Performance Paper Lee Osborne, Information Programme Manager Ros Francke, Director of Finance

SUMMARY REPORT Meeting 28 January 16 Date: Agenda Item: 8.1 Enclosure Number: 5b Meeting: Title: Author: Accountable Director: Other meetings presented to or previously agreed at: Trust Board Performance Paper Lee Osborne, Information Programme Manager Ros Francke, Director of Finance Key Committee Date Reviewed Points/Recommendation from that Committee 25 January 16 R&P Purpose of the report The purpose of this report is to provide the Board with an overview of our performance for 2015/16 with the position as at 31st December 2015. The Performance Report provides an overall assessment of our performance against the ten corporate objectives that have been agreed by the Board. Each objective is assessed against a range of performance indicators that are intended to be proxy measures for overall progress against the objective Strategic Priorities this report relates to: Consider for Action Approval Assurance Information To deliver high quality care To support people to live independently at home To deliver integrated care To develop sustainable community services 1 Accountable Directors: Ros Francke Meeting Date: 25th January 2016

Summary of key points in report The Trust is currently monitoring performance against 90 KPIs structured against 10 corporate objectives. Of the 90 KPIs 17 are currently rated as red compared to 17 last month. Where appropriate these have recovery plans in place. 6 of the 17 indicators will remain red throughout the remainder of the year as they have already exceeded the year to-date targets of none for each indicator A high level assessment of the 10 corporate objectives shows three are rated as green, six amber and one red. The TDA oversight and escalation status is 4 (green / amber) which is the highest rating possible prior to completing the CQC inspection. Delayed Transfers of Care (DTOC) has increase through December from 10.78% in November to 17% against a target of 3.5%. Additional information is provided on Page 13 of the report. Across the Trust there has been significant progress through the year in reducing the number of patients waiting over 18 weeks and the Trust continues to deliver compliance against the 18 week RTT incomplete Pathway. The actual November reported position for incomplete Pathways was 96.55% against the 92% target which was an improvement on the previous months reported position (95.17%) There is a noted drop in performance for 18 week RTT for non-admitted patients (detailed below) this indicator is no longer monitored nationally however the Trust continues to monitor this indicator locally as part of its Performance framework. Performance for November is 94.73% against a 95% target. The target was not achieved mainly due to MSK with approximately 35 breaches partly due to inherited waiting times from SaTH with the commencement of the new MSK service along with the inclusion of the APCS which are now part of the report. The Trusts Patient access policy is currently being revised to include the new rules around RTT that came into effect on 1 October 2015. This will be submitted for ratification to the committees in March 2016. A renewed focus from the Operational Divisions has resulted in an improvement in December Appraisal although this is still below target at 78% compliance against a 90% target The number of retirees remain high as do the number of leavers not specifying a reason for leaving The TDA have now approved the procurement of the Trusts EPR solution. As the approvals process has extended into the New Year this will necessitate a significant review of the planned deployment timetable and will inevitably delay the entire process. Further details are available on page 36 Key Recommendations 2 Accountable Directors: Ros Francke Meeting Date: 25th January 2016

The Board is asked to: Discuss the actions taken to maintain performance, quality and safety and the key incidents reported and actions taken to mitigate those risks Discuss the content to ensure appropriate assurance is in place Consider the current performance in relation to KPIs Review the actions being taken where performance requires improvement Is this report relevant to compliance with any key standards? YES OR NO State specific standard or BAF risk CQC Yes Regulations 9,10,11,12,13,14,15,16,17,18,20 NHSLA IG Governance Toolkit Board Assurance Framework Impacts and Implications? Patient safety & experience Financial (revenue & capital) OD/Workforce Legal Yes Yes Version 9, 603 Yes YES or NO Yes Yes Yes No 991 Clinical Quality and Patient Safety If yes, what impact or implication The report and actions taken and planned developments will provide a basis for assurance on safety and experience Costs of treatment for harms Costs of temporary staffing Action plans implemented through teams to ensure learning from incidents and external visits. Potential impact from claims 3 Accountable Directors: Ros Francke Meeting Date: 25th January 2016

Integrated Performance Report Month 9 December 2015 Version 2.0 1 Accountable Director: Ros Francke,

Table of Content 1. Introduction... 3 2. High Level Overview/Performance Summary... 4 3. Integrated Dashboard... 5 4. TDA Accountability... 7 5. Key Performance Indicators Outside Performance Range... 8 5.1. Caring... 10 5.2. Responsive... 12 5.3. Effective... 20 5.4. Well led... 22 5.5. Safe... 24 5.6. Designed around the patient... 26 5.7. Increased range of services... 29 5.9. Financially sustainable... 32 5.10. Delivered in suitable environments... 34 5.11. Making the best of technology... 36 6. Key... 38 Appendix 1 -- Bank Agency Shifts October 2015 2 Accountable Director: Ros Francke,

1. Introduction The Integrated Performance Report provides an overall assessment of the Trusts performance. The report is structured against the ten corporate objectives that have been agreed by the Board. Each objective is assessed against a range of performance indicators that are intended to be proxy measures for overall progress against the objective. Performance indicators are drawn from a number of sources; the Trust Development Authority (TDA) Accountability Framework, commissioner negotiations, identified internal targets and Care Quality Commission (CQC) targets. For some objectives the measures relate to the delivery of projects, for example, IT implementation and service redesign. The TDA issued a revised accountability framework in April 2015, this set out 133 performance indicators. All the Trust indicators (TDA and local) continue to be internally reviewed and 141 have been considered relevant to the Trust. The Trust performance scorecard shows the status of all performance indicators. Table one details the number of indicators against each objective and the status on data availability. Table 1 Structure of KPIs Trust KPI Number of indicators Reviewed and data available Number of additional indicators awaiting guidance and under review Total Safe 21 6 27 Effective 8 2 10 Financially sustainable 9 0 9 Responsiveness 24 6 30 Caring 3 11 14 Well Led 7 25 32 Designed around the 10 1 11 patient Increased range of services 1 0 1 Delivered in suitable 3 0 3 environments Making best of technology 4 0 4 Total indicators 90 51 141 This report is structured into sections Section 2 to 3 Section 4 Section 5 Section 5.1-5.10 Provides a high level overview against each of the ten objectives and shows the overall performance scorecard. TDA oversight self-certification - Trusts best estimate of how the TDA would assess the organisation Highlights the KPIs that are currently reported as red and identifies those that have recovery plans in place. Reviews each corporate objective. 3 Accountable Director: Ros Francke,

2. High Level Overview/Performance Summary Objective Summary Position rating Objective Summary Position rating Caring - Staff involve and treat people with compassion, kindness, dignity and respect Responsive- Services are organised so that they meet people s needs. Effective- Peoples care, treatment and support achieves good outcomes, promotes a good quality of life and is based on the best available evidence Well Led - The leadership, management and governance of the organisation assure the delivery of high quality person centred care, supports learning and innovation and promotes an open and fair culture Safe - People are protected from abuse and avoidable harm. Limited range of KPIs currently with defined targets. Unmet need reported relating to a patient in Rheumatology Waiting times for all reportable services are within target. DTOC increased in November. Drop in performance around the 3 data quality indicators. Data entry, ethnic coding and unallocated data. Average length of Stay increased in November. Appraisals increased in Increased in December to 78% The number of retirees remains high as do the number of leavers. Monthly sickness absence rate increased in December to 4.54% One patient was found to be positive to C Diff in Ludlow Hospital in December. VTE assessments totals improved There were a total of four grade two pressure ulcers reported in December Designed around the patient - Our services will be continually reviewed and modified placing the patient at the centre of the redesign. Working across organisational boundaries to deliver integrated care. Increased range of services - We will seek opportunities to extend the range and scale of services delivered in the community Financially sustainable - We will review services to deliver them as efficiently as possible enabling reinvestment in patient care Delivered in suitable environments - We will review the use of our estate and develop where appropriate. Making best of technology - We will deploy technology to improve patient care and increase efficiency ensuring that the right information is available to the right people ate the right time regardless of care setting. Admission avoidance pathways are now fully implemented. There remain high numbers of not appropriate referrals to ICS The percentage of tenders won by the Trust has dropped from 20% to 17% The overall financial position is in line with plan. Further work is required to fully plan CIPs, hence rating of amber. The estates strategy still requires further updates and amendments. Property maintenance programmes are in place The TDA have now approved the procurement of a EPR and the EPR deployment planning process is progressing. 4 Accountable Director: Ros Francke,

3. Integrated Dashboard All Indicators Safe Caring Indicator RAG Trend Clostridium Difficile - incidence rate Clostridium Difficile - Variance from plan MRSA bacteraemia rate Proportion of admissions screened for MRSA Central Alerting System (CAS) - Outstanding Falls - Number of Falls Falls - Number of Patients Grade 2 Pressure Ulcers - avoidable Grade 3 Pressure Ulcers - avoidable Grade 4 Pressure Ulcers - avoidable Medication Incidents that affect patients Safety Never Events Never events - incidence rate Never events - repeat events* Never events - time since last event* Safety Thermometer - harm free care Serious Incidents (all) Serious Incidents - falls Serious Incidents rate VTE Venous Thromboembolism Risk Assessment WHO Surgical Checklist Compliance Effective Indicator RAG Trend Data entry within 21 days Ethnic coding data quality Unallocated data Use of NHS number Bed utilisation (overall) Deaths - unexpected Did Not Attend rates (DNA) Length of Stay (overall) Indicator RAG Trend New Birth Visits % within 14 days Access to Healthcare for people with Learning Disability Single Sex Accomodation Breaches Responsive Indicator RAG Trend Complaints - % of action plans implemented (well founded complaints) to ensure continuous improve Complaints - acknowledged within 3 working days Complaints - upheld by the Ombudsman Complaints -(All) - % responded to within timescales CQC Conditions or Warning Notices Number of Claims for compensation received Proportion of patients not treated within 28 days of last minute cancellation 18 week Referral To Treatment (RTT) for admitted patients 18 week Referral To Treatment (RTT) for non admitted patients 18 week Referral To Treatment (RTT) incomplete pathways Community Equipment Store - Response within 7 days Diagnostics for Audio/Ultrasound District Nurse response within 24 hours (urgent) District Nurse response within 48 hours (non-urgent) MIU Assessment Times assessed within 15 minutes MIU Percentage of people who leave MIU without being seen MIU Total time in department - discharged within 4 hours MIU Treatment Times (Arrival to Seen Time) - Median wait of 60 mins MIU Unplanned Re-Attendances (within 7 days of discharge) Outpatients > 6 week - consultant led Outpatients > 6 week - non consultant led Proportion of Delayed Transfers of Care Referral to Treatment Incomplete 52+ Week Waiters

Well Led Financially Sustainable Indicator RAG Trend Appraisal Rates Employee Numbers (FTE) Information Governance Requirements Leavers < 1 year in service (FTE) Leavers All (FTE) Other Mandatory Core Requirements Sickness absence - all Delivered in Suitable Environments Indicator RAG Trend Actual efficiency recurring/non-recurring compared to plan - Forecast compared to plan Actual efficiency recurring/non-recurring compared to plan - Year to date actual compared to plan Bottom line I&E position - Forecast compared to plan Bottom line I&E position - Year to date actual compared to plan Forecast underlying surplus/deficit compared to plan Forecast year end charge to capital resource limit Is the trust forecasting a funding requirement for liquidity purposes? Non-commissioner funded agency expenditure Overall CoS rating Indicator RAG Trend Designed around the Patient Delivery of maintenance programmes Development of estates strategy Peat Rating Increased Range of Services Indicator RAG Trend Proportion of Tenders successfull Making best use of technology Indicator RAG Trend Delivery of WIFI infrastructure EPR implementation Performance and Quality reporting Systems availability Indicator RAG Trend ICS - Admission Avoidance ICS - Average Length of Stay ICS ICS - Community Hospital (Average LOS) Discounting P3 D2A ICS - Core Team WTE Per Week ICS - Discharged No Further Support ICS - DTOC Delayed Days across all hospital settings (SATH, CH s & Redwoods, OOC) ICS - Integrated Community Services staus ICS - Maximum ICS Domiciliary Care Hours Per Week ICS - MFFD Average Wait ICS - Timely Supported Discharge Per Week ICS Readmission Overall NI 125

4. TDA Accountability The Trust continues to perform well against the headline standards which are applicable to community Trusts. The Trust remains compliant against the monthly TDA oversight self-certification and Monitor Licence requirements. Although there are a large number of indicators without defined thresholds the Trusts best estimate of how the TDA would assess the organisation is set out in the table below. TDA forecast assessment Status Oversite and Escalation 4 Quality 4 Sustainability 3 Finance Amber The overall approach to measuring and tracking NHS trust performance remains consistent with last year s Accountability Framework. There are a number of domains each with an associated set of indicators. The Quality and Finance ratings will primarily be rules-based using a set of thresholds for each indicator. The scores will be aggregated to the overall domain level according to performance against each indicator, individual indicator weightings and business rules. The sustainability score will not directly feed the escalation score but will be a factor in its determination. In addition and consistent with our current approach, the overall escalation score will be subject to a moderation process led by the TDA Directors of Delivery and Development supported by Portfolio Directors, Business and Quality Directors to determine the level of risk and appropriate level of intervention for each organisation. The results of the rules-based scores will be supplemented with softer intelligence from a range of third party reports including CQC warning notices. Consideration will also be given to any future risks faced by trusts. Escalation scores will be refreshed on a monthly basis. The NHS TDA will publish the overall results of the moderated process on a monthly basis. Alongside this the data supporting the indicators will also be made available alongside a metadata file that will outline the construction of the indicators and the criteria for assessment. 7 Accountable Director: Ros Francke,

5. Key Performance Indicators Outside Performance Range The Trust performance management framework defines a requirement that where KPIs are reported as red a recovery plan should be developed unless there is a clear reason not to. Where recovery plans are not yet in place for KPIs the relevant teams have been tasked with developing them. KPIs outside of performance range (Total number reported this month = 17 compared to 17 last month) RAG score Trust Objective Recovery plan signed off Recovery date Staff Sickness Absence all. Sickness absence rate increased in December to 4.54% (against a target of 3.5%) Approval Sept 15 Schedules in place Central Alerting System (CAS) Alerts open beyond due date. The Fire Stopping alert remains open. Work is nearing completion and it is anticipated that the alert will be closed shortly. Y January 2016 Appraisal Rates. The proportion of employees receiving an appraisal in the 12 months to December increased to 78% after recent falls in compliance against a target of 90% Y Dec 2015 Leavers all (WTE) The number of retirees remain high as do the number of leavers Plan review - Sept 15 Delayed Transfers of Care (DTOC). The proportion of DTOC Increased from 10.78% in November to 17% in December Y Mar 2016 against a target of 3.5%. Actual efficiency recurring/ non-recurring compared to plan Forecast vs Plan. Y Mar 2016 The RAG rating is red in line with the TDA reporting, which reflects that non-recurrent savings are offsetting a recurrent CIP shortfall Actual efficiency recurring/ non-recurring compared to plan YTD vs Plan Y Mar 2016 The RAG rating is red in line with the TDA reporting, which reflects that non-recurrent savings are offsetting a recurrent CIP shortfall Forecast underlying surplus/deficit compared to plan. The forecast underlying surplus has reduced from a 240k Y Mar 2016 surplus at month 8 to a 159k surplus month 9. ICS- Admission Avoidance -.Demand and delivery is below trajectory Y Tender success rate for Shropshire Community Health NHS Trust- The percentage of tenders won by the Trust has dropped from 20% to 17% Progress against EPR implementation. The EPR deployment planning process is progressing, however the TDA have still not approved the procurement 8 Accountable Director: Ros Francke,

KPIs outside of performance range that will remain throughout the remainder of the year The below indicators remains red as the year to date position has already exceeded the year to date target. YTD Trust Objective Trend Deaths Unexpected - There were no unexpected deaths reported in December but the indicator remains red due to the three that have been reported in the year to date. Proportion of patients not treated within 28 days of last minute cancellation. Indicator remains red due to one incident in June. No further incidents reported. Serious Incidents falls There were no falls reported as serious incidents in December This indicator remains red due to the four previous such falls reported in year. Number of claims for compensation received There were no claims for compensation received in December. Total number of claims received year to date is now 5. Indicator will remain red through the remainder of the year Clostridium Difficile (C Diff). A post 72 hour C Diff infection was diagnosed in a sample sent from a patient at Ludlow Hospital in December bringing our total for the year to four against a target of no more than two Grade Two Pressure Ulcers (Avoidable) There were a total of four grade two pressure ulcers reported in December of which one to date has been identified as avoidable. Recovery plan signed off Y NA Recovery date Immediate NA KPI change log New Red Indicators reported this month Removed red indicators (improved from last month) 9 Accountable Director: Ros Francke,

5.1 Caring Caring Indicators Indicator Dec-14 Jan-15 Feb-15 Mar-15 Apr-15 May-15 Jun-15 Jul-15 Aug-15 Sep-15 Oct-15 Nov-15 Dec-15 Actual YTD YTD YTD YTD Trend Target Status New Birth Visits % within 14 days 92.29 94.48 94.50 89.71 95.32 92.74 93.33 92.54 97.00 96.17 91.79 94.55?...? 90.00 Access to Healthcare for people with Learning Disability 100.00 100.00 100.00 100.00 100.00 100.00 100.00 100.00 100.00 100.00 100.00 100.00 99.65... 99.65 100.00 Single Sex Accomodation Breaches 0 0 0 0 0 0 0 0 0 0 0 0 0... 0 0

Access for People with LD In December our compliance against the target of 100% was 99.65%. This was because there was an unmet need reported relating to a patient in Rheumatology not receiving a reminder phone call about their appointment and therefore they did not attend. The service has reviewed their process to ensure a reminder of this requirement is on the patient s record and a reminder is set on the team calendar to telephone the patient before the appointment. A new appointment has been made for this patient. 11 Accountable Director: Ros Francke,

5.2 Responsive Responsive Indicators Indicator Dec-14 Jan-15 Feb-15 Mar-15 Apr-15 May-15 Jun-15 Jul-15 Aug-15 Sep-15 Oct-15 Nov-15 Dec-15 Complaints - % of action plans implemented (well founded complaints) to ensure continuous improve 100.00 100.00 100.00 100.00 100.00 100.00 100.00 100.00 100.00 100.00 100.00 100.00 100.00... 100.00 100.00 Complaints - acknowledged within 3 working days 100.00 100.00 100.00 100.00 77.00 100.00 100.00 100.00 100.00 100.00 100.00 100.00 100.00... 97.44 100.00 Complaints - upheld by the Ombudsman 0 1 0 0 0 0 0 0 0 0 0 0 0... 0 0 Complaints -(All) - % responded to within timescales 66.60 80.00 100.00 100.00 100.00 100.00 66.66 100.00 100.00 100.00 90.00 79.00 87.00... 91.41 95.00 CQC Conditions or Warning Notices 0 0 0 0 0 0 0 0 0 0 0 0 0... 0 0 Number of Claims for compensation received 0 1 0 0 2 0 1 0 1 0 0 1 0...... 5 0 Proportion of patients not treated within 28 days of last minute cancellation????? 0.00 1.00 0.00 0.00 0.00???... 0.20 0.00 18 week Referral To Treatment (RTT) for admitted patients 100.00 98.65 94.87 96.59 94.62 96.10 98.99 98.99 100.00 100.00 96.05 100.00?... 98.20 90.00 18 week Referral To Treatment (RTT) for non admitted patients 98.64 99.08 99.32 98.16 98.99 99.35 98.86 99.58 99.01 99.05 97.66 94.73?... 97.74 95.00 18 week Referral To Treatment (RTT) incomplete pathways 99.53 99.54 98.61 99.29 99.49 99.22 99.67 99.42 99.06 97.35 95.17 88.21?... 95.44 92.00 Community Equipment Store - Response within 7 days 99.19 99.28 99.31 99.16 99.23 99.15 99.15 99.21 99.10 99.04 99.19 99.19?... 99.16 99.00 Diagnostics for Audio/Ultrasound 100.00 100.00 100.00 100.00 100.00 100.00 100.00 100.00 100.00 99.52 100.00 100.00?... 99.96 99.00 District Nurse response within 24 hours (urgent) 89.29 97.69 98.73 96.89 98.77 100.00 98.56 100.00 100.00 100.00 98.99 99.02?... 99.36 100.00 District Nurse response within 48 hours (non-urgent) 96.53 99.47 96.83 96.24 98.79 97.16 98.72 100.00 99.30 99.17 100.00 98.98?... 98.95 100.00 MIU Assessment Times assessed within 15 minutes 100.00 100.00 100.00 100.00 100.00 100.00 100.00 100.00 100.00 100.00 100.00 100.00?... 100.00 95.00 MIU Percentage of people who leave MIU without being seen 0 0 0 1 0 0 1 0 1 0 1 0?... 1 5 MIU Total time in department - discharged within 4 hours 99.93 99.93 100.00 100.00 99.95 100.00 100.00 100.00 100.00 100.00 99.94 100.00?... 99.99 95.00 MIU Treatment Times (Arrival to Seen Time) - Median wait of 60 mins 6 7 7 8 9 8 10 12 10 10 11 8?... 10 60 MIU Unplanned Re-Attendances (within 7 days of discharge) 1.43 2.19 1.70 2.26 1.93 1.92 2.23 1.67 2.28 1.93 1.27 1.55?... 1.86 5.00 Outpatients > 6 week - consultant led 54.48 38.26 44.42 34.93 39.03 40.72 40.51 41.22 38.35 40.33 35.14 36.34?... 39.13 50.00 Outpatients > 6 week - non consultant led 26.10 27.86 38.10 24.57 24.54 20.56 24.41 29.60 32.05 34.99 12.92 38.91?... 24.97 50.00 Proportion of Delayed Transfers of Care 4.08 2.68 8.26 10.00 12.96 10.19 11.93 6.00 5.83 6.45 14.29 10.78 17.00... 17.00 3.50 Referral to Treatment Incomplete 52+ Week Waiters???? 0 0 0 0 0 0 0?? 0 0 Actual YTD YTD YTD Trend Target YTD Status

Number of claims for compensation received - There were no claims for compensation received in December. Total number of claims received year to date is now 5. Indicator will remain red through the remainder of the year. Delayed Transfers of Care (DTOC) The proportion of DTOC Increased from 10.78% in October to 17% in December against a target of 3.5%. Performance against this indicator is worsening due to problems in securing care packages for patients to be supported at home safely with the ICS team. Patients have to wait longer than usual for the start of care packages There are daily discussions with regards to bed based capacity and DTOC. A new discharge leaflet is being piloted at Ludlow in readiness for roll out to the other hospitals at the beginning of February. Proportion of patients not treated within 28 days of last minute cancellation. This indicator remains red as the year to date number of patients affected is one against a target of none. There have been no reported cancellations since that incident in June. District Nurse Response within 48 hours. November data shows 98.9% against a target of 100%.. The indicator remains amber for the year to date with compliance of 98.95%. District Nurse Response within 24 hours November data showed a figure of 99.02% against a target of 100%. Actions remain in place to achieve 100% target. recently identified coding anomaly in data quality report to teams which has now been rectified by Informatics. This will support achievement of target by December. No risk to patient care is identified. The indicator remains amber for the year to date with compliance of 99.36%. Waiting times A joint letter from NHS England, Monitor and TDA confirmed that the admitted and non-admitted RTT operational standards were to abolished in October 2015, and the incomplete standard would become the sole measure of patients constitutional right to start treatment within 18 weeks. NHS England also released a new version of the rules, these were updated to reflect that there is now no provision to report pauses or suspensions in RTT waiting time clocks in monthly RTT returns to NHS England under any circumstances. The Trusts Patient access policy is currently being revised to include the new rules around RTT that came into effect on 1 October 2015. This will be submitted for ratification to the committees in March 2016. To maintain transparency and ensure effective operational planning and delivery, the collection of information on admitted (unadjusted) and nonadmitted completed pathways will continue alongside the information on incomplete pathways 13 Accountable Director: Ros Francke,

Across the Trust there has been significant progress through the year in reducing the number of patients waiting over 18 weeks and the Trust continues to deliver compliance against the 18 week RTT incomplete Pathway. 18 week RTT Incomplete pathways. The actual November reported position for incomplete Pathways was 96.55% against the 92% target which was an improvement on the previous months reported position (95.17%) There is a noted drop in performance for 18 week RTT for non-admitted patients (detailed below), this indicator is no longer monitored nationally however the Trust continues to monitor this indicator locally as part of its Performance framework. Performance for November is 94.73% against a 95% target. 18 week RTT for non-admitted 14 Accountable Director: Ros Francke,

The target was not achieved mainly due to MSK with approximately 35 breaches partly due to inherited waiting times from SaTH with the commencement of the new MSK service along with the inclusion of the APCS which are now part of the report. APCS ENT had 9 breaches which were due to the increase in demand caused by reduced capacity within the local health economy. The Community Trust is over performing against contract for this service. Additional clinics have been performed to reduce the wait. The MSK service inherited waiting lists from SaTH and this also included APCS services who are part of the report. The APCS ENT service had an increase in demand due to the lack of capacity across the local health economy. The service is over performing against contracted levels and is providing additional clinics to reduce the waits. 18 week RTT for Admitted The actual November reported position for admitted Pathways was 100% against the 90% target which was an improvement on the previous months reported position (96.05%) NON RTT services Most services provided by the Trust do not meet the definition for monitoring waiting times against national waiting time targets however the Trust monitors waits for all areas The table below shows the numbers of patients waiting by service >18 weeks (open clocks) 15 Accountable Director: Ros Francke,

Community Hospitals Community Services Childrens and Families MSK 92 Wheelchair Service 164 CAMHS Tier 2 48 APCS - SC 70 Interdisciplinary Teams 147 Child Development Centre 27 APCS - TW 30 Falls 47 CAMHS Tier 3 18 Podiatry 28 Community Neuro Rehab Team 17 Community Paediatrics 6 Bridgnorth Hospital 13 Continence 5 Childrens Physiotherapy 5 Rheumatology 4 Diabetic Nursing 4 Childrens Occupational Therapy 4 Adult Physiotherapy (Blue Badge) 3 Pulmonary Rehab 1 School Nurses 2 Adult Physiotherapy 2 Respiratory - SC 1 CAMHS LAC Shropshire 1 Adult Occupational Therapy 0 Respiratory - TW 1 Enuresis 1 DAART 0 Moving & Handling 0 LAC Nurses 1 Ludlow Hospital 0 Tissue Viability 0 Childrens Speech and Language 0 Whitchurch Hospital 0 Community Paediatric Nursing 0 Podiatry (DFS Screening) 0 Nursery Nursing 0 Paediatric Psychology 0 Audiology 0 CAMHS Telford & Wrekin YOS 0 Children s and Families Division service manager update (Nicki Ballard) Children s OT- < 4% of children waiting over 18 weeks therefore within nominal target.- Continue to monitor Children s Physio< 4% of children waiting over 18 weeks therefore within nominal target. Continue to monitor Children s SLT- 0% of children waiting over 18 weeks therefore within nominal target.- Continue to monitor 16 Accountable Director: Ros Francke,

CDCs <26% of children waiting over 18 weeks, Risk assessment completed for every child. Formal bid for access to emergency Neuro Disability (ND) funds submitted to CCG Commissioners 21.12.15. Plan to clear backlog by 30.4.16 with additional funding advised Paul Devlin (PD) 4.1.16 who will liaise with Nicky Ballard (NB) re related CAMHS bid. PD advised progressing outcome of that bid with CCGs 4.1.16- awaiting call back meeting with Educational Psychology Service (EPS) and LA Commissioner re EPS options plan 7.1.16 [they contribute to MDA and have limited capacity] Long term options paper in response to increased referral trends submitted for comment 1.12.15 across MD team within and outside Trust. Feedback due 18.1.16 CAMHS have an action plan and have offered permanent staff additional hours to mitigate the potential risk of waiting times going up in Shropshire, with Dr Arshad finishing this week. Additional clinics have been appointed in Whitchurch and Oswestry to address waiting times for the community paediatricians Community Hospitals Division service manager update (Andy Mathews) Advanced Primary Care (APCS) APCS SC as previous reported these are ENT patients awaiting 1st appointment due to the service receiving too many referrals; this is being dealt with by way of a Contract Performance Notice with the CCG. APCS TW these are MSK patients which have been transitioned to the new MSK Service and do not apply to the CHOP report. Podiatry & APCS- After validating the waiting list report for podiatry, 18 patients are showing as waiting over 18 weeks due to their choice. All other waits for each of the departments disciplines are a true reflection of our current waits. Bridgnorth Community Hospital - Bridgnorth: there are 13 patients over 18 weeks listed and breakdown is as follows: Opthalmology = 11 and this relates to Visual fields and they are follow ups. Orthotics = 1 patient over 18 weeks and this is follow up T&0 = 1 patient on inpatient admitted list who will be at 18 weeks at date of TCI on 12th January and unable to bring forward. 17 Accountable Director: Ros Francke,

Telford Musculoskeletal Service (MSK) There are still a number of patients (1250) that still need adding to the MSK waiting list. The referrals have been validated and are all currently waiting between 0 and 4 weeks, scheduled completion for this backlog is the end of January 2016. The 1250 backlog patients have been added into the Trusts RTT reporting function and have been apportioned across the MSK specialties. As of December 2015 there is no impact on the 92% incomplete pathway performance as all additional patients are waiting between 0 and 4 weeks Concerns have been raised around the capacity available to deal with this additional demand, specifically when the this hump of activity moves through the longer waiting times bands up to and over possibly over 18 weeks. To mitigate this demand a capacity workshop has taken place and the modelling of required resources is continuing with a completion target of 26 th January. The modelling is looking at both delivery of the 18 week pathway and the delivery of 4 weeks RTT. Following completion of this work the Trust will engage with commissioners with a view of agreeing additional funding for resources to meet the increase in demand. It is anticipated that 80% of the additional demand is also going to be managed through available capacity in therapies rather than the traditional consultant pathway. Rheumatology all 4 breaches owing to lack of Consultant time and patient choice Community Services Division service manager update (Karen Taylor) There are 17 patients waiting 18+ weeks for community Neuro rehab (CNRT). All waits relate to internal waits between disciplines. A recovery plan is in place to improve this situation and a reduction of 76% is anticipated by mid-january. Actions to support patients with longer waits include weekly review at team meetings and support from other disciplines currently caring for each patient. 4 patients are waiting 18+ weeks within Diabetic nursing, 3 x waits relate to patients changing appointments (multiple appointments offered) 1 x relates to patient specifically choosing a date. All patients are offered telephone support during their wait 18 Accountable Director: Ros Francke,

There are 47 patients currently waiting 18+ weeks, recovery plan in place although currently activity below plans. Additional actions including work with voluntary sector and additional hours being worked are being implemented. Risk to those waiting above 18 weeks is mitigated by offering alternative support from IDT physio and telephone triage/support 147 patients reported as long waits within Interdisciplinary Teams. Waits relate to data quality issues / timeliness of data entry. Cleanse is underway recovery anticipated by April 16 CSM to support Team leaders. No risk to patient care. There is 1 respiratory wait above 18+ weeks. This is down to patient requests. Patient risk is managed by telephone support from the team offering alternative appoint times and venues and the possible impacts of delaying attendance The wheelchair services data collection system identifies all waits including internal waits between MDT. Capital bid being requested to upgrade system to provide more sensitive reporting. 164 patients currently identified as 18+weeks. The data collection shows both New and Referrals to the service. New referrals waiting above 18 weeks =11 of these 2 do not have a wheel chair however this is because they are age 1 & 2 and require additional seating support. All referrals have a current chair provision. Clinical triage and prioritisation reduce the risk of harm to patients waiting above 18 weeks. The service has a recovery plan in place and is continuing to make headway against targets within it. 19 Accountable Director: Ros Francke,

5.3 Effective Effective Indicators Indicator Dec-14 Jan-15 Feb-15 Mar-15 Apr-15 May-15 Jun-15 Jul-15 Aug-15 Sep-15 Oct-15 Nov-15 Dec-15 Actual YTD YTD YTD YTD Trend Target Status Data entry within 21 days 97.92 95.61 92.37 96.13 95.21 96.50 97.92 97.62 98.15 96.59 97.39 96.47 95.79... 96.86 100.00 Ethnic coding data quality 96.40 96.28 96.17 96.04 96.40 96.68 96.47 95.88 96.01 95.94 95.51 95.66 95.81... 96.04 85.00 Unallocated data 0.47 0.15 0.38 0.54 0.52 0.40 0.42 0.32 0.32 0.41 0.51 0.61 0.64... 0.46 0.50 Use of NHS number 97.89 97.92 97.65 97.76 97.90 97.95 97.81 98.23 98.40 98.69 98.38 98.29 98.66... 98.25 95.00 Bed utilisation (overall) 92.66 93.92 101.89 89.43 87.30 94.50 98.10 93.22 94.28 96.08 95.11 94.85?... 92.04 91.00 Deaths - unexpected 0 0 0 0 0 0 2 0 0 0 1 0 0... 3 0 Did Not Attend rates (DNA) 11.52 11.95 10.94 11.25 11.04 3.10 3.21 3.28 3.08 3.24 3.61 3.21?... 3.49 10.00 Length of Stay (overall) 17 17 17 19 18 19 20 19 18 18 20 21?... 19 20

Unexpected Deaths. There were no unexpected deaths reported in December but the indicator remains red due to the three that have been reported in the year to date. Data Entry within 21 days. All mandatory reporting requirements are already being met in line with national definition and timescales. This indicator is more relevant to the Non PBR services delivered in the community. The 2015-16 NHS Standard contract required some local reporting to Commissioners to be completed within 10 working days of the end of the month being reported. Shropshire Community Health NHS Trust were unable to fully comply with this requirement so as part of the Trusts Data Quality improvement plans (DQIP) the Trust agreed to reduce the reporting period time from the 7th day of the second month after the month being reported to comply with contract requirement for all local reporting requirements. The consequence of not achieving this target is not detailed within the contract (Subject to General Condition 9 (Contract Management)) however it is anticipated that no achievement will result in financial penalties through non-payment of activity due to information not being available within the contracted reporting timescales A phased approached to bringing the reporting timescales in line with the national standard was agreed and the milestone dates within the agreement were: Milestone date 1-31st March 2016 - Reporting within 28 days after the end of the month being reported. This brings forward from the 7th day of the second month following the reporting period, approx. 10 days earlier. Milestone date 2-31st March 2017-10 working days of the end of the month being reported. Discussions will need to take place between SCHT and Commissioner to agree options that will lead to improved reporting and possible access to real-time data reporting. There still remains a significant amount of data that is not being captured in a timely manner. The December data shows a compliance of 95.79% against a target of 100% for the 21 days target. All services with underperformance have recovery plans in place. In particular, ICS which equates to 50% of the backlog have been encouraged to review their recovery plan as progress against it has not been sustained. Additional recovery plans have been put in place regarding data inputting timeliness over the last year with a goal of inputting within 2 working days, this is going to be further supported with the introduction of 2 working day data entry KPI from mid-january to allow monitoring of performance. The 2 day KPI will replace the 21 day KPI in April 2016. 21 Accountable Director: Ros Francke,

5.4 Well Led Well Led Indicators Indicator Dec-14 Jan-15 Feb-15 Mar-15 Apr-15 May-15 Jun-15 Jul-15 Aug-15 Sep-15 Oct-15 Nov-15 Dec-15 Actual YTD YTD YTD YTD Trend Target Status Appraisal Rates 82.81 83.24 84.28 81.31 79.73 78.84 79.46 76.00 74.00 67.00 71.00 72.00 78.00... 78.00 90.00 Employee Numbers (FTE) 1,247... 1,250... 1,251... 1,253... 1,259... 1,268... 1,267... 1,255... 1,252... 1,257... 1,262... 1,274... 1,268...... 1,262... 1,286... Information Governance Requirements 71.22 69.77 73.80 95.33 90.75 88.75 85.75 87.92 88.02 87.68 86.89 85.63 86.29... 86.29 95.00 Leavers < 1 year in service (FTE) 1.25 0.00 1.08 1.63 0.00 0.00 1.00 1.64 1.88 1.20 0.84 1.70 0.58... 0.98 1.33 Leavers All (FTE) 0.78 1.17 1.02 1.09 1.15 0.68 0.96 1.35 0.88 1.11 0.79 1.11 1.16... 9.19 7.20 Other Mandatory Core Requirements 72.53 71.58 70.79 76.55 79.50 78.78 80.71 81.29 82.27 81.77 81.99 82.37 84.39... 84.39 85.00 Sickness absence - all 5.19 5.48 5.26 5.17 5.09 4.73 4.60 4.83 4.37 4.10 3.79 4.04 4.54... 4.45 3.39

Appraisal Rates. A renewed focus from the Operational Divisions has resulted in an improvement in December. This has been facilitated by: Detail on individual employees compliance supplied by HR to line managers Weekly updates by HR to divisional managers. In addition, Corporate Directorates will also receive monthly updates Leavers All (WTE). The number of retirees remain high as do the number of leavers not specifying a reason for leaving therefore it is difficult to understand whether there are underlying themes for people to leave the Trust Sickness Absence (All). We saw a 0.5% increase in the overall sickness rate in December. Much of this was described as being increased stress and anxiety and with particular hotspots in the IDTs. Support is provided to staff on an individual basis and the underlying cause of this stress is being investigated Other Mandatory Core Requirements. We have seen an improved compliance with this indicator and we are now less than 1% from the target of 85%. Information Governance Requirements. In December we saw a slight improvement in compliance 86.29% against a target of 9%. 23 Accountable Director: Ros Francke,

5.5 Safe Safe Indicators Indicator Dec-14 Jan-15 Feb-15 Mar-15 Apr-15 May-15 Jun-15 Jul-15 Aug-15 Sep-15 Oct-15 Nov-15 Dec-15 Actual YTD YTD YTD YTD Trend Target Status Clostridium Difficile - incidence rate???? 0.00 1.00 0.00 0.00 0.00 0.00 1.00 1.00 1.00... 1.00 0.00 Clostridium Difficile - Variance from plan 0 0 1 0 0 1 0 0 0 0???...?? MRSA bacteraemia rate 0 0 0 0 0 0 0 0 0 0 0 0 0... 0 0 Proportion of admissions screened for MRSA 100.0 100.0 96.5 98.8 100.0 100.0 98.9 100.0 100.0 99.0 100.0 99.2?...?? Central Alerting System (CAS) - Outstanding 0 0 0 0 2 1 1 1 1 1 1 1 1... 10 0 Falls - Number of Falls 28 22 29 37 28 28 19 34 15 19 19 19 24... 205 288 Falls - Number of Patients 26 19 19 30 23 21 17 26 12 15 13 18 19... 164 189 Grade 2 Pressure Ulcers - avoidable 0 0 0 5 0 0 0 0 0 1 0 1 0... 2 0 Grade 3 Pressure Ulcers - avoidable 1 0 0 0 0 0 0 0 0 0 0 0 0... 0 0 Grade 4 Pressure Ulcers - avoidable 0 0 0 0 0 0 0 0 0 0 0 0 0... 0 0 Medication Incidents that affect patients Safety 17 6 4 23 28 25 9 8 6 1 8 3 5... 93 0 Never Events 0 0 0 0 0 0 0 0 0 0 0 0 0... 0 0 Never events - incidence rate???? 0 0 0 0 0 0 0 0 0... 0 0 Never events - repeat events*???? 0 0 0 0 0 0 0 0 0... 0 0 Never events - time since last event*???? 0 0 0 0 0 0 0 0 0... 0 0 Safety Thermometer - harm free care 93.56 91.23 91.34 92.75 93.67 93.21 95.02 96.93 94.62 96.56 95.91 95.69 96.06... 95.30 95.00 Serious Incidents (all) 3 0 1 0 1 3 2 1 2 1 4 4 0... 18 0 Serious Incidents - falls 0 0 0 0 0 0 0 2 1 0 0 1 0... 4 0 Serious Incidents rate??????? 0.00?????? 0.00 VTE Venous Thromboembolism Risk Assessment 93.33 95.27 95.10 95.56 92.95 93.70 92.64 95.33 90.34 90.65 94.17 94.31 95.80... 93.32 95.00 WHO Surgical Checklist Compliance Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes... Yes Yes

Clostridium Difficile (C Diff). A post 72 hour C Diff infection was diagnosed in a sample sent from a patient at Ludlow Hospital in December. The patient was a known C diff carrier on admission and had several courses of antibiotics prior to admission and has required more since admission. The CDI ribotyping is the same as the carrier, therefore indicating that the patient did not acquire the infection at Ludlow. A full post infection review is being carried out and a review meeting will be held following which the case will be monitored through the Infection Prevention and Control group. Serious Incidents Falls. There were no falls reported as serious incidents in December. Investigations related to the one reported in November are on-going Central Alerting Systems Outstanding Alerts. The Fire Stopping alert remains open. Work is nearing completion and it is anticipated that the alert will be closed shortly. Pressure Ulcers (Grade 2 Avoidable) There were a total of four grade two pressure ulcers reported in December of which one to date has been identified as avoidable. The patient was being cared for at home. VTE Assessment. The figures have improved for December and we are compliant against the Trust Target of 95% (95.80%). The Community Hospitals have been working hard to support our local GP partners to be compliant with completing VTE assessments in a timely manner. This has been supported by a change in documentation and VTE being discussed regularly at the Medical Advisors meetings. The indicator remains Amber as the YTD actual is 93.32 against the 95% target 25 Accountable Director: Ros Francke,

5.6 Designed Around the Patient Designed around the Patient Indicators Indicator Dec-14 Jan-15 Feb-15 Mar-15 Apr-15 May-15 Jun-15 Jul-15 Aug-15 Sep-15 Oct-15 Nov-15 Dec-15 Actual YTD YTD YTD YTD Trend Target Status ICS - Admission Avoidance? 12 12 12 12 12 45 49? 154 396 ICS - Average Length of Stay ICS? 24 21 20 23 25 24 25? 23 24 ICS - Community Hospital (Average LOS) Discounting P3 D2A 20 19 19 20 19 18 20 21? 19 20 ICS - Core Team WTE Per Week? 77 54 62 70 70 69 69? 471 450 ICS - Discharged No Further Support? 69.74 77.00 72.00 74.00 74.00 74.33 73.68? 73.54 65.00 ICS - DTOC Delayed Days across all hospital settings (SATH, CH s & Redwoods, OOC)? 937 991 950 950 931 1,334 0? 870 664 ICS - Integrated Community Services staus Level 1 - Normal Work... ICS - Maximum ICS Domiciliary Care Hours Per Week? 7,303 6,690 6,690 6,230 6,740 8,545 6,945? 49,143 44,262 ICS - MFFD Average Wait? 5??????? 5 3 ICS - Timely Supported Discharge Per Week? 34 31 34 34 37 43 42? 37 45 ICS Readmission Overall 19 19 19 19 19 19 17 17? 18 20 NI 125? 83.08 79.45 79.50 82.50 83.60 83.10 90.15? 83.05 82.40 Level 1 - Normal Work... Level 1 - Normal Work... Level 1 - Normal Work... Level 1 - Normal Work... Level 1 - Normal Work... Level 1 - Normal Work... Level 1 - Normal Work...?... Level 1 - Normal Work... Level 1 - Normal Work...

Urgent Care December 2015 position High level Overview/ Performance Summary Economy MIU KPI Target Actual Status Overal Rating A&E 4 Hour Waits (October postion) 95% 90% Medically fit for Discharge (MFFD) 45 avg 79 DToC - data to be sourced KPI Target Actual Status Overal Rating A&E 4 Hour Waits (MIU) 95% 100% A&E Left Without Being Seen 5% 0.00% A&E Time to Initial Assessment 95% <=15 mins 100% A&E Time to Treatment Decision 60 Mins 100% A&E Unplanned Re-Attendance Rate 5% 2% Total time in department (Arrival to Discharge) 95% <=4 hrs 100% Community Hospitals ICS KPI Target Actual Status Overal Rating Bed utilisation (overall) November position 91% 94.9% Length of Stay (overall) November position 20 21 Proportion of delay transfer of care 3.50% 17.00% Readmission (overall) KPI Target Actual Status Overal Rating Length of Stay (overall) (23 days) 23 24 Admission Avoidance (overall) 124 49 Early Supported Discharge (overall) 180 43 Readmission (overall) 20% 16.6 Ni125 (83%) 83.0% 83.1% The above table shows the high level overview for the urgent care measures. Data collection and reporting on some of these indicators continues to be progressed and a fully completed dashboard is expected to be in place for the November reporting cycle. 27 Accountable Director: Ros Francke,

Domiciliary Hours - The Domiciliary Care hours continue to be under extreme pressure which has been increased by the delay in access to the increased care hours planned to be rolled out on November 2015. This Preferred Provider provision of care hours will now deliver up to 1500 care hours per week by mid-january although there are still gaps in some localities and a backlog of people waiting for care at home. Patient s needs are being monitored during the time that they are waiting for care. Early supported discharge Early Supported Discharge is increasing however dependent on SATH discharge decisions. Current performance shows below demand (45 per week). This is due to discharge to assess pathways supporting more patients through pathway 2 or 3 bed (based rehabilitation/long term placement) than initially modelled. The ICS Lead is working with the Commissioner for ICS to engage with key stakeholder to encourage appropriate use of the service. The service has rolled out extended working. The ICS workforce are now available between 08.00hours and 20.00 hours, 7 days a week. Admission avoidance Admission avoidance pathways are now fully implemented and are now being promoted and embedded. Demand and delivery is below trajectory (31 per week) which may in part be due to reduced Primary Care access due to the holiday period. A number of actions have been agreed to increase demand including increased use of CCC, presence in A&E, promotional activity in care homes and with GP s. These activities are due to be completed by 18/01/16 Appropriate referrals - There remain high numbers of not appropriate referrals to ICS, in particular to Central ICS who receive referrals from SATH for the whole county. This is due to the process for early warning from SaTH to ICS which is received too early in the discharge planning process. Implementation of the Trusted Assessor process commenced in December which, when fully embedded should address this problem, the ICS Lead is now working with SATH to embed this. Resolving this issue will create capacity for ICS and SaTH. Economy wide DToC - Whole system performance is significantly above target (low is good) a number of schemes within the Urgent Care Recovery plan is looking to address this problem. For ICS these areas include implementation of the ICS preferred provider framework which will ensure timely access to domiciliary care this is being introduced in a phased approach with the intended full implementation planned for the beginning of December 2015, implementation was delayed as many providers are experiencing difficulty in recruitment of domiciliary care staff only 56% capacity was achieved by 06/12/2015 (now increased to 78%). A revised plan is in place with Preferred Providers which will see 100% capacity by 18/01/2016.. Prior to Christmas 2015 some patients moved into alternate settings in care/residential homes while they were waiting for care. Numbers on the MFFD list Not able to monitor this indicator as no mechanism to capture. 28 Accountable Director: Ros Francke,