SOMERSET PARTNERSHIP NHS FOUNDATION TRUST PERFORMANCE REPORT Report to the Trust Board 27 January 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 31 December 2014. The Trust met all applicable standards contained with the Monitor Risk Assessment Framework. The Trust also met all of its CQUIN measures and majority of its other compliance standards for measures contained on the Corporate Dashboard. Areas in which the Trust is performing well include: M16: Delayed discharge rate (mental health) inpatient wards: During December 2014 the Trust achieved a delayed discharge rate of 4.8% against a required compliance standard of 7.5% or less; C1.3a: Friends and Family Test (community hospitals): during the period from 1 October to 31 December 2014 a rate of 60.5% was recorded, against a required standard of 30% or more; C1.3b: Friends and Family Test (minor injury units): during the period from 1 October to 31 December 2014 a rate of 60.3% 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 2014 to 30 November 2014; 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; January 2015 Public Board - 1 -
3: Psychiatric emergency readmissions. The rate recorded during December 2014 was 9.6%, against a Trust target of no more than 10%; 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 98.0% was recorded during December 2014, against a compliance rate of 95% or more; 6b. Percentage of Improving Access to Psychological Therapies (IAPT) treatment population moving to recovery: during December 2014 a rate of 68.2% was recorded against a required compliance rate of 50% or more. Other corporate dashboard indicators meeting the Trust s exception reporting criteria during December 2014 were: 1: Clients referred by primary care to mental health offered first appointment within three weeks. The rate recorded during December 2014 fell to 91.5%. This indicator includes the performance of the Child and Adolescent Mental Health service, which is temporarily working to a six week standard; 6a: Percentage of IAPT treatment population entering treatment. The latest available information, as at 30 September 2014, showed performance to be 5.2% below the agreed trajectory; 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 December 2014 increased to 11.0%. Patients awaiting residential or nursing home placements accounted for the greatest numbers of bed days lost; 11: Mandatory Training. As at 30 November 2014, the overall compliance rate for the Trust was 92.6%. Of the Trust s 18 mandatory training courses, five courses had rates below the 90% compliance standard; January 2015 Public Board - 2 -
12: Staff Sickness Absence Rate. Sickness absence for November 2014, the latest month for which information is available, was 4.7%. As outlined in the Quality report to the 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 & 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. In order to provide additional short term flexible capacity, the Trust developed plans to re-designate Luke Ward, Athlone and Hadspen Wards as mixed sex wards and these plans were agreed with Somerset Clinical Commissioning Group. Somerset Partnership staff have been briefed and the Trust has implemented the arrangements carefully and sensitively in order to ensure that every patient cared for in these wards continues to receive care in line with the Trust s privacy and dignity standards. Notwithstanding this, the arrangements implemented by the Trust do not comply fully with national guidance relating to the provision of mixed sex accommodation. The NHS Standard Contract for 2014/15, agreed between the Trust and Somerset Clinical Commissioning Group, specifies in Schedule 4 - Quality Requirements, Section A Operational Standards, that each recorded breach of the national requirements relating to mixed sex accommodation shall carry a financial consequence to the Trust in the sum of 250 per day per service user affected. The Trust submits a monthly return in respect of mixed sex accommodation breaches, which typically shows the Trust to have incurred no breaches. Following the inception of the arrangements outlined above, the Trust reported 39 breaches in December 2014. The Trust will ensure that all affected wards return to full compliance with national requirements relating to single sex occupancy as soon as is practical. Actions required by the Board: The Board is requested to discuss and note the report. January 2015 Public Board - 3 -
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SOMERSET PARTNERSHIP NHS FOUNDATION TRUST PERFORMANCE REPORT Table 1: Corporate Dashboard Indicators Meeting Exception Reporting Criteria during December 2014 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% December 2014: 91.5% 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. This is due to current pressures on the service, which have been recognised by Somerset Clinical Commissioning Group. Of a total of 791 patients, 67 were outside of the three week standard, of whom 63 were CAMHS patients. Excluding CAMHS, the compliance rate against the three-week standard for December 2014 was 99.7%, an increase on the compliance rate of 98.3% recorded in November 2014. 6a (Dashboard page 5) Percentage of IAPT treatment population entering treatment Performance below the compliance target September 2014: 5.2% below plan By 31 March 2015, 7,610 patients of the total identified treatment population of 54,351 must have entered treatment. A trajectory, agreed with Somerset Clinical Commissioning Group, requires that by 30 September 2014, 3,628 of the identified treatment population should have entered treatment. As at 30 September 2014 a total of 3,441, (187 patients below trajectory) were recorded as having entering treatment, which is 5.2% below the agreed trajectory. Due to the complexities of how this performance indicator is currently calculated the compliance level can only be accurately assessed around three months after the end of the reporting period. This will allow changes that can occur to patients during this period to be transacted and accounted for. Consequently the latest position that can be reported is as at 30 September 2014. January 2015 Public Board - 5 -
No. Measure Description Exception Reporting Criteria Values Recruitment relating to service expansion has now taken place and the service is in the implementation phase of rolling out low intensity / group based interventions for patients with Long Term Conditions. The service manager has identified that the anticipated increase of referrals in respect of patients with long term conditions has not yet materialised. Actions continue to be undertaken by the service, which includes: opening the course up to people with any long term condition, not just the three conditions outlined in the original specification; opening to direct referrals from GPs and undertaking a communication exercise to promote the service; training the Trust s own staff to identify those in the mainstream Talking Therapies Service who may require this course; advising all Heads of Division to reinforce to their community service teams to consider patients on their caseload for referral to the IAPT Service; undertaking a validation exercise to ensure that discharge dates are being correctly recorded so the compliance rate is not being under reported. An initiative to bring more people into treatment more quickly is also being undertaken, with additional staff and existing staff offered extended hours to ensure that people are seen in a timely manner. The service is also proactively encouraging people who have not activated their referral to do so, to try to reach those people who find it hard to make contact with the service. Both of these additional initiatives aim to ensure that the required number of people will enter treatment in line with the agreed trajectory. The additional hours from staff, along with the additional external staffing, which is all due to be effective from 5 January 2015, should instantly increase capacity within the Service. 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. December 2014: 11.0% Compliance Target: 3.5% The number of community hospital bed days lost due to delayed discharges during December 2014 was 775, a slight increase on the total reported during November 2014, which totalled 727. Of the 775 days, 656 (84.6%) were recorded as attributable to Social Services, a significant increase compared to the 70.3% recorded as attributable to Social Services in November 2014. During December 2014 both Wincanton and Frome Community Hospitals had rates of bed days lost due to delayed discharges of 23%. January 2015 Public Board - 6 -
No. Measure Description Exception Reporting Criteria Values The categories between which the numbers of occupied bed days lost were split during the month of December 2014 were as follows: G Awaiting care home placement/residential/nursing home: Awaiting completion of assessments: Awaiting patient or family choice: Awaiting housing: Awaiting further non acute NHS care: Awaiting community equipment: Awaiting care package in own home: Public funding: 365 bed days lost (NHS 5 days, Social Services 360 days); 167 bed days lost (NHS 5 days, Social Services 146 days, both 16 days); 96 bed days lost (NHS 8 days, Social Services 55 days, Both 33 days); 52 bed days lost (Social Services 52 bed days); 41 bed days lost (NHS 41 days); 22 bed days lost (Social Services 11 days, Both 11 days); 22 bed days lost (Social Services 22 days) 10 bed days lost (Social Services 10 days). A weekly conference call is undertaken with community hospitals, to review delayed discharges at individual patient level, to consider the actions which have been taken to ensure that patients can be discharged appropriately, and to consider what additional actions can be undertaken. Relevant cases are also escalated to senior managers within Social Services to try to eliminate unnecessary delays. Daily and weekly reports of Social Services-attributable cases are shared with a senior Social Services manager. Key issues have also been discussed with Somerset Clinical Commissioning Group, as part of daily, multi-organisation teleconferences, and bed management issues, including delayed discharge rates and average lengths of stay, are a standing agenda item at Operational Finance and Performance meetings. 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. December 2014: five of the Trust s 18 mandatory training courses had compliance rates below 90%. The overall compliance rate in respect of mandatory training as at 31 December 2014 was 92.6%. Five of the Trust s 18 mandatory training courses had compliance rates below the 90% standard compared to four as at 30 November 2014. These five courses were: Information Governance: 89.6% (up from 89.4% in November 2014); Basic Life Support: 88.3% (down from 89.3% in November 2014); Preventing, Managing Violence and Aggression Module 2 88.3% (down from 90.0% in November 2014); January 2015 Public Board - 7 -
No. Measure Description Exception Reporting Criteria Values Clinical Risk Assessment and Management: 88.3% (up from 87.7% in November 2014). Immediate Life Support: 84.1% (up from 80.1% in November 2014). 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 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: Information Governance the Learning and Development Business Partners are focusing on this compliance in this area of training, which is really available as an e-learning package and Test your knowledge. Workshops continue to be delivered for staff who have difficulties in accessing the e-leaning module. Basic Life Support and Immediate Life Support - Additional courses have been commissioned from the Trust s training providers and work with clinical staff and their managers to ensure that staff access required course in a timely manner. The Learning and Development Business Partners offer further help and guidance to staff and managers who encounter difficulties in accessing courses. 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 manages to ensure that all staff access the course in a timely manner; Clinical Risk Assessment and Management Training compliance rates improved by 6.0% as at 30 November 2014, as a result of additional training dates, use of the competency framework and changes to the way medical staff demonstrate compliance with this course; Immediate Life support Same actions being taken as Basic Life support. 12 (Dashboard page 5) Staff Sickness Absence Rate Any month in which the rate is above the 4% standard. November: 4.7% Compliance target: 4.0% January 2015 Public Board - 8 -
No. Measure Description Exception Reporting Criteria Values Sickness absence for November 2014, the latest month for which information is available, was 4.7%, which is a reduction compared to rates reported since August 2014. Over the previous twelve month period stress/anxiety accounted for 26% of reported sickness absence. The other largest contributors to overall sickness were: musculoskeletal problems(10%); gastrointestinal problems (8%); injury, fracture (6%); back problems (6%); cold, cough, influenza (6%). The 52 Week Rolling Leadership Programme commenced from October 2014 and includes various leadership learning sets which support managers to take time out to reflect about how they can lead and empower their teams to work with pressure at work and contribute to reducing stress and anxiety. The Stress Awareness Workshop was delivered to almost 300 staff including managers and directors through 24 workshops during 2013/14. Following feedback it has been reviewed and plans are in place to deliver further workshops during 2014/15. These workshops have received very positive feedback and raise awareness of a number of things including the difference between pressure and stress. This is an important distinction and enables people to think differently about how they can take ownership to reduce stress. The Director of Workforce and Human Resources is also reviewing the Well@Work Service. Workforce and Human Resources are also looking at different ways for people to cope with stress and over the next three months will priorities and focusing on more targeted work with teams where sickness is higher than average within the Trust. January 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 January 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. January 2015 Public Board - 11 -
SOMERSET PARTNERSHIP NHS FOUNDATION TRUST CORPORATE DASHBOARD: DECEMBER 2014 Strategic Theme Measure Thresholds Jul-14 Aug-14 Sep-14 Oct-14 Nov-14 Dec-14 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 98.4% 99.4% 99.1% 99.2% 98.5% 97.2% 98.0% 96.0% M3. Referral to Treatment Waiting Times: 92% of patients waiting within 18 weeks: (Incomplete) >= 92% = Green <92% = Red 99.4% 99.4% 99.6% 99.3% 99.2% 99.6% 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 99.7% 99.9% 99.8% 99.8% 99.6% 99.6% 99.5% 99.0%, Quality and M9a. Percentage of clients on CPA (Level 2) seen within 7 days of discharge >=95% = Green <95% = Red 95.8% 96.2% 98.5% 98.6% 98.6% 96.7% 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% = Green <95% = Red 97.8% 98.0% 98.8% 96.6% 96.6% 96.9% 95.0%, Quality and M10. Emergency Admissions of 18-65 year olds via crisis support services >=95% = Green <95% = Red 98.2% 98.4% 98.2% 98.4% 96.8% 96.6% 95.0% 90.0%, Quality and M11. Meeting commitment to serve new psychosis cases by early intervention teams. >=174 = Green <174 = Red 194 185 189 183 187 190 195 185 175 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 4.4% 4.7% 4.3% 5.4% 4.7% 4.8% M17. Mental Health Data Completeness: Identifiers >=97% = Green <97% = Red 99.8% 99.8% M18. Mental Health Data Completeness: Outcomes for patients on CPA >=50% = Green <50% = Red 79.9% 79.0% M20a. Data completeness: community services Referral to treatment information >=50% = Green <50% = Red M20b. Data completeness: community services Referral information >=50% = Green <50% = Red 91.1% 93.9% Page 1 of 5
SOMERSET PARTNERSHIP NHS FOUNDATION TRUST CORPORATE DASHBOARD: DECEMBER 2014 Strategic Theme Measure Thresholds Jul-14 Aug-14 Sep-14 Oct-14 Nov-14 Dec-14 Trend M20c. Data completeness: community services Treatment activity information >=50% = Green <50% = Red 98.5% 98.9% 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 Implementation of Friends and Family Test within the Trust mental health inpatients wards rolled out and is set to commence from 1 October 2014, to meet with requirements of this CQUIN. 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% 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%, 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) Nov 14 <=4 cases = Green >4 = Red 4 (1 case in Apr, 0 in May, 3 in Jun. 0 in Jul, 0 in Aug, 0 in Sept, 0 in Oct, 0 in Nov) Data being validated, 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) Nov 14 <=24 = Green >24 = Red 21 (2 case in Apr, 8 in May, 2 in Jun, 0 in Jul, 1 in Aug, 2 in Sept, 3 in Oct, 3 in Nov) Data being validated Page 2 of 5
SOMERSET PARTNERSHIP NHS FOUNDATION TRUST CORPORATE DASHBOARD: DECEMBER 2014 Strategic Theme Measure Thresholds Jul-14 Aug-14 Sep-14 Oct-14 Nov-14 Dec-14 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) Q3 Implement training programme Developing a training plan to be implemented Training plan being rolled out and progress report to be submitted to Somerset clinical Commissioning Group 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 81.6% (2,867staff of 3,512 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 Audit undertaken and report presented to and signed-off by Somerset CCG. Audit being under taken Page 3 of 5
SOMERSET PARTNERSHIP NHS FOUNDATION TRUST CORPORATE DASHBOARD: DECEMBER 2014 Strategic Theme Measure Thresholds Jul-14 Aug-14 Sep-14 Oct-14 Nov-14 Dec-14 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 will be 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) Undertake planned during Q2 Audit undertaken and report presented to Somerset Clinical Commissioning Group. Audit to report compliance in respect of Q4 is planned to be undertaken between 19 and 20 January 2015 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) >=80% = Green <80% = Red 90.0%, Patient Experience 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 and Q4 report compliance to set trajectories) Set baseline Baseline collected and reported to Somerset Clinical Commissiong Group. Awaiting agreement of proposed trajectory to confirm compliance of required the 25% achievement rate required for Q3, Quality and 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%) Local >=95% = Green >=85% and <95% = Amber <85% = Red >=95% = Green >=85% and <95% = Amber <85% = Red 95.3% 95.0% 93.9% 93.1% 92.5% 91.5% 97.9% 97.3% 98.5% 98.5% 96.1% 97.6% 95.0% 90.0% 97.5% 95.0%, Quality and 3. Psychiatric emergency readmission rate within 28 days of discharge. <=10% = Green <=12% and >10%=Amber >12% = Red 10.3% 12.5% 13.0% 10.8% 15.6% 9.6% 20.0% 10.0% 0.0% Page 4 of 5
SOMERSET PARTNERSHIP NHS FOUNDATION TRUST CORPORATE DASHBOARD: DECEMBER 2014 Strategic Theme Measure Thresholds Jul-14 Aug-14 Sep-14 Oct-14 Nov-14 Dec-14 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 Quarterly performance will be 8 weeks after period end. (by 31 March 2015 to achieve 15% of relevant population being 7,609 clients ) >=90% = Green >=85% and <90% = Amber <85% = Red 90% = Green 80% - <90% = Amber <80% = Red >=95% = Green >=80% and <95% = Amber <80% = Red Aug 14 3,007 >=3,007 = Green <3,007 = Red 92.0% 92.6% 91.2% 91.6% 91.3% 91.5% 90.5% 90.0% 90.2% 90.7% 90.7% 90.5% 95.6% 95.7% 95.1% 99.0% 98.9% 98.0% 2369 (0.8% below plan) 2903 (3.5% below plan) 3441 (5.2% below plan) Due to how this indicator is currently calculated, compliance level can only be accurately assessed 3 months after the end of the reporting period. Therefore, July 2014 is the latest position that is possible to report. 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 20145 achieve 50%) >=50% = Green <50% = Red 39.9% 39.9% 47.1% 51.1% 69.1% 68.2%, 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 >=95% = Green 90%-to <95% = Amber <90% = Red >=95% = Green 90%-to <95% = Amber <90% = Red 95.0% 95.1% 95.2% 95.2% 95.2% 95.2% 99.7% 94.8% 97.2% 98.2% 98.6% 97.1% 98.9% 98.8% 98.7% 98.9% 98.8% 98.7% 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 7.7% 10.0% 11.1% 8.5% 10.9% 11.0% 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 92.9% 92.9% 93.4% 93.5% 93.1% 92.6% 4.5% 4.8% 5.2% 5.3% 4.7% Data awaited 96.0% 93.0% 90.0% Apr-14 Aug-14 Dec-13 Page 5 of 5