SOMERSET PARTNERSHIP NHS FOUNDATION TRUST PERFORMANCE REPORT Report to the Trust Board 24 March 2015 Sponsoring Director: Author: Purpose of the report: Key Issues and Recommendations: Director of Finance and Business Development. Associate Director Strategic Planning and Performance. Senior Performance Manager. This report presents the main issues, in relation to the performance of Somerset Partnership NHS Foundation Trust against its key targets, as at 28 February 2015. The Trust met all applicable standards contained with the Monitor Risk Assessment Framework. The Trust also met all of its CQUIN measures and the majority of its other compliance standards for measures contained on the Corporate Dashboard. Areas in which the Trust is performing well include: M10: Emergency admissions of 18 to 65 year olds (mental health): During February 2015, all emergency admissions were appropriately gate kept; M16: Delayed discharge rate (mental health) inpatient wards: During February 2015 the Trust achieved a delayed discharge rate of 3.7% against a required compliance standard of 7.5% or less; C1.3a: Friends and Family Test (community hospitals): during the period 1 February to 28 February 2015 a rate of 54.1% was recorded, against a required standard of 30% or more; C1.3b: Friends and Family Test (minor injury units): during the period 1 February to 28 February 2015 a rate of 71.4% was recorded, against a required standard of 20% or more; C2.1a and C2.1b: Reduction in Pressure Ulcer Incidence: Both measures relating to incidence of avoidable pressure ulcer damage relating to community hospital and community district nursing are within the set CQUIN trajectories for period 1 April to 31 January 2015; March 2015 Public Board - 1 -
C6: Consultant Review of young people presenting with Eating Disorder: 100% of patients diagnosed were seen inside the six week standard against a standard of 90% or more; 5b. Where there is a registered carer, a carer's assessment has been offered and, if not declined, this has been carried out: a rate of 98.8% was recorded during February 2015, against a compliance rate of 95% or more; 6a Percentage of Improving Access to Psychological Therapies (IAPT) treatment population entering treatment: during February 2015, a total of 1,388 patients had had a first therapeutic session, against a target trajectory of 1,117; 6b. Percentage of Improving Access to Psychological Therapies (IAPT) treatment population moving to recovery: during February 2015 a rate of 66.6% was recorded against a required compliance standard of 50% or more. Other corporate dashboard indicators meeting the Trust s exception reporting criteria during February 2015 were: 1: Clients referred by primary care to mental health offered first appointment within three weeks. The rate recorded during February 2015 improved to 93.6%. This indicator includes the performance of the Child and Adolescent Mental Health service, which is temporarily working to a six week standard; 3: Psychiatric readmissions. The rate increased to 11.9%, with ten out of 84 admissions being patients who had been discharged within the previous 28 days; 10: Monthly percentage of community hospital bed days lost due to delayed discharges, as a proportion of the total number of occupied bed days. The actual rate for February 2015 decreased to 10.5%. Patients awaiting residential or nursing home placements accounted for the greatest numbers of bed days lost; 11: Mandatory Training. As at 28 February 2015, the overall compliance rate for the Trust was 92.0%. Of the Trust s 18 mandatory training courses, 12 courses had rates above the 90% compliance standard; March 2015 Public Board - 2 -
12: Staff Sickness Absence Rate. Sickness absence for January 2015, the latest month for which information is available, was 5.0%. As outlined in the December 2014 and the Quality Report to the Trust Board, the Trust opened additional bed capacity in late December 2014, in West Mendip, Dene Barton Luke ward, Wincanton Athlone ward and Wincanton Hadspen ward. This was in order to help alleviate pressures at Yeovil District Hospital NHS Foundation Trust and Taunton and Somerset NHS Foundation Trust, which were delivering care in higher than anticipated numbers of escalation beds, some of which were not in designated ward areas. Since the inception of the arrangements outlined above, there have been no breaches in respect of sleeping accommodation. All occurrences relating to bathroom/toilet facilities have been reported locally to Somerset Clinical Commissioning Group. Actions required by the Board: The Board is requested to discuss and note the report. March 2015 Public Board - 3 -
March 2015 Public Board - 4 -
March 2015 Public Board - 5 - SOMERSET PARTNERSHIP NHS FOUNDATION TRUST PERFORMANCE REPORT Table 1: Corporate Dashboard Indicators Meeting Exception Reporting Criteria during February 2015 No. Measure Description Exception Reporting Criteria Values 1 (Dashboard page 4) Clients referred by primary care to mental health offered first appointment within three weeks Any month performance falls below 95% February 2015: 93.6% Compliance Target: 95.0% Underperformance against the three-week standard relates principally to the Child and Adolescent Mental Health Service (CAMHS), which continues to work to the temporarily agreed six week waiting time standard. Of a total of 751 patients, 48 were outside of the three week standard, of whom 44 were CAMHS patients. Excluding CAMHS, the compliance rate against the three-week standard for February 2015 was 99.3%, an increase on the compliance rate of 98.2% recorded in January 2015. The CAMHS compliance rate against the revised six week standard for February 2015 was 100%. 3 (Dashboard page 4) Psychiatric emergency readmission rate within 28 days of discharge. Performance below the compliance target February 2015: 11.9% Compliance Target 10% The percentage of readmissions increased during February 2015, with 10 out of 84 admissions being patients who had been discharged within the previous 28 days. Patients are only discharged after careful planning with teams and their care co-ordinator. Psychiatric readmission rates relate to when someone is discharged and then readmitted within 28 days. Some may have been a planned readmission, e.g. a patient with a personality disorder is discharged and then presents at A&E as they cannot manage in the community. Their care plan may say they can be readmitted if in distress although most people with a personality disorder do not benefit from time in hospital. Data relating to psychiatric readmissions is received by Ward Managers to review individual patients and provide responses to the Head of Division as to the reasons for readmission, to help identify trends or areas of concern.
No. Measure Description Exception Reporting Criteria Values 10 (Dashboard page 5) Monthly percentage of community hospital bed days lost due to delayed discharges, as a proportion of the total number of occupied bed days. Any month in which the rate is above the 3.5% standard. February 2015: 10.5% Compliance Target: 3.5% The number of community hospital bed days lost due to delayed discharges during February 2015 was 744, a decrease on the number reported during January 2015, which totalled 838. The percentage rate also decreased, from 10.6% in January 2015 to 10.5% in February 2015. Of the 744 days, 596 (80.1%) were recorded as attributable to Social Services, a decrease in the percentage of 82.7% reported in January 2015. During February 2015, Dene Barton and Wincanton Community Hospitals had rates of bed days lost due to delayed discharges of over 25%. The categories between which the numbers of occupied bed days lost were split during the month of February 2015 were as follows: Awaiting care home placement/residential/nursing home: 397 bed days lost (Social Services 381 days, Both 16); Awaiting completion of assessments: 168 bed days lost (NHS 28 days, Social Services 107 days, both 33 days); Awaiting further non acute NHS care: 56 bed days lost (NHS 28 days, Social Services 28); Awaiting patient or family choice: 43 bed days lost (NHS 15, Social Services 28 days); Awaiting care package in own home: 42 bed days lost (Social Services 42 days); Disputes: 28 bed days lost (NHS 28 days); Awaiting community equipment: 10 bed days lost (Social Services 10). Numbers of delayed transfers of care are monitored and discussed as standard agenda items on a weekly basis via the strategic calls set up and hosted by Somerset Clinical Commissioning Group, covering winter pressures. These calls have director level participation from the three Somerset Foundation Trusts and Adult Social Care and are chaired by the Managing Director of the Clinical Commissioning Group. Social care attributable delays and the current efforts being made by Adult Social Care to address the current situation are central points of discussion at present. The Trust s Chief Operating Officer has also written to the Interim Director of Adult Social Care to raise formally the issue of the deteriorating position on delayed transfers of care, requesting immediate action and making suggestions to address this issue. This letter is being further followed up with a meeting, scheduled to take place before the end of March 2015. March 2015 Public Board - 6 -
No. Measure Description Exception Reporting Criteria Values 11 (Dashboard page 5) Mandatory Training If the composite rate is 90% or above, but compliance rates for any individual training courses are below 90%, the composite rate will be traffic-lighted Amber and details of those courses will be included in the exception report. G February 2015: six of the Trust s 18 mandatory training courses had compliance rates below 90%. The overall compliance rate in respect of mandatory training as at 28 February 2015 was 92.0%. Twelve of the Trust s 18 mandatory training courses had compliance rates above the 90% standard, the same number as in January 2015. The six courses with compliance rates below the required standard were: Infection Control: 89.5% (down from 90.1% in January 2015); Information Governance: 89.4% (down from 89.7%); Moving and Handling Level 2 (Patients): 88.8% (down from 89.7%); Basic Life Support: 87.7% (down from 88.2%); Preventing, Managing Violence and Aggression Module 2: 87.7% (down from 88.2%); Immediate Life Support: 80.7% (up from 80.1%). A new Learning Management System is due to be implemented from 1 April 2015. This e-learning system will be more accessible for staff, and will enable team managers to manage their staff training needs proactively whilst ensuring that operational duties are subject to the minimum disruption. However, the implementation of the new system will mean that data for mandatory training compliance rates will not be available for around two months. The Trust s Learning and Development Business Partners work with Heads of Division, managers and staff on all areas of training to ensure that sufficient numbers of places are available on all training courses and that the managers and staff are aware of other options available for accessing training. Specific actions are being taken in respect of the courses specified above are as follows: Infection Control Of a total of 3,545 staff eligible to undertake this course, it requires another 19 staff to complete their training in order for the compliance standard to be met. It is expected that the 90% standard will be achieved in March 2015. March 2015 Public Board - 7 -
No. Measure Description Exception Reporting Criteria Values Information Governance The Learning and Development Business Partners continue to focus on this area of training, which is readily available as an e-learning package and Test your knowledge. Workshops continue to be delivered for staff who have difficulty in accessing the e-leaning module, and further workshops are scheduled for the coming weeks; Moving and Handling Level 2 (Patients) Additional trainers are now available which has resulted in more training dates being made available to ensure that there is sufficient course availability. Learning and Development Business Partners are working with team managers to ensure that staff whose training has expired are booked to attend this training; Basic Life Support and Immediate Life Support and Immediate Life support The Learning and Development Business Partners, along with the Heads of Service, will review all current non-compliant staff and staff whose training is due to expire in the near future, to ensure dates are booked to attend the appropriate course. Action is also to be undertaken to reduce the loss of course places due to staff not attending training places which have been booked. The Learning and Development team has taken a targeted approach to these two courses in March 2015, circulating lists to Heads of Division, of staff whose training has expired, with a request that staff are booked into training sessions, and their booked dates confirmed to the Learning and Development team within one week; Preventing, Managing Violence and Aggression The Learning and Development Business Partners and instructors of Preventing and Managing Violence and Aggression are focusing on compliance in this area, working with staff and managers to ensure that all staff access the course in a timely manner. Availability of courses remains under review. 12 (Dashboard page 5) Staff Sickness Absence Rate Any month in which the rate is above the 4% standard. January 2015: 5.0% Compliance target: 4.0% Sickness absence for January 2015, the latest month for which information is available, was 5.0%. During the period from 1 October to 31 December 2014, a total of 13,642 days were lost due to sickness/absence, and of this total 3,719 days were attributable to stress/anxiety. The number of episodes of sickness absence shows a steady reduction since October 2014. In recent months, there has been a key focus on developing return to work plans for staff who continue to remain off work with long term sickness. The Human Resources Team and Operational Managers have developed plans, tailored to meet individual needs to ensure a return to work. March 2015 Public Board - 8 -
No. Measure Description Exception Reporting Criteria Values Additionally, the Leading the Health and Wellbeing of My Team leadership module has been implemented, supporting managers to take time out to reflect on how they can lead and empower their teams to work with pressure at work and contribute to managing stress and anxiety. The Director of Workforce and Human Resources is also reviewing the Well@Work Service. Workforce and Human Resources teams are also reviewing different ways for people to cope with stress, and in the coming months will focus on more targeted work with teams where sickness is higher than average within the Trust. March 2015 Public Board - 9 -
Links to Strategic Themes: Identify to which of the Somerset Partnership NHS Foundation Trust strategic themes this report relates by including a cross behind the relevant theme(s) Quality and X Innovation Viability and Growth Integration X Culture and People X Links to the Assurance Framework: Links to the NHS Constitution and Trust Values: Links to CQC Domains: Identify to which risks of the Assurance Framework this report relates the Trust fails to make optimal use of available capacity in its community hospitals and mental health inpatient wards; failure to achieve the CQUIN targets will mean the Trust has to deliver a great cost improvement programme to achieve its surplus target; the Trust fails to secure targeted commissioned business which impacts on income and reputation; the Trust fails to achieve safer staffing requirements leading to poorer patient care and potential CQC intervention. Identify the Values to which the issues raised in this report relate by including a cross behind the relevant value(s Working together for patients Respect and dignity Commitment to quality of care X X Compassion Improving lives X Everyone counts Identify which of the CQC domains are covered by this report by including a cross behind the relevant domain(s) Is it safe? X Is it caring? X Is it well-led? Is it effective? X Is it responsive to people s needs? X March 2015 Public Board - 10 -
Public/Staff Involvement History: Previous Consideration: Legal or statutory implications/ requirements: not applicable. performance reports are presented to the Board on a monthly basis. the Trust is required to comply with the performance targets set out in the Clinical Commissioning Group contract with the Trust and the performance targets set out in the Monitor Risk Assessment Framework. March 2015 Public Board - 11 -
SOMERSET PARTNERSHIP NHS FOUNDATION TRUST CORPORATE DASHBOARD: FEBRUARY 2015 Strategic Theme Measure Thresholds Sep-14 Oct-14 Nov-14 Dec-14 Jan-15 Feb-15 Trend Monitor M1. Referral to Treatment Waiting Times: 90% of patients treated within 18 weeks: Admitted hospital based (Completed) >= 90% = Green <90% = Red 95.0% 90.0% M2. Referral to Treatment Waiting Times: 95% of patients treated within 18 weeks: Non Admitted hospital based (Completed) >= 95% = Green <95% = Red 99.1% 99.2% 98.5% 97.2% 97.8% 98.7% 98.0% 96.0% M3. Referral to Treatment Waiting Times: 92% of patients waiting within 18 weeks: (Incomplete) >= 92% = Green <92% = Red 99.6% 99.3% 99.2% 99.6% 99.4% 99.4% 99.0% 98.0% M4. Percentage of Minor Injury Unit patients waiting under four hours from arrival to admission, transfer or discharge >=95%=Green <95%=Red 99.8% 99.8% 99.6% 99.7% 99.9% 99.7% 99.5% 99.0%, Quality and M9a. Percentage of clients on CPA (Level 2) seen within 7 days of discharge <95% = Red 98.5% 98.6% 98.6% 96.7% 97.1% 96.6% 97.5% 95.0%, Quality and M9b. All recovery care plans (level 2) to be reviewed at least annually Based on care co-ordinator contacts <95% = Red 98.8% 96.6% 96.6% 96.9% 96.9% 95.9% 95.0% 90.0%, Quality and M10. Emergency Admissions of 18-65 year olds via crisis support services <95% = Red 98.2% 98.4% 96.8% 96.6% 98.5% 95.0% 90.0%, Quality and M11. Meeting commitment to serve new psychosis cases by early intervention teams. >=174 = Green <174 = Red 189 183 187 190 185 186 195 185 175 M16. Delayed discharge rate as a percentage of total bed days available for people over 18 in acute beds (mental health). <=7.5% = Green >7.5% = Red 4.3% 5.4% 4.7% 4.8% 3.9% 3.7% M17. Mental Health Data Completeness: Identifiers >=97% = Green <97% = Red 99.8% 99.8% Reported Quarterly M18. Mental Health Data Completeness: Outcomes for patients on CPA >=50% = Green <50% = Red 79.9% 79.0% Reported Quarterly M20a. Data completeness: community services Referral to treatment information >=50% = Green <50% = Red Reported Quarterly M20b. Data completeness: community services Referral information >=50% = Green <50% = Red 91.1% 93.9% Reported Quarterly Page 1 of 5
SOMERSET PARTNERSHIP NHS FOUNDATION TRUST CORPORATE DASHBOARD: FEBRUARY 2015 Strategic Theme Measure Thresholds Sep-14 Oct-14 Nov-14 Dec-14 Jan-15 Feb-15 Trend M20c. Data completeness: community services Treatment activity information >=50% = Green <50% = Red 98.5% 98.9% Reported Quarterly CQUIN Patient Experience C1.1 Friends and Family Test: Implementation of Staff Friends and Family Test (Implementation by 30 June 2014) Implementation: by 30 June 2014 Implemented within required timescale and evidence submitted to CCG Patient Experience C1.2 Friends and Family Test: Implementation of Mental Health Inpatients Friends and Family Test (Implementation by 31 October 2014) Implementation: by 31 October 2014 Implemented within required timescale and evidence submitted to CCG Patient Experience C1.3a. Friends and Family Test: Increased Response Rate - Community Hospitals (Response rate of 30% in Quarter 4 of 2014/15) >=30% = Green <30% = Red 50.2% 60.5% 54.1% Patient Experience C1.3b. Friends and Family Test: Increased Response Rate - Minor Injury Units (Response rate of 20% in Quarter 4 of 2014/15) >=20% = Green <20% = Red 50.3% 60.3% 71.4%, Patient Experience C2.1a Reduction In Pressure Ulcer Incidence in Community Hospital inpatients (By Q4 achieve 40% reduction (6 cases only) compared to the reported 2013/14 number of incidents of avoidable pressure ulcer Grade two and above) Jan 15 <=5 cases = Green >5 = Red 4 4 4 4 4 Data being validated (Cumulative numbers for the year to date), Patient Experience C2.1b Reduction In Pressure Ulcer Incidence of patients on the District Nurse caseload (excluding patients resident in a care home) (By Q4 achieve 15% reduction (39 cases only) compared to the reported 2013/14 number of incidents of avoidable pressure ulcer Grade two and above) Jan 15 <=30 = Green >30 = Red 15 18 21 24 25 Data being validated (Cumulative numbers for the year to date) Page 2 of 5
SOMERSET PARTNERSHIP NHS FOUNDATION TRUST CORPORATE DASHBOARD: FEBRUARY 2015 Strategic Theme Measure Thresholds Sep-14 Oct-14 Nov-14 Dec-14 Jan-15 Feb-15 Trend, Patient Experience C2.2. Pressure Ulcer Prevention To identify the top 10 sources of non trust acquired incidents within Trusts patient population and work collaboratively with agencies and organisations to raise awareness (Q1 confirm top ten, Q2 develop a training and implementation plan and Q4 demonstrate plan has been delivered) Q4 Demonstrate training programme has been delivered Developing a training plan to be implemented Training plan being rolled out. To report compliance to agreed rollout plan to Somerset Clinical Commissioning Group after 31 March 2015. Effectiveness C3.1.1. Percentage of patients aged 75 and over who have been asked the dementia screening question within 72 hours following admission to hospital. (CQUIN Target: 90% or more over each quarter relating to 3.1.1, 3.1.2 and 3.1.3) >=90% = Green <90% = Red Effectiveness C3b. Percentage of patients aged 75 and over screened as at possible risk of dementia who have had a dementia risk assessment during the admission stay. (CQUIN Target: 90% or more over each quarter relating to 3.1.1, 3.1.2 and 3.1.3) >=90% = Green <90% = Red Effectiveness C3c. Percentage of patients aged 75 and over, identified as at risk of having dementia (positive or inconclusive assessment outcome) who are referred for further diagnostic advice or follow-up. (CQUIN Target: 90% or more over each quarter relating to 3.1.1, 3.1.2 and 3.1.3) >=90% = Green <90% = Red Effectiveness Named Consultant Identified Named consultant identified Effectiveness 3.2 Dementia Clinical Leadership (Continue rollout of dementia training) Rollout of dementia training 83.8% (3,016 staff of 3,600 trained) Effectiveness C3.3 Supporting Carers of People with Dementia: Provider must demonstrate that they have undertaken a monthly audit of carers of people with dementia (Undertake monthly audits and provide quarterly reports to commissioner on findings) Undertake monthly audits Report presented to Somerset CCG. Audit being undertaken. Page 3 of 5
SOMERSET PARTNERSHIP NHS FOUNDATION TRUST CORPORATE DASHBOARD: FEBRUARY 2015 Strategic Theme Measure Thresholds Sep-14 Oct-14 Nov-14 Dec-14 Jan-15 Feb-15 Trend Effectiveness C4. Cardio Metabolic Assessment for Patients with Schizophrenia (By Q3 Demonstrate through a national audit process full Complete audit by implementation of appropriate processes for assessing, 31 December 2014 documenting and acting on cardio metabolic risk factors in patients with schizophrenia) Audit data completed within agreed deadline of 31 December 2014 and submitted in accordance with the required submission of 16 January 2015. C5. Patients on CPA: Communication with General Practitioners (Undertake two audits, one during Q2 and one in Q4 and achieve 90% in second audit) >=90 = Green <90% = Red Report presented to Somerset CCG Audit to report compliance in respect of Q4 is planned to be undertaken between 19 and 20 January 2015 92% Effectiveness C6. Consultant Review of young people presenting with Eating Disorder (ED) according to the ED Pathway Diagnosed patients are seen by a Consultant Psychiatrist within 6 weeks of diagnosis being recorded. (Q1 set baseline, Q2 70%, Q3 80% and Q4 95% or non more than one breach if patient cohort under 10 patients) <95% = Red 90.0%, Patient Experience, Quality and C7. Personalised Care Plans for Patients with identified long term conditions (Q1 identify suitable patient cohort, agree template and sharing mechanism and pilot use, Q2 Set baseline, Q3 achieve 25% and Q4 achieve 50% compliance to agreed baseline) 1. Clients referred by primary care to mental health offered first appointment within 3 weeks. (2010/11 CQUIN Target - 95%) 2. Percentage of all adult inpatients who have had a venous thromboembolism risk assessment on admission to hospital using the clinical criteria of the national tool during the month (2013 CQUIN Target - 95%) >=50% = Green <50% = Red Local >=85% and <95% = Amber <85% = Red >=85% and <95% = Amber <85% = Red Baseline reported to Somerset CCG 69.2% To be reported at the end of the quarter. 93.9% 93.1% 92.5% 91.5% 87.1% 93.6% 98.5% 98.5% 96.1% 97.6% 97.5% 95.6% 92.5% 85.0% 97.5% 95.0%, Quality and 3. Psychiatric emergency readmission rate within 28 days of discharge. <=10% = Green <=12% and >10%=Amber >12% = Red 13.0% 10.8% 15.6% 9.6% 9.9% 11.9% 20.0% 10.0% 0.0% Page 4 of 5
SOMERSET PARTNERSHIP NHS FOUNDATION TRUST CORPORATE DASHBOARD: FEBRUARY 2015 Strategic Theme Measure Thresholds Sep-14 Oct-14 Nov-14 Dec-14 Jan-15 Feb-15 Trend, Quality and, Quality and, Quality and, Quality and 4. Clients on CPA to have a crisis plan 5a. For new mental health clients, an identified carer who provides regular and substantial care must be registered. 5b. Where there is a registered carer, a carer's assessment has been offered and, if not declined, this has been carried out. 6a. Percentage of IAPT treatment population entering treatment 15% of IAPT treatment population having a first therapeutic session (During Q4 2,038 patients to have had a first therapeutic session) >=90% = Green >=85% and <90% = Amber <85% = Red 90% = Green 80% - <90% = Amber <80% = Red >=80% and <95% = Amber <80% = Red Feb 15 1,117 patients >=1,117 = Green <1,117 = Red 91.2% 91.6% 91.3% 91.5% 90.5% 91.3% 90.2% 90.7% 90.7% 90.5% 91.0% 90.0% 95.1% 99.0% 98.9% 98.0% 96.6% 98.8% New measure 512 1,388 90.0% 80.0% 94.0% 91.0% 88.0% 96.0% 92.0% Jan-00 Jan-00 6b. Percentage of IAPT treatment population moving to recovery (As at 31 March 2015 achieve 50%) >=50% = Green <50% = Red 47.4% 51.3% 69.8% 67.5% 57.7% 66.6%, Quality and, Quality and 7. Recording of service user ethnicity 8. Monthly percentage compliance with hand hygiene audit standards 9. Monthly percentage compliance with hospital cleanliness audit standards 90% = Green 80% - <90% = Amber <80% = Red Local target 90%-to <95% = Amber <90% = Red 90%-to <95% = Amber <90% = Red 95.2% 95.2% 95.2% 95.2% 95.1% 95.1% 97.2% 98.2% 98.6% 97.2% 97.8% 98.2% 98.7% 98.9% 98.8% 98.7% 98.6% 98.8% 96.0% 92.0% 88.0% 95.0% 90.0% 95.0% 90.0% 10. Monthly percentage of community hospital bed days lost due to delayed discharges, as a proportion of the total number of occupied bed days (Contract Target: 3.5% in all months) <=3.5% = Green >3.5%- to <=7.5% = Amber >7.5% = Red 11.1% 8.5% 10.9% 11.0% 10.6% 10.5% Culture and People Culture and People 11. Mandatory Training Aggregate percentage of staff who have received appropriate statutory and mandatory training * - the compliance rates for all individual mandatory training courses must be 90% or higher in order for the composite rate to be rated Green 12. Staff Sickness Absence Rate >=90% = Green 85% - <90% =amber <85% =red <=4%= green >4% to <=5% =amber >5% =red 93.4% 93.5% 93.1% 92.6% 92.4% 92.0% 5.2% 5.3% 5.0% 5.1% 5.0% Data awaited 96.0% 93.0% 90.0% Jun-14 Oct-14 Feb-14 Page 5 of 5