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: 29 March 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 11 (February) 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 11. 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 March 2018 Report 3

4 CONTENTS Section PAGE Trust Metrics Scorecard 5 Trust Quality & Safety Summary 6-7 Trust Patient Experience Summary 8 Trust Workforce Summary 9-12 Trust Safe Staffing Summary Specialist Division Scorecard 17 Specialist Integrated Performance Summary Adult Community Mental Health Scorecard 24 Adult Community Mental Health Integrated Performance Summary Adult Mental Health Inpatient Scorecard 27 Adult Mental Health Inpatient Integrated Performance Summary Older Adult Mental Health Scorecard 34 Older Adult Mental Health Integrated Performance Summary Finance Summary and Data Early Warning Tool

5 LPFT Integrated Scorecard Trust Performance Metrics Historical data Nov Final Dec Final Jan Final Decr - / Incr + % on Primary vs Final Data* Latest Data Feb '18 Same Month previous year Target 1 2 Single Oversight Framework Number of Never events MHSDS Identifier Metrics 99.6% 99.5% 99.7% 0.0% 99.9% 99.6% 95% 4 MHSDS Priority Metrics 84.4% 84.9% 88.7% 0.0% 88.0% 69.5% 85% 5 Cardio metabolic Inpatient 90% 6 Cardio metabolic Community 65% 7 Cardio metabolic Early Intervention 65% 8 Early Intervention Psychosis 2 week wait 57.7% 69.6% 67.7% 0.0% 84.0% 100.0% 50% 9 % of CPA patients receiving a follow up within 7 days of discharge 96.2% 94.0% 96.6% 0.0% 97.6% 90.9% 95% 10 Admissions to Adult facilities of patients aged 16 or under % Lincolnshire IAPT services Recovery rate 55.9% 56.7% 54.0% 54.7% 55.2% 50% 12 Lincolnshire IAPT services Wait from Referral to Treatment within 6 weeks 87.9% 88.3% 87.3% 83.2% 86.6% 75% 13 Lincolnshire IAPT services Wait from Referral to Treatment within 18 weeks 99.4% 99.8% 98.6% 98.6% 100.0% 95% 14 Friends and Family Test Recommend rate 86% 89% 88% 90% 92% 71% 15 % of Complaints as against Trust whole time equivalent staff numbers (New measue Nov 2017) 1% 0% 1% 0% Info only 16 % sickness absence 5.0% 5.3% 5.1% 0.0% 4.4% 4.6% 4.5% 17 Finance Score Agency Spend compared to Agency cap ( 000's) Info only 19 Net Income and expenditure ( 000) Cash balance ( m) 12,117 11, Non Single Oversight Framework PbR Compliance - % of patients in scope with an in date cluster review (added March 2018) 81.7% 96% 23 Crisis Gate-keeping 97.6% 98.0% 98.0% 0.0% 98.1% 96.7% 95% day Unplanned re-admissions 10.3% 1.7% 3.2% 0.0% 7.7% 5.4% <10% 25 Whistle Blowing (New Cases in the month) Info only 26 Lincolnshire IAPT services Access rate 19.5% 16.1% 19.8% 17.6% 16.3% 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 98.2% 97.7% 97.7% 0.0% 96.2% 95% week RTT non-admitted incomplete pathways (Consultant led, still waiting) Incl Int Referrals 92.6% 91.1% 91.2% 0.0% 90.5% Info only week RTT non-admitted incomplete pathways (Consultant led, still waiting) Exc Int Referrals 95.2% 92.8% 92.6% 0.0% 92.2% 93.9% 92% 32 Zero tolerance RTT waits over 52 weeks % 0 0 0% 33 Delayed Transfer of Care - Trust Position 1.8% 0.3% 0.2% 0.0% 2.5% 10.8% 3.5% 34 % of CPA patients with a formal review within the last 12 months 95.1% 95.7% 96.5% 0.0% 95.1% 95.0% 95% 35 % Compliance with CQUINS (Forecast) 91% 92% 92% 100% 36 % Complaints % compliance with plan 75% 82% 90% 96% 100% 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 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 Trust Quality & Safety Summary All aspects of quality and safety continue to be monitored by the Quality and Safety Team to identify any themes, trends, exceptions and actions taken to address any issues highlighted. February 2018 showed an overall small reduction in Patient to Staff incidents of violence, abuse and harassment (VAH) (n=80). The Specialist Services Division reported 15 patient to staff incidents of VAH. For comparison 11 incidents have been reported during the period January 2017 December 2017, and 13 in January The Older Adults Mental Health division reported a reduction in the number of Patient to Patient incidents of VAH, with 42 reported in January 2018 and 23 reported in February There were 9 serious incidents reported in February Six occurred in February 2018 and of these 3 occurred in the Adult Mental Health Inpatient Division, 2 in the Adult Community Mental Health Division and 1 in the Older Adult Mental Health Division. Of the remaining 3 incidents reported: 2 occurred in January 2018 within ACMH and 1 in November 2017 within AMHI Number of Serious Incidents (SIs) and Number of Incidents February February 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 Number of which are SIs Number of Incidents There is an overall upward trend in the number of self-injurious behaviour (SIB) across the Trust. More detailed analysis is provided within the Divisional sections of this report. Self Injurious Behaviour - LPFT Total February February There were 20 Patient to Inanimate Object incidents reported across the Trust. Details of these incidents are provided in the Divisional breakdowns. 6

7 Trust Quality & Safety Hotspot Violence, Abuse & Harassment (VAH) It has been agreed that twice each year, a hotspot themed report will be presented to the Board of Directors, through the Integrated Performance Report, with a focus on one of four quality and safety themes. This month s hotspot report is in respect of Violence, Abuse and Harassment. Reports will follow in subsequent months on falls, the use of restrictive interventions, and medication errors. Trust Wide The Seclusion Policy has been reviewed with seclusion plans being included in the sequential paperwork utilised during each episode of seclusion. The facility has been provided for every patient who is secluded to have a care plan formulated. Concordance with policy will be monitored through the 6 monthly seclusion audits. The reporting function on Datix was reviewed in January 2018 and has resulted in the increased accuracy and quality of data, which will allow for targeted work to commence. Due to the improvement in Datix reporting the Trust is now able to demonstrate where de-escalation occurs in the designated areas i.e. extra care area/de-escalation room. This is in response to concerns raised by the CQC in the comprehensive inspection 2017 regarding the lack of monitoring of extra care areas in older adults. Lead Restrictive Intervention Team Leader Adult Mental Health Inpatient Division A review of the Psychiatric Intensive Care Unit (PICU) service is being undertaken that has included interviews with staff and patients, a review of the physical environment, and a review of current guidance / literature in relation to PICU services. Information collected to date suggests that a number of factors may contribute to the number of incidents of VAH including: aspects of the physical ward environment (most notably the size of communal spaces); patient perceptions of restrictions in place on the ward; and inconsistency in staff responses to patients at times. A factor that may be protective in reducing incidents of VAH has been identified as the range and frequency of meaningful activities available to the patients. Examples of what is being done to reduce and respond to incidents of VAH include: A piece of work led by the ward manager to identify and reduce the blanket restrictions on the ward and increase staff awareness of individualised risk management plans. Dedicated psychology input for the service to facilitate formulations of individual patient needs, risks, and risk management plans. Reflective practise encouraged across the unit with staff encouraged to reflect on, and learn from, interactions with patients. Debrief training is being offered to staff within the division in March 2018 to support staff following incidents of VAH. In addition to the work being undertaken with the PICU, specific work is being undertaken with the women s wards (as Charlesworth and the Vales account for 26% of the incidents reported within the division) to further develop access to meaningful activity and sensory aware environments to support a reduction in incidents of VAH. Lead Quality Improvement & Assurance Lead, Adult Mental Health Inpatient Division 7

8 Trust Patient Experience Summary In February the Trust received 7 complaints (the lowest number of complaints received in one month for 2017/18), 6 of these were regarding the Adult Community Mental Health Division and 1 regarding the Adult Mental Health Inpatient Division. These are covered in more detail within the Divisional summaries. The Trust s compliance against complaint timeframe plan was 96% against a target of 90%. Whilst response times are one quality indicator in complaint management, another important aspect is the quality of the response. Of the 14 open complaints, 6 complainants have agreed an extension to allow an in-depth comprehensive investigation and resolution. One complaint was 1 day overdue and has since been closed. The other complaints that were overdue were due to face to face meetings being arranged and undertaken (3), delays in staff responses (2), awaiting information from another Trust as the complaint was a joint one (1) and a 1 day delay in the final response letter being sent (1). The number of reopened complaints continues to show a downward trend (0 reopened in February) which indicates that people are satisfied with their original responses and therefore investigations have become more thorough and person centred. Friends and Family Test (FFT) ratings for all community teams was 91% satisfaction from a 14% response rate and for all inpatient wards, an 81% satisfaction rate from a 73% response rate. The Trust wide percentage of people who would recommend our services in February is 86%. 8

9 Trust Workforce Summary Sickness Absence The Trust s overall sickness has decreased by 0.76% from 5.13% to 4.37%. There have been significant decreases in days lost due to; Cold, Cough, Flu ( ), Gastrointestinal Problems ( ) and Back Problems (-90.54). Cumulative sickness has reduced from 4.99% to 4.96%. The below table demonstrates the areas where sickness is above 5% (based on rolling year). Service Number in Post Turnover Sickness Absence % Month Sickness Absence % Cumulative Ranking # Adult Inpatient Rehabilitation % 6.32% 8.48% 1 Specialist Eating Disorders % 1.33% 7.81% 2 Older Adult Liaison % 3.90% 7.75% 3 Specialist Learning Disabilities % 6.38% 7.06% 4 Adult Community Complex & Forensic Community Service % 3.36% 6.83% 5 Older Adult OA Inpatient % 7.83% 6.76% 6 Adult Community Community Services IAPT % 5.59% 6.65% 7 Adult Community Principal Social Worker % 8.37% 6.43% 8 Adult Community Therapy Services % 5.53% 5.82% 9 Adult Inpatient Forensic Inpatient % 6.98% 5.68% 10 Adult Community ICMHT % 4.76% 5.63% 11 Adult Inpatient Acute Inpatient % 3.66% 5.59% 12 Older Adult OA Community % 5.83% 5.50% 13 Human Resources are fully involved and aware of sickness absence cases within the services. Each Service area has a dedicated HR advisor and monthly sickness reports regarding both episodic and long term sickness are reviewed by HR and management. 9

10 The below actions have taken place in the last 2 months. No corporate services currently feature in sickness hot spots. Service Older Adults Adult Inpatient Adult Community Older Adult Action Long term sickness meetings: Brant 3 (1 still absent, 2 back at work) Langworth 2 ( 1 still absent, 1 back at work) Manthorpe 1 (back at work) Stage 1 meetings: Manthorpe 1 meeting held and stage 1 improvement notice issued Informal Sickness Reviews held 13 Occupational Health (OH) referrals 7 Staff Wellbeing Service (SWS) referrals 8 Rehabilitation Long term sickness meetings: 1 (Wolds) contract terminated under ill health Stage 1 Improvement Notice: 1 (Wolds) extension of stage 1 Informal Sickness Reviews Advised 20 Occupational Health (OH) referrals - 5 Staff Wellbeing Service (SWS) referrals 4 Steps2Change Informal Sickness Review meeting - 6 Long term sickness meeting - 1 Stage 1 improvement notice issued - 3 Stage 2 improvement notice issued -0 OA Liaison This was due to long term sickness of a staff member during an organisational change process due to the closure of the Peterborough liaison service. Acute Inpatient Long term sickness meetings: 1 (Charlesworth) due to return 1 (Ward 12) Scheduled Informal Sickness Reviews Advised 13 Occupational Health (OH) referrals 3 Staff Wellbeing Service (SWS) referrals - 2 CMHT Informal Sickness Reviews - 6 OH - 4 SWS - 3 Physio 1 OH - 1 SWS - 3 Physio - 2 S75 Social care 1 employee has received treatment for a long term condition and now returned back from long term sickness, and being supported to remain in work. No long term sickness all staff being managed in terms of short term absences. 10

11 Pharmacy Long term sickness meetings: 0 Stage 1 Improvement Notice:0 Informal Sickness Reviews Advised 1 Occupational Health (OH) referrals - 0 Staff Wellbeing Service (SWS) referrals 0 Specialist *Previously had some staff off on Long Term sickness. All now returned. Specialist 4 long term cases within the Learning Disability service, all being managed by Staff Wellbeing Service and manager. 2 of staff have returned to work. 1 LTS meeting planned in March, final absent staff member underwent surgery in December so is still in recovery. Mandatory Training The mandatory training figure has increased from 86% in January to 88% in February Appraisal The appraisal rate has decreased from 82.6% in January to 80.97% in February Vacancy Rate The Trust s overall vacancies have increased in the last few months to 10.03%. The increase in the vacancy rate has been caused by a combination of an increase in the funded establishment, and a decrease in the actual establishment, particularly during January During January, the funded establishment increased from in December, to (predominantly because the establishments were entered for PCDU). The actual staffing numbers dropped from to due to the large number of leavers that we had during the month. These two factors resulted in the increase in the vacancy rate from 7.47% to 10.37%. The vacancy rate has dropped slightly during February to 10.08% because of a slight increase in the actual numbers employed. 11

12 Turnover The overall turnover figure has decreased from 15.8% to 15.04%. That said turnover remains high and plans have been agreed to improve our retention rate. Employee Relations (ER) Cases As at 28 February LPFT had a headcount of 1967 and the employee relation ratios continue to be low overall albeit with a small rise in bullying and harassment cases 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 obtained from Safe care* (*software that pulls information from the Health Roster and combines it with patient dependency data [dependency level 1 is lower dependency and 5 higher 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 February 2018 as follows: Ward Exception Report Staffing level Amalgamated RN/HCSW Total Monthly Planned Hours RN Total Monthly Actual Hours RN Total Monthly Planned Hours HCSW Total Monthly Actual Hours HCSW Dependency* (1- lowest & 5 - highest) Bed Occupancy Rationale Ash Villa (CAMHS Mixed Sex) 145.6% HCSW (days) 126.1% RN (nights) 124.8% HCSW (nights) ( ) ( ) Dependency 3-5 Bed occupancy x RN vacancies, 1 x HCSW vacancy 1 x RN redeployed for HR reason, 1 x RN maternity leave 1 x long term sickness, 4 x short term sickness Annual leave within headroom Additional duties created for RN and HCSW due to increased dependency of patient group. Increased levels of violence and aggression, increased self-harm incidents 2 x naso-gastric feeding requiring restrictive intervention (RI), one of whom is waiting transfer to PICU. Ashley House (Adult Rehab Mixed Sex) 125.4% RN (days) 78.9% HCSW (days) ( ) ( ) Dependency 2-4 Bed occupancy x RN worked supernumerary due to physical injury 1 x HCSW long term sickness Substantive RNs working HCSW shifts 2 x HCSW bank shifts covered by RN Urgent admission from locked rehabilitation 13

14 Francis Willis Unit Adult Low Secure Male) 117.7% HCSW (nights) (-6.5) ( ) Dependency 4-5 Bed occupancy x RN vacancies, adverts out since December x HCSW vacancy, interviews planned for March x RN long term sickness 5 episodes of seclusion 1 x new admission requiring increased observations Ward 12 (Adult Acute Mixed Sex) 116.9% HCSW (nights) (+13.92) ( ) Dependency 3-5 Bed occupancy x RN and 2 x HCSW short term sickness 1 x HCSW long term sickness 23% headroom exceeded by annual leave 1 x Band 6 vacancy 3.8 Band 5 vacancies 2 Band 2 vacancies Increase in observations and a seclusion incident requiring additional staffing The Fens (Adult Locked Rehab Male) 116.1% RN (days) 89.2% HCSW (days) ( ) ( ) Dependency 3-5 Bed occupancy 15 Substantive RNs working HCSW shifts 1 x band 6 vacancy 1 band 2 vacancy 2 x HCSW short term sick 1 x HCSW Long term sick Out of area escort and increased observations requiring additional staffing The Vales (Adult Locked Rehab Female) 87.8% RN (days) (-72.5) ( ) Dependency 3-5 Bed occupancy x RN vacancies, 2 x maternity, 1 x long term sickness 2 x HCSW vacancies, 1 x maternity, 1 x supernumerary for physical health reason 23% headroom exceeded by annual leave 2 x new admissions and high levels of self-harm requiring additional staffing and increased observations 14

15 Charlesworth Ward (Adult Acute Female) 77.4% RN (days) 85.7% RN (nights) 132.3% HCSW (nights) ( ) ( ) Dependency 2-5 Bed occupancy x RN vacancies, no applicants 4 x HCSW vacancies, 2 new starters in March 2018, 1 April 2018, 1 out to advert 1 x RN and 1 x HCSW long term sickness, seeking advice from occupational health regarding return to work for RN Increase in observations requiring additional HCSW shifts, 1 x 2:1 observations Not able to fill second RN on nights due to vacancies so these filled with HCSW Ward manager in staffing numbers regularly and this is not reflected on Healthroster What is being done about it? It is worth noting that February 2018 was the beginning of inclement weather which caused some wards to have additional staffing added to their ward template due to staff staying overnight in their workplace. Since July 2017 the Trust has been working with NHS Improvement s (NHSI) 90 day rapid improvement initiative focused on rostering. This work has already resulted in improved rostering and a reduction in unused hours. As this work progresses, it is anticipated that it will continue to impact positively on Bank and Agency usage. Healthroster team have begun to roll this work out across all inpatient wards and have begun to make necessary changes to rosters based on staffing need. The plan is to revisit each ward and continue to revise roster templates as necessary to meet demand. Staffing adjustment recommendations from the last in-patient safe staffing review (Trust Board October 2017), based on evidence based metrics for staffing ratio and numbers, are being implemented. It will, however, be a number of months before the impact of these adjustments will be seen due to the time taken for recruitment. Successful recruitment and retention remains a priority to support achieving safe staffing across in-patient units. As yet, not all of the posts have been recruited to but are out to advert. Work is underway to prepare for the first wave Nursing Associate (NA) trainees registering with the NMC and coming into the workforce from January 2019; and clinical divisions are identifying opportunities for this new role to support their workforce safe staffing from 2019 onwards. Close working with clinical leads to achieve consistent dependency assessment using Safecare continues, to enable best use of this data in staffing forecasting and planning. Work is planned to engage Ash Villa in maintaining a consistent approach to recording Safecare dependency. Extending some of the functionality of Safecare has been completed; and tasks are now recorded accurately and account for activities such as staff escort and observation duties. Initiatives to support recruitment to the Trust s Bank Staffing Unit (BSU) continue. Staffing adjustments have been made within the Adult In-patient Division s rehabilitation units (Maple Lodge and Ashley House) and it is anticipated the exception reporting for high RN usage will reduce gradually over the coming months as a result of this. One RN at Maple Lodge has retired. One RN at Ashley House has been redeployed to Grantham CRHT. 15

16 In-patient safe staffing reviews are held on a six monthly basis to review staffing requirements; and the safe staffing review (March 2018) is currently underway. Early indications are that no further adjustment to staffing numbers are likely to be recommended. This is in part due to the clinical divisions still working to fully recruit to the additionally funded posts agreed following the last safe staffing review (September 2017). A full briefing report on the March 2018 in-patient safe staffing review will be tabled by the Director of Nursing, AHPs and Quality at the next Trust Board (May 2018). The Specialist Services Division s management team are working closely with commissioners to problem-solve issues including out of area CAMHS admissions that require transfer to CAMHS PICU. Charlesworth Ward has met with the Carter Project Team to review their staffing template; and adjustments have been made to correctly reflect the staffing requirements for the ward on Healthroster. This adjustment will be reflected from April 2018 in the ward s safe staffing reports. 16

17 Specialist Division Scorecard Divisional Performance Metrics Nov Final Dec Final Historical data Jan Final Decr - / Incr + % on Primary vs Final Data* Latest Data Feb '18 Same Month previous year Target Specialist Services Scorecard Operational Performance Metrics Lincolnshire CAMHS waiting times (Emergency referrals seen or offered within 24 hours) 100.0% 100.0% 80.0% 13.4% 100.0% 77.8% 95% 44 Lincolnshire CAMHS waiting times (Urgent referrals seen or offered within 72 hours) 98.6% 86.3% 95.6% 4.6% 100.0% 80.4% 95% 45 Lincolnshire CAMHS waiting times (Routine referrals seen or offered within 6 weeks) 72.0% 77.0% 69.8% 4.1% 83.6% 57.8% 95% 46 Lincolnshire CAMHS waiting times (Looked after Children seen or offered within 4 weeks) 100.0% 100.0% 83.3% -16.7% 87.5% 57.1% 95% 47 Lincs CAMHS DNA rates (clinical appointments) 11.8% 13.5% 10.6% 0.0% 12.2% Info only 48 NELincs CAMHS waiting times (Urgent referrals seen within 5 days) 80.0% 60.0% 100.0% 0.0% 100.0% 90.0% 95% 49 LD Services waiting times (Routine referrals seen within 12 weeks) 88.3% 90.9% 85.7% 2.4% 82.8% 73.6% 95% 50 PbR Compliance - % of patients in scope with an in date cluster review (added March 2018) 93.7% 96% Workforce and Efficiency Mandatory training compliance 89.7% 90.7% 88.6% 0.0% 90.1% 94.0% 95% 53 % sickness absence 3.9% 3.9% 4.5% 0.0% 3.8% 4.2% 4.5% 54 Vacancy factor % of WTE 94.3% 95.2% 93.2% 0.0% 93.4% 102.3% Info only 55 % staff appraisal 91.7% 90.4% 91.2% 0.0% 90.3% 93.7% 95% Quality & Safety Safe staffing - Average % fill rate DAY 105.0% 114.3% 97.1% 131.0% 91.5% Info only 58 Safe staffing - Average % fill rate NIGHT 102.1% 108.2% 99.9% 125.1% 100.4% Info only 59 Violence & Abuse (Patient on Patient) Info only 60 Violence & Abuse (Patient on Staff) Info only 61 Friends and Family Test Response rate 25% 19% 18% 10% 21% 20% 62 Friends and Family Test Recommend rate 90% 88% 81% 85% 83% 71% 63 Number of medication errors Info only 64 Number of complaints Info only 65 Number of Incidents requiring Duty of Candour Info only * Please note that any + / - is due to late data entry and/or additional data validation 17

18 Specialist Division Integrated Performance Summary Divisional updates There is significant improvement in CAMHs waits, with CAMHs crisis data not reflected in this report as they are on target this month. Similarly, NEL, Eating Disorders, Lincolnshire Secure Unit and Healthy Minds are all meeting their contractual targets and receiving very positive feedback from service users and commissioners. The Healthy Minds Service continues to be inundated with referrals and the 6 month review with commissioners will facilitate a discussion around how we might manage this demand. The implementation of the new model of care to include Children and Young Peoples Mental Health and Emotional Well-being in North East Lincolnshire is placing a significant demand on the division and a decision has been taken for the divisional business manager to take dedicated time out to project manage the implementation, as there is no back-fill for her this will have a knock-on impact on the division. Operational Exceptions Issue Lincolnshire CAMHS waiting times - Routine (Scorecard line 45) February s achievement is 86.4%. This is an increase from the previous month. The associated action plan for this was given within the Integrated Performance Report in February 2018, where it was noted that the exception would next be reported on fully in May This is a significant improvement in performance and continues to be on trajectory for achievement in May, however there may be a slight drop for March/April as a number of appointments were cancelled due to the adverse weather. Lead Service Manager, Community CAMHs Specialist Division 18

19 Issue Lincolnshire CAMHS waiting times Looked After Children (Scorecard line 46) January s achievement was reported as 100% (5 out of 5 referrals). The refreshed report gives an achievement of 83.3% (5 out of 6 referrals). There has been some late data entry and the referral that was entered late had been a breach. February s achievement is 87.5%, which reflects that 7 out of 8 referrals were seen within the targeted time. The 1 referral that breached was within the Boston team. Lead Service Manager, Community CAMHs Specialist Division 19

20 Learning Disabilities Services Routine Referrals % of routine seen within 12 weeks vs 95% target 100% 90% 80% 70% 60% 50% 40% 30% 20% 10% 0% Issue Learning Disabilities Service waiting times (Scorecard line 49) February s achievement is 82.8%. This is a decrease from previous months. This reflects that 24 out of 29 LD patients seen in February were seen within 12 weeks. There were 5 breaches. 4 of these were Speech and Language Therapy breaches due to two full time vacancies out to advert. We have had one applicant and the closing date is The service has been looking at linking in to De Montfort University for newly qualified but as yet haven t had much response. The service is developing a risk tool to help prioritise the dysphagia referrals to ensure urgent referrals are seen quickly. The communication referrals will be considered in a different way. Lead Service Manager, Learning Disability Services Issue PbR Compliance (Scorecard line 50) The % of patients in scope with an in date cluster review is below the target of 96%. Compliance as at 2 March 2018 is 93.7%. Lead Service Managers Specialist Division 20

21 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 unit continues to have difficulties in attracting experienced Band 6 staff to the unit and the ward manager is currently working with the divisional management team to look at innovative ways of attracting advanced clinical skills to the nursing team. The acuity on the unit continues which further compounds the issues around inexperienced staff. 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 over a 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 has started to show real signs of progress. The service manager continues to work closely to support both the team managers and teams in continuing the work they have started to address this issue. Staffing has slightly improved with vacancies being appointed to but still waiting for some staff to physically start. Learning Disabilities Services continue to experience difficulties in recruiting and retaining Speech and Language Therapists, this is impacting on service responsiveness and adversely affecting waits for those people who require this element of the service. Despite working closely with the recruitment team, we are currently unable to attract people to these posts. There are currently no concerns within the Adult Eating Disorder Service, Healthy Minds, or the Low Secure Unit (LSU). Complaints & Friends & Family Test (scorecard lines 61, 62 & 64) Specialist Services Complaints - April February Apr-17 May-17 Jun-17 Jul-17 Aug-17 Sep-17 Oct-17 Nov-17 Dec-17 Jan-18 Feb-18 Median Patient/Carer Expressions of Satisfaction 74 The division continues to work with Envoy and the Patient Experience department to get a single agreed Experience of Service questionnaire for feedback. Incidents of Violence, Abuse & Harassment (scorecard lines 59-60) There were 26 VAH incidents reported overall in Specialist Division (patient to patient, patient to staff and patient to inanimate object). 24 occurred at Ash Villa, 1 CAMHS Grantham Core and 1 Learning Disabilities Community Hub West. 13 were physical assaults to staff, 2 verbal to staff, 7 patient to inanimate object, 2 patient to patient verbal and 2 patient to patient physical. Specialist Division 21

22 Of the 24 incidents at Ash Villa, there were 4 patients involved with 1 patient attributable to 17 incidents. All incidents resulted in no harm. This reflects the current cohort of patients on the unit at the moment, 2 patients from outside of Lincolnshire have been identified as needing specialist placements; however there is not a unit in the country which will accept them. It is hoped that with the NHSE commissioning of specialist PICU and ED beds in Midlands and East region contracts to be commenced on 1 st April, these very complex patients from East Mids will be more appropriately placed. Lead Person Service Manager, Complex CAMHs Self-Neglect (no scorecard line) There were 70 incidents reported under the Datix category of self-neglect, sub categories of refused treatment and dietary.69 occurred at Ash Villa and related to Nasogastric Feeding. 68 of the incidents involved RI (5 supine, 62 seated and 1 kneeling). The 69 incidents were attributable to 3 patients and of those, 49 incidents were attributable to 1 patient and 19 to another patient. What s being done about it? The RI clinical team leader is attending Ash Villa to work with the staff team and ensure that the correct techniques are being used for NG tube feeding, in close liaison with the unit s Physical Healthcare Practitioner. This reflects the current cohort of patients on the unit at the moment, 2 patients from outside of Lincolnshire have been identified as needing specialist placements; however there is not a unit in the country which will accept them. It is hoped that with the NHSE commissioning of specialist PICU and ED beds in Midlands and East region contracts to be commenced on 1 st April, these very complex patients from East Mids will be more appropriately placed. Lead Person Service Manager, Complex CAMHs Self-Injurious Behaviour (no scorecard line) What s the issue? There is an emerging upward trend of self-injurious behaviour (n=52), 51 incidents occurred on Ash Villa. 48 of these were actual self-harm and 3 of these were attempted self-harm. Of the 52 incidents within the Division, 25 incidents were ligation without a fixed point, 2 were head banging, 19 were self-harm, 4 attempted self-harm and 2 punching. Of the 25 ligature incidents, there were 6 patients involved with 1 patient attributable to 9 and another to incidents resulted in low harm and 37 in no harm. Detailed analysis undertaken by the Quality and Safety Team to look at timing of the incidents has identified that from March 2017 to February 2018, 79% (n=177) of incidents occurred between 18:00 and 00:00. Specialist Division 22

23 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 Ash Villa Actual Self Injurious Behaviour (exc. attempted self harm) February February Number of Patients Number of Incidents What s being done about it? This reflects the current cohort of patients on the unit at the moment, 2 patients from outside of Lincolnshire have been identified as needing specialist placements; however there is not a unit in the country which will accept them. It is hoped that with the NHSE commissioning of specialist PICU and ED beds in Midlands and East region contracts to be commenced on 1 st April, these very complex patients from East Mids will be more appropriately placed. Lead Person Service Manager, Complex CAMHs Workforce Mandatory training (scorecard line 52) Compliance for February is 90.1% against a target of 95%. Training data continues to not reflect the evidence from the teams. The business manager has met with Kay Gilman to look at the issues. It is hoped that the return to training being delivered through ESR with automated upload will address this issue. Sickness & Absence (scorecard line 53) The absence rate for February is 3.8% against a target of 4.5%. The division continues to exceed this target. Appraisal rate (scorecard line 55) The completion rate for February is 90.3% against a target of 95%. There are continued concerns about the accuracy of the reported data, which are being explored, as actual achievement is believed to be higher. A targeted piece of work between the Data Quality lead and Learning and Development is now underway to address these concerns.. Safe Staffing (scorecard lines 57-58) Ash Villa has had to use significantly more staff to ensure staff and patient safety due to the nature of the patient cohort as described above. Safe staffing - Average % fill rate DAY 131.0% Safe staffing - Average % fill rate NIGHT 125.1% Specialist Division 23

24 Adult Community Mental Health Division Scorecard Divisional Performance Metrics Historical data Nov Final Dec Final Jan Final Decr - / Incr + % on Primary vs Final Data* Latest Data Feb '18 Same Month previous year Target Adult Community Division Scorecard Operational Performance Metrics Lincolnshire Steps2Change East CCG Recovery rate 53.0% 51.6% 54.4% 50.5% 55.7% 50% 69 Lincolnshire Steps2Change East CCG Access rate 17.6% 16.9% 19.2% 16.0% 16.0% 15% 70 Lincolnshire Steps2Change West CCG Recovery rate 54.7% 56.3% 50.0% 58.6% 51.1% 50% 71 Lincolnshire Steps2Change West CCG Access rate 20.4% 11.8% 19.2% 19.4% 17.9% 15% 72 Lincolnshire Steps2Change South CCG Recovery rate 54.8% 59.0% 52.5% 52.7% 54.6% 50% 73 Lincolnshire Steps2Change South CCG Access rate 21.5% 18.3% 20.5% 18.8% 13.7% 15% 74 Lincolnshire Steps2Change South West CCG Recovery rate 63.4% 62.4% 63.7% 58.1% 60.4% 50% 75 Lincolnshire Steps2Change South West CCG Access rate 19.2% 19.8% 21.6% 15.8% 16.8% 15% 76 PbR Compliance - % of patients in scope with an in date cluster review (added March 2018) 78.3% 96% Workforce and Efficiency Mandatory training compliance 89.8% 89.8% 89.7% 0.0% 91.2% 95.8% 95% 79 % sickness absence 5.3% 7.2% 5.8% 0.0% 5.2% 5.5% 4.5% 80 Vacancy factor % of WTE 92.0% 92.2% 89.9% 0.0% 88.3% 91.5% Info only 81 % staff appraisal 87.1% 86.7% 87.9% 0.0% 87.5% 93.2% 95% Quality & Safety Violence & Abuse (Patient on Patient) Info only 84 Violence & Abuse (Patient on Staff) Info only 85 Number of complaints Info only 86 Number of medication errors Info only 87 Friends and Family Test Response rate 16% 10% 27% 31% 19% 20% 88 Friends and Family Test Recommend rate 90% 96% 94% 91% 98% 71% 89 Number of Incidents requiring Duty of Candour Info only *Please note that any + / - is due to late data entry and/or additional data validation 24

25 ICMHT Boston & Skegness ICMHT Grantha m/sleafo rd ICMHT Lincoln North Outpatie nt Departm ent Boston Social Care North Adult Community Mental Health Division Integrated Performance Summary Divisional Updates None given in the exception report do we need to add some in? The Division is continuing work on the redesign of the Community Mental Health Teams to address capacity and demand challenges, to improve care pathways and to enhance patient experience. The division is notably implementing Accreditation for Community Mental Health Services (ACOMHS) across the services. Operational Exceptions Issue PbR Compliance (Scorecard line 76) The % of patients in scope with an in date cluster review is below the target of 96%. Current compliance across the Division is 78.3%. The Outpatients area accounts for 97% of patients who do not have an in date cluster review. Key Actions 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. Timescale Lead 3 months Business Manager Quality and Safety Early Warning Tool There are no overall concerns about a particular team. Any individual issues are being addressed. Complaints & Friends and Family Test (FFT) (scorecard lines 61, 62 & 64) Adult Community Complaints - April February Median Apr-17 May-17 Jun-17 Jul-17 Aug-17 Sep-17 Oct-17 Nov-17 Dec-17 Jan-18 Feb-18 Adult Community Complaints by Team February Adult Community Mental Health Division 25

26 What s the issue? The 6 complaints in this division were regarding a PHSO enquiry from Lincolnshire County Council asking for further information regarding a previous complaint, a relative asking for specific therapy which LPFT are not commissioned to provide, attitude of administrative and medical staff, concerns raised by an MP regarding antisocial behaviour and welfare of a service user, medical staff not seen as supportive and perceived lack of social care support. Patient/Carer Expressions of Satisfaction 50 What s being done about it? There have been a reduction in the number of complaints, they are being dealt with locally and some have involved face to face resolution meetings which have given the complainant the opportunity to voice their concerns and find a mutual resolution. We continue to encourage patients to complete FFT and are reporting other methods of feedback from the teams monthly. Lead Person Service Development Lead Medication Errors (scorecard line 86) There were 3 medication errors reported in the Division. 2 occurred within ICMHT Spalding/Stamford and 1 in ICMHT Lincoln South. All resulted in No Harm. All 3 incidents related to depot medication. 1 concerned the administering of a depot 1 day early and the other 2 administering a depot without signature. What s being done about it? We are working with pharmacy colleagues who have highlighted these errors when undertaking checks of medicine cards within the teams. These errors have been addressed with the individual clinicians. Lead Person Service Manager Workforce Mandatory training (scorecard line 78) Training compliance continues to improve. The compliance for February is 91.2% against a target of 95%. Additional training is being arranged where required. Sickness & Absence (scorecard line 79) The Division s sickness rate has shown some decline from 7.2% in December and 5.8% in January. The sickness absence rate for February is 5.2% against a target of 4.5%. This is an overall improving picture across the Division. Appraisal rate (scorecard line 81) The % of staff with a completed appraisal is 87.5% for February, against a target of 95%. Any non-compliance is being dealt with on an individual basis. Adult Community Mental Health Division 26

27 Adult Mental Health Inpatient Division Scorecard Divisional Performance Metrics Historical data Nov Final Dec Final Jan Final Decr - / Incr + % on Primary vs Final Data* Latest Data Feb '18 Same Month previous year Target Adult Inpatients Scorecard Operational Performance Metrics 30 day Unplanned re-admissions 10.3% 1.7% 3.2% 0.0% 7.7% 5.4% <10% 93 % of CPA patients receiving a follow up within 7 days of discharge 96.2% 94.0% 96.6% 0.0% 97.6% 90.9% 95% 94 Crisis 4 hr response times 97.4% 100.0% 95.7% 0.0% 95.5% 86.4% 95% 95 Delayed Transfer of Care 1.0% 0.2% 0.0% 0.0% 1.1% 3.8% 3.5% 96 PbR Compliance - % of patients in scope with an in date cluster review (added March 2018) 88.6% 96% Workforce and Efficiency Mandatory training compliance 81.5% 82.7% 82.9% 0.0% 85.3% 91.0% 95% 99 % sickness absence 6.0% 5.7% 5.4% 0.0% 4.2% 4.6% 4.5% 100 Vacancy factor % of WTE 92.3% 91.9% 86.7% 0.0% 88.6% 93.1% Info only 101 % staff appraisal 82.1% 80.8% 83.3% 0.0% 82.2% 92.9% 95% Quality & Safety Safe staffing - Average % fill rate DAY 100.8% 100.7% 94.2% 98.8% 102.6% Info only 104 Safe staffing - Average % fill rate NIGHT 101.8% 104.4% 95.2% 95.2% 99.1% Info only 105 Violence & Abuse (Patient on Patient) Info only 106 Violence & Abuse (Patient on Staff) Info only 107 Number of complaints Info only 108 Number of medication errors Info only 109 No. of Falls (inpatients) Info only 110 Friends and Family Test Response rate 8% 8% 5% 9% 3% 20% 111 Friends and Family Test Recommend rate 76% 87% 90% 88% 91% 71% 112 Number of Incidents requiring Duty of Candour Info only *Please note that any + / - is due to late data entry and/or additional data validation 27

28 Adult Mental Health Inpatient Division Integrated Performance Summary Divisional Updates Donna Bradford, Service Manager, has completed a two week family and carer therapy course. As a result, the division is reshuffling the management team to allow Donna to focus on embedding this work across the division. From 1st April for six months Donna will become the family and carer lead, Gareth Price will be the service manager for the PICU (Psychiatric Intensive Care unit), PCDU (Psychiatric Clinical Decisions Unit) and bed management services and Jos White will be the service manager for rehab and low secure services. Jude Snailham is working with Active Lincolnshire on a joint project to look at physical activity during transition from inpatient wards to community. There have been a number of forums with staff and service users from the division to establish the benefits of physical activity on mental wellbeing and barriers faced. A working group will be set up to take this work forward from this very early exploratory stage. The new PCDU continues to receive excellent service user feedback from their first eight weeks of operation. Operational Exceptions Issue PbR Compliance (Scorecard line 96) The % of patients in scope with an in date cluster review is below the target of 96%. Current compliance is 88.6%. 90% of patients have an assigned cluster, 129 people are awaiting a cluster allocation and there are 41 people clustered in 1-3. % Reviewed Patients Need Review Total Patients FORENSIC INPATIENTS 100.% 0 12 REHABILITATION INPATIENTS 98% PSYCHOLOGY SEVERE AND ENDURING 89% 1 9 ACUTE INPATIENTS 88% CRHT 74% Key Actions The Informatics team have developed a weekly report to identify patients clustered at 1-3 and the management admin team send this report out weekly to teams to reduce cluster errors. A monthly report is provided by the Business Manager summarising PbR position and expected actions (due to very limited number of licences only the Business Manager has access to this report which is no longer produced by Informatics or Performance). Training on the use of the Mental Health Clustering Tool is taking place on 19 th March 2018 for staff as an introduction and refresher training. Thereafter L&D will provide training opportunities. Timescale Lead Monthly on going monitoring Business Manager (supporting each Service Lead) 28

29 Quality and Safety Early Warning Tool The Vales and Charlesworth High vacancy levels and sickness rates contributed to reduced rates of completed appraisals and mandatory training resulting in high scores for these 2 wards in January An active recruitment campaign has continued since January and some posts have 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). International Womens Day on 8 th 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 patient are being arranged on each of these wards to discuss current patient experience of being cared for on these wards and identify areas for potential quality improvement projects. Hartsholme (PICU) As above, an active recruitment campaign has continued since January to address the high vacancy and turnover rates identified on the PICU in January 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). Medicines management has also been identified as an area for improvement across the division. The Modern Matron and Clinical Pharmacy Lead are supporting the divisional management team to identify training needs in this area and address concerns re: the number of medication errors and the escalation and management of medication errors once identified. Complaints & Friends & Family Test (FFT) 4 Adult Inpatients Complaints - April February Median Apr-17 May-17 Jun-17 Jul-17 Aug-17 Sep-17 Oct-17 Nov-17 Dec-17 Jan-18 Feb-18 Adult Mental Health Inpatient Division 29

30 What s the issue? The one complaint in this division relates to perceived attitude of CRHT staff. 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 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. The Service Managers and ward managers are liaising with IT re: resolving these on-going issues. 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 in April Timescale April 2018 Lead Person Quality Improvement & Assurance Lead Incidents of Violence, Abuse & Harassment (VAH) What is the issue overall? Overall, there were 81 VAH incidents reported within the Division. There were 2 incidents of patients refusing medication, 12 patient to inanimate object, 18 patient to patient assaults (11 of which were physical), 47 patient to staff assaults, 1 patient to third party and 1 third party to staff. There were a total of 34 restrictive interventions used out of 81 incidents. 4 prone, 3 prone to supine, 10 seated, 8 standing and 9 supine. There were 15 incidents of seclusion overall. Patient to staff assaults There is an emerging upward trend in patient to staff incidents. Of the 47 incidents reported 27 were physical assaults, 3 sexual, 1 racial and 16 verbal. 4 incidents resulted in low harm to staff and 43 resulted in no harm. 15 occurred on The Vales, 1 The Fens, 1 Maple Lodge, 1 Psychiatric Clinical Decisions Unit (PCDU), 4 on Francis Willis Unit, 2 with CRHT Boston, 1 CRHT Lincoln, 4 on Ward 12, 7 on Hartsholme (PICU), 6 on Conolly Ward, and 5 on Charlesworth Ward. Of the 47 incidents 21 required the use of restrictive intervention and 11 resulted in seclusion. 5 of the 7 prone restraints were as a result of patient to staff VAH. 3 of the 5 were turned to supine. Adult Mental Health Inpatient Division 30

31 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 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 VAH Patient to Staff - Adult Inpatients February February The Vales - Patient to Staff February February 2018 The Vales What is being done about it? The upward trend may be attributable to one or an interaction of several following factors: Opening of the Hartsholme Unit The clarification of RI incidences logged in areas other than VAH. The introduction of Datix training on RI courses promoting accurate reporting through Datix Increases due to specific patient groups. Continued analysis of the quality and reporting culture will determine whether the number of incidents develops an ongoing trend or settles into common cause variation. Adult Mental Health Inpatient Division 31

32 Charlesworth Ward Conolly Ward Ward 12 Hartsholme (PICU) Francis Willis Unit Ashley House The Vales The Fens The Wolds Maple Lodge VAH Patient to Inanimate Object There were 12 Patient to Inanimate Object incidents reported within the Division in February required the use of restrictive interventions, with 3 resulting in seclusion. What s being done about it? The Division continues to work with the Trust Restrictive Intervention Team Leader to identify patterns and implement approaches that may reduce the occurrence of incidents. Specific work is being undertaken within the female wards to further develop access to meaningful activity and sensory aware environments to support a reduction in incidents of violence and aggression. Timescale Lead Person Ongoing Quality Improvement & Assurance Lead Self-Injurious Behaviour What is the issue? The graphs below detail an overall decrease in self injurious behaviour incidents since December 2017 for inpatient wards. There has been a third consecutive decrease in self injurious behaviour on The Vales and an increase on Charlesworth Ward, PICU and Ward Self Injurious Behaviour - February February 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 Self Injurious Behaviour Adult Inpatient Wards December February 2018 Dec-17 Jan-18 Feb-18 Adult Mental Health Inpatient Division 32

33 What s being done about it? Specific work is being undertaken within the female wards to further develop access to meaningful activity and sensory aware environments to support patients to manage distress and reduce incidents of self-harming behaviours. Timescale Lead Person Ongoing Monthly Monitoring Quality Improvement & Assurance Lead Patient Falls There were 4 falls reported in Adult Inpatients Division; 1 on Conolly Ward and 3 at Ashley House attributable to 1 patient. 1 fall resulted in low harm. What is being done about it? Patient medication on Ashely House was reviewed by the Responsible Clinician and reduced. Patient seen and assessed by OT and recommendations made. Lead Person: Matron, Older Adult Services Workforce Mandatory training & Appraisal rate There has been an increase in the compliance for mandatory training, with February showing an achievement of 85.3% against a target of 95%. The completion rate for appraisals in February is 82.2% against a target of 95%. The division continues to performance manage this issue. All wards will be aligned and working the same shift pattern from April 2018 thus enabling time out sessions to complete mandatory training, supervision appraisals and clinical supervision. If staff are attending training at the L&D centre and this finishes early they have been asked to complete any outstanding on-line training prior to leaving that day. Sickness & Absence The Division is showing a sickness absence rate of 4.2%, against a target of 4.5%. Safe Staffing Safe staffing - Average % fill rate DAY 98.8% Safe staffing - Average % fill rate NIGHT 95.2% Adult Mental Health Inpatient Division 33

34 Older Adult Mental Health Division Divisional Performance Metrics Nov Final Dec Final Historical data Jan Final Decr - / Incr + % on Primary vs Final Data* Latest Data Feb '18 Same Month previous year Target Older Adult Scorecard Operational Performance Metrics Liaison - Ward referrals - % seen within 24 hours 92.9% 93.1% 95.6% 0.0% 95.3% 98.1% 90% 116 Older Adult CMHT s- % of patients seen within 18 weeks 94.0% 94.8% 98.2% 0.1% 94.6% 97.8% 95% 117 Older Adult MHSDS Priority Metrics 87.0% 87.7% 89.7% 0.0% 87.9% 85% week RTT non-admitted incomplete pathways (Consultant led, still waiting) Exc Int Referrals 86.7% 87.9% 85.0% 92% 119 Older Adult Delayed Transfer of Care 3.5% 0.5% 0.7% 0.0% 6.0% 25.3% 3.5% 120 PbR Compliance - % of patients in scope with an in date cluster review (added March 2018) 83.7% 96% Workforce and Efficiency Mandatory training compliance 82.8% 84.1% 85.0% 0.0% 86.2% 91.0% 95% 123 % sickness absence 6.9% 7.5% 8.5% 0.0% 7.0% 5.4% 4.5% 124 Vacancy factor % of WTE 94.6% 94.4% 89.8% 0.0% 90.0% 95.7% Info only 125 % staff appraisal 77.6% 72.0% 79.7% 0.0% 79.2% 88.4% 95% Quality & Safety Safe staffing - Average % fill rate DAY 104.8% 106.6% 94.2% 103.3% 104.5% Info only 128 Safe staffing - Average % fill rate NIGHT 104.6% 105.5% 95.2% 99.9% 114.0% Info only 129 Violence & Abuse (Patient on Patient) Info only 130 Violence & Abuse (Patient on Staff) Info only 131 Number of complaints Info only 132 Number of medication errors Info only 133 No. of Falls (inpatients) Info only 134 Friends and Family Test Response rate 4% 6% 9% 8% 9% 20% 135 Friends and Family Test Recommend rate 97% 100% 97% 92% 97% 71% 136 Number of Incidents requiring Duty of Candour Info only *Please note that any + / - is due to late data entry and/or additional data validation 34

35 Older Adult Mental Health Division Integrated Performance Summary Divisional Updates Langworth Ward came second in the British Nursing Journal Awards for innovation. A further community engagement event has been held at Boston which received positive feedback. We had a Positive 15-steps Report for Brant Ward and recognition of improvements made by staff in feedback. A QI project relating to care planning is due to be piloted in April 2018 and the draft care plan has received positive feedback from staff and patients. Operational Exceptions 100% 90% 80% 70% 60% 50% 40% 30% 20% 10% 0% Older Adult Community Mental Health Team Waits % of patients seen within 18 weeks vs 95% target 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 Issue Community Mental Health Team (CMHT) Waiting Times (Score card line 116) The actual waiting time for the Community Mental Health Teams (CMHT) is below the target of 95% of patients to be seen within 18 weeks. The current achievement is 94.6%, which reflects that 88 out of 93 people seen this month had their appointment within 18 weeks of being referred. The 5 patients outside of target are below, for your information and potential data quality validation. Key Actions The data has been checked and a percentage of the variance is due to data entry issues which are being rectified. Spalding CMHT waits are being closely monitored by the Service Manager, Team Coordinator and Clinical Director. Stamford CMHT Nurses are supporting the Spalding team 3 sessions per week. The final full time post has been appointed to and the person will be in post by June induction. Medical staff are making clinical sessions available to support new referrals and reduce delay. Older Adult Mental Health Division 35

36 A new Grantham CMHT Team Coordinator is in post and they are clinically reviewing all current waits and caseloads with the team. An away day has been planned for 3 rd April 2018 for the team to review caseloads and waits due to sickness and vacancies. Data cleansing in ongoing in all teams as some waits are still noted to be due to incorrect codes input on to the clinical system. The Service Manager is meeting regularly with the Performance and Information team to review data and identify performance issues to support timely action. This exception report will be provided again in May Timescale Expected achievement of target April 2018 Lead Acting Service Manager, Community Services 100% 90% 80% 70% 60% 50% 40% 30% 20% 10% 0% Older Adult Consultant-led Pathway % of patients currently waiting less than 18 weeks vs 95% target 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 Issue Waiting times for a Consultant-led Service (Scorecard line 118) The current waiting times for access to a Consultant-led service within the Older Adults Mental Health Division is below the target of 92% of referrals being seen within 18 weeks. The current achievement is 85% The associated action plan for this was given within the Integrated Performance Report in February 2018, where it was noted that the exception would next be reported on fully in May Lead Clinical Director & Service Manager, Older Adult Community Services Older Adult Mental Health Division 36

37 15% Delayed Transfer of Care % of delayed bed days vs target 10% 5% % Trust target 0% Apr-17 May-17 Jun-17 Jul-17 Aug-17 Sep-17 Oct-17 Nov-17 Dec-17 Jan-18 Feb-18 Issue Delayed Transfer of Care (DToC) (Scorecard line 119) The % of delayed bed days is 6% for February, against a target of 3.5%. The primary hot spot is the Manthorpe Centre with 4 delays attributed to Health (patient and family choice). One delay has since ended. Key Actions Timescale Lead Finalisation of the choice agenda to facilitate the process of increasing throughput and removal of blockages. The confirm and challenge process continues with the Senior Adult Social Care Lead to discuss and agree DToC codes. This has proven successful in reducing the number of DToC cases and is ensuring correct recording. 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). 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 their home of choice. Awaiting approval of Choice Agenda Policy Acting Service Manager, Inpatient Services Issue PbR Compliance (Scorecard line 120) The % of patients in scope with an in date cluster review is below the target of 96%. Current compliance is 83.7%. Key Actions There are issues across all areas with the exception of Stamford and Boston with initial clustering and subsequent reviews. 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. Compliance is monitored within Band 7 supervisions by service manager and at divisional level through DMT. Timescale Expected achievement of target is expected June 2018 Lead Acting Service Manager for Community Older Adult Mental Health Division 37

38 Quality and Safety Early Warning Tool Community there are no specific issues but additional management support has been put in for the Boston & Skegness team due to the long term sickness of the team coordinator to ensure that the quality of the service is maintained. Psychology has dipped in performance due to sickness absence, vacancies, appraisals and training. Key staff are returning which will improve performance against metrics. There are no concerns relating to the quality of the service. Over the last 3 months Langworth Ward continues to deteriorate slightly on their Early Warning Tool Score. This is being monitored by the Service Manager and there is increased support for the Acting Ward Manager. Manthorpe Centre and Brant Ward are improving overall on the Early Warning Tool. Manthorpe Centre has issues with sickness, vacancies, staff turnover, mandatory training and agency spend. The most recent agency data shows that there has been a reduction between January and February on this metric. The Quality Improvement project on Manthorpe, developed with the clinical leadership team on the ward, aims to tackle cultural issues and aims to improve the clinical environment to support a reduction in falls, enhance privacy and dignity, a reduction in incidences of violence, abuse & aggression and to increase support mechanisms for team support and reflection. This is anticipated to have a positive impact upon staff morale and stress related sickness episodes. The Ward Manager has engaged positively and proactively with improvement methodology. Complaints & Friends & Family test (FFT) (scorecard lines 131, 134 & 135) 4 5 Older Adults Complaints - April February Median Apr-17 May-17 Jun-17 Jul-17 Aug-17 Sep-17 Oct-17 Nov-17 Dec-17 Jan-18 Feb-18 Patient/Carer Expressions of Satisfaction 27 What s being done about it? Inpatient teams are exceeding the required target of 20% across the service following a specific improvement plan which placed additional prompts in the system on discharge The focus of the next improvement plan is community older adult services which are below target. All 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. 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. Older Adult Mental Health Division 38

39 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 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 Timescale Target expected to be achieved by June 2018 Lead Person Quality Improvement Lead & Acting Service Manager, Community Incidents of Violence, Abuse & Harassment (VAH) (Scorecard lines 129 & 130) What s the issue? Patient to Patient and Patient to Staff incidents: There has been a reduction in the number of patient to patient assaults on Manthorpe Unit. Manthorpe continues to report the highest number of patient to patient assaults (n=18). 6 patients were involved in the 18 incidents and of the 18 incidents 12 were attributable to 2 patients. The data indicates a difference in the nature of the VAH incidents and the use of RI between the two organic wards. The percentage of RI used for all VAH incidents is 43% on Langworth Ward compared to on 10% on Manthorpe. Older Adults Overall Patient to Patient VAH February February Older Adults Overall Patient to Staff VAH February February What is being done about it? A meeting is to be confirmed between the Restrictive Intervention (RI) Team Leader, Occupational Therapy (OT) Lead from Adult Mental Health Inpatient Division and the OT Lead from Older Adult Mental Health Division to look at the how the role of OT s and Activity Coordinators can support a reduction in the number of incidents. Ongoing monitoring of number of incidents. The establishment of the RI Steering Group enables the RI Team Leader and the Clinical Lead for RI to support ward areas as required to ensure prompt review, the safe care of patients and the safety of staff. Older Adult Mental Health Division 39

40 Lead The RI Team Leader oversees the RI annual work plan, which aligns to highest RI Trust priorities and best practice guidance. The priority areas include: detailed analysis of data, accurate identification of themes / trends, supporting targeted training needs, policy review, and implementation of collaborative behaviour support plans. Restrictive Intervention Team Leader Due to increased risk between two patients on Manthorpe (challenging dynamics) one gentleman was transferred to Langworth which subsequently increased incidents there. Targeted QIP to reduce violence and aggression by 30% has been developed with targeted work on therapeutic engagement; environmental stressors and leadership skills to support management of distressed patients. A band 6 bespoke leadership programme is also underway, a quality improvement component of which aims to address levels of VAH on the ward. Sensory intervention continues on Langworth but the recent building works on the unit have had a negative impact upon VAH incident figures as the extra care suite used for de-escalation is currently out of action and the amount of floor space has been reduced to ensure safety during the alterations (no current access to kitchen, fifties lounge and extra care suite). Access to rooms is expected 4 th April which should have a positive impact on figures. Timescale June 2018 Lead Quality Improvement Lead & Acting Service Manager, Inpatients Patient Falls (scorecard line 133) There has been a slight increase in the number of patient falls compared to the previous 2 months. 60 Older Adult All Reported Slips, Trips and Falls Older Adult Mean UCL LCL Linear (Older Adult) What s the issue? Of the 30 patient falls reported within the Division; 16 occurred on Manthorpe Ward, with 9 falls attributable to 1 patient, 5 of which were unwitnessed falls. 7 occurred on Langworth Ward with 2 falls attributable to 1 patient, Brant ward had 7 falls, with 3 being attributable to 1 patient. Of the 30 falls, 29 resulted in low or no harm. One fall on Langworth Ward resulted in moderate harm. A detained patient suffered a broken neck of femur which has been investigated as a serious incident. The patient was admitted to Lincoln County Hospital for surgery and has since returned to Langworth Ward. Older Adult Mental Health Division 40

41 Apr-17 May-17 Jun-17 Jul-17 Aug-17 Sep-17 Oct-17 Nov-17 Dec-17 Jan-18 Feb Older Adults Falls Ward Tracking Langworth Brant Manthorpe Rochford What is being done about it? Detailed analysis continues to be conducted by the Older Adults Division Matron. Locality falls meetings to review trends held monthly. Sensory pathway and environmental work ongoing across Specialist dementia wards. Training update - A number of the OA community staff have already received falls reduction training and the remainder will receive it in the near future. Ongoing roll out of training programme to outstanding clinical teams: Rochford Ward, Boston/Skegness CMHT, Spalding/Stamford CMHT, Louth CMHT, Grantham CMHT and Adult Inpatients. Frailty Agenda - LPFT is increasingly linking with LCHS Matron Kim Barr who specialises in the frailty agenda of which falls is integral; and this is an area that is being prioritised to support patients at risk of falls to access community services to minimise falls. Seeking external identified areas of positive practice to learn from/share practice (LCHS Team Skegness). Service Wide review of falls rescheduled due to weather for the 30 th April to look at trends and themes from falls within the service. Timescale 30 th June 2018 Leads Matrons for Older Adults and Adult In-Patients, Older Adult Clinical Specialist Occupational Therapist & Quality Improvement Lead Older Adult Mental Health Division 41

42 Workforce Mandatory training (scorecard line 122) There continues to be an increase on the reported mandatory training compliance within the Division, with February showing an achievement of 86.2% against a target of 95%. Team Coordinators are monitoring compliance and working robustly in meeting the trust wide target of 95%. Variations are monitored by Service Managers within supervision sessions. Low uptake areas are targeted and staff given time to complete. Ward Managers are ensuring rosters are utilised to allow e- learning time to complete mandatory training. Sickness & Absence (scorecard line 123) The sickness absence rate is 7% against a target of 4.5% Grantham and Boston CMHTs and Lincoln and Boston Mental Health Liaison Team s (MHLT s) are outliers for raised sickness levels. ISRs are being completed and team working with HR colleagues to support processes and return to work. Inpatient outliers within the division remain Manthorpe and Brant wards with increased levels of long term sickness. Ward managers are working effectively with HR to manage as per policy. The Quality improvement project on Manthorpe aims to increase support mechanisms for team support and reflection to support staff well-being. The aim is that it will have an impact upon staff moral and stress related sickness episodes. Sickness is monitored by service managers on a monthly basis and divisionally through DMT. Leads Acting Service Manager, Community & Acting Service Manager, Inpatients & MHLS Manager Appraisal rate (scorecard line 125) The appraisal completion rate for February is 79.2% against a target of 95%. Community - On review on 12/03/2018 the appraisal rate in service has increased to 82.11% within the community. This is an improving picture overall for the service. Team coordinators have booked dates for all those with outstanding appraisals Outliers within inpatients are Brant and Langworth wards. All appraisals are now booked and from next year will be staggered to avoid non-compliance of numerous appraisals all occurring at the same time. Sickness and ward acuity has been reported to have affected compliance figures. Within MHLT Lincoln has all appraisals booked that are outstanding Leads Acting Service Manager, Community & Acting Service Manager, Inpatients & MHLS Manager Safe Staffing (scorecard lines 127 & 128) There are no issues to report. Safe staffing - Average % fill rate DAY 103.3% Safe staffing - Average % fill rate NIGHT 99.9% Older Adult Mental Health Division 42

43 Financial summary 2017/18 YTD Summary 2017/18 Year end Summary Indicator 17/18 YTD Actual Outturn 17/18 YTD Planned Outturn Variance % Achieved of Plan 17/18 Forecast Outturn 17/18 Planned Outturn Variance % Achieved of Plan EBITDA Surplus (-)/Loss(+) ( 000's) '000 '000 '000 % '000 '000 '000 % -4,504-4, % -5,971-5, % Net Surplus(-)/Loss (+) ( 000's) % -1, % Surplus(-)/Loss (+) on a Control Total Basis ( 000's) % -2,106-1, % Single Oversight Finance Score Cost Improvement Target Against Delivery (- 000's) -2,137-3, % -2,349-3, % Agency Staff Utilisation ( 000's) 2,664 2, % 2,861 2, % Percentage of invoices paid within 30 days per BPPC 90% CQUIN Achievement Against Plan 1,224 1, % 1,652 1, % Cash Balance ( 000's) 13,088 9,553 3, % 11,256 8,813 2, % Capital Expenditure ( 000's) 2,830 4,077-1,247 69% 4,031 4, % The Trust s Month 11 Income and Expenditure position is a 0.5m surplus, 0.1m higher than a planned surplus of 0.4m. The Trust is forecasting a net surplus of 1.6m which is 0.9m higher than planned achievement of 0.7m. 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/impairments. On a control total basis the Trust is reporting a surplus of 1.0m compared to a planned surplus of 0.8m at Month 11. The full year forecast is a surplus of 2.1m, which is 1.0m higher than the planned control total position of 1.1m surplus. NHS Improvement has recently announced an STF incentive scheme for 2017/18. This scheme results in Trusts receiving additional income of 1 for every 1 achieved above the control total by the end of the year. The forecast values shown above include additional income of 0.5m relating to this incentive scheme. CIP achievement stands at 2.14m to date at Month 11, compared to a target of 3.04m. This is an achievement of 70%. The full year CIP forecast achievement is 2.35m which is 70% of the Trust s target of 3.34m. The Trust is reporting a reduced NHSI finance score rating of 2 at Month 11, due to increased expenditure on agency staff. The Trust is forecasting a return to a 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 11 the Trust paid 90% of invoices (both NHS and non NHS) within 30 days compared to 89% in Month

44 Agency Spend summary Agency spend has increased within Quarter 4. The Trust s spend on agency staffing at Month 11 exceeds the cumulative monthly agency expenditure cap issued by NHSI for 2017/18 ( 2.66m against a capped level of 2.04m). The Trust is forecasting agency utilisation of 2.86m which exceeds the full year cap of 2.14m by 0.7m. The table below provides a high level summary of spend on agency by staff group. 2017/18 YTD Summary 2017/18 Year end Summary Type of agency 17/18 YTD Actual Outturn 17/18 YTD Planned Outturn Variance % Achieved of Plan 17/18 Forecast Outturn 17/18 Planned Outturn Variance % Achieved of Plan '000 '000 '000 % '000 '000 '000 % Medical agency 1,642 1, % 1,762 1, % Admin & Ancillary agency % % Qualified Nursing agency % % Unqualified Nursing and Scientific & Therapeutic Agency % % Total spend on agency 2,664 2, % 2,861 2, % 44

45 Cash Summary The Trust s Month 11 cash balance is 13.09m compared to a planned 9.55m. 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 which is forecast to continue to the year end. This is offset by planned asset sales not yet materialising. The Trust s forecast cash position is 11.26m which is 2.44m higher than planned. 45

46 Capital Summary Capital expenditure to date is 2.83m compared to a planned 4.08m. This is mainly due to slippage on a few schemes which are now forecast to happen later in the year. Several planned schemes have also been cancelled. The Trust is forecasting to spend 4.03m in the year which is 0.30m lower than planned. This forecast includes 0.3m of expenditure funded by Public Dividend Capital. 46