Board of Directors Board/Trust Board Documents/… · 07/02/2017 Gallagher Damian Director of HR...

Board of Directors Thursday 03 August 2017

08:30am

Boardroom, Trust HQ, Sceptre Point, Sceptre Way, Walton Summit, Preston,

PR5 6AW

Board of

Directors

Quality Committee

Finance & Performance Committee

Nomination / Remuneration

Committee

Audit Committee

Board of Directors

Meeting Board of Directors Meeting

Location Boardroom, Trust HQ, Sceptre Point, Sceptre Way, Walton Summit, Preston, PR5 6AW

Date Thursday 3 August 2017

Time 08:30

FORMAL BOARD (PUBLIC MEETING)

PART ONE

Reference Item Lead Action Enc. FOIA

TB 099/17 Welcome and opening comments Chair Verbal

TB 100/17 Apologies for absence and confirmation of quoracy Chair Verbal

TB 101/17 Declarations of Interest Chair Verbal

TB 102/17 Minutes of the previous meetings Chair Decision Paper

TB 103/17 Action Tracker Chair Decision Paper

SCRUTINY & ASSURANCE

TB 104/17 Staff Story Head of Development Noting Video

TB 105/17 Chief Executive’s Report Chief Executive Discussion Paper

TB 106/17 Audit Committee Annual Report Chair of Audit Committee Noting Paper

TB 107/17 Finance Report Chief Finance Officer Noting Paper

TB 108/17 Quality and Performance Report Chief Operating Officer Noting Paper

TB 109/17 Quarterly Workforce Report Director of HR Noting Paper

TB 110/17 Caldicott Guardian Annual Report Medical Director Noting Paper

TB 111/17 Board Assurance Framework Associate Director of Risk & Assurance

Decision Paper

PART TWO (PRIVATE MEETING)

TB 112/17 Minutes of the last meeting Chair Decision Paper

TB 113/17 Chief Executive Report Chief Executive Noting Paper

TB 114/17 Red Rose Corporate Services Performance and Business Plan Update

Chief Finance Officer Decision Paper & Verbal

TB 115/17 Any Other Business Chair

TB 116/17 Date & Time of the Next Meeting Chair

INFORMATION SHARING (PRIVATE MEETING)

TB 117/17 Learning Disabilities Session Chief Operating Officer Presentation

Declaration of Interest – Board of Directors

Date of Declaration

Surname First Name

Job Title Nature of Interest

Do you envisage a conflict of interest between outside employment and

your NHS employment?

Nil Declaration

21/02/2017 Eva David Trust Chair Employed by Union Learn as National Manager

Yes TUC funds learning in relation to apprenticeship and Trade Union representation.

06/02/2017 Tierney-Moore Heather Chief Executive

1. Director of Lancashire Sport Partnership2. Trustee of Community Integrated Care3. Macmillan Allumni Patron4. Retained Consultant Glenview5. Patron Breakthrough Mental Health Charity

Yes Potential risk of CIC bidding to provide services in Lancashire that are also of interest to LCFT

13/02/2017 Furlong Gwynne Non-Executive Director & SID

1. NED - Prospect (GB) Ltd. (Subsidiary ofRiverside Housing Association)

2. NED - Progress Housing Group3. NED – Together Housing Group4. CEO of Regain Sports Charity5. Trustee of Chorley Youth Zone

No

13/02/2017 Ballard Peter Deputy Chair & Non-Executive Director Chief Executive DSE Service No

29/03/2017 Dickinson Louise Non-Executive Director

1. Director at Talegar Limited2. Consultancy Services at Talegar Limited3. Foundation Governor and Finance Chair at

St.Vincents Primary School

No

03/02/2017 Wilson Isla Non-Executive Director

1. NED - Progress Housing Group2. Shareholder – FSquared Ltd3. Shareholder - Ruby Star Associates Ltd4. Consultancy/Advisory Work – Ruby Star

Associates5. Chair – Borough Care (Stockport)

No

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Declaration of Interest – Board of Directors

03/02/2017 Curtis David Non-Executive Director 1. Director at Clinical and Corporate Governance

Limited2. Clinical Associate at MIAA (Advisory Section)

No

07/02/2017 Gregory Bill Chief Finance Officer

1. Trustee of Healthcare Financial ManagementAssociation

2. Governor of Stockport College3. Co-opted member of Lancaster University

Financial and General Purpose Committee.4. Director of Red Rose Corporate Services

No

25/01/2017 Possener Julia Non-Executive Director (Start date 01.02.2017)

1. Sole director and shareholder of JC PossenerLimited. Provides management consultancyservices. No formal/informal contracts with theTrust nor any other NHSorganisations/organisations providing servicesto the NHS.

2. Lay member of the Lancaster UniversityManagement School and Faculty of Arts andSocial Science Ethics Committee. Although theTrust and LU have a working relationship andcollaborate such matters do not fall usuallywithin these Faculties.

3. My partner's sister is the owner of a domiciliarycare business which does have contracts withThe Trust. I am including this for the sake ofcompleteness. Bluebird Lancaster and SouthLakeland Ltd. I have no formal nor informalinvolvement in that business.

No No business with the Trust or other NHS organisation or organisations providing services to NHS No unrelated faculties or formal or informal business.

13/02/2017 Roach Dee Executive Director of Nursing & Quality

06/02/2017 Marshall Max Medical Director

06/02/2017 Moore Sue Chief Operating Officer

07/02/2017 Gallagher Damian Director of HR

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BOARD OF DIRECTORS

Minutes of the Part One Board of Directors meeting held on 06 July 2017 in the

Boardroom, Sceptre Point

PRESENT: Gwynne Furlong, Non-Executive Director (chair)

Heather Tierney-Moore, Chief Executive Sue Moore, Chief Operating Officer Damian Gallagher, Director of HR Bill Gregory, Chief Finance Officer Louise Dickinson, Non-Executive Director Jo Alker, Company Secretary Isla Wilson, Non-Executive Director Dee Roach, Director of Nursing & Quality Julia Possener, Non-Executive Director Richard Morgan, Deputy Medical Director

IN ATTENDANCE: Alan Ravenscroft, Lead Governor Viv Prentice, Deputy Company Secretary

Bridgett Welch, Deputy Director of Nursing, Safeguarding (Item TB 84/17) Bev Howard, Head of Communications Ashley Christian, Executive Assistant to CEO (minutes)

TB 079/17 WELCOME & OPENING COMMENTS

The Chair welcomed everyone to the meeting.

TB 080/17 APOLOGIES FOR ABSENCE & CONFIRMATION OF QUORACY Apologies were received from David Eva, Trust Chair, Max Marshall, Medical Director, David Curtis and Peter Ballard, Non-Executive Directors. Confirmation of quoracy was provided.

TB 081/17 DECLARATIONS OF INTEREST There were no declarations of interest. TB 082/17 MINUTES OF THE PREVIOUS MEETING

The minutes of the previous meeting held on 01 June 2017 were approved as a true and accurate record.

TB 083/17 ACTION TRACKER

The Board considered the action tracker. Both open items would be closed off during the meeting as substantive agenda items.

Bridgett Welch joined the meeting. TB 084/17 SAFEGUARDING ANNUAL REPORT

The Deputy Director of Nursing for Safeguarding introduced the Safeguarding Annual Report and provided an overview to the Board of the key highlights. The achievements to safeguard children and vulnerable adults across Lancashire in partnership with multi agency partners were outlined alongside the priorities for the coming year. These included the domestic abuse agenda and committing to provide high quality training to further build staff competencies. Further context

UNCONFIRMED

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was provided about HMP Haverigg referred to within the report. Assurance was provided that the recent changes arising from the organisational reset had not affected the ability of the Safeguarding Team to care for and safeguard those in need. A Non-Executive Director prompted a discussion on the levels of training available around the Prevent agenda and how this training is delivered to priority groups. Bridgett Welch left the meeting.

TB 085/17 STAFF STORY

A video which collated the views and thoughts of staff transferring across to LCFT as part of the Southport and Formby community contract was shown. The Board discussed the positive feeling of staff, the examples of good engagement and hearing first-hand the things which are important to staff; including being listened to by the Trust to ensure the positivity of the induction is carried forward. The Board reflected positively on the key lessons learned from the transfer of TCS in 2012 and how the learning had been applied to the Southport and Formby transfer.

TB 086/17 TRUST CHAIR REPORT

The Chair introduced the report and summarised the key points, noting the resignation of a Public Governor and status of the Lead Governor role.

TB 087/17 CHIEF EXECUTIVE REPORT

The Chief Executive discussed the importance of transitioning prison health care provision with the new provider making clear that the risk profile would also transfer to the new provider. The Board noted the improvement plan was fully transparent and accepted by both the CQC and the new provider. The Board noted the outcome of the Quality Improvement Conference and contribution to the Trust’s Quality Story, and recognised the achievement of a staff member becoming an AQuA Fellow. The Chief Finance Officer outlined the Trust’s work in responding to additional fire safety checks required after the Grenfell tower fire. Checks had been completed and confirmation provided about the type of cladding used on Trust owned buildings and that all inpatient sites are compliant with fire safety requirements. The Board noted the Trust had been re-allocated into segment one of the Single Oversight Framework by NHS Improvement. The Chief Executive discussed how the Trust seeks to continue the valuable relationship with the regulator but confirmed the Trust is no longer required to have quarterly meetings. The Board reviewed the justification for a high value requisition and

approved the sign off of the contract related to Canon services. A Non-Executive Director noted her involvement in a recent Sit and See visit.

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TB 088/17 FINANCE REPORT The Chief Finance Officer outlined a less favourable position at month two and the impact on the full year forecast deficit should current pressures continue, in particular the entitlement to STF funding. The Financial Recovery Group would be reviewing the position accordingly to continue robust Board oversight of the detailed issues and recovery plans. The Chief Finance Officer described the main pressures which were mental health wards (including secure) and issues to staying on plan with CIPs. Specific network meetings to review and recover the position were taking place, with consequential impact and quality impact assessment of all recovery measures being considered. The OAPs position was in line for the month two trajectory but is beginning to create pressure during month three. The detail around the cash position, STF monies and further information on debtors was provided. The Board recognised the efforts to reduce the impact of OAPs spend through negotiation of rates for private beds, commissioning of additional capacity through CWP at lower NHS rates and the provision of alternative care options such as the crisis house. The Chief Executive and Chief Operating Officer discussed some early indications of increased demand but clarified the need to establish whether there is a sustained increase in demand prior to raising this in discussions with commissioners regarding capacity and demand. An update was provided on the acceleration of estates disposals following a query by a Non-Executive Director. A Non-Executive Director prompted a discussion about the leadership, resilience and support to the mental health network recognising the growth in size following the organisational reset.

TB 089/17 QUALITY & PERFORMANCE REPORT

The Chief Operating Officer outlined the key highlights of the Quality & Performance Report for month two. The further work around readmission was noted. The IAPT service prevalence target failure in month one was now being reviewed by commissioners. Assurance was provided that the IAPT service and work towards the target is being fully managed. The Board noted the increased number of Delayed Transfers of Care in A&E and MAU. An explanation of action being taken to revisit the shared protocol which exists between the Trust and the acute hospitals was provided, in the context of the national pressure on providers to improve A&E performance targets overall. The Chief Operating Officer shared an amendment to the Health & Justice indicators and provided the context to ongoing issues with HMP Liverpool prison. The Board noted the shadow Quality and Performance Report for Southport and Formby which remained in development whilst appropriate quality metrics are refined and data collected.

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TB 090/17 QUALITY PLAN The Director of Nursing & Quality introduced the quarter one update against the Quality Plan. The Board noted the alignment of key activity as part of the Quality Plan to include CQC actions, CQUIN activity and other areas such as supervision. Quality Metrics for certain quality priorities were still being worked up and the Board would help shape these quality priorities through an in-depth discussion session in the near future.

Feedback from a Non-Executive Director was positive regarding the clarity of the Plan and the Board discussed interdependencies with existing priorities and objectives, in particular the importance of linked plans; Workforce, Estates and Health Informatics.

TB 091/17 STRATEGIC PLAN 2017 – 2022 UPDATE The Board had considered the updated strategic plan in detail at a recent Board session. The Chief Finance Officer outlined the key updates and amendments made in response to external influences and internal Trust priorities. Further detail was provided on the specific Board development sessions and the Board discussed the importance of shaping the content appropriately. The Chief Executive provided additional context on the Trust leadership within the digital health workstream and a discussion took place about the key areas of focus and development of digitally enabling technology for service provision. Particularly utilising the Innovation Agency as part of furthering strategic links to external technology partners. The Board were clear that the importance of engaging the workforce with the benefits of digital health was not to be underestimated and an explanation of how the Trust is progressing this was provided.

TB 092/17 GUARDIANS OF SAFE WORKING The Deputy Medical Director introduced the report which addresses requirements to provide assurance that appropriate contractual obligations for junior doctors are being met. Assurance was provided that there is an established process in place to review junior doctor rotas and working time, with relevant staff having been appropriately trained and a safe working forum established to allow doctors to raise issues they may have. The Board noted there had been no exceptions to safe working hours reported. Known issues related to vacancy levels for junior doctors and potential for junior doctors to undertake supplementary shifts which require them to opt out of the WTD, though active recruitment process is taking place.

TB 093/17 DATE & TIME OF THE NEXT MEETING 03 August 2017, 08:30am

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Board of Directors

Agenda Item TB 105/17 Date: 03/08/2017

Report Title Chief Executive’s Report

FOIA Exemption Part Exemption

Prepared by Heather Tierney-Moore, Chief Executive

Presented by Heather Tierney-Moore, Chief Executive

Action required Discussion

Supporting Executive Director Chief Executive PURPOSE OF THE REPORT:

Report purpose The purpose of this report is to provide Board members with an overall summary of the Trust position and highlight areas for further discussion.

Strategic Objective(s) this work supports

To provide high quality services

Board Assurance Framework risk 2.1 – The Trust does not receive assurance of the accuracy, timeliness and consistency of data and reporting with the potential to compromise decision making and service quality

CQC domain Well-led Introduction This report aims to give Board members an overview of the activity undertaken since the last Board meeting, both within the Trust and externally. QUALITY AND SAFETY

Serious Incidents

During June 2017, seven serious incidents were reported: (brief information is provided to protect confidentiality, the term suicide is only used once a Coroner’s

Inquest has returned a verdict of suicide) Death (suspected suicide) of a patient discharged from the Crisis Resolution and Home Treatment

Team within six months of the death; Serious harm (overdose) by a patient under care of the Community Mental Health Team; Two instances of serious harm (suspected falls) of prisoners under care of the healthcare service

at HMP Liverpool; Serious harm (suspected jump from height) by a patient on leave from an inpatient mental health

ward; Death (suspected suicide) of a patient under care of the Crisis Resolution and Home Treatment

Team; Pressure ulcer on a patient under care of the District Nursing Service.

In all cases, a formal investigation is now underway and the incidents have been reported to commissioners, NHS England and regulators as required under the NHS Serious Incident Framework.

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Raising Concerns

During June 2017, eight concerns were reported through the various mechanisms including Dear David:

Delays to a patient’s care by social services; No feedback from a trial of new technology; Staffing challenges, feeling unsafe, level of assaults and lack of management support; Incorrect health records sent to LCFT from another Trust; Not using bank staff to fill vacant shifts leaving staff vulnerable; Safety and quality of services at HMP Liverpool (received from NHS England); Prohibitive controls implemented in response to a health records incident; Unfair treatment during the organisational re-set process.

In all cases a review of proportionate scale has been commissioned. The findings from each review are individually fed back to the person raising the concern if they have provided their name. The findings from every concern is summarised in the Quality Matters bulletin. The Trust has been undertaking a fact finding review into a number of concerns raised by anonymous sources over recent months. The concerns related to individual named managers and the overall culture of the former Specialist Services Network. The purpose of the fact finding review was to determine whether more formal investigations should be commissioned. The review has been completed and as a result formal management investigations have been commissioned in some cases, and in one case a counter fraud referral has been made. The findings of the fact finding review and action taken have been shared with NHS England, NHS Improvement and the Care Quality Commission. A joint response from the Trust and those regulators is being sent to the people who raised concerns.

Regulation 28 Notice

The Trust received a Regulation 28 (Prevention of Future Deaths) Notice from the Assistant Coroner of the North and East Lancashire, Preston and South West Districts. This followed the inquest into the death of a patient under the care of the Crisis Resolution and Home Treatment Team with the coroner determining the cause of death as suicide. The death occurred in November 2016. The coroner raised two concerns in relation to the care and treatment provided by the Trust:

Following a telephone call with the patient, a message should have been relayed to the Multi-Disciplinary Team (MDT) the following day for their consideration however this was not completed and the MDT did not review the clinical notes where an entry had been made;

Following a conversation with the patient after a significant overdose, a message was relayed to the MDT querying following-up by the team however the MDT did not discuss the patient which resulted in the patient not being followed up.

The Associate Director of Safety and Quality Governance is working with the service to develop an improvement plan which will also be submitted to the coroner. Good Practice Visits:

7th June 2017: Hospital Liaison Services Blackburn

Tania Hibbert – LCFT Head of Operations David Curtis – LCFT Non-Executive Director Pauline Walsh - LCFT Governor Adnan Gharib Omar – LCFT Governor Michelle Prescott – LCFT Quality Assurance & Improvement Lead

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Summary of CMHT good practice visit

The LCFT Hospital Liaison Service in East Lancashire is based at Hillview and serves East Lancashire Hospitals. It is a 24 hour service and staff work rotationally to cover the hours required. Referrals come from wards/departments within the Blackburn and Burnley hospital sites, the majority of these coming from Emergency or Urgent care. In March and April a test was carried out with a Mental Health Practitioner being based in A&E. 40-50% of people were managed at triage which resulted in admissions being reduced, with people supported in their community. The Quality Team will continue to engage with the CMHT to further develop this quality improvement initiative. The visiting team recognised the team’s collective efforts in creating and building better relationships and shape new ways of working with acute services at times of conflicting pressures.

Sit and See

To support everyone to achieve our quality outcome of ‘people are at the heart of everything we do’ we are committed to undertake “sit and see” observations across our services. Sit and see is a simple observation tool that has been developed, to capture and record the smallest things that make the biggest difference to people. In May a number of observations were carried out across 5 in-patient environments. Following the visit verbal feedback was given to the Ward Manager and an A3 poster style report shared with suggested areas for improvement forwarded to the teams.

The Lancaster Learning Disability Team ‘Making the Service Even Better Project’ Dr Sue Austen, Consultant Clinical Psychologist in Learning Disabilities and the team have continued to share their work relating to their Service User centred service evaluation/ improvement project. This week Sue presented, via WebEx, to other Always Event pilot services across the country, NHS

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England, IHI and Picker Europe. This follows numerous presentations to others’ services, including at national conferences and network meetings. The Point of Care Foundation will also be highlighting the team’s work on their website in the coming months. This project, guided by both the Experience Based Co-design and Always Event Frameworks, has involved gathering and sharing people’s stories to find out what really matters to people who both use and provide the service. The themes highlighted out of this was for service improvements for example initial contact card and team information sheets into Lancaster Team as standard practice and initial data from the process measures being collected to show a month on month increase in consistency of implementation. Service users and team staff worked together to co-design their Always Vision going forward and in line with this, developed service ‘change ideas’. On April 1st, key changes ideas were implemented into standard team practice and the impact of these changes are currently being measured. Allied Health Professions (AHP) Membership on External Boards Patsy Probert Associate Director for Allied Health Professions has been successful in an expression of interest to sit as Allied Health Professions representative on the Care Professions Board for the Lancashire & Cumbria STP. Patsy has also been successful in being offered membership on the North West Allied Health Professions Workforce Board. Both provide opportunity to maximise the potential for AHPs in new models of care and new roles in workforce design. Southport and Formby AHP Staff Engagement Allied Health Professions clinical staff in Southport and Formby attended a Professional Leadership development session on the 8th June. This session was part of planned activity to welcome Clinicians in the Southport and Formby services. A range of Allied Health Professionals attended including Physiotherapists, Podiatrists, Occupational Therapists, Dietitians and Speech and Language Therapists. The session enabled Clinicians to understand the professional leadership structures and functions within LCFT and the value placed on professional leadership in the organisation. It also gave staff the chance to talk about the elements of their current service provision they are most proud of and where quality improvements could be introduced. Feedback from the day was extremely positive. AHP Return to Practice Guidance As part of the AHP recruitment and retention plan implementation, AHP return to practice has been formalised. A collaborative piece of work has been completed with AHP Lead, Human Resources and Education Lead. This aligns to Health and Care Professions Council Standards and ensures a consistent approach to the organisation, governance and quality of the placements. Promotional activity to reach any local staff looking to re-register is underway. FINANCE AND PERFORMANCE

Finance Report The position as at Month 3 sees a year to date operating deficit of -£1.3m, excluding planned Sustainability and Transformation funding of £0.3m, against a plan to date of -£0.1m. The position continues to be undermined by staffing cost pressures, primarily in ward areas, and a slow start against CIP delivery. It is intended that the full year operating deficit is in line with plan but the unmitigated projections indicate a gap of c£5m, c£7m without STF monies, so this will not be without significant management challenge. The position also assumes that Out of Area Placements are contained within the £3m envelope. The Board Balanced Scorecard demonstrates an EBITDA (earnings before interest, taxes, depreciation and amortisation) of £2.6m against a plan of £3.8m, full

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year projection assumes a forecast in line with plan (£18m). The new Use of Resources (UoR) metric is rated at 3, but will rise to a 2 should the Trust meet its financial plans and targets. The full Finance Report can be viewed under item TB 107/17.

Quality & Performance Report The Quality & Performance Report can be viewed under item TB 108/17

Innovation Agency Q1 Performance Report The Quarter One performance report for the Innovation Agency is provided for assurance to the Board here. Previously the Board had delegated the review of this report to the Finance & Performance Committee however the Committee have recently recommended that the Performance Report be included within the Chief Executive Report going forwards for continued Board oversight.

Communication & Engagement Q1 Report The Quarter One Communication and Engagement KPI Report can be viewed here.

High Value Requisition The Board are asked to approve a high value requisition for the OCS Soft Service contract for the period July 2017 to 31 March 2018. The OCS contract to provide domestic, waste, catering and other soft services to Trust properties commenced in July 2012 following a competitive tender process and has since been extended for a further two years (under OJEU number 2011/108428). The contract requisition cost totals £4,348,352 including VAT and therefore requires Board approval.

GOVERNANCE

MCP Alliance Leadership Agreement FOIA Exempt Commercial Sensitivity

PEOPLE & LEADERSHIP

Mary Seacole Localisation Programme The Trust has been chosen to host the Mary Seacole programme for the Lancashire and South Cumbria STP footprint as part of the localisation process for the North West. NHS North West Leadership Academy have purchased programme licences for each of the three STP areas and are expecting high demand for sign up due to much lower local delivery costs (£150 per person compared to previous fees of £995 per person). The host organisations for each of the STP areas were collaboratively agreed with the Royal Liverpool and Broadgreen University Hospitals NHS Trust chosen to host for Cheshire & Merseyside, and both Central Manchester University Hospitals NHS Foundation Trust and University Hospital of South Manchester NHS Foundation Trust collaborating to host for Greater Manchester. Next steps will involve gauging the level of demand in each STP area prior to the planning stages of the programme.

BUSINESS DEVELOPMENT

FOIA Exempt Under Section 43 Commercial Interest

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https://www.lancashirecare.nhs.uk/media/Trust%20Board/Trust%20Board%20Documents/August%202017/App%201_Q1%20Innovation%20Agency.pdf

https://www.lancashirecare.nhs.uk/media/Trust%20Board/Trust%20Board%20Documents/August%202017/App%202_Q1%20Comms%20KPI.pdf

Board of Directors


Report Title Audit Committee Chairs Report

FOIA Exemption Part Exemption Section 43: Commercial Interests

Prepared by Ashley Christian, Corporate Governance Officer

Presented by Louise Dickinson, Chair of Audit Committee

Action required Noting


Report purpose To provide an outline of the activity undertaken by the Audit Committee, highlight assurance received and risks identified.



Board Assurance Framework risk 7.1 The Trust does not comply with Monitor Licence.

CQC domain Well-led

1.0 INTRODUCTION The Audit Committee Annual Report 2016/17 has been provided for review by the Board and will be formally presented to the Council of Governors in August. A copy of the full Audit Committee Annual Report can be viewed here.

2.0 BOARD ACTION

The Board of Directors is asked to note the Audit Committee Annual Report for assurance.

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Board of Directors


Report Title Finance Report

FOIA Exemption Part Exemption Section 41: Information provided in Confidence

Prepared by Shannon Carroll – Financial Services Director

Presented by Bill Gregory – Chief Finance Officer


Supporting Executive Director Chief Finance Officer PURPOSE OF THE REPORT:

Report purpose To summarise and analyse actual and forecast financial performance and standing of the Trust, the implications and any proposed management action.


To provide excellent value for money in a financially sustainable way

Board Assurance Framework risk 5.1 The Trust does not achieve financial performance sufficient to maintain resilience and sustainability

CQC domain Effective

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Summary

Actual Plan Var Forecast Plan VarSustainability

EBITDA 2,565 3,822 -1,257 18,011 17,745 266Operational Deficit -1,291 -72 -1,219 2,200 2,167 33

CIPs (against Trust Plan) 2,385 3,379 -994 15,100 15,100 0Cash and Liquidity 7,983 14,325 -6,342 13,657 10,989 2,668Capex 455 2,555 -2,100 9,600 9,591 9UOR

Capital Service 3 2 2 2Liquidity 1 1 1 2I&E Margin 4 3 2 2I&E Variance 3 1 1 1Agency 2 1 2 1Overall 3 2 2 2

Sustainability

CIPs

Liquidity

Capital and Financing

Use of Resources (UoR) risk ratings

Forecasting

Key Actions

#

Current Out-Turn

At £2.4m in month 3 the Trust is c£1m behind the plan of £3.4m. This is partly attributable to delays in scheme starts, but more significantly due to lower than planned traction in schemes designed to address pressures on ward based staffing. Additional support is being provided to areas behind plan.

Month 3 sees a year to date operating deficit of -£1.3m, excluding planned Sustainability and Transformation funding of £0.3m, against a plan to date of -£0.1m. The position continues to be undermined by staffing cost pressures, primarily in ward areas, and a slow start against CIP delivery. It is intended that the full year operating deficit is in line with plan but the unmitigated projections indicate a gap of c£5m, c£7m without STF monies, so this will not be without significant management challenge. The position also assumes that Out of Area Placements are contained within the £3m envelope - see Out Of Area Activity for more details. The Board Balanced Scorecard demonstrates an EBITDA (earnings before interest, taxes, depreciation and amortisation) of £2.6m against a plan of £3.8m, full year projection assumes a forecast in line with plan (£18m). The new Use of Resources (UoR) metric is rated at 3, but will rise to a 2 should the Trust meet its financial plans and targets, see below.

Cash shows an adverse variance of c£6.3m from plan. This is again primarily due to the Debtors position and in particular issues around council debt (c£4.5m) and outstanding 2016/17 STF monies (c£3.5m) but these have now been resolved and payment received - see Cash and Liquidity for more details.

•Maintain focus on improving agency.

The current I&E position is constraining the current UoR to a 3, assuming current pressures and risks are addressed and financial performance achieves (or exceeds) plan the Trust will achieve a forecast UoR of 2 in line with the revised plan. Should conditions persist and costs not be managed within the control total then the resulting deterioration might attract regulatory attention (a rating of 2 can trigger a regulatory review of the Trust's position).

To Date the Trust has spent £0.5m against the original profile of £2.6m. Spend profile on schemes is dependant on a number of tendering exercises to be completed in Q1/Q2 and the control total is likely to vary dependant on amount of external funding secured for the Inpatient scheme (now agreed through STP, amount to be finalised) and/or Perinatal (ongoing). The Trust currently expects to complete its capital programme in line with its control total and funding.

• Key focus on development of a Recovery Plan to deliver the control total and appropriate UoR ratings.

• Increase focus on delivery of CIPs.• Increase focus on addressing Ward Staffing.

• Maintain focus on OATs and delivery of mitigations.

The Trust is currently forecasting the achievement of plan but there are significant pressures challenges involved:• Achievement of ward staffing savings, given acuity and occupancy pressures.• Curtailment of OAPs below funded trajectory• Achievement of Sexual Health income targets.• Achievement of all cost improvement target savings by services.

• Ensure outstanding issues and income challenges from commissioners are resolved. 16 of 215

Forecast ForecastYTD YTD Out-turn Out-turn

Jun 2017 May 2017 at Jun 2017 at May 20173 2 Note 12 12 Note

Plan -0.072 -0.048 Plan 2.167 2.167

Major Variances Major VariancesCIP Slippage -0.752 -0.752 - See CIP section CIP Slippage 0.000 0.000 - See CIP sectionOATs 0.000 0.000 - See OATs section OATs 0.000 0.000 - See OATs sectionStaffing -2.284 -1.806 - See also Bank and Agency section Staffing -7.394 -6.425 - See also Bank and Agency sectionOther Bud Vars 0.695 0.679 - See Services section Other Bud Vars 1.465 1.228 - See Services sectionReserves 1.123 1.320 - See Reserves section Reserves 5.962 5.197 - See Reserves sectionAddl Contract Income 0.000 0.000 - Addl Contract Income 0.000 0.000Minor Variances 0.000 0.000 Minor Variances 0.000 0.000

Variance -1.219 -0.559 Variance 0.033 0.000

Actual -1.291 -0.607 Actual Forecast 2.200 2.167

--

Surplus - YTD (£m) Surplus - Out-turn (£m)

This month sees an operating deficit of £1.3m, £1.2m behind plan, of which £0.3m relates to STF funding.The full year projection is an operating surplus of £2.2m, accounting for the STF funding in the plan. The position models an upside of c£5.4m.

-6,000.0

-5,000.0

-4,000.0

-3,000.0

-2,000.0

-1,000.0

0.0

1,000.0

2,000.0

3,000.0

Plan CIP Surplus OATs Staffing Other BudVars

Reserves Addl Income MinorVariances

2,167.0 0.0 0.0 -7,394.2 1,465.2 5,961.9 0.0 0.0

-3,500.0

-3,000.0

-2,500.0

-2,000.0

-1,500.0

-1,000.0

-500.0

0.0

Plan CIP Shortfall OATs Staffing Other BudVars

Reserves Addl Income MinorVariances

-72.0 -752.1 0.0 -2,284.0 694.7 1,122.5 0.000 0.0

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Plan 82.518 55.011 Plan 332.908 332.908

Major Variances Major VariancesCommunity Services -0.194 -0.491 - Note 1 Community Services 2.324 1.433 - Note 1Mental Health 0.893 1.082 - Note 2 Mental Health 1.412 0.922 - Note 2Specialist Services 0.065 0.009 - Note 3 Specialist Services -1.188 -1.154 - Note 3Non NHS Healthcare Income-0.346 -0.209 - Note 4 Non NHS Healthcare Income-1.348 -1.338 - Note 4R&D 0.100 0.053 R&D 0.319 0.297ETR 0.026 -0.038 - Student Income ETR -0.071 -0.486 - Student IncomeMiscellaneous -0.036 0.023 - Note 5 Miscellaneous 2.286 2.118 - Note 5

Minor Variances 0.000 0.000 Minor Variances 0.000 0.048

Variance 0.508 0.429 Variance 3.732 1.840

Actual 83.025 55.440 Actual Forecast 336.640 334.748

12

345 Major increases in the latter part of the year generated by AHSN.

Monthly Income Variances (£m) Cumulative Income Variances (£m)

Major decrease (£0.8m) due to Southport commencing in May and not April. Minor gains in other services include Rheumatology and District Nursing.Major increases revolve around the phasing of the Out of Area Placements expenditure, in addition to Liaison & Diversion and Eating Disorders. Major decreases in Rehabilitation Services and Hospital Liaison.Income is in line with plan at this stage. Year end variances are driven by the anticipated cessation of the HIV contract.Major decrease expected is respect of lower than planned activity in Sexual Health services and Offender Health later in the year.

0.000

5.000

10.000

15.000

20.000

25.000

30.000

Apr May Jun Jul Aug Sep Oct Nov Dec Jan Feb Mar

Actual/Forecast

Plan

0.000

50.000

100.000

150.000

200.000

250.000

300.000

350.000

400.000


Actual/Forecast

Plan

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Budget 70.707 46.596 Budget 281.873 277.796

Major Variances Major VariancesMental Health -2.440 -1.899 - Note 1 Mental Health -5.900 -5.838 - Note 1Community & Wellbeing -0.107 -0.129 - Note 2 Community & Wellbeing 0.000 -0.049 - Note 2Children & Young People 0.172 0.100 - Note 3 Children & Young People 0.054 0.200 - Note 3Pharmacy 0.094 0.076 - Note 4 Pharmacy 0.237 0.199 - Note 4Property Services 0.000 -0.001 - Note 5 Property Services 0.000 0.000 - Note 5Corporate -0.061 -0.025 - Note 6 Corporate -0.321 0.291 - Note 6

Variance -2.341 -1.879 -5.929 -5.197

Actual 73.049 48.475 Actual Forecast 287.802 282.993

1

23

4

5

6 Corporate services are slightly behind plan year to date, with overspends in Human Resources and IM&T currently met by underspends in Finance, Medical, Nursing and Innovation.

Mental Health in year overspend is driven more acutely by excess staffing costs, primarily on wards, (£1.1m). Actions to review the patients in inpatients setting, their appropriateness for the ward and levels of staffing associated with acuity are advanced and should furnish us with the appropriate information to discuss necessary action to recover the position. There is also significant CIP slippage, as all CIPS have been withdrawn but some schemes are still in development (c£0.4m). The Network's position is diminished further by ward overspends in Secure Services wards (c£0.7m).Community's position is impacted by undelivered CIPs to date (£0.3m). Underspends on community teams and non-pay continue to alleviate the current position.Children and Young People have similarly been impacted by a shortfall on CIP delivery(£0.1m) and Sexual Health activity shortfall (£0.1m) but is currently being compensated for by vacancies and non-pay underspends.

YTD Service Net Expenditure Variance (£m) Forecast Service Net Expenditure Variance (£m)

Pharmacy is performing broadly in line with plan.

Property Services are performing in line with plan and are expected to remain so.

-£3,000

-£2,500

-£2,000

-£1,500

-£1,000

-£500

£0

£500Mental Health

Community &Wellbeing

Children &Young People Pharmacy

PropertyServices Corporate Total

Service Forecast Variance

-£7,000

-£6,000

-£5,000

-£4,000

-£3,000

-£2,000

-£1,000

£0

£1,000Mental Health

Community &Wellbeing

Children &Young People Pharmacy

PropertyServices Corporate Total

Service Year to Date Variance

19 of 215

CIP Achievement (£)

Notes

Year to Date PerformanceAt £2.4m in month 3 the Trust is c£1m behind the plan of £3.4m. This is partly attributable to delays in scheme but more significantly due to lower than planned traction in schemes designed to address pressures on ward based staffing. Additional support is being provided.

Schemes to be Transacted£3.11m of schemes are yet to be transacted at month 3 leading to year to date slippage of c£0.78m. There is a good degree of confidence in the delivery of these schemes.

Schemes In Process£2.22m of additional schemes identified are not yet sufficiently detailed to transact and has resulted in slippage of c£0.56m. As slippage was anticipated within plan this figure falls to £0.20m. There is some confidence in the delivery of these schemes.

Schemes to be Identified£1.01m of additional schemes are required if the Trust is to achieve its CIP.

ForecastThe programme is currently expected to achieve the Annual Plan.

Plan Actual Variance Plan Forecast Variance

£'m £'m £'m £'m £'m £'m

Cost Improvement Programmes 2.78 2.09 -0.69 11.10 13.10 -2.00

Run Rate Reduction Programmes 0.60 0.30 -0.30 4.00 2.00 2.00

Total 3.38 2.39 -0.99 15.10 15.10 0.00


£'m £'m £'m £'m £'m £'m

Monitored Schemes 2.40 2.36 -0.04 9.77 9.75 0.02

Schemes to be transacted 0.78 -0.78 3.11 3.09 0.02

Schemes in Process 0.20 -0.20 2.22 1.25 0.97

Slippage/Schemes to be identified 0.00 0.00 1.01 -1.01

Total 3.38 2.36 -1.02 15.10 15.10 0.00

Year to Date Annual

Year to Date Annual

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Month Month Month MonthJun 2017 May 2017 Jun 2017 May 2017

3 2 Note 3 2 Note

Agency Spend 711 691 Note 1 Bank Spend 1,625 1,267

Network Analysis Network AnalysisMental Health 539 512 - Note 2 Mental Health 1333 1067 - Note 2Children & Young Peoples 22 57 - Note 3 Children & Young Peoples 65 66 - Note 3Community & Wellbeing 196 165 - Note 4 Community & Wellbeing 175 106 - Note 4Other Clinical 0 0 Other Clinical 0 0 -Corporate Services -46 -43 - Note 5 Corporate Services 52 28 - Note 5

Actual 711 691 Actual 1,625 1,267

1

2

34

5

The Trust has been given a ceiling by NHS Improvement for agency spend. This target is£7.695m for the year. At the end of period 3, the Trust is -£132k, or 7% above it's trajectory.The new Use of Resources rating measures agency against target and contains trigger points.Key trigger points are a requirement for 50% and 25% or better for ratings of 3 and 2respectively. An individual rating of at least 3 is required to obtain an overall rating of 2 (seealso Use of Resources section).

Corporate Services is net of the charge levied for agency staff. Agency spend is negligible with the exceptions of Health Informatics and AHSN. Bank use dipped in HR and Nursing in May but has returned to earlier levels.

Agency Costs Over Time (£'000) Bank Costs Over Time (£'000)

A high level of vacancies is supported by bank and agency, though high levels of recruitment mean overall staffing costs remain high. Agency costs remain similar to last month and although bank costs have risen, this is mainly as a result of the impact of a five week month.Mental Health Networks bank and agency costs are primarily due to the level of acuity on inpatient wards being beyond the level established. When taking into account the 5 week month the position is to last month.Children and Young Peoples temporary staffing remains relatively minor and consistent.Community and Wellbeing sees increases in Bank and Agency, with Learning Disabilities and Mindsmatter standing out amongst an across the board rise on bank, and Psychiatry and Dietetics accounting for much of the increases on agency costs.


2015/16 935 1108 932 1180 1119 1176 1139 1183 1170 1072 1289 1209

2016/17 1536 1521 1728 1390 1238 1570 1154 1219 1401 1289 1321 1613

2017/18 1312 1268 1625

0200400600800

100012001400160018002000


2015/16 1030 988 1262 1242 909 1202 1149 939 1073 1077 978 1174

2016/17 1098 862 1250 1184 986 1133 781 827 825 738 661 1006

2017/18 647 691 711

0

200

400

600

800

1000

1200

1400

Agency Ceiling Apr May Jun Total Projection

Actual 647 691 711 2,049 8,201Plan 639 639 639 1,917 7,695Variance -8 -52 -72 -132 -506% of Plan -7% -7%

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Month Month YTD ForecastJun 2017 May 2017 Jun 2017 Out-turn

3 2 Note 3 12 Note

Plan 0.4 0.4 Plan 14.3 11.0

Major Variances Major VariancesI&E -0.7 -0.8 - Note 2 I&E -1.3 0.3 - Note 2Capital & financing 0.6 0.7 - Note 2 Capital & financing 2.1 -0.3 - Note 2Contract Vars and Adjs 0.0 -0.7 Note 3 Contract Vars and Adjs -1.4 Note 3Debtors 0.2 -2.2 - Note 4 Debtors -8.2 -0.2 - Note 4Timing of settlements to suppliers 0.4 -1.9 - Note 4

Timing of settlements to suppliers -1.3 0.1 - Note 4

Provisions and deferred income -0.9 1.0 - Note 5

Provisions and deferred income 1.0 0.0 - Note 5

Opening cash 0.0 0.0 Opening adjustment 2.7 2.7

Minor Variances 0.0 0.4 Minor Variances 0.0 0.0

Variance -0.3 -3.5 Variance -6.3 2.7

Actual 0.1 -3.1 Note 1 Forecast Actual/Forecast 8.0 13.7 - Note 1

1

2

34

4

5 Provisions and Deferred Income are currently generating gains of c£1m over plan, mainly due to higher than anticipated levels of deferred income. As expected crystallisation of income and redundancy settlements continue to reduce gains from previous month and this is factored into forecasts.

Monthly Cash and Liquidity Variance (£m) Forecast Cash and Liquidity (£m)

Timing of settlements to suppliers is having a negative impact on cash, these are largely transient in nature and, as expected, the position has started to move toward plan.

Reductions in capital expenditure are supporting cash more than compensating for the impact of the deficit. Forecasts assume planned revenue and capital forecasts are achieved.

Debtors are currently behind of plan, mainly due to the council debt position (£4.5m - now paid) and STF monies (£3.5m - now paid) though outstanding block from NHSE and CCG's was also high by c£2m (c£1m - now paid).

Forecast cash is ahead of plan by c2.7m largely due to the change in opening position c2.7m (factors brought forward such as STF monies, improved Cash etc..). The forecast assumes that proposed management action to bring financial performance back in to line is achieved and also that the Trust, as a result, maintains eligibility for Sustainability Funding.

Cash shows an adverse variance of £6.3m from plan. This is primarily due to the Debtors position and in particular issues around council debt (now paid) and outstanding 2016/17 STF monies (now paid)- see note 4 below.

Contract variations and phasing adjustments negatively impact on cash and are not included in plans.

-8.000-6.000-4.000-2.0000.000

2.0004.0006.0008.000

10.00012.000


Opening cash balance

Financing and Other

Capital and Investment Activities

Changes to WC

Non Cash Flows

Cash flows from operating activities

0.000

5.000

10.000

15.000

20.000

25.000


Forecast

Plan

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YTD Plan YTD Act Annual ForecastJun 2017 Jun 2017 Variance Plan Out-turn Variance

£000 £000 £000 £000 £000 £000

IT Schemes 0.570 0.157 -0.413 2.500 1.900 -0.600 - Note 1

Estate and infrastructure SchemesLarge Schemes 1.535 0.000 -1.535 4.815 4.550 -0.265 - Note 2

High Priority Schemes 0.000 0.000 0.000 1.200 1.260 0.060 - Note 3

Maintenance 0.150 0.121 -0.029 0.600 0.620 0.020General 0.300 0.177 -0.123 0.476 1.270 0.794

Total 2.555 0.455 -2.100 9.591 9.600 0.009

1

2

345

Capital Expenditure

To Date the Trust has spent £0.5m against the original profile of £2.6m. Spend profile on schemes is dependant on a number of tendering exercises to be completed in Q1/Q2 and the control total is likely to vary dependant on external funding secured for Perinatal and/or Inpatient schemes.The Trust currently expects to complete its capital programme in line with its control total and funding.

Work has been focussed on ensuring the IT demands of the transferring Southport & Formby services are met, much of the capital costs for which were incurred in 2016/17.Discussions are ongoing regarding inpatient project design and funding. External funding has now been provisionally allocated through the STP, though the exact amount has yet to be agreed. Upon conclusion tender exercises will be undertaken with a view to start on site in Q3.

No planned/expenditure to date. Schemes are progressing and expenditure is expected to start to be incurred in the near future. Programmes is underway with no issues forecast, some delays as a result of focus on fire safety.Decisions on Perinatal funding is awaited.

Note 4-

- Note 5

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Use Of Resource Metric

unitsPlan

YTD ending 30-Jun-2017

Actual YTD ending 30-

Jun-2017

Variance YTD ending 31-May-17

Plan YTD ending 31-

Mar-2018

Forecast YTD ending 31-

Mar-2018

Forecast Variance

Year ending31-Mar-18

Threshold 1 2 3 4

\ Capital Service Cover 2.5 1.75 1.25 <1.25Capital Service Cover Liquidity 0 -7 -14 <-14

I&E Margin 1.00% 0.00% -1.00% <=-1%

Capital service metric 0.0x 2.059 1.366 (0.693) 1.909 1.882 (0.027) Variance from plan 0.00% -1.00% -2.00% <=-2%

Capital service rating Rating 2 3 2 2 Agency 0.00% 25.00% 50.00% >=50%

Liquidity Metric Weighting

Capital Service Cover rating 20.00%

Liquidity metric £m 0.147 3.932 3.785 (0.433) 2.038 2.471 Liquidity rating 20.00%

Liquidity rating Rating 1 1 2 1 I&E Margin rating 20.00%

Variance From Plan rating 20.00%I&E Margin Agency Spend 20.00%

I&E Margin metric % (0.10%) (1.60%) (1.50%) 0.70% 0.70% 0.00%

I&E Margin rating Rating 3 4 2 2

I&E Variance From Plan

I&E Variance from plan metric % (1.50%) 0.00%

I&E Variance from plan rating Rating 3 1

Agency

Agency metric % (0.30%) 6.60% 6.90% (0.90%) 6.60% 7.50%

Agency rating Rating 1 2 1 2

Use Of Resources Rating

Overall rating unrounded Rating 2.60 1.60 If unrounded score ends in 0.5 Rating - -Rounded score Rating 3 2

Use Of Resources Rating before overrides Rating 3 2

4 Rating Trigger for Use Of Resources Rating Text Trigger No trigger

Use Of Resources Rating after 4 rating override Rating 3 2

Control total override - Control total accepted Text YES YES

Is the provider in Financial Special Measures? Text No No

Use Of Resources Rating after overrides Rating 3 2

Finance and use of resources is one theme of 5 in the Single Oversight Framework. Segmentation and therefore autonomy and support is dependent on performance across all themes.

Note that under the Single Oversight Framework a score of 1 is now the best rating and 4 the worst. A rating of 4 on any metric or an average rating of 3 triggers a concern and a potential support need.

Overall performance against the new UoR (draft) is rated at 3 against a plan of 2. The rating is primarily driven by the I&E performance and in particular the I&E Margin rating of 4. Assuming management action to bring financial performance back in to line is successful the Trust will maintain eligibility for Sustainability Funding and will achieve a UOR of 2 in line with plan. Should conditions persist and costs not be managed within the control total then the resulting deterioration might attract regulatory attention (a rating of 3 can trigger a regulatory review of the Trust's position).

• Capital Service is currently a 3 against a plan of 2, an increase in operating performance of c£0.7m would be required to increase the rating to 3.

• Liquidity is currently a 1 against a plan of 1, a deterioration in the liquidity metric of c£3.9m would be required to reduce the rating to 2.

• I&E Margin rating is currently 4 against a plan of 3, an increase in operating performance of c£0.4m would be required to increase the rating to 3 - Note that the deficit of -£1.3m is £0.9m behind the RCT).

• I&E Variance from Plan is currently 3, an increase in operating performance of c£0.4m would be required to increase the rating to 2.

• Agency is currently 2 based on a metric of 107%, a decrease in agency costs of c£0.1m would be required to increase rating to 1.

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Reserves

Reserve Budget Actual £ Annual Projected £

To Date To Date Variance Budget Actual Variance Narrative

£'000 £'000 £'000 £'000 £'000 £'000

Capital Charges £3,887 £3,862 £24 £15,546 £14,410 £1,136 Anticipated Profit on Disposals offset by var due to revaluation of estate

Pay Reserve £502 £243 £259 £1,559 £973 £586 Charge for Apprentice Levy and Junior Medic ContractPressures Reserve £101 £78 £23 £403 £152 £251 Funds to be applied to servicesCIP Reserve £384 -£20 £404 £1,834 -£880 £2,714 Gain on CIP to be applied to service pressuresEmerging Pressures -£530 £0 -£530 -£2,121 £0 -£2,121 Gain on CIP to be applied to service pressuresDevelopments £317 £175 £142 £961 £400 £561 Costs to be applied as incurredContracts £83 £0 £83 £214 £0 £214 Minor contract gains to be applied to servicesOrganisational Reset £442 £0 £442 £1,766 £600 £1,166 Funds to be returned to Networks, with some staffing chargesAgency & Direct Engagement -£150 -£142 -£8 -£600 -£699 £99 Premium for using non-contracted staff

Non Pay Inflation £274 £61 £213 £794 £102 £692 Funds to be applied for inflationary pressures

Total £5,308 £4,257 £1,051 £20,356 £15,058 £5,299

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MATTERS

ID Meeting DatePaper Status2017/01 Jul-17 Verbal Partial

2017/02 Jul-17 VerbalPartial

2017/03 Jul-17 VerbalIncluded

2017/04 Jul-17 VerbalPartial

2017/05 Jul-17 Verbal

Excluded

2017/05 Jul-17 VerbalExcluded

The Trust is actively exploring the potential for land sales. Gains may crystallise in 17/18 dependent on timing and profits willcontribute toward the control total.

On-going Claims: VAT claims continue to be pursued in relation to older developments and changes in rulings. A recent ruling nowsupports our claim, but the claim is by no means certain to succeed. Timing and amounts are uncertain though value may be up to £2mno gain is assumed.

SubjectA number of disputes require resolution and may result in arbitration. These concern NHSE, West Lancs, and Pennine CCGs.

STF monies have been included in forecasts on the assumption that the Trust will achieve its revenue control total. Should this not bethe case £2m of funding would be lost.

The forecast trajectory with regard to Out of Area Placements (OAPs) is currently projected to remain within funding. However thereremains a risk to this this position.

Provision for charges incurred as a result of the organisational reset have been made, however the position is unresolved and so somerisk remains.

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OUT OF AREA ACTIVITY

NetworkActual/ Forecast April May June July August September October November December January February March TotalAcute OATs (places) 15 11 14 6 3 3 0 0 0 0 0 0 52PICU OATs (places) 9 13 9 5 4 4 4 4 2 2 2 2 60Total Beds 24 24 23 11 7 7 4 4 2 2 2 2 112Acute OATs (£'000) 244 185 228 101 50 49 0 0 0 0 0 0 857PICU OATs (£'000) 206 308 206 118 95 92 95 92 47 47 43 47 1396Total £'000 450 493 434 219 145 141 95 92 47 47 43 47 2253

12

345

ForecastActuals

The Trust is mobilising Acute Therapy Services in Pennine and Chorley, Crisis Support Units in Preston and Blackpool, and a Crisis House in Coppull. These services have an impact on the bed trajectory and variations in timing will alter the OAPs usage accordingly.

There is a fund of c£3m for OAPs, financed 50:50 by the Trust and Lancashire CCGs. Any underspend can be used to support inpatient staffing while occupancy is above 90%.

Current projection suggest there will be expenditure of £2.3m for OAPs in 2017/18.

The Network has developed a trajectory against which we are monitoring performance. The forecast assumes the mobilisation of the commissioned developments.

Commissioners have asked for, and are receiving, monthly actual performance against the profile.

0

100

200

300

400

500

600

0

5

10

15

20

25

30

April May June July August September October November December January February March

Out of Area Placements 2017/18 Trajectory

Beds Plan Actual Beds Cost £000 Actual £000

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Board of Directors


Report Title Quality and Performance Report (QPR)

FOIA Exemption No Exemption Not Applicable

Prepared by Ian Cheung, Head of Performance

Presented by Sue Moore, Chief Operating Officer


Supporting Executive Director Chief Operating Officer PURPOSE OF THE REPORT:

Report purpose To appraise the Board of Directors of key elements and themes from the Month 3 QPR



Board Assurance Framework risk 2.1 The Trust is unable to reposition in the marketplace to become established as a provider of choice achieving excellence

CQC domain Well-led

The Board are asked to note the QPR for month 3 with following comments below. The Board are also asked to note the following:

The re-formatting of the Board Balanced Scorecard (BBSC) to align with the Strategic Priorities was completed in Month 1 and this format has been retained for this month’s QPR report. In addition, work to refresh the metrics within the BBSC is underway and these will be reported from Quarter 2. The aim is establish and then report the key, headline metrics that will inform the Board as to the progress towards achieving our strategic priorities over the next 5 years. This month, we introduce new metrics that will be part of the scorecard from Quarter 2.

Are we SAFE?

Current CQC rating is ‘requires improvement’ It was noted last month that there is Quality Improvement work underway to improve on this rating. The Quality Plan will cover all improvement areas within this domain and it is set to deliver on 16 Quality priorities, utilising Quality Improvement (QI) methodologies. This will be supported by the new quality improvement software (Life QI) which was recently launched and will be used to track delivery of outcomes resulting from specific interventions, making it clear to see the interventions that are successful in driving improvement. A lead person has been identified for each of the 16 Quality Priorities, and by the end of Q2 each priority will have a detailed delivery plan and defined outcome measures. Progress on the 16 key priorities will be monitored through the designated sub-committee. In addition, from August the BBSC will track the status of quality plan.

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Pressure ulcer avoidance, shortfalls in particular elements of core skills training and physical violence towards staff were highlighted last month as measures to be sighted on. Avoidable pressure ulcers (grade 3 and 4) increased in M3 (2 in M3 from 0 in M2), although the increase is small and only 8 have been reported in the last 12 months, 6 have been reported since February 2017 to date. A significant amount of work has been undertaken over recent years (eg. the React to Red initiative) to reduce the number of pressure ulcers to the current low numbers, however, the target is to achieve a position of zero attributable avoidable pressure ulcers by 2020. To this end, a root cause analysis is conducted of each pressure ulcer to identify and implement improvement necessary. This is performed in parallel to the QI work which will ensure consistent implementation of the interventions that have proved effective at reducing the numbers of pressure ulcers across all teams. Physical violence towards staff has seen an increase in M3 (216 in M3 from 151 in M2). The Positive and Safe Group established to oversee implementation of improvements in this area are monitoring this rise closely. The rise has occurred despite a number of changes being implemented. Therefore, workshops have been held throughout Q1 with stakeholders to come to a collective understanding of the issues and the barriers to improvement in relation to the initiatives already tried. Additional support from the Violence Reduction lead has been agreed and will target areas reporting increased levels of restraint. In addition, during Q2, the QI plan will be finalised and the trajectory of improvement will be agreed. Currently, the Trust benchmarks above the mean for incidents of violence and restraint, the target for achievement the first instance will be based upon achieving a level below the mean. Are we CARING?

Current CQC rating is ‘Good’. The number of complaints has increased to 157 in M3, from 112 in M2 and as described previously is viewed in a positive light as a means of gaining feedback to drive continuous learning and improvement. However, whilst the number of complaints has increased, it is positive that the number of upheld complaints has fallen to 15 for month 3 from month’s 2 position of 19, continuing the downward trend initiated in month 12. Feedback received through the Friends and Family test continues to be positive at 95% and although the number of compliments has dropped from 829 in M2 to 639 this is still well above the rolling 12 month average. Are we EFFECTIVE?

Current CQC rating is ‘Good’. Readmission rate for 90 days fell below the <15% for the first time since January 2017. Team leader reviews at CMHT/CRHTT clinical discussion meetings are having a positive effect along with analysis or readmission data being routinely reviewed in locality governance groups. Readmission rate for 30 days has risen slightly (13% in M3 from 12% in M2) continuing to underperform against the <8.7% threshold. 45% were from the female assessment wards along with 22% from the male assessment wards. The Mental Health Network has established a monthly thematic review of all readmissions to the assessment wards to identify potential areas of improvement in care delivery. This is important as it will identify whether the repeat admissions are appropriate or

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whether care through the new crisis house (as an alternative intensive support service) would be a preferable and more appropriate alternative for the patients with wider social needs alongside their mental health presentations. Average Length of stay continues to underperform against target (PICU 20 days and Acute 30 days). PICU Length of stay has stabilised at around 38 for four consecutive months as a result of the positive impact of the Joint Advisory Group. Acute has seen a sharp increase in M3 (M3 46 days from M2 36 days). Silver command has been initiated with commissioners joining twice weekly conference calls to assist with alleviating any blockages in the discharge of patients, and as this measure is average length of stay upon discharge, it is the focus on discharging longer stay patients that has resulted in this increase. Are we RESPONSIVE?

Current CQC rating is ‘Good’. The Trust continues to perform well against all NHS I indicators. We also demonstrate responsiveness in relation to our achievement of the 18 week referral to treatment (RTT) standard for AHPs across all relevant services where this is measured and also dental waiting times within Adult Community Services, however, the Children and Young People’s Wellbeing Network continue to have performance challenges. Performance in Child Psychology for month 3 was 66.9% against the 95% RTT standard for patients starting treatment, this is an improvement on last month’s position and similar to that of M1. The waiting list continues to reduce by a further 10% from 431 in M2 to 390 and the number of long waiters (over 18 weeks) has reduced from 162 to 129 in M3, the majority of who (82) are from Blackpool / Fylde & Wyre team. Plans are in place to address the capacity shortfalls and alternative models of service delivery are being implemented. Performance will continue to be challenged whilst the backlog of waiting patients is reduced and the Network is pursuing alternative provision of capacity to enable a waiting list initiative to clear this and generate an accelerated recovery of performance. The timeline for this will be reported next month. The CAMHS Tier 3 service are reporting non-compliance against the 95% RTT standard for completed pathways for the 4th consecutive month with Chorley and South Ribble being the main contributor to this under performance. Capacity shortfalls caused by sickness and vacancies have partly been addressed by the appointment of a new team leader. The service manager is carrying out a review of vacancies, staff working hours, job plans and the admin processes of the Referral Assessment Centre (RAC). Alongside this review formulation of a recovery plan to reduce waiting times is currently underway which forecasts improvement in performance from September 2017. Speech and Language Therapy continue to be on track with the agreed recovery trajectory which forecasts all locality teams meeting the 92% target in September 2017. Memory assessment services have achieved 70.4% against the 70% target against the 6 week referral to assessment standard, a target not achieved since December 2015. This is extremely positive however the Central Lancs MAS team’s progress continues to be constrained by an absence of agreement for shared care, and carries 88 of the 89 people waiting for more than 6 weeks. As

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performance was only 0.4% above target there is a risk of maintaining this position and therefore continued discussions with commissioners around the shared care agreement are important. Mindsmatter teams brought significant focus to recover Quarter 1 IAPT prevalence at 15% across all teams. All teams achieved Quarter 1 prevalence, apart from St Helens. However, within St Helens, prevalence has increased month on month and June was the first month where the monthly prevalence target was met since March 2017. The service is continuing to perform well against the recovery targets and the NHS I indicators for referral to treatment in 6 and 18 weeks in M3, It is also positive that the number of patients on the waiting list exceeding 18 weeks has significantly reduced. The Trust continues to be challenged by the demand for inpatient beds with silver command still in place throughout the month of June. The number of out of area placements (OAPs) required for patients in M3 was 25.67, which is higher than the predicted range forecast for M3. A higher than average referral rate has impacted on this position. The operationalisation of the next phase of intensive support schemes (which is on track) is expected to start to decrease the number of OAPs. Mental health liaison teams (MHLT) saw stabilisation of the 1 hour response at 47% albeit still well below the target of 95%. A review is still ongoing assessing the MHLT pathway to map recommendations from the Royal College of Psychiatry to provide a gap analysis and highlight shortfalls in provision in localities. The number of 12 hour breaches rose sharply for M3 however there appears to be inconsistencies in the way these are reported by the Hospitals. Discussions with NHSE, CCGs and Acute partners is to take place standardise the reporting to ensure consistency in reporting 12 hour breaches.

Are we WELL-LED?

Current CQC rating is ‘Good’. The Staff engagement score has slightly deteriorated from 3.77 in Q4 to 3.73 in Q1. While this trend is slightly concerning it is anticipated that as the People Plan gains traction throughout 2017/18 the Engagement score will improve. Sickness rates have risen for the third consecutive month to 5.96%. This trend is not reflective of sickness absence throughout the trust as two of the three clinical networks have decreased their sickness absence percentage. Mental Health has risen from 7.04% to 7.30% and the Network are currently focusing on implementing a Back to Basics Sickness Absence Management approach which is being supported by HR. This is a multi-factorial issue and wider initiatives focussing on reducing dependency upon bank and agency utilisation and improvements in e-rostering will be important in generating sustained improvement. Summary and Recommendations

The information in the QPR provides evidence of our performance against key metrics aligned to each CQC domains. From this, and the exception reporting against each measure, we are able to provide information that supports the assessment of our position against each domain.

31 of 215

Quality & Performance

Report

Month 3 – June 2017

32 of 215

Performance Management

Quality and Performance Report:-

Section 2:- Performance and Data Quality

Section 2.1:- Performance Activity

• NHS Improvement Indicators Dashboard • NHS Improvement Indicators Kitemarking • Key Exceptions • CCG level data • Network level summary • Key Network Exceptions

Section 2.2:- Patient Flow • Patient flow summary • Key patient flow exceptions

Section 2.3:- Data Quality • Data Quality summary • Key Data Quality exceptions

Section 3:- Finance and Contracting

Section 3.1:- Financial Activity

• UoR Risk Rating • Summary I&E Position • Summary of Clinical Services • CIPS • Capital Expenditure

Section 3.2:- Community Contract Activity • Community & Wellbeing – Network Line Totals • Community & Wellbeing – Service Line Totals • Community & Wellbeing – Total Activity Split by CCG • Children & Young People’s Wellbeing – Service Line Totals • Children & Young People’s Wellbeing – Total Activity Split by CCG • Mental Health – Activity Totals

Section 3.3:- Commissioning for Quality & Innovation • CQUIN Executive Summary

2

Section 6:- Risk

• Board Assurance Framework

Section 4:- Quality

• Quality Tile • Quality Surveillance - Safety • Quality Surveillance - Experience & Effectiveness • Leadership • Delivering the Strategy

Section 5:- Workforce • Actual Workforce Costs Compared to Budget • Sickness Absence Rates • Appraisals and Mandatory Training Compliance • Vacancy Management and Active Recruitment • Core Workforce Headcount • Workforce Turnover

Section 1:- Board Balanced Score Care

• Trust Strategic Priorities • Board Summary • Quality & Safety • Service Delivery • People & Leadership • Finance

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Board Balanced Score Card

Section 1

3

34 of 215


1. Board Balanced Score Card Trust Strategic Priorities

Strategic Priority Strategic Blueprint

Co

mp

as

sio

n

To provide high quality

services

We will ensure that people who use our services are at the heart of everything we do, and the people who deliver and support delivery of services are motivated, engaged and proud to provide high quality, compassionate, continually improving care. We will empower people to share their stories so that we know how we are doing and we will listen to learn and to improve quality together. We will continue to strive to be the best that we can be by upholding our 8 quality commitments and the ‘I’ statements, empowering everyone to embrace these personal pledges.

Inte

gri

ty

To deliver sustainable

services that meet the needs

of local people

We will collaborate with partners to deliver system wide transformation and we will be an active partner in delivering a bespoke offer to a number of Accountable Care Systems by

being the prime provider of specialist, acute and community mental health services, and

a lead provider in delivering new models of integrated physical and mental health out of hospital services, and

realising the benefits of our geographical footprint to deliver system wide sustainable infrastructure solutions and organisational vehicles for new models of care.

Whilst our principal footprint for delivery of services is Lancashire and South Cumbria, we will continue to seek opportunities across North West STP footprints.

Te

am

wo

rk

To become recognised for

excellence

Our service users and carers will tell us that our services are of high quality. Our people will recommend us to family and friends. We will be respected by our commissioners and other providers as a co-producing partner in shaping new service models that deliver our aligned strategies with an emphasis on place based care.

Res

pe

ct

To employ the best people

We will develop an organisational culture and leadership team equipped to meet its strategic intent and the needs of both its workforce and the population it serves; in short, a culture of high performing, continually improving and compassionate care. Staff will be motivated, engaged, high performing and proud of the service they provide. We will proactively support staff to look after their own health and wellbeing, and to reach their full potential. We will identify and grow our future leaders. People will want to work here.

Ac

co

un

tab

ilit

y

To provide financially

sustainable services

We will restore and maintain financial balance, and provide services that offer excellent value for money without compromising financial sustainability. We will work with local partners to deliver system wide efficiency measures. We will actively seek business opportunities that add value for local people.

Ex

ce

lle

nc

e

To innovate and exploit

technology to transform care

We will develop and promote digital enabled care, and lead research and innovation to enhance patient experience, reduce costs and/or improve quality. We will have a culture where staff are given the time, training and resources to research and innovate. Research will validate innovations and innovations will direct research. Partnerships with third party organisations will enable rapid execution and exploitation of innovation projects. 4

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Research Studies

Apr May Jun

201 67 79

Business Gained - Lost

Apr May Jun

£868k £13.382m £0

OAPS

Apr May Jun

24 26 26

NHSI Compliance

Apr May Jun

100% 100% 100%

Sickness Absence

Apr May Jun

5.74 5.88 5.96

Agency Ceiling

Apr May Jun

-6,206 -49,848 -69,455

UoR

Apr May Jun

2 3 3

Revenue Control Total

Apr May Jun

0.4% -2.5% -2.5%

CIP

Apr May Jun

67% 67% 67%

Liquidity

Apr May Jun

1 1 1

1. Board Balanced Score Card Summary

Capital Expenditure

Apr May Jun

17% 10% 18%

Contract Performance (MH)

Apr May Jun

- - -

Contract Performance (Comm)

Apr May Jun

- - -

Engagement Score

Q4 16-17

Q1 17-18

Q2 17-18

3.77 3.73

National COPD Audit

Programme

Report due Feb 2018

Use of depot/LA antipsychotics for

relapse prevention – baseline audit

Report due Nov 2017

Prescribing for bipolar disorder

(use of sodium valproate) re-audit

Report due Feb 2018

Quality Plan

17/18 objectives 16

On track Off track

- -

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1. Board Balanced Score Card Summary

Metric changes:

Inclusions – • National COPD audit programme • Topic 15: Prescribing for bipolar disorder (use of sodium

valproate) – re-audit • Topic 17: Use of dept/LA antipsychotics for relapse

prevention – baseline audit

Metric changes:

Inclusions – • None this month

Metric changes:

Inclusions – • None this month

Metric changes:

• None this month

Removals – • Annual Staff Survey – This measure is incorporated into

the Engagement Score. • Induction Attendance

Removals – • National Audits & Accreditation Schemes – replaced with National

Audit reports. • Friends & Family Test • Harm Free Care (Mental & Physical) • Serious Incidents • Mental Health Community Survey • Violence Reduction – This measure is now being tracked through

the Quality Plan as an objective. Detail of this can be found in the Quality section of the QPR.

Removals – • Data Quality – This measure was introduced as there were Trust-

led concerns around PBR clustering. The Trust is now compliant at 95%, therefore this measure has been removed.

• EIP – This measure is now reported as a standard NHSI measure, which can be found in the NHSI indicator dashboard.

Removals – • None this month 37 of 215


1. Board Balanced Score Card Quality & Safety

Quality Plan

Target: 16 objectives

All 16 objectives in the Quality Plan are on track for delivery in 17/18.

On track 16 Off track -

Research Studies

Data is subject to a 6-8 week lag as it is uploaded by research teams to a national system, retrospectively. Activity is currently forecast to meet this year’s annual target. Target 100 ppts monthly

Achieved 79

7

National COPD Audit Programme

Report due Feb 2018. Target TBC

Prescribing for bipolar disorder

(use of sodium valproate) re-

audit Report due Feb 2018.

Target TBC

Use of depot/LA antipsychotics

for relapse prevention – baseline

audit Report due Nov 2017.

Target TBC

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1. Board Balanced Score Card Service Delivery

Business Gained – Business

Lost

Target 1.5% over next 12 months

(year-end)

Out of Area Placements (OAPS)

The average number of OAPs rose marginally in June by 0.15, however a slight reduction in the OAP OBD was noted in June with a position of 770, a reduction of 21 from May. It is anticipated that significant decrease will be realised with the operationalisation of the next phase of alternatives to admission (East ATS, CSU, Crisis House/Crisis Beds).

Target 15 contracted beds

Achieved 26

Contract Activity - Community

The Community Baseline Proposal has been completed and submitted to the CSU and the Exception Reporting Proposal has also been agreed.

Variances against plan will therefore be produced from M4 and exception reporting will commence in line with the Exception Reporting Proposal. Target 100% +/-10%

Contract Activity – Mental Health

The Mental Health Baseline Proposal has been agreed at service level for 40 of the 43 baselines and the first draft will be submitted to the CSU

shortly however work continues to calculate the CCG activity plans by service. Target 100% +/-10%

NHSI Compliance

Target achieved. Target 100% in each quarter

Achieved 100%

8

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Agency Ceiling Month 3 shows a further worsening of the Trust Agency position, with just under £20,000 more spent month-on-month from May. The vacancy and absence position at HMP Liverpool has driven increased demand in Month 3 and has been a contributing factor in this, as has the increased clinical acuity/observations seen on inpatient wards. Medical Agency spend has also increased from the previous month driven in the most part by vacancies and the respective rota gaps being filled by Agency Doctors.

Target 710,705

Not achieved

1. Board Balanced Score Card People & Leadership

Apr May Jun YTD Target 641,250 641,250 641,250 YTD Actuals 647,456 691,098 710,705 Under/(Over)

Agency Usage -6,206 -49,848 -69,455

Engagement Score Q1 2017/18 period results : Recommend LCFT as a place to receive treatment (Workforce Advocacy): Yes – 70.20%, No - 11.25%, Don’t Know – 18.54% Recommend LCFT as a good place to work: (Workforce Involvement and Motivation): Yes – 48.71%, No – 21.77%, Don’t Know – 29.52% Improvement Initiatives: A Wellbeing assessment is being added to the Quarterly Staff FFT questionnaire to supplement the feedback already received from our workforce and to further enhance our understanding of the factors that affect the engagement of our workforce. Work to link the Staff FFT measurements to People Plan activity performance is still underway.

Target Top 25% of other

Trusts

Achieved 3.73

Sickness Absence

The sickness absence rate for June is 5.96% which is a slight increase on the rate from May. Please refer to the relevant M3 QPR detailed slides for information about Improvement plans and initiatives. Target 4.5%

Achieved 5.96

9

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1. Board Balanced Score Card Finance

Use of Resources (UoR)

The current I&E position is constraining the current UoR to a 3, assuming current pressures and risks are addressed and financial performance achieves (or exceeds) plan the Trust will achieve a forecast UoR of 2 in line with the revised plan. Target 2

Achieved 3

Capital Expenditure

Spend profile on schemes is dependant on a number of tendering exercises to be completed in Q1/Q2 and the control total may vary if we are successful in securing external funding for Perinatal and/or Inpatient schemes. The Trust currently expects to complete its capital programme in line with its control total and funding.

Target 85-100%

Achieved 18%

Revenue Control Total

A number of risks and pressures have been identified that if not addressed will compromise the Trusts ability to deliver the planned control total for 2017/18. Target – ≥0%

Achieved -2.5%

Cost Improvement

Programmes (CIPs) At £2.3m in month 3 the Trust is £1.1m behind the plan of £3.4m. This is partly attributable to delays in scheme starts, but more significantly due to lower than planned traction in schemes designed to address pressures on ward based staffing. Additional support is being offered and the Trust fully expects to deliver the target by year end. Target ≥100%

Achieved 67%

Liquidity

Forecasts indicate that with the delivery of the planned surplus the Trust will achieve a liquidity of 1. Target 2

Achieved 1

10

*Under the Single Oversight Framework ,the Trust is now managed against the Use of Resource Metrics (UoR). Under the Single Oversight Framework ,a score of 1 is now the best rating and 4 the worst. A rating of 4 on any metric or an average rating of 3 triggers a concern and a potential support need.

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2. Performance and Data Quality

11



• NHS Improvement Indicators Dashboard • NHS Improvement Indicators Kite Marking • Key Exceptions • CCG level data • Network level Summary • Key Network Exceptions

Section 2.2:- Patient Flow

• Patient Flow summary • Key Patient Flow exceptions Section 2.3:- Data Quality • Data Quality summary • Key Data Quality exceptions

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Performance Activity

Section 2.1

12

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2.1 Performance Activity NHS Improvement Indicators Dashboard

13

Indicator Target Jul-16 Aug-16 Sep-16 Oct-16 Nov-16 Dec-16 Jan-17 Feb-17 Mar-17 Apr-17 May-17 Jun-17 Q1 17-18 YTD Rolling 12 Month Sparkline

MR01 - 7 Day Follow Up 95.00% 97.8% 98.1% 96.5% 96.0% 96.9% 98.2% 98.8% 96.1% 97.6% 98.6% 96.8% 95.9% 97.1% 97.10%

MR02 - CPA Review within 12 Months 95.00% 96.8% 96.7% 97.1% 97.7% 97.4% 97.8% 96.9% 97.1% 97.5% 97.0% 97.1% 96.1% 96.7% 96.71%

MR03 - Mental Health Delayed Transfers of Care ≤ 7.5% 2.42% 2.82% 4.18% 4.08% 3.68% 4.19% 3.81% 2.84% 2.59% 3.01% 3.21% 3.41% 3.2% 3.21%

MR05 - RTT - Consultant Led (Completed Pathway) 95.00% 98.0% 97.3% 93.2% 92.4% 95.2% 96.3% 96.7% 97.6% 100.0% 100.0% 100.0% 100.0% 100.0% 100.00%

MR06 - RTT - Consultant Led (Incomplete Pathway) 92.00% 96.4% 95.0% 95.7% 96.3% 95.2% 95.4% 97.3% 100.0% 99.2% 100.0% 100.0% 100.0% 100.0% 100.00%

MR07 - IP Access to Crisis Res. Home Treatment 95.00% 99.4% 99.4% 98.9% 98.3% 100.0% 100.0% 98.6% 99.4% 97.7% 100.0% 100.0% 99.5% 99.8% 99.83%

MR08 - MH Data Completeness - Identifiers 97.00% 99.6% 99.7% 99.6% 99.6% 99.6% 99.6% 99.6% 99.6% 99.6% 99.6% 99.6% 99.7% 99.6% 99.62%

MR09 - MH Data Completeness - Outcomes 50.00% 80.8% 82.0% 83.2% 83.7% 83.7% 83.8% 83.4% 83.2% 83.4% 83.7% 82.2% 81.8% 82.5% 82.50%

MR10 - CIDS Completeness - Referral Information 50.00% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 100.00%

MR11 - CIDS Completeness - RTT Information 50.00% 99.7% 99.4% 99.3% 99.5% 99.6% 99.8% 99.1% 99.3% 99.1% 99.3% 99.2% 99.1% 99.2% 99.19%

MR12 - CIDS Completeness - Activity Information 50.00% 91.3% 93.4% 93.3% 93.3% 93.9% 94.3% 93.9% 92.9% 93.1% 94.2% 93.9% 93.5% 93.9% 93.86%

MR13 - 2 Week wait for Treatment for EIP Programme 50.00% 77.1% 67.7% 75.0% 69.0% 74.3% 76.7% 82.0% 81.4% 74.4% 69.0% 83.3% 90.9% 81.5% 81.52%

MR14 - RTT - IAPT 6 Weeks 75.00% 90.2% 92.1% 90.8% 95.0% 93.0% 96.5% 95.1% 95.7% 93.4% 96.4% 94.7% 95.1% 95.4% 95.39%

MR15 - RTT - IAPT 18 Weeks 95.00% 99.2% 99.5% 99.1% 99.3% 99.0% 99.8% 99.4% 99.8% 98.8% 99.4% 99.2% 99.7% 99.5% 99.45%

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2.1 Performance Activity NHS Improvement Indicators Kitemarking

Kitemarking Key:

• SOP – Does the indicator have an associated SOP that is within date? • External Audit – Has this measure been subjected to an external audit within

the last 2 years?

• Internal Audit – Has this measure been subjected to an internal audit within the last 2 years?

• Electronically Populated – Is this indicator produced using electronically generated numerators and denominators?

• Manual Overrides – Has the performance for this indicator been produced using manual overrides to indicate false positives or negatives?

14

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2.1 Performance Activity NHS Improvement Indicators Kitemarking

15

46 of 215


Note: The total figures in the tables above differ from page 13 as they are

representative of only 8 contracted CCGs.

NHS Morecambe Bay CCG launched in April 2017, merging Lancashire North

CCG and South Cumbria CCG area, therefore please be aware that Morecambe Bay

CCG will now be shown within the CCG breakdown.

Trust position for Lancashire CCGs: - In Month 3, the Trust has achieved a Performance of 97.5% against a target of 95% across 8 CCGs. CCG Position: - In Month 3, the Trust has underperformed in 2 CCGs: East Lancashire and West Lancashire.

16

Trust position for Lancashire CCGs: - In Month 3, the Trust has achieved a Performance of 96.2% against a target of 95% across 8 CCGs. CCG Position: - In Month 3, the Trust has achieved compliance for all CCGs.

Unassigned CCG: - In Month 3, there were 74 records unassigned a CCG, of which 67 (90.5%) were completed.

CPA 12 Month Review 7 Day Follow Up

2.1 Performance Activity NHS Improvement Indicators reported by CCG

Feb-17 Mar-17 Apr-17 May-17 Jun-17

100.0% 100.0% 100.0% 94.7% 100.0%

87.9% 97.4% 94.4% 96.9% 97.4%

94.7% 100.0% 100.0% 94.7% 100.0%

97.9% 95.9% 98.0% 100.0% 93.5%

94.4% 95.7% 100.0% 100.0% 100.0%

100.0% 100.0% 100.0% 96.0% 100.0%

100.0% 92.3% 100.0% 94.4% 100.0%

100.0% 100.0% 100.0% 100.0% 90.0%

96.4% 97.5% 98.5% 97.1% 97.5%

NHS Fylde & Wyre CCG

NHS Greater Preston CCG

NHS Morcambe Bay CCG

NHS West Lancashire CCG

7 DFU CCG

NHS Blackburn with Darwen CCG

NHS Blackpool CCG

NHS Chorley & South Ribble CCG

NHS East Lancashire CCG

Total Figure - 8 CCGs


98.8% 99.0% 98.5% 98.3% 97.2%

95.2% 96.5% 96.6% 96.4% 95.8%

99.2% 98.5% 98.0% 96.6% 95.2%

96.2% 97.2% 96.1% 96.7% 95.1%

96.1% 96.5% 96.9% 98.8% 96.0%

98.4% 99.0% 98.8% 98.2% 97.9%

98.6% 95.7% 93.5% 95.8% 96.7%

95.9% 99.5% 100.0% 96.7% 95.6%

97.2% 97.7% 97.2% 97.2% 96.2%




NHS Morecambe Bay CCG



12 month CPA


NHS Blackpool CCG


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Delayed Transfers of Care (DToC)

17

IP Access to Crisis Resolution Home Treatment

Trust position for Lancashire CCGs: - In Month 3, the Trust has achieved a Performance of 2.99% against a target of <7.5% across 8 CCGs. CCG Position: - In Month 3, the Trust has achieved compliance for all CCGs.

Trust position for Lancashire CCGs: - In Month 3, the Trust has achieved a Performance of 99.4% against a target of 95% across 8 CCGs. CCG Position: - In Month 3, the Trust has underperformed in 1 CCG: Morecambe Bay.


94.7% 95.8% 100.0% 100.0% 100.0%

100.0% 97.4% 100.0% 100.0% 100.0%

100.0% 95.2% 100.0% 100.0% 100.0%

100.0% 98.0% 100.0% 100.0% 100.0%

100.0% 100.0% 100.0% 100.0% 100.0%

100.0% 100.0% 100.0% 100.0% 100.0%

100.0% 94.4% 100.0% 100.0% 94.7%

100.0% 100.0% 100.0% 100.0% 100.0%

99.4% 97.6% 100.0% 100.0% 99.4%







% IP Access to CRHTT


NHS Blackpool CCG



1.70% 3.61% 3.85% 4.17% 3.97%

1.51% 0.27% 1.72% 0.83% 0.68%

4.09% 4.52% 2.78% 0.00% 2.00%

1.81% 2.13% 3.98% 5.17% 3.20%

4.61% 3.13% 3.70% 1.68% 4.20%

4.51% 4.45% 4.84% 4.78% 5.68%

0.00% 0.00% 0.00% 0.00% 0.00%

4.63% 4.12% 0.00% 3.57% 0.14%

2.81% 2.74% 3.18% 3.07% 2.99%




NHS Lancashire North CCG



DToC


NHS Blackpool CCG


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RTT – Consultant Led (Completed Pathway)

18

RTT – Consultant Led (Incomplete Pathway)

Trust position for Lancashire CCGs: - In Month 3, the Trust has achieved a Performance of 100% against a target of 95% across 8 CCGs. CCG Position: - In Month 3, the Trust has achieved compliance for all CCGs.

Trust position for Lancashire CCGs: - In Month 3, the Trust has achieved a Performance of 100% against a target of 92% across 8 CCGs. CCG Position: - In Month 3, the Trust has achieved compliance for all CCGs.

Note: NHS England guidance published in October 2015 confirmed that the incomplete pathway operational standard should became the sole measure of patients’ constitutional right to start treatment within 18 weeks. And whilst we are required to maintain reporting on the completed admitted pathway, the removal of the completed admitted pathway as an operational standard means that there is no longer any provision to report pauses or suspensions in RTT waiting time clocks in monthly RTT returns to NHS England. This means that patients choosing to cancel appointments can impact negatively on this measure.


- - - - 100.0%

- - - - -

97.2% 100.0% 100.0% 100.0% 100.0%

- - - - -

- 100.0% 100.0% - -

97.8% 100.0% 100.0% 100.0% 100.0%

100.0% 100.0% 100.0% 100.0% 100.0%

- - - - 100.0%

97.5% 100.0% 100.0% 100.0% 100.0%Total Figure - 8 CCGs






RTT Complete


NHS Blackpool CCG



- - - 100.0% -

- - - - -

100.0% 97.5% 100.0% 100.0% 100.0%

- - - - -

100.0% 100.0% - - 100.0%

100.0% 100.0% 100.0% 100.0% 100.0%

100.0% 100.0% 100.0% 100.0% -

- - 100.0% 100.0% -

100.0% 99.2% 100.0% 100.0% 100.0%Total Figure - 8 CCGs






RTT Incomplete


NHS Blackpool CCG


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MH Identifiers

19

MH Outcomes

Trust position for Lancashire CCGs: - In Month 3, the Trust has achieved a Performance of 99.8% against a target of 97% across 8 CCGs. CCG Position: - In Month 3, the Trust has achieved compliance for all CCGs. Unassigned CCG: In Month 3, there were 3366 records unassigned a CCG, of which 3173 (94.2%) were completed.

Trust position for Lancashire CCGs: - In Month 3, the Trust has achieved a Performance of 81.9% against a target of 50% across 8 CCGs. CCG Position: - In Month 3, the Trust has achieved compliance for all CCGs. Unassigned CCG: In Month 3, there were 206 records unassigned a CCG, of which 174 (84.4%) were completed.


99.8% 99.8% 99.8% 99.8% 99.8%

99.9% 99.9% 99.8% 100.0% 99.9%

99.7% 99.7% 99.7% 99.7% 99.7%

99.8% 99.8% 99.8% 99.8% 99.8%

99.8% 99.8% 99.8% 99.8% 99.7%

99.8% 99.8% 99.8% 99.8% 99.8%

99.8% 99.7% 99.7% 99.7% 99.7%

99.5% 99.5% 99.5% 99.5% 99.7%

99.8% 99.8% 99.8% 99.8% 99.8%

MH Identifiers


NHS Blackpool CCG









79.9% 79.6% 79.1% 77.4% 77.3%

78.7% 78.4% 78.8% 78.5% 78.6%

89.3% 89.8% 90.5% 87.8% 86.8%

84.1% 84.5% 85.3% 83.4% 83.0%

87.7% 87.4% 89.0% 86.3% 84.9%

82.4% 82.4% 82.4% 80.4% 80.4%

88.7% 90.4% 91.3% 90.0% 89.5%

79.5% 80.6% 80.8% 76.9% 77.1%

83.4% 83.7% 84.1% 82.3% 81.9%







MH Outcomes


NHS Blackpool CCG


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CIDS - Referrals

20

CIDS - Referral to Treatment

CIDS - Activity

Trust position for Lancashire CCGs: - In Month 3, the Trust has achieved a Performance of 100% against a target of 50% across 8 CCGs. CCG Position: - In Month 3, the Trust has achieved compliance for all CCGs. Unassigned CCG: - In Month 3, there were records 224 unassigned a CCG, of which 224 (100%) were completed.

Trust position for Lancashire CCGs: - In Month 3, the Trust has achieved a Performance of 99.1% against a target of 50% across 8 CCGs. CCG Position: - In Month 3, the Trust has achieved compliance for all CCGs. Unassigned CCG: - In Month 3, there were 93 records unassigned a CCG, of which 90 (96.7%) were completed.



100.0% 100.0% 100.0% 100.0% 100.0%

100.0% 100.0% 100.0% 100.0% 100.0%

100.0% 100.0% 100.0% 100.0% 100.0%

100.0% 100.0% 100.0% 100.0% 100.0%

100.0% 100.0% 100.0% 100.0% 100.0%

100.0% 100.0% 100.0% 100.0% 100.0%

100.0% 100.0% 100.0% 100.0% 100.0%

100.0% 100.0% 100.0% 100.0% 100.0%

100.0% 100.0% 100.0% 100.0% 100.0%

CIDS Referrals


NHS Blackpool CCG









98.8% 98.5% 98.4% 98.3% 98.3%

100.0% 100.0% 100.0% 100.0% 100.0%

99.4% 99.4% 99.8% 99.8% 99.9%

99.5% 100.0% 100.0% 100.0% 100.0%

96.8% 100.0% 100.0% 100.0% 100.0%

99.6% 99.0% 99.6% 99.6% 99.1%

100.0% 100.0% 100.0% 100.0% 100.0%

100.0% 100.0% 96.6% 100.0% 100.0%

99.3% 99.0% 99.3% 99.3% 99.1%

CIDS RTT


NHS Blackpool CCG









90.6% 89.7% 90.7% 89.7% 89.4%

89.7% 90.0% 90.7% 86.1% 83.3%

94.1% 94.8% 96.1% 96.1% 95.4%

93.7% 92.9% 84.2% 85.7% 84.6%

86.7% 86.8% 91.9% 89.3% 87.8%

86.7% 86.8% 91.9% 89.3% 87.8%

90.2% 90.6% 91.7% 88.7% 90.8%

76.7% 71.3% 68.1% 70.2% 70.8%

92.8% 93.0% 94.2% 93.8% 93.5%

CIDS Activity


NHS Blackpool CCG








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EIS 2 Week Wait

21



93.3% 80.0% 85.7% 57.1% 83.3%

- 85.7% - 100.0% -

87.5% 100.0% 40.0% 66.7% 66.7%

85.7% 50.0% 80.0% 100.0% 100.0%

75.0% 60.0% 100.0% 50.0% 100.0%

20.0% 83.3% 100.0% 100.0% 100.0%

100.0% 100.0% 100.0% 100.0% 100.0%

100.0% 0.0% 0.0% 100.0% 50.0%

81.0% 73.7% 76.9% 83.3% 90.3%

2ww EIS


NHS Blackpool CCG








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IAPT – 6 Weeks

22

IAPT – 18 Weeks




98.7% 86.0% 95.6% 91.4% 77.3%

97.5% 98.0% 95.6% 93.6% 97.4%

97.2% 97.1% 96.8% 97.2% 96.1%

95.2% 90.1% 94.7% 95.8% 97.6%

93.5% 87.0% 94.6% 93.4% 95.3%

95.2% 96.3% 97.3% 90.7% 94.2%

93.4% 89.3% 98.5% 94.1% 97.3%

95.9% 93.1% 96.1% 94.3% 94.4%

Not Commissioned







RTT IAPT 6 Wks


NHS Blackpool CCG



100.0% 98.2% 100.0% 98.6% 98.7%

100.0% 100.0% 99.1% 99.2% 100.0%

100.0% 100.0% 100.0% 100.0% 100.0%

100.0% 96.0% 98.9% 97.2% 100.0%

100.0% 97.2% 99.1% 99.3% 100.0%

98.9% 100.0% 100.0% 99.0% 98.1%

100.0% 98.7% 98.5% 100.0% 100.0%

99.9% 98.8% 99.5% 99.2% 99.6%

RTT IAPT 18 Wks


NHS Blackpool CCG




Not Commissioned





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2.1 Performance Activity Summary – Mental Health

23

Indicators achieved Target Type Target Jun-16 Jul-16 Aug-16 Sep-16 Oct-16 Nov-16 Dec-16 Jan-17 Feb-17 Mar-17 Apr-17 May-17 Jun-17Rolling 12 Month

Sparkline

NHS Improvement

CPA 7 Day Follow Up (Total Network Performance) NHSI 95.00% - - - - - 96.7% 98.1% 98.7% 96.7% 97.8% 98.5% 96.8% 95.7%

CPA 7 Day Follow Up (AMH) NHSI 95.00% 97.5% 97.5% 97.7% 96.7% 97.5% 96.8% 98.4% 98.5% 96.9% 98.4% 98.9% 96.9% 96.2%

CPA 7 Day Follow Up (OA) NHSI 95.00% 100.0% 100.0% 100.0% 80.0% 83.3% 95.5% 95.7% 100.0% 95.0% 93.5% 96.2% 100.0% 96.0%

CPA 7 Day Follow Up (SS) NHSI 95.00% - - - - - 100.0% 100.0% 100.0% 50.0% 100.0% 0.0% 80.0% 50.0%

CPA 12 Month Review (Total Network Performance) NHSI 95.00% - - - - - 97.3% 97.7% 96.7% 97.0% 97.5% 97.0% 97.2% 95.9%

CPA 12 Month Review (AMH) NHSI 95.00% 96.6% 96.4% 96.3% 96.8% 97.4% 96.9% 97.4% 96.3% 96.6% 97.3% 96.5% 96.8% 95.3%

CPA 12 Month Review (OA) NHSI 95.00% 99.4% 98.2% 98.1% 98.5% 98.8% 100.0% 99.7% 100.0% 100.0% 100.0% 99.7% 100.0% 99.1%

CPA 12 Month Review (SS) NHSI 95.00% 98.8% 98.2% 98.8% 99.4% 98.8% 100.0% 100.0% 98.2% 98.2% 97.0% 100.0% 98.8% 100.0%

Delayed Transfers of Care (Total Network Performance) NHSI ≤ 7.50% - - - - - 4.20% 4.79% 3.76% 2.60% 2.39% 3.10% 3.33% 3.52%

Delayed Transfers of Care (AMH) NHSI ≤ 7.50% 4.01% 2.55% 3.35% 2.96% 1.82% 1.23% 3.06% 3.66% 2.19% 2.27% 3.26% 3.42% 3.03%

Delayed Transfers of Care (OA) NHSI ≤ 7.50% 2.87% 2.71% 3.44% 11.77% 16.59% 14.48% 10.34% 4.11% 3.92% 2.70% 3.27% 2.06% 3.08%

Delayed Transfers of Care (SS) NHSI ≤ 7.50% 1.33% 2.02% 0.85% 1.66% 1.35% 2.41% 2.77% 3.91% 3.80% 3.08% 2.74% 3.85% 4.61%

IP Access to Crisis Res. Treatment (Gatekeeping) NHSI 95.00% 96.6% 99.4% 99.4% 98.9% 98.3% 100.0% 100.0% 98.6% 99.4% 97.7% 100.0% 100.0% 99.5%

MH Data Completeness - Identifiers NHSI 97.00% - - - - - - - - - - 99.6% 99.6% 99.7%

MH Data Completeness - Identifiers (AMH) NHSI 97.00% 99.7% 99.7% 99.7% 99.6% 99.6% 99.7% 99.7% 99.7% 99.8% 99.7% - - -

MH Data Completeness - Identifiers (SS) NHSI 97.00% 98.0% 98.0% 98.1% 97.9% 98.1% 98.1% 97.9% 98.4% 98.4% 98.5% - - -

MH Data Completeness - Outcomes NHSI 50.00% - - - - - - - - - - 85.8% 84.8% 84.5%

MH Data Completeness - Outcomes (AMH) NHSI 50.00% 78.0% 81.1% 82.2% 83.7% 84.4% 85.1% 85.3% 85.2% 85.2% 85.4% - - -

MH Data Completeness - Outcomes (SS) NHSI 50.00% 83.4% 82.9% 84.0% 84.2% 84.3% 85.1% 83.4% 82.5% 81.3% 79.6% - - -

Other Indicators

AQ Dementia (OA) (1 month in arrears) NHSE 59.30% 100.0% 100.0% 100.0% 100.0% 100.0% 90.9% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% -

Memory Assessment Service (MAS) seen within 6 weeks (OA) NHSE 70.00% 39.3% 38.2% 34.4% 37.4% 40.5% 40.2% 39.5% 25.7% 40.3% 48.4% 47.0% 52.1% 70.4%

PBR Clustering NHSE 95.00% 90.2% 91.5% 93.5% 94.1% 94.2% 96.1% 96.4% 96.8% 96.4% 96.5% 96.5% 96.6% 96.7%

No of Patients without a Care Co-ordinator Allocated > 2 Weeks (Total Network Performance) NHSE 0

432 437 355 418 407 331 307 313 255 260 267 255 211

No of Patients without a Care Co-ordinator Allocated > 2 Weeks (AMH) NHSE 0 363 355 284 326 324 292 266 262 222 253 245 243 187

No of Patients without a Care Co-ordinator Allocated > 2 Weeks (SS) NHSE 0 69 82 71 92 83 39 41 51 33 7 22 12 24

MHLT

MHLT 1hr compliance Commissioners 95.00% - - 54.3% 55.2% 37.8% 52.6% 45.7% 46.9% 38.7% 51.8% 51.7% 47.4% 47.5%

No of 4hr breaches (Percentage of total) 5.00% - - 0.0% 0.0% 4.8% 10.1% 7.7% 11.2% 15.4% 9.7% 8.9% 10.5% 14.8%

No of 4hr breaches (Number of breaches) 37 - - - - 25 53 49 75 102 71 67 79 110

No of 12hr breaches (Percentage of total) 0.00% - - - - 1.5% 2.1% 0.9% 1.5% 1.2% 3.3% 0.8% 1.3% 4.0%

No of 12hr breaches (Number of breaches) 0 - - - - 8 11 6 10 8 24 6 10 30

Stretch

Stretch

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2.1 Performance Activity Summary – Mental Health (Secure)

24


Sparkline

Secure Mental Health Business Unit

Overall Gross Occupancy NHSE 93.00% 91.5% 90.3% 90.5% 90.7% 90.5% 90.5% 90.2% 91.8% 93.3% 93.7% 97.2% 95.9% 96.0%

Violent Incidents resulting in Restraint Stretch ≤ 20.00% 18.8% 18.0% 23.6% 35.4% 23.8% 20.3% 16.1% 20.8% 17.5% 20.5% 18.4% 15.6% 22.2%

% of SU that have had a CPA Review in last 6 months Stretch 100% 97.0% 97.0% 100.0% 99.3% 100.0% 100.0% 100.0% 100.0% 99.3% 99.3% 98.0% 97.4% 96.1%

% of service users who have a Care Coordinator allocated within 2 weeks Stretch 100% - - - - - 60.0% 62.5% 75.0% 77.8% 75.0% 66.7% 100.0% 50.0%

% of CPA reviews attended by Local Care Coordinators Stretch 80% - - - - - 37.5% 50.0% 25.0% 42.9% 39.3% 65.2% 33.3% 51.7%

% of service users who have Cardiometabolic risk factors assessed within 12 months

Stretch 90% - - - - - 94.4% 94.6% 96.0% 89.7% 96.8% 100.0% 100.0% 99.4%

25hrs Meaningful Activity - Offered NHSE 100% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0%

25hrs Meaningful Activity - Uptake NHSE 100% 83.9% 82.3% 88.4% 80.7% 87.9% 82.4% 82.8% 85.0% 80.4% 79.9% 75.6% 82.3% 81.3%

Community Business Unit

% of caseload with a Local Care Coordinator allocated Stretch 100% - - - - - 89.8% 96.1% 96.0% 97.9% 100.0% 95.3% 97.0% 95.5%

% of caseload carried longer than 12 months post SMHBU discharge Stretch ≤ 20.00% - - - - - 57.1% 58.8% 72.0% 66.7% 74.0% 60.9% 60.6% 59.7%

% of CPA Reviews Attended by Local Care Coordinators / Local Teams Stretch 80% - - - - - 42.9% 50.0% 62.5% 75.0% 30.0% 33.3% 40.0% 54.5%

No of Incidents exceeding PACE Clock Commissioners 0 6 6 3 8 6 4 3 4 3 5 7 3 4

Health & Justice Business Unit - HMP Liverpool

GP Waits over 2 Weeks NHSE 0% 13.3% 45.8% 37.6% 44.9% 43.6% 52.6% 64.1% 55.0% 59.5% 64.2% 49.4% 22.8% 0.0%

NHS Health Checks NHSE 40.00% 7.7% 3.7% 8.4% 6.1% 13.5% 19.8% 3.6% 26.1% 13.2% 8.9% 1.9% 57.1% 28.6%

Well Man Assessment completed NHSE 100.00% - - - - - 98% 98% 97% 95% 89% 75% 63% 33%

Hep B Vaccinations completed NHSE - - - - - 0.0% 25.0% 30.4% 25.0% 0.0% 3.7% 0.0% 8.6%

Chlamydia Screening U25's Uptake NHSE 50.00% 2.9% 21.5% 2.2% 11.0% 8.8% 6.3% 20.7% 14.3% 33.3% 5.3% 13.0% 27.3% 63.6%

Men C Vaccinations Uptake NHSE 95.00% 6.8% 20.0% 9.6% 10.7% 12.8% 5.7% 5.7% 12.2% 4.9% 2.6% 2.4% 21.1% 44.7%

MMR Vaccinations Uptake NHSE 95.00% 16.7% 19.3% 17.5% 10.5% 21.7% 50.0% 4.4% 11.1% 0.0% 14.3% 23.8% 3.6% 2.3%

Prison 6 Month CPA Reviews NHSE 100.00% 100.0% 100.0% - 100.0% 100.0% 100.0% 100.0% - 100.0% 100.0% 100.0% 100.0% 100.0%

QOF NHSE 238 277 273 256 266 302 322 327 323 314 319 316 323 334

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2.1 Performance Activity Summary – Community & Wellbeing

25

Indicators achieved Target Type Target Jul-16 Aug-16 Sep-16 Oct-16 Nov-16 Dec-16 Jan-17 Feb-17 Mar-17 Apr-17 May-17 Jun-17Rolling 12 Month

SparklineNHS Improvement

Delayed Transfers of Care NHSI <7.5% - - - - - - - - - 0.0% 0.0% 0.0%

RTT - Consultant Led (Completed Pathway) NHSI 95% 98.0% 97.3% 93.2% 92.4% 95.2% 96.3% 96.7% 97.6% 100.0% 100.0% 100.0% 100.0%

RTT - Consultant Led (Incomplete Pathway) NHSI 92% 96.4% 95.0% 95.7% 96.3% 95.2% 95.4% 97.3% 100.0% 99.2% 100.0% 100.0% 100.0%

RTT - IAPT 6 Weeks NHSI 75% 90.2% 92.1% 90.8% 95.0% 93.0% 96.5% 95.1% 95.7% 93.4% 96.4% 94.7% 95.1%

RTT - IAPT 18 Weeks NHSI 95% 99.2% 99.5% 99.1% 99.3% 99.0% 99.8% 99.4% 99.8% 98.8% 99.4% 99.2% 99.7%

Waiting Times - AHP RTT

Adult Learning Disability Service NHSE 95% 83.7% 91.2% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0%

Community Stroke Service NHSE 95% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0%

Intermediate Care NHSE 95% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0%

Podiatry NHSE 95% 95.9% 100.0% 100.0% 100.0% 99.9% 100.0% 100.0% 99.8% 100.0% 100.0% 100.0% 100.0%

Pulmonary Rehabilitation NHSE 95% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0%

Rapid Assessment Team NHSE 95% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0%

Adult Speech and Language Therapy NHSE 95% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 99.0% 100.0% 100.0% 100.0%

Community Neuro Team NHSE 95% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0%

Community Respiratory Service NHSE 95% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0%

Continence Service NHSE 95% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 97.8% 100.0%

Domiciliary Physiotherapy NHSE 95% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0%

Falls Team NHSE 95% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 99.5%

Nutrition & Dietetics NHSE 95% 98.8% 100.0% 97.2% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0%

IAPT

IAPT in Month Prevalence NHSE 1.25% 1.50% 1.53% 1.38% 1.39% 1.44% 1.39% 1.67% 1.28% 1.72% 1.05% 1.32% 1.43%

IAPT Cumulative Prevalence NHSE 3.75% 6.02% 7.56% 8.93% 10.32% 11.76% 13.15% 14.82% 16.10% 17.82% 1.05% 2.36% 3.79%

IAPT Waiting Times (Internal Target) Stretch 0pts >26 wks 37 18 38 47 45 73 46 5 12 22 23 23

IAPT Recovery NHSE 50% 51.0% 48.7% 52.2% 51.8% 56.3% 56.3% 53.8% 57.0% 53.4% 54.5% 52.6% 57.0%

Other Indicators

RTT Complete Learning Disablity Commissioner 95% 97.2% 99.3% 98.4% 97.3% 98.1% 98.8% 98.9% 98.9% 100.0% 98.7% 96.1% 96.3%

12 Week Dentist Waits - HMP Liverpool Commissioner 95% 94.8% 94.0% 93.0% 95.7% 100.0% 98.7% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0%

Community Dental Waits Commissioner 95% 80.4% 88.8% 91.1% 88.9% 91.2% 95.2% 96.1% 98.0% 99.4% 97.1% 98.3% 100.0%

Unallocated Cases NHSE 0 11 11 15 8 12 11 12 12 7 15 13 2

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2.1 Performance Activity Summary – Children & Young People’s Wellbeing

26

Note:

• The Platform and The Junction have been replaced with The Cove.

• Narrative not provided as this measure is to be superseded by new EIS measures (dashboard) currently in development.

Indicators achievedTarget

TypeTarget Jun-16 Jul-16 Aug-16 Sep-16 Oct-16 Nov-16 Dec-16 Jan-17 Feb-17 Mar-17 Apr-17 May-17 Jun-17

Rolling 12 Month

Sparkline

NHS Improvement

CPA 7 Day Follow Up NHSI 95.00% 88.89% 100.0% 100.0% 100.0% 75.0% 100.0% 100.0% 100.0% 100.0% 95.5% 100.0% 100.0% 100.0%

CPA 12 Month Review NHSI 95.00% 98.9% 98.3% 97.2% 98.2% 98.8% 97.6% 98.3% 99.5% 98.5% 97.9% 97.5% 95.6% 99.00%

MH Data Completeness - Identifiers NHSI 97.00% 99.8% 99.7% 99.7% 99.7% 99.6% 99.7% 99.7% 99.7% 99.7% 99.7% 99.6% 99.6% 99.7%

MH Data Completeness - Outcomes NHSI 50.00% 61.5% 67.7% 67.3% 67.3% 67.1% 67.2% 66.3% 64.8% 81.3% 64.9% 63.5% 60.7% 59.3%

2 Week wait for Treatment for EIP Programme NHSI 50.00% 86.7% 77.1% 67.7% 75.0% 69.0% 74.3% 76.7% 82.0% 81.4% 74.4% 69.0% 83.3% 90.9%

Waiting Lists - RTT 18 Weeks (Completed Outcomes)

EIS Therapies (The Hub) NHSE 95.00% 100.0% 100.0% 97.6% 92.5% 86.8% 90.3% 93.0% 83.9% 80.0% 94.7% 92.7% 94.7% 100.0%

Child Psychology - Total Network Performance NHSE 95.00% 71.8% 68.6% 68.6% 67.6% 70.7% 69.9% 70.9% 71.0% 60.3% 64.8% 66.6% 62.4% 66.9%

CAMHS Tier 3 - Total Network Performance NHSE 95.00% 99.7% 98.8% 96.7% 99.3% 96.4% 99.0% 97.5% 100.0% 98.1% 88.8% 79.4% 78.0% 78.4%

Waiting Lists - RTT 18 Weeks (Incompleted Outcomes)

CITNS - Occ Therapy - Total Network Performance NHSE 92.00% 67.5% 74.3% 67.1% 80.6% 83.1% 81.8% 81.8% 88.2% 91.2% 95.1% 94.9% 94.0% 96.4%

CITNS - Physiotherapy - Total Network Performance NHSE 92.00% 99.4% 98.6% 100.0% 100.0% 100.0% 100.0% 100.0% 98.1% 100.0% 100.0% 100.0% 100.0% 100.0%

CITNS - SLT- Total Network Performance NHSE 92.00% 81.3% 80.4% 85.5% 91.7% 92.6% 86.9% 86.9% 86.6% 83.6% 82.7% 84.2% 86.7% 87.0%

CAMHS Tier 4

Bed Occupancy - The Cove NHSE 85.00% 86.0% 88.7% 84.0% 88.8% 83.0% 65.0% 55.0% 65.5% 80.5% 90.5% 92.8% 86.5% 96.7%

Average Length of Stay (days) - The Cove Bench 83 45.00 28.00 55.00 54.00 80.00 78.00 57.00 44.00 41.00 39.00 67.00 57.00 33.30

National Child Measurement Programme

NCMP - Central NHSE 90.00% 95.0% 95.0% - - 4.4% 19.3% 26.8% 39.5% 52.6% 64.5% 73.8% 88.7% 94.4%

NCMP - BwD (Cumulative) NHSE 95.00% 96.8% 97.6% - - 5.5% 17.8% 24.9% 37.1% 46.3% 60.2% 67.6% 82.2% 95.7%

NCMP - East (Cumulative) NHSE 90.00% 98.1% 98.1% - - 9.1% 21.9% 30.3% 44.3% 56.0% 67.9% 79.5% 93.0% 98.5%

Other Indicators

ADHD - NEW < 18 Weeks NHSE 95.00% 61.2% 58.0% 61.4% 57.5% 64.3% 61.7% 59.9% 63.9% 68.4% 62.3% 53.6% 61.0% 64.3%

PBR Clustering NHSE 95.00% 92.6% 95.4% 96.1% 97.0% 95.7% 94.9% 93.6% 96.2% 96.3% 95.4% 96.0% 97.2% 96.4%

Number of Patients without a Care Co-ordinator Allocated > 2 Weeks NHSE 0 9 27 14 16 16 13 14 8 18 29 23 5 4

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2.1 Performance Activity Mental Health – Memory Assessment Service (MAS)

27

MAS: Actions:

In June, MAS services have achieved the 70% target with 70.4% of cases ‘seen within 6 weeks’ wait target. Exceptional effort has taken place across all teams and a significant increase has been achieved across Q1. East Lancs have seen an increase from 18.99% in April to 85.11% of service users being seen within the 6 week target in June. Central Lancs have significantly reduced their average waiting time from 119.6 days in April to 84.8 days in June and the waiting list has reduced by 133 to 221 for June. This improvement is expected to continue into Q2 and steadily increase the number of service users that can then be seen within the 6 week target. Fylde Coast, Lancaster and Blackpool continue to achieve above target with all teams achieving 100% 'seen within 6 weeks' wait target for June. West Lancs achieved 96.67% with one service user not being seen within the 6 week timescale. In June, across all services 486 patients were seen with 342 being ‘seen within 6 weeks,’ an increase of 60.56% of service users being 'seen within 6 weeks' across the Q1. Referrals have continued to increase in Q1 with June seeing an 11% increase in the total number of referrals from May. At the time of reporting, 523 were accepted from a potential of 625 referrals. Blackpool has been relatively stable; however, an increase has been seen across all other areas. East Lancs, Central and Fylde Coast have seen increases of 29%, 28% and 27% respectively and West Lancs has experienced an 80% increase from 30 referrals in April to 54 referrals in June. The average waiting time has continued to improve from 45.2 days in May to 37 days in June, a reduction of 33.69% across the quarter. There are now 439 people waiting on the waiting list which continues to be a significant improvement with a reduction of 495 across the quarter. Analysis of longest waits remains in place to ensure effective waiting list management. The longest wait is currently 16 weeks in Central Lancashire and the service user has an appointment booked for the 4th July 2017. Services have stabilised and continue to demonstrate improvement across all localities. Central Lancs MAS continues to have some pressure and they are concentrating working through the waiting list which is generating pressure on other MAS related activities, which under current staffing provision will not be sustainable long term. The meeting between managers with Chorley & South Ribble and Greater Preston CCGs went ahead on 13th June 2017. Best practice is the main forum for reviewing quality and robust clinical practice pan Lancashire.

6 week wait (capacity / activity) and

waiting list:

• Locality variations in team skill mix will continue to be reviewed in staffing and recruitment.

• Productivity levels and capacity will continue to be measured by a daily SITREP.

Local recovery action plans per team

operating:

• Work continues to reduce recording requirements to increase clinical capacity.

• East Lancs and Central Lancs continue to frontload their Front line to meet demands for assessments and waiting lists.

• Blackpool, Fylde Coast and North MAS services are focusing on quality improvements now that the position has been improved and sustained.

• Action plans will be reviewed in light of the recovery and updated where appropriate.

• From the meeting with Chorley & South Ribble and Greater Preston CCGs on 13th June 2017, LCFT have an action to review with finance the current structure for MAS and then feedback at the next meeting to be arranged for a month’s time.

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2.1 Performance Activity Mental Health – MAS

28

Waiting list profile:

Total 055 23 11 0 0459 370

West Lancs MAS 39 38 1 0 0 0 0 0

0 0 0 0Lancaster MAS 26 26 0 0

0 0 0 0Fylde Coast MAS 41 41 0 0

0 0 0 0East Lancs MAS 105 105 0 0

Central Lancs MAS 215 127 54 23 11 0 0 0

Blackpool MAS 33 33 0 0 0 0 0 0

13 - 18

weeks

19 - 24

weeks

25 - 30

weeks

31 - 40

weeksMAS Team / CCG / NHS Number

Number of

Patients /

Wks Wait

0 - 6

weeks

7- 9

weeks

10 - 12

weeks

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2.1 Performance Activity Mental Health – MAS

29

60 of 215


2.1 Patient Flow Mental Health – Mental Health Liaison Team (MHLT)

30

MHLT: Actions:

1 Hour Compliance: The Network is reporting low compliance in the target for patients to be seen within 1 hour of referral with 47.5% compliance in M3. 4 Hours Breaches: The Network is reporting 110 actual 4 hour breaches in A&E for which LCFT were responsible in month 3, this is 14.77% of all A&E referrals to MHLT. This is a declined position from 10.5% in M2. 12 Hours Breaches: The Network is reporting 30 actual 12 hour breaches in A&E from the decision to admit time in month 3, this is 4.0% of all A&E referrals to MHLT.

• The Network Knowledge Manager is working with the Performance team to improve data quality and reporting measures.

• Review of the MHLT Pathway is being undertaken to map the recommendations from the RCP review of East MHLT to provide a gap analysis across all MHLTs and highlight shortfalls in provision in localities.

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2.1 Patient Flow Mental Health – Mental Health Liaison Team (MHLT)

31

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32

Violent Incidents resulting in Restraint: Actions:

In June 2017, staff reported a total of 117 incidents of verbal and physical violence within the inpatient unit. This is a decrease of 35% from May 2017. The number of service users involved in the incidents of restraint in June 2017 is 18, 11% of total service users increasing from 10% in May 2017. In June, the locality saw an increase in the use of restraint with 22% of violent incidents ending in restraint. This compares to 16% in May 2017; NB - this figure does not include restraint deployed to manage self-injury. Elmridge Ward continues to report above average levels of restraint with a high number of these incidents occurring due to self-harm. This is reflective of the clinical need of the Service User group. Whinfell Ward has also had a higher than average restraint use for June with one service user requiring restraint 7 times. These restraints have all been low level techniques in order to guide the service user to a low stimulus area following an increase in early warning signs.

• The Service Manager continues to meet with the Clinical Leads and Lead Nurse to review clinical areas where violence is seen to have increased.

• Following discussions with the VR Lead additional support has been agreed and is to be targeted to the areas reporting increased levels of restraint.

• Individual cases of increased acuity are subject to debrief by the MDTs, including the Service User. Support is provided to the staff groups by increased supervision and psychological input from the localities Community Teams.

• The Service Manager has identified two previously trained VT instructors to refresh their training to support the ongoing training in this area.

2.1 Performance Activity Mental Health (Secure Services) – Violent Incidents

resulting in Restraint

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33

2.1 Performance Activity Mental Health (Secure Services) – Violent Incidents

resulting in Restraint

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34

CPA Reviews within 6 Months SMHBU: Actions:

Out of 154 service users eligible to have had their first CPA, 6 have not had a CPA within the last 6 months. 1 was postponed from May due to the service user needing an ASC assessment, this has now taken place and the CPA has been rescheduled for 10th July. 1 was postponed from June due to an incident and the subsequent transfer of ward of the service user. The CPA has been rescheduled for 17th July which was the next available date. 3 were postponed from June due to a transfer of Responsible Clinician (RC); all have been re-scheduled for the next available dates in July. 1 was postponed in June as the RC was on annual leave; this has been rescheduled for the next available date on 10th July. The process in place to monitor the CPA reviews is working and providing robust monitoring. However, due to circumstances such as internal transfers, clinician changes and service user requests which impact a review taking place within the timescale, in these cases they are always rebooked to the earliest available date.

• The performance analyst is continuing to monitor all service users who are due a CPA review in the coming months to ensure that they have a meeting scheduled and that this falls within the 6 month timeframe.

• All re-scheduled CPAs have not resulted in delays regarding care pathways.

• AMD to review the issues regarding RC involvement.

2.1 Performance Activity Mental Health (Secure Services) – CPA Reviews

Within 6 Months SMHBU

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35

2.1 Performance Activity Mental Health (Secure Services) – CPA Reviews

Within 6 Months SMHBU

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36

Local Care Co-ordinator >2weeks: Actions:

In June, there were 4 admissions and 2 were not allocated a local care co-ordinator (see below). 1 service user was placed in a medium secure bed on a temporary basis whilst waiting for a PICU bed. He was transferred to Keats PICU at the Harbour within 5 days and did not require local care co-ordinator allocation. 1 service user was admitted urgently from HMP Liverpool on 30th June. A referral has been made to the appropriate team and is expected to be allocated within the timescales.

• The service continues to ensure that referrals for local care co-ordinator allocations are sent to the relevant teams for service users placed on the waiting list. This will ensure allocation within the timescales. The Flow and Capacity Manager will continue to escalate any outstanding issues to the relevant CCG, CMHT Managers and NHSE case managers.

• An anomaly has been noted this month with regard to the reporting period with regards to this indicator. This will be rectified in M4 reporting.

2.1 Performance Activity Mental Health (Secure Services) – Local Care Co-ordinator

>2weeks

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37

Attendance of CPA reviews: Actions:

Of the 29 CPAs planned for June, 15 local care co-ordinators attended, 7 sent apologies and 7 did not attend. Performance improved in June. 6 CPAs for Blackpool, 4 attended, 1 DNA and 1 sent apologies 1 CPA for Lancaster, 1 sent apologies 3 CPAs for Preston, 2 attended and 1 sent apologies 7 CPAs for Blackburn, 4 attended, 2 DNA and 1 sent apologies 3 CPAs for Hyndburn, Rossendale & Ribble Valley, 1 attended, 1 DNA and 1 sent apologies 1 CPA for Burnley & Pendle, 1 DNA 2 CPAs for West Lancs, 2 attended 6 CPAs for Non LCFT, 2 attended, 2 DNA and 2 sent apologies. One LCFT CPA was missing evidence of an invite. One local care co-ordinator from LCFT gave apologies for the CPA, however will be attending the service user’s CTM on 18th July. 2 LCFT local care co-ordinators attended meetings via Skype.

• The LCFT CPA missing evidence for an invite has been escalated to the admin manager to follow up with staff.

• Upcoming CPA dates for the next 3 months will continue to be forwarded to the relevant community team managers, to allow coordination in advance, to promote further attendance.

• The promotion of Skype is to be reiterated to the Senior MDT secretaries to ensure it is being offered on all invites. Failure to provide Skype, as requested, has been escalated with the admin manager to address during supervision.

• The Network is considering a Performance Management approach with regards to non attendees.

2.1 Performance Activity Mental Health (Secure Services) – Attendance of

CPA reviews

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38


CPA reviews

Attended Apologies DNA23 13 5 56 2 2 2

Breakdown of LCCNo of CPA reviews

LCFT LCCNon LCFT LCC

Jun-17

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39

25hr Meaningful Activity: Actions:

In June, 6 wards failed to meet the 100% target in relation to meaningful activity uptake. Uptake has decreased from 82.28% in May to 81.29% in June. Forrest Beck ward have 2 service users that are not engaging as well as the other service users. Fairoak ward has seen improvement and an increase in activity and the recording of it. Marshaw ward has experienced a decrease in the number of service users achieving 25hrs of meaningful activity due to staffing issues and the use of bank and agency staff. It is felt that this is impacting the accurate recording of the activities taking place. On Mallowdale ward all service users were offered between 37 and 45 hrs meaningful activities with an uptake of between 8 and 24hrs being recorded. There are a number of service users that have negative symptoms impacting the uptake. During the Recovery College Roadshow staffs were targeted to promote the Recovery College and think about courses that could be provided.

• On Forrest Beck ward staff have been asked to read and refresh themselves with the information leaflet regarding what counts towards 25 hour activity to help improve engagement.

• Staff continue to work with all service users and are reminded to be mindful of accurate recording.

• A pilot is taking place to increase accessibility to Recovery

College courses. By the end of Q2, 3 wards have been asked to deliver a recovery session to their service user groups. The sessions should be co delivered by a service user and a member of staff. The wards are to feedback by the end of July and deliver their sessions in August / September.

• Varying levels of compliance is apparent across wards. A best

practice approach is being considered to ensure consistency.

2.1 Performance Activity Secure Services – 25hr Meaningful Activity

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40

2.1 Performance Activity Secure Services – 25hr Meaningful Activity

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2.1 Performance Activity Mental Health (Secure Services) – % of FCMHT

Caseload with Care Co-ordinator allocated

41

% of FCMHT Caseload with Care Co-ordinator allocated: Actions:

In June, the 3 service users without a care coordinator allocated are recent requests which have now been resolved. The process of allocation can take up to 2 weeks it is therefore difficult to achieve the 100% as there may always be those needing allocation near to the end of the month.

• The team will continue to monitor allocations to Local Care Co-ordinators. If any concerns over allocation are experienced these will be escalated to the manager to resolve. Being within the wider Mental Health Network is expected to assist the allocation process.

• An anomaly has been noted this month with regard to the reporting period with regards to this indicator. This will be rectified in M4 reporting.

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42

% of FCMHT Caseload >12 months: Actions:

There are currently 66 service users on the FCMHT case load, 40 of these service users have been on the FCMHT case load for over 12 months. Pathways have been reviewed for the caseload and it is apparent that the current target of less than 12 months is clinically unrealistic and that a more robust and clinically safe pathway takes significantly longer to achieve a sustainable pathway into locality community services to reduce risk of reoffending/readmission.

• The new service manager will continue to work with the team to review pathways and the continued need for intensive input by the FCMHT.

• There will also be discussion with SMT to review this indicator and the pathways within it.

2.1 Performance Activity Mental Health (Secure Services) – % of FCMHT

Caseload >12 months

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43

Attendance of CPA Reviews within Community Services: Actions:

In June, 6 out of 11 CPA reviews were attended by the local care co-ordinators. The FCMHT continue to work with all local care co-ordinators to improve attendance. Out of those not attended, any actions/minutes will be communicated. No delayed transfers of care have resulted from local care co-ordinator non-attendance.

• The promotion of Skype is to be reiterated to the Senior MDT secretaries to ensure it is being offered on all invites. Failure to provide Skype, as requested, has been escalated with the admin manager to address during supervision.

• The Network is considering a Performance Management approach with regards to non attendees.


CPA Reviews within Community Services

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2.1 Performance Activity Mental Health (Secure Services) – Number of

Incidents exceeding PACE Clock

44

Number of Incidents exceeding PACE Clock: Actions:

There were 4 reported episodes of individuals being detained in Police Custody beyond the 24 hour limit. Of the breaches, 1 was in excess of 97 hours, 1 in excess of 68 hours, 1 in excess of 41 hours and 1 in excess of 32 hours longer in Police custody than the PACE Limit of 24hrs. Two occurred at Blackpool Custody and two at Preston Custody. Acute Ward contingency beds are being utilised for PACE patients, though these are also used for A&E potential breaches and s136 patients, thus demand for these beds is not limited to PACE patients.

• The PACE breach escalation plan continues to be followed for all PACE breaches. This enables senior managers to unlock any blocks which can be addressed to resolve potential PACE breaches. The level of incidents will continue to be monitored to ensure the process continues to deliver improvement.

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HMP Liverpool – HJIP Indicators: Actions:

GP Waiting Times: There are currently 105 service users on the GP waiting list, with the longest wait being 2 weeks 20 hours, which is a further reduction in the waiting list for June from 2 weeks 6 days in May. Waiting times have reduced significantly across the quarter and this figure is now comparable to community waiting times with no service users waiting over 14 days. The number of service users seen has increased for the third consecutive month with 264 being seen in June an increase of 42 from May. Despite the improvement, there are still concerns with the clinic DNA rate. NHS Health Checks: All of the 14 eligible service users were sent appointments: 9 did not attend, 1 was released from court and 4 were seen. The only obstacle to 100% compliance is the issues with enablement. Wellman Screening: Due to the demands of the Integrated Mental Health Team (IMHT), it has been difficult to keep up with the increased number of Wellman Screens to be completed. Immunisations and Vaccinations: The Imms and Vacs programme continues to suffer from an above average DNA rate. Of the 35 patients offered Men C and MMR, 15 patients did not attend (43%). 108 patients were called up for Hep B vaccination and 45 of those did not attend (42%). As a result of actively canvassing service users and recording if they declined involvement with the vaccination programme, the eligible total for MMR has dropped from 225 to 132. Across Q1, the number of individual Hep B vaccinations given per month has increased from 31 in April to 72 in June.

DNA – Enablement Issues: • The issue of enablement was raised at the Prison Contract

meeting with NHSE on 27th June 2017. It was agreed that a clinic start time of 9.45am would be trialled to comply with the Prison regime and officer shortages. Twenty seven new officers are due to start in July as soon as inductions are completed, this is expected to have a positive impact on enablement. In addition, the Physical Health Lead from Guild Lodge will be working full time in Liverpool Prison from 17th July.

NHS Health Checks: • Enablement issues will continue to be monitored, as mentioned

above.

Wellman Screening: • From week commencing 3rd July 2017, an extra member of staff

has been recruited with the sole duty of completing Wellman Screening. Once the prison gains access to the two wings currently being refurbished, the operation capacity will increase to approx. 1200 men. This will obviously have an effect on the number of reception spaces available for the courts and in turn will increase the number of Wellman Screenings. The number of outstanding Wellman Screenings is monitored weekly. Once the existing backlog has been addressed the reception process will be reviewed with focus on the Wellman Screening.

Immunisations and Vaccinations: • DNA rates will continue to be monitored along with the

enablement of service users to attend clinics.

2.1 Performance Activity Mental Health (Secure Services) – HMP Liverpool

HJIP Indicators

45

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2.1 Performance Activity Mental Health (Secure Services) – HMP Liverpool HJIP

Indicators

46

Aug-16 Sep-16 Oct-16 Nov-16 Dec-16 Jan-17 Feb-17 Mar-17 Apr-17 May-17 Jun-17227 229 192 167 165 134 258 247 103 14 14

8.37% 6.11% 13.54% 19.76% 3.64% 26.12% 13.18% 8.91% 1.94% 57.14% 28.57%91 91 34 32 29 28 18 19 23 11 11

2.20% 10.99% 8.82% 6.25% 20.69% 14.29% 33.33% 5.26% 13.04% 27.27% 63.64%83 84 39 35 35 41 41 38 41 38 38

9.64% 10.71% 12.82% 5.71% 5.71% 12.20% 4.88% 2.63% 2.44% 21.05% 44.74%63 67 23 10 23 27 25 21 21 225 132

17.46% 10.45% 21.74% 50.00% 4.35% 11.11% 0.00% 14.29% 23.81% 3.56% 2.27%0 4 1 2 1 0 5 2 6 2 2- 100.00% 100.00% 100.00% 100.00% - 100.00% 100.00% 100.00% 100.00% 100.00%

Patients received NHS HC Screen

Patients Accpeting Men C Vacc

Patients Accpeting MMR Vacc

SU received CPA review <6 months

Total Eligible

% Screened

Total Eligible

% ScreenedTotal Eligible

% Screened

Total Eligible

% Recieved

Patients Screened for Chlamydia

Total Eligible

% Screened

MonthMar-17

Apr-17

May-17Jun-17

8-14 days35

52

029 18 3121 39 45

23

80

0-2 Days 3-7 days16 41

11 19

GP Waits

14+ days165

MonthPts vacc >4wks

Total Vaccs in month 1st dose 2nd dose 3rd dose

Booster

Mar-17 0 7 2 3 2 0Apr-17 1 31 15 9 4 3May-17 0 61 24 17 14 6Jun-17 3 72 21 27 16 8

Breakdown of Vaccs given

No of new receptions

No of pts accepting Hep B

% pts accepting vacc within 4 wks

0.00%3.70%0.00%8.57%

336 35

296261

327

35358

MonthMar-17

Apr-17

May-17Jun-17

211

No of new receptions

No of Wellman Health

Physical & Mental Health Wellman Checks

358 117

% Completed89.33%

75.10%

62.80%32.68%

375 335

261 196

336

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2.1 Performance Activity Community & Wellbeing – Improving Access to

Psychological Therapies (IAPT)

47

IAPT - Prevalence: Actions:

Prevalence In June, all teams achieved prevalence targets. This is a further improvement since May 2017. Mindsmatter teams brought significant focus to recover Quarter 1 prevalence at 15% across all teams. Most teams achieved Quarter 1 prevalence, apart from St Helens team. However, within this locality, prevalence has increased month on month and June was the first month where monthly prevalence target was met since March 2017. Blackburn with Darwen in particular have been working at a reduced prevalence target as agreed last financial year due to a reduction in the contract value. A meeting has been arranged for 20/07/17 between commissioners and LCFT to discuss and confirm the enhanced prevalence target for 17/18. A cumulative prevalence model has been presented to the CCGs to enable Mindsmatter to achieve the 16.8% prevalence target set by NHS England. Quarter 1 = 15%, Quarter 2 = 15.8%, Quarter 3 = 16.2%, Quarter 4 = 16.8%. Confirmation is being sought by the CSU to ensure this adheres to national IAPT guidance. LCFT Quarter 2 prevalence targets have been adjusted in light of this. St Helens CCG have agreed that prevalence will remain at 15% as they have not received any national LTC funding.

Prevalence • The leadership team have daily oversight of performance across all teams. Recovery and

Prevalence data is examined within teams three times per week, whilst waiting times data is shared once per week (due to the level of analysis required in gathering this report).

• The leadership team analyse performance data on a daily basis to identify areas of deficit in prevalence and, in conjunction with team members, direct the focus and resource within each specific locality.

• A 'Team Performance Review' template which includes prevalence, recovery and waiting time data, priority action plans and concerns is shared with teams. Team based engagement has created a greater ownership of performance within the wider team.

• The leadership team are working closely with the interim line managers and team modality leads to action and review the 'Team Performance Review' three times per week. Cross team working is in place to optimise productivity and enhance consistency of response in each team.

• Deficits and risk areas to achieve prevalence are raised at team and line management level and are escalated to the Leadership team and the Network Managers immediately in order to expedite actions.

• A service wide action log based on risks and interventions to mitigate against further deterioration is in place. This enables the leadership team to have an oversight of risks and develop trajectories for improvement . The risk log is reported to the Head of Operations, Deputy Head of Operations and Care Group Manager within thrice weekly skype calls to scrutinise performance.

• A capacity and demand group has been formed in order to sustain performance in the longer term. The group are currently completing a process map of all team level activity. Representatives from performance, HR, finance and TAS will be involved in the capacity and demand model.

• The prevalence target trajectory for Quarter 2,3 and 4 has been amended internally to reflect the 16.8% cumulative prevalence model proposed. Final agreement is required at the next Lancashire Care CCG Performance and Effectiveness Group meeting, to confirm this proposal reflects NHS England's IAPT technical guidance.

• The PIN development is progressing to enable LCFT to offer a prime provider model and subcontract to a number of third sector partners. A meeting has taken place with an interested Social Enterprise and a further day has been arranged to meet with all the original third sector organisations that expressed an interest.

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48


1.26% 0.89% 0.74% 1.84% 1.13%

1.02% 1.67% 0.88% 1.13% 1.31%

1.08% 1.44% 1.29% 1.53% 1.47%

1.11% 1.77% 1.00% 1.13% 1.64%

0.96% 1.40% 1.23% 1.33% 1.36%

1.18% 1.20% 0.92% 1.38% 1.46%

1.22% 1.41% 1.34% 1.07% 1.40%

0.83% 1.53% 1.13% 1.51% 1.34%

1.09% 1.47% 1.04% 1.32% 1.43%






CWB IAPT Prev CCG


NHS St Helens CCG



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49

IAPT - Waits: Actions:

Waits 23 people were waiting 26 weeks or over at the end of June, this is the same number that were waiting over 26 weeks in May. The team and modality which has continued to increase is CBT in Fylde and Wyre. A review of the CBT waiting list has been completed to analyse the reasons for the lengthy waits. An action plan is in place to address some changes identified in the review and will be monitored in the weekly Leadership meetings. Greater Preston had 1 wait other over 26 weeks, this has been reviewed to understand the reasons for the wait and this has been actioned. Waiting times across each waiting time bracket are being reviewed weekly by the leadership team and priority areas are being addressed at team level.

Waits • The leadership team monitor and analyse performance data on a daily basis in

order to closely examine prevalence and recovery targets and the direct impact this could have on waiting times.

• Performance data is shared with teams to enable teams to focus on priority deficit areas. The 'Team Performance Review' template includes waiting time data in each waiting bracket, including welcome calls waits, capacity concerns and areas of vulnerability.

• Team based action plans have been developed to address waiting time concerns, these will include:

• Internal waiting times and blockages in appointments. • Capacity and flow across the modalities and team. • Diary management, including admin requirements to maintain the flow

of booking patients appointments. • team performance and clinical contact hours .

• Action plans based on waiting time risks and actions are in place to mitigate against further increases are reviewed and actioned on a weekly basis by the leadership team.

• The Head of Operations, Deputy Head of Operations, Care Group Manager and Service Manager oversee performance within thrice weekly skype calls.

• A capacity and demand group has been formed in order to improve and sustain performance across all performance targets. The group are currently completing a process map of all team level activity. Representatives from performance, HR, Finance and TAS will be involved in the capacity and demand model.

• Across team working and the development of locality teams is being developed to increase productivity and consistency across teams.

• An action plan based on the analysis of waiting times in Fylde and Wyre has commenced to reduce over 26 week waits.

• Women’s Centre contract and priority areas is being reviewed.

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50

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2.1 Performance Activity Children & Young People’s Wellbeing – Child Psychology

51

Child Psychology (Total Network Performance): Actions:

In M3, overall service performance increased to 67%, an increase of 5% from M2. One out of the five team’s performance remains above the target of 95% and four teams under the target. The total number of SUs on the waiting list continues to reduce, from 431 to currently 390. The number of SUs that waited over 18 weeks reduced from 162 in M2 to 129 in M3. 64% of waiters over 18 weeks are from Blackpool/Fylde & Wyre team (82). 23 have TCI dates. Issues affecting performance: Blackpool/Fylde team performance is affected by ongoing staffing capacity issues. Additional hours had previously been provided by the Lead Psychologist for the Network in addition to budgeted capacity, which have ceased following the organisational reset. Performance in Blackpool has increased by 15% from M2 to 40.6% - with 26 SUs waiting under 18 weeks. The total number of SUs waiting in Blackpool and Fylde has reduced by 19, to 123 in M3. 7 SUs have TCI dates. Staff capacity is improving following the recruitment of a full-time Locum Psychologist at the end of May. A Band 6 Mental Health Practitioner is due to start mid July, with a view to working on the waiting list. A Band 8b Clinical Psychologist has also been recruited. The CPS team continue to work with the Fylde & Wyre CAMHS team who are seeing cases from the CPS waiting list to reduce waiting times. Preston Community performance is currently at 50% and is also affected by ongoing staffing capacity issues. The total number of children waiting has reduced further to 50, the lowest level in the last year. In June, 3 families failed to attend appointments and 1 requested to remain on the list to be seen by a Clinical Psychologist. Two further children at 27 weeks failed to attend and appointments have been re-arranged. There are 13 families with appointments allocated by the second week in July that have waited between 24 and 19 weeks. This brings the waiting list down further to 18 weeks, with staff providing regular new appointments in CPS. There are five children that will be discharged from the waiting list: three because more information was not received from the referrer and two were rejected. There are also staffing changes commencing as part of the recovery plan – outlined below. A member of staff has now returned from maternity leave for 3 days per week. The main challenge for the waiting list was one member of staff (0.9 WTE) going on maternity leave and an additional member of staff leaving a (0.3 WTE) post. Temporary measures were put in place and this is now reducing again. Encouragingly, Lancaster performance continues to improve for a 4th consecutive month rising from 48.5% in February to 74.5% in June. Of the 14 SUs waiting over 18 weeks, 4 have TCI dates.

• To define the waiting list trajectories with the Network Analyst. Responsibility - Helen Lynch and Richard Bibby. Timescale- 31 October 2017.

• 1 x Band 8b Clinical Psychologist has also been recruited in Blackpool/Fylde. Responsibility - Helen Lynch. Timescale – 1 October 2017.

• 1 x Band 6 Mental Health Practitioner recruited to in Blackpool/Fylde. Responsibility - Helen Lynch. Timescale - 17 July 2017.

• Preston CAMHS worker has been offering to see the longest waits as part of waiting list initiative . Responsibility - Richard Bibby. Timescale - On-going.

• In Preston CPS, maternity leave cover increased their days from 2 to 3. Responsibility - Richard Bibby . Timescale - End of October 17.

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2.1 Performance Activity Children & Young People’s Wellbeing – Child Psychology

52

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2.1 Performance Activity Children & Young People’s Wellbeing – CAMHS Tier 3

53

CAMHS Tier 3 Actions:

Chorley & South Ribble: Performance in M3 reduced further from 62.5% in M2 to 60.7%, and the percentage of children waiting over 18 weeks has decreased month on month since January 2017. This equates to 144 out of 366 service users, an increase from 104 in M2. 24 currently have TCI dates. Issues affecting performance:

1 staff member on long term sickness absence in the team. 1 staff member completing a phased return in May following a return from long term sickness. No team leader in post during May/June 2017. 1 x band 5 vacancy who left her post on the 1st May 2017. The team continues to manage large numbers of Autistic Spectrum Disorder referrals which do not meet the criteria for Tier 3 CAMHS; this is custom practice and has not yet been resolved.

• New team leader appointed and will commence role. Responsibility - Helen Lynch. Timescale – 17 July 17.

• Following appointment of the TL post, the service manager will carry out a deep dive alongside the new team leader and formulate a recovery plan to address the performance issue with regards to increasing the assessment capacity of the team and reducing waiting times. This will include a review of current vacancies and staff working hours /job plans. Responsibility - Helen Lynch. Timescale – 7 August 17.

• Admin processes are being reviewed in the Referral Assessment Centre (RAC). Options paper to be drafted regarding future functioning of the RAC. Responsibility - Helen Lynch. Timescale – 07 July 17.

• HR still supporting the long term sickness absence, service manager to request update. Responsibility - Helen Lynch. Timescale – 31 July 217.

When performance is expected to meet the target:

Subject to the team reaching full staffing levels, we anticipate to see improvement in performance from September 2017.

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2.1 Performance Activity Children & Young People’s Wellbeing – CAMHS Tier 3

54

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2.1 Performance Activity Children & Young People’s Wellbeing – CITNS

Speech & Language Therapy

55

CITNS SLT (Total Network Performance): Actions:

As a speciality, Speech & Language Therapy performance in M3 was 87.0% against the 92% threshold for open RTT pathways, an increase of 0.3% from last month. The total waiting list size reduced by 50 in M3, with the total number waiting over 18 weeks reducing by a further 11 to 184, of which 144 have appointment dates. The longest waiter is currently at 30 weeks, which is a decrease of 2 weeks from M2. These children are spread across BwD (30 weeks – this is 1 outlier as the child had an appointment in June but was re-scheduled to July by his parents, the next longest wait is 25 weeks), Burnley & Pendle (28 weeks), Hyndburn, Ribble Valley & Rossendale (24 weeks) and Chorley & South Ribble (20 weeks). Three teams (West Lancs, Greater Preston and Chorley & South Ribble) have achieved the 92% target in M3. Below is detail of the position for the three teams who have not achieved 92%. Blackburn with Darwen team’s performance has increased by 12% since M2, achieving 91.2%. There has been a significant decrease in the number of children waiting over 18 weeks from 70 children in M2 to 27 children in M3 - of which 26 children have an appointment and the remaining child without a plan has received an invite to call which parents have yet to respond to. Burnley & Pendle team’s performance has decreased by 2.6% in M3. There are currently 78 children waiting over 18 weeks, an increase of 15 from M3. The decrease in performance is due to team capacity, however new staff are now in post. There is now a comprehensive clinic plan which is now operational and will assist recovery to achieve the 92% which is forecast for the end of August. Hyndburn, Ribble Valley and Rossendale team’s performance has decreased by 10.5% in M3. Whilst the number of children waiting overall reduced by 53 to 295, the number waiting over 18 weeks increased to 68 from 44 in M2. Of the 68 children waiting over 18 weeks, 59 have an appointment. The longest wait is now 24 weeks a reduction of 2 weeks since M2. There is a waiting recovery initiative planned for August which will offer an additional 50 appointments, which will assist in achieving recovery to the 92% by the end of August. Chorley & South Ribble team have achieved in M3 a performance target of 94.2%. There are now 11 children waiting over 18 weeks all of which have an appointment. The longest wait continues at 20 weeks.

• Review of waiting lists to ensure that priority to given to those children waiting the longest. Responsibility - Team Co-ordinators. Timescale – Weekly.

• Whole staffing review to harmonise workforce in line with contracts. Responsibility - Liz McGladdery (Service Manager) & Andrea Bolton (Network Accountant). Timescale – End August 17.

• Service workforce/skill mix review to be undertaken. Responsibility - Ann-Marie Caunce (Professional Lead) & Team Co-ordinators Professional . Timescales – Commence in July 17.

• Staff to be moved in order to alleviate capacity issues in team. Responsibility - Service Manager/Team Co-ordinators. Timescales – Ongoing.

• To support new starters into the post with a robust induction package which will allow the practitioner to working to full capacity as soon as possible. Responsibility – Team Co-ordinators. Timescales – July – October 2017.

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2.1 Performance Activity Children & Young People’s Wellbeing – CITNS

Speech & Language Therapy

56

87 of 215


2.1 Performance Activity Children & Young People’s Wellbeing – ADHD

57

ADHD: Actions:

Performance in M3 improved by 3% with the number of service users waiting under 18 weeks for treatment increasing slightly to 64.25% from 60.95% in M2. The total number of new cases added to the waiting list increased from 210 to 221. The service was closed to referrals in May 2017, having opened again in June 2017, and this has caused a surge of referrals into the team from 6 in May to 32 in June, and increased the waiting list time. Issue affecting performance:

One NMP left the service in April 17, meaning that 50% of our prescribing capacity was lost and as a result new assessments have not been taken off the list. The caseload is over 3 times higher than the service was commissioned - 180 patients, whilst current caseload is 681. Around 130 patients are also open to Consultant Psychiatrists within the Trust and although it was agreed by the MD they would be transferred back to secondary care this has not gone ahead as Medics had not been fully briefed as to how the process would work and therefore resistant to take over cases of ADHD. The current rate of DNA’s is twice the projected number when the service was running as a pilot project (10%). We have completed an audit of new assessment DNA rates and there is no pattern in relation to geographic area in relation to appointment location. All patients are contacted at the beginning of the week to remind them of their appointments. Cancellations are then attempted to be filled. The service is unable to overbook appointments due to prescribing patterns. Shared Care arrangements in certain GPs have impacted on clinical time due to requests for prescriptions. This is a cultural issue with the GPs in question and CCGs have been aware of this since the opening of the service. Outreach to SUs has been attempted by the service and has not yet been successful.

• Patients are now offered a ‘call and book’ system to ensure the contact us to book their assessment appointment. Those who do not opt in are discharged.

• Ongoing review of Shared Care arrangements in certain GPs is being carried out to reduce the impact on clinical time due to requests for prescriptions.

• Seeking approval to recruit to additional

permanent Band 7 nurse prescriber, to help reduce waiting list.

• A second NMP has been in post for 3 months and training is still in process. This training could take up to 6 months before an impact on the waiting list is seen.

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2.1 Performance Activity Children & Young People’s Wellbeing – ADHD

58

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Patient Flow

Section 2.2

59

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2.2 Patient Flow Summary – Patient Flow

60


Sparkline

Patient Flow

Average Number of Patients (OAPS) Commissioner 15 41.50 40.42 32.23 28.93 22.65 33.10 27.42 22.48 23.29 23.42 24.27 25.52 25.67

OAPS Occupied Bed Days Commissioner 460 1245 1253 999 868 702 993 850 697 652 726 728 791 770

LCFT and OAPS Occupancy % (Total Network Performance) Commissioner 85.00% - - - - - 104.8% 100.6% 101.1% 98.2% 96.8% 105.7% 106.1% 106.4%

Number of LCFT and OAPS Occupied Bed Days (Total Network Performance) Commissioner 9519 - - - - - 10943 10880 10667 10009 10927 10593 10988 10665

LCFT and OAPS Occupancy % (AMH) 110.9% 110.8% 105.0% 104.7% 102.4% 107.1% 101.0% 102.9% 102.8% 101.2% 108.6% 107.9% 108.0%

Number of LCFT and OAPS Occupied Bed Days (AMH) 8284 8260 8516 8260 8351 8481 8297 7799 7630 8317 8148 8364 8097

LCFT and OAPS Occupancy % (OA) 99.5% 99.3% 100.3% 99.2% 97.7% 97.7% 99.2% 96.5% 85.8% 85.0% 97.0% 100.8% 101.9%

Number of LCFT and OAPS Occupied Bed Days (OA) 2508 2586 2613 2499 2544 2462 2583 2868 2379 2610 2445 2624 2568

LCFT only Occupancy % (Total Network Performance) NHSE 85.00% 100.3% 100.3% 98.3% 99.6% 99.5% 99.6% 96.9% 98.7% 100.1% 98.5% 98.5% 98.5% 98.8%

Number of LCFT only Occupied Bed Days (Total Network Performance) Stretch 9519 7041 7007 7517 7412 7649 9950 10030 9970 9357 10201 9865 10197 9895

LCFT only Occupancy % (AMH) 100.3% 100.3% 98.3% 99.6% 99.5% 100.3% 96.1% 99.6% 99.9% 99.1% 99.2% 98.3% 99.0%

Number of LCFT only Occupied Bed Days (AMH) 7041 7007 7517 7412 7649 7491 7447 7102 6990 7679 7437 7622 7426

LCFT only Occupancy % (OA) - - - - - 97.6% 99.2% 96.5% 100.6% 96.9% 96.3% 98.9% 98.0%

Number of LCFT only Occupied Bed Days (OA) - - - - - 2459 2583 2868 2367 2522 2428 2575 2469

Secure Overall Gross Occupancy NHSE 93.00% 91.5% 90.3% 90.5% 90.7% 90.5% 90.5% 90.2% 91.8% 93.3% 93.7% 97.2% 95.9% 96.0%

Average Episode Length of Stay (LOS) - (Total Network Performance) - - - - - - - - - - - - -

Average Episode Length of Stay (LOS) (AMH) Bench 31 38.80 39.00 33.20 35.10 41.70 31.30 31.20 29.72 40.23 33.00 34.70 36.10 46.40

Average Ward Length of Stay (LOS) (PICU) 43.88 111.53 56.25 34.20 47.70 58.50 45.08 58.50 55.20 37.80 39.90 35.10 38.80

Average Episode Length of Stay (LOS) (OA) 111.80 91.90 91.10 107.70 119.60 109.40 144.50 123.56 95.35 115.60 122.30 135.50 97.90

Re-Admission Rates - 30 Days (AMH) % NHSE <8.7% 8.6% 8.4% 8.6% 11.1% 9.9% 9.1% 16.7% 7.8% 12.6% 9.5% 15.3% 13.8% 14.8%

Re-Admission Rates - 30 Days (AMH) Number of patients NHSE 18 15 16 17 21 20 22 36 18 24 22 31 30 30

Re-Admission Rates - 30 Days (OA) % NHSE <8.7% - - - - - 0.0% 4.5% 0.0% 0.0% 3.4% 8.0% 0.0% 4.0%

Re-Admission Rates - 30 Days (OA) Number of patients NHSE 2 - - - - - 0 1 0 0 1 2 0 1

Re-Admission Rates - 90 Days (AMH) % NHSE 15% 17.1% 13.2% 16.2% 19.5% 17.7% 12.8% 25.0% 16.5% 23.0% 19.0% 20.7% 22.6% 22.2%

Re-Admission Rates - 90 Days (AMH) Number of patients NHSE 30 30 25 32 37 36 31 54 38 44 44 42 49 45

Re-Admission Rates - 90 Days (OA) % NHSE 15.00% - - - - - 0.0% 4.5% 0.0% 0.0% 13.8% 0.0% 10.3% 4.0%

Re-Admission Rates - 90 Days (OA) Number pf patients NHSE 4 - - - - - 0 1 0 0 4 - 3 1

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2.2 Patient Flow Out of Area Placements (OAPS)

61

OAPS: Actions:

The average number of OAPs rose marginally in June by 0.15, however a slight reduction in the OAP OBD was noted in June with a position of 770, a reduction of 21 from May. Habilitation beds are now in operation and as of the 13th July there are 5 beds in use. It is anticipated that significant decrease will be realised with the operationalisation of the next phase of alternatives to admission (East ATS, CSU, Crisis House/Crisis Beds). The East ATS is now open and has been accepting patients from the end of June. Willow House, Crisis House opened at the beginning of May and now has all 6 beds occupied. Plans are developing for a Crisis House in East. The Birchwood Centre has relaunched and the usage of this has now increased throughout June. The Preston CSU has opened in early July and plans are developing for a CSU in North.

• Maintain focussed case review panel with senior commissioning managers.

• Daily bed calls with Service Managers to address blocks to discharge such as funding delays.

• Home Treatment Team attendance at FED meetings to identify patients whose care can transfer to hospital at home with the Home Treatment Team.

• Maintain the process of identifying and escalating all 180+ day LOS inpatients for review. Fortnightly scheduled meeting in place with stakeholders regarding review of these patients.

• Continue regular review of C&WL OAPs to identify any that can be stepped to the Crisis House/beds.

• System in place to support funding out of panel quickly for those that have follow on placements identified. 2 OAP's patients identified recently with one being reviewed on 13th July.

• As a result of pressures in the system Silver Command has been initiated. Commissioners are also joining twice weekly conference calls to assist with alleviating any blockages in the discharges of patients.

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2.2 Patient Flow OAPS

62

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2.2 Patient Flow OAPS Occupied Bed Days

63

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2.2 Patient Flow Occupancy – Mental Health

64

Occupancy: Actions:

LCFT and OATs Occupancy position in June declined slightly from the May position and was in line with trajectory at 106.44%. Notably, the occupancy for LCFT beds reduced to 98.75% in June. The position was impacted by a higher than average referral rate for the first three months of June. Willow House Crisis House opened on the 23rd May for Chorley & South Ribble and Greater Preston patients and offers 6 beds as an alternative to admission and an intervention offered by the HTT. West Lancs Crisis Beds (Birchwood Centre) has been relaunched and usage has increased throughout June.

• Maintain focussed case review panel with senior commissioning managers.

• Daily bed calls with Service Managers to address blocks to discharge such as funding delays.

• Continue Home Treatment Team attendance at FED meetings to identify patients whose care can transfer to hospital at home with the Home Treatment Team.

• Maintain the process of identifying and escalating all 180+ day LOS inpatients for review. Fortnightly scheduled meeting in place with stakeholders regarding review of these patients.


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2.2 Patient Flow Occupancy – Adult Mental Health

65

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2.2 Patient Flow Occupancy – Older Adults

66

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2.2 Patient Flow Occupancy – Mental Health Total

67

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2.2 Patient Flow Mental Health – Average Length of Stay – PICU

68

Average Ward Length of Stay - PICU: Actions:

The Network is reporting an average length of stay of 38.80 days. The Network has maintained a LOS under 40 days for four months for PICU, indicating a level of stability. The Joint Advisory Group is having a positive impact on PICU LOS and the feedback from Care Co-ordinators and the Gateway team is positive about this group. The average LOS for PICU has decreased by 29.71% from January to June.


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2.2 Patient Flow Mental Health – Average Episode LOS – Adult

69

Average Episode Length of Stay - Adult: Actions:

The Network is above the Trust set target of average 30 day length of stay for Acute Bed LOS, reporting an average LOS of 46.40 days for June. PICU LOS is included within the Average Network LOS, it is noted that PICU LOS has slightly increased in June.


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2.2 Patient Flow Mental Health – Average Episode LOS – Older Adult

70

Average Episode Length of Stay – Older Adult: Actions:

M3 has seen a decrease in the average length of stay, reporting an average LOS 97.9 days. A contributory factor to this has been the discharge of a number of patients with protracted admissions to the wards. Continued efforts in proactive discharge management across all wards and additional member to the discharge facilitator team has added support across the wards, working towards timely discharge

• Discharge planning for all patients near completion of assessment/treatment to be discussed daily at the bed call

• Escalation routes are clear - the capacity and flow manager is to be utilised to expedite any difficulties.

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2.2 Patient Flow Mental Health – Readmission Rate (30 days)

71

Re-Admission Rate (30 days): Actions:

The Network failed to achieve compliance with the target of 8.7% in M3 with a rate of 13.6%. This is a declined position from 12.2% in M2. There have been 31 readmissions within 30 days, one of these was an Older Adult patient, the remainder were Adult Mental Health patients. Average time between admissions was 14.29 days, though 10 cases were re-admitted within 7 days. 45.16% of re-admissions were from the female assessment ward. 22.58% of re-admissions were from the male assessment ward.

• Team Leaders to ensure to review in CMHT/CRHTT Clinical Discussion Meetings.

• Re-admission data to be routinely reviewed in locality governance groups.

• The Network will complete a thematic review of all re-admissions to the assessment wards.

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72

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73

Re-Admission Rate (90 Days): Actions:

The Network is achieving compliance with the 90 day re-admission rate this month with 10.96% for M3. This includes Older Adult ward data. The underlying position with Adult Wards has improved slightly from M2 with a compliance of 22.17%. Older Adults had 1 re-admission in M3. 46 cases were re-admitted within 90 days. These include the 31 cases re-admitted within 30 days. 15 cases were re-admitted 31-90 days after discharge.

• Team Leaders to ensure to review in CMHT/CRHTT Clinical Discussion Meetings.

• Re-admission data to be routinely reviewed in locality

governance groups.

• The Network will complete a thematic review of all re-admissions to the assessment wards.

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74

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Data Quality

Section 2.3

75

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2.3 Data Quality Summary – Data Quality

76

Data Quality:

• PBR remains ahead of target and continues to be monitored and actioned weekly. • BI have commenced work on re-writing DQ reports, some have been released for validation which is in progress. • A caseload report has been written and is being validated, subject to satisfactory completion the Unallocated report, can then be

changed to reflect the new target for next month’s report. • Included this month are records of manual overrides to NHSI reports. It should be noted that these were overrides at the

validation stage, in most cases the source system will have been corrected and no longer will hold the incorrect data that led to the override in the first place.

Indicators achieved Actual Target Performance Exception Reports Additional comments

PBR Clustering

Trust PBR Clustering 96.64% 95.00% Achieved NoMH PBR Clustering 96.65% 95.00% Achieved NoCYP PBR Clustering 96.35% 95.00% Achieved NoUnallocated Patients < 2 weeks > 2 weeks

Trust Unallocated Patients 587 228 Underperforming YesMH Unallocated Patients 211 381 Underperforming YesCWB Unallocated Patients 33 2 Underperforming YesCYP Unallocated Patients 25 4 Underperforming YesManual Overrides

Trust NHSI Manual Overrides 16 Underperforming

MR01 NHSI Manual Overrides 4 Underperforming

MR07 NHSI Manual Overrides 11 Underperforming

Other NHSI Manual Overrides 1 Underperforming MR03

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2.3 Data Quality Data Quality – Manual Overrides

77

Manual Overrides:

Of the 15 manual overrides, 14 were for Mental Health and 1 was for Secure Services. There has been an increase in the manual overrides for MR07 (Gatekeeping) due to staffing issues within the Mental Health Network therefore validation was not able to be completed before WD6. During the months reporting there was a late change for 1 record within the MR03 indicator.

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78



• UoR Risk Rating • Summary I&E Position • Summary of Clinical Services • CIPS • Capital Expenditure

Section 3.2:- Contract Activity

• Community & Wellbeing – Network Line Totals • Community & Wellbeing – Service Line Totals • Community & Wellbeing – Total Activity Split by CCG • Children & Young People’s Wellbeing – Service Line Totals • Children & Young People’s Wellbeing – Total Activity Split by CCG • Mental Health – Activity Totals

Section 3.2.1:- Southport & Formby Contract Activity

• Queens Court – Palliative Care Section 3.3:- Commissioning for Quality & Innovation

• CQUIN Executive Summary

3. Finance and Contracting

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Financial Activity

Section 3.1

79

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3.1 Financial Activity Use of Resources (UoR) Risk Rating

80

Use of Resources rating (UoR)

The current I&E position is constraining the current UoR to a 3, assuming current pressures and risks are addressed and financial performance achieves (or exceeds) plan the Trust will achieve a forecast UoR of 2 in line with the revised plan.

Should conditions persist and costs not be managed within the control total then the resulting deterioration might attract regulatory attention (a rating of 2 can trigger a regulatory review of the Trust's position).

FINANCE AND USE OF RESOURCES METRICS

Plan Actual Plan Forecast

Capital service cover rating 2 3 2 2

Liquidity rating 1 1 2 1

I&E margin rating 3 4 2 2

Distance from financial plan 1 2 1 2

Agency rating 1 2 1 2

Overall 2 3 2 2

Year to Date Annual

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Summary I&E Position 3.1 Financial Activity Summary I&E Position

81

Sustainability

At month 3, we have a £1.3m deficit which is £1.2m behind plan. Of this, £0.3m relates to Sustainability and Transformation funding which leaves a shortfall against the control total of £0.9m. Unmitigated projections indicate the Trust is heading for a £3m deficit, a shortfall against the planned surplus of £2.2m of some £5m (£7m excluding STF). The current forecast assumes current pressures and risks are addressed and financial performance achieves (or exceeds) plan but several challenges will have to be managed if the Trust is to achieve this: • Cost Improvement Programmes • Cost Reduction Schemes • Reset/Redundancies • Southport • Out of Area Placements • Ward Staffing

FUNDED WTE BUDGET DETAIL BUDGET ACTUAL £ ANNUAL PROJECTED £

EST. ACTUAL TO DATE TO DATE VARIANCE BUDGET ACTUAL VARIANCE

£'000 £'000 £'000 £'000 £'000 £'000

Healthcare Income 76,327 76,015 -312 304,314 305,060 745

5,770.6 5,820.9 Clinical Services -57,767 -60,047 -2,281 -228,801 -234,409 -5,608

790.4 742.8 Corporate Services -12,941 -13,001 -61 -53,072 -53,393 -321

Reserves and Capital Charges -5,620 -4,257 1,363 -22,441 -15,058 7,384

6,561.0 6,563.6 -1,291 -1,291 2,200 2,200

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3.1 Financial Activity Summary of Clinical Services

82

FUNDED WTE BUDGET DETAIL BUDGET ACTUAL £ % ANNUAL PROJECTED £

EST. ACTUAL TO DATE TO DATE VARIANCE VARIANCE BUDGET ACTUAL VARIANCE

£'000 £'000 £'000 £'000 £'000 £'000

PAY

2,939.7 3,162.9 ADULT PAY 29,287.4 31,500.0 -2,212.6 -7.6 116,923.2 123,743.7 -6,820.5NON PAY 2,889.5 3,181.5 -292.1 -10.1 9,134.3 9,232.4 -98.0PATIENT RELATED INCOME -226.3 -264.1 37.8 -16.7 -625.1 -824.6 199.4NON PATIENT RELATED INCOME -593.3 -620.4 27.1 4.6 -2,373.3 -3,192.8 819.5

2,939.7 3,162.9 TOTAL 31,357.2 33,797.1 -2,439.9 -7.8 123,059.1 128,958.7 -5,899.6

1,632.2 1,540.9 ADULT COMMUNITY PAY 13,585.3 13,855.0 -269.7 -2.0 55,040.5 55,489.9 -449.4NON PAY 3,012.1 2,863.9 148.2 4.9 12,406.4 12,217.4 188.9PATIENT RELATED INCOME -2,122.7 -2,148.6 25.9 -1.2 -8,511.3 -8,827.5 316.2NON PATIENT RELATED INCOME -671.0 -659.8 -11.3 -1.7 -2,469.8 -2,414.3 -55.5

1,632.2 1,540.9 TOTAL 13,803.7 13,910.5 -106.8 -0.8 56,465.9 56,465.6 0.3

1,143.6 1,066.1 CHILDREN AND FAMILY PAY 10,799.4 10,665.9 133.5 1.2 43,147.8 43,445.4 -297.6NON PAY 1,505.8 1,220.7 285.1 18.9 4,990.7 4,346.9 643.8PATIENT RELATED INCOME -159.2 96.5 -255.7 160.6 -922.5 -594.4 -328.1NON PATIENT RELATED INCOME -345.7 -355.0 9.2 2.7 -1,162.0 -1,198.4 36.3

1,143.6 1,066.1 TOTAL 11,800.2 11,628.2 172.1 1.5 46,054.0 45,999.5 54.5

55.2 50.9 PHARMACY PAY 671.3 606.5 64.8 9.7 2,685.3 2,512.0 173.3NON PAY 134.2 106.5 27.8 20.7 537.0 479.0 58.0NON PATIENT RELATED INCOME 0.0 -1.4 1.4 No Budget 0.0 -5.6 5.6

55.2 50.9 TOTAL 805.6 711.6 94.0 11.7 3,222.3 2,985.4 236.9

5,770.6 5,820.9 TOTAL 57,766.7 60,047.3 -2,280.6 -3.9 228,801.3 234,409.2 -5,608.0

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CIPs 3.1 Financial Activity CIPs

83

Cost Improvement Programmes

At £2.3m in month 3 the Trust is £1.1m behind the plan of £3.4m. This is partly attributable to delays in scheme starts, but more significantly due to lower than planned traction in schemes designed to address pressures on ward based staffing. Additional support is being offered and the Trust fully expects to deliver the target by year end.

Note: a number of schemes are still being transacted and that mapping of individual schemes to projects and programmes is still being finalised.


£'m £'m £'m £'m £'m £'m

Cost Improvement Programmes 2.78 1.96 -0.82 11.10 13.10 -2.00

Run Rate Reduction Programmes 0.60 0.30 -0.30 4.00 2.00 2.00

Total 3.38 2.26 -1.12 15.10 15.10 0.00

Year to Date Annual

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Capital Expenditure 3.1 Financial Activity Capital Expenditure

84

Capital Expenditure

To date, the Trust has spent £0.5m against the original profile of £2.6m.

Spend profile on schemes is dependant on a number of tendering exercises to be completed in Q1/Q2 and the control total may vary if we are successful in securing external funding for Perinatal and/or Inpatient schemes.

The Trust currently expects to complete its capital programme in line with its control total and funding.

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Contract Activity

Section 2.2

85

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86

3.2 Contract Activity – Variance to Plan Community & Wellbeing - Network Line Totals

Network Apr-17 May-17 Jun-17 YTD 17-18

Community & Wellbeing Total

Against Plan89,912 94,811 98,197 282,920

Children and Young People's

Wellbeing Total Against Plan3,233 4,398 3,910 11,541

Trust Total Against Plan 93,145 99,209 102,107 294,461

2017-18 Baseline Proposal LCFT Performance Team have submitted the completed Community Baselines Proposal to the commissioners for review along with answers to various queries raised from the initial submission. It’s been identified that a further amendment to the Paediatric Liaison Baseline will need to made due to the referrals and contacts figures being transposed through the Schedule 6 report, LCFT are also seeking further clarification from Commissioners as to the data capture and reporting of different referral types. The planned activity figures per service and CCG has been revised to apply the agreed demographic growth per CCG which totals a 0.3% increase across all CCGs. based on the Following discussions with Midlands and Lancashire CSU we are planning to check the CCG activity split against the financial spilt for each service prior to re-submitting the baselines back to the commissioners towards the end of June. 2017-18 M3 Activity

For M3 LCFT have continued to provided the activity totals and YTD position only, however now that baselines have been submitted and the planned activity figures have been calculated, these will be submitted to the BI Team so that the Trust can start reporting variances against the agreed plans from M4 and any further amendments to the baselines will be made in year if required. Throughout the year the Performance Team intend to monitor all Contract Variations that impact on activity numbers and the baselines will be adjusted appropriately in line with the CV commence date. Activity Reporting LCFT Performance team and Midlands and Lancashire CSU have signed off the Exception Reporting Proposal which aims to give specific guidelines to business managers around exception reporting and will standardise the process across both Community and Mental Health Contracts. Now that both Baselines and the Exception Report Proposal have been finalised LCFT will commence exception reporting against reported variances from M4.

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87

3.2 Contract Activity – Variance to Plan Community & Wellbeing - Service Line Totals

Service Apr-17 May-17 Jun-17 YTD 17-18

Adult Learning Disability Service Total 1,625 2,315 2,141 6,081

Adult Speech and Language Therapy Total 349 296 375 1,020

CHESS Total 307 427 300 1,034

Children's Learning Disability Service Total 1,235 1,660 1,626 4,521

Community IV Service BwD Total 84 97 66 247

Community Matrons Total 1,262 1,198 1,289 3,749

Community Neuro Team Total 1,058 1,237 1,241 3,536

Community Respiratory Service Total 1,967 2,072 1,933 5,972

Community Stroke Service Total 339 359 379 1,077

Complex Case Management Total 412 395 385 1,192

Continence Service Total 227 305 223 755

Dermatology Service Total 454 489 399 1,342

DESMOND Total 65 78 64 207

Diabetes Specialist Nursing Total 842 954 968 2,764

District Nursing Total 40,740 40,835 39,706 121,281

Domiciliary Physiotherapy Total 694 609 708 2,011

Falls Team Total 425 658 656 1,739

Heart Failure Service Total 147 249 261 657

Intermediate Care Total 2,802 3,166 3,083 9,051

Nutrition & Dietetics Total 265 255 240 760

Oxygen Service Total 237 269 313 819

Phlebotomy Total 16,855 16,160 22,004 55,019

Podiatry Total 4,392 5,453 5,065 14,910

Pulmonary Rehabilitation Total 441 598 680 1,719

Rapid Assessment Team Total 1,659 1,860 1,780 5,299

Rheumatology Total 1,314 1,594 1,736 4,644

Specialist Nurse TB Total 549 352 442 1,343

Tissue Viability Service Total 228 247 267 742

Treatment Room Total 8,859 10,501 9,763 29,123

Viral Hepatitis Service Total 79 123 104 306

Community & Wellbeing Total Against Plan 89,912 94,811 98,197 282,920118 of 215


3.2 Contract Activity – Variance to Plan Community & Wellbeing – Total Activity split by CCG

Community & Wellbeing - Total Activity split by CCG Apr-17 May-17 Jun-17 YTD 17-18

Central Lancs Locality Total 16,855 16,160 22,004 55,019

NHS Blackburn with Darwen CCG Total 21,811 24,510 23,156 69,477

NHS Blackpool CCG Total 150 120 142 412

NHS Chorley and South Ribble CCG Total 26,064 26,284 26,100 78,448

NHS East Lancashire CCG Total 778 1,058 855 2,691

NHS Fylde & Wyre CCG Total 259 301 384 944

NHS Greater Preston CCG Total 23,253 25,334 24,397 72,984

NHS Morecambe Bay CCG Total 344 489 581 1,414

NHS West Lancashire CCG Total 398 555 578 1,531

Community & Wellbeing Totals 89,912 94,811 98,197 282,920

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3.2 Contract Activity – Variance to Plan Children & Young People’s Wellbeing - Service Line Totals

89

Service Apr-17 May-17 Jun-17 YTD 17-18

Children's Occupational Therapy Total 614 820 750 2,184

Children's Physiotherapy Total 549 614 600 1,763

Children's Speech & Language Therapy Total 1,934 2,794 2,405 7,133

Paediatric Liaison Total 136 170 155 461

Children and Young People's Wellbeing 3,233 4,398 3,910 11,541

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3.2 Contract Activity – Variance to Plan Children & Young People’s Wellbeing - Total Activity by CCG

90

Children & Young People's Wellbeing -

Total Activity split by CCGApr-17 May-17 Jun-17 YTD 17-18

NHS Blackburn with Darwen CCG Total 559 737 635 1,931

NHS Chorley and South Ribble CCG Total 745 918 959 2,622

NHS East Lancashire CCG Total 861 1,317 1,159 3,337

NHS Greater Preston CCG Total 679 878 685 2,242

NHS West Lancashire CCG Total 389 548 472 1,409

Children & Young People's Wellbeing

Total Against Plan3,233 4,398 3,910 11,541

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3.2 Contract Activity – Variance to Plan Mental Health – Activity Totals

Metric Apr-17 May-17 Jun-17 YTD 17-18

ADHD Contacts Total 370 253 386 1,009

Adult Ward Occupied Bed Days Total 5,744 5,835 5,677 17,256

Adult/PICU Ward Admissions Total 169 195 180 544

Adult/PICU Ward Discharges Total 167 187 177 531

CCTT Teams - Accepted Referrals Total 153 171 168 492

CCTT Teams - Contacts Total 8,189 9,706 9,396 27,291

CMHT Contacts Total 2,584 2,846 2,769 8,199

CMHT Referrals Total 90 9,135 131 9,356

Community Restart Teams - Accepted Referrals Total 130 176 174 480

CRHT Face to Face Contacts - Below 18 Total 123 242 153 518

CRHT Face to Face Contacts - 18 to 65 Total 3,667 4,042 3,756 11,465

CRHT Face to Face Contacts - Over 65 Total 65 74 43 182

CRHT Teams - Referrals Total 720 793 862 2,375

CRHT Telephone Contacts - Below 18 Total 66 128 96 290

CRHT Telephone Contacts - 18 to 65 Total 2,130 2,487 2,156 6,773

CRHT Telephone Contacts - Over 65 Total 37 106 47 190

Criminal Justice Liaison - Contacts Total 573 668 572 1,813

Eating Disorder Service - Contacts Total 1,049 1,286 1,304 3,639

Eating Disorder Service - Referrals Total 73 86 93 252

Hospital Liaison Contacts Total 618 745 657 2,020

Hospital Liaison Referrals Total 149 171 155 475

MAS Teams - Contacts Total 5,917 6,588 6,151 18,656

MAS Teams - Referrals Total 492 565 624 1,681

Older Adult (Dementia) Inpatient Ward Admissions Total 7 12 6 25

Older Adult (Dementia) Inpatient Ward Discharges Total 10 6 8 24

Older Adult (Dementia) Ward Occupied Bed Days Total 812 850 854 2,516

Older Adult (Functional) Inpatient Ward Admissions Total 11 9 10 30

Older Adult (Functional) Inpatient Ward Discharges Total 12 10 9 31

Older Adult (Functional) Ward Occupied Bed Days Total 1,034 1,104 1,074 3,212

PICU Ward Occupied Bed Days Total 817 849 846 2,512

PICU Wards - Transfers In Total 16 27 24 67

RITT Contacts Total 1,921 2,265 2,257 6,443

RITT Referrals Total 169 154 167 490

Mental Health Metric Total 38,084 51,771 40,982 130,837

Metric Apr-17 May-17 Jun-17 YTD 17-18

Older Adult (Functional) Inpatient 30 Day ReAdmissions 1 0 0 1

Older Adult (Functional) Inpatient 90 Day ReAdmissions 1 1 0 2

Adult Inpatient 30 Day ReAdmissions Total 9.58% 7.49% 9.04% 8.66%Adult Inpatient 90 Day ReAdmissions Total 14.97% 13.90% 16.38% 15.07%

122 of 215


92

3.2 Contract Activity – Variance to Plan Mental Health – Activity Totals

2017-18 Baseline Proposal LCFT Performance team have internally agreed 40 of the 43 Mental Health Baselines and are preparing to send the first draft Proposal over to Midlands and Lancashire CSU however the planned activity figures per service and CCG are still to be completed before the overall proposal can be internally agreed and formally submitted. 2017-18 M2 Activity

For M3 LCFT have provided the activity totals and YTD position only, whilst the Baselines are still being agreed and the percentage split of activity is still being finalised as above. Activity Reporting

LCFT and Midlands and Lancashire CSU have signed off the Exception Reporting Proposal which aims to give specific guidelines to business managers around exception reporting and will standardise the process across both Community and Mental Health Contracts. Whilst the Baselines remain outstanding LCFT will continue to report the activity totals and YTD position only, with a view to reporting variances against plan and exception reporting as soon as they have been internally agreed and formally submitted. As previously mentioned, Lancashire Care have amended the MH Contract Monitoring Report which groups metric currencies rather than showing them within one worksheet (as shown above). This revised MH Contract Monitoring Report has been completed and currently being validated and is planned to be ready for submission from M4.

123 of 215


3.2 Contract Activity – Variance to Plan Children & Young People’s Wellbeing – Sexual Health Activity

as at w/c 26th June 2017

93

• Revised planned attendances full year are 27,344. Actual attendances during June 2017 was 1,336 – 116 below the planned total of 1,452.

• Analysed income for 16/17 shows the projected income was narrowly missed. Initial income for the 17/18 monitoring year will be incorporated in the June update.

124 of 215


94

3.3 CQUIN Executive Summary

CQUIN Executive Summary:

2017/18 schemes:

New Leads have been identified for the schemes following the organisational reset. Discussions are ongoing with acute trusts regarding the A&E CQUIN however we are working towards the targets for the scheme with commissioner support. All other CQUINs are well underway and there are no concerns at this point. Quarter 1 CQUIN submissions are due to commissioners the 3rd week of July.

Executive Summary

Contract Expected

Loss/

concern Expected

Loss/

concern Expected

Loss/

concern Expected

Loss/

concern % Met Expected

Loss/

concern

Mental Health 100% £652,503 £0 100% £558,284 £0 100% £515,457 £0 100% £1,842,663 £0 100% £3,568,908 £0Southport 100% £45,584 £0 100% £48,657 £0 100% £33,294 £0 100% £128,513 £0 100% £256,048 £0Community 100% £238,378 £0 100% £254,446 £0 100% £174,107 £0 100% £672,046 £0 100% £1,338,977 £0NHS England - Spec Comm MH 100% £193,941 £0 100% £193,941 £0 100% £193,941 £0 100% £193,941 £0 100% £775,762 £0NHS England - Liaison & Diversion 100% £5,201 £0 100% £5,201 £0 100% £5,201 £0 100% £5,201 £0 100% £20,803 £0NHS England - Imm & Vacc 100% £3,675 £0 100% £3,675 £0 100% £7,350 £0

Qtr 4

100%

Expecte

d

Position

Full Year

100%£2,842,363 £0 £5,967,848 £0£0

Expecte

d

Position

£922,000 £0100%

July 2017 CQUIN Position

Expected

PositionTotal

Expected

Position100%

Qtr 2Qtr 1

£1,139,282 100% £1,064,203 £0

Qtr 3

125 of 215


Quality

Section 4

95

126 of 215


96

Section 4:- Quality

• Quality and Safety Tile • Quality Surveillance – Safety • Quality Surveillance – Experience & Effectiveness • Quality Surveillance – Leadership • Delivering the Strategy

4. Quality

127 of 215


4. Quality Quality & Safety Tile

97

98 1474

0 277

37 94%

2 7334

0

11

2

1785

94%

84%

Due to the Network Re-design historical data prior to 15 May 2017 is recorded in the four Network structure and has been aggregated in this report to provide the best available comparison.

CQC Overall Trust Rating

Data provided shows the following 12 month figure (where a number) or the rolling 12 month average (where a percentage).

Physical Health Harm Free Care Rate

12 Risks

Good

Number of overdue 7 day reviews

Number of overdue 3 day reviewsMental Health Harm Free Care Rate

Number of compliments

Avoidable MRSA incidents

CQC Intelligence Monitoring Risks

Compliance with Core Skills

CQC Overdue Actions

LEADERSHIP

Other serious HCAI incidents

Regulation 28 Notices received

EFFECTIVENESS

Avoidable C. Diff. incidents

Physical violence to staff

SAFETY

QUALITY AND SAFETY TILE

EXPERIENCE

Number of upheld complaints

F&F Test - Patients

Number of complaints

Number of RIDDOR incidents

Number of serious incidents

Number of Never Events

128 of 215


4. Quality Safety

98

Domain Indicator Target Jul Aug Sep Oct Nov Dec Jan Feb Mar Apr May Jun12 months

total

12 months

averageSparkline Risk

Number of STEIS-reportable

serious incidentsn/a 14 11 6 16 6 6 7 9 4 7 7 5 98 8.2

% reduction from 2014/15 >10% -18% -45% -54% 23% -65% -57% -70% 80% -60% -61% -56% -86% - -39.08%

Number of RIDDOR incidents n/a 4 3 4 2 2 6 2 0 3 4 5 2 37 3.1

Number of Never Events 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0.0

Duty of candour breaches 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0.0

C. Diff. incidents 0 1 0 1 0 0 0 0 0 0 0 0 0 2 0.2

MRSA incidents 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0.0

Other serious HCAI incidents n/a 0 1 0 1 1 4 1 0 1 1 0 1 11 0.9

Overdue CAS alerts 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0.0

Mixed sex breaches 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0.0

Use of restraint n/a 253 279 215 257 349 252 189 263 308 327 296 400 3388 282.3

Potentially avoidable grade 3

and 4 pressure ulcersn/a 2 0 0 0 0 0 0 2 0 2 0 2 8 0.7

Physical violence to staff from

patients n/a 138 137 122 148 162 137 140 129 151 154 151 216 1785 148.8

% reduction from 2014/15 >10% 52% 80% 77% 20% 42% 19% 32% 43% 3% 57% 64% 100% - 49.08%

Legal Regulation 28 Notices received n/a 0 0 0 0 0 0 0 0 1 0 0 1 2 0.2

Regulatory Inspection Visits or Enforcement

Action:

None.

QUALITY AND SAFETY SURVEILLANCE - Safety

QUALITATIVE INDICATORS

QUANTITATIVE INDICATORS

Staff safety

Incidents

IPC

Patient safety

129 of 215


4. Quality Experience & Effectiveness

99


total

12 months


Number of complaints n/a 103 110 90 118 126 160 119 112 167 100 112 157 1474 122.8

Number of upheld complaints n/a 32 27 35 7 38 23 16 16 27 22 19 15 277 23.1

Number of reopened

complaintsn/a 5 2 5 2 3 3 3 4 2 1 4 6 40 3.3

Number of PHSO complaints n/a 0 1 1 1 0 0 1 2 3 1 3 1 14 1.2

Number of MP enquiries n/a 15 8 7 12 8 7 13 9 15 7 8 4 113 9.4

F&F Test - Patients 95% 94% 97% 97% 91% 85% 87% 96% 96% 96% 96% 97% - 93.85%

F&F Test - Response Rate n/a 1934 2666 2004 2517 3371 1744 1659 2042 1562 1263 1815 22577 2052.5

Compliments Number of compliments n/a 551 897 565 549 562 469 433 667 646 527 829 639 7334 611.2

QUALITY AND SAFETY SURVEILLANCE - Experience


Complaints

Friends & Family

Domain Indicator Target Jul Aug Sep Oct Nov Dec Jan Feb Mar Apr May Jun Sparkline Risk

Physical Health HFC Rate 95% 96% 94% 94% 94% 93% 94% 95% 95% 93% 94% 96% 94%

Mental Health HFC Rate 90% 82% 82% 83% 81% 82% 83% 86% 84% 85% 83% 83% 84%

QUALITY AND SAFETY SURVEILLANCE - Effectiveness


Harm Free Care

12 months

average

94%

83%

130 of 215


4. Quality Leadership

100


total

12 months


Overall Trust Rating Good RI RI RI RI RI RI Good Good Good Good Good Good

Intelligent Monitoring Risks

(six monthly reporting)n/a - - - - - - - - - - - -

Number of overdue CQC actions 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0.00

Number of raising concerns

(six monthly reporting)n/a - - - -

Compliance with Core Skills 85% 83.01% 86.19% 86.19% 86.56% 87.72% 88.24% 89.07% 89.41% 90.68% 90.33% 89.26% 91.06% - 88.14%

Compliance with Care

Certificate80% 24.00% 39.00% 35.00% 38.00% 36.00% 54.00% 62.00% 63.00% 67.00% 64.00% 70.00% 77.00% - 52.42%

No. of overdue 7 day reviews 0 1652 1305 1176 1267 1295 6695 2231.67

No. of overdue 3 day reviews 0 105 80 71 65 77 398 132.67

QUALITY AND SAFETY SURVEILLANCE - Leadership


CQC

Core Skills

Good

12 Risks

* NEW *

Incident

Investigation

131 of 215


4. Quality Leadership

101

June 2016 - The CQC conducted an unannounced review of safeguarding children and services for looked after children across Lancashire. The report has now been

published and an action plan developed.

July 2016 - HMP Liverpool. The CQC were looking specifically at the four previously issued requirement notices. The report has now been published on the CQC website

and an action plan developed by the Trust.

September 2016 - The CQC undertook a comprehensive inspection of the Trust resulting in an overall rating of 'Good'. The inspection reports have now been published

and our action plan response submitted to the CQC. The Quality Summit was held as planned on the 21st February. The Trust presented its acton plan and approach to

improvement based on the inspection team's findings, whilst also seeking system-wide support to help make improvements and continue our journey of continuous

quality.

October 2016 - A joint HMIP/CQC inspection was undertaken of HMP Wymott. The final inspection report has now been published and a Requirement Notice issued

against Regulation 17. The action plan in response to this Requirement Notice was returned to the CQC on the 28th February. Prison healthcare services transferred to

the new provider, GMW/Bridgewater, on the 1st April 2017.

January 2017 - A joint HMIP/CQC inspection was undertaken of HMP Garth. The final inspection report has now been published and the final requirement notice letter

received. In view of the fact that we are handing over this service on the 1st April to GMW/Bridgewater, we will not be submitting the formal Requirement Notice Action

Plan. However, we will respond with what actions have been completed, actions that have been started but not completed and what has been handed over to the new

provider.

March 2017 - A joint HMIP/CQC inspection was undertaken of HMP Preston. Infomation in relation to the outcome of the inspection was received on the 29th March.

This was sent in advance of the joint inspection report as areas of practice were found whether the Trust needs to make improvements. This will be handed over to the

new provider, Spectrum, on the 1st April 2017.CQC Mental Health Act Monitoring Visits (year to

date):

QUALITATIVE INDICATORS

CQC Inspection Visits (year to date):

Community and Wellbeing - 0

Children & Families - 1

Adult Mental Health - 24

Please refer to the network report for further details

April 2017 - Please also note, the CQC carried out an appreciative inquiry through a programme of focused Mental Health Act (MHA) one day visits to contribute new

evidence in the following areas: (1) Information on the local uses of compulsory MH Act powers, looking at activity changes, the reasons for increases or decreases of

detentions, and the response by local services, including commissioning bodies. (2) Identify how local Approved Mental Health Professional (AMHP) services are being

managed, what information is collected and current local issues impacting on AMHP provision and the ability to run a 24 hour AMHP service. The visit was held at the

Harbour on the 27th April. The CQC are currently collating all the information acquired durng the visit and will forward a report over the coming weeks.

Healthwatch Enter and View Visits (year to date):

Internal Quality Assurance visits (year to date):

Commissioner Quality Visits (year to date):

Community Wellbeing - 1












132 of 215


4. Quality Delivering the Strategy

102

Programme Description Type of Scheme

Exec SRO Sue Moore

Programme SRO Louise Corlett

Programme Manager Carly Steer

Reporting Period June 2017 (Month 3)

Report date 18-Jul-17

Description Responsible

Status - Overall health

For all schemes that have been initiated, work is ongoing to pull together

the programme documentation that will define each scheme and support

delivery, which is demonstrated on the network heat map. Significant

progress has been made in month to progress schemes that have been

initiated and we have high level delivery plans for most schemes that have

been initiated across DTS. Governance and reporting structure have been

agreed and Programme Assurance Groups are being set up to manage

performance of each portfolio.

Head of

Delivery&Performance

and SROs

Timescales

Timescales cannot be currently assessed accurately until plans for all

schemes are in place. Although most schemes now have a plan in place,

further work is required to ensure we have robust delivery plans for all

initiated schemes.

Head of


and SROs

Resources (corporate/other/kit)

Resources are aligned to most projects from the networks, TAS and other

corporate areas with a small number of gaps currently being resolved.

Scheme that have yet to be initiated will be evaluated against a framework,

to determine what resources will be required to support the schemes.

Head of Delivery and

PMO Lead

Budget

The financial savings target for the programme is £15.1m - with £11.1m of

traditional CIP schemes and £4m of cost reduction schemes. There are plans

to the value of £10.86m registered on Sharepoint, £9.7m as approved, with

£1.1m at Feasibility stage. Within the £9.8m approved, £3.4m relates to cost

reduction scheme for which delivery ytd is unconfirmed. A gap exists

currently to the value of £4.2m.

Head of


and SROs

Quality QIAs are being developed alongside PIDs, target date for PIDs with QIAs to

be in place inline with the completion of the PID.

Head of


Associate Director

Quality and Patient

Experience and SROs

RisksThe risk profile is emerging and will be further developed as PIDs and QIAs

are approved

Head of


and SROs

The purpose of Delivering the Strategy (DTS) is to deliver the Trust's

transformation programme and the operational annual plan. The focus is on

tranformational schemes that are aligned to the STP and LDPs and on

continuous improvement of quality within our services. There are 6 DTS

portfolios in 2017/18 aiming to deliver a wide range of redesign

programmes.

Transformational, cost

saving and income

generating

DTS Programme Progress Report

133 of 215


103


Stages17/18

TargetIdentified

Feasibility

StageApproved

Current

Forecast

Slippage

(-ve) / Over-

delivery in

Approved

Schemes

Balance btw

Identified

Amount to

Target 17/18

Balance btw

CIP Tracker

and

Identified

Non

Recurrent

Schemes

in Fcast

YTD

Delivery

YTD

Approved

Plan

YTD

Slippage

(-ve)

Month 2 15,100,000 10,864,918 1,521,421 9,343,497 9,330,497 -13,000 4,235,082 5,756,503 162,554 750,769 751,474 -705

Month 3 15,100,000 10,860,573 1,109,421 9,770,356 9,751,151 -19,205 4,239,427 5,329,644 162,554 2,385,022 2,395,865 -10,843

Variance 0 -4,345 -412,000 426,859 420,654 -6,205 4,345 -426,859 0 1,634,253 1,644,391 -10,138

CIP Tracker Tool Performance to Month 2

134 of 215


104


135 of 215


105


Programme SRO Goal (£000) Month Transacted Narrative

Apr (01) 84,969

May (02)86,026

Jun (03) 86,026

The LD, CPSR and the IAPT programme have now been inititated, most documentation

is inplace but further work required to define and monitor delivery of the IAPT

programme. The dental scheme, is currently being defined and will be presented at the

BDT on the 10th August, to formally initiate the scheme. Most plans i are on track with

some small delays in the LD programme, which can be mitigated through work ongoing

within the programme delivery group. CPOC to be scoped out to determine whether this

scheme will be initiated in year.

£1.4m is registered on the CIP system, £1156k approved and £264k at feasibility which

has increased the number of schemes at approved by £400 . Current forecast of £1156k

delivery with £11k slippage on the continence scheme. Further work required on the

gap of £845k and a series of workshops have been set up to find additional schemes.

Community

Wellbeing

Tanya

Hibbert2,265,460

136 of 215


106


Apr (01) 419,610

May (02)419,610

Jun (03) 454,610

All programmes within the Mental Health Portfolio have now launched excepted

transforming secure services and models of care. There is a workshop planned for the

9th August to scope out transforming secure services. Most schemes are fully scoped

out and have upto date plan in place. All schemes are on track against their delivery

plans. Significant progress has been made since last month.

£5.5m of schemes are registered as approved, which includes £2.4m of schemes

related to cost reduction for staffing and OAPs. This is a static position on last month,

however, an additional 435k has been identified within pipeline schemes. Tracking of

the progress and delivery £2.4m cost reduction schemes related to bank and agency

and OAPs spend is required to evidence the delivery of these schemes. Current

forecast of £5.49m with a 8k slippage. Mental HealthLisa

Moorhouse7,869,522

137 of 215


107


Apr (01) 81,806

May (02) 81,806

Jun (03) 81,806

All programmes within the Children & Young People's portfolio have now launched

except Complex Packages of Care . PIDs and draft project plans are in place for 3 work-

streams , and QIAs will be developed as the model is agreed. Some dates and task

owners still to be agreed within plans. These documents are iterative and will develop as

plans become more mature.

2,142,770

£1.28m of schemes are registered on the system, £865k at approved which is an

improved position and schemes to the value of £413k at feasibility stage leaving a

further gap of £864k. Pipeline schemes to the value of £778k are in train- this is a

significant increase on last month, if all schemes are approved there will be a gap of

£85k .Children &

Young PeopleSteve Tingle

138 of 215


108


Savings delivered through this programme will be reported through the relevant

Network or Corporate services

It was expected that £335k would be delivered through the mobilisation of S&F

community services, which will be tracked and accounted towards the C&W target.

The Southport and Formby Transformation governance and reporting structure has

been established to oversee the full service transformation of S&F community services.

All transformation is in the initial planning stage- there is very little baseline data

available from Southport Community services so we are working closely with

Performance. Cross service themes from the workshops are developing to create the

large scale transformation plan. 17 Workshops are being delivered to be completed by

completed by 18th August and project plan and priorities to be confirmed by 31st

August. Perinatal full business case due be signed off by the

board 6th July 2017.

Business case requests £3.5m capital funds to renovate a site a Chorley Hospital into the

new Cumbria and Lancashire Mother and Baby Unit. Mobilisation plan is inplace and on

track against plans.Apr (01) 186992

May (02) 186992

Jun (03)

186992

Organisational

reset

Louise

Corlett

Mobilisation &

DemobilisationLouise Giles

Corporate

Services

Schemes to the value of £2.24m are registered at approved stage, which is a small

improvement on last month. £423k of schemes now stand at feasibility. Additional

schemes still to be identified by Nursing and Quality. Pharmacy have put forward an

additional scheme to the value of £400 to be credited against CIP targets for18/19.

Once processed, the overall Support Services target will be set to over achieve by

£305k.

Dominic

McKenna2,801,600

139 of 215


109

4. Quality Audit 2017

National Audit Data collection period Report due Compliance

National Audit of Intermediate Care (NAIC)

May 2017 to August 2017

Participants will be asked for outturn data

April 2018

National chronic Obstructive

Pulmonary Disease (COPD) audit

programme

April 2017 to July 2017 February 2018

National Diabetes Audit – Adults April 2017 to July 2017 February 2018

Sentinel Stroke National Audit programme (SSNAP)

April 2017 to March 2018 Collection: April to July, August to November, December to March, April to March (annual)

January 2018

UK Parkinson’s Audit: (incorporating Occupational Therapy

Speech and Language Therapy, Physiotherapy

Elderly care and neurology)

1 May 2017 to 30 September 2017

May 2018

National Audit of Psychosis Autumn/Winter 2017 TBC

National Audit of Anxiety & Depression TBC TBC

Topic 17: Use of depot/LA

antipsychotics for relapse prevention

– baseline audit

May 2017 to June 2017

Sampling & Data Collection: May 2017

Online Data Submission: June 2017

Nov 2017

Topic 15: Prescribing for bipolar

disorder (use of sodium valproate) –

re-audit

September 2017 to October 2017

Sampling & Data Collection: Sept 2017

Online Data Submission: October 2017

Feb 2017

Topic 6: Assessment of side effects of depot antipsychotic medication – 2nd supplementary

February 2018 to March 2018

Sampling & Data Collection: February 2018

Online Data Submission: March 2018

July 2018

140 of 215


Workforce

Section 5

110

141 of 215


5. Workforce

111

Section 5:-

• Actual Workforce Costs Compared to Budget • Sickness Absence Rates • Appraisals and Mandatory Training Compliance • Vacancy Management and Active Recruitment • Core Workforce Headcount • Workforce Turnover

142 of 215


112

Actual Workforce Costs Compared to Budget - Quarterly Trend

Peripheral Workforce Spend and Usage

5. Workforce Actual Workforce Costs Compared to Budget

Spend £ % Spend £ % Spend £ %

T rust 19,295,502 1,621,440 7.5% 394,814 1.8% 312,756 1.4% 2,329,010 21,624,513 10.77%

M ental Health 8,729,368 1,332,566 12.6% 281,785 2.7% 257,493 2.4% 1,871,844 10,601,212 17.66%

Community & Wellbeing

4,501,263 174,659 3.6% 128,026 2.6% 67,814 1.4% 370,500 4,871,763 7.61%

Children & Young People

3,403,182 65,338 1.9% -6,228 -0.2% 28,070 0.8% 87,179 3,490,361 2.50%

Corporate 2,661,689 48,877 1.8% -8,770 -0.3% -40,620 -1.5% -512 2,661,177 -0.02%

Flexible Labour

Reliance %Business AreaCore

Workforce Spend £

Bank Agency M edical AgencyTotal Spend

£

2017 06

Total Peripheral Workforce

Spend £

Actual Workforce Costs compared to

Budget:

Overall spend on peripheral labour has increased for June from the May position. Actions:

Mental Health Network: Secure Services and the Harbour are

holding weekly Bank and Agency meetings to establish the reasons for high usage and agree how this can be mitigated. The content of this meeting updates the monthly Network Bank and Agency usage meeting.

Regular reviews are being conducted by the Care Teams to appraise the level of service user acuity and staffing levels. Their focus is to ensure an appropriate level of staffing is in place to provide safe and effective care.

Community & Wellbeing Network: The consultation for the Dental Services

redesign concluded in June. Delivery of the planned workforce changes will address the use of and reliance on Bank Workers at the Dental Nurse and Dentist level and the network are expecting to see spend improvements through Q2.

Services continue to review their need for the use of Bank and Agency and usage escalation processes in place at Longridge have been extended to Southport & Formby.

50 Applications are currently being processed to convert regular Agency Workers in use in Southport & Formby to LCFT Bank Workers.

143 of 215


5. Workforce Sickness Absence Rates

113

Trust 12 Month, Year on Year Trend

Sickness Absence Breakdown

Rate Rate Rate Trend

2017 04 2017 05 2017 06

% Long

Term

Absence

% Short

Term

Absence

12mths

Trust 5.73% 5.88% 5.96% 52.58% 47.42%

Mental Health 6.82% 7.04% 7.30% 58.15% 41.85%

Community & Wellbeing 5.82% 5.73% 5.67% 42.07% 57.93%

Children & Young People 5.25% 4.85% 4.56% 49.96% 50.04%

Support Services 2.46% 3.58% 3.86% 51.07% 48.93%

2017 06

Sickness Absence Rates:

Sickness Absence in June has increased for the second consecutive month, reporting 5.96%. The increasing trend for June is slightly up on seasonal trends in sickness experienced by LCFT. Mental Health Network has shown a rising trend since the inclusion of Secure Services in April. Community & Wellbeing and Children & Young People’s Wellbeing Networks have shown steady decrease since the Organisational Reset. Actions:

Mental Health Network: The management of sickness absence remains a top priority for the

Network’s Senior Leadership Team as is the focus on the Back to Basics Sickness Absence Management Action Plan.

Service Managers are working closely with HR to effectively manage sickness absence.

Community & Wellbeing Network: Network continues to focus on the management of Long Term Sickness to

facilitate the return of employees or dismiss al due to capability (ill health) . Sickness absence management remains a top priority with Network SMT

and the Network continues to review its action plan alongside the Trust Back to Basics plan

Action plans are in place for significant Long Term Sickness Cases in the Network and are monitored by and discussed with Care Group managers on a monthly basis

Children & Young Persons Wellbeing Network: Network is embedding the Sickness Absence Back to Basics

Management project within the network and are working to align this with the new Reset Management Structure.

Network continues to focus on the management of Long Term Sickness to facilitate the return of employees, medical redeployment trial periods or dismissal due to capability (ill health) .

144 of 215


5. Workforce Appraisals and Mandatory Training Compliance

114

Appraisals and Mandatory Training Compliance:

Mandatory and Statutory training rates continue to steadily increase across the Trust as Networks continue to work closely with Quality Academy and focus on improvement in this key performance measure. The Appraisal Compliance for Q1 is calculated on number of employees who have objectives in the system.

Actions: Mental Health Network: The Network continue to work closely with the Quality Academy to develop and implement their Network compliance improvement plans for the training

areas that are, individually, below the compliance target. PDR compliance is monitored on a monthly basis at the Network People Group Meeting and uses the Tier 2 monthly Network People Performance

Report. The new Network structure has enhanced accountability and responsibility lines for ensuring that there is a quality PDR process in place across the

Network. Community & Wellbeing Network: • Network continue to work closely with Quality Academy to improve compliance and enhance data quality. • PDR compliance has been monitored on a monthly basis at the Network SMT and People Group Meeting using the Tier 2 monthly Network People

Performance Report. • The new network structure is expected to enhance accountability and reasonability lines for ensuring that Quality PDR process take place and that

compliance across the Network is improved and bi-weekly tracking will recommence post reset for Q2. • Refinement of reporting lines post reset continues to take place and systems updated to ensure alignment of staff to mangers to allow PDR completion. Children & Families: • Significant progress has made been made during Q1 with validating central compliance data. Completion of this work is expected to enable the

discontinuation of local compliance reporting. • The new Network structure has enhanced accountability and responsibility lines for ensuring that there is a quality PDR process in place across the

Network. 145 of 215


5. Workforce Vacancy Management and Active Recruitment

115

Budgeted

Establ ishment (BE)

(FTE)

Actual

Establ ishment (FTE)

Budgeted

Establ ishment

Vacancies

(FTE)

BE Vacancy

Rate

Active Vacancy

Rate

Active Vacancy

FTENo. Pos i tions

Avg. No Days

to Recruit

Trust 6554.96 5930.67 624.29 9.52% 59.24% 369.86 455 41.13

Mental Health 2939.71 2623.89 315.82 10.74% 51.71% 163.31 198 45.50

Community & Wel lbeing 1633.17 1506.91 126.26 7.73% 81.05% 102.34 109 40.85

Chi ldren & Young People 1143.56 1040.66 102.90 9.00% 60.26% 62.01 97 39.40

Support Services 838.52 759.21 79.31 9.46% 53.21% 42.20 51 38.75

2017 06

Establ ishment Vacancies Vacancies in Active Recruitment

Vacancy Management and Active Recruitment:

The Establishment Vacancy Rate remains stable against the May position and reports a closing rate of 9.52% for June. The number of those vacancies being actively recruited has decreased slightly, moving from 62.41% in May to 59.24% in June. Actions:

Mental Health Network: The Network have been completing the Organisational Reset activity and a number of vacancies that were held to support the displacement and

redeployment process are in recruitment. The new Network have amalgamated the Specialist Services and Mental Health Ongoing Recruitment Programmes, designed to target hard to fill

posts and continue to effectively manage its delivery.

Community & Wellbeing Network: Vacancy clarity and management continues to be high on the Network agenda. The Network have been managing Organisational Reset and other transformation programme activity and a number of vacancies have been held to

support displaced staff and the redeployment process. Children & Young People Wellbeing Network: The new Head of Operations has been in post since July 2017, as has the new Service Manager covering the Central and West Lancashire

Portfolio. Vacancies held to support the CAMHS Tier 4 and Sexual Health BwD have been released and are being progressed through recruitment. 146 of 215


5. Workforce Core Workforce Headcount

116

Core Workforce

Network Headcount FTE Headcount FTE

Trust 6965 5961.14 6672 5924.54

Mental Health 2843 2631.16 2828 2620.26

Community & Wellbeing 2084 1519.27 1821 1507.41

Children & Young People 1216 1047.02 1208 1039.66

Support Services 822 763.69 815 757.21

2017 05 2017 06

147 of 215


5. Workforce Workforce Turnover

117

148 of 215


118

6. Risks Board Assurance Framework 17/18 Quarter 1

BOARD ASSURANCE FRAMEWORK DASHBOARD 2017/18

Strategic

Priority BAF Risk Sub-committee Director Lead

Risk

Score

01.04.17

Risk

Score

Q1

Risk

Score

Q2

Risk

Score

Q3

Risk

Score

Q4

2017/18

Risk

Target

2017/18

Risk

Target Gap

Final

Risk

Target

Final Risk

Target

Gap

SP

1

Qu

ality

1.1 If we do not meet regulatory standards for quality and safety we will not be fit for purpose as care provider.

Quality & Safety DoNQ 12

High

8

High

4

Tolerable

4

Moderate

8

Close Monitoring

1.2 If we do not create a culture of learning then we will be unable to provide high quality care.


Significant

12

High

4

Tolerable

4 Moderate

12

Significant

1.3 If we do not provide integrated physical and mental health services we will lose opportunities to improve patient outcomes.

Quality & Safety MD 16

Significant

12

High

4

Tolerable

4 Moderate

12

Significant

SP

2

Su

sta

inab

le

Serv

ices

2.1 If we do not work collaboratively with partners we will not be able to influence system wide transformation.

Business Dev & Delivery

COO 12

High

8

High

4

Tolerable

4 Moderate

8

Close Monitoring

2.2 If we do not deliver new models of care we will cease to be a creditable lead provider.


COO 12

High

8

High

4

Tolerable

4 Moderate

8

Close Monitoring

SP

3 E

xc

ell

en

ce

3.1 If we do not engage with our patients and service users we cannot achieve excellence and quality.


High

8

High

4

Tolerable

4

Moderate

8

Close Monitoring

3.2 If we fail to project our achievements then our reputation will not improve.


COO 16

Significant

12

High

4

Tolerable

4 Moderate

12

Significant

SP

4

Pe

op

le

4.1. If we do not support the health and wellbeing of staff we will struggle to attract, recruit and retain our workforce.

People HRD 20

Significant

10

High

10

Concern

5

Moderate

15

Significant

4.2 If staff are not provided with extensive education, training and leadership development we will not have an organisational culture that supports high performance.

People HRD 9

High

6

Moderate

3

Tolerable

3

Low

6

Close Monitoring

SP

5

Mo

ne

y

5.1 If we do not meet financial objectives we will not be able to provide sustainable services.

Finance CFO 15

Significant

10

High

5

Tolerable

10

High

5

Tolerable

5.2 If we do not work with partners to deliver system wide efficiencies this will undermine our own financial position and that of the STP.

Finance CFO 15

Significant

10

High

5

Tolerable

5

Moderate

10

Concern

SP

6

Inn

ovati

on

6.1 If we do not develop and maintain infrastructure, we will not be able to deliver safe, responsive and efficient care.

Infrastructure CFO 12

High

8

High

4

Tolerable

4

Moderate

8

Close Monitoring

6.2 If we do not exploit the full capabilities of the new EPR system and wider technology to redesign services we will miss important opportunities to improve care.

Infrastructure CFO 12

High

8

High

4

Tolerable

4

Moderate

8

Close Monitoring 149 of 215

Quality & Performance

Report

Southport & Formby

Month 3 – June 2017

150 of 215


Quality and Performance Report:-



• NHS Improvement Indicators Dashboard • NHS Improvement Indicators Kitemarking • Southport & Formby Summary • Key Exceptions

Section 1.2:- Data Quality

• To be confirmed



• To be confirmed

Section 2.2:- Community Contract Activity

• Queen’s Court - Palliative Care

Section 4:- Workforce • To be confirmed

2

Section 5:- Risk

• To be confirmed

Section 3:- Quality

• Quality Tile • Quality Surveillance - Safety

151 of 215


Performance Activity

Section 1.1

3

152 of 215


1.1 Performance Activity

NHS Improvement Indicators Dashboard

4

Indicators achieved Target Type Target May-17 Jun-17

NHS Improvement

CIDS - Referrals NHSI 50.00% 100.00%

153 of 215



NHS Improvement Indicators Kitemarking

Kitemarking key:

• SOP – Does the indicator have an associated SOP that is within date? • External Audit – Has this measure been subjected to an external audit

within the last 2 years?

• Internal Audit – Has this measure been subjected to an internal audit within the last 2 years?

• Electronically Populated – Is this indicator produced using electronically generated numerators and denominators?

• Manual Overrides – Has the performance for this indicator been produced using manual overrides to indicate false positives or negatives?

5

154 of 215



NHS Improvement Indicators Kitemarking

6

155 of 215



Summary - Southport & Formby

7

Indicators achieved Target Type Target May-17 Jun-17 Date Available

Services

Blue Badge Commissioner TBC TBCCommunity Emergency Response Team Commissioner TBC TBCChronic Care Commissioner TBC TBCCommunity Adult Therapies Commissioner TBC SeptemberCommunity Matrons Commissioner TBC SeptemberCommunity Neuro Commissioner TBC TBCContinence Commissioner TBC AugustDiabetes Commissioner TBC TBCDietetics Commissioner TBC TBCDischarge Commissioner TBC TBCDistrict Nursing Commissioner TBC SeptemberFalls Commissioner TBC TBCPain Commissioner TBC TBCPalliative Care Commissioner TBC TBCPodiatry Commissioner TBC TBCPsychology Commissioner TBC TBCSpeech & Language Therapy Commissioner TBC TBCStoma Commissioner TBC TBCTreatment Rooms Commissioner TBC August

156 of 215


Financial Activity

Section 2.1

8

157 of 215


9



• To be confirmed

Section 2.2:- Community Contract Activity

• Queens Court Contract Activity

2. Finance and Contracting

158 of 215


Use of Resources (UoR) Risk Rating 2.1 Finance and Contracting

Detail for Southport and Formby can be found in the Trust's main QPR Finance and Contracting Section.

159 of 215


Contract Activity

Section 2.2

11

160 of 215


2.2 Contract Activity – Variance to Plan Southport & Formby

12

A temporary data sharing agreement is in place and data will start to populate the Trust’s data warehouse over the coming weeks and

months. When data has been validated it will appear within this report. A project has been initiated to validate each service’s

data. The projected end date for all services is Oct 2017.

161 of 215


2.2 Contract Activity – Variance to Plan Queens Court – Palliative Care subcontract

13

CNS MAY JUNE Q1 Total

Number of referrals received 88 84 172 172% appropriate referrals (SEEN BY SERVICE) 80% 79% 79% 79%Primary health care team (GP) 20 15 35 35Specialist nurse / team (internal) 9 13 22 22Other hospital staff (internal) 47 46 93 93Internal Referral (QCH & SPCS) 11 10 21 21Other(other) 1 0 1 1Not recorded 0 0 0 0Pain/Symptom Control 83 76 159 159Psychological Support 44 48 92 92Social/Financial 0 0 0 0Family Support 0 1 1 1Other 0 1 1 1

Number of patients 'active' 364 363 727 72782 41 123 12319 18 37 37

Inappropriate 1 0 1 1Died within 24hrs of referral 2 2 4 4Declined 0 1 1 1Unable to contact (includes admissions) 1 0 1 1Contact made, appointment arranged 12 11 23 23Other 3 3 6 6Unknown 0 1 1 1Number 70 66 136 136New and re-referred as % of all patients seen

in month41% 39% 40% 40%

Cancer 42 44 86 86Non-malignant 28 22 50 50Not recorded 0 0 0 0% Primary Diagnosis of Cancer 60% 67% 63% 63%Total (New Non F2F) 82 84 166 166Within 48 hours 69 69 138 138% target achieved 84% 82% 83% 83%

Referrals not seen (non F:F)

Number of referrals ended (of those seen)

Reason for Referral (maybe more

then 1 per patient)

Referral source

Diagnosis (of those seen)

New and re-referred patients (seen)

Initial Telephone contact

Time from referral to patient contact.

No more than 48hours (75% target)

162 of 215



14

New assessment with patient (New F2F) 54 64 118 118OPD 0 20 44 44

Current place of residence 54 44 74 74Review FU with patient (face-to-face) 251 266 578 578

OPD 0 78 139 139Current place of residence 312 188 439 439

Review FU with patient (telephone) 270 270 540 540Advice & Support relative/carer F:F 185 171 356 356Advice/support to a Professional F:F 168 173 341 341Advice & Support relative/carer Tel 222 232 454 454Advice/support to a Professional Tel 147 184 331 331Bereavement visit with relative / carer 0 0 0 0Bereavement Telephone with relative / carer 11 16 27 27Bereavement Letter to relative / carer 14 17 31 31DNA (Total DNA) NR NR NR NR0 31 23 54 541 15 14 29 292 5 3 8 83 1 5 6 64 4 6 10 105 1 3 4 46 2 1 3 37 1 4 5 58-14 6 6 12 1215-21 3 0 3 322-28 0 0 0 029-41 0 0 0 0> 42 0 0 0 0Primary healthcare team 24 15 39 39Internal referral 1 3 4 4Died 57 21 78 78Other 0 2 2 2Not recorded 0 0 0 0

Time from Referral to Assessment

in days (seen)

Discharged to (of those seen)

Contacts

(related to caseload)

163 of 215



15

Average time 119 21 32 32Shortest time 0 0 0 0Longest time 1898 154 1898 1911

63% 33% 55% 55%Home 16 3 19 19Hospital 21 14 35 35Hospice 13 0 13 13Care home 7 4 11 11Prison 0 0 0 0Other 0 0 0 0Unknown 0 0 0 0PPC achieved 29 9 38 38PPC not achieved 14 3 17 17PPC unknown 14 9 23 23Not recorded 0 0 0 00 - 5 57 54 111 111

6 - 14 9 11 20 20

15 - 21 3 0 3 3

22 - 28 0 0 0 0

29 - 42 0 0 0 0

> 42 0 0 0 0

% Non Hospital Deaths (of those seen)

Time on caseload (of those seen)

Time to receiving care

for referrals in this month

(active data)

Deaths (of those seen)

Place of death (of those seen)

164 of 215



16

Activity perfomance indicator Report frequency May June Q1 Annual total

SERVICE USER EXPERIENCE

1. Complaints received Monthly 0 0 0 02. Compliments Monthly 6 9 15 77523. Incidents reported (about the service) Monthly 0 0 0 04. Incidents reported (by the service) Monthly 1 0 1 3775. Iwantgreatcare (number of returns) AnnuallySTAFF TURNOVER /ATTENDANCE

1. Left employment Quarterly 1 142. Recruited Quarterly 0 03. Sickness % per establishment Quarterly 2.88% 2.88%STAFF TRAINING / DEVELOPMENT

1. Annual apprisals completed 100% Annually2. Mandatory training completed 100% Annually3. Clinical supervision (hours) 100% Monthly 0 0 0 0GSF Attendance Monthly 6 6 12 5922

165 of 215


Quality

Section 3

17

166 of 215


3 Quality Safety

18


total

12 months


Number of serious incidents n/a 0 0 1 1 0.3

Number of RIDDOR incidents n/a 1 1 0 0 0 1 0 0 1 0 0 0 4 0.3

Potentially avoidable grade 3

and grade 4 pressure ulcers0 0 0 0 0 0 0 0 0 0 0 0 1 1 0.1

Duty of candour breaches 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0.0

Number of complaints 0 1 0 1 0 0 0 0 0 0 0 1 2 5 0.4

Number of upheld complaints n/a 0 0 0 0 0 0 0 0 0 0 0 0 0 0.0

Number of compliments n/a 0 0 4 4 1.3

F&F Test - Patients 95% - -

F&F Test - No of Surveys received n/a 1 0 0 0 0 0 0 0 0 0 0 1 0.1

Effectiveness Physical Health HFC Rate 95% 98% 93% 1.91 1.0

Leadership Compliance with Core Skills 85% 80.35% - 0.8

QUALITY AND SAFETY SURVEILLANCE - Community and Wellbeing Network: Southport and Formby


Safety

Experience

167 of 215

Board of Directors


Report Title Quarterly Workforce Board Report 2017/18 – Q1

FOIA Exemption No Exemption

Prepared by Michelle Kaye, Head of Workforce Planning and Information

Presented by Damian Gallagher, Director of Human Resources



Report purpose To support and inform the Board’s delivery of the LCFT Workforce Strategy


To employ the best people

Board Assurance Framework risk 4.1

CQC domain Well-led

168 of 215

Introduction: The LCFT Workforce Board Report has been designed to provide the Board with a quarterly update on the organisations performance against ten agreed workforce Key Performance Indicators (KPI’s). The data presented is supported with narrative that highlights the current workforce management challenges being experienced by the Business. The structure of the narrative is designed to provide high level information about the remedial and supportive activities and actions being taken to manage performance improvement and provide assurance to the Board that the organisation is committed to effectively managing and mitigating the identified workforce management risks. This report provides performance against the workforce indicators for the Quarter 1 period, 01 April 2017 to 30 June 2017. The data presented in this report is sourced from the following LCFT Directorates:

Human Resources Finance Quality Academy

Information to support the preparation of narrative is provided by HR Business Partners in conjunction with Network Management. Members of the Board are invited to note the content of the report and are encouraged to ask any questions and make requests for further information with the Director of Human Resources.

Workforce KPI Performance Headlines: The workforce indicators set out on page 3 of the Workforce Board Report present LCFT’s overall performance against the ten workforce KPI’s in the Quarter 1 period. Performance is rated against the Trusts defined targets, using the Red and Green indicators adopted by LCFT. These are supplemented with an indicative performance trend arrow. The trend is set against performance reported in the previous quarter. This report has been updated to report against the new Organisational Reset Structure and presents the three new Networks, Mental Health Network (MHN), Community & Wellbeing Network C&WN) and the Children & Young People’s Wellbeing Network (C&YPWN) and Support Services (formally Corporate). 1. Peripheral Workforce Reliance LCFT’s use of a Bank and Agency workforce has increased steadily through the Q1 period, ending

the first quarter of the financial year with a 10.77%. The Quarter 1 closing rate is an improvement on the Quarter 4 closing position of 12.02%. LCFT Bank Workers continue to be the primary source of flexible labour for the Trust.

All Networks are working to achieve their refreshed targeted improvement plans for the 2017/18

operating year to address Bank and Agency expenditure and flexible labour reliance, as aligned to the 2017/18 Financial Plan.

2. Operational Gap The Trust operating gap has remained below the Trust target of 5% throughout the quarter and

LCFT reports a stable Q1 closing rate of 3.04%. The total operating gap (including Sickness Absence and Annual Leave absences) is 17.54% at

the close of Q1. This is a slight increase on the Quarter 4 closing percentage of 16.5%.

169 of 215

3. Sickness Absence

Sickness Absence has fluctuated through Q1 and reports a quarter closing rate of 5.96% for the Trust. All Networks report their continued commitment to a new Network targeted Sickness Absence Management project that aligns closely with the Trust ‘Back to Basics’ Attendance Management Action Plan and all are currently realigning their Absence meetings to best engage the new network management and accountability structures.

Long term and short term sickness absence remain close to an even split with 52.58% of absences

being attributable to Long Term Sickness (Absences lasting 28 days or more in one episode). 4. Vacancy Rate The Board Report provides two rates to support the assessment of vacancies.

Establishment Vacancy Rate: The number of vacancies the business runs with against its Budgeted Establishment

Active Vacancy Rate: The number of vacancies being actively recruited to (this is a count of any vacancy that is within the recruitment process from recruitment authorisation through to starting with the trust). The budgeted establishment vacancy rate has gradually increased through the Q1 period and

reports a closing rate of 9.52% (against 8.82% at the close of Q4). The number of these in active recruitment has reduced to 59.24% at the close of Q1. This equates

to 455 ‘live’ recruitment events totalling 369.86 FTE across the Trust. 42 of these vacancies are at the internal redeployment recruitment stage (32.66FTE) and 413 vacancies are in Open Recruitment (337.20 FTE).

5. Safer Employment Compliance

Core Workforce Compliance in recruiting and employment, across the Core Workforce, continues to perform well

with 99% compliance in Safer Recruitment practice and 99% for Safer Employment practice.

Bank Workers Compliance within the Bank Only Worker population for Safer Recruitment Practice also continues

to perform well and is reporting 94% compliance in Q1. Bank Worker Engagement Compliance reports 86% for the quarter.

6. Turnover Rate

Quarter 1 has seen a slight reduction in the Trust Turnover rate, reporting 12.49% at the close of the quarter. The 2017/18 Operating Year Q2 Workforce Performance Report will see a reporting enhancement to the Turnover reporting suite with the introduction of Redeployment management performance and Financial Impact Trajectory.

7. Appraisal Performance Quarter 1 of the 2017/18 performance year is the first cycle of PDR management – PDR Initiation. The Quarter 1 Appraisal report uses four categories to measure PDR activity and performance against the Trust target:

170 of 215

The proportion of employees who have either: 1. The proportion of employees who have initiated their 2017/18 PDR in the ePDR system and

have objectives in place. 2. Have completed the Medical Workforce Appraisal process.

1. The proportion of New Starters, within the 60 day grace period, who have registered with the ePDR system but do not yet have personal objectives in place.

2. Members of the Medical Workforce who have arrangements in place to complete their Medical Appraisal and are inside the approved timescales for completion.

3. The proportion of employees who have initiated their 2017/18 PDR but don’t have any objectives in place.

The proportion of existing employees who have either: 1. Have not initiated the 2017./18 PDR in the ePDR system. 2. Have not registered with the ePDR system and for whom we have no information. 3. Members of the Medical Workforce who have not completed the Medical Appraisal process and are outside of their ‘Appraisal birthday’.

The proportion of New Starters, within the 60 day grace period, who have not registered with the ePDR system.

The overall Trust Appraisal compliance rate for Q1 (inclusive of the Medical Workforce) is 28.76%. This represents the number of employees who are either rated Green or Amber, according to the categories above. Compliance is below the Trust target of 85%.

3. Mandatory & Statutory Training Compliance Overall mandatory and statutory training compliance continues to improve month on month and

has achieved the Trust Target, reporting an overall compliance of 89% at the close of Q1. Significant improvements have been achieved in this area over the last performance year and continue to be achieved at the start of the new financial and performance year.

The People sub-committee continues to monitor this target closely and each Network reports

improvements in compliance and accuracy of centrally held compliance data. Work is currently underway within the Quality Academy to explore non-compliance and non-attendance for core skills training to further inform how the Trust can approach Mandatory and Statutory Training to continue the improvements in compliance across all core skill areas for compliance.

4. Induction The Induction completion rate has fallen slightly below the Trust Target of 95% at the close of Q1

but continues to perform well, reporting a closing performance rate of 93.75%. Damian Gallagher HR Director

171 of 215

Page 1

LCFT Workforce Board Report

Quarter 1

April 2017 to June 2017 Prepared by Michelle Kaye & Phil Connolly

172 of 215

Page 2

• Operational Gap • Sickness Absence Rate • Appraisal Rate

• Staff Turnover • Sickness Absence • Peripheral Workforce Spend

to Core Workforce Spend

• Vacancy Rate • Safer Employment Compliance • Sickness Absence • Peripheral Workforce Spend to

Core Workforce Spend • Operational Gap

• Appraisal Rate • Mandatory & Statutory

Training Compliance

• Appraisal Rate • Mandatory & Statutory Training Compliance

173 of 215

Page 3

KPI PERFORMANCE OVERVIEW

The HR and L&OD Key Performance Indicators have been devised to update the Trust Board on the Trusts current performance against the agreed key workforce indicators and highlight any areas of concern and provide assurance by identifying the action taken to mitigate risk and improve performance.

Information in this report is accurate as at 30th June 2017.

Key Performance Indicators Trust TargetQuarter 4 Closing

Figures(Q4: 2016/17)

Quarter 1 Closing

Figures(Q1: 2017/18)

Trend (Against Previous

Quarter)

Total Workforce Expenditure (Cumulative Spend in Quarter)

£63,711,081

Budget£64,803,474 £63,983,430 q

Peripheral Workforce Reliance (Bank, Agency & Locum spend % of Total Pay Spend)

6.0% 12.02% 10.77% q

Operational Gap 5.0% 3.01% 3.04% p

Sickness Absence 4.5% 5.93% 5.96% p

Vacancy Rate 5.0% 8.82% 9.52% p

Of which in Active Recruitment - 76.20% 59.24% q

Safer Employment Compliance

(Core workforce)85.0% 98.73% 98.96% p

( Bank workers) 85.0% 97.63% 90.01% q

Turnover Rate 10.0% 13.38% 12.49% q

Appraisal Performance 85.0% 76.85% 28.76% q

Mandatory & Statutory Training

Compliance 85.0% 85.63% 88.83% p

Induction (within 28 days of starting) 95.0% 96.15% 93.75% q

174 of 215

Page 4

WORKFORCE EXPENDITURE

Workforce Expenditure against Established Budget – Quarter 1 Source Data: EFIN Finance Ledger

The HR and L&OD Key Performance Indicators have been devised to update the Trust Board on the Trusts current performance against the agreed key workforce indicators and highlight any areas of concern and provide assurance by identifying the action taken to mitigate risk and improve performance.

Workforce Expenditure against Established Budget – Quarter 1 Cumulative figures

0

5

10

15

20

25

2017 04 2017 05 2017 06

£ m

illio

ns

Medical Agency

Agency

Bank

Core

Budget

Business Area Established Budget

£'s

Spend on Core

Workforce £'s

Spend on Peripheral

Workforce £'s

Total Spend on

Workforce £'s

Budget &

Expenditure

Variance £'s

Trend (Against

Previous

Quarter)

Trust 63,711,081 57,744,974 6,238,456 63,983,430 272,349 p

Mental Health 13,447,782 12,956,069 898,874 13,854,943 407,162 p

Community & Wellbeing 28,891,407 26,492,420 5,003,312 31,495,732 2,604,325 p

Children & Young People 10,827,984 10,338,441 327,181 10,665,622 -162,361 p

Support Services 10,543,909 7,958,044 9,088 7,967,132 -2,576,777 q175 of 215

Page 5

VACANCY RATE

The Vacancy Rate presents the % difference between the Trusts budgeted establishment and its actual spent establishment. This measurement has been based on FTE and is one of the measures referenced when assessing core workforce stability.

To enhance this measure, the Active Vacancy Rate has been supplied. This rate highlights the % of budgeted establishment vacancies that are being actively recruited to by the organisation.

Budgeted Establishment Vacancy Rate – 12 Month Trend

Budgeted Establishment & Active Vacancy Rate Comparison – Position as at 30th June 2017

Source Data: ESR and Finance Ledger

0.0%

2.0%

4.0%

6.0%

8.0%

10.0%

12.0%

14.0%

2016 06 2016 07 2016 08 2016 09 2016 10 2016 11 2016 12 2017 01 2017 02 2017 03 2017 04 2017 05 2017 06

Trust

Mental Health

Community & Wellbeing

Children & Young People

Support Services

Budgeted Est. FTE

(BE)FTE in Post

Budgeted FTE

Vacant

Budgeted Est.

Vacancy Rate

(BE VR)

Vacant FTE in Active

Recruitment

Active Vacancy Rate

(AVR)

6554.96 5930.67 624.29 9.52% 369.86 59.24%176 of 215

Page 6

Vacancy Rate & WTE – Quarter 1 Monthly Actuals, by Business Area Source Data: ESR, Finance Ledger, Recruitment



VACANCY RATE

Hot Spot Analysis:

Mental Health Network: The Establishment Vacancy Rate has gradually increased during Q1, closing at 10.74%. The Network have been completing the Organisational Reset activity and a number of vacancies that were held to support the displacement and redeployment process are in recruitment. Board Assurance: 33 new appointments have been made to work with the Network and are

currently undergoing the recruitment engagement process. The new Network have amalgamated the Specialist Services and Mental

Health Ongoing Recruitment Programmes, designed to target hard to fill posts and continue to effectively manage its delivery.

BE FTE FTE In Post BE VR AVR BE FTE FTE In Post BE VR AVR BE FTE FTE In Post BE VR AVR

Trust 6351.17 5795.18 8.75% 0.00% 6610.70 5973.41 9.64% 62.41% 6554.96 5930.67 9.52% 59.24%

Mental Health 2959.14 2661.37 10.06% 0.00% 2954.54 2639.99 10.65% 65.70% 2939.71 2623.89 10.74% 51.71%

Community &

Wel lbeing1415.55 1313.70 7.19% 0.00% 1650.16 1519.71 7.91% 68.11% 1633.17 1506.91 7.73% 81.05%

Chi ldren & Young

People1129.49 1052.21 6.84% 0.00% 1153.50 1047.02 9.23% 60.45% 1143.56 1040.66 9.00% 60.26%

Support Services 846.99 767.90 9.34% 0.00% 852.5 766.69 10.07% 44.13% 838.52 759.21 9.46% 53.21%

2017 05 2017 062017 04

Community & Wellbeing Network: The Establishment Vacancy Rate has fluctuated through Q1, closing the quarter at 7.73%. 81.05% of the vacancies are being actively recruited to. This is an increased position when compared to the close of Q4 2016/17. Vacancy clarity and management continues to be high on the Network agenda. Board Assurance: The Network have been managing Organisational Reset and other

transformation programme activity and a number of vacancies have been held to support displaced staff and the redeployment process.

177 of 215

Page 7

Vacancy Rate & WTE Hot Spot Analysis continued Source Data: ESR and Finance Ledger



VACANCY RATE

Children & Young People's Wellbeing Network: The Establishment Vacancy Rate has seen an increase through the Quarter, closing the period at 9%. The network are actively recruiting to around 60% of these vacancies. The Network are currently holding a number of vacancies across the 0-19 Universal and CAHMS Tier 3 Services due to recent changes to contract that have resulted in a reduction in the financial envelope being made available for the delivery of services and the removal of the CAHMS Grant.

Board Assurance: The new Head of Operations has been in post since July 2017, as has the

new Service Manager covering the Central and West Lancashire Portfolio. Vacancies held to support the CAMHS Tier 4 and Sexual Health BwD have

been released and are being progressed through recruitment.

178 of 215

Page 8

Operational Gap is the measure of absences that affect operational performance other than Sickness and Annual Leave. This section of the report considers employees who are absent from operational work for the following reasons: Career Break, Maternity & Adoption, Paternity, Out on External Secondment (Paid), Out on External Secondment (Unpaid), Suspend No Pay, Suspend With Pay.

Operational Gap by Business Area – 12 Month Trend Source Data: ESR

OPERATIONAL GAP

Total Operational Gap Analysis, by Reason – Position as at 30th June 2017

Active 83.5%

Annual Leave 9.6%

Sickness Absence 4.9%

Mat / Adoption Leave 1.6%

Career Break 0.3%

Suspension 0.2%

Other 0.4%

0.00

50.00

100.00

150.00

200.00

2016 07 2016 08 2016 09 2016 10 2016 11 2016 12 2017 01 2017 02 2017 03 2017 04 2017 05 2017 06

F

T

E

Mental Health Community & Wellbeing Children & Young People Support Services Specialist Services

Indicator Heads FTE

Total Workforce 6668 5930.67

Mat / Adoption Leave 157 140.36

Career Break 22 16.01

Secondment 8 8.00

Suspension 15 16.01

Sickness Absence 421 373.24

Annual Leave 548 504.93

Total Workforce Gap 1171 1058.56179 of 215

Page 9

Operational Gap by Business Area – Quarter 1 Monthly Actuals, by Business Area Source Data: ESR

OPERATIONAL GAP Operational Gap is the measure of absences that affect operational performance other than Sickness and Annual Leave. This section of the report considers employees who are absent from operational work for the following reasons: Career Break, Maternity & Adoption, Paternity, Out on External Secondment (Paid), Out on External Secondment (Unpaid), Suspend No Pay, Suspend With Pay.

Average

FTE

Average No

Absent

Employees

Gap Average

FTE

Average No

Absent

Employees

Gap Average

FTE

Average No

Absent

Employees

Gap

Trust 5785.96 179.18 3.10% 5961.14 181.04 3.04% 5924.54 180.39 3.04%

Mental Health 2654.65 81.34 3.06% 2631.16 76.54 2.91% 2620.26 74.58 2.85%

Community & Wellbeing 1313.20 35.25 2.68% 1519.27 44.86 2.95% 1507.41 44.54 2.95%

Children & Young People 1052.21 41.79 3.97% 1047.02 39.83 3.80% 1039.66 41.47 3.99%

Support Services 765.90 20.80 2.72% 763.69 19.80 2.59% 757.21 19.80 2.61%

2017 04 2017 05 2017 06

180 of 215

Page 10

The Sickness Absence rate is calculated as follows:

Total absence (hours) during a month ÷ Total actual headcount contracted time (hours) during a month x 100

Sickness Absence Rate – Year on Year 12 Month Trend Analysis Source Data: ESR

SICKNESS ABSENCE

Sickness Absence Rates by Business Area – Quarterly Actuals

0.00%

2.00%

4.00%

6.00%

8.00%

10.00%

Jul Aug Sep Oct Nov Dec Jan Feb Mar Apr May Jun

Current Yr Prev Yr Target

Rate Rate Rate

2017 04 2017 05 2017 06

% Long

Term

Absence

% Short

Term

Absence

Trust 5.73% 5.88% 5.96% 52.58% 47.42% 537,108 31,471 2,588,718

Mental Health 6.82% 7.04% 7.30% 58.15% 41.85% 240,260 16,944 1,304,847

Community & Wel lbeing 5.82% 5.73% 5.67% 42.07% 57.93% 131,918 7,566 663,295

Chi ldren & Young People 5.25% 4.85% 4.56% 49.96% 50.04% 95,455 4,667 416,692

Support Services 2.46% 3.58% 3.86% 51.07% 48.93% 69,475 2,294 203,884

2017 06 Total

Available FTE

Days in

Quarter

Total FTE Days

Lost To

Sickness in

Quarter

Estimated

Cost to Trust

in Quarter £

Trend

12mths

181 of 215

Page 11

The Sickness absence rate is calculated as follows:


Sickness Absence Hot Spot Analysis Source Data: ESR

SICKNESS ABSENCE

0.00%

2.00%

4.00%

6.00%

8.00%

10.00%



Mental Health Network: Q1 has seen a significant increase in sickness absence across the Network. Some of this increase can be attributed to the inclusion of Secure Services and there have been noted increases in Inpatient Unit sickness.

Board Assurance: The management of sickness absence remains a top priority for the Network’s

Senior Leadership Team as is the focus on the Back to Basics Sickness Absence Management Action Plan.

During Q1, one employee has been dismissed on grounds of capability. This is expected to increase in Q2, in light of management stage of a number of sickness cases. Service Managers are working closely with HR to effectively manage sickness absence.

Care Group managers are being provided with detailed sickness absence data for their localities. This is followed up with meetings with Service Managers to agree an action plan for every sickness absence case and a new HR Sickness Management reporting process has been put in place.

0.00%

2.00%

4.00%

6.00%

8.00%

10.00%



Community & Wellbeing Network: Sickness absence has maintained a downward trend in Q1 and closes the quarter with a rate of 5.67%.

Board Assurance: Network focus on sickness absence has resulted in the facilitated return to work

of 16 employees (from long term absence) and 2 dismissals due to capability during Q1. The network has met its business plan objectives trajectory for Q1 (6% target).

Sickness absence management remains a top priority with Network SMT and the Network continues to review its action plan alongside the Trust Back to Basics plan.

Action plans are in place for significant Long Term Sickness cases in the Network and are monitored by and discussed with Care Group managers on a monthly basis.

182 of 215

Page 12

The Sickness absence rate is calculated as follows:


Sickness Absence Hot Spot Analysis Source Data: ESR

SICKNESS ABSENCE

Children & Young Persons Wellbeing Network: The sickness absence rate has gradually decreased through the Quarter, and closes at 4.56%.

Board Assurance: Network continues to focus on the management of Long Term Sickness. This

has resulted in the facilitated return of 60 employees, 2 medical redeployment with no current trial periods and 3 dismissals due to capability (ill health) during Q1.

Network is embedding the Sickness Absence Back to Basics Management project within the network and are working to align this with the new Reset Management Structure. 0.00%

2.00%

4.00%

6.00%

8.00%

10.00%



183 of 215

Page 13

AGENCY & BANK SPEND

Agency & Bank spend is calculated as a percentage of the total salary spend. Usually, a link can be seen between the level of expenditure on peripheral workforce (Bank, Agency and Locum), the Vacancy Rate, Sickness Absence and Operational Gap.

Bank & Agency Pay Spend by Business Area Source Data: Finance, Healthroster & ESR


Trust 18,831,115 1,312,055 6.3% 385,650 1.9% 257,402 1.2% 1,955,108 20,786,223 9.41%

Mental Health 8,925,982 1,049,143 10.0% 287,786 2.7% 215,860 2.1% 1,552,789 10,478,771 14.82%

Community & Wel lbeing 3,886,474 135,897 3.3% 97,614 2.4% 23,765 0.6% 257,276 4,143,750 6.21%

Chi ldren & Young People 3,474,043 72,431 2.0% 10,870 0.3% 33,378 0.9% 116,680 3,590,723 3.25%

Support Services 2,544,615 54,584 2.1% -10,620 -0.4% -15,600 -0.6% 28,363 2,572,979 1.10%


Trust 19,618,357 1,267,164 5.9% 337,857 1.6% 349,317 1.6% 1,954,338 21,572,694 9.06%

Mental Health 8,837,069 1,066,584 10.2% 229,714 2.2% 282,382 2.7% 1,578,679 10,415,748 15.16%


Chi ldren & Young People 3,461,216 66,440 1.9% 15,250 0.4% 41,633 1.2% 123,322 3,584,539 3.44%

Support Services 2,751,739 28,323 1.0% -24,844 -0.9% -22,242 -0.8% -18,763 2,732,976 -0.69%

Total

Peripheral

Workforce

Spend £

Total

Peripheral

Workforce

Spend £

2017 04

2017 05

Agency Medical AgencyBusiness Area

Total Core

Workforce

Spend £

Bank

Business Area

Total Core

Workforce

Spend £

Bank Agency Medical Agency

Flexible

Labour

Reliance %Total Spend

£

Flexible

Labour


£

184 of 215

Page 14

AGENCY & BANK SPEND

Bank & Agency Pay Spend by Business Area Source Data: Finance, Healthroster & ESR

Agency & Bank spend is calculated as a percentage of the total salary spend. Usually, a link can be seen between the level of expenditure on peripheral workforce (Bank, Agency and Locum), the Vacancy Rate, Sickness Absence and Operational Gap.

Mental Health Network: Reliance on peripheral workers has continued to increase through the Q1 period. This increase is attributable to the inclusion of Secure Services in the Mental Health Network and the Network focus on ensuring that the minimum qualified staffing levels are achieved. The Network report acuity of Service Users and sickness absence as key contributors to the level of spend on Bank and Agency. Board Assurance: Secure Services and the Harbour are holding weekly Bank and Agency

meetings to establish the reasons for high usage and agree how this can be mitigated. The content of this meeting updates the monthly Network Bank and Agency usage meeting.

Regular reviews are being conducted by the Care Teams to appraise the level of service user acuity and staffing levels. Their focus is to ensure an appropriate level of staffing is in place to provide safe and effective care.


Trust 19,295,502 1,621,440 7.5% 394,814 1.8% 312,756 1.4% 2,329,010 21,624,513 10.77%

Mental Health 8,729,368 1,332,566 12.6% 281,785 2.7% 257,493 2.4% 1,871,844 10,601,212 17.66%


Chi ldren & Young People 3,403,182 65,338 1.9% -6,228 -0.2% 28,070 0.8% 87,179 3,490,361 2.50%

Support Services 2,661,689 48,877 1.8% -8,770 -0.3% -40,620 -1.5% -512 2,661,177 -0.02%

Total

Peripheral

Workforce

Spend £

2017 06

Agency Medical AgencyBusiness Area

Total Core

Workforce

Spend £

Bank

Flexible

Labour


£

Community & Wellbeing Network: Q1 has seen an increase in the use of and spend on peripheral workforce against Q4 performance and reports a final position of 7.61%. The inclusion of Southport & Formby Community Services in May 2017 has contributed to the increase in spend on Agency workers as they operate with a high use of agency workers. The Network continue to report vacancies and sickness absence as contributors to the current level of spend on additional workforce.

Board Assurance: The consultation for the Dental Services redesign concluded in the last month

of Q1. Delivery of the planned workforce changes will address the use of and reliance on Bank Workers at the Dental Nurse and Dentist level and the network are expecting to see spend improvements through Q2.

Services continue to review their need for the use of Bank and Agency and usage escalation processes in place at Longridge have been extended to Southport & Formby.

50 Applications are currently being processed to convert regular Agency Workers in use in Southport & Formby to LCFT Bank Workers.

185 of 215

Page 15

TURNOVER

The Turnover Rate is one of the indicators used to assess employee satisfaction with the Trust. It is presented as a rolling 12 month figure, calculated at the end of each reporting period and is calculated as follows:

Total number of leavers ÷ total number of contracted employees.

To provide the Board with a true picture of turnover activity in the Organisation, three measures of turnover are reported: Overall Trust Turnover, BAU Turnover and TUPE Transfer Turnover.

Turnover Rate – 12 Month Trend Analysis Source Data: ESR

Leaving Reasons for Quarter Turnover by Business Area

Reporting Enhancement: The Quarter 2 2017/18 Workforce Board Report will include an overview of Redeployment Activity and a Financial Impact Trajectory for redundancy should those ‘at risk’ not secure suitable alternative employment. This was planned for Q1 and has had to be rescheduled

0.00%

2.00%

4.00%

6.00%

8.00%

10.00%

12.00%

14.00%

2016 07 2016 08 2016 09 2016 10 2016 11 2016 12 2017 01 2017 02 2017 03 2017 04 2017 05 2017 06

BAU Turnover TUPE Turnover All Turnover

Business AreaHeadcount

2017 062017 04 2017 05 2017 06

Trust 5,925 13.96% 12.35% 12.49%

Mental Health 2,620 6.00% 5.91% 5.94%

Community & Wel lbeing 1,507 12.44% 8.54% 9.06%

Chi ldren & Young People 1,040 11.20% 11.10% 11.01%

Support Services 757 13.47% 11.68% 11.78%

Resignation 64.1%

Retirement 19.2%

Redundancy 6.0%

Dismissal 4.8%

End of FTC 4.8%

TUPE 0.6% Ill Health

Retirement 0.6%

186 of 215

Page 16

APPRAISAL RATE

Appraisal Rate – Quarter 1 Performance Source Data: Learning & Development

The Appraisal data presented has been designed to highlight the % initiation of Annual Performance Objectives (Appraisal) for the relevant Performance Review Year and demonstrate the PDR process is ‘live’ through the measurement of periodic PDR review and performance year end PDR closure.

28.76%

71.24%

Overall Appraisal Compliance

% Compliant % Non Compliant

Active

HeadcountCompliant

%

Compliant

% Non

Compliant

Trust 6197 1782 28.76% 71.24%

Mental Health 2736 546 19.96% 80.04%

Community & Wellbeing 1525 549 36.00% 64.00%

Children & Young People 1149 419 36.47% 63.53%

Support Services 787 268 34.05% 65.95%

0

1000

2000

3000

4000

5000

6000

7000

Trust Mental Health Community &Wellbeing

Children &Young People

SupportServices

Act

ive

He

adco

un

t

AfC Appraisals

With Objectives & Review Taken Place With Objectives

New Starters Registered on PDR Not Compliant With PDR Process

New Starters Not Registered on PDR

0

20

40

60

80

100

120

Trust Mental Health Community &Wellbeing

Children &Young People

SupportServices

Act

ive

He

adco

un

t

Doctors Apprasials

Completed Medical Appraisal Process Exempt

187 of 215

Page 17

APPRAISAL RATE

Appraisal Rate – Quarter 1 Performance Source Data: Learning & Development

The Appraisal data presented has been designed to highlight the % initiation of Annual Performance Objectives (Appraisal) for the relevant Performance Review Year and demonstrate the PDR process is ‘live’ through the measurement of periodic PDR review and performance year end PDR closure.

Hot Spot Analysis: Mental Health Network: The Network continue to track PDR compliance on a monthly basis at the Locality level. PDR Q1, cycle 1, compliance is low. Board Assurance: PDR compliance is monitored on a monthly basis at the Network People

Group Meeting and uses the Tier 2 monthly Network People Performance Report.

The new network structure has enhanced accountability and responsibility lines for ensuring that there is a quality PDR process in place across the Network.

Children & Young Persons Wellbeing Network: The Network track PDR compliance on a monthly basis through the Network Business Development Group meetings using the T2 Monthly Network Report. PDR Q1, cycle 1, compliance is low. Board Assurance: The new network structure has enhanced accountability and responsibility

lines for ensuring that there is a quality PDR process in place across the Network.

Community and Wellbeing Network: The Network continue to track PDR compliance on a monthly basis. PDR Q1, cycle 1, compliance is low. Board Assurance: PDR compliance has been monitored on a monthly basis at the Network

SMT and People Group Meeting and uses the Tier 2 monthly Network People Performance Report.

The new network structure is expected to enhance accountability and reasonability lines for ensuring that Quality PDR process take place and that compliance across the Network is improved and bi-weekly tracking will recommence post reset for Q2.

Refinement of reporting lines post reset continues to take place and systems updated to ensure alignment of staff to mangers to allow PDR completion.

188 of 215

Page 18

TRAINING & INDUCTION

The Induction rate calculation is as follows: Total Number of New Starters requiring Corporate Induction that have attended within 28 dayS of starting in their new role.

Induction Completion Rate – Quarter 1 Performance Source Data: ESR and Quality Academy

The following New Starters are defined by Quality Academy as not requiring Corporate Induction: PIP Clinical Assessors (Employment is confirmed on successful completion

of PIP Training) Retiree’s returning to work within 6 months of leaving Individuals engaged to work on a short-term Fixed Term Contract (3

months or less)

New

Starters

New

Starters

requiring

Induction

Completed

induction

within 4

weeks

Not

CompletedIC Rate

New

Starters

New

Starters

requiring

Induction

Completed

induction

within 4

weeks

Not

CompletedIC Rate

New

Starters

New

Starters

requiring

Induction

Completed

induction

within 4

weeks

Not

CompletedIC Rate

Trust 40 36 34 2 94.44% 48 33 32 1 96.97% 306 32 30 2 93.75%

Mental Health 26 22 22 0 100.00% 31 23 22 1 95.65% 16 12 12 0 100.00%

Community & Wellbeing 10 10 8 2 80.00% 11 6 6 0 100.00% 276 5 5 0 100.00%

Children & Young People 2 2 2 0 100.00% 3 2 2 0 100.00% 6 5 5 0 100.00%

Support Services 2 2 2 0 100.00% 3 2 2 0 100.00% 8 10 8 2 80.00%

2017 03 2017 04 2017 05

0

5

10

15

20

25

30

35

40

2017 03 2017 04 2017 05

Not Completed

<28 Days

189 of 215

Page 19


Mandatory Training covers 10 core skills courses.

Source Data: Learning & Development

Mandatory & Statutory Training Compliance by Business Area – Position as at 30th June 2017

Co

nfl

ict

Res

olu

tio

n

3yr

E&D

3yr

Fire

Saf

ety

1yr

Hea

lth

& S

afet

y 3

yr

Infe

ctio

n C

on

tro

l

Ad

min

2yr

Infe

ctio

n C

on

tro

l

Clin

ical

1yr

Man

ual

Han

dlin

g 1

3yr

Men

tal C

apac

ity

Act

(Ad

min

) O

ne

Tim

e

Co

mp

leti

on

Men

tal C

apac

ity

Act

(Clin

ical

) 3

yr

Res

usc

itat

ion

1yr

Safe

guar

din

g

Ch

ildre

n 1

3yr

Safe

guar

din

g A

du

lts

1 3

yr

Co

re T

ota

l

ILS

1yr

Man

ual

Han

dlin

g 2

3yr

Man

ual

Han

dlin

g 3

2yr

Safe

guar

din

g

Ch

ildre

n 2

3yr

Safe

guar

din

g

Ch

ildre

n 3

3yr

Info

rmat

ion

Go

vern

ance

Loca

l To

tal

Co

re &

Lo

cal T

ota

l

Mental Health 86% 99% 90% 99% 97% 90% 96% 91% 87% 83% 98% 96% 93% 82% 75% 69% 93% 76% 94% 82% 89%

Community &

Wellbeing87% 97% 88% 93% 96% 87% 94% 76% 83% 82% 93% 97% 89% 94% 91% 83% 92% 79% 89% 88% 89%

Children & Young

People90% 97% 85% 95% 97% 83% 94% 90% 85% 84% 97% 94% 91% 83% 89% 83% x 93% 93% 88% 90%

Support Services 68% 96% 90% 97% 95% 91% 97% 71% 79% 89% 92% 93% 88% 100% 74% x 96% 100% 93% 93% 90%

Trust 87% 98% 89% 96% 96% 88% 96% 80% 85% 83% 95% 96% 91% 83% 83% 78% 93% 84% 92% 85% 89%

Core Mandatory & Statutory Training Local Mandatory & Statutory Training

190 of 215

Page 20


Mandatory Training covers 10 core skills courses.

Source Data: Learning & Development

Hot Spot Analysis:

Mental Health Network: Overall, the Network are achieving the Trust Target of 85% and report an overall compliance rate for the close of Q1 of 89%. The Network continue to work closely with the Quality Academy to develop and implement their Network compliance improvement plans for the training areas that are, individually, below the compliance target . Board Assurance: MHN continue to explore and deliver new initiatives to increase the

accessibility of training and training resources for all staff to support the achievement of compliance rate improvement.

Mandatory & Statutory Training Compliance Hot Spot Analysis

Community & Wellbeing Network: Network continue to work closely with Quality Academy to improve compliance and enhance data quality. Board Assurance: Monthly reporting through the Tier 2 Network Report and facilitates the

tracking and monitoring of compliance and data quality. Quality Academy provide weekly reports, now including Southport &

Formby Community Services. Action plans continue to be progressed for hot spot areas in each locality.

191 of 215

Page 21

SAFER EMPLOYMENT

Core Workforce Quarter 1 Compliance

Safer Recruitment

Bank Workers Quarter 1 Compliance

Safer Recruitment

Safer Employment reports against the Trusts compliance with its legal obligations as an employer, in recruiting and providing a Safe Workforce.

The KPI’s presented measure the Trusts compliance against the Safe Recruitment Standards and Safer Staffing Frameworks in place within the NHS.

Safer Employment Safer Engagement

Business Area % Compliant % Compliant

Right to Work 92%

DBS Cleared pre 1st shift 89%

Visas & Work Permits 100%

Overall Compliance 94%


DBS Renewals 79%

Professional Membership

Registration Renewals80%

Visas & Work Permit Renewals 100%



Right to Work 99%

DBS Cleared pre start date 98%

Visas & Work Permits 100%



DBS Renewals 98%

Professional Membership Registration

Renewals99%




DBS Renewals 79%

Professional Membership

Registration Renewals80%


Overall Compliance 86%192 of 215

Page 22

SAFER EMPLOYMENT Core Workforce

Source Data: ESR & Recruitment Team



Safe Recruitment Standards Compliance, by Business Area – Quarter 1 Performance Right to Work, DBS, Visa / Work Permit Checks and Professional Registration Validation

Business Area

Total

New

Starters

Total Right

to Work

Entries

% Compliant

Total New

Starters

Requiring

DBS

Total No DBS

Entries% Compliant

Total No.

New Starters

requiring Visa

/ Work permit

Total No.

Work Permit

/ Visa

Entries on

ESR

%

Compliant

Trust 369 365 99% 353 345 98% 4 4 100%

Mental Health 47 47 100% 46 46 100% 1 1 100%

Community & Wel lbeing 18 18 100% 18 18 100% 0 0 100%

Chi ldren & Young People 11 11 100% 11 11 100% 0 0 100%

Support Services 17 17 100% 7 7 100% 0 0 100%

TUPE 276 272 99% 271 263 97% 3 3 100%

Hot Spot Analysis: DBS Checks: 8 of the 271 DBS checks undertaken for TUPE Transferees into the Trust are outstanding. The TUPE took place on 1st May 2017 and the Trust is now outside of the 60 day TUPE Transfer grace period. Board Assurance: 7 individual's outstanding DBS checks - Recruitment is working closely with

the HRBP to resolve. Links to the DBS Application have been issued. 1 Individual is on Maternity Leave.

Right to Work Entries: 4 of the 271 DBS checks undertaken for TUPE Transferees into the Trust remain outstanding. The TUPE took place on 1st May 2017 and the Trust is now outside of the 60 day TUPE Transfer grace period. Board Assurance: All individual's have been contacted and Recruitment have escalated this to

the HRBP for resolution.

193 of 215

Page 23

Source Data: ESR, Recruitment Team, Medical & Dental Team, Employee Relations Team

SAFER EMPLOYMENT Core Workforce



Safer Employment Compliance, by Business Area – Quarter 1 Performance DBS Renewals, Professional Membership Registration Revalidation and Visa and Work Permit Renewals

Hot Spot Analysis:

DBS Renewals: 4 individuals have not completed their DBS renewal this Quarter.

Board Assurance: 4 are non compliant - All have been escalated to the Network Manager

and HR Business Partner for investigation (C&YPN)

Business Area

Total DBS

Renewals

Required

Total Number

of Expired

Entries

%

Compliant

Total

Professional

Membership

Renewals

Required

Total Number

of Expired

Entries on ESR

%

Compliant

Total No of

Work Permit &

Visa Renewals

Required

Total

Number of

Expired

Entries on

ESR

%

Compliant

Trust 211 4 98% 206 2 99% 0 0 100%

Mental Health 6 0 100% 92 2 98% 0 0 100%

Community & Wel lbeing 0 0 100% 35 0 100% 0 0 100%

Chi ldren & Young People 205 4 98% 57 0 100% 0 0 100%

Support Services 0 0 100% 22 0 100% 0 0 100%

Professional Membership Renewals: 2 NMC Professional Memberships have expired this Quarter. Board Assurance: 1 is no longer practising. 1 expiry was linked to Nurse Revalidation and an extension had been granted.

NMC Registration has now been updated.

194 of 215

Page 24

SAFER EMPLOYMENT Bank Workers



Safe Recruitment Standards Compliance, by Business Area – Quarter 1 Performance (Bank Only Post holders) Right to Work, DBS, Visa / Work Permit Checks and Professional Registration Validation

Source Data: ESR & Temporary Staffing Team

Business Area

Total No.

New Bank

Workers

Total Right to

Work Entries

%

Compliant

Total No.

New Bank

Workers

Requiring DBS

Total No.

New Bank

Workers

Requiring DBS

Released to

Work

Total No

Blank

Entries

%

Compliant

Total No. New

Bank Workers

requiring Visa /

Work permit

Total No.

Work Permit

/ Visa

Entries on

ESR

%

Compliant

Total Bank 88 81 92% 80 72 8 89% 3 3 100%

Clinical 70 63 90% 70 62 8 87% 2 2 100%

Non-clinical 18 18 100% 10 10 0 100% 1 1 100%

Hot Spot Analysis:

Right to Work Entries: 7 Clinical Staff are not compliant with the safe engagement for bank workers.

Board Assurance: 6 Prison Clinical Staff retained on the LCFT Work Bank following the TUPE

transfer of their substantive LCFT Post. Bank assignments are marked inactive in ESR and the Bank member will not be released for work until fully compliant.

1 retained on the LCFT Work Bank after leaving their substantive LCFT post. Bank Assignment marked inactive in ESR and the Bank member will not be released for work until fully compliant.

DBS Checks: 7 Clinical Staff and 1 Medic are not compliant with the DBS re requirements of their Bank Assignment.

Board Assurance: 6 are Prison Staff, retained on the LCFT Work Bank following the TUPE

transfer of their substantive LCFT Post. Bank assignments are marked inactive in ESR and the Bank member will not be released for work until fully compliant

1 retained on the LCFT Work Bank after leaving their substantive LCFT post. Bank Assignment marked inactive in ESR and the Bank member will not be released for work until fully compliant.

1 new member of the LCFT Medic Work Bank. Bank Assignment marked inactive in ESR and the Bank member will not be released for work until fully compliant. 195 of 215

Page 25

Source Data: ESR & Temporary Staffing Team

The expired DBS entries for Non-clinical Admin are where bank workers have decided not to renew their DBS. These bank workers are consequently restricted from positions requiring a DBS and position moves on ESR will be actioned.

SAFER EMPLOYMENT Bank Workers



Safer Engagement Compliance, by Bank Worker type – Quarter 1 Performance DBS Renewals, Professional Membership Registration & Revalidation, Visa and Work Permit Renewals

Business Area

Total DBS

Renewals

Required

Total No.

Expired

Entries

%

Compliant

Total

Professional

Membership

Renewals

Total No.

Expired

Entries on ESR

% Compliant

Total No.

Work

Permit &

Visa

Renewals

Required

Total No.

Expired Entries

on ESR

% Compliant

Total Bank 163 34 79% 15 3 80% 0 0 100%

Clinical 146 24 84% 15 3 80% 0 0 100%

Non-clinical 17 10 41% 0 0 100% 0 0 100%

Hot Spot Analysis:

DBS Renewals: 22 Clinical Staff and 1 Medic are non-compliant with the DBS renewal requirements of their Bank Assignment this quarter. Board Assurance: 22 Clinical Staff retained on the LCFT Work Bank on leaving a substantive

LCFT Position. Bank assignments are marked inactive in ESR and the Bank member will not be released for work until DBS clearance has been received.

1 Medical Bank Worker has not renewed their DBS Clearance. Bank Registration to be removed.

10 Clerical Bank Worker DBS Checks have expired. Restrictions placed on the assignments they can fulfill. Being moved into a Bank Worker role that does not require DBS clearance.

Professional Membership Registrations: 2 Clinical Staff and 1 Medic have had their Professional Membership lapse in the quarter. Board Assurance: 2 Clinical Staff have been written to and their Bank Assignments marked

inactive in ESR. The Bank member will not be released for work until their Professional Membership has been renewed.

1 Medical Bank Worker has not renewed their Professional Membership. The Bank Registration is to be removed.

196 of 215

Board of Directors


Report Title Annual Caldicott Guardian Report 2016/17

FOIA Exemption No Exemption Not Applicable

Prepared by Dr Chris Linton, Acting Deputy Medical Director / Chief Clinical Information Officer

Presented by Prof Max Marshall, Medical Director


Supporting Executive Director Medical Director

PURPOSE OF THE REPORT:

Report purpose To update the Board on the role and work of the Caldicott Guardian function over the last year, to highlight current issues, and where necessary to advise the Board of any issues relating to confidentiality and data protection assurance.



Board Assurance Framework risk

1.1 If we do not meet regulatory standards for quality and safety we will not be fit for purpose as a care provider

CQC domain Safe

197 of 215

SUMMARY

The report covers the period 01/04/16 – 31/03/17. The purpose of this report is to update the Board on the role and work of the Caldicott Guardian (CG) function over the last year, to highlight current issues, and where necessary to advise the Board of any issues relating to confidentiality and data protection assurance. 1 BOARD ACTION

The Board is asked to note the report.

2 INTRODUCTION

The 1997 report ‘Review of Patient-Identifiable Information’, chaired by Dame Fiona Caldicott, made a number of recommendations for regulating the use and transfer of person identifiable information (PII) within the NHS and between the NHS and other bodies. These recommendations included the appointment in each NHS organisation of a ‘guardian’ to oversee the arrangements for the use, access and sharing of personal clinical information. A number of subsequent developments have added further dimensions to the Caldicott Guardian role - especially the Data Protection Act, 1998, the Human Rights Act, 1998, the Freedom of Information Act, 2000, the NHS Code of Practice on Confidentiality (2003), and the mandating of the Senior Information Risk Owner role (2008). The Guardian should have a close relationship with senior health professionals responsible for promoting clinical governance, must work closely with the SIRO, and needs to have seniority and clear authority from the Board to influence policy development and planning. The key Guardian responsibilities can be divided into three areas: (a) strategic: representing governance, especially Information Governance,

requirements at senior management level; (b) operational: supporting and advising on information processing and sharing

arrangements; and, (c) advisory: confidentiality and Data Protection expertise. Staff should be advised, and

able, to seek assistance from the Guardian where necessary. 3 LCFT ARRANGEMENTS

Since March 2010, the CG role has been undertaken by the Medical Director, with the Deputy Medical Director deputising where appropriate. This allows the Guardian to be in a position to actively promote and consider information governance issues at an appropriately senior level within the Trust.

In October 2016 Dr Chris Linton, Acting Deputy Medical Director and Chief Clinical

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Information Officer, stepped in to the role of Deputy Caldicott Guardian following the tragic death of Dr Gurpal Gosall. He completed external training in “An Introduction to Caldicott Guardian Training.”

The Caldicott Guardian function is firmly embedded within LCFT:

4 ADVISORY ROLE

The Guardian and Deputy receive a significant number of direct requests from a variety of LCFT staff seeking guidance on professional duties and interpretation of legal and Caldicott principles, especially around disclosure of confidential information without consent. All such inquiries are logged on the CG Log, together with the actions or any further follow-up required (see below).

5 NEAR MISSES AND SERIOUS INCIDENTS

Information confidentiality breaches and related incidents are also recorded in the CG log. A process has also been established for the CG / Deputy CG to sign off serious incidents to be logged on the IGT SIRI and formal ICO responses to patient related incidents.

6 INFORMATION GOVERNANCE AND CALDICOTT GUARDIAN MEETING Monthly meetings between the Deputy CG and the Information Governance (IG) and Health Records leads within the Health Informatics department have continued. There is a well-established working relationship between the Caldicott function and IG. Open entries on the Caldicott log are reviewed and discussed, helping to keep progress notes up-to-date and close incidents in a timely manner. An action tracker is maintained for discussions and actions. The meeting also discusses improvement ideas and scans the horizon for looming issues.

Completed actions resulting from these monthly meetings have included:

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Introduction a new SoP with checklist for the disclosure of patient information outside of the EEA – particularly relevant to a new requirement of GDPR

Approval of a new SAR process for overseas transfer Approval of a new updated Health Records Track and Trace Procedure

7 CLINICAL RECORDS AND INFORMATION GOVERNANCE MANAGEMENT GROUP

The Clinical Records & Information Governance (CRIG) Management Group is attended by the Deputy CG, Deputy Senior Information Risk Owner (SIRO) and the Information Governance and Health Records Leads alongside representation from the clinical networks by Information Asset Owners. This is a bimonthly meeting, chaired by the Deputy CG, and reports to the SIRO/CG meeting. The functions of the meeting are to:

– Review implementation of IAO & IAA structure – this has required revision of the ToR for the CRIG to ensure correct membership following the Organisation Reset.

– Planning, preparation and review of submission of IG Toolkit – Review Serious Incidents and Risk Assurance framework – Review network IG audits – eg record keeping – Networks to raise their IG risks and issues

8 CALDICOTT ISSUES LOG

The CG log records issues raised with the Guardian, or incidents, and details who is taking the required actions, the outcome or resolution, and the dates of ‘opening’ and ‘closure’ of the item. Over the last year, 21 requests were made for CG advice. All requests are closed with no outstanding requests.

Themes on CG Log

Recurring themes have been: (4) - Approval to disclose deceased patient information (211, 217, 220, 226) (3) - Request for removal, deletion or redaction of patient record information

(221, 225, 232) (2) - Unlawful access to patient information (214, 230) (2) - Subject Access Request (SAR) disclosure queries (219, 222) (2) - S29 disclosure requests from the Police

Other Advice includes the following: Handling lost patient records sent to Trust HQ (212) Resolving differing medical opinion about the same patient (215) Approval of data to be shared with Blackpool Council Public Health for a drugs

related audit (216) Clinical Record keeping guidance in case of court disclosure (223) Approval of SAR disclosure outside of the EEA (224) Confirmation that doctors GMC numbers can be provided to a prisoner (229) Appropriate electronic storage of research documentation (231)

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Consideration of reporting a potential serious incident to the ICO (213)

9 CURRENT ISSUES

Subject Access Requests:

A particular concern relates to the issue of SAR’s. This has been raised in the previous two Annual CG Reports. These have focused on issues with the timeliness and completeness of responding to DPA SAR’s due to the requirement for clinical review of the records and redaction of information which “may cause harm” and which relates to/is received from “third parties”. A recent audit of this topic identified that during the period April 2016 to December 2016 a total of 27 breaches have been reported trust wide on the Datix system. Any further breaches could result in a fine from the Information Commissioners Office (ICO) which currently could be up to a maximum of £500,000 (see below for changes in GDPR).

The main recommendation of the audit is on forming a centralised team for managing all SAR’s. Among the 30 recommendations are for a much stronger role in the management process for Network IAO’s and the exploration of SAR/third party functionality within the new EPR.

A very recent serious IG breach, which lies in the 2017/18 year, clearly identifies deficiencies in the process of responding to SAR’s, with third party information disclosed to the data subject. Immediate agreement has been reached on keeping copies of all information which is disclosed to service users through the SAR process.

10 HORIZON SCANNING

The General Data Protection Regulation (GDPR) will apply in the UK from May 2018 and replaces the Data Protection Act 1998 (DPA).

GDPR will increase the need for support from the CG function, particularly:

Serious IG incidents must be reported to the Information Commissioners Office (ICO) within 72 hours of notification – currently there is no time limit. This will require Datix incidents to have more complete details, SIRI assessments to be written up sooner and either the Caldicott Guardian, SIRO or their deputies to be available to review and approve prior to logging the incident to the ICO

o A large increase in fines; o Failing to notify a breach when required could result in a fine of up to 10

million Euros or 2% of global turnover (whichever is higher) o Failing to respond in the required timescale could result in a fine of up to

20 million Euros or 4% of global turnover (whichever is higher) Requests for rectification, erasure/deletion in a patient record is likely to increase

due the significantly enhanced rights for the data subject within GDPR. It will no longer be the case of receiving direction from the Court to do this

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Data Portability is being introduced as part of GDPR. There is likely to be requests by data subjects for copies of their information to be stored by a third party of their choice. This will mean providing a copy of the record as specified by the data subject i.e. it could be all or parts of a record. Changes to that record will have to be advised to the third party

Subject Access Requests – GDPR will remove the fee which data subjects currently have to pay under DPA to access their own data. The expectation is that this will increase the number of requests. There is also a reduced timeframe to comply with requests, reducing from 40 working days to 30 calendar days.

GDPR will have a significant impact on our consent processes:

We will be required to have clear and more granular opt-in methods, good records of consent, and simple easy-to-access ways for people to withdraw consent. The changes reflect a more dynamic idea of consent: consent as an organic, ongoing and actively managed choice, and not simply a one-off compliance box to tick and file away. (Information Commissioner’s Office: Consultation: GDPR Consent Guidance, March 2017)

Work has commenced to gain a better understanding of consent models in the local health and social care economy. An early focus of the EPR Core Clinical Forum will be to develop and agree a standardised consent processes around both information governance and clinical care. This can be applied to all services ahead of their go-live with the new EPR.

11 RECOMMENDATION

The Board is asked to note the report.

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Board of Directors


Report Title Board Assurance Framework (BAF) Q1 Review

FOIA Exemption Part Exemption Appendix 1 – BAF Risks

Prepared by Andrew Mawdsley, Risk and Assurance Business Partner

Presented by Julie-Ann Bowden, Associate Director of Risk and Assurance

Action required Discussion


Report purpose To provide assurance in relation to the Q1 review of the BAF risks.

Strategic Priority this work supports


Board Assurance Framework risk This report contains an update relating to all 2017/18 BAF risks

CQC domain Well-led PAPER DEVELOPMENT PROCESS:

Meeting Presented Action Date

All sub-committees and committees within the governance framework over the course of Q1 have reviewed relevant BAF risks and 15 and above risks

NA NA NA

Senior Leadership Team Andrew Mawdsley Discussion 18.07.17 1.0 INTRODUCTION 1.1 The Board of Directors has overall responsibility for ensuring that systems and controls are in

place that are adequate to mitigate any significant strategic risks which threaten the achievement of the strategic objectives.

1.2 The strengthened management processes around the analysis and evaluation of risk and

assurance supported by the governance arrangements, continues to promote detailed analysis. This has provided Senior Leadership Team with an opportunity to look at the aggregation of risk from a management perspective and examine the impact on the strategic priorities of the organisation.

1.3 As part of the end of Q1 process the Board Assurance Framework (BAF) has been reviewed in

detail with each risk owner. The review has considered:

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The need to consider the re-scoring of the BAF risks taking account of an assessment of the assurances and controls and any gaps identified during Q1. This takes particular account of assurances delivered through the governance meetings and information in the Chairs’ Reports.

Work to strengthen the analysis of mitigating actions required to close the gap between the current risk score and the target risk score.

Ensuring that systems and controls are in place that are adequate to mitigate any significant strategic risks which threaten the achievement of the strategic objectives.

1.4 The report provides an opportunity for the Board to review the Q1 BAF risk position along with the

operational plan objectives aligned with the BAF. In addition, themes and gaps that the Risk and Assurance team have identified as part of the risk profiling and assurance mapping are included which has also been informed through discussions with Executive Directors and reporting through to the corporate governance meetings.

2.0 RISK MANAGEMENT

2.1 Effective review of the Board Assurance Framework (BAF) is carried out at each committee and sub-committee for the BAF risks. This provides an opportunity to review the information relating to the BAF risks, commission additional assurances and escalate any associated risks that need reporting. For 2017/18 all operational objectives are now mapped to the BAF risks and included within the BAF risk reports. This facilitates the management of the risks and provides a further opportunity to identify controls and assurances through the delivery of the objectives.

2.2 The 15 and above risks are scored using the Trust’s standard risk scoring matrix and are aligned against the relevant BAF risk so that Executive Directors have the opportunity to review significant operational risks as reported on Datix. These risks may also collectively impact on the strategic risks contained within the BAF. The review of 15 and above risks takes place in management meetings across the organisation as well as at sub-committee level in the organisation.

2.3 To support the Q1 review of the BAF risks the Risk and Assurance team has undertaking assurance mapping throughout the quarter. The information has mainly been identified through attendance at committees and sub-committee meetings and review of chairs reports from all sub-committees.

3.0 REVIEW OF THE BAF STRATEGIC RISK REGISTER Q1

3.1 The quarterly review process provides an opportunity for Executive Director leads to meet with the Associate Director of Risk and Assurance to discuss the update of their relevant risks. All these meetings have taken place and adjustment to the BAF risks has subsequently been undertaken prior to review by Senior Leadership Team on 17.07.17. The proposed end of Q1 position for the BAF risks with associated operational plan objectives can be viewed in Appendix

1.

3.2 Following the review of the BAF process at the end of 2016/17, 15 and above risks are summarised on the BAF with a full review taking place at sub-committee level and in SLT. For the purposes of the Q1 process, the 15 and above risks can be accessed via this link.

3.3 The Heat Maps for the year can be reviewed in Appendix 2. There has been a positive improvement in the scoring of risk during Q1 as follows:-

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https://www.lancashirecare.nhs.uk/media/Trust%20Board/Trust%20Board%20Documents/August%202017/15%20and%20above%20Risk%20Register.pdf

BAF risk 6.1 - If we do not maintain and develop appropriate infrastructure, we will not be able to deliver safe, responsive and efficient care.

The risk rating has been reduced in Q1 as a result of material tests on Estates and IT controls which have demonstrated robust infrastructure is in place. The impact of the world-wide cyber-attack in May 2017 was significantly reduced due to security measures previously developed and deployed by Health Informatics and in respect of fire safety Property Services provided assurance that the Trust is 100% compliant with Fire Risk Assessments and 95% of staff were compliant with mandatory fire safety awareness.

The Fire Safety report provided to the Board of Directors on 6 July highlighted that the Trust are still awaiting information from NHS Property Services in relation to buildings with cladding. However, with the latest Cabinet Office data return the need for the information is now less of a risk as none of the buildings fall into the latest criteria (Aluminium cladding on buildings over 18 meters high). The Trust is well placed to provide the Cabinet Office information.

3.4 There has been an increase in the scoring of risks during Q1 as follows:-

BAF risk 5.1 - If we do not meet financial objectives we will not be able to provide sustainable services

This risk has increased in score during Q1 due to the financial pressures identified for 2017/18. The score for this risk was reduced in Q4 2016/17 due to the achievement of the control total, however at month 2 there is a forecasted deficit position of £5m and CIP plans haven’t made as much traction as planned, therefore the risk scored has been increased from 15 to 20.

4.0 REVIEW AND THEMING OF RISKS

4.1 Following the end of the year review process the risk themes for 2017/18 that will be reported to Board have been updated to align with the refreshed strategy and reflect the key challenges facing the Trust. The relevant wording for each theme is provided below:

4.1.1 Financial Pressures The Trust achieved its control total for 2016/17, resulting in NHSI re-categorising the Trust to segment 1 under the Single Oversight Framework. However the financial objectives for 2017/18 remain a challenge and at month 2 there is forecasted deficit position of £5m. In addition, some CIP programmes have not gained as much traction as hoped. Management are in the process of developing a financial recovery plan with will be monitored by the Financial Recovery Group. . 4.1.2 Workforce The Trust continues to have an ongoing significant workforce risk on the basis that recruitment remains a significant challenge for clinical staff. Sickness rates continue to be above the 4.5% target however the rate for April and May 2017 (5.74% & 5.88%) is the lowest rate since July 2016. The Education and Learning elements of the Quality Academy had their ownership

Original Score 01.04.17

Score at Q1

2017/18 Risk Target

Final Risk Target

16 12 8 4

4x4 3x4 2x4 1x4

Original Score 01.04.17

Score at Q1

2017/18 Risk Target

Final Risk Target

15 20 10 10

3x5 4x5 2x5 2x5

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transferred to the Human Resources Directorate from 03 July 2017. Whilst Core Skills has achieved the overall Trust compliance target in May 2017 there is poor performance across specific subjects including Mental Capacity Act and Resuscitation. 4.1.3 Quality The strong operational risk profile across a number of BAF risks highlights the significant challenge in providing quality services. Risks that support this theme relate to a cross section of types of risk including risks to patient safety, compliance with regulatory requirements and services provided and staffing at HMP Liverpool. The delivery of the Quality Led Strategy supports the mitigation of these risks and controls have been increased to support the culture of continuous learning and improvement. However, cultural change is a gradual process and there are some parts of the organisation where challenges exist to learning and improvement. A review of the associated operational risks at HMP Liverpool is being undertaken by the Mental Health network and a new objective to implement and review e-resorting at the prison is in the process being commissioned. This will ensure that closer scrutiny of performance takes place during Q2. The Mental Health risk health check will also support the approach towards risk in the network. 4.1.4 Collaboration and Partnerships The Trust is engaged in work streams with partners across the local health economy with the aim of supporting the transforming services and delivering of system-wide efficiencies. This collaboration will play a key part in the delivery of new models or care and impacts the reputation of the Trust. There have been a number of new models of care secured during quarter 1, however there is a risk around having the capability and capacity to manage collaborations and deliver new models of care. Also, it is acknowledged that further clarity is needed regarding details of the STP process and its component parts, and Board is to have dedicated time to consider this area further.

5.0 ASSURANCE FRAMEWORK BENCHMARKING

5.1 MIAA have issued an Assurance Framework Benchmarking paper which summarises the results from their review of the Assurance Frameworks across the 31 trusts (acute, foundation, mental health and ambulance). The review assesses the 3 areas which are used to inform the Trust annual Director of internal audit opinion which is provided below. The full report can be found at Appendix 3: The structure of the Assurance Framework; Board engagement in the review and use of the Assurance Framework; The quality of the content of the Assurance Framework and whether it demonstrates clear

connectivity with the Board agenda and external environment.

5.2 There are a total of seven testing criteria which inform the results for the three areas listed above. The testing criteria are RAG rated and Lancashire Care received a rating of green for all seven areas indicating that our BAF fully meets the requirements for each test. This demonstrates that the Trust’s BAF compares favourably to other Trusts. The report also provides 9 examples of best practice identified by MIAA from their review of Assurance Frameworks. There are two examples which are not fully embedded into the BAF process:

A distinction is made between internal and external sources of assurance; Positive assurances are signposted back to the report that provided the assurance and the date

when it was reviewed by a committee of the board.

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5.3 Consideration has been given to how the BAF process can be

enhanced to incorporate these examples of best practice. It is proposed that making the distinction between internal and external sources of assurance is put in place for Q2 review. In regards to signposting assurance the Risk and Assurance team are currently doing this as part of the assurance mapping which is part of the audit trail of the BAF quarterly review process. Consideration will be given to how this can be included within the BAF template.

6.0 RECOMMENDATION

6.1 The Board of Directors is requested to approve the BAF Risk Register position at Q1.

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APPENDIX 2

BAF Heat Maps 2017/18

Risk Key

HIGH

MEDIUM

LOW

Original Risk Score April 2017 Risk Score at Q1 Risk Target 17/18

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Trust Assurance Framework Reviews (Structures, Engagement and Alignment 2016/17)

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The overall purpose of the insight is to summarise the results of the 2016/17 Assurance

Framework reviews, highlighting good practice examples and key areas for enhancement.

1. Context

All government bodies, including the NHS, are required to have processes in place to provide

a full annual governance statement (AGS) each year. The Assurance Framework is a key piece

of evidence to support the Board in reaching their conclusions on the effectiveness of their

internal control systems. The regulatory frameworks for NHS organisations have also

increasingly re-emphasised the importance of organisations determining and managing the

nature and extent of their strategic risks.

Whilst the principles of assurance frameworks have been in place for a number of years, there

has been a continued focus on ensuring the embeddedness of these processes and the extent

they are used by the Board. The context of assurance rather than reassurance is one that has

been played out in a number of organisations, and more than ever, there is a need to

demonstrate that the Assurance Framework is at the heart of Board reporting supporting the

Board in ensuring the required assurances are sought and received.

This paper summarises the results from the detailed individual reviews of the Assurance

Frameworks across the 31 trusts (acute, foundation, mental health and ambulance) in MIAA’s

client base which were undertaken in support of the 2016/17 Director of Audit Opinions. The

review assessed 3 distinct areas:

- The structure of the Assurance Framework

- Board engagement in the review and use of the Assurance Framework

- The quality of the content of the Assurance Framework and whether it demonstrates clear

connectivity with the Board agenda and external environment

Each of the 3 criteria above was tested for each Trust and the results were RAG rated as follows:

KEY: GREEN – Fully meets AMBER – Partially meets RED – Does not meet

Finally, the risks included in the Assurance Framework were compared to the Top 10 risks

identified in MIAA’s 2016 Assurance Framework ‘What Keeps You Awake at Night’

benchmarking review to identify any potential gaps.

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2. Summary of Good Practice

From our review of the Assurance Frameworks (AFs) across the client base, the best examples

demonstrated the following:

- Each risk has been linked to one or more of the strategic objectives of the organisation

and to any associate corporate risk register risks. Each risk would assign a lead director

and any responsible committee whom are charged with reducing gaps in control and

assurance.

- The controls and assurances that are in place to mitigate the risks are listed and a

distinction is made between internal and external sources of assurance.

- Positive assurances that are gained are included within the Assurance Framework and

signposted back to the report that provided the assurance and the date when it was

reviewed by a committee of the board.

- There is a clear section dedicated to list any identified gaps in control and assurance that

are used to drive the action plan.

- An action plan is included against each risk in the Assurance Framework and includes

timescales for completion and a responsible officer is assigned to highlight whom is

accountable for the implementation of an action.

- The Assurance Framework is regularly presented to the Board (at least quarterly)

- The Board minutes demonstrate regular discussion and update of the Assurance

Framework.

- Discussion and update of the Assurance Framework is embedded into the work

programme of the Board committees.

- There is a clear link between Board agenda items and the Assurance Framework (this can

be made through more explicit reference to the Assurance Framework and clear

identification of the Assurance Framework risks on agenda item cover sheets).

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3. Review Results

The following provides an overview of the findings from the detailed assessments.

Structure:

Testing Criteria Red Amber Green

The structure of the Assurance Framework meets the NHS

requirements in respect of defining objectives, risks, controls,

assurances and gaps

No.

%

0

0

0

0

31

100

The objectives within the Assurance Framework align with

those in the strategic plan.

No.

%

0

0

4

13

27

87

The format of the Assurance Framework provides an action plan

to address the gaps

No.

%

0

0

3

10

28

90

The structure of the Assurance Frameworks (AF) reviewed, complied with the requirements,

including the provision of an action plan, across the client base. This was a 100% compliant

for 2016/17 compared with 97% in MIAA’s 2015/16 benchmarking exercise.

Most Trusts had linked the risks on their assurance frameworks to their strategic objectives. In

some examples, such as safety based risks, the risk was also linked to a CQC standards. This

scoring has remained consistent compared to the 2015/16 benchmarking.

90% of Assurance Frameworks provided an action plan. This compares to 85% against the

2015/16 benchmarking. In a number of Trusts, it was found that the action plan included

timescales for completion and assigning of a responsible officer to promote timely

implementation of actions and to increase accountability.

The majority of Trusts had assigned and included within the AF, the Executive Lead responsible

for the management of the risk. Best practice examples included further identification of the

subcommittee of the board, charged with receiving assurances.

There was a large variation in the way in which each Trust presented its risk score and

movement over time. Best practice examples included an initial or inherent score, current score

and target or appetite score for the organisation. A number of Trusts had provided a

graphically representation or a heat map which highlighted the trend of the risk over time.

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A number of Trusts specifically noted if assurances were internal or external, with two Trust

utilising the ‘3 lines of defence’ approach, grading assurances as internal (management),

internal (peer review) or external. External assurances, by their nature (being independent) are

generally regarded as more robust. Separating internal and external assurances allows

organisations to see where a high/extreme risk has only internal assurances and they perhaps

need to consider gaining further external assurance.

Engagement:


The Assurance Framework is regularly presented to the Board.

No.

%

0

0

1

3

30

97

The minutes of the Board clearly demonstrate discussion,

review and update of the Assurance Framework

No.

%

0

0

8

26

23

74

The number of Trusts regularly presenting the AF to the Board had significantly increased to

97% from 82% in the 2015/16 benchmarking exercise. There was one Trust were it was

recommended that the AF should be presented at each Board meeting.

Although the AF may be regularly presented to the Board, it does not necessarily follow that

they use it to best effect. In order to test this, we reviewed Board and committee minutes for

evidence that the organisation demonstrates the use of the AF as one its key tools in achieving

its strategic objectives. This could be demonstrated both through direct discussion and

consideration at Board meetings (as evidenced through their minutes) but also through the

visibility and discussion of the AF at committee meetings (assuming that the committees

present updates or minutes to the Board which we specifically tested for).

The majority of organisations were rated as Green. Trusts were rated as Amber typically

because either:

o Committee minutes received by the Board do not demonstrate the visibility or use

of the AF by the Committees. The AF itself may reference the Committees in terms

of sources of assurances for specific risks, but these assurances are not effectively

connected to the AF and reported upwards.

o Minutes of the Board meetings did not demonstrate collective ownership of the AF

and there was limited or no discussion of the strategic risks, assurances or

consideration of any mitigating actions required.

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Quality and Alignment:


The risks within the Assurance Framework are visible on the

Board agenda.

No.

%

0

0

1

3

30

97

The risks identified within the Board minutes are reflected in the

Assurance Framework

No.

%

0

0

2

6

29

94

As the table above demonstrates, across the MIAA’s Trust client base there was very high

compliance in relation to the quality and alignment of the Assurance Framework in the Board

agenda and minutes.

Overall, we found that 30 Trust’s AF (97%) was visible on the Board agenda and was used to

drive the discussion of strategic risks. This is a slight reduction in compliance compared to the

2015/16 benchmarking exercise, which was 100%. For 2016/17, where this had not been

undertaken, it was recommended that the Trust include the AF as a standing agenda item and

use the discussions to drive the Board agenda.

We also found that 29 Trust’s (94%) had identified risks within their board minutes and this

was reflected in the AF. Again, this was a slight reduction from 97% compared to 2015/16. F0r

2016/17, where Trusts had not undertaken this, it was recommended that there should be

added emphasis on the connection of risks from Board minutes and sub-committees.

4. Risks

The table below shows the top 10 risk themes identified from a wider benchmarking exercise

undertaken by MIAA in November 2016. A similar review was undertaken in 2015 which

provides a comparison of the movement of risks.

Top 10 Trust AF Risk Themes 2016 Top 10 Trust AF Risk Themes 2015

1. Quality of Services & Patient Safety 1. Transformation & Service Redesign

2. Staff Capacity & Capability (including leadership) 2. Staff Capacity & Capability (including

leadership)

3. Financial Duties, Continuity of Services & CIP 3. IMT, Data Quality & New System

Implementation

4. Transformation & Service Redesign 4. Financial Duties, Continuity of Services &

CIP

5. Regulatory Standards 5. Performance Targets

6. IMT, Data Quality & New System Implementation 6. Quality of Services & Patient Safety

7. Contracts and Demand 7. Regulatory Standards

8. Performance Targets 8. HR, OD & Employment Framework

9. Patient Experience, Feedback & Complaints 9. Business Development & Growth

10. Staff Engagement and Culture 10. Estates (including H&S & Maintenance

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We reviewed the 2016/17 AFs to determine how many of these risks (2016) were included.

Typically, Trusts had around 6 or 7 of the 10 risks areas in their AFs. Risks 9 and 10 –Patient

Experience, Feedback & Complaints and Staff Engagement and Culture, were those which

were less prevalent across the AFs that we tested.

Trusts may wish to review their AF risks to consider whether any risks with regard to the above

list should be included.

5. Next Steps

The Insight summarises the results of the 2016/17 Assurance Framework

reviews, highlighting areas of good practice examples and also key areas

for enhancement. It provides information to support organisations in

understanding how their approach to the Assurance Framework compares

to others. It is intended to prompt and inform discussions on this important

aspect of Trust governance.

Review the outcomes of the benchmarking to establish if there are any learning points

for your organisation.

Contact MIAA for further information on the issues raised, or please speak to your Senior

Audit Manager for information and support.

For more information or to request a benchmarking topic please speak to your Senior

Audit Manager or contact:

Louise Cobain, Assistant Director

r&[email protected]

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