Integrated Performance & Quality Report

Integrated Performance & Quality Report March 2015 (Month 12) FINAL

Introduction The Central London Integrated Performance & Quality Report is aimed at providing a monthly update on the performance of the based on the latest performance information available, and reporting on actions being taken to address any performance issues with progress. The contents of the report are defined by the s priorities which are informed by nationally defined objectives for commissioners - the NHS Constitution and Everyone Counts Guidance for 2014-15 (operating framework). The report is split into 3 sections. Section 1 of the report provides an update on and related providers operational performance against national standards. This includes 18 weeks RTT, cancer waits, A&E waits and ambulance handover times. Detailed information on underachieving indicators including trends and action log are also provided. Quality and Safety issues are covered in section 2 of the report. The key areas highlighted in this section are Serious Incidents, Never Events, SHMI, maternity services, complaints and patient experience. These are presented in trend charts and tables with commentary and actions for areas of concern. Section 3 provides an update on Mental Health Serious Incidents. 1

Section 1: Performance Exception Report

Performance Overview Access Threshold Prev. Month Month 12 YTD Other Measures Threshold Prev. Month Month 12 YTD Community Services Threshold CLA - Review Health Assessments (RHA) conducted 1.1 18 weeks RTT - Admitted Pathway 90% 82.3% 83.3% 84.7% NEWL2_M 4.1 Cancelled Ops - 28 Day Guarantee breaches 0 CC2 6.1 within 6 wks (incl late notifications) 1.2 18 weeks RTT - Non-admitted Pathway 95% 94.1% 93.9% 94.6% 4.2 Urgent Cancellations for the 2nd time 0 CC311 Referrals responded to during the day, twilight or 6.2 night service periods within 24 hrs 1.3 18 weeks RTT - Incomplete Pathway 92% 90.7% 92.3% 89.6% CB_B17_n 4.3 Mixed Sex Accommodation Breaches (MSA) 0 2 2 6 CC52 Number of Rapid Response referrals responded to 6.3 with 2 hrs 1.4 52 week RTT Waiters - Incomplete pathway 0 1 1 14 HQU01 4.4 HCAI - MRSA 0 0 0 2 CC81 Palliative care patients achieving preferred place of 6.4 death 1.5 6 Weeks Diagnostics 1% 1.8% 1.8% 1.6% HQU02 4.5 HCAI - CDIFF 3 7 7 37 CC6 Prev. Month Month 12 YTD 90% 100.0% 100.0% 98.8% 95% 96.2% 96.5% 98.0% 98% 100.0% 100.0% 99.9% 80% 100.0% 100.0% 97.1% Section Venous leg ulcers healed within 12 weeks 2 60% 75.0% 80.0% 63.6% CC5 6.5 Pre-booked appointments DNA or UTA rate 4% 2.6% 1.4% 2.7% Cancer Waits Threshold Prev. Month Month 12 YTD Mental Health* Threshold 2.1 2 weeks of an urgent GP referral 93% 95.9% 91.3% 93.8% 5.1 IAPT - Access 0.9% 0.8% 1.1% 7.7% Out of Hospital Services Threshold 2.2 2 weeks of an urgent referral for breast symptoms 93% 92.8% 93.1% 90.7% 5.2 IAPT - Recovery (YTD) 50% 42.2% 43.5% 41.4% 7.1 LAS Cat A Red 1 responses within 8min 67.1% 67.2% Prev. Month Month 12 YTD Prev. Month Month 12 YTD 2.3 31 Day - 1st definitive treatment 96% 97.6% 96.4% 89.1% 5.3 CPA Reviews with 12 months 95% 95.2% 94.9% 95.6% 7.2 LAS Cat A Red 2 responses within 8min 58.7% 59.1% 2.4 31 Day Subsequent treatment (Surgery) 94% 100.0% 100.0% 96.7% 5.4 Outcomes Data Completeness - CPA Patients 50% 61.9% 92.7% 67.2% 7.3 LAS - Cat A 19 transportation within 19min 91.9% 92.3% 2.5 31 Day Subsequent treatment (Drugs) 98% 100.0% 100.0% 99.6% 5.5 CPA Follow-Ups within 7 days 95% 100.0% 92.3% 98.3% 7.4 NHS 111 - % calls answered in 60 secs 97.6% 96.7% 2.6 31 Day Subsequent treatment (Radiotherapy) 94% 100.0% 95.0% 98.7% 5.6 Inpatient gates kept by CRHT Teams 95% 100.0% 100.0% 99.3% 7.5 NHS 111 - % calls abandoned in 30secs 0.1% 0.2% 2.7 62 Day - 1st definitive treatment (Urgent GP Referral) 85% 68.8% 81.0% 87.2% 5.7 New psychosis cases served by EIS (YTD) 95% 133.3% 200.0% 114.3% 7.6 NHS 111 - % calls where call back was offered 6.4% 6.7% 2.8 62 Day - 1st definitive treatment (Screening Service) 90% 100.0% 100.0% 96.8% 5.8 Delayed Transfers of Care <7.5% 1.6% 1.8% 3.9% 7.7 GP Out of Hours 2.9 62 Day - 1st definitive treatment (Cons. Upgrade) 85% 80.0% 100.0% 96.9% 5.9 DNA - 1st Appointments <15% 7.5% 7.7% 8.8% A&E / LAS Threshold Prev. Month 5.10 DNA - Follow-Ups Appointments <15% 9.2% 10.5% 9.0% Month 12 YTD 5.11 Carers offered assessment 55% 89.3% 93.3% 71.7% 3.1 Total time spent in A & E < 4 hours (all activity types) 95% 5.12 HoNOSCA Completion rates on acceptance 80% 100.0% 93.3% 92.4% 3.2 Trolley Waits in A&E 0 5.13 HoNOSCA Completion rates on discharge 80% 100.0% 93.3% 94.8% 3.3 No. of LAS arrival to handover > 30mins 0 5.14 CAMHS - 1st Appt. DNA Rates <15% 13.0% 16.0% 14.3% 3.4 No. of LAS arrival to handover >60mins 0 5.15 CAMHS -FU Appt. DNA Rates <15% 7.1% 6.1% 9.3% RAG rated cells without data indicate under performance at one or more of s key providers - ICHT,CW,RBH. * CNWL except IAPT which is for all providers 3

1.1 & 1.2) Exception Report 18 Weeks RTT 18 Weeks admitted RTT performance was largely driven by Imperial College Healthcare Trust (ICHT) and to a lesser extent Chelsea and Westminster (CW) and University College London (UCL ). The is meeting the incomplete target overall with performance at 92.3% in M12. There has been an improvement in the incomplete RTT backlog (patients waiting > 18 weeks) from 949 in M11 to 772 in M11. In total the proportion of number of the backlog comprises of 62.05% at ICHT, 15.28% at CW, 13.86% at UCL and 8.81% at other organisations. ICHT: obligations agreed under 14/15 18 week RTT Query Notice which have not been delivered have been translated into the 15/16 agreed contract schedules and continue to remain in force. ICHT has agreed RTT incomplete improvement trajectory to reduce the overall backlog to 4000 by the end of April ICHT: Backlog for the has decreased from 658 in M11 to 479 in M12. However, their backlog remains at an unsustainable level. Performance due to data quality issues leading data quality issues leading to the inability to forecast and manage demand. CW: Backlog for the has stayed constant from 118 in M11 to 118 in M12 and close to meeting the national best practice level. Trust is close to meeting RTT standards overall. ICHT have nearly met RTT incomplete improvement trajectory to reduce the overall backlog to 5000 by the end of March 2015 achieving 5080. Backlog reduction plan for challenged specialities completed. ICHT: RTT incomplete backlog has not improved within weekly reporting and the number reported is higher than month end position. This indicates that the validation processes post month end are removing over 3000 incorrect pathways each month. On-going data quality issues on the incomplete waiting list. This leads to the inability to accurately assess demand and can lead to a capacity imbalance and further deterioration in performance. Lack of a robust admitted RTT delivery plan and the inability to deliver a capacity boost in Q1 2015/16. Detailed demand & capacity assessments within challenged specialties have not been completed. 4

1.1 & 1.2) Exception Report 18 Weeks RTT Issue Action Action M12 RTT performance not met ICHT Develop detailed activity planning assumptions for 2015/16 to be followed-up with IST demand and capacity plans for most challenged specialties. Open Yes EY NG No 30/04/15 29/05/15 14/15 query - 5

1.4) Exception Report 18 Weeks RTT 18 Weeks RTT 52 week breach One case in ENT at Imperial College Healthcare Trust (ICHT) ICHT - Action plan to resolve data quality issues with a trajectory to reduce RTT backlog to 4000 by the end of April. ICHT - The Trust reported a total of fifteen breaches overall for all s. Trust has confirmed: 11 cases have been treated 2 with treatment dates in May 2015 1 patient who was identified through validation has a diagnostic booked in May 2015 1 data quality issue. Continued 52 week breaches at ICHT in Q4. On-going data quality issues at ICHT resulting in difficulties to manage RTT waiting lists. Issue Action RTT standards not met due to: Performance reporting issues following PAS implementation. Demand and capacity imbalance. ICHT Trust provide details of breaches and actions to improve pathways Action Closed Yes EY NG Yes 12/05/15 N/A query in place 5000 6

1.5) Exception Report Diagnostic Waits Majority of breaches were reported by UCLH (25) and ICHT (20) out of a total of 50 breaches in total. ICHT breaches due to capacity and equipment issues within cystoscopy. UCLH Trust has reported an increase in demand within MRI, lack of capacity and staff vacancies as the root causes for breaches. ICHT Reduced breaches in other modalities other than cystoscopy. UCLH - Reduced breaches for Central London in M12 but this is not replicated across NW London s ICHT Trust reported that an internal business case to increase cystoscopy equipment has been approved. UCLH query in place and remedial action plan agreed. Trust trajectory to meet performance from July 2015 ICHT Cystoscopy breaches will not be reduced until additional equipment has been purchased. Trust report a staffing issue in radiology has led to diagnostic breaches in M1. On-going data quality issues following Cerner implementation UCLH current achievement against RAP and trajectory is unknown. Issue Action Action Diagnostic breaches to the 6 week standard ICHT Update on improvement actions at CQC. Open Yes JC KH Yes 28/05/15 N/A No contract action N/A Diagnostic breaches UCLH Trust update to RAP and trajectory Open Yes JP NELCSU Yes 29/05/15 N/A N/A N/A 7

2.1) Exception Report Cancer Waits CL did not achieve the two-week wait breast symptomatic standard (91.3%) in M12. This was as a result of 30 patient breaches. The breach reason were patient choice (27) and administrative errors (3). Patients were referred to: ICHT (19), CW (4), UCLH (3), RMH (2), GSTT (1) and LNWHT (1) All NWL provides achieving standard, therefore no action required currently CL achieving the standard for 2014/15. All NWL providers consistently achieving standard. No identified gaps in assurance. Issue Action Action Two-week wait standard (93%) All NWL providers achieving the standard. No action required. 8

2.7) Exception Report Cancer Waits CL did not achieve the 62 day standard (81%) in M12. This was as a result of four patient breaches, due to delay in workup (2) administrative delay (1) and patient choice (1). Two patient were treated at UCLH, one at ICHT and one shared breach between CW/RMH. One patient waited over 100 days (UCLH). CW will submit individual breach and exception reports. NWL action plan to improve inter provider pathways progress on actions. Cancer focus at May CWHHE Performance Committee CL is achieving the 62 day standard for 2014/15 ICHT is achieving the 62 day standard for 2014/15 ICHT did not achieve Q4 - ICHT have provided assurance on future performance UCLH are not achieving the 62 day standard. UCLH contract is held outside of NWL, via NCL CSU. Issue Action Action 62 day standard (85%) CW Trust to submit breach and exception reports Open Yes CH AK Yes 18/05/15 - - - 62 day standard (85%) All NWL Cancer discussion at May CWHHE Performance Committee Open Yes JE All provider COO Yes 21/05/15 - - - 9

3.1 3.3) Exception Report A&E & LAS (ICHT) A&E (all types) national standard analysis at St Marys (Nov 2014) indicates: increase in A&E attendances by 10%, higher acuity levels and 33% increase in Category A conveyances compared to previous year. 48% ED breaches were with patients ultimately discharged. Breaches peak in the evening (32% breaches occur 4-9 p.m.) increase in patients from W10 and NW10 using St Mary s Hospital A&E. increase in non-elective admissions (6-8 per day). Bed flow impacted as patients with LOS >14 days has increased by 22% and discharges happening late in the day. The trust-wide actions focus on: A&E: Targeting first hour with improvements in Registration/ streaming; and speciality team responsiveness. Updating escalation triggers and actions to improve grip on A&E processes. Discharge: 8 a.m. board round, criteria led discharge Bed flow: Role of bed manager (from July 2015 hours increased to 8-8 ), communicating bed availability; effective use of discharge lounge Internal processes: delays in diagnostics, Cath labs; streamline transfers Capacity changes: 6 extra consultants; new acute medical model; extended ambulatory care. On-going focus on delayed transfer of care with TriBorough s and social services. M12 improved with 1.2% delayed bed days compared to 1.5% in M11. Improving specialist review processes query issued on the 8 th May 2015. Issue Action M12 performance improved when compared to the previous two months. Action Performance has not recovered in March 2015 and therefore the Trust has not met the agreed improvement trajectory. 2014/15 performance (93.72%) is a deterioration from 2013-4 (96.12%). ICHT had 292 x 30 min handover breaches (deterioration from M11). LAS handover performance deteriorated when compared to 2013-14 i.e. 2296 x 30min breaches compared to 872 in 2013-14. On Track Not meeting A&E all type national standard ICHT Based on non achievement of the Trust s action plan, contract query notice has been issued and contract management meeting to be arranged. Open Partly EY NG Yes 22/05/15 N/A CQN issued None 292 breaches of the LAS >30mins handover waits 0 breaches of the LAS >60mins handover waits ICHT penalties of 200 per 30 minute breach and 1000 per 60 minute breach being applied. Close d Trust audit in place EY NG Yes 30/04/15 N/A Review at next CQG 200 / 1000 per case 10

3.1 3.3) Exception Report A&E & LAS (ChelWest) CW reported 50 LAS handover waits over 30 minutes and 2 cases over one hour. A deterioration when compared to M11. A&E attendances were higher in M12 when compared to the previous year. Bed capacity was impacted by higher than predicted admissions and with beds closed due to infection control issues at the end March. Trust escalation processes in place. Winter beds (Annie Lunz) remained open into April 15 as contingency for the beds impacted by infection control issues. CW is achieving national A&E standard YTD 96.36%. On-going breaches against this standard Ambulance handover deteriorated in 2014-15 as compared to 2013-14 i.e. 776 x 30 min breaches and 28 x 60 min breaches compared to 318 and 1 respectively the previous year. Issue Action Action 50 breaches of the LAS >30mins handover waits 2 breaches of the LAS >60mins handover waits CW penalties of 200 per 30 minute breach and 1000 per 60 minute breach being applied. Closed No, other than escalation plans LP LG N/A 30/04/15 N/A Review at next CQG 200 / 1000 per case 11

4.1) Exception Report Cancelled Operations (CW) CW reported one patient breach for a patient cancelled on the day of planned procedure. This procedure was booked on a Saturday and where the diagnostic scan was not available. Patient procedure has been rebooked. Low levels of cancellations (0.4%) in 2014/15 overall. Six breaches to this standard in 2014/15. Low level of breaches to this standard in 2014/15. Issue Action Action to date Cancelled operation standards not met ICHT Trust requested to provide an assessment of current issues and actions in place. Closed Yes CB KM No trajectory 12/05/15 N/A Review at next CQG Cost of procedure not charged 12

4.3) Exception Report MSA Two breaches were reported by UCLH. Root cause not yet known UCLH to provide an assessment of their issues and actions. UCLH Low level of breaches in 2014/15. UCLH current drivers for performance unknown. Issue Action Action MSA breaches UCLH Trust requested to confirm issues and action Open No JP NELCSU Yes 22/05/15 N/A N/A N/A 13

4.5) Exception Report HCAI 7 C.Diff cases in M12 with 3 apportioned to acute Trusts, UCLH (2) and Royal Marsden (1). Central London has met 2014/15 standard with 37 cases against a trajectory of 39. Dedicated infection control resource within CWHHE that support on-going review of infection control and anti microbial prescribing across CWHHE providers. Continuous system to review GP prescribing. Training provided to 161 care home staff from Q2 2014/15. Dedicated infection control support in CWHHE not replicated across London. Low level of cases within community and mental health providers. Joint review of C.Diff cases at ICHT has provided assurances that robust processes are in place. Prescribing analysis demonstrates good antimicrobial prescribing practice within primary care. Issue Action Action Improvement infection control and prescribing practice All providers in CWHHE On-going review of infection control and anti microbial prescribing. Open Yes JB All Yes 31/03/15 N/A N/A N/A 14

5.1) Exception Report IAPT Description IAPT Access: % of people with common mental illness (CMI) receiving psychological therapy Recovery rate IAPT: % of people who complete treatment and are moving to recovery Threshold Annual Target NHS CENTRAL LONDON CNWL In mth YTD In mth YTD In mth YTD In mth YTD In mth YTD 12.9% 8.7% LES COUNSELLORS PRIMARY CARE COUNSELLORS In mth/ YTD Target 1.3% 12.9% 0.9% 8.4% - - - - - - MIND - - - Actual 1.3% 10.4% 1.1% 7.7% 0.07% 1.21% 0.12% 1.50% 0.01% 0.16% Local Target 50.0% 50.0% 50.0% 50.0% - - - - - - Actual 42.4% 41.4% 43.5% 41.4% 40.7% 30.8% 37.0% 43.8% 100.0% 38.1% Referral levels have been identified as a key contributor affecting under performance for IAPT Access. Recovery rates are affected by complex caseloads and transient populations. CNWL is working closely with CL to improve appropriate referral rates into the service, specifically focusing on increasing appropriate referrals for older adults, carers and hard to reach groups. An extensive programme of direct contact with other health professionals and 3rd sector groups is underway. Contacts have been made with universities, community LTC providers, older adult charities and many others. Joint action plan in place between trust and monitored via monthly IAPT meetings. Performance continues to improve since November. M12 target achieved. Quarter 4 target not achieved for IAPT Access. Under performance against IAPT Recovery target at year. Significant improvement required in performance to achieve IAPT Access and Recovery targets in 15-16. Issue Action Action On Track to date A detailed action plan has been agreed with CL with joint actions. meetings are taking place to ensure actions are completed. Closed Yes KC/ER DM Yes 31/03/15 30/04/15 N/A N/A Under performance against IAPT Access and IAPT Recovery targets at year. CNWL Meetings held with local residents group to raise awareness on service and increase referrals. There was interest in running workshops. Closed Yes KC/ER DM Yes 30/04/15 N/A N/A N/A IAPT Workshops being run in Westminster, Imperial and Kings Universities to increase access and will continue. Open Yes KC/ER DM Yes 31/05/2015 N/A N/A N/A 15

5.2) Exception Report IAPT (continued) Issue Action CNWL On-going postnatal groups being held within children's centres to publicise the service. Update: On-going postnatal groups being held within children's centres. Good recovery rates for first group held. Action On Track to date Open Yes KC/ER DM Yes 31/03/15 30/04/15 N/A N/A Under performance against IAPT Access and IAPT Recovery targets at year. CNWL CNWL Increase in number of group sessions undertaken in February and March to increase access numbers. Impact expected in M12 data submission. IAPT training to be held in May for Mindfulness Group for people with LTCs to increase referrals rates. Closed Yes KC/ER DM Yes 17/04/15 N/A N/A N/A Open Yes KC/ER DM Yes 31/05/15 N/A N/A N/A CNWL Programme of work to increase referrals from Older Adults and people with long term conditions including IAPT meeting held with Westminster Community Rehab Team, liaison work with falls service. Plans to run another stress and worry group for older adults at Victoria Medical Centre. Open Yes KC/ER DM Yes 31/05/15 N/A N/A N/A 16

Exception Report CPA reviews/careplans sent to GPs in 2 weeks The trust have reported that under performance against this indicator is reflected in a number of teams, primarily the Recovery Team. The contributing factors have been data quality issues with incorrect data entry and staff changes. Data Quality issues have been raised in the teams and the team managers are engaging with individual clinicians to ensure that care plans. are sent in a timely manner. M9 was the first time this KPI was reported this year as agreed with the DQIP. On-going Monitoring via FIG and CQG. Performance is below target however this is the fourth month of reporting in line with DQIP. Issue Action Action CNWL The Trusts Business and Transformation manager is meeting with all team managers to standardise review processes and a monthly meeting has been set up with all team managers to review performance Open Yes ER TW Yes 30/04/2015 31/05/2015 N/A N/A Underperformance on the CPA reviews/care plans sent to GPs within 2 weeks target CNWL Weekly reports are to be used by Team manager as part of the individual clinical supervision and reinforce the importance of recording it consistently on Jade system Open Yes ER TW Yes 31/05/2015 N/A N/A N/A CNWL Administrators to run BI tool reports minimum twice a week to identify any gaps or recording errors. Open Yes ER TW Yes 31/05/2015 N/A N/A N/A 17

5.3) Exception Report CPA reviews within 12 months In month breach relates to Older Adults service. Reason for breach within service is unclear however the older adults service has consistently met this target in previous months. Work is underway with teams to ensure that mechanisms are in place to review performance. The trust has achieved the year end 95.0% target with performance of 98.3% at M12 YTD. None. Issue Action Action CPA Reviews within 12 weeks CNWL The individual breaches will be raised with the Older Adults team and addressed to ensure there are no further breaches. Open Yes ER TW Yes 31/05/2015 N/A N/A N/A 18

5.5) Exception Report CPA follow up The under performance relates to 2 patients. In one of the cases the follow up contact had taken place but had been recorded incorrectly. The second case was not follow up in time. The breaches have been raised with the matrons and ward managers. All the wards have been reminded of the guidance for recording 7 day follow up contacts. Meeting held with the inpatient senior managers to review the performance indicators for the teams. The trust has achieved the 95.0% target every month this year and achieved 98.3% at year to date. None. Issue Action Action CPA follow up within 7 days CNWL Weekly reporting protocols put in place with the ward staff. Open Yes ER TW Yes 31/05/2015 N/A N/A N/A 19

Exception Report Safe Discharge Protocol Breach in Q4 relates to the Westminster South Community Recovery Team where one Discharge summary was not sent. Trust will monitor compliance with the protocol through appropriate local assurance measure to avoid breaches. On going monitoring performance via CQG. This is only the second quarter of reporting in line with the DQIP. Deterioration from Q3 performance. Improvements in awareness and adherence of Safe Discharge Protocol required. Issue Action Action CNWL May CQG to include review of Safe discharge Policy Open Yes ER TW Yes 31/05/2015 N/A N/A N/A % of patients discharged from secondary to primary care according to the Safe Discharge Protocol CNWL CNWL The trust will re-circulate the Safe Discharge Protocol to all applicable teams, to ensure that they are aware of the processes and actions required of them. Trust will disseminate the results of the Safe Discharge Protocol audit with the local teams and ensure that they are aware of their current performance. Open Yes ER TW Yes 30/06/2015 N/A N/A N/A Open Yes ER TW Yes 30/06/2015 N/A N/A N/A 20

Exception Report Mental Health Tariff The trust has reported that the breaches (data inputting) are reflected in a range of teams but represent very small numbers of individual cases in each of the teams. Better monitoring of compliance by administrative and team/ward manager. Regular reports and reminders to review their clustering validity breaches The individual breaches have been sent to the teams for review and action. Limited assurance, as trust has not met the 95% target in any month this year. Clustering and data quality issues are not being addressed adequately by the trust. The trust has not met the MH Tariff targets this year. Issue Action Action Underperformance on the MH tariff timeliness and cluster review KPIs CNWL New weekly review processes have been put in place with the teams and a monthly performance review meeting has been established The trust Business and transformation manager is working with all teams to review the processes in place to ensure clustering validity Closed Yes ER TW Yes 30/04/15 N/A N/A N/A Open Yes ER TW Yes 30/04/15 31/05/2015 N/A N/A 21

5.14) Exception Report CAMHS - 1st Appt DNA Rates 3 identified recording errors were not rectified to reflect accurate DNA rates Trust Business Support team is supporting teams by identifying possible recording errors not rectified in timely manner by clinical staff and therefore impacting on DNA data. The trust have achieved the 15.0% target with performance of 14.3% at year-to-date in M12. DNA Rates starting to increase since January. Issue Action Action CAMHS 1 st Appointment DNA Rates CNWL Team Manager has discussed data accuracy with staff and will be raising again at next Business Meeting Open Yes LR TW Yes 31/05/2015 N/A N/A N/A 22

Exception Report Patients 65yrs and over assessed for dementia Manual reporting system has led to poor data quality and under reporting. Data capture and reporting issues resulting in delayed reporting and late start in reporting for 2014-15. Automated data collection is being developed as part of SystmOne deployment across the trust for 2015-16. Query in Place and monitored via CQG. Action plan to resolve reporting issues required from trust. Issue Action Action Dementia Screening Patients 65yrs and Over. CLCH Action Plan requested from trust as part of Query Open No LC TS Yes 31/05/2015 N/A Query in Place N/A 23

7.1 7.3) Exception Report LAS Description Threshold In Month YTD (31 st March) Cat A Red 1 responses within 8 mins 75% 62.7 % 67.2 % Cat A Red 2 responses within 8 mins 75% 59.1% 59.7% Cat A 19 transportation within 19 mins 95% 92.3% 92.0% Cat A 8:45 Performance In Month 65.9%% Central London (Cat A 8 Performance) 75% 67.1% (Month) 68.2% (YTD) Root Causes: Paramedic levels under established levels LAS unable to meet required levels of shift cover Ambulance utilisation rates high, meaning LAS are unable to cope with surges in demand in the system. Whilst activity is broadly in line with plan, the acuity of cases has increased Weekly assurance meetings between LAS and Commissioners, TDA and NHS England Daily and weekly performance updates showing progress against plan LAS have provided recovery trajectory and have developed a sustainable improvement plan to address medium and longer term solutions. Bespoke OT/incentive scheme introduced over Bank Holidays & weekends. O/T has been positive and is increasing over identified high risk days. National & International Recruitment Continues with 221 new frontline staff expected to start by end March 2015. LAS have received special Home Office dispensation to bring International paramedics across earlier. Increased use of the Hear & Treat model Drive to reduce multiple attendance ratio Trajectory based on unsustainable recovery methods. Year end position will need to be constantly reevaluated based on most recent performance. New staff are less experienced and therefore have less confidence in making decisions. s have been asked to raise the profile around wider system pressure but there are no mechanisms to monitor this. Issue Action Action New EAC staff recruited Green Yes Yes 28/2/15 (Cohort 1) N/A LAS unable to meet established staffing levels LAS National Paramedic recruitment International Paramedic recruitment Staff retention difficult LAS Create new senior paramedic role to aid retention Rob Elizabeth Paul Amber Yes Yes 31/03/15 Larkman Ogunoye Woodrow (Cohort 1) Amber Yes Yes 31/03/15 N/A Green Yes Rob Larkman Elizabeth Ogunoye Paul Woodrow N/A Signed None (Applied at year end for ambulance) Yes 31/03/2015 N/A Signed None (Applied at year end for ambulance) 24

7.1 7.3) Exception Report LAS Issue Action Action LAS offering incentive payments & double time to incentivise uptake Amber Yes Rob Larkman Elizabeth Ogunoye Paul Woodrow No Ongoing Ongoing Signed None (Applied at year end for ambulance) LAS unable to fill shifts to required levels Demand on LAS increasing LAS LAS LAS increasing PAS usage to fill shifts LAS to use taxis for low priority HCP journeys LAS increasing use of Hear & Treat LAS expanding operation hours of METDG Amber Yes Rob Larkman Amber Yes Rob Larkman Green Yes Rob Larkman Green Yes Rob Larkman Elizabeth Ogunoye Elizabeth Ogunoye Elizabeth Ogunoye Elizabeth Ogunoye Paul Woodrow Paul Woodrow Paul Woodrow Paul Woodrow No Ongoing Ongoing Signed None (Applied at year end for ambulance) Yes Ongoing Ongoing Signed None (Applied at year end for ambulance) Yes 19/10/14 N/A Signed None (Applied at year end for ambulance) Yes Ongoing N/A Signed None (Applied at year end for ambulance) 25

7.4 7.6) Exception Report NHS 111 March 2015 INWL Call standards No. calls % Number of calls offered 13332 N/A Rate of call back above target due to ringfencing of clinical resource to reassess green ambulance disposition calls. Ongoing queue management to ensure highest priority calls are dealt with first. Reporting of call backs which breach 1 hour. Number of calls answered 12920 N/A Calls answered in 60 secs 12492 96.7% Calls abandoned in 30 secs 32 0.2% Calls triaged 11044 85.5% Bi-monthly contract monitoring meetings Weekly sitrep submission None Calls where a call back was offered 861 6.7% Call backs within 10 minutes 405 47.0% Led to ambulance dispatches 961 8.7% Recommended to attend A&E 731 6.6% Recommended to attend primary/community care Recommended to attend other services 5742 52.0% 410 3.7% Did not recommend to attend other service 3200 29.0% * Central London, West London, Hammersmith & Fulham Data source: UNIFY2 Issue Action Action N/A 26

7.7) Exception Report GP Out of Hours National Quality Requirements Target Central/ West London & H&F s No exceptions reported for March N/A % calls triaged within 20 minutes (urgent) 95% 99% % calls triaged within 60 minutes (routine) 95% 97% % walk-ins triage complete within 20 minutes (urgent) 95% 100% % walk-ins triage complete within 60 minutes (routine) 95% 95% GP cons available at all times & places 100% 100% % emergencies consulted within 1 hour 95% 100% % urgent consulted within 2 hours 95% 100% % routines consulted within 6 hours 95% 95% % emergencies visited within 1 hour 95% 100% % urgent visited within 2 hours 95% 100% % routines visited within 6 hours 95% 99% Patient communication - special needs met 95% 100% reporting Quarterly contract meetings None Issue Action Action CSU N/A 27

Exception Report Chelsea & Westminster UCC Expected activity KPI Description Result Percentage of patients seen, treated and discharged or redirected by UCC 60.4% A&E 4 hour wait Percentage of patients treated and discharged from UCC within 4 hours 99.2% Clinical Assessment Percentage of all patients streamed within 20 minutes 50.0% Assessment time Percentage of adult patients attending with minor injuries assessed and examined within 2 hours 90.3% reporting 50% of patients streamed within 20 minutes; data appears to be inaccurate and has been queried by the commissioner. None at present; awaiting confirmation from provider of correct figure for clinical assessment within 20 minutes. Assessment time Assessment time Percentage of child patients attending with minor illnesses assessed and examined within 2 hours Percentage of patients in GP Priority stream assessed and given final treatment within 2 hours 88.5% 86.0% KPI reporting. Quarterly contract meetings. None Issue Action Action CSU to date N/A 28

Quality Premium funding achievement will be based on year-end performance against the pre-qualifying criteria, national and local measures with adjustments for constitutional gateway measures breaches. Please note IAPT performance is measured against plans submitted to NHSE. Financial Gateway Operate in a manner consistent with Managing Public Money in 2014/15 Not Incur Unplanned deficit in 2014/15, or require financial support to avoid unplanned deficit Not incur a qualified audit report in respect of 2014/15 Quality Premium Measures Reducing Potential Years of Life Lost (PYLL) through causes considered amenable to healthcare and including addressing locally agreed priorities for reducing premature mortality 2014/15 Target YTD/Qtrly Targets 1743 (per 100k population) 1743 (per 100k population) YTD M12/Qtrly Performance Available in summer 2015 Maximum Available Potential Deductions Reporting Frequency 145,108 Annual Improving Access to Psychological Therapies (IAPT) (Quarterly Performance - Q4) 12.89% 3.95% 3.31% 145,108 Quarterly National measures Reducing avoidable emergency admissions (Composite Measure) Improving Patient Experience: (i) Supporting roll-out of Friends and Family Test (FFT) by local providers (ii) Improvement in 'Patient Experience of Hospital Care' 1735 (admissions per 100k pop.) 1735 (admissions per 100k pop.) Available in summer 2015 Evidence of engagement Evidence of engagement tbc Improvement on 2013/14 score of 72.1 Improvement on 2013/14 score of 72.1 Available in summer 2015 241,846 Annual 145,108 Annual Central London Local Measure Total Improving the reporting of medication-related safety incidents Number of new health and social care related plans (as defined by NHS Choices) created in year Total Maximum Funding Available Local s Target Local s Target tbc 145,108 4000 4688 tbc 145,108 tbc 967,385 0 967,385 Gateway measures (Penalty) Constitutional Measures 18 Week RTT (Incomplete Pathway) A&E waits ( mapped from HES provider data) Cancer waits - 14 days (Urgent GP referral for Suspected Cancer) Cat A red 1 ambulance calls (LAS performance) Potential Year End Achievement (after Gateway Measures Performance Adjustments) Target YTD Target YTD M12 Performance Potential % Adjustment to Funding Potential Adjustment to Funding Reporting Frequency 92% 92% 89.6% 25% -241,846 95% 95% 95.5% - 93% 93% 93.8% - 75% 75% 62.7% 25% -241,846 483,693 29

Section 2: Quality & Safety Exception Report

Quality and Safety Overview Acute s Community - CLCH Mental Health - CNWL Serious Incidents ICHT CW RBH Serious Incidents reported within 48 hours of identification 100% 93% 50% Serious Incident Root Cause Analysis Reports submitted within deadline 100% 50% NA Maternity ICHT CW RBH Breast feeding 84.2% 88.6% 12 Weeks assessment 93.3% 94.1% Smoking at delivery 2.4% 1% Homebirths 0.8% 0.5% Elective C-Sections 11.1% 12.8% Non-Elective C-Sections 13.8% 18.1% 3rd degree tear 1.5% 1.2% Post Partum Haemorrhaging 0% 1.7% 1:1 midwife care in established labour NR 100% Midwife to birth ratio Obstetric Consultant Ward Coverage (hours) 1:33 SMH 1:33 QCCH 98 SMH 98 QCCH 1:30 Pregnant women with a named midwife/team NR NR Quality ICHT CW RBH HASU thrombolysis treatment within 45 mins 100% N/A 90% time on stroke ward 92.5% 100% TIA treated within 24 hours 100% 57.1% N/A TB access within 2 weeks 100% 100% VTE Risk Assessments 97.5% 95.8% 95.7% NRLS uploads Yes Yes Yes Overdue safety alerts 0 1 0 Friends and Family Test ICHT CW RBH Inpatient Response Rate 46.3% 40.2% 36.7% A&E Response Rate 16.9% 27.6% Mat Response Rate 28.9% 23.2% N/A Complaints ICHT CW RBH Acknowledged in 3 days 93% 100% 100% Responded to within agreed timescales 59% 77% 82% 110 N/A Serious Incidents All s Serious Incidents reported within 48 hours of identification Serious Incident Root Cause Analysis Reports submitted within deadline Complaints Safeguarding Training - All s Falls M12 67% 75% M12 Acknowledged in 3 days 100% Responded to within agreed timescales NA YTD Adult Safeguarding 89.9% Children Safeguarding 91.3% M12 Falls per 1000 bed days 0.1% Clinical Effectiveness Patients with venous ulcers healed within 12 weeks Key M12 80% Serious Incidents - All s Serious Incidents reported within 48 hours of identification Serious Incident Root Cause Analysis Reports submitted within deadline Complaints M12 63% 100% M12 Acknowledged in 3 days 100% Responded to within agreed timescales 100% Safety Under 18s admitted to adult psychiatric wards Patients feeling safe on an inpatient unit (quarterly) Safeguarding Training In month/quarter performance within threshold/ target met In month/ quarter performance close to threshold / target In month/quarter performance outside of threshold/ target met Data for indicator was not submitted/ reported in month/quarter There were no instances in month/quarter of the numerator/denominator which the indicator measures Indicator is not applicable to provider Adult and Children Safeguarding Training M12 0 90% Q4 89% No data (NR) No activity (NA) N/A 31

Maternity Dashboard 1 ICHT NWLHT EHT THH WMUH ChelWest Target Mar YTD Target Mar YTD Target Mar YTD Target Mar YTD Target Mar YTD Target Mar YTD % of first booking maternity apps 12 weeks + 6 days as % of apps (exc. late referrals) 95% 93.3% 90.8% 95% 96.3% 96.8% 95% 82.7% 95.4% 90% 97.7% 97.1% 95% 98.9% 98.1% 95% 94.1% 94.8% 90% 84.2% 85% 90% 85.1% 91.4% 90% 86.1% 90.3% 83% 83.5% 84.1% 95% 85.9% 91.1% 90% 88.6% 91.2% Breastfeeding initiation rate 1.35% 0.8% 0.4% TBC 0% 0.2% 1% 1.7% 1.4% 2.1% 2% 2.4% 2% 0.5% 1% Home Births N/A Percentage of women smoking at the time of delivery 10% 2.4% 3.1% 10% 6.3% 5.5% 10% 6.4% 4.7% 10% 7.9% 7.4% 10% 4% 3.2% 10% 1% 1.5% Percentage of women experiencing 3rd degree tear 5% 1.5% 1.6% 5% 3.4% 3.1% 5% NR 5% 2.3% 2.5% 5% 3.4% 3.8% 5% 1.2% 1.6% Not Reported 32

Maternity Dashboard 2 Percentage of women that have elective caesarean sections ICHT NWLHT EHT THH WMUH ChelWest Target Mar YTD Target Mar YTD Target Mar YTD Target Mar YTD Target Mar YTD Target Mar YTD TBC 11.1% 11.7% 10% 8.9% 11.3% 12% 10.4% 10.7% 27% 35.1% 26.7% 12% 10.7% 10.4% 15% 12.8% 13% Percentage of women that have elective /non elective caesarean sections combined (THH only) Percentage of women that have nonelective caesarean sections 15% 13.8% 15.7% 15% 22.5% 18.4% 15% 17.3% 19.0% 12% 16.9% 14.6% 15% 18.1% 17.1% 2.4% 0% 0.3% 2.4% 2.1% 1.2% 2.4% 2.3% 0.7% 2.4% 0.6% 0.9% 2.4% 1.7% 1.9% 2.4% 1.7% 1.7% Post Partum Haemorrhage 2 litres and above 1:1 midwife care in established labour NA NR NR 100% NR 100% 90% NR 95% 95.4% 95.6% 95% 83.3% NR 98% 100% NR Not Reported Not Reported Midwife to birth ratio - ICHT Target: 1:30 SMH in month: 1:33 QCCH in month: 1:33 1:30 1:24 NA 1:30 1:30 NA 1:30 1:29 NA 1:30 1:36 NA 1:30 1:30 NA Consultant ward coverage hours per week ICHT Target: 168 hrs SMH in month: 98 hrs QCCH in month: 98 hrs 98 98 NA 60 60 NA 98 96 NA 98 144 NA 98 110 NA 33

Exception Report: CLCH Serious Incidents Head of SI team has left the trust. Trust is aware of the decrease in reporting SIs and submitting RCA reports and is looking at change in systems. Fall in performance again in March. Trust has been 100% compliant for the previous two months. NB: Breaches in March are due to 26 (of 27) SIs were reported within 48hrs and 11 (of 14) RCA reports were submitted within timeframe. Issue Action Action SI reporting and investigating process CLCH LW and Nicola Clarke to meet with the trust to discuss the systems in place to support the SI and RCA process. Open Yes Lizzie Wallman TBA TBA 30/04/15 31/05/15 Ongoing Nil 34

Exception Report: ICHT Safeguarding Training There is currently a capacity issue within the team at Imperial College as they had a safeguarding vacancy which is being recruited to, this will hopefully resolve this issue. The current mitigating actions are that they are actively recruiting to their safeguarding post, however if this proves difficult some additional actions around safeguarding training may need to be considered. NB: 7040 (of 8381) eligible staff have received children s safeguarding training by March. Children safeguarding training has seen significant improvement over the last four months. Adults safeguarding training is currently at 86% (surpassing 85% target). The trust will need to indicate how it can access safeguarding children s training to support staff. Issue Action Action On Track Lower level of safeguarding children training being achieved. ICHT To recruit a new member of staff to ensure there is sufficient capacity within Being achieved Yes there is a plan that is being implemented Nicky Brownjohn ICHT Yes 28/02/2015 31/05/15 On-going Nil 35

Exception Report: ICHT First booking maternity appointments Possible Cerner data quality issue. Trust does not report this as below threshold so we should be able to see some improvements made. There trust has employed additional staff to assist with the data quality issues data to be resubmitted. New midwifery staff appointed by the trust to reach the 1:30 ratio required. NB: Breach in March is due to 48 (of 713) patients not having their appointments completed by 12 weeks. Figures approaching target levels. Expected improvements have not materialised. The trust has previously given assurance that this would resolve. The trust has been requested to provide a trajectory for recruitment of new midwives to increase capacity information is awaited. Issue Action Action On Track to date Attributed to Cerner data issue ICHT Trust reviewing clinic capacity and numbers of women being referred from Ealing. Open Yes Mary Mullix Pippa Nightingale No 31/12/14 30/06/2015 On-going Nil 36

Exception Report: ICHT Breastfeeding initiation rate NB: Breach in March is due to 114 (of 720) patients not initiating breastfeeding missing target of 648. The trust has indicated that due to it s demographic profile and women s choice they have been unable to reach the target of 90% breast feeding initiation. Figures reflect the pre-cerner implementation levels. The trust has been requested to investigate and report on the reasons why the 114 women did not initiate breast feeding whether this is due to choice, cultural norms, condition of mother or baby at birth. The trust was able to provide information in April in relation to women s choices. Figures are unchanged over the past few months. Issue Action Action On Track Levels of breast feeding initiation are below expected rates. ICHT Further exploration of demographic data required from the trust Open In development Mary Mullix Pippa Nightingale No 31/12/14 30/06/15 On-going Nil 37

Exception Report: ICHT Home births London wide issue. Part of SaHF strategy to increase home births. The maternity network has reviewed the key performance indicator in light of the proposed changes and have suggested a lower threshold whilst the changes are taking place in relation to Ealing maternity services and the staffing to support changes is reviewed. Month 12 shows a slight improvement. NB: Breach in March is due to 6 (of 720) patients having home births, missing target of 10. Any actions to address the decline in home births. Issue Action Action Low occurrence of home-births ICHT Continue to monitor Open Yes Mary Mullix Jacqueline Dunkley- Bent No 31/12/14 30/06/15 On-going Nil 38

Exception Report: ICHT Consultant Ward Coverage Difference in data reported to performance team and trust reported data. Trust reports currently at 98 hours however should be reporting 168 hours from month 7. Discussed with Director of Children s and Women s Services who advised that the increase in consultant hours is linked to Ealing closure. Advised to develop trajectory for delivery of additional consultant hours. Discussed with Director of Children s and Women s Services and actions will now be identified. No firm trajectory business case suggests that 130 hours will be achieved within 2015/16. No trajectory for achieving the 130 hours shared with. Issue Action Action Consultant obstetric labour ward cover ICHT Plan or business case to achieve 168 hours cover Open No Mary Mullix Pippa Nightingale Mandish Dhanjal No 31/03/15 30/06/15 On-going Nil 39

Exception Report: ICHT Midwife to birth ratio Challenge of recruiting to vacant midwifery posts. Requirement to recruit additional midwives and additional midwives will be recruited and was reported via the CQG in January. Use of agency and bank midwifery to address shortfall until such a time that new staff have been recruited into post. Trajectory for recruitment received in May 2015 to be monitored monthly linked to performance data submitted The trust has been asked to produce the trajectory for staff coming into post and the impact on the midwife to birth ratio. Issue Action Action On Track Midwife to birth ratio above expected threshold ICHT The trust was asked to produce a trajectory for recruitment of staff this was received in May 2015 and will be updated each month Open Yes Mary Mullix Pippa Nightingale TBC 31/12/14 30/06/15 On-going Nil 40

Exception Report: ICHT Complaints The low level of complaint responses is below the national target. This was discussed at the January 2015 CQG and the Trust wish to move to one single point of contact for complaints the trust internal systems are in the process of change and alongside changes within the complaints team can occur. Complaints were discussed as part of the CQG in January and questions were asked of the provider for further assurances to the commissioners on response times. The Trust would like to move to a single point of access for complaints which they believe will help in future in meeting the targets as laid down. This process needs to be embedded within the organisation and a sustainable improvement in complaint response times demonstrated. Awaiting further information from the trust on timescales for the outcome of the single point of access. Issue Action Action Low level of complaint responses within timeframes. ICHT There needs to be a robust action plan to address the issue of achievement of the target. Some actions have been planned no timescales on achievement as yet Open No Mary Mullix Guy Young No 28/02/14 31/05/15 On-going Nil 41

Exception Report: CW Percentage of people referred with a suspected TIA, who are at high risk of stroke, who are assessed and treated within 24 hours To be determined. NB: Breach in March is due to 3 (of 7) patients not being assessed and treated within 24 hours. Understanding of issues impacting on these 3 cases and what has been put into place to prevent this re-occurring. Issue Action Action to date Failure to refer patients suspected of TIA within timescales CW Continue to monitor. Open TBA TBA Lizzie Wallman TBA 31/05/15 TBA On-going Nil 42

Exception Report: CW Serious Incidents Retaining trained RCA investigators. The organisation recognises that its clinical governance and associated reporting structures can be significantly improved. The Trust is still using a paper based reporting system which contributes to delays in externally reporting incidents. External audit of clinical governance processes commissioned at the Trust and a plan is in place to restructure the governance team and to update the reporting to an electronic system. Raised at March meeting. CW represented at RCA training hosted by in March. The Trust has an action plan in place, as part of their CQC response and as part of a longer term plan to improve their internal processes. The CQC also identified gaps in the assurance processes regarding reporting and governance at the Trust. NB: Breaches in March are due to 1 (of 14) SIs and 4 (of 8) RCA reports not submitted within deadline. Issue Action Action Serious incident reporting processes CW Continue to monitor. Open Yes Lizzie Wallman LM TBA 31/01/14 31/05/15 Ongoing Nil 43

Exception Report: CW Overdue patient safety alerts Late reporting. Alert relates to risk of severe harm and death from unintentional interruption of non-invasive ventilation. NB: Breach in March is due to NHS/PSA/W/2015/003 being closed off after deadline. Action were completed and alert closed off four days (2 working days) after deadline. Issue Action Action Patient safety alert not closed off within deadline. CW All actions possible in relation to the alert have been achieved. Closed N/A Lizzie Wallman TBA N/A N/A N/A On-going Nil 44

Exception Report: CW First booking maternity appointments Unknown cause. NB: Breach in March is due to 21 (of 356) patients not having their appointments completed by 12 weeks. YTD performance is at 94.8% Issue Action Action to date First booking maternity appointments CW Continue to monitor. Open TBA TBA Lizzie Wallman TBA N/A TBA On-going Nil 45

Exception Report: CW Breastfeeding Initiation Rate NB: Breach in March is due to 47 (of 414) babies not having breastfeeding initiated missing target of 373). YTD performance is at 91.2% which is above the 90% target. Further detail from the trust on the numbers of women who chose to artificially feed or babies admitted to special care or neonatal intensive care Issue Action Action to date Breastfeeding initiation rate CW Continue to monitor. Seek further details from the trust on women s choices, women and babies admitted to intensive care as a proportion of the number of babies considered. Open TBA TBA Lizzie Wallman TBA N/A TBA On-going Nil 46

Exception Report: CW Home Births London wide issue. Part of SaHF strategy to increase home births. To be monitored and raised with Trust at April CQG meeting. NB: Breach in March is due to 2 (of 414) patients having home births, missing target of 9. Metric to be reviewed as part of Quality Schedule Discussions. Continually below target throughout the financial year. YTD performance is at 1% which is below the 2% target. Issue Action Action Low occurrence of home-births CW Continue to monitor Open Yes Lizzie Wallman TBA No 31/12/14 31/05/15 On-going Nil 47