Lincolnshire CAMHS waiting times (Urgent referrals seen or offered within 72 hours) 86.3% 95.6% 100.0% 0.0% 96.7% 94.6% 95% 45 Lincolnshire CAMHS waiting times (Routine referrals seen or offered within 6 weeks) 77.0% 69.8% 83.6% 0.0% 90.6% 59.9% 95% 46 Lincolnshire CAMHS waiting times (Looked after Children seen or offered within 4 weeks) 100.0% 83.3% 87.5% 0.0% 50.0% 50.0% 95% 47 Lincs CAMHS DNA rates (clinical appointments) 13.5% 10.6% 12.2% 0.0% 10.4% Info only 48 NELincs CAMHS waiting times (Urgent referrals seen within 5 days) 60.0% 100.0% 100.0% 0.0% 80.0% 100.0% 95% 49 LD Services waiting times (Routine referrals seen within 12 weeks) 90.9% 85.7% 82.8% 0.0% 92.3% 75.8% 95% 50 PbR Compliance - % of eligible caseload assigned to a cluster (added April 2018) 82.2% 85.3% 96% 51 PbR Compliance - % of patients in scope with an in date cluster review (added March 2018) 93.7% 91.5% 96% 52 Workforce and Efficiency 53 Mandatory training compliance 90.7% 88.6% 90.1% 0.0% 91.2% 94.1% 95% 54 % sickness absence 3.9% 4.5% 3.8% 0.0% 3.7% 3.4% 4.5% 55 Vacancy factor % of WTE 95.2% 93.2% 93.4% 0.0% 94.8% 102.6% Info only 56 % staff appraisal 90.4% 91.2% 90.3% 0.0% 89.5% 94.7% 95% 57 Quality & Safety 58 Safe staffing - Average % fill rate DAY 114.3% 97.1% 131.0% 115.3% 103.8% Info only 59 Safe staffing - Average % fill rate NIGHT 108.2% 99.9% 125.1% 107.4% 111.5% Info only 60 Violence & Abuse (Patient on Patient) Info only 61 Violence & Abuse (Patient on Staff) Info only 62 Friends and Family Test Response rate 19% 18% 10% 5% 26% 20% 63 Friends and Family Test Recommend rate 88% 81% 85% 91% 86% 71% 64 Number of medication errors Info only 65 Number of complaints Info only 66 Number of Incidents requiring Duty of Candour Info only * Please note that any + / - is due to late data entry and/or additional data validation 16

17 Specialist Division Integrated Performance Summary Divisional updates Work continues to realign the North East Lincolnshire Child & Adolescent Mental health Service (NEL CAMHS) to the new service model which is underpinned by the i-thrive model. The service redesign will incorporate both emotional wellbeing and CAMHS under one service and a service user competition for naming the service has chosen the name Young Minds Matter for this new service. Learning Disabilities services has increased its focus on stopping over medication of people with a learning disability and autism with psychotropic medicines, STOMP, with the introduction of the secondment of a Nurse Medical Prescriber to focus on a county wide roll out of this national agenda. The project goes fully live from April 18 and will support and continue previous work already undertaken in the East Hub facilitated by Dr Speight and the team. Operational Exceptions 100% 90% 80% 70% 60% 50% 40% 30% 20% 10% 0% Lincs CAMHS Looked After Children % of patients seen in month who were seen or offered an appointment within 4 weeks vs 95% target Issue Lincolnshire CAMHS waiting times Looked After Children (scorecard line 46 ) March s achievement is 50%, which reflects that 1 out of 2 referrals were seen within the targeted time. The 1 referral that breached was within the Lincoln Team at 4.7 weeks. The young person who was not seen within the 4 week target is in an out of county placement. Commissioners had requested a comprehensive assessment of need and support required in order to review whether her needs could be met within a Lincolnshire placement. Due to the specific request and nature of presenting problems it was agreed that they would require two experienced workers in both LAC and attachment to undertake the assessment, this combined with the need to see the patient out of county resulted in a delay that led to the 4.7 week wait. Lead: Service Manager, Community CAMHs Specialist Division 17

18 100% 90% 80% 70% 60% 50% 40% 30% 20% 10% 0% NEL CAMHS Urgent Referrals % of urgent patients seen within 5 days vs 95% target Issue NELincs CAMHS waiting times (Urgent referrals seen within 5 days) (scorecard line 48) March s achievement is 80%, which reflects that 8 out of 10 referrals were seen within the targeted time. Of the 2 referrals that breached, one patient did not attend their appointment and the other patient cancelled their appointment. Both of these original appointments were within the 5 day target. Lead: Service Manager, NEL CAMHS 100% 90% 80% 70% 60% 50% 40% 30% 20% 10% 0% Learning Disabilities Services Routine Referrals % of routine seen within 12 weeks vs 95% target Specialist Division 18

19 Issue LD Services waiting times (scorecard line 49) March s achievement is 92.3%. This is an increase from previous months. This reflects that 36 out of 39 LD patients seen in March were seen within 12 weeks. There were 3 breaches. Speech & Language Therapist (SaLT) vacancies continue to be the major cause of the waits. Key Actions Despite recurrent adverts we have failed to attract qualified SaLTs to the service with the most recent applicant deciding not to attend for interview. The plan to address this continuing issue is, to train the physical health care liaison nurses to undertake dysphagia triage utilising a service developed risk tool, with a view to reduce demand on the SaLT. Additional to this, we are looking to undertake fixed term recruitment of SaLT assistant posts at Band 4 to work with people with less complex SaLT needs and provide targeted pieces of work. The Assistant SaLT job description is being developed. Timescale: Dysphagia triage training taking place during April 18 Lead: Service Manager, Learning Disability Services Issue PbR Compliance Assigned clusters & Reviewed clusters (scorecard lines 50 & 51) The % of the Division s eligible caseload assigned to a cluster is below the target of 96%. Current compliance is 85.3%. The % of patients in scope with an in date cluster review is below the target of 96%. Current compliance is 91.5%. Key Actions Work between the division and informatics have identified anomalies within the report which has been including non-pbr service within the divisional figures. This data cleansing exercise will result in an improvement in meeting targets. Quality and Safety Early Warning Tool Ash Villa continues to have an inexperienced developing staff group with frequent movement of experienced staff to community posts. The most recent advert for the vacant Band 6 posts has attracted a number of candidates and interviews are planned for 2 nd May. The ward manager is currently working with the divisional management team to look at innovative ways of attracting even higher advanced clinical skills to the nursing team. The acuity on the unit continues to be high and staffing has been running at increased fill levels to manage the presenting risks. The ward manager and service manager continue to work to ensure that staff are receiving the right level of support and leadership. NEL CAMHS is working towards implementing the new model that will be required to deliver the new contracted Young Person s Emotional Health, Wellbeing and Mental Health Services. The divisional business manager has taken on the role of project lead role to support the service in making the necessary changes in line with the new contract. Whilst this has provided increased support to the NEL contract it has left the rest of the division with decreased input from the business manager role. The target work previously reported over waiting times in Lincolnshire CAMHS continues to show real signs of progress. The service manager is working closely to support both the team managers and teams in continuing the work they have started to address this issue. Specialist Division 19

20 Learning Disabilities Services continue to experience difficulties in recruiting and retaining Speech and Language Therapists (SaLT), this is impacting on service responsiveness and adversely affecting waits for those people who require this element of the service. The service is looking at innovative ways to bridge the gap by introducing dysphagia triage by the physical health liaison nurses and band 4 SaLT assistants. Healthy Minds continue to see increasing demand, with referrals much higher than anticipated, creating waits within the system. The service is working closely with commissioners to review capacity and demand, with a view to creating a joint strategy to address the developing situation of growing waiting times. There are currently no concerns within the Adult Eating Disorder Service or the Low Secure Unit (LSU). Complaints & Friends & Family Test (scorecard lines 62, 63 & 65) Specialist Services Complaints - April March Apr-17 May-17 Jun-17 Jul-17 Aug-17 Sep-17 Oct-17 Nov-17 Dec-17 Jan-18 Feb-18 Mar-18 Median Patient/Carer Expressions of Satisfaction 84 The response rate for FFT remains below the Trust target of 20%. It was 5% for March The tools for CAMHS experience of service questionnaire that contains the friends and family test has now been agreed and the standardised tool was uploaded onto the envoy system at the beginning of April. Services will now undertake a back dating of questionnaires onto the system that have been collated whilst waiting for the correct tool to be available. Workforce Mandatory training (scorecard line 53) Work continues to ensure that peoples training is accurately reported in a timely way within the report. Team managers are reviewing training compliance within supervision records and working with Learning and Development department to ensure staff are aligned to the right competencies. % Staff Appraisals (scorecard line 56) Work continues to ensure that staff appraisal is accurately reported in a timely way within the report. Local records evidence that staff are showing as having had their appraisal but there is often a time lag before this shows within the report. Safe Staffing (scorecard lines 58 & 59) Ash Villa has continued to run with increased staffing due to the acuity of the service users on the Unit. Specialist Division 20

21 Adult Community Mental Health Division Scorecard Divisional Performance Metrics Historical data Dec Final Jan Final Feb Final Decr - / Incr + % on Primary vs Final Data* Latest Data Mar '18 Same Month previous year Target Adult Community Division Scorecard Operational Performance Metrics Lincolnshire Steps2Change East CCG Recovery rate 51.6% 54.4% 50.5% 52.7% 55.0% 50% 70 Lincolnshire Steps2Change East CCG Access rate 16.9% 19.2% 16.0% 16.1% 15.0% 15% 71 Lincolnshire Steps2Change West CCG Recovery rate 56.3% 50.0% 58.6% 51.3% 51.6% 50% 72 Lincolnshire Steps2Change West CCG Access rate 11.8% 19.2% 19.4% 17.0% 17.2% 15% 73 Lincolnshire Steps2Change South CCG Recovery rate 59.0% 52.5% 52.7% 60.8% 58.1% 50% 74 Lincolnshire Steps2Change South CCG Access rate 18.3% 20.5% 18.8% 19.9% 16.5% 15% 75 Lincolnshire Steps2Change South West CCG Recovery rate 62.4% 63.7% 58.1% 65.5% 61.8% 50% 76 Lincolnshire Steps2Change South West CCG Access rate 19.8% 21.6% 15.8% 14.1% 19.2% 15% 77 PbR Compliance - % of eligible caseload assigned to a cluster (added April 2018) 91.6% 91.6% 96% 78 PbR Compliance - % of patients in scope with an in date cluster review (added March 2018) 78.3% 80.0% 96% Workforce and Efficiency Mandatory training compliance 89.8% 89.7% 91.2% 0.0% 93.1% 96.5% 95% 81 % sickness absence 7.2% 5.8% 5.2% 0.0% 3.9% 5.1% 4.5% 82 Vacancy factor % of WTE 92.2% 89.9% 88.3% 0.0% 89.8% 90.6% Info only 83 % staff appraisal 86.7% 87.9% 87.5% 0.0% 87.6% 94.6% 95% Quality & Safety Violence & Abuse (Patient on Patient) Info only 86 Violence & Abuse (Patient on Staff) Info only 87 Number of complaints Info only 88 Number of medication errors Info only 89 Friends and Family Test Response rate 10% 27% 31% 21% 18% 20% 90 Friends and Family Test Recommend rate 96% 94% 91% 98% 95% 71% 91 Number of Incidents requiring Duty of Candour Info only *Please note that any + / - is due to late data entry and/or additional data validation 21

22 Adult Community Mental Health Division Integrated Performance Summary Divisional Updates Work continues on the re-design of the community mental health services. A paper is to be presented to the Trust s Quality Committee in May 2018, outlining some of the challenges being faced in respect of improving patient experience, meeting the high levels of demand, integrating the outpatient function into the community mental health teams and the challenge of meeting the needs of people with complex, trauma related presentations. The latter challenge has an impact across the wider health, social care and criminal justice system. There are plans to discuss this with the Safer Lincolnshire Partnership Strategy Board and with commissioners. Operational Exceptions Issue South West CCG Access Rate (scorecard line 76) The Steps2Change teams servicing the South West CCG area have dropped below the access rate threshold in March with 14.1% against a target of 15%. This is a year-end cumulative target with expected seasonal variation across the whole year meaning there is volatility when comparing one month directly with the next. The service has no concerns with the access target projection for the year end. Key Actions Expected seasonal variation, Service Manager to monitor. Timescale Ongoing Issue PbR Compliance Assigned clusters (scorecard line 77) The current % of the Division s eligible caseload assigned to a cluster is 91.6%, which is below the target of 96%. Of those without a cluster assigned, 85% are within the Adult Outpatients Service and 6% are within the Adult Psychology Service. Key Actions Data has been sent out to all teams within the Division and will be addressed over the next 3 months Timescale Lead Person 3 months Jeremy Faint, Business Manager Quality and Safety Early Warning Tool The score for the Boston & Skegness Integrated Community Mental Health Team (ICMHT) has shown a significant increase in recent months. There are gaps within the qualified vacancies: one has since been filled and the other is being recruited to. This has led to an increase in Bank staff spend, as has staff sickness levels. There has also been a serious incident for this team in which a Bullying & Harassment investigation is currently being carried out for by an independent investigator. There are no quality & safety or patient experience metrics within the Adult Community Division which require reporting-by-exception for March Workforce There are no workforce & efficiency metrics within the Adult Community Division which require reporting-byexception for March Adult Community Mental Health Division 22

23 Adult Mental Health Inpatient Division Scorecard Divisional Performance Metrics Historical data Dec Final Jan Final Feb Final Decr - / Incr + % on Primary vs Final Data* Latest Data Mar '18 Same Month previous year Target Adult Inpatients Scorecard Operational Performance Metrics 30 day Unplanned re-admissions 1.7% 3.2% 7.7% 0.0% 7.7% 2.2% <10% 95 % of CPA patients receiving a follow up within 7 days of discharge 94.0% 96.6% 97.6% 0.0% 92.7% 97.8% 95% 96 Crisis 4 hr response times 100.0% 95.7% 95.5% 0.0% 95.1% 92.0% 95% 97 Delayed Transfer of Care 0.2% 0.0% 1.1% 0.0% 1.0% 9.9% 3.5% 98 Crisis Gate-keeping 98.0% 98.0% 98.1% 0.0% 98.0% 96.4% 95% 99 PbR Compliance - % of eligible caseload assigned to a cluster (added April 2018) 89.9% 90.4% 96% 100 PbR Compliance - % of patients in scope with an in date cluster review (added March 2018) 88.6% 94.6% 96% Workforce and Efficiency Mandatory training compliance 82.7% 82.9% 85.3% 0.0% 85.7% 91.0% 95% 103 % sickness absence 5.7% 5.4% 4.2% 0.0% 5.1% 6.1% 4.5% 104 Vacancy factor % of WTE 91.9% 86.7% 88.6% 0.0% 89.6% 94.4% Info only 105 % staff appraisal 80.8% 83.3% 82.2% 0.0% 85.0% 93.2% 95% Quality & Safety Safe staffing - Average % fill rate DAY 100.7% 94.2% 98.8% 97.8% 100.4% Info only 108 Safe staffing - Average % fill rate NIGHT 104.4% 95.2% 95.2% 103.8% 103.9% Info only 109 Violence & Abuse (Patient on Patient) Info only 110 Violence & Abuse (Patient on Staff) Info only 111 Number of complaints Info only 112 Number of medication errors Info only 113 No. of Falls (inpatients) Info only 114 Friends and Family Test Response rate 8% 5% 9% 11% 2% 20% 115 Friends and Family Test Recommend rate 87% 90% 88% 88% 72% 71% 116 Number of Incidents requiring Duty of Candour Info only *Please note that any + / - is due to late data entry and/or additional data validation 23

24 Adult Mental Health Inpatient Division Integrated Performance Summary Divisional Updates The rehabilitation wards have their AIMS accreditation visits this month and are awaiting the outcome of this review. The division has appointed a very experienced manager into a six month pilot as Carer Lead within inpatient services. A police lead for mental health from the Australian Federal Police in Canberra is visiting Lincolnshire to talk about our crisis and police liaison work and how they could develop a similar model. Operational Exceptions 100% 7 Day Follow Up % of CPA patients receiving a 7 Day Follow Up vs target of 95% 80% 60% 40% 20% 0% Mar-17 Apr-17 May-17 Jun-17 Jul-17 Aug-17 Sep-17 Oct-17 Nov-17 Dec-17 Jan-18 Feb-18 Mar-18 Issue % of CPA patients receiving a follow up within 7 days of discharge (scorecard line 95) For March this was 92.7%. There were 4 breaches in total: 3 of the breaches were patients who were sent to prison on discharge; 1 breach was down to a wrong address on Silverlink and also a delay in obtaining an interpreter. Key Actions Where patients are escorted from the ward to court and then into custody, 7 day follow up by a community crisis team is not possible (staff cannot offer face to face or telephone contact to the patient in this circumstance). However as the patient is in the care of a statutory service (HMS Prison/police) ongoing support is assured. On transfer, the inpatient team do liaise to ensure that the psychiatric history is known. With regards to the wrong address on Silverlink, work with all staff including admin to ensure accurate information related to the patient is continuing. The divisional Silverlink super-user group includes this as a regular agenda item. Timescale Lead Person Monthly Monitoring Crisis Resolution & Home Treatment Service Lead Adult Mental Health Inpatient Division 24

25 Issue PbR Compliance Assigned clusters & Reviewed clusters (scorecard lines 99 & 100) The % of the Division s eligible caseload assigned to a cluster is below the target of 96%. Current compliance is 90.4%. The % of patients in scope with an in date cluster review is below the target of 96%. Current compliance is 94.6%. Key Actions The division is currently seeking more licenses for the PbR dashboard to allow more staff to access it (currently only the business manager has a licence). The issue of PbR compliance is now a standing agenda item in the monthly divisional business meeting to ensure improved performance management. Weekly reports are also sent out to teams to address performance. Timescale July 2018 Lead Person Business Manager and Service Leads Quality and Safety Early Warning Tool The Vales and Charlesworth: High vacancy levels and sickness rates continue to contribute to reduced rates of completed appraisals and mandatory training resulting in high scores for these 2 wards in February An active recruitment campaign has continued since January and some posts have since been recruited to. There are specific challenges recruiting qualified nursing staff to the division. The Divisional Management Team is working with HR to further develop recruitment and retention strategies as well as reviewing workforce requirements on specific wards (for example recruiting RGN s to each of these wards when appropriate to the skill mix of the team). The Matron for Inpatients is also working with the ward managers to identify patterns around a number of medication errors that have contributed to the high scores on the EFT and put training / support / performance plans in place to address these. International Women s Day on 8th March 2018 also marked the launch of a 12 month commitment by the Division to improve and enhance the experience of women within Adult Inpatient Services. Quality forums with staff and patients have been arranged on each of these wards as an opportunity for staff and patients to work together to recognise what is working well on the wards and suggest areas for Quality Improvement Initiatives. The first of these forums took place on the Vales on 4th April with a good level of attendance and contributions from both patients and staff. Complaints & Friends & Family Test (FFT) (scorecard lines 111 & ) There has been an increase in the number of complaints received by the division in March Whilst the Divisional response rate is below the trust target of 20% for FFT, there has been an increase from 5% to 9%. Patient/Carer Expressions of Satisfaction 3 Adult Mental Health Inpatient Division 25

26 Jun-16 Jul-16 Aug-16 Sep-16 Oct-16 Nov-16 Dec-16 Jan-17 Feb-17 Mar-17 Apr-17 May-17 Jun-17 Jul-17 Aug-17 Sep-17 Oct-17 Nov-17 Dec-17 Jan-18 Feb-18 Mar Adult Inpatients Complaints - April March Apr-17 May-17 Jun-17 Jul-17 Aug-17 Sep-17 Oct-17 Nov-17 Dec-17 Jan-18 Feb-18 Mar-18 Median What s being done about it? The tablets for survey inputting were delivered to the wards in November. Since this time there have been ongoing difficulties with connectivity that have taken some time to resolve with IT. The importance of receiving and responding to feedback from service users has been discussed at length within Divisional Quality Governance Meetings. The Crisis teams are also planning to pilot text message completion of the F&FT, wording has been agreed and consent to share information forms amended to include the receipt of text messages for this purpose. The pilot is scheduled to start this month. Complaints continue to be managed according to Trust policy and themes from complaints are being collated by the divisional Quality Lead and learning shared within monthly divisional Quality Governance meetings. Timescale Lead Person Review Monthly Quality Improvement & Assurance Lead Rapid Tranquilisation (no scorecard line) There has been a noted increase in the use of rapid tranquilisation. 25 Adult Inpatient - Use of Rapid Tranquilisation Number of occurences Mean (CL) UCL LCL Adult Mental Health Inpatient Division 26

27 What s being done about it? The increase in use of rapid tranquilisation is mostly attributable to repeated use with one patient. This patient has been assessed as appropriate for female low secure services and is awaiting admission assessment. The use of all restrictive interventions is being monitored across the division with data being provided by the Restrictive Intervention Lead on a monthly basis. Trends are analysed and discussed with individual ward managers to support on-going reduction of the use of restrictive interventions across services. Timescale Lead Person Review Monthly Quality Improvement & Assurance Lead Workforce Mandatory training & Appraisal rate (scorecard lines 102 & 105) The improving trend continues with regards to compliance for mandatory training, with March showing an achievement of 85.7% against a target of 95%. The completion rate for appraisals also shows an improvement in March of 85% against a target of 95%. Work continues in the division to improve performance. Sickness & Absence (scorecard line 103) The Division is showing an increased sickness absence rate of 5.1%, against a target of 4.5% on the previous month. This is mainly due to short term seasonal illness. Adult Mental Health Inpatient Division 27

28 Older Adult Mental Health Division Divisional Performance Metrics Historical data Dec Final Jan Final Feb Final Decr - / Incr + % on Primary vs Final Data* Latest Data Mar '18 Same Month previous year Target 117 Older Adult Scorecard 118 Operational Performance Metrics 119 Liaison - Ward referrals - % seen within 24 hours 93.1% 95.6% 97.2% 1.9% 92.5% 91.2% 90% 120 Older Adult CMHT s- % of patients seen within 18 weeks 94.8% 98.2% 94.7% 0.1% 96.3% 96.7% 95% 121 Older Adult MHSDS Priority Metrics 87.7% 89.7% 87.9% 0.0% 89.2% 85% week RTT non-admitted incomplete pathways (Consultant led, still waiting) Exc Int Referrals 86.7% 87.9% 81.8% 89.4% 92% 123 Older Adult Delayed Transfer of Care 0.5% 0.7% 6.0% 0.0% 3.6% 19.1% 3.5% 124 PbR Compliance - % of eligible caseload assigned to a cluster (added April 2018) 95.1% 95.0% 96% 125 PbR Compliance - % of patients in scope with an in date cluster review (added March 2018) 83.7% 83.0% 96% 126 Workforce and Efficiency 127 Mandatory training compliance 84.1% 85.0% 86.2% 0.0% 87.4% 91.0% 95% 128 % sickness absence 7.5% 8.5% 7.0% 0.0% 5.7% 6.5% 4.5% 129 Vacancy factor % of WTE 94.4% 89.8% 90.0% 0.0% 91.2% 94.9% Info only 130 % staff appraisal 72.0% 79.7% 79.2% 0.0% 80.7% 88.4% 95% 131 Quality & Safety 132 Safe staffing - Average % fill rate DAY 106.6% 94.2% 103.3% 103.8% 111.9% Info only 133 Safe staffing - Average % fill rate NIGHT 105.5% 95.2% 99.9% 99.9% 112.1% Info only 134 Violence & Abuse (Patient on Patient) Info only 135 Violence & Abuse (Patient on Staff) Info only 136 Number of complaints Info only 137 Number of medication errors Info only 138 No. of Falls (inpatients) Info only 139 Friends and Family Test Response rate 6% 9% 8% 9% 11% 20% 140 Friends and Family Test Recommend rate 100% 97% 92% 99% 99% 71% 141 Number of Incidents requiring Duty of Candour Info only *Please note that any + / - is due to late data entry and/or additional data validation 28

29 Older Adult Mental Health Division Integrated Performance Summary Divisional Updates Langworth Ward has been nominated for the NHS 70 Awards. Further innovation bids have been submitted for older adults to support hydration in older adults. The division management team have reviewed the community mental health patient survey by age, which shows the division met or exceeded the national average on 30 out of 39 measures: a positive reflection but lots of work will continue around patient experience, person centred care and communication. Planning work has started for the estate improvements at Brant Ward to convert the ward into single rooms and enhance the environment. The division continues to undertake engagement events on transformation plans, with initial feedback events and third sector engagement being planned. Services have seen a significant reduction in complaints - currently none in the division, and only two in the last six months. This is the result of pro-active complaints management. Operational Exceptions 15% Delayed Transfer of Care % of delayed bed days vs target of 3.5% 10% 5% % Trust target 0% Issue Delayed Transfer of Care (DToC) (Scorecard line 123) The current position is 3.6%, which is above the target of 3.5%. There was a peak of 4 patients identified where patient choice was indicated as the reason for delay in discharge. Working in conjunction with the Social Care lead, suitable accommodation was procured to the satisfaction of the patients and family. Key Action The Choice Agenda policy has been finalised and circulated to all ward managers, and key elements will be incorporated into carer information booklets to support admission processes. The Confirm and Challenge process with Senior Adult Social Care Lead to discuss and agree DToC codes continues within the service. This has supported an overall reduction in DToC within older adults and has improved communication between older adults and social care. Within the inpatient wards, interim placements are being offered in a timely manner by social services but if turned down by the patient or family member the delay then becomes a health code (choice) which impacts on performance. Ward managers are having discussions on admission with patient and carers in regards possible necessity for interim placements if delays become evident when waiting for home of choice at the earliest indication to support timely transfer and discharge and to avoid disagreements and delays. Timescale May 2018 Lead Person Alan Pattison Business Manager / Deb Blant Inpatient Service Manager 29

30 Issue PbR Compliance Assigned clusters (scorecard line 124) The current % of the Division s eligible caseload assigned to a cluster is 95%, which is below the target of 96%. Of those without a cluster assigned, the highest proportion fall into Older Adult Outpatients (24% of all unassigned patients) and the Older Adult Community Mental Health Team Spalding (21% of all unassigned patients). The service is 1% off reaching target required Key Actions The Spalding performance metrics are being closely monitored by the service manager, team coordinator and clinical director. The Stamford CPN s are now supporting the Spalding team 3 sessions per week to support timely assessments and clustering. The team s final full time post has been appointed into and will be in post by June This will have an impact on waits and associated KPI such as clustering. The Older Adult Community Service manager meets regularly with the performance and information team to review performance data and identify performance issues to support timely action. The Service Manager raises issues with medical admin to support improvements in timely clustering within outpatient services. PbR is also on the divisional risk register and actions are monitored through the divisional management meeting and supervision framework. Timescale June 2018 Lead Person Deb Blant Service Manager/ Alan Pattison Business Manager Quality and Safety Early Warning Tool There is noted improvement within the inpatient services at Manthorpe and Brant Ward. A slight deterioration at Rochford has been noted on previous performance which has been discussed with the ward manager and a plan to focus on improving on performance metrics has been developed to prevent further deterioration. MHLT have improved as has specialist psychology which was impacted by recruitment and sickness previously. There are currently no divisional concerns relating and where there have been issues the division provides targeted support from the service. Complaints (scorecard line 136) The Older Adult Division has had the smallest number of complaints within the Trust over the last 6 months (n=2). The Patient Experience Lead asked the Quality Improvement and Assurance Lead to update the board regarding complaints within the division. They explained that the team coordinators and ward managers are encouraged to manage concerns locally to avoid escalation to formal complaints. The division also undertakes weekly team huddles where any issues and difficulties are raised and support and advice is given. Ward managers escalate issues early to the quality lead and service manager to support robust management, provision of support to prevent the issues escalating into a complaint. When a number of complaints had been raised in a particular area action plans are developed and implemented to prevent similar complaints reoccurring. The divisional management is also keeping a watchful eye on the low number of complaints received. The overall performance and monitoring of complaints is monitored by the Quality lead within the division. Patient/Carer Expressions of Satisfaction 25 30

31 Friends and Family Test (scorecard lines 139 & 140) The divisional response rate of 9% is below the target of 20%. What s being done about it? The inpatient wards are performing above the target of 20% following a targeted improvement plan. The focus of the next improvement plan is community older adult services which are below target and impacting on the divisional target overall. All Community teams have been prompted to ensure that they have F&F leaflets in place and ensure these clearly identify which areas they are being sent from as this has previously been an issue which has impacted on performance figures. Team coordinators are ensuring these are given out on final visits to patients/discharge letters. The service is planning on implementing text F&F service to support teams once the pilot has been completed in adult services to support having a range of prompts for gathering feedback. Timescale June 2018 Lead Person Dawn Parker, Quality Improvement and Assurance Lead Workforce Mandatory training (scorecard line 127) The overall performance is improving in relation to training within the division. Recent recruitment on the inpatient wards through the staffing review has impacted or is likely to impact on compliance levels due to new starters appearing in figures. Ward managers and team coordinators are supporting staff to complete training through protected time and raising issues through supervision and team meetings. Sickness & Absence (scorecard line 128) The Sickness and absence figure has reduced within the division on previous month although it is recognised that the work is ongoing to meet the Trust target. The service managers are monitoring performance with ward managers and team coordinators and engage human resources to support robust management of sickness and a number of improvement notices have been issued. Significant improvements have been noted on the inpatient units particularly Manthorpe which has reduced sickness since last month and Brant has significantly improved in this area. Appraisal rate (scorecard line 130) There has been an overall improvement across the division on appraisal compliance. Significant improvement on Brant Ward compliance with appraisals from last month s figures. Lincoln MHLT and Rochford remains an outlier which has been impacted on recruitment issues and new starters. This is being monitored by the Band 7s and service managers and is compliance levels are beginning to improve overall. Lead Person Clare Kirk, Acting Service Manager Community; Deb Blant, Acting Service Manager Inpatients; Alan Pattison, Service Manager Mental Health Liaison Service 31

32 Financial summary 2017/18 YTD Summary Indicator 17/18 YTD Planned Outturn 17/18 Year End Outturn Variance % Achieved of Plan EBITDA Surplus (-)/Loss(+) ( 000's) '000 '000 '000 % -5,557-6, % Net Surplus(-)/Loss (+) ( 000's) ,137-58% Surplus(-)/Loss (+) on a Control Total Basis ( 000's) -1,143-2,337-1, % Single Oversight Finance Score Cost Improvement Target Against Delivery (- 000's) -3,339-2,263 1,076 68% Agency Staff Utilisation ( 000's) 2,139 2, % Percentage of invoices paid within 30 days per BPPC CQUIN Achievement Against Plan 82% 1,841 1, % Cash Balance ( 000's) 8,813 11,795 2, % Capital Expenditure ( 000's) 4,330 3, % The Trust s Month 12 Income and Expenditure position is a 0.4m deficit, 1.1m lower than a planned surplus of 0.7m. This is due largely to a higher than planned impairment charge following the revaluation of the Trust s Estate carried out as part of this year s annual accounts process. The Trust is monitored by NHS Improvement (NHSI) against a control total which was determined prior to the start of the financial year. This total does not include categories such as asset revaluations or impairments. On a control total basis the Trust is reporting a surplus of 2.3m for the year compared to a planned surplus of 1.1m. The Trust s year-end control total surplus includes unplanned benefits relating to Sustainability and Transformation Fund (STF) Incentive income. This funding results in Trusts receiving additional income of 1 for every 1 achieved above the control total by the end of the year. The year end values shown above include income of 0.6m relating to this incentive scheme. CIP achievement stands at 2.26m, compared to a target of 3.34m. This is an achievement of 68%. The Trust is reporting an NHSI finance score rating of 1 at the year end, in line with plan. This rating represents only the finance elements which form part of the Trust s overall rating. The BPPC requires the Trust to pay all undisputed invoices by the due date or within 30 days of receipt of goods or a valid invoice, whichever is later. The Trust aspires to pay at least 95% of invoices on time. In Month 12 the Trust paid 85% of invoices (both NHS and non NHS) within 30 days compared to 90% in Month 11. This reduction is due to a higher volume of non NHS invoices being processed at year end in comparison to February, but this figure is above the yearly average of 82%. 32

33 Agency Spend summary Agency spend has increased within Quarter 4. The Trust s spend on agency staffing for the year exceeds the cumulative monthly agency expenditure cap issued by NHSI for 2017/18 by 0.83 ( 2.97m against a capped level of 2.14m). The table below provides a high level summary of spend on agency by staff group. 2017/18 YTD Summary Type of agency 17/18 YTD Planned Outturn 17/18 YTD Actual Outturn Variance % Achieved of Plan '000 '000 '000 % Medical agency 1,197 1, % Admin & Ancillary agency % Qualified Nursing agency % Unqualified Nursing and Scientific & Therapeutic Agency % Total spend on agency 2,139 2, % 33

34 Cash Summary The Trust s year end cash balance is 11.80m compared to a planned 8.81m. This is driven by a higher opening cash balance, and the unplanned receipt of Sustainability and Transformation Funding relating to the Trust s financial performance for 2016/17. This has been further increased by lower than planned capital expenditure. This is offset by planned asset sales not materialising. Capital Summary Capital expenditure for the year was 3.50m compared to a planned 4.33m. This reduction in spend is mainly due to several planned schemes being cancelled during the year with some schemes slipping into the next financial year. This outturn position includes 0.1m of expenditure funded by Public Dividend Capital. 34