Board of Directors - Lancashire and South Cumbria NHS … Board/Trust Board... · 2018-01-18 ·...

Board of Directors Thursday 04 January 2018

08:30am Board Development 11:45am Part One Formal Board Meeting

Training Room 1 & 2, The Harbour, Windmill Rise, off Preston New Road,

Blackpool, FY4 4FE (Sat Nav postcode FY4 4XQ)

Board of

Directors

Quality Committee

Finance & Performance Committee

Nomination / Remuneration

Committee

Audit Committee

Board of Directors

Meeting Board of Directors Meeting

Location Training Room 1&2, The Harbour, Windmill Rise, off Preston New Road,

Blackpool, FY4 4FE

Date Thursday 04 January 2018

Time 8.30am Board Development

11:45am Formal Public Board meeting

Reference Item Lead Action Enc. FOIA

BOARD DEVELOPMENT

TB 001/18 Digitally enabled care Chief Finance Officer

BREAK – 11.35 AM

PART ONE (PUBLIC MEETING) 11:45 AM

TB 002/18 Welcome and opening comments Chair Verbal

TB 003/18 Apologies for absence and confirmation of quoracy

Chair Verbal

TB 004/18 Declarations of Interest Chair Verbal

TB 005/18 Minutes of the previous meetings Chair Decision Paper

TB 006/18 Action Tracker Chair Decision Paper

SCRUTINY & ASSURANCE

TB 007/18 Trust Chair’s Report Chair Noting Paper

TB 008/18 Chief Executive’s Report Chief Executive Discussion Paper

TB 009/18 Quality Report Director of Nursing Noting Paper

TB 010/18 Performance Report Chief Operating Officer Noting Paper

TB 011/18 Finance Report Chief Finance Officer Noting Paper

PART TWO (PRIVATE MEETING)

STRATEGY

TB 012/18 Minutes of the last meeting Chair Decision Paper

TB 013/18 Chief Executive Report Chief Executive Noting Verbal

TB 014/18 CAMHS Transformation Preparation

Chief Operating Officer Decision Paper

TB 015/18 Quarterly Strategy Plan Update Chief Finance Officer Noting Paper

TB 016/18 Waiting Times for Children and Young People’s Services

Chief Operating Officer Discussion Paper

TB 017/18 Any Other Business Chair Verbal

TB 018/18 Date & Time of the Next Meeting

01 February 2018, 8.30am

Chair Verbal

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 Partnership 2. Trustee of Community Integrated Care 3. Macmillan Allumni Patron 4. Retained Consultant Glenview 5. Patron Breakthrough Mental Health Charity

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

06/09/2017 Furlong Gwynne Non-Executive Director &

SID

1. 1. Non-Executive Director of Together Housing Group

2. 2. CEO of Regain Sports Charity 3. 3. Trustee of Chorley Youth Zone 4. 4. Non-Executive Director of subsidiary of

Progress Housing Group called Concert Living Limited

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 Limited 2. Consultancy Services at Talegar Limited 3. Foundation Governor and Finance Chair at

St.Vincents Primary School

No

03/02/2017 Wilson Isla Non-Executive Director

1. NED - Progress Housing Group 2. Shareholder – FSquared Ltd 3. Shareholder - Ruby Star Associates Ltd 4. Consultancy/Advisory Work – Ruby Star

Associates

No

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Declaration of Interest – Board of Directors

5. Non Exec Director for Healthier Lancashire & South Cumbria STP

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

Limited 2. Clinical Associate at MIAA (Advisory Section)

No

07/02/2017 Gregory Bill Chief Finance Officer

1. Trustee of Healthcare Financial Management Association

2. Governor of Stockport College 3. Co-opted member of Lancaster University

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

No

02/10/2017 Possener Julia Non-Executive Director (Start date 01.02.2017)

1. Lay member of the Lancaster University Management School and Faculty of Arts and Social Science Ethics Committee. Although the Trust and LU have a working relationship and collaborate such matters do not fall usually within these Faculties.

2. My partner's sister is the owner of a domiciliary care business which does have contracts with The Trust. I am including this for the sake of completeness. Bluebird Lancaster and South Lakeland Ltd. I have no formal nor informal involvement 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 07 December 2017 Boardroom, Sceptre Point

PRESENT: David Eva, Trust Chair (Chair)

Heather Tierney Moore, Chief Executive Gwynne Furlong, Deputy Chair Max Marshall, Medical Director Bill Gregory, Chief Finance Officer Sue Moore, Chief Operating Officer Dee Roach, Director of Nursing Damian Gallagher, Director of HR Louise Dickinson, Non-Executive Director Isla Wilson, Non-Executive Director Julia Possener, Non-Executive Director David Curtis, Non-Executive Director Jo Alker, Company Secretary

IN ATTENDANCE: Bev Howard, Head of Communications Viv Prentice, Deputy Company Secretary (minutes)

OBSERVERS: Lisa Knight, Insight Development Programme

Emma Allen, Staff Governor TB 179/17 WELCOME & OPENING COMMENTS

The Chair welcomed everyone to the meeting.

TB 180/17 APOLOGIES FOR ABSENCE & CONFIRMATION OF QUORACY There were no apologies for absence and confirmation of quoracy was provided.

TB 181/17 DECLARATIONS OF INTEREST There were no declarations of interest. However, Non-Executive Director, Isla Wilson confirmed that an updated declaration of interest had been submitted following her recent position as Non-Executive Director of Healthier Lancashire and South Cumbria STP.

TB 182/17 MINUTES OF THE PREVIOUS MEETING

The minutes of the previous meeting held on 02 November 2017 were approved as a true and accurate record subject to noting the request from Non-Executive Director, Louise Dickinson for additional data in respect of access and waiting times in children’s services. This had been omitted from the minutes and the subsequent the action tracker. A paper will therefore be produced to support a conversation around access and waiting times for children’s services.

TB 183/17 ACTION TRACKER

The Board reviewed the action tracker and noted the updates that would be presented as part of today’s agenda.

TB 184/17 FINANCE REPORT The Chief Finance Officer presented the Finance Report for month 7 which highlighted a year to date operating deficit of -£2.3m, excluding planned Sustainability and Transformation funding of £0.9m, against a planned surplus to date of £0.6m. The Board noted the improvement on last month’s position which was as a result of commissioners agreeing to a 50% risk share for the cost of out of area placements. There had also been improvements in CIP delivery.

UNCONFIRMED

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A discussion had taken place with the External Auditors around VAT recovery and this had been accounted for in the recovery plan. The Chief Finance Officer confirmed that the key risks continued to be CIPs and ward staffing. In addition, additional pace was required in respect of the model for mental health. Following a query from a Non-Executive Director around land disposals, the Chief Finance Officer confirmed that both Ribbleton and Ridge Lea disposals were progressing and was therefore hopeful that these would be finalised before year end. The Financial Recovery Group in December would consider month 8 figures. The Board noted the month 7 finance position.

TB 185/17 PERFORMANCE REPORT The Chief Operating Officer presented the Performance Report for month 7 and confirmed that the Trust was compliant with all NHS Improvement indicators with the exception of performance against the Early Intervention in Psychosis (EIS) two week target. The methodologies for a two week wait had been adopted, and whilst the Trust would not achieve the target for quarter three there had been significant improvements in November that would be included in the month 8 report. Key highlights from the report were outlined which included the extensive waiting times in the Children and Young People’s Network and the work that was being undertaken to address this. The Chief Operating Officer confirmed that a further update would be provided to Board in January. ACTION

The Chief Operating Officer drew attention to the revised Single Oversight Framework from NHSI which contained changes to operational performance metrics, in particular the introduction of a new measure on inappropriate out of area placements. It was highlighted that the Trust was not an outlier compared to other Trusts in the North West. Following a query from a Non-Executive Director in respect of the number of OAPs forecast for December, the Chief Operating Officer outlined the work that was taking place to reduce the number of OAPs. This included the implementation of an integrated discharge team to address the 180 day length of stay and the use of both the community support and mental health decision units. In addition, the Trust was awaiting confirmation in respect of allocation of winter monies.

The Chief Operating Officer responded to a question in relation to IAPT waiting times confirming that whilst there was an action plan in place to address this a further update would be provided within the January performance report. ACTION However, in terms of what the Trust is measured against, the Chief Operating Officer confirmed that the Trust had met the contractual targets set but had not met the internal cumulative targets. Non-Executive Director, David Curtis took the opportunity to formally thank the Chief Operating Officer for the work that had been undertaken in improving care co-ordinator attendance at CPA reviews.

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The Board noted the content of the Performance Report.

TB 186/17 TRUST CHAIR’S REPORT The Chair presented his report which included an overview of the activity of both Non-Executive Directors and Governors. The Chair drew attention to the departure of Deputy Chair, Peter Ballard, whose term of office had concluded on the 30 November 2017. In line with NHSI requirements, the Chair proposed that Non-Executive Director, Gwynne Furlong be appointed as the new Deputy Chair with effect from 01 December 2017. In addition, the Chair proposed that Non-Executive Director, Isla Wilson be appointed as the new Senior Independent Director with effect from 01 December 2017, a role previously held by Gwynne Furlong.

The Board noted the content of the Chair’s Report and agreed to recommend to the Council of Governors the following appointments:

The appointment of Gwynne Furlong as the Deputy Chair with effect from01 December 2017.

The appointment of Isla Wilson as Senior Independent Director witheffect from 01 December 2017.

TB 187/17 QUALITY COMMITTEE CHAIR’S REPORT The Chair of the Quality Committee introduced the Chair’s Report and highlighted the key areas of discussion and focus for the Committee. This included the assurance received in respect of the Raising Concerns systems and processes and the introduction of the Raising Concerns Advocates. In addition, the Committee had noted good progress being made with both the Quality Account and Quality Improvement initiatives. The Committee had also noted the forthcoming changes to sections 135 and 136 of the Mental Health Act and whilst this may potentially create some challenge for the Trust, overall there had been improvements in respect of the implementation of the Mental Health Act.

A discussion ensued in relation to the number of staff raising concerns that wished to remain anonymous. Non-Executive Director, Isla Wilson explained that in the absence of benchmarking data, the number of anonymous concerns provided an indication of how staff felt about the process.

The Board noted the content of the Quality Committee Chair’s Report.

TB 188/17 CHIEF EXECUTIVE’S REPORT The Chief Executive introduced her report, key highlights of which included the forthcoming changes to the Mental Health Act and the recent CQC inspection of the Trust’s 136 suites. The Trust was also in receipt of the draft HMIP/CQC inspection report following the joint inspection of HMP Liverpool. The Director of Nursing confirmed that whilst the reports were aggregated together, it had been agreed that, following direct intervention from the CQC, the reports would be published separately. The CQC report would therefore be available in the public domain within two weeks, whilst the HMIP report would be published on the 16 January 2018.

The Chief Executive confirmed that an Improvement Board had now been established with considerable public health representation. Additional support had also been provided by the prison to work directly with healthcare staff and NHS England had appointed a Project Manager to support the team.

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In terms of the recent media request from the BBC in respect of HMP Liverpool, the Chief Executive envisaged that the report would be featured by the end of the week.

The Chief Executive confirmed that the national focus remained on winter pressures, in particular finance and A&E performance, and that additional non-recurrent funding of just over £1million had been allocated to each health economy. The Trust was currently bidding for some of the funding and was confident that this would be supported. Following a question from a Non-Executive Director in respect of allocation of the funding, the Chief Executive confirmed that the majority would be assigned to the hospital to improve patient flow and delayed transfers of care; however, the Trust was hoping to receive some non-recurrent monies.

The Chief Executive drew the Board’s attention to the high value requisition and requested that Board provide authorisation to progress works on the central Perinatal Unit following the Trust successfully winning the tender to provide this service. The scheme is within the financial envelope of £3.5m and the contracted works will commence December 2017 with a completion target date of July 2018. The Board approved the purchase order requisition for £2,122,535.28 including VAT to enable the work package to be completed within the agreed timeframes for the Chorley re-design work.

The Chief Executive requested the Board’s support in signing the Memorandum of Understanding (MOU) for the Ribblesdale Community Partnership (RCP) which was formed to involve organisations in looking at ways that services can be locally developed for the Ribblesdale community. The Chief Executive confirmed that Ribblesdale Community Partnership were extremely pleased to have a mental health team engaged with them and reassured the Board that this did not undermine any primary care work. The Board agreed to sign off the Memorandum of Understanding (MOU).

Following a query from Non-Executive Director, Louise Dickinson in respect of the serious incidents reported within the Chief Executive’s report during October, in particular the death of a patient under the care of the Mindsmatter Service in West Lancashire, the Director of Nursing agreed to ascertain the detail. In addition, the Chair agreed to provide further information following a concern raised through Dear David regarding culture and clinical practice at the Harbour. ACTION The Chair described some of the excellent practice he had witnessed on a recent visit to the Harbour, in particular the use of the Nervecentre.

The Chief Executive formally recognised the Trust’s recent significant achievement in being listed in the top 50 inclusive organisations

TB 189/17 QUALITY REPORT The Director of Nursing presented the second report of the new format Quality Report, key highlights of which included the extensive deep dive into levels of physical violence and restraint which would be presented to the next Quality and Safety Sub-Committee.

The Board’s attention was drawn to the high number of overdue incident reviews, particularly within the Mental Health Network, and the targeted work that was taking place to address this. Following concerns voiced by a Non-Executive Director in respect of the actual number of overdue incident reviews, the Director

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of Nursing confirmed that all incidents were recorded on Datix and that the seven day review process was an internal policy in line with national guidance and provided additional scrutiny at a senior level.

The Director of Nursing discussed response times for complaints and concerns and noted that weekly reporting had been introduced that had demonstrated improvements. Following a question from a Non-Executive Director in relation to the timeframe for responses, the Director of Nursing confirmed that in accordance with NHS guidance the Trust benchmarked its response rate against the 25 day deadline, whilst taking into account the complexity of the complaint.

The Medical Director presented the mortality review data which was included in the report for the first time in accordance with requirements set out by NHS Improvement. A detailed overview of the mortality review process was provided which highlighted to the Board the complexity of the process.

The four categories for the classification of deaths was outlined which further highlighted the complexity in determining which deaths would require further review. The Medical Director highlighted that there may be some movement between the four categories as the process solidified.

Attention was drawn to the overall rate of suicide incidents which showed a noticeable increase over the rolling 12 months. No emerging risks had been identified for this sudden increase and all suicides were being investigated through the Trust’s SI process and the SI Review Panel. The Medical Director confirmed that a proportion of suicides related to HMP Liverpool and would therefore have an impact on figures.

The Medical Director presented the data in relation to local clinical audits and drew attention to the audits that had seen a lack of improvement following the baseline audit, implementation of an action plan and subsequent re-audit. These were identified as nursing management of clozaril, managing diabetes, carers and rapid tranquilisation. It was noted that these had been difficult to resolve and as a result, meetings had been held within the network and deep dives undertaken. Further detail in respect of these re-audits would be presented to the Quality Committee. In addition, more robust action plans had been formulated, two of which would be monitored via the Medical Director’s Steering Group.

The Medical Director provided further detail on how data had been recorded in relation to the carer’s audit and confirmed that this would be resolved by the action plan previously referred to.

Following an observation from Non-Executive Director, Louise Dickinson in respect of the number of internal audits within the Mental Health Network where compliance was rated as amber, the Medical Director confirmed that whilst there was a substantive challenge within this network the audits were not indicative of this. The Medical Director offered to discuss this in more detail outside of the meeting.

The Medical Director provided an overview of the national clinical audits and confirmed that where the Trust was unable to undertake benchmarking, internal audit standards were applied. The Board noted that upper quartile performance had been achieved by adult wards and PICUs in respect of the POMHUK Audit: High Dose and Combination Antipsychotic Prescribing.

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A deep dive had been undertaken following the POMHUK Rapid Tranquillisation Audit and this would be tracked personally by the Medical Director through the National Audit Steering Group.

TB 190/17 ANY OTHER BUSINESS There was no other business to discuss.

TB 191/17 DATE AND TIME OF NEXT MEETING 04 January 2018 @ 08:30a.m. Training Room 1 & 2, The Harbour

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Board of Directors

Agenda Item TB 007/18 Date: 04/01/2018

Report Title Trust Chairs Report

FOIA Exemption No Exemption

Prepared by Louise Dole, Corporate Governance Support

Presented by David Eva, Trust Chair

Action required Noting

Supporting Executive Director Chief Executive

PURPOSE OF THE REPORT:

Report purpose The purpose of the report is to provide the Board with an overview of the activity undertaken by the Board and Non-Executive Directors in addition to the Board of Director meetings and Council of Governor meetings.

Strategic Objective(s) this work supports

To become recognised for excellence

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 Well-led

1.0 NON-EXECUTIVE DIRECTOR ACTIVITY

The Non-Executive Directors have been attending the Board Committee meetings of which they are a member (including the Financial Recovery Group) and apologies have been given where they were unable to attend. All NEDs attended the ‘are we assured’ meeting which was held with the Trust Chairman and the Company Secretary. Following this a quarterly meeting was held with the Trust Chairman. The Non-Executive Directors attended the Board of Directors away day which was held on the 19th December 2017. In addition to the usual Board business, Non-Executive Directors (NEDs) have been involved in their areas of special interest during the period of November 2017 – December 2017: Gwynne Furlong

Attended the Land Committee Meeting Attended a preliminary meeting to support the scoring of the CEA application forms. Attended the Clinical Excellence Awards

Louise Dickinson

Attended the NWC Conference - Digital Innovation in Patient Safety Attended the Financial Recovery Group Meeting Attended a meeting to discuss the outcome of the internal audit review. Met with the Corporate Governance Manager

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Julia Possener

Attended the Associate Managers Forum Attended the Opportunity Knocks Event Attended the MHA Managers Forum Met with the Chief Operating Officer

David Curtis

Met with the Chief Operating Officer

Isla Wilson

Attended the QIA Star Chamber Attended the Financial Recovery Group

In addition to the above:

Gwynne, Isla, and David Curtis attended the December Council of Governors meeting.

2.0 CHAIRS ACTIVITY

Attended the Board meetings and Council of Governors meeting Had weekly catch up meetings with the Chief Executive, has had monthly meetings with

the Company Secretary and has met with several Board members and Senior Managers and Colleagues

Attended external meetings including the Partnership Leaders meeting Continues to meet with MPs and local authority members Met with a member of the public Attended a meeting with the Senior Independent Director to discuss Housing Association Met with the Senior Matron at the Harbour for a tour of the hospital. Attended the HSJ - Transforming Mental Health Summit with the Chief Executive Met with the Insight Programme Coordinator Met with the Director of Operations, Cheshire & Wirral Partnership NHS Attended the STP Decision Making Workshop Had an introductory meeting with the new Head of Organisational Development, Emma

Dawkins Attended the Partnership Leaders Forum

3.0 COUNTER FRAUD CONTRACT

MIAA were appointed to provide the counter fraud services to the Trust for a three-year contract from 1 April 2015 with the provision for a two-year extension. The Audit Committee considered this extension provision at the meeting on 24 October 2017. The Audit Committee were happy to recommend that the contract be extended for a further two years with effect from 1 April 2018. The appointment of the Local Counter Fraud Specialist is a matter reserved for the Board and in line with the Decision Rights Framework ref 5.5, the Board is asked to approve the extension of the MIAA contract for further two years with effect from 1 April 2018.

4.0 COUNCIL OF GOVERNORS UPDATE

This section has been added to the Chair’s Report in order to keep the Board updated on Council of Governor activity, recognising that since 01 April 2017, Board members have been attending meetings on an invitation basis. Since the last Chair’s Report received on 07 December 2017, the following items have been considered by the Council of Governors:

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The Council of Governors agreed the appointment of Isla Wilson as the Senior Independent Director and Gwynne Furlong as the new Deputy Chair.

The new Board committee membership is as below, which came into effect from the 01 of December.

Non-Exec Role

David Eva Trust Chair

Gwynne Furlong Deputy Chair

Isla Wilson Senior Independent Director

Board of Directors Audit Committee Quality Committee

Finance and

Performance

Committee

Charitable

Trustee Funds

Committee

David Eva

Chair

Louise Dickinson

Committee Chair

David Curtis

Committee Chair

Isla Wilson

Committee Chair

Gwynne Furlong

Committee Chair

Gwynne Furlong

Louise Dickinson

David Curtis

Isla Wilson

Julia Possener

David Curtis

Julia Possener

Gwynne Furlong

Isla Wilson

Gwynne Furlong

Louise Dickinson

Julia Possener

2017 TRUST GOVERNOR ELECTIONS

The 2017 Trust governor elections were held using the new constituencies approved at the

Annual Members Meeting held in October.

The following Public Governors have been elected;

Central Lancashire - Christine Cartwright Pennine Lancashire - Paul Graham West Lancashire - Chris Burgess and Kenneth Lowe

In North Lancashire and South Cumbria where there were 3 public governor vacancies, initially

only 1 candidate stood for election (Michael Helm, elected unopposed). The North Lancashire

and South Cumbria election was reopened and 6 candidates have been nominated for the

remaining 2 public governor vacancies. Voting will start on 4 January and close on 19 January.

In total, 17 candidates stood in the 2017 public governor elections for 7 vacancies.

The following Staff Governors have been elected;

Staff Governor Administrative and Clerical – Geraldine Gasson

Nursing professions and support staff - Judy Laing

Other clinical and social care professionals and clinical support staff - Sallyann Walker

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In total 12 candidates stood in the 2017 staff governor elections for 3

vacancies.

It is pleasing to report that the Trust will have contested elections in all 7 public and staff constituencies where there were governor vacancies. In total, 29 candidates stood for 10 vacancies

NOMINATED GOVERNOR RESIGNATION

Pamela Beswick, Nominated Governor, has resigned with effect from the 06 December 2017 5.0 USE OF THE COMMON SEAL

To inform the Board that the Common Seal has not been used since the Board of Directors meeting on the 07 December 2017.

6.0 RAISING CONCERNS

As Trust Chair I continue to oversee the Dear David process for staff to raise concerns. This process compliments other mechanisms for staff to raise concerns such as the Raising Concerns Guardian. During November 2017, the following concerns were raised with me through Dear David:

Lack of parking and the impact on staff safety at Bridge House in Blackburn;

Several concerns about the movement of staff to alternate premises in Mindsmatter;

Costs of urgent minor estate works that could be solved through other means, or with less

priority;

Several concerns about the lack of parking and the impact on staff safety at West Strand

in Preston

Fraudulent sickness absence of a staff member;

Regular low staffing (one nurse and one support worker) on Mallowdale Ward at Guild

Lodge;

Availability of doctors at Guild Lodge;

Workload of a staff member in Mindsmatter;

Changes to the background image on computer screen making it difficult to read;

Behaviour of a staff member;

Long waiting times in Lancaster and Morecombe Assessment and Treatment Team.

The Executive Director of Nursing and Quality (as Executive Lead for Raising Concerns) and Associate Director of Safety and Quality Governance (as Raising Concerns Guardian) continue to administer the Dear David process on my behalf and they have ensured that all concerns are being reviewed with feedback provided to those raising concerns directly, where possible, and also included in the Quality Matters electronic bulletin to staff.

7.0 BOARD ACTION The Board is asked to note the updates provided for information.

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Board of Directors


Report Title Chief Executive’s Report

FOIA Exemption Part Exemption Business Development Section

Prepared by Heather Tierney-Moore, Chief Executive

Presented by Heather Tierney-Moore, Chief Executive

Action required Discussion/Decision

Supporting Executive Director Chief Executive


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.


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 November 2017, the following 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 under the care of Community Child and Adolescent Mental Health Services (CAMHS) and Community Learning Disability Services;

Death (suspected suicide) of a patient under the care of the Community Mental Health Team (CMHT) in Morecambe;

Serious self-injury of a patient in a Psychiatric Intensive Care Unit (PICU) at the Harbour (linked and jointly investigated with an incident involving the same patient at the Cove);

Death (suspected natural causes) of a prisoner at HMP Liverpool;

Death (suspected drug overdose) of a patient recently discharged from an Acute Ward the Harbour.

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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Significant Health and Safety Incidents

During November 2017, the following incident was reported to the Health and Safety Executive and

Care Quality Commission under the Reporting of Injuries, Diseases and Dangerous occurrences

Regulations (RIDDOR) (brief information is provided to protect confidentiality):

Injury to a staff member during restraint resulting in an absence from work of over seven days.

Raising Concerns

During November 2017, the following concerns were reported through the various mechanisms

including the Raising Concerns Guardian and through Dear David:



Costs of urgent minor estate works that could be solved through other means, or with less

priority;

Several concerns about the lack of parking and the impact on staff safety at West Strand in

Preston


Regular low staffing (one nurse and one support worker) on Mallowdale Ward at Guild Lodge;






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.

Statement of Intent ‘Healthy Eating’

As part of our continued commitment to Health and Wellbeing and to support accreditation of the

Workplace Wellbeing Charter as identified in our Quality Plan our ‘Statement of Intent for Health

Eating’ has been produced and promoted. This statement details the current evidenced based

recommendations and encourages our people to take a balanced approach to their diet. Given the

national concerns regarding obesity together with the high consumption of sugar and fat it is important

that the NHS sets an example. The Trust has endorsed this to ensure support for this work.

Lancashire Learning Disability Team

The Hyndburn and Ribble Valley Lancashire Learning Disability Team co-facilitated an event with

AFTA-Thought on 1st December to deliver training to a number of paid carers and family members

supporting service users in Hyndburn and Ribble Valley and Burnley Pendle and Rossendale. The

training is delivered for carers (paid/unpaid) supporting adults with a learning disability who have

recently been diagnosed with dementia. The training was introduced and co-facilitated by Isobel Lamb

- Consultant Clinical Psychologist. The training was well received and has a huge emotional impact as

well as helping staff to feel more knowledgeable and skilled in supporting adults with a learning

disability.

Mindsmatter

Mindsmatter have presented the Improving Access to Psychological Therapies Long Term Conditions

work from Wave 1 (Pennine) alongside NHS England to the North West Coast Strategic Clinical

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Network and the Greater Manchester and Eastern Cheshire Strategic Clinical Network, where the

developments have been well received.

Quality improvement in action: an Always Event QI at Guild - ‘Our Voice Always Matters’

Staff at Guild Lodge recently facilitated a ‘thinking space’ with people who use our services, carers

and advocacy colleagues to understand why there might be limited feedback from people using the

services and low number of complaints. The ‘thinking space’ also included members of the care team,

members of the Hearing Feedback and the Quality Improvement Team to explore this. Feedback said

that people did not feel their voices were being heard and listened to and so as a result the Guild

Lodge Always Event “My Voice Always Matters” saw a co-design team exploring different ideas to

ensure people’s voices were heard and listened to. These ideas included:

Post boxes within the secure environment to enable people to feedback directly to the Hearing

Feedback Team – with posters advertising all the ways to give feedback, including the free

phone number for the central Hearing Feedback team as impartial investigators of complaints

A person centred approach to responding to feedback through the case management model

Personalised response and agreed timescales to all complaints

The Guild Lodge Service Manager and a member of the Hearing Feedback Team are working as part

of the co-design team to case manage feedback received. The result of this approach is that feedback

has increased and complaints from Guild Lodge are

meeting Trust deadlines and NHS regulations for

responding.

At the end of November Claire Marshall, Experience of

Care Professional Lead along with Lorraine Wolfenden,

Leadership Support Manager from the Patient Experience

Team at NHS England, visited Guild Lodge to meet the

Always Event Co-Design team and hear about the journey

so far. Following the visit Claire Marshall shared that she

“was encouraged to see openness and honesty in the

discussion that took place, the ideas that flowed from the

service users, the mutual respect and humour that was

evident from the interactions, and the will from all involved

to describe the difference coproduction had meant to

service users feeling “Our Voice will always matter”. The

co design team acknowledged there was a way to go with

the change ideas and embedding the changes within the

service however they could easily describe the

improvements seen already with the work taking place.

Their enthusiasm and commitment to make it happen was

clearly led from the local level and together they will

achieve that I’m sure. I would love to come back to see the progress in the Always Event in 2018. In

the words of one service user ‘This group is like a blossoming flower’. The key ingredient in the mix is

the ability to work together to find a way forwards to ensure the flower becomes permanently in full

bloom. I look forward to seeing it grow – please thank the co design team for their time”.

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The co-design team are looking forward to sharing more about their Always Event journey and the

outcomes for people using services with NHS England in the summer. For more information about

Always Events please click here to visit the NHS England website where the Always Event Toolkit

and Always Event Evaluation Report (Picker, 2016) can be found. Both documents reference the

work of the Trust.

FINANCE AND PERFORMANCE

Finance Report After adjusting for impairments of £0.2m the deficit for month 8 is a -£1.9m which excludes year to date planned Sustainability and Transformation Funding of c£1.1m, against a plan surplus to date of £0.9m. Performance is therefore £2.8m behind the control total and £1.7m behind excluding STF. The position continues to be driven by staffing pressures in ward and prison areas and the lack of performance on delivery against planned cost improvement programmes, particularly ward staffing. In addition, expenditure is exceeding funding on OAPs resulting in current and forecast pressures. Performance does however show an improvement on the Month 7 in month position of £0.5m and an in month surplus over plan of £0.3m. Unmitigated projections indicate a gap of c£4.6m (£6.8m without STF), which again shows an improvement over the month 7 position of c£0.2m. The deficit is driven by excess OAPs of c£1.0m, prisons (see Bank and Agency section of the Finance Report) and additional mental health pressures. Though improvements in performance are evident, continued delivery will require sustained and coordinated responses with robust management and oversight. After taking in to account £1.7m of disposals, which are accounted for after EBITDA, EBITDA is broadly in line with I&E Margin. The new Use of Resources (UoR) metric is rated at 2, an improvement from month 7 (rated at 3), should the Trust meet its financial plans and targets the Trust will achieve a rating of 2. Performance Report & Quality Report The Quality Report can be viewed under TB 009/17 and the separate Performance Report can be viewed under item TB 010/17. Early Intervention Service (EIS) Update Following reporting issues identified in EIS, significant effort has been focussed on improving performance against the 50% 14 day RTT target and ensuring that the Trust offers the most clinically appropriate and timely service to patients with a suspicion of a first episode of psychosis (FEP). As previously reported, the correction of the reporting errors highlighted a number of issues with the patient pathway which is preventing timely treatment within the 14 day window:

Delay in allocation of a care coordinator (this along with meaningful engagement with the care coordinator “stops the clock”) for patients where it is unclear whether there is FEP. These patients undergo an extended assessment and miss the 14 day window as a result.

Delay in referral to EIS following FEP (clock starts when FEP first suspected therefore timely referral imperative) although during this time service users tend to be in contact with other mental health services either as outpatients or inpatients.

Delays resultant from patient-related factors i.e. readiness/fitness to engage To provide assurance that no unnecessary harm has been caused to service users a 10% sample of those 154 people who had waited the longest time was taken. The care records for each of these people were then accessed to determine the assessment and/or treatment that was offered during this period prior to acceptance into EIS. All service users from the sample during this time were either being assessed, actively engaged or in receipt of treatment from: EIS in a period of extended assessment, inpatient teams, the Crisis Resolution and Home Treatment Team, Single Point of Access or Assessment and Treatment Team. Due to the actions from these teams it is considered very unlikely that any unnecessary harm has been caused. It is also worth noting that out of the entire

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https://www.england.nhs.uk/ourwork/pe/always-events/

sample of people coming into the service during 2017-18 the average number of days that the RTT was missed was 20 days. Performance against the RTT is now recovering and is expected to reach the 50% target for Quarter 4 of 2017-18. Daily management of waiting times is in place through SITREPS and senior management oversight of a remedial action plan. For future months reporting, breaches of the target will have a breach reason allocated (and reported via the Performance Report) and will be subject to a root cause analysis. A separate fact finding review is still ongoing undertaken by the Company Secretary and the outcome of this investigation will be reported once completed.

BUSINESS DEVELOPMENT

LCIA Test Bed Update Philips UKI has been the lead innovator since the beginning of the Lancashire and Cumbria

Innovation Alliance (LCIA) Test Bed Programme. It has been a very positive working relationship

which has contributed to delivery and testing innovation across two new models of care. In relation to

the spread and adoption of this, Philips UKI made the following statement in December:

“To focus on bringing product innovations to market that Philips UKI anticipates will offer patients

and clinicians increased flexibility and choice, Philips UKI has decided to withdraw the Motiva

telehealth product. This means that it will close its existing UK customer accounts, and will not be

extending its contract with the Lancashire and Cumbria Innovation Alliance within the NHS

England test-bed programme, beyond March 31st 2018. Motiva customers have been informed

and Philips is working closely with these stakeholders to ensure minimal disruption to patient

care. Where necessary Philips is supporting alternative arrangements with third parties to

continue care provision. Philips continues to invest in and deliver innovative population health

solutions focused on improving people’s health and enabling better health outcomes.”

Evaluation of the TestBed is ongoing and Philips UKI will continue to contribute to a proof of concept

for a health population approach to managing long term conditions using digital technology.

Lancashire Care will work with colleagues from NHS England, the Innovation Agency and other

partners to find a new telehealth solution for spread and adoption.

Central Lancashire Local Delivery Partnership

Discussions are progressing in Central Lancashire regarding the accountable care partnership. A

particularly helpful Team to Team took place on 21st December where a proposition to enact work by

April 2018 was explored. A further update will be provided in the Board meeting.

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Board of Directors


Report Title Quality Report

FOIA Exemption No Exemption Not Applicable

Prepared by Matthew Joyes

Associate Director of Safety and Quality Governance

Presented by Dee Roach, Executive Director of Nursing and Quality

and

Professor Max Marshall, Medical Director

Action required Decision

Supporting Executive Director Executive Director of Nursing & Quality


Report purpose To provide the Trust Board with latest version of the Quality Report



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 Well-led

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Quality and Safety Report

January 2018

(data from December 2016 to November 2017)

Prepared by: Presented to the Trust Board by:

Matthew Joyes, Associate Director of Safety and Quality Governance Dee Roach, Executive Director of Nursing and Quality

Max Marshall, Executive Medical Director

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Contents

Contents ................................................................................................................... 2

Quality and Safety Tile ............................................................................................. 3

Executive Summary ................................................................................................. 4

Safe .......................................................................................................................... 5

Serious Incidents .................................................................................................. 6

RIDDOR Incidents ................................................................................................ 7

Never Events ........................................................................................................ 8

Serious HCAI Incidents ........................................................................................ 8

Pressure Ulcer Incidents – Potentially Avoidable Grade 3 and Grade 4 ............. 9

Physical Violence to Staff Incidents ..................................................................... 9

Use of Restraint.................................................................................................. 10

Suicide (Reported as a Serious Incident) .......................................................... 10

Staffing Incidents – One or Less Qualified Staff on Duty ................................... 11

Staffing Incidents – Red Flags ........................................................................... 11

Safer Staffing – Wards with over 40% hours worked by bank staff ................... 12

Safer Staffing – Wards with over 10% hours worked by agency staff ............... 12

Mortality Review – Numbers of Deaths and Reviews ........................................ 13

Mortality Review – Classification of Deaths ....................................................... 13

Effective .................................................................................................................. 14

Mental Health Harm Free Care .......................................................................... 15

Physical Health Harm Free Care ....................................................................... 15

Local Clinical Audit ............................................................................................. 16

Local Clinical Re-Audit ....................................................................................... 16

National Clinical Audit ........................................................................................ 17

Clinical Audit Summary Report .......................................................................... 18

Caring ..................................................................................................................... 19

Friends and Family Test – Results ..................................................................... 20

Friends and Family Test – Submissions ............................................................ 20

Compliments ...................................................................................................... 21

CQC Community Mental Health Survey ............................................................. 21

Responsive ............................................................................................................. 22

Complaints ......................................................................................................... 23

Mixed Sex Breaches .......................................................................................... 23

Well Led ................................................................................................................. 24

Care Quality Commission (CQC) Rating) .......................................................... 25

Core Skills .......................................................................................................... 25

Overdue Incident Reviews ................................................................................. 26

Accreditations ..................................................................................................... 26

Concerns Raised ................................................................................................ 27

Quality Plan Dashboard ..................................................................................... 28

Quality Plan Summary Report ............................................................................ 29

Appendix 1 – Extracts from the Quality and Safety Surveillance Report and Mental

Health Law Surveillance Report ............................................................................. 30

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Quality and Safety Tile

17521 95.28%

91 8789

37

1

9 1635

3943 306

13 52%

2664

2236

90.42%

95% 42.14%

83% 13

QUALITY AND SAFETY TILE

CARING

Compliments

F&F Test

RIDDOR incidents

Incidents

STEIS-reportable serious incidents

EFFECTIVE

Never Events

Number of red flag incidents

(inpatients only)

Core Skills (%)

SAFE

Physical violence to staff from

patients

Serious HCAI incidents

Use of restraint

Potentially avoidable grade 3 and 4

pressure ulcers

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

Physical Health HFC Rate (%) Appraisals (%)

Mental Health HFC Rate (%) Concerns raised

Good

Completed within agreed timeframe

(%)

RESPONSIVE

Complaints

Upheld/partially upheld complaints

WELL LED

Trust CQC rating

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Lancashire Care NHS Foundation Trust Quality and Safety Report

Page 4 of 35

Executive Summary

This is the third Quality and Safety Report for the Trust Board. Prior to review by the Board, the Quality and Safety Sub-committee receives the report for further scrutiny and challenge to Networks and Support Services. In the Safe domain, attention is drawn to the slight increase in serious incidents. This is against the backdrop of a sustained reduction over recent years and likely reflects a plateau of that reduction with new average of eight serious incidents per month. Each serious incident is subject to detailed investigation by the Trust Investigations and Learning Team, with the Serious Incident Learning Panel maintaining its oversight role. The regular thematic review of serious incidents will be received by the Quality Committee in January 2018. The second area of focus in this domain is violence to staff and restraint (which are linked issues). The Quality and Safety Sub-committee is receiving a series of deep dive presentations into violence and restrictive practices across inpatient units utilising an internal benchmarking format. In recognition of the need to take stock of the continuing challenge to deliver improvement, the Associate Director of Safety has commissioned a full review of the total approach to violence reduction and management within the Trust with a view to a refreshed programme being launched in April 2018 (the next quarter being taken to fully review the programme and involve clinical staff fully in the review). In the Effective domain, attention is drawn to the clinical audit report which highlights current progress of the programme. The Mental Health Harm Free Care rate remains below the Trust aspiration and this is linked to violence, restraint and medication incidents. In the Caring domain, attention is drawn to the positive Friends and Family Test results which have been above the target since January 2017. Whilst there has been a reduction in the number of completed responses, this is primarily due to changes in the way data is collected to reduce people being repeatedly asked for a response over short periods of time. In total, 1,169 responses were received in October 2017. In the Responsive domain, attention is drawn to the notable increase in complaints. This position is reflected nationally, and is also considered to be partly attributable to the new hearing feedback model where the Trust has been actively seeking out feedback from people who use services, their families and carers. The CQC Community Mental Health Survey was published in November 2017, and will be scrutinised at the January 2018 meeting of the Quality and Safety Sub-committee alongside the quarter three Hearing Feedback Report. In the Well Led domain, attention is drawn to the areas of under-performance in some Core Skills and Essential Skills subjects. Whilst not on this report, concern also exists around the compliance level for appraisals. Further detail on these areas will be included in the Workforce Report. The number of overdue incident reports is increasing; Networks have been instructed to take action on this through the Quality and Safety Sub-committee.

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Page 5 of 35

Safe

This section of the report looks at the domain of safety – that services are safe, and people are protected from abuse and avoidable harm. The following

indicators are covered in the report:

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Page 6 of 35

Serious Incidents A serious incident is defined as “acts or omissions in care that result in; unexpected or avoidable death, unexpected or avoidable injury resulting in serious harm - including those where the injury required treatment to prevent death or serious harm, abuse, Never Events, incidents that prevent (or threaten to prevent) the ability to continue to deliver healthcare services and incidents that cause widespread public concern resulting in a loss of confidence in healthcare services.” The number of serious incidents fell throughout 2014-2016, however the long term reduction has now plateaued with a minor increase over the rolling 12 month period. During November 2017, the following serious incidents were reported:

Death (suspected suicide) of a patient under the care of Community Child and Adolescent Mental Health Services (CAMHS) and Community Learning Disability Services;

Death (suspected suicide) of a patient under the care of the Community Mental Health Team (CMHT) in Morecombe;

Serious self-injury of a patient in a Psychiatric Intensive Care Unit (PICU) at the Harbour (linked and jointly investigated with an incident involving the same patient at the Cove);

Death (suspected natural causes) of a prisoner at HMP Liverpool;

Death (suspected drug overdose) of a patient recently discharged from an Acute Ward the Harbour.

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

0

2

4

6

8

10

12

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

Serious Incidents - Rolling 12 Months

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Page 7 of 35

RIDDOR Incidents The Trust is required to report certain incidents under the Reporting of Injuries, Diseases and Dangerous Occurrences Regulations 2013. These notifications are received by the Care Quality Commission and Health and Safety Executive. A RIDDOR incident is defined as an incident were someone has died or has been injured because of a work-related accident including specified injuries to workers (certain fractures, amputations, loss of sight, crush injury to head or torso, serious burns, loss of consciousness, etc.), injury causing absence of work for more than 7 days, injuries to non-workers requiring transfer to hospital, occupational diseases and certain dangerous occurrences. The number of RIDDOR incidents shows a decrease during the year. The predominance of incidents relate to absence of work of over 7 days and originates from violence to staff. During November 2017, the following RIDDOR incident was reported:

Injury to a staff member during restraint resulting in an absence from work of over seven days.

0

1

2

3

4

5

6

7


RIDDOR Incidents - Rolling 12 Months

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Page 8 of 35

Never Events Never events are serious incidents that are entirely preventable as guidance, or safety recommendations providing strong systemic protective barriers, are available at a national level, and should have been implemented by all healthcare providers. Each never event type has the potential to cause serious patient harm or death. However, serious harm or death is not required to have happened as a result of a specific incident occurrence for that incident to be categorised as a never event. The Trust reported one Never Event in September 2017, which related to an incident in June 2017. This related to an overdose of methotrexate in rheumatology services. The report is due for completion in January 2018 and will be reviewed by the Serious Incident and Learning Panel.

Serious HCAI Incidents A serious HCAI incident is considered to be an avoidable incident of Clostridium Difficile (C.Diff), Meticillin-Resistant Staphylococcus Aureus (MRSA), Methicillin-Susceptible Staphylococcus Aureus (MSSA), Gram-negative bacteria, Carbapenemase-Producing Enterobacteriaceae (CPE), or another infection control incident resulting in a ward closure. The number of HCAI incidents remains low with no exceptions to report. The Infection Prevention and Control Team continue to drive improvements in reporting and compliance with the Essential Steps Hand Hygiene Audit and to drive forward the annual staff flu vaccination campaign.

0

1

2


Never Events - Rolling 12 Months

0

1

2

3

4

5


HCAI Incidents - Rolling 12 Months

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Page 9 of 35

Pressure Ulcer Incidents – Potentially Avoidable Grade 3 and Grade 4 Pressure ulcers are injuries to the skin and underlying tissue, primarily caused by prolonged pressure on the skin. Pressure ulcers can affect any part of the body that's put under pressure. They're most common on bony parts of the body and often develop gradually, but can sometimes form in a few hours. In a grade three pressure ulcer, skin loss occurs throughout the entire thickness of the skin and the underlying tissue is also damaged. The underlying muscles and bone are not damaged. A grade four pressure ulcer is the most severe type of ulcer. The skin is severely damaged and the surrounding tissue begins to die (tissue necrosis). The underlying muscles, or bone, may also be damaged. People with grade four pressure ulcers have a high risk of developing a life-threatening infection The number of pressure ulcer incidents increased over the summer period but has declined over the last two months. There have been no reported incidents in the last month. Pressure ulcer prevention is a priority for 2017/18 in the Quality Plan and work so far has included revising the policy, introducing safety huddles, a safety senate and the safety cross. Localities where these initiatives have been piloted have shown a reduction incidents.

Physical Violence to Staff Incidents Physical violence to staff includes any degree of harm, including near miss incidents, where staff are physical assaulted. Incidents are recorded by staff on the Trust’s quality governance system (Datix). The number of incidents of physical violence to staff increased notably in 2014 and remained increased since, with a further increase during 2017/18 which appears to have levelled during the last few months. Hot spots have been identified in older adult wards and psychiatric intensive care units (PICUs). A deep dive into the data for PICUs was presented to the Quality and Safety Sub-committee in October, with a deep dive into older adults planned for December 2017. Details of the improvement work underway is covered in the Quality Plan Update later in this report.

0

1

2

3

4

5

6


Potentially Avoidable G3 and G4 Pressure Ulcer Incidents - Rolling 12

Months

0

50

100

150

200

250

300


Physical Violence to Staff Incidents -Rolling 12 Months

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Page 10 of 35

Use of Restraint The use of restraint shows a notable increase. This is closely linked to the increase in violence and the work to address violence includes restraint reduction as an outcome measure. The hot spot areas mirror those for violence and aggression mentioned earlier in the report.

Suicide (Reported as a Serious Incident) The overall rate of suicide incidents (deemed to meet the criteria for a serious incident) shows a static position rolling 12 months with April 2017 and October 2017 seeing the highest reported number over that period. An emerging area of potential concern is suicide soon after discharge; the Mental Health Network is undertaking exploration of this with support from the Safety and Quality Governance Department. This will be reported here when complete.

0

50

100

150

200

250

300

350

400

450

500


Use of Restraint - Rolling 12 Months

0

1

2

3

4

5

6

7


Suicide (Reported as a Serious Incident) - Rolling 12 Months

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Page 11 of 35

Staffing Incidents – One or Less Qualified Staff on Duty Instances of one qualified staff on duty are reported and escalated in accordance with the Staffing for Quality and Safety Escalation Procedure. This allows managers to put into place mitigations by moving staff, supporting the area with senior nurses or using bank and agency staff. There has been a notable decrease in reported incidents which is a reflection of the increased scrutiny led by the Executive Director of Nursing and Quality through the Staffing for Quality and Safety Group. Networks continue to produce monthly reports to this group on progress.

Staffing Incidents – Red Flags All staff are encouraged to use the Red Flag facility on the eRostering Safe Care system to alert managers to staffing incidents such as low staffing numbers, missed breaks, etc. The majority of Ref Flag incidents relates to the above issue of one or fewer qualified staff on duty.

0

50

100

150

200

250


One or Less Qualified Staff on Duty -Rolling 12 Months

0

50

100

150

200

250

300


Red Flags - Rolling 12 Months

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Page 12 of 35

Safer Staffing – Wards with over 40% hours worked by bank staff The teams on the graph reported bank staff usage of greater than 40%. Dunsop, Bronte, Byron, Elmridge and Marshaw Wards all reported over 40% usage in the last report. The majority of these teams also reported higher levels of sickness absence. The Executive Director of Nursing and Quality is continuing the task and finish group to review particular challenges on inpatient wards.

Safer Staffing – Wards with over 10% hours worked by agency staff No teams reported agency usage over 10% (data based on eRostering).

40% 45% 50% 55% 60% 65% 70%

Dunsop Ward

Bronte Ward

Byron Ward

Elmridge Ward

ATT Lancaster & Morecambe

Marshaw Ward

Dutton Ward

Greenside Ward

Caler Ward

Lathom Suite

Scraisbrick Unit

LDSL Sharoe Green Lane

LDSL North Syke Avenue

LDSL Cromwell Road

Wards with over 40% hours worked by bank staff

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Page 13 of 35

Mortality Review – Numbers of Deaths and Reviews The Trust is required to declare how many deaths were deemed as avoidable. Deaths are reviewed through two processes: the serious incident (SI) process and the structured case judgement (SCJ) process. The SI process determines whether a death was predictable and/or preventable. The SCJ process determines whether a death was due to a problem in care. Neither of these terms are legal terms or formal causes of death. Since April 2017, one death reviewed through the serious incident process was deemed predictable and preventable. No structured case judgement reviews have taken place – a cohort of reviewers have been recruited and the process will commence in January 2018. The Trust is engaged in the Learning Disability Mortality Review Programme (LeDeR) and the Child Death Overview Panel process.

Mortality Review – Classification of Deaths The Trust records deaths as incidents, where appropriate and in accordance with the Incident Procedure. A daily review process, supported by a weekly review panel, determines which deaths meet the threshold for a serious incident and (when established) which deaths will be subject to a structured case judgement review. Deaths are recorded against one of four categories: Expected Natural (i.e. terminal illness), Expected Unnatural (i.e. drug misuse), Unexpected Natural (i.e. sudden cardiac condition) and Unexpected Unnatural (i.e. suicide). This framework was developed by Mazars in their investigation into deaths at Southern Health NHS Foundation Trust and helps determine which deaths require further review.

0

20

40

60

80


Numbers of Deaths and Mortality Reviews - Rolling 12 Months

SCJ Reviews SI Reviews Deaths

0

20

40

Jul Aug Sep Oct Nov

Classification of Deaths - Rolling 12 Months (data available from July

2017)

Expected Natural Expected Unnatural

Unexpected Natural Unexpected Unnatural

Not Yet Known

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Page 14 of 35

Effective

This section of the report looks at the domain of effectiveness – that care, treatment and support achieves good outcomes, helps people to maintain quality of

life and is based on the best available evidence. The following indicators are covered in the report:

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Page 15 of 35

Mental Health Harm Free Care The Mental Health Harm Free Care rate remains below the aspirational goal of 90%. The overall rate is made up of several individual measures. The area’s most impacting the overall measure includes violence, restraint, medication safety and feeling safe. The individual measures are detailed in the quality surveillance tables later in this report.

Physical Health Harm Free Care The Physical Health Harm Free Care rate has achieved the target in 8 of the last 12 months with an improving picture seen over recent months. The overall rate is made up of several individual measures. The individual measures are detailed in the quality surveillance tables later in this report.

74%

76%

78%

80%

82%

84%

86%

88%

90%

92%


Mental Health Ham Free Care - Rolling 12 Months

91%

92%

93%

94%

95%

96%

97%


Physical Health Harm Free Care -Rolling 12 Months

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Page 16 of 35

Local Clinical Audit

Clinical Audits Network Compliance (%) Date

Prevention of Dehydration MHN 54% Q2

Absent Without Leave MHN 55% Q2

Section 132 Rights MHN 90% Q3

Completion of Waterlow risk CWN 85% Q1

Wound assessment documentation CWN 70% Q2

Care of the Dying CWN 79% Q1

Learning Disability CWN 85% Q2

Cerebral Palsy in under 25's (NICE) CYPWN 85% Q1

Risk Assessments CYPWN 83% Q2

Nutrition (NICE) CYPWN 77% Q1

Clozapine CYPWN 80% Q2

Local Clinical Re-Audit

Clinical Audits Network Original

Compliance (%)

Standards Re-audited

Re-audit Compliance

(%)

Nursing Management of Clozaril MHN 63% 3 60%

Rehabilitation Accommodation MHN 66% 4 84%

Consent to treatment MHN 32% 2 94%

Diabetes MHN 57% 5 65%

Acupuncture- Rheumatology & Physiotherapy

CWN 86% 1 97%

Antibiotics in dentistry CWN 88% 1 94%

Use of restrictive practices within LD CWN 77% 2 93%

Carers CYPWN 45% 5 54%

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Page 17 of 35

National Clinical Audit

Audit Start Quarter End Quarter 2016/17 Compliance

2017/18 Compliance

National Chronic Obstructive Pulmonary Disease (COPD) audit programme Q1 2017/18 Q4 2017/18 90% Ranking not

possible

National Diabetes Foot care Audit - Adults Q1 2017/18 Q4 2017/18 81% Ranking not

possible

Sentinel Stroke National Audit programme (SSNAP) Q1 2017/18 Q4 2017/18 LCFT were above national average in a total of 6 out of 16 indicators

POMHUK High Dose and Combination Antipsychotic Prescribing Q4 2016/17 Q2 2017/18 41/57

POMHUK Rapid Tranquillisation Audit Q4 2016/17 Q2 2017/18 41/58 - 41%

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Page 18 of 35

Clinical Audit Summary Report National Audit of Psychosis The National Audit of Psychosis (NCAP) is one of the largest national audit programmes in Mental Health. It is the second round of the National audit of Schizophrenia which was undertaken in 2011. It has been confirmed that LCFT submitted 100% of all required data, of which only 27% of participating Trusts were able to do so. Following completion of data collection further work is needed to fully understand some of the issues relating to data accuracy. National COPD Audit This is the first time LCFT has taken part in the National COPD audit programme. The audit demonstrates that the 2 sites included in the audit are meeting a number of national standards and are working to a high standard. There are some differences found between the 2 services, this is due to commissioning differences. National Diabetes Foot Care Audit This project audited 5 indicators. LCFT performed above the national average for all 5 indicators. Sentinel Stroke National Audit The above results indicate LCFT are below the national average for 10 indicators included in the national audit. LCFT Community Neurological Rehabilitation Team does not provide a comparable service to an Early Supported Discharge service. The national report makes assumptions in relation to the services available and neurological rehabilitation teams and Early Supported Discharges services have been compared in the national results.

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Page 19 of 35

Caring

This section of the report looks at the domain of caring – that staff involve and treat people with compassion, kindness, dignity and respect. The following


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Page 20 of 35

Friends and Family Test – Results A key part of the Trust’s real time feedback process is the Friends and Family Test (FFT). The Friends and Family Test is a tool that supports the fundamental principle that people who use NHS services should have the opportunity to provide feedback on their experience. It asks people if they would recommend the services they have used and offers a range of responses. When combined with supplementary follow-up questions, the FFT provides a mechanism to highlight both good and poor patient experience. The Friends and Family Test overall response rate has been at or above the target of 95% for 10 of the last 12 months with the target achieved and maintained since January 2017. Data is available one month in arrears due to national reporting dates.

Friends and Family Test – Submissions The number of submissions has notably reduced over the 12 months, however has remained broadly consistent during the last 10 months. There are a number of reasons for this including changes to how the data is captured (such as reducing multiple collection points). Data is available one month in arrears due to national reporting dates.

75%

80%

85%

90%

95%

100%

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

Friends and Family Test Results -Rolling 12 Months

0

500

1000

1500

2000

2500

3000

3500

4000

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

Friends and Family Test Submissions -Rolling 12 Months

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Page 21 of 35

Compliments The number of compliments has been broadly static during the last 12 months.

CQC Community Mental Health Survey The CQC use national surveys to find out about the experience of service users receiving care and treatment from healthcare organisations and mental healthcare providers. CQC asked people to answer questions about different aspects of their care and treatment. Based on their responses, CQC gave each NHS Trust a score out of 10 for each question (the higher the score the better). Each trust also received a rating of ‘About the same’, ‘Better’ or ‘Worse’. Responses were received from 172 people who use services of the Trust. The Trust was rated as “about the same” for all ten questions and each of their sub-questions.

0

200

400

600

800

1000

1200


Compliments - Rolling 12 Months

1

3

5

7

9

Workers

Organising care

Planning care

Reviewing care

Staff changes

Crisis care

Treatments

Support andwellbeing

Overall views

Overallexperience

CQC Community Mental Health Survey

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Page 22 of 35

Responsive

This section of the report looks at the domain of responsiveness – that services are organised so that they meet people’s needs. The following indicators are

covered in the report:

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Page 23 of 35

Complaints The number of complaints has noticeably increased over the 12 months. This reflects a national picture. The predominant themes (from the latest quarterly hearing feedback report) are in relation to access to treatment or drugs (22%), admission and discharge (17.5%), communication (14%), appointments including delays and cancellations (10%) and clinical treatment (9%). Despite the overall increase, the number of upheld or partially upheld complaints remains consistent although there is a noticeable increase in October which will be closely monitored.

Mixed Sex Breaches There have been zero mixed sex breaches over the rolling 12 month period.

0

50

100

150

200


Complaints - Rolling 12 Months

Complaints Upheld Complaints

0

1


Mixed Sex Breaches - Rolling 12 Months

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Page 24 of 35

Well Led

This section of the report looks at the domain of well les – that the leadership, management and governance of the organisation make sure it's providing high-

quality care that's based around individual needs, that it encourages learning and innovation, and that it promotes an open and fair culture. The following


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Page 25 of 35

Care Quality Commission (CQC) Rating) The Trust was last inspected in September 2016 and the overall rating was Good. Two core services were rated as Requires Improvement – community inpatient services and community health services. The CQC inspected healthcare services at HMP Liverpool in September 2017 in a process separate from the main Trust inspection and as part of a joint inspection of HM Inspectorate of Prisons who inspected the prison. The final report was published on 15 December 2017. The joint HMIP/CQC report is due for publication in January 2018.

Core Skills The overall Core Skills rate is above the Trust target of 85% however performance remains below target in:

Manual Handling Level 2 (84.87%)

Basic Life Support (79.18%)

Intermediate Life Support (77.06%)

Safeguarding Children Level 3 (84.85%) The following Essential Skills subjects are also below the 85% target:

Prevent (49.17%)

Mental Capacity Act Level 2 (43.02%)

Mental Health Act Level 2 (44.78%)

Violence Reduction (61.26%)

Safeguarding Adults Level 2 (46.33%)

70%

75%

80%

85%

90%

95%


Core Skills - Rolling 12 Months

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Page 26 of 35

Overdue Incident Reviews The number of overdue incident reports (particularly 7 Day Reviews for incidents categorised as Level 1, 2 or 3) remains high with no improvement over the last 12 months. Targeted work has taken place within the Networks and has seen improvement in the Community and Wellbeing Network in particular. The Mental Health Network accounts for the vast predominance of overdue incidents. Networks have been instructed to take action to remedy this concern by the Quality and Safety Sub-committee.

Accreditations This section is currently under development.

0

1000

2000

3000

Feb Mar Apr May Jun Jul Aug Sep Oct Nov

Overdue Incident Reports - Rolling 12 Months (data available from Feb

2017)

7 Day Reviews 3 Day Reviews

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Page 27 of 35

Concerns Raised During November 2017, the following concerns were reported through the various mechanisms including the Raising Concerns Guardian and through Dear David:



Costs of urgent minor estate works that could be solved through other means, or with less priority;

Several concerns about the lack of parking and the impact on staff safety at West Strand in Preston


Regular low staffing (one nurse and one support worker) on Mallowdale Ward at Guild Lodge;






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 themes from concerns over the year to date are management culture and conduct, demand, staffing and violence. The Mindsmatter service has reported a number of concerns, mainly through Dear David, over the year and support is being provided to the Network to help them identify and address more staff concerns locally.

0

10

20

Apr May Jun Jul Aug Sep Oct Nov

Concerns Raised - Rolling 12 Months(data available from April 2017)

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Quality Plan Dashboard Key: Off Track On Track Complete Data Not Provided

Priority Lead QI Plan CQC Requirements

Process Measures

Outcome Measures

Balancing Measures

Mental Health Clinical Risk Assessment and Management Helen Lilley Holistic Care Planning Patsy Probert Standards of Record Keeping Patsy Probert Staffing for Quality and Safety Paula Flint Seclusion Anne Allison End of Life Care Michaela Toms Supporting Staff following Adverse Events Caroline Waterworth Reduction in Violence and Aggression Caroline Waterworth Pressure Ulcers Michaela Toms Medication Safety Sonia Ramdour Physical Healthcare in Mental Health In-patient Services Debra Wilson Appraisals Damian Gallagher Core Skills Deborah Cox Supervision Gita Bhutani New Professional Roles Patsy Probert Mental Health Law Matthew Joyes

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Quality Plan Summary Report The following exceptions are provided (using November data):

Reducing violence and aggression – significant work is underway however the outcome of a reduction is not being realised across all services. Detailed deep dive presentations are underway to the sub-committee. 226 incidents of physical violence to staff were reported. Following discussion at the last Quality and Safety Sub-committee, the Positive and Safe Group reviewed the range of initiatives being used in the Trust e.g. Safewards, REsTrain yourself, RAID, relational security and violence reduction training. The Associate Director of Safety and Quality Governance has commissioned a review of the totality of the Trust approach to preventing and managing violence and aggression. A refreshed Trust-wide programme will be developed, drawing on the best practice in these programmes and replace all existing initiatives and training with one single and consistent model. The proposed plan of work is:

o December 2017 – Develop the outline of the programme o January 2017 – Start detailed development work on the programme ‘modules’ o February 2017 – Business case to the Senior Leadership Team o March 2017 – Programme detail presented to Quality and Safety Sub-committee for assurance including programme rollout o April 2017 – Programme goes live

It is proposed that the Violence Reduction Team facilitate the development of the programme detail in partnership with clinical leads. To enable this to happen the Violence Reduction Team will prioritise the development of the programme.

Staffing for Quality and Safety – significant work is underway as reported separately, however challenges remain in many services.

Appraisal – there is no information in Life QI. Overall performance is 42.14%.

Core Skills - there is no information in Life QI. Overall performance is 91.9% however the trust is below target in Manual Handling Level 2 (84.87%), BLS (79.18%), ILS (77.06%), Safeguarding Children Level 3 (84.85%), Prevent (49.17%), MCA Level 2 (43.02%), MHA Level 2 (44.78%), Violence Reduction (61.26%), and Safeguarding Adults Level 2 (46.33%). Performance within individual teams is highly variable.

Supervision – work is underway to develop and implement the long term and interim technical solutions; however, data provided to the CQC shows overall supervision at 71% with some services as low as 41% (Community Mental Health Services for Adults).

Mental Health Law – the programme has delivered its improvement work however compliance remains low; percentage of patients given rights within 24 of admission (31%), percentage of CTO patients with rights in place at the begging of the month (70%).

The Executive Director of Nursing and Quality and Associate Director of Safety and Quality Governance will be holding confirm and challenge meetings with each priority lead in January 2018 to ascertain progress.

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Page 30 of 35

Appendix 1 – Extracts from the Quality and Safety Surveillance Report and Mental Health Law Surveillance Report

The Quality and Safety Surveillance Report is designed to provide the Committees and Subcommittee of the Trust Board with a range of indicators that

provide assurance and/or early warning escalation of risk. Risk indicators are used to draw attention to areas of focus. Green flags indicate a measure that is

on target or where performance is in-line with accepted levels. Yellow flags indicate a measure for close watch (perhaps because of a worsening position) or

where a measure is off target but has no immediate risk. Red flags indicate a measure that presents an immediate and/or high level risk. The Quality and

Safety Tile, in the front of this report, is a headline summary of key indicators.

In addition, a Mental Health Law Surveillance Report is produced alongside Network-level Quality Surveillance Report.

The data tables from the Trust Quality and Safety Surveillance Report (monthly) and Mental Health Law Surveillance Report (quarterly) are included in this

Quality and Safety Report for additional information and context.

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Page 31 of 35

Domain Indicator Target Dec Jan Feb Mar Apr May Jun Jul Aug Sep Oct Nov12 months

total

12 months

averageSparkline Risk

Incidents n/a 1867 2094 2345 2358 2168 2090 2329 2270 17521 2190.1

Incidents with harm n/a 404 436 487 547 437 473 535 462 3781 472.6

STEIS-reportable serious incidents n/a 6 7 9 4 9 8 10 4 11 8 10 5 91 7.6

RIDDOR incidents n/a 6 2 0 3 4 5 2 6 1 6 1 1 37 3.1

Never Events 0 0 0 0 0 0 1 0 0 0 0 0 0 1 0.1

Medication incidents n/a 127 149 177 150 148 183 186 9 1129 141.1

Infection control Serious HCAI incidents 0 4 1 0 1 1 0 1 0 0 1 0 0 9 0.8

Use of restraint n/a 252 189 263 308 329 300 400 461 335 346 398 362 3943 328.6

Use of seclusion n/a 85 65 73 68 66 64 65 93 579 72.4

Safeguarding alerts n/a 100 158 138 129 130 95 152 116 1018 127.3

Potentially avoidable grade 3 and 4

pressure ulcersn/a 0 0 2 0 2 0 5 1 2 0 1 0 13 1.1

Number of instances of 1 or less

qualified on duty (inpatients)0 207 192 170 145 139 197 140 132 177 132 84 74 1789 149.1


(inpatients only)n/a 261 260 268 221 195 270 227 228 258 228 137 111 2664 222.0

Staff safetyPhysical violence to staff from

patients n/a 137 140 129 151 155 150 218 268 220 223 219 226 2236 186.3

Legal Regulation 28 Notices received n/a 0 0 0 1 0 0 1 1 0 0 0 0 3 0.3

QUALITY AND SAFETY SURVEILLANCE - Safe

Incidents

Patient safety

Staffing

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

Pressure ulcers (%) - 3.96% 2.72% 2.91% 5.27% 3.45% 3.45% 4.04% 3.05% 3.12% 2.55% 2.72% 2.57%

Falls with harm (%) - 1.29% 1.28% 1.64% 1.55% 1.55% 0.60% 0.75% 1.21% 0.64% 0.93% 0.53% 0.53%

Catheter and UTI (%) - 0.18% 0.64% 0.27% 0.26% 0.43% 0.45% 0.27% 0.21% 0.07% 0.23% 0.15% 0.08%

VTE (%) - 0.55% 0.08% 0.36% 0.35% 0.35% 0.15% 0.69% 0.43% 0.43% 0.93% 0.38% 0.23%

Physical Health HFC Rate (%) 95% 94% 95% 95% 93% 94% 96% 94% 95% 96% 96% 96% 97%

Self harm (%) - 3.35% 4.04% 3.55% 3.43% 3.56% 3.76% 3.75% 4.37% 4.63% 3.71% 3.59% 4.22%

Victim of violence (%) - 1.89% 1.62% 2.71% 1.07% 2.30% 1.46% 2.50% 1.66% 1.89% 1.75% 3.17% 2.53%

Feel unsafe (%) - 9.22% 6.26% 8.35% 9.01% 9.62% 10.65% 7.08% 7.90% 10.53% 8.08% 11.21% 7.81%

Omission of medication (%) - 18.87% 13.74% 16.08% 17.17% 17.99% 18.37% 23.54% 20.37% 19.79% 20.09% 24.10% 19.62%

Restraint (%) - 6.29% 4.65% 4.80% 3.65% 5.23% 5.43% 7.08% 6.86% 7.16% 5.68% 4.86% 5.91%

Mental Health HFC Rate (%) 90% 83% 86% 84% 85% 83% 83% 84% 81% 80% 84% 80% 83%

QUALITY AND SAFETY SURVEILLANCE - Effective12 months average

3.3%

1.0%

0.3%

83.0%

Physical Health

Harm Free Care

Mental Health

Harm Free Care

0.4%

19.1%

5.6%

95.1%

3.8%

2.0%

8.8%

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Page 33 of 35


total

12 months


F&F Test 95% 87% 96% 96% 96% 96% 97% 95% 97% 97% 97% 95% 95.28%

F&F Test - Response Rate n/a 1744 1659 2042 1562 1263 1815 1218 1241 1652 923 1669 1526.2

Compliments Compliments n/a 529 678 1031 788 593 987 697 774 819 537 549 807 8789 732.4

QUALITY AND SAFETY SURVEILLANCE - Caring

Friends & Family -

Patients

The Friends and Family Test real time reporting is locked and nationally reported on the 19th of each month and will therefore be reported in arrears most months

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Page 34 of 35

Domain Indicator Target Dec Jan Feb Mar Apr May Jun Jul Aug Sep Oct Dec12 months

total

12 months


Complaints n/a 150 114 111 167 95 108 152 134 173 149 145 137 1635 136.3

Upheld/partially upheld complaints n/a 26 22 21 31 26 23 19 24 22 21 43 28 306 25.5

Completed within agreed timeframe

(%)n/a 54.0% 50.0% 104.0% 52.0%

Reopened complaints n/a 3 3 4 2 4 4 7 5 0 0 3 3 38 3.2

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

MP enquiries n/a 7 13 9 15 7 8 5 9 11 5 12 8 109 9.1

Environment Mixed Sex Breaches 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0.0

QUALITY AND SAFETY SURVEILLANCE - Responsive

Complaints

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Page 35 of 35


total

12 months


Trust CQC rating Good RI Good Good Good Good Good Good Good Good Good Good Good

Regulatory inspections/visits n/a 4 5 4 3 4 3 2 1 2 1 4 33 3

CQC notifications n/a

Core Skills (%) 85% 88.24% 89.07% 89.41% 90.68% 90.33% 89.26% 91.06% 91.55% 90.81% 90.87% 91.64% 92.12% - 90.42%

Supervision (%) n/a

Appraisals (%) n/a 42.14% - 42.14%

Overdue 3 day reviews 0 105 80 71 65 77 82 74 59 97 103 813 81.30


Overdue incident actions 0 94 150 - 122

Duty of candour breaches 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0.00%

Overdue safety alerts 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0.00%

Concerns raised n/a 9 17 26 13

Quality Plan priorities off track 0 0 0 0 0 5 - 1

Quality assurance visits n/a 1 0 0 0 2 1 4 0.67

Assurance

QUALITY AND SAFETY SURVEILLANCE - Well Led

Regulatory

People

Good

Learning and

candour

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Board of Directors


Report Title Performance Report

FOIA Exemption No Exemption Choose an item.

Prepared by Louise Corlett, Head of Business Intelligence

Presented by Sue Moore, Chief Operating Officer

Action required Noting

Supporting Executive Director Chief Operating Officer


Report purpose To appraise the Board of Directors of key elements and themes from the Month 8 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

PAPER DEVELOPMENT PROCESS:

Meeting Presented Action Date

The Board is asked to note the QPR for month 8 with following comments below:

All NHS I metrics are compliant with the exception of the Early Intervention in Psychosis 2 week target.

The measures within the Board Balanced Scorecard continue to show the challenges faced by the

organisation currently in relation to our financial position and attracting the best people. The Service

Delivery domain of the Board Balanced Scorecard will be developed over future months to contain a

summary of the 5YFV dashboard of performance metrics.

A new 5YFV dashboard is included in the main body of the QPR. This will be developed over future

months and currently shows the new Eating Disorders access standards. The 5YFV states a requirement

to achieve a 1 week wait for urgent referrals and a 4 week wait for routine referrals for 95% of patients

by 2020. The trajectory of improvement has not been confirmed with LCFT, but will be included in the

dashboard once available.

Work has been conducted on the new NHS I measure for Inappropriate Out of Area Placements. A

trajectory has been submitted by the STP and the performance against trajectory will be included in the

QPR from next month. Discussions have taken place with NHS I and NHS E regarding the application of

the definition to ensure appropriate interpretation and reporting.

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As there is now a specific Quality Report, this cover sheet no longer references the Quality metrics

available within the QPR.

Are we SAFE?

The current CQC rating is ‘requires improvement’

Our performance in completing appraisals and mandatory training was a contributory factor in the CQC rating

for this domain. Overall the Trust is compliant against our 85% target for Mandatory Training at 92% for month

8. However, for some training courses performance is below 85% (page 134). These hotspots are being closely

monitored to ensure ongoing improvement. Appraisal continues to be a challenge however, the position is

improving and is being kept under close monitoring (page 134).

The use of contingent staffing (and therefore bank and agency spend) continues to be an area of concern.

Weekly task and finish meetings are in place and are focussed on interventions to deliver an improvement on

the position. In addition, a series of meetings have been held with a number of wards where use of contingent

staffing is greatest. These meetings have been chaired by the Executive Director of Nursing to understand the

detail of the issues impacting upon staffing for safety and quality. This exercise has proved valuable and has

provided an informative insight into challenges faced by individual wards. A full report will be submitted to

Finance Recovery Group in due course.

Are we CARING?

The current CQC rating is ‘Good’.

Attendance at CPA reviews by care coordinators in secure services has been an issue over a protracted period of

time. Despite assurances that this will be resolved, disappointingly, performance this month has fallen short of

the internal target of 80%. For inpatient reviews, 72% was achieved (page 33) and for community reviews 45.5%

was achieved (page 37). The Chief Operating Officer will be intervening directly and will be writing to each

individual involved to set out expectations. A failure to improve will be treated as a performance issue.

There has been a gap in reporting of patients on the mental health caseload who have not had a care

coordinator allocated –‘unallocated cases’. This was due to the script for the report from the data warehouse

being deleted in error. The report has been rebuilt and shows that for the Mental Health Network, the number

of unallocated patients has reduced significantly during month 8, whilst the number in the Children and Young

People’s Network has been maintained at a very low level (page 72).

Are we EFFECTIVE?


The improvement in the readmission rate for both 30 and 90 days, across both adult and older adult services,

has been retained for the fifth consecutive month. The standard of below 8.7% for readmissions within 30 days

was achieved for both adult and older adult patients. For 90 day readmissions, the target number of 28 was not

met for adult patients with 31 patients readmitted in month 8 (page 69&70). Despite this, the current position is

a marked improvement on the first 6 months of the calendar year and continues to reflect the work the Mental

Health Network has undertaken to raise the profile of this measure.

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Average Length of stay (ALOS) (on discharge) has risen for the adult patient cohort to 43.9 days, which is above

the 31 day standard and represents an increase of 5 days from last month (page 67). The length of stay on adult

wards includes PICU patients, however, it is noted that PICU length of stay has remained static at 34 days (page

66). It is inevitable that the LOS will be variable as patients are discharged, therefore the QPR now contains a

graph to illustrate the LOS profile of current inpatients (page 67) in order to provide a more rounded picture.

Currently, there are 19 adult and 9 PICU patients. The information provided in the graph on page 67 will be used

to chart the number of patients in the higher LOS bands over time. This will demonstrate the impact of the

current focus on the patients with LOS of greater than 180 days.

Are we RESPONSIVE?


The Trust continues to meet all NHS I indicators with the exception of the Early Intervention in Psychosis 2 week

RTT standard.

As reported in the Month 6 QPR, an issue has been identified regarding performance in the Early Intervention in

Psychosis service against the 2 week target. Current performance falls significantly below the required 50% and

in month 8 is 23.9%. This is a marked improvement on the position reported in month 7 of 9.5% (Page 48).

Progress on implementing the actions identified in the remedial action plan are on track and continue to be

monitored through a fortnightly task group.

Daily teleconferences with team leads are being maintained to provide operational support to the team leaders.

This has led to a dramatic reduction in the number of ‘legacy’ patients in the system (61 patients in month 7 to

17 in month 8). However, this has impacted upon our reported performance. The daily call is also facilitating

current referrals to be managed in accordance with the 2 week standard, notwithstanding patient choice (which

is expected to be exacerbated over the festive period) and timely referral which both challenge our achievement

of the target.

A further update on progress has been provided to SLT where it was confirmed that December’s performance at

this stage is compliant (57% on the 18th Dec). The improved performance in December will improve the Quarter

3 performance. However, the numbers of patients meeting the target are insufficient to recover the Quarter 3

performance to meet the 50% target.

Responsiveness is also demonstrated through our achievement of the 18 week referral to treatment (RTT)

standard for AHPs and for dental waiting times. In the Community Wellbeing Network, the dental service RTT in

Liverpool prison has maintained 100% following the failure to meet the 95% target in month 6 (page 24). The

Community Well Being Network are compliant against all contractual RTT measures (page 24).

In the Children and Young People’s Wellbeing Network, 3 out of 5 services are compliant in month 8 against the

18 week RTT, which maintains the improvement seen for the last 3 months.

The 2 areas of performance that remain challenged are Child Psychology and CAMHs Tier 3.

Child Psychology: Performance for month 8 has achieved 86% against the 92% target for incomplete pathways

(page 50 and 51).

Whilst this is a deterioration from last month’s position of 89%, it reflects a slight increase in the number of

children on the waiting list who have waited greater than 18 weeks (37 in month 8, compared to 32 in month 7).

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However, the total number of patients on the waiting list has reduced (270 from 290 last month) affecting the

overall percentage compliance. At the current waiting list size of 270 patients, the service needs to achieve less

than 21 children waiting over 18 weeks.

It is notable that the Preston Community Child Psychology team have achieved the 92% target this month for

the first time. Therefore, the focus is now on resolving capacity issues in the Preston Hospital and Lancaster

team (who have the majority of long waiters) in order to offer children who have waited greater than 18 weeks

appointments for treatment.

CAMHS Tier 3: Conversely, performance in the CAMHS Tier 3 service continues to perform significantly below

the standard for incomplete pathways. Month 8 performance was 60% compared to 56% in month 7 against the

92% standard (page 52 and 53).

The overall number of children waiting beyond 18 weeks for treatment has fallen from 289 to 228. This

improvement is masked in the percentage described above because the waiting list size has dropped in parallel.

The Chorley and South Ribble team continue to be the main contributor to the under-performance and have

197 children waiting longer than 18 weeks, but again this is an improved position compared to the 264 reported

last month.

A focus on contacting the longest waiters is being maintained to enable validation of the waiting list and

allocation/arrangement of appointments in waiting time order. Gaps in capacity to enable maximum activity are

being progressed through recruitment. Further improvement is expected from month 10.

In Mindsmatter, a number of measures are monitored that indicate our overall responsiveness. The service

continues to perform well against the NHS I indicators for referral to treatment in 6 and 18 RTT weeks and also

the percentage of patients entering recovery (page 24).

Performance against prevalence continues to be challenging at team level. Cumulative prevalence is being

measured against the current target and also the trajectory required to meet the 16.8% by Q4 (with the

exception of Blackburn with Darwen and St Helens). In month 8, St Helens and Greater Preston CCGs failed to

meet the monthly prevalence targets. In depth monitoring is being maintained, as are a number of interventions

to increase prevalence (page 42-45). A result of the focus on prevalence is an increase in the patient caseload

for onward treatment and, in particular, CBT. This, along with a reduction in capacity resulting from vacancies

and sickness, has caused an upward surge in the number of patients waiting longer than 26 weeks for

treatment. In month 8, 59 patients exceeded 26 weeks compared to 14 last month (page 46 and 47). As

discussed at Trust Board last month, this is an increasing trend, the detail of which is provided on page 46.

Patients who have waited over 26 weeks are being individually managed and a plan is being implemented for

each patient. A prospective report is available to support teams to plan for people nearing the 26 week mark

and prevent the increase in this cohort in future months.

The high demand for inpatient beds continues, with occupancy levels exceeding 100%. Consequently, the

number of out of area placements (OAPs) continues to exceed plan and have increased to an average across the

month 8 of 29.93 (page 59). Work on reducing the number of patients who have a length of stay of greater than

180 days continues, as identification of alternative provision would potentially enable the resolution of the OAPs

position. The Network has secured support for the implementation of an integrated discharge team during

December and have established delegated authority to progress placements up to an agreed maximum value in

order to expedite appropriate patient discharge.

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Mental health liaison teams (MHLT) are reporting 8 12 hours breaches for month 8. This maintains the

improvement seen in recent months and is the third month that less than 10 breaches have been reported

(page 27 and 28). This demonstrates the impact of the significant operational management oversight on patient

flow and ensuring patients access care in a timely manner. Demand for the teams continues to be challenging

and performance against the 1h and 4h metrics remains below target. However, it is encouraging that the

number of 4 hour breaches have dropped below 100 for the first time since May 17, with 80 in month 8 (page

27 and 28). Ongoing improvement is expected over coming months given the early investment that has been

secured around Core 24.

Are we WELL-LED?


As reported last month, the staff engagement score for the Q2 position shows a static position with only a

decimal point increase on the Q1 position. A further update will be available after Q3.

Sickness rates for the organisation as a whole are static at 6.8%, and off track in relation to achieving a 4.5%

target (page 133). In month, there are some minor fluctuations at Network level, with a small decrease in the

Mental Health Network and Children and Young People rates, whilst a small increase in Community Wellbeing

Network rate. Work continues on absence management across all areas in accordance with policy.

The Business Development and Delivery Sub-committee meeting received each of the 3 Network Reports for

month 8; the links for which are provided below –

https://www.lancashirecare.nhs.uk/media/Trust%20Board/Trust%20Board%20Documents/Network%20

Reports%20-%20Dec%202017.pdf

The COO, as Chair for the group also received a report on the services that have been under-performing for 6

months or more. The purpose of this was to re-set the expectation that recovery of performance needs to be

expedient and effective within a 6 month window.

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.

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https://www.lancashirecare.nhs.uk/media/Trust%20Board/Trust%20Board%20Documents/Network%20Reports%20-%20Dec%202017.pdf

https://www.lancashirecare.nhs.uk/media/Trust%20Board/Trust%20Board%20Documents/Network%20Reports%20-%20Dec%202017.pdf

Quality & Performance

Report

Month 8 – November 2017

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Performance Management

Quality and Performance Report:-

Section 2:- Performance and Data Quality

Section 2.1:- Performance Activity

• NHS Improvement Indicators Dashboard • 5 Year Forward View 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 • Community & Wellbeing – Activity Exception Reports by CCG • Children & Young People’s Wellbeing – Service Line Totals • Children & Young People’s Wellbeing – Exception Reports by

Service • Children & Young People’s Wellbeing – Total Activity Split by CCG • Mental Health – 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 and Safety Tile • Quality Surveillance – Safe • Quality Surveillance – Effective • Quality Surveillance – Caring • Quality Surveillance – Responsive • Quality Surveillance – Well Led • Audits • 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

Appendix 1:- Southport & Formby

• NHS Improvement Indicators Dashboard • NHS Improvement Indicators Kitemarking • Southport & Formby Summary • Finance & Contracting • Quality • Workforce

65 of 255


Board Balanced Score Card

Section 1

3

66 of 255


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

Sep Oct Nov

60 52 115

Business Gained - Lost

Sep Oct Nov

-£602,688 -£51,600 -£400,000

OAPS

Sep Oct Nov

26.17 24.58 29.93

NHSI Compliance

Sep Oct Nov

92.9% 92.9% 92.9%

Sickness Absence

Sep Oct Nov

6.35% 6.88% 6.84%

Agency Ceiling

Sep Oct Nov

-222,185 -132,475 -64,550

UoR

Sep Oct Nov

3 3 2

Revenue Control Total

Sep Oct Nov

-1.4% -1.2% -0.8%

CIP

Sep Oct Nov

86% 88% 87%

Liquidity

Sep Oct Nov

1 1 1

1. Board Balanced Score Card Summary

Capital Expenditure

Sep Oct Nov

29% 31% 32%

Contract Performance (MH)

Sep Oct Nov

+0.84% -0.84% -0.75%

Contract Performance (Comm)

Sep Oct Nov

-0.4% -0.6% 2.1%

Engagement Score

Q4 16-17 Q1 17-18 Q2 17-18

3.77 3.73 3.74

National COPD Audit

Programme

Report due Feb

2018

Use of depot/LA

antipsychotics for relapse

prevention – baseline audit

Report due date TBC

Prescribing for bipolar

disorder (use of sodium

valproate) re-audit

Report due Feb 2018

Quality Plan

17/18 objectives 16

On track Off track

10 6

Service Delivery Quality & Safety

People & Leadership Finance

5

Prescribing of high dose

antipsychotics

Acute wards & PICU rank 14/57

Secure Services 20/46

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1. Board Balanced Score Card Quality & Safety

Quality Plan

The following prioritised areas are off track: staffing for quality and safety, violence reduction, appraisals, core skills, supervision

and mental health law. In most cases, this is due to the outcomes/improvements not being achieved within the intended

timescale. Exception reporting for each priority is included in the Quality and Safety Report to the Trust Board.

Target: 16 objectives

On track 10 Off track 6

Research Studies

Data is subject to a 6-8 week lag as it is uploaded by research teams to a national system retrospectively. Recent recruitment

to the SSHEW clinical trial has an additional 5 weeks until randomisation, leading to significant lag in recruits appearing in

national figures. Local data shows that activity is currently forecast to exceed this year’s annual target. Target: 100 participants monthly

115

6

National Audit –

National COPD Audit

Programme

The aim of the project is to audit the activity of the 2 LCFT PR programmes against BTS Quality standards for Pulmonary Rehabilitation in Adults

and compare results with the initial audit which took place in 2015.

The report is due February 2018. Target: Upper quartile nationally

National Audit –

Prescribing for bipolar disorder

(use of sodium valproate) re-

audit

The aim of this topic is to identify any improvement in practice around prescribing in bipolar since the initial audit carried out by POMH-UK.

The report will be published Feb 2018.

Target: Upper quartile nationally

National Audit –

Use of depot/LA antipsychotics

for relapse prevention –

baseline audit LCFT have been notified of a delay in the report being published. POMH-UK have not provided a new release date.


National Audit –

Prescribing of High dose

antipsychotics

A total of 3 standards were included in the audit. The results demonstrated the trust was in the upper quartile for 2 standards.

These standards assessed that the dose of an antipsychotic was within SPC/BNF limits and that only one antipsychotic should

be prescribed at a time. Upper quartile performance was not achieved for standard 3, this was a newly introduced audit

standard. However, overall across all 3 standards acute wards and PICUs were in the upper quartile nationally. Secure Services

were not in the upper quartile, this was a smaller sample than for acute wards and PICUs and an improvement plan has been

developed.


Achieved

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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 increased in November by 5.35 alongside an increase in the OAP OBD in November with a position of 898, an

increase of 136 from October. The overall number of OAPs again remains relatively static against an assumed fall in the trajectory. It is anticipated

that the operationalization of the Integrated Discharge Team in December will begin to reduce the number of 180+ day length of stay patients,

ensuring that they access a more appropriate care environment.

Target: 15 contracted beds

29.93

Contract Activity - Community

Target achieved. Target: 100% (+/-10%)

2.1%

Contract Activity – Mental

Health

Target achieved. Target: 100% (+/-10%)

-0.75%

NHSI Compliance

All NHSI measures are compliant for M8 except for EIP (MR13) which has been under a period of revalidation and investigation. Work within the

Network is currently ongoing and it is anticipated that performance will improve for quarter 4. Target: 100% in each quarter

92.9%

7

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Agency Ceiling

Agency usage in the Prison Service has remained relatively steady

(month-on-month). Community has seen a small increase due to an

increased number of vacancies. Inpatient wards have seen a reduction

in Agency usage as the effects of recruitment to substantive vacancies

and the efforts of the Staffing for Safety & Quality Task Group and

Carter/NHSI activity have begun to be applied.

Target: 641,250

Not achieved

1. Board Balanced Score Card People & Leadership

Sep Oct Nov

YTD Target 641,250 641,250 641,250

YTD Actuals 863,435 773,725 705,800

Under/(Over)

Agency

Usage

-222,185 -132,475 -64,550

Engagement Score Q2 2017/18 period results :

• Recommend LCFT as a place to receive treatment (Workforce Advocacy): Yes – 71.41%, No – 10.31%, Don’t Know – 18.28%

• Recommend LCFT as a good place to work: (Workforce Involvement and Motivation): Yes – 51.75%, No – 27.35%, Don’t Know – 20.89%

Improvement Initiatives:

A Wellbeing dimension has been added to the Quarterly Staff FFT questionnaire. This supplements the 3 existing dimensions of Advocacy,

Motivation and Involvement. The first Staff FFT report to include this new dimension will be available in January 2018.

Target: Top 25% of other Trusts

Not achieved

Sickness Absence

The sickness absence rate for November has decreased, reporting at 6.84%. Please refer to the relevant M8 QPR detailed slides for information

about Improvement plans and initiatives. Target: 4.5%

6.84

8

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1. Board Balanced Score Card Finance

Use of Resources (UoR)

The improved I&E position now yields a rating of 3 and a Capital Service rating of 3 improving the overall UoR to a 2 ( 3 at Month 7). Assuming

current pressures and risks are addressed through the recovery plan and I&E performance achieves (or exceeds) forecast the Trust will achieve

a UoR of 2 in line with the plan. Target: 2

2

Capital Expenditure

Progress against the capital programme has been slow to date with expenditure at £2.1m against the original profile of £6.6m.

With the resolution of a number of issues the Trust is working with contractors to minimise the impact of delays on the

programme though the initial work indicates some slippage on the Inpatient and Perinatal schemes is now inevitable. Target: 85-100%

32%

Revenue Control Total The Trust has developed a recovery plan to enable it to achieve its the Control Total. Improvements in performance are evident, but continued

delivery will only be achieved with a considerable coordinated and sustained effort across the organisation and though the Trust is currently

forecasting achievement of the control total for 2017/18 a number of risks and pressures remain that if not addressed may compromise the

position.

Target: ≥0%

-0.8%

Cost Improvement

Programmes (CIPs) At £8.5m in month 8 the Trust is c£1.3m behind the plan of £9.8m. The adverse variance is attributable to a lack of performance on Run Rate

Reduction Programmes on staffing pressures. The Trust continues to invest significant time and effort in managing and developing compensating

CIPs and network management are being supported to implement measures aimed at improving the position. Target: ≥100%

87%

Liquidity

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

1

9

*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

10

Section 2:- Performance and Data Quality

Section 2.1:- Performance Activity

• NHS Improvement Indicators Dashboard

• 5 Year Forward View 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

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Performance Activity

Section 2.1

11

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2.1 Performance Activity NHS Improvement Indicators Dashboard

12

.

Indicator Target Dec-16 Jan-17 Feb-17 Mar-17 Apr-17 May-17 Jun-17 Jul-17 Aug-17 Sep-17 Oct-17 Nov-17 Q1 17-18 Q2 17-18 YTDRolling 12

Month Sparkline

MR01 - 7 Day Follow Up 95.00% 98.2% 98.8% 96.1% 97.6% 98.6% 96.8% 95.9% 94.1% 96.8% 99.5% 98.0% 96.9% 97.1% 96.7% 97.03%

MR02 - CPA Review within 12 Months 95.00% 97.8% 96.9% 97.1% 97.5% 97.0% 97.1% 96.1% 95.9% 97.0% 96.4% 96.5% 96.5% 96.7% 96.4% 96.55%

MR03 - Mental Health Delayed Transfers of Care ≤ 7.5% 4.19% 3.81% 2.84% 2.59% 3.01% 3.21% 3.36% 2.80% 2.52% 2.77% 2.65% 2.18% 3.19% 2.70% 2.81%

MR05 - RTT - Consultant Led (Completed Pathway) 95.00% 96.3% 96.7% 97.6% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 100.00%

MR06 - RTT - Consultant Led (Incomplete Pathway) 92.00% 95.4% 97.3% 100.0% 99.2% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 99.7% 99.3% 100.0% 100.0% 99.85%

MR07 - IP Access to Crisis Res. Home Treatment 95.00% 100.0% 98.6% 99.4% 97.7% 100.0% 100.0% 99.5% 100.0% 100.0% 100.0% 100.0% 100.0% 99.8% 100.0% 99.93%

MR08 - MH Data Completeness - Identifiers 97.00% 99.6% 99.6% 99.6% 99.6% 99.6% 99.6% 99.7% 99.4% 99.4% 99.4% 99.4% 99.4% 99.6% 99.4% 99.50%

MR09 - MH Data Completeness - Outcomes 50.00% 83.8% 83.4% 83.2% 83.4% 83.7% 82.2% 81.8% 81.8% 81.7% 80.8% 81.2% 82.5% 82.5% 81.4% 81.92%

MR13 - 2 Week wait for Treatment for EIP Programme 50.00% 76.7% 82.0% 81.4% 74.4% 11.1% 7.1% 0.0% 9.5% 11.8% 15.6% 9.5% 23.9% 6.0% 12.6% 12.24%

MR14 - RTT - IAPT 6 Weeks 75.00% 96.5% 95.1% 95.7% 93.4% 96.4% 94.7% 95.1% 94.5% 94.4% 94.5% 94.6% 94.8% 95.4% 94.4% 94.84%

MR15 - RTT - IAPT 18 Weeks 95.00% 99.8% 99.4% 99.8% 98.8% 99.4% 99.2% 99.7% 99.3% 99.4% 99.5% 99.7% 99.8% 99.5% 99.4% 99.50%

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2.1 Performance Activity 5 Year Forward View Dashboard

13

.

Note: Remaining measures are in development.

Indicator Target Q2 16-17 Q3 16-17 Q4 16-17 Q1 17-18 Q2 17-18 YTD

Rolling

12 Month

Sparkline

Eating Disorders (Urgent) TBC 16.7% 23.5% 10.0% 41.7% 57.1% 49.40%

Eating Disorders (Routine) TBC 46.9% 58.3% 47.1% 57.1% 89.7% 73.44%

CYP Access Target TBC - - - - - -

Inappropriate OAPS TBC - - - - - -

MHSDS Data Quality Maturity Index TBC - - - - - -

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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

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Trust position for Lancashire CCGs:

- In Month 8, achieved a performance of 96.3% against a target

of 95% across 8 CCGs.

CCG position:

- In Month 8, the Trust has underperformed in 3 CCGs: Blackburn

with Darwen, Blackpool and West Lancs.

Unassigned CCG:

- In Month 8, there were 4 records unassigned a CCG, of which

100% (4) were completed.

16


- In Month 8, the Trust has achieved a performance of 96.7%

against a target of 95% across 8 CCGs.

CCG position:

- In Month 8, the Trust has achieved compliance for all CCGs.

Unassigned CCG:


84.74% (50) were completed.

CPA 12 Month Review 7 Day Follow Up

2.1 Performance Activity NHS Improvement Indicators reported by CCG

Note: The total figures in the tables above differ from page 12 as they are

representative of only 8 contracted CCGs.

Jul-17 Aug-17 Sep-17 Oct-17 Nov-17

95.3% 98.8% 96.7% 95.6% 97.1%

95.5% 96.2% 96.8% 95.5% 95.3%

95.1% 96.6% 94.0% 95.3% 97.2%

95.6% 96.0% 96.0% 96.5% 95.6%

95.6% 98.0% 98.0% 99.6% 100.0%

97.9% 98.4% 98.2% 98.0% 96.1%

97.0% 95.5% 96.8% 96.1% 96.3%

95.6% 96.9% 95.2% 97.8% 99.1%

96.0% 97.1% 96.5% 96.6% 96.7%

12 month CPA

NHS Blackburn with Darwen CCG

NHS Blackpool CCG

NHS Chorley & South Ribble CCG

Total Figure - 8 CCGs

NHS East Lancashire CCG

NHS Fylde & Wyre CCG

NHS Greater Preston CCG

NHS Morecambe Bay CCG

NHS West Lancashire CCG


90.9% 94.7% 100.0% 100.0% 94.1%

100.0% 92.9% 96.2% 100.0% 93.9%

83.3% 100.0% 100.0% 100.0% 95.2%

95.7% 100.0% 100.0% 98.0% 100.0%

95.5% 100.0% 100.0% 100.0% 95.8%

94.7% 100.0% 100.0% 93.8% 96.9%

100.0% 86.7% 100.0% 95.0% 100.0%

90.9% 100.0% 100.0% 100.0% 88.9%

94.6% 97.2% 99.5% 97.9% 96.3%Total Figure - 8 CCGs

7 DFU CCG


NHS Blackpool CCG







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Delayed Transfers of Care (DToC)

17

IP Access to Crisis Resolution Home Treatment



against a target of <7.5% across 8 CCGs.

CCG position:


Unassigned CCG:


100% (9) were completed.


- In Month 8, the Trust has achieved a performance of 100%


CCG position:



1.57% 1.56% 1.55% 1.63% 1.60%

0.00% 0.09% 2.32% 2.00% 0.91%

6.70% 3.82% 2.64% 4.05% 2.28%

2.69% 2.53% 2.92% 3.91% 4.26%

3.37% 2.80% 2.21% 2.11% 0.48%

4.49% 4.63% 3.56% 2.64% 2.99%

0.00% 0.13% 2.09% 0.00% 0.00%

0.00% 3.67% 4.28% 4.98% 0.00%

2.55% 2.47% 2.72% 2.61% 2.11%

DToC


NHS Blackpool CCG





NHS Lancashire North CCG




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%







% IP Access to CRHTT


NHS Blackpool CCG


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RTT – Consultant Led (Completed Pathway)

18

RTT – Consultant Led (Incomplete Pathway)


- In Month 8, the Trust has achieved a performance of 100%


CCG position:





CCG position:


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% - -

- - - 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%

RTT Complete


NHS Blackpool CCG









- - - - -

- 100.0% 100.0% - -

100.0% 100.0% 100.0% 100.0% 100.0%

- 100.0% - - -

- 100.0% - - -

100.0% 100.0% 100.0% 99.4% 98.9%

- 100.0% 100.0% 100.0% -

- - - - -

100.0% 100.0% 100.0% 99.7% 99.3%

RTT Incomplete


NHS Blackpool CCG








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MH Identifiers

19

MH Outcomes




CCG position:


Unassigned CCG:

- In Month 8, there were 3426 records unassigned a CCG, of

which 94.48% (3237) were completed.




CCG position:


Unassigned CCG:


82.04% (137) were completed.


99.8% 99.8% 99.8% 99.8% 99.7%

99.7% 99.7% 99.8% 99.8% 99.8%

98.8% 98.8% 98.8% 98.9% 98.9%

99.8% 99.8% 99.8% 99.8% 99.7%

99.7% 99.7% 99.7% 99.7% 99.7%

99.6% 99.6% 99.6% 99.6% 99.6%

99.7% 99.7% 99.7% 99.6% 99.6%

99.7% 99.7% 99.7% 99.6% 99.6%

99.6% 99.6% 99.6% 99.6% 99.6%

MH Identifiers


NHS Blackpool CCG









76.0% 74.7% 72.9% 73.8% 74.6%

77.7% 78.6% 78.1% 79.3% 82.8%

86.6% 86.0% 85.0% 84.2% 85.0%

83.4% 83.4% 82.8% 82.5% 83.0%

84.8% 84.9% 86.0% 85.8% 89.4%

80.6% 80.9% 80.4% 80.5% 80.9%

90.1% 89.4% 89.0% 89.9% 91.0%

78.1% 78.2% 75.6% 75.2% 77.4%

81.9% 81.7% 80.9% 81.3% 82.7%

MH Outcomes


NHS Blackpool CCG








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2ww EIS

20


- In Month 8, the Trust has achieved a performance of 23.9% against

a target of 50% across 8 CCGs.

CCG position:

- In Month 8, the Trust has underperformed in 4 CCGs: Blackburn

with Darwen, Blackpool, East Lancashire and Greater Preston.

Due to ongoing validation, CCG split is only available from October.


- - - 16.7% 9.1%

- - - 0.0% 0.0%

- - - 0.0% 50.0%

- - - 0.0% 27.8%

- - - 0.0% -

- - - 0.0% 0.0%

- - - 50.0% 50.0%

- - - 0.0% 100.0%

- - - 9.5% 23.9%

2ww EIS


NHS Blackpool CCG








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IAPT – 6 Weeks

21

IAPT – 18 Weeks




CCG position:





CCG position:



78.7% 82.0% 83.8% 79.6% 85.7%

95.6% 95.1% 99.1% 92.4% 93.6%

98.1% 97.5% 97.4% 97.4% 96.9%

94.1% 96.7% 94.4% 97.8% 96.3%

94.4% 91.9% 94.8% 99.2% 94.4%

91.1% 92.4% 90.4% 88.7% 93.3%

93.9% 98.6% 92.7% 98.5% 93.9%

93.6% 93.8% 94.1% 94.2% 94.1%

RTT IAPT 6 Wks


NHS Blackpool CCG


Not Commissioned








100.0% 100.0% 100.0% 100.0% 100.0%

100.0% 99.2% 100.0% 100.0% 100.0%

100.0% 100.0% 100.0% 100.0% 100.0%

97.1% 98.9% 98.9% 100.0% 98.8%

99.2% 98.1% 98.7% 100.0% 99.1%

96.7% 100.0% 97.9% 98.1% 100.0%

100.0% 100.0% 100.0% 100.0% 100.0%

99.2% 99.4% 99.4% 99.8% 99.7%



Not Commissioned





RTT IAPT 18 Wks


NHS Blackpool CCG


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2.1 Performance Activity Summary – Mental Health

22

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

Sparkline

NHS Improvement

CPA 7 Day Follow Up (Total Network Performance) NHSI 95% 98.1% 98.7% 96.7% 97.8% 98.5% 96.8% 95.7% 94.3% 96.6% 99.4% 97.8% 97.1%

CPA 7 Day Follow Up (AMH) NHSI 95% 98.4% 98.5% 96.9% 98.4% 98.9% 96.9% 96.2% 94.4% 96.0% 99.4% 97.5% 97.3%

CPA 7 Day Follow Up (OA) NHSI 95% 95.7% 100.0% 95.0% 93.5% 96.2% 100.0% 96.0% 92.3% 100.0% 100.0% 100.0% 95.8%

CPA 7 Day Follow Up (SS) NHSI 95% 100.0% 100.0% 50.0% 100.0% 0.0% 80.0% 50.0% 100.0% 100.0% 100.0% 100.0% 100.0%

CPA 12 Month Review (Total Network Performance) NHSI 95% 97.7% 96.7% 97.0% 97.5% 97.0% 97.2% 95.9% 95.7% 96.8% 96.3% 96.4% 96.5%

CPA 12 Month Review (AMH) NHSI 95% 97.4% 96.3% 96.6% 97.3% 96.5% 96.8% 95.3% 95.1% 96.3% 95.7% 95.9% 96.0%

CPA 12 Month Review (OA) NHSI 95% 99.7% 100.0% 100.0% 100.0% 99.7% 100.0% 99.1% 98.4% 99.7% 99.7% 99.4% 98.5%

CPA 12 Month Review (SS) NHSI 95% 100.0% 98.2% 98.2% 97.0% 100.0% 98.8% 100.0% 100.0% 99.4% 100.0% 100.0% 100.0%

Delayed Transfers of Care (Total Network Performance) NHSI ≤7.5% 4.79% 3.76% 2.60% 2.39% 3.10% 3.33% 3.48% 2.89% 2.39% 2.55% 2.49% 2.04%

Delayed Transfers of Care (AMH) NHSI ≤7.5% 3.06% 3.66% 2.19% 2.27% 3.26% 3.42% 2.94% 2.31% 1.06% 0.49% 0.66% 1.10%

Delayed Transfers of Care (OA) NHSI ≤7.5% 10.34% 4.11% 3.92% 2.70% 3.27% 2.06% 3.08% 2.72% 4.03% 6.29% 6.01% 2.72%

Delayed Transfers of Care (SS) NHSI ≤7.5% 2.77% 3.91% 3.80% 3.08% 2.74% 3.85% 4.61% 4.00% 3.82% 4.03% 3.68% 3.34%

IP Access to Crisis Res. Treatment (Gatekeeping) NHSI 95% 100.0% 98.6% 99.4% 97.7% 100.0% 100.0% 99.5% 100.0% 100.0% 100.0% 100.0% 100.0%

MH Data Completeness - Identifiers NHSI 97% - - - - 99.6% 99.6% 99.7% 99.5% 99.5% 99.6% 99.5% 99.5%

MH Data Completeness - Identifiers (AMH) NHSI 97% 99.7% 99.7% 99.8% 99.7% - - - - - - - -

MH Data Completeness - Identifiers (SS) NHSI 97% 97.9% 98.4% 98.4% 98.5% - - - - - - - -

MH Data Completeness - Outcomes NHSI 50% - - - - 85.8% 84.8% 84.5% 84.6% 84.5% 83.6% 83.7% 85.0%

MH Data Completeness - Outcomes (AMH) NHSI 50% 85.3% 85.2% 85.2% 85.4% - - - - - - - -

MH Data Completeness - Outcomes (SS) NHSI 50% 83.4% 82.5% 81.3% 79.6% - - - - - - - -

Inappropriate OAPs NHSI TBC - - - - - - - - - - - -

Other Indicators

AQ Dementia (OA) (1 month in arrears) NHSE 59.3% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% -

Memory Assessment Service (MAS) seen within 6 weeks (OA) NHSE 70% 39.5% 25.7% 40.3% 48.4% 47.0% 52.1% 70.4% 79.8% 80.4% 79.6% 78.1% 74.6%

PBR Clustering NHSE 95% 96.4% 96.8% 96.4% 96.5% 96.5% 96.6% 96.7% 96.4% 95.7% 95.9% 95.1% 95.4%

No of Patients without a Care Co-ordinator Allocated > 2 Weeks (Total

Network Performance)NHSE 0

307 313 255 260 267 255 211 233 210 - - 152

No of Patients without a Care Co-ordinator Allocated > 2 Weeks (AMH) NHSE 0266 262 222 253 245 243 187 203 183 - - 152

No of Patients without a Care Co-ordinator Allocated > 2 Weeks (SS) NHSE 0 41 51 33 7 22 12 24 30 27 - - -

MHLT

MHLT 1hr compliance Commissioners 95% 45.7% 46.9% 38.7% 51.8% 51.6% 45.9% 47.5% 40.8% 39.5% 42.5% 45.5% 49.3%

No of 4hr breaches (Percentage of total) 5% 7.7% 11.2% 15.4% 9.7% 9.5% 11.4% 14.8% 16.1% 15.1% 16.4% 14.5% 12.4%

No of 4hr breaches (Number of breaches) 32 49 75 102 71 67 79 110 116 102 108 104 80

No of 12hr breaches (Percentage of total) 0% 0.9% 1.5% 1.2% 3.3% 0.9% 1.4% 4.0% 1.8% 2.5% 1.2% 0.8% 1.2%

No of 12hr breaches (Number of breaches) 0 6 10 8 24 6 10 30 13 17 8 6 8

Stretch

Stretch

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Sparkline

Secure Mental Health Business Unit

Overall Gross Occupancy NHSE 93% 90.2% 91.8% 93.3% 93.7% 97.2% 95.9% 96.0% 94.2% 91.3% 91.0% 92.4% 91.3%

Violent Incidents resulting in Restraint Stretch ≤ 20.00% 16.1% 20.8% 17.5% 20.5% 18.4% 15.6% 22.2% 27.1% 17.2% 29.1% 19.3% 16.4%

% of SU that have had a CPA Review in last 6 months Stretch 100% 100.0% 100.0% 99.3% 99.3% 98.0% 97.4% 96.1% 94.5% 97.2% 96.0% 100.0% 100.0%

% of service users who have a Care Coordinator allocated within 2 weeks Stretch 100% 62.5% 75.0% 77.8% 75.0% 66.7% 100.0% 50.0% 66.7% 99.3% 100.0% 100.0% 99.3%

% of CPA reviews attended by Local Care Coordinators Stretch 80% 50.0% 25.0% 42.9% 39.3% 65.2% 33.3% 51.7% 42.9% 44.0% 48.1% 43.5% 72.0%

% of service users who have Cardiometabolic risk factors assessed within

12 months Stretch 90% 94.6% 96.0% 89.7% 96.8% 100.0% 100.0% 99.4% 100.0% 100.0% 100.0% 100.0% 100.0%

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%

25hrs Meaningful Activity - Uptake NHSE 100% 82.8% 85.0% 80.4% 79.9% 75.6% 82.3% 81.3% 86.8% 74.1% 78.2% 85.2% 86.4%

Community Business Unit

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

% of caseload carried longer than 12 months post SMHBU discharge Stretch ≤ 20.00% 58.8% 72.0% 66.7% 74.0% 60.9% 60.6% 59.7% 63.5% 58.2% 60.9% 66.0% 70.6%

% of CPA Reviews Attended by Local Care Coordinators / Local Teams Stretch 80% 50.0% 62.5% 75.0% 30.0% 33.3% 40.0% 54.5% 33.3% 50.0% 63.6% 25.0% 45.5%

No of Incidents exceeding PACE Clock Commissioners 0 3 4 3 5 7 3 4 5 5 9 3 9

Health & Justice Business Unit - HMP Liverpool

GP Waits over 2 Weeks NHSE 0% 64.1% 55.0% 59.5% 64.2% 49.4% 22.8% 0.0% 18.8% 43.6% 43.1% 44.9% 23.5%

NHS Health Checks NHSE 40% 3.6% 26.1% 13.2% 8.9% 1.9% 57.1% 28.6% 14.3% 22.6% 0.0% 33.3% 33.3%

Well Man Assessment completed NHSE 100% 98% 97% 95% 89% 75% 63% 33% 96% 120% 98% 124% 83%

Hep B Vaccinations completed NHSE 25.0% 30.4% 25.0% 0.0% 3.7% 0.0% 8.6% 0.0% 0.0% 4.2% 0.0% 0.0%

Chlamydia Screening U25's Uptake NHSE 50% 20.7% 14.3% 33.3% 5.3% 13.0% 27.3% 63.6% 100.0% 21.4% 13.3% 17.7% 11.1%

Men C Vaccinations Uptake NHSE 95% 5.7% 12.2% 4.9% 2.6% 2.4% 21.1% 44.7% 5.3% 7.7% 7.1% 19.4% 4.2%

MMR Vaccinations Uptake NHSE 95% 4.4% 11.1% 0.0% 14.3% 23.8% 3.6% 2.3% 2.3% 1.0% 1.7% 4.1% 3.0%

Prison 6 Month CPA Reviews NHSE 100% 100.0% - 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 0.0% 100.0%

QOF NHSE 238 327 323 314 319 316 323 334 354 385 381 410 457

Note: *Work is ongoing with the Hub in order to display the PACE clock measure within the context of all PACE clocks.

*

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Sparkline

NHS Improvement

RTT - Consultant Led (Completed Pathway) NHSI 95% 96.3% 96.7% 97.6% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0%

RTT - Consultant Led (Incomplete Pathway) NHSI 92% 95.4% 97.3% 100.0% 99.2% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 99.7% 99.3%

RTT - IAPT 6 Weeks NHSI 75% 96.5% 95.1% 95.7% 93.4% 96.4% 94.7% 95.1% 94.5% 94.4% 94.5% 94.6% 94.8%

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

Waiting Times - AHP RTT

Adult Learning Disability 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%

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% - -

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% 99.4%

Podiatry NHSE 95% 100.0% 100.0% 99.8% 100.0% 100.0% 100.0% 100.0% 100.0% 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% 99.0% 100.0% 100.0% 100.0% 98.6% 100.0% 98.6% 100.0% 98.6%

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% 98.7% 98.0%

Continence Service NHSE 95% 100.0% 100.0% 100.0% 100.0% 100.0% 97.8% 100.0% 100.0% 98.5% 98.3% 100.0% 98.1%

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% 99.5% 100.0% 100.0% 99.0% 100.0% 100.0%

Nutrition & Dietetics 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%

Other Indicators

RTT Complete - Learning Disability Commissioner 95% 98.8% 98.9% 98.9% 100.0% 98.7% 96.1% 96.3% 99.2% 99.2% 100.0% 100.0% 100.0%

12 Week Dentist Waits - HMP Liverpool Commissioner 95% 98.7% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 94.6% 100.0% 100.0%

Community Dental Waits Commissioner 95% 95.2% 96.1% 98.0% 99.4% 97.1% 98.3% 100.0% 97.5% 98.2% 98.1% 100.0% 97.6%

Unallocated Cases NHSE 0 11 12 12 7 15 13 2 7 19 - - 43

Note: Allocated patients report is back online after re-build. Network re-alignment has meant that some results have changed but does not completely mask a growth in unallocated cases.

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Sparkline

IAPT

IAPT in Month Prevalence

Blackburn with Darwen CCGCommissioner 1.18% 1.22% 1.32% 1.26% 0.89% 0.74% 1.85% 1.13% 1.27% 1.38% 1.20% 1.09% 1.60%

IAPT Cumulative Prevalence

Blackburn with Darwen CCGCommissioner 9.47% - - - - 0.74% 2.59% 3.72% 4.99% 6.37% 7.57% 8.66% 10.26%


East Lancashire CCGCommissioner 1.25% 1.05% 1.56% 1.11% 1.77% 1.00% 1.13% 1.64% 1.42% 1.22% 1.30% 1.38% 1.36%


East Lancashire CCGCommissioner 10.00% - - - - 1.00% 2.13% 3.76% 5.19% 6.41% 7.72% 9.09% 10.45%


Chorley & South Ribble CCGCommissioner 1.25% 1.42% 1.59% 1.08% 1.44% 1.29% 1.53% 1.47% 1.31% 1.45% 1.38% 1.40% 2.10%


Chorley & South Ribble CCGCommissioner 10.00% - - - - 1.29% 2.81% 4.29% 5.60% 7.05% 8.43% 9.83% 11.93%


Greater Preston CCGCommissioner 1.25% 1.14% 1.24% 1.18% 1.20% 0.92% 1.38% 1.46% 1.41% 1.07% 1.24% 1.67% 1.24%


Greater Preston CCGCommissioner 10.00% - - - - 0.92% 2.30% 3.76% 5.17% 6.23% 7.48% 9.15% 10.39%


West Lancashire CCGCommissioner 1.25% 1.26% 1.71% 0.83% 1.53% 1.13% 1.51% 1.34% 1.08% 1.48% 1.21% 1.33% 1.67%


West Lancashire CCGCommissioner 10.00% - - - - 1.13% 2.64% 3.98% 5.06% 6.54% 7.75% 9.08% 10.75%


Fylde and Wyre CCGCommissioner 1.25% 1.55% 1.33% 0.96% 1.40% 1.23% 1.33% 1.36% 1.44% 1.35% 1.37% 1.33% 1.88%


Fylde and Wyre CCGCommissioner 10.00% - - - - 1.23% 2.55% 3.91% 5.35% 6.70% 8.07% 9.39% 11.27%


Morecambe Bay CCGCommissioner 1.25% 1.64% 1.31% 1.22% 1.41% 1.34% 1.07% 1.40% 1.46% 1.32% 1.27% 1.03% 1.75%


Morecambe Bay CCGCommissioner 10.00% - - - - 1.34% 2.41% 3.81% 5.27% 6.59% 7.86% 8.88% 10.64%


St Helens CCGCommissioner 1.25% 0.74% 1.31% 1.02% 1.67% 0.88% 1.13% 1.31% 1.07% 1.09% 1.43% 1.56% 1.20%


St. Helens CCGCommissioner 10.00% - - - - 0.88% 2.01% 3.32% 4.39% 5.48% 6.91% 8.47% 9.67%

IAPT Waiting Times (Internal Target) Stretch 0 pts >26 wks - - - - 22 23 23 25 14 26 14 59

IAPT Recovery NHSE 50% 56.3% 53.8% 57.0% 53.4% 54.5% 52.6% 57.0% 50.0% 55.1% 57.3% 53.6% 53.4%

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

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

Sparkline

NHS Improvement

CPA 7 Day Follow Up NHSI 95% 100.0% 100.0% 100.0% 100.0% 95.5% 100.0% 100.0% 100.0% 88.9% 100.0% 100.0% 100.0% 95.2%

CPA 12 Month Review NHSI 95% 97.6% 98.3% 99.5% 98.5% 97.9% 97.5% 95.6% 99.0% 99.5% 100.0% 98.7% 98.7% 98.0%

MH Data Completeness - Identifiers NHSI 97% 99.7% 99.7% 99.7% 99.7% 99.7% 99.6% 99.6% 99.7% 99.6% 99.6% 99.5% 99.6% 99.5%

MH Data Completeness - Outcomes NHSI 50% 67.2% 66.3% 64.8% 81.3% 64.9% 63.5% 60.7% 59.3% 58.1% 57.9% 56.7% 58.8% 59.3%

2 Week wait for Treatment for EIP Programme NHSI 50% 74.3% 76.7% 82.0% 81.4% 74.4% 11.1% 7.1% 0.0% 9.5% 11.8% 15.6% 9.5% 23.9%

Waiting Lists - RTT 18 Weeks (Completed Outcomes)

EIS Therapies (The Hub) NHSE 95% 90.3% 93.0% 83.9% 80.0% 94.7%

Child Psychology - Total Network Performance NHSE 92% 69.9% 70.9% 71.0% 60.3% 64.8% 66.6% 62.4% 66.9% 74.1% 77.7% 84.4% 89.0% 86.3%

CAMHS Tier 3 - Total Network Performance NHSE 92% 99.0% 97.5% 100.0% 98.1% 88.8% 79.4% 78.0% 78.4% 68.1% 64.5% 59.1% 56.9% 60.8%

Waiting Lists - RTT 18 Weeks (Incompleted Outcomes)

CITNS - Occ Therapy - Total Network Performance NHSE 92% 81.8% 81.8% 88.2% 91.2% 95.1% 94.9% 94.0% 96.4% 99.1% 96.3% 98.2% 97.9% 96.2%

CITNS - Physiotherapy - Total Network Performance NHSE 92% 100.0% 100.0% 98.1% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 99.4% 99.5%

CITNS - SLT- Total Network Performance NHSE 92% 86.9% 86.9% 86.6% 83.6% 82.7% 84.2% 86.7% 87.0% 88.4% 96.2% 96.3% 98.0% 99.6%

CAMHS Tier 4

Bed Occupancy - The Cove NHSE 85% 65.0% 55.0% 65.5% 80.5% 90.5% 92.8% 86.5% 96.7% 94.6% 68.8% 68.2% 78.9% 90.6%

Average Length of Stay (days) - The Cove Bench 83 78.00 57.00 44.00 41.00 39.00 67.00 57.00 33.30 60.70 27.70 48.10 26.60 38.80

National Child Measurement Programme

NCMP - Central NHSE 90% 19.3% 26.8% 39.5% 52.6% 64.5% 73.8% 88.7% 94.4% - - - 5.1% 20.0%

NCMP - BwD (Cumulative) NHSE 95% 17.8% 24.9% 37.1% 46.3% 60.2% 67.6% 82.2% 95.7% - - - 22.4% 28.1%

NCMP - East (Cumulative) NHSE 90% 21.9% 30.3% 44.3% 56.0% 67.9% 79.5% 93.0% 98.5% - - - 6.4% 21.4%

Other Indicators

ADHD - New < 18 Weeks NHSE 92% 38.3% 40.1% 36.1% 31.6% 37.7% 46.4% 39.0% 35.7% 22.7% 20.9% 34.7% 36.7% 35.1%

PBR Clustering NHSE 95% 94.9% 93.6% 96.2% 96.3% 95.4% 96.0% 97.2% 96.4% 96.5% 95.1% 95.3% 95.1% 93.9%

Number of Patients without a Care Co-ordinator Allocated > 2 Weeks NHSE 0 13 14 8 18 29 23 5 4 2 2 - - 99

Currently being validated

Note: Allocated patients report is back online after re-build. Network re-alignment has meant that some results have changed but does not completely mask a growth in unallocated cases.

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

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MHLT:

1 Hour Compliance:

The Network is reporting low compliance in the target for patients to be seen within 1 hour of referral with 49.3% compliance in M8.

4 Hours Breaches:

The Network is reporting 80 actual 4 hour breaches in A&E for which LCFT were responsible in month 8, reporting 87.6% compliance.

12 Hours Breaches:

The Network is reporting 8 actual 12 hour breaches in A&E from the decision to admit time in month 8, this is 1.2% of all A&E referrals to

MHLT.

Actions: Due: Owner: Outcome:

CORE 24 workshops in progress for development of the working

models. Apr-18

Deputy Head of

Operations Workshop held.

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

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29

Occupancy:

Throughout November, occupancy levels across the service continue to be below the contracted threshold and occupancy has decreased

to 91.3%. The following rationale illustrates the reasons for the monthly bed occupancy:

•Bleasdale Male Medium ABI had 2 vacancies - no one currently on waiting list

•Whinfell Ward Male Low ABI had 4 vacancies - 1 SU currently placed on the waiting list

•Forest Beck Ward Female Step down service had 2 vacancies - SU identified from Fellside East to transfer to Forest Beck

•Hermitage ABI/MI Step down Community House had 4 vacancies - Male Community Bed

•FairoakWard Male Low had 1 vacancy - SU identified to transfer from step down to Fairoak

•Fellside East Ward Female LSU had 1 vacancy - MDT working with service user from MSU to transition to LSU.

•Fairsnape Ward MSU had 1 vacancy.

There are no actions for this measure.

2.1 Performance Activity Mental Health (Secure Services) – Occupancy

OBD Available %

1998 2250 88.80%

1646 1680 97.98%

846 990 85.45%

4490 4920 91.26%

Low Secure Wards

Step down Wards

Total

Nov-17

Medium Secure Wards

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Violent Incidents resulting in Restraint:

In November, staff reported a total of 110 incidents of verbal and physical violence within the inpatient unit .This is a 27% reduction

compared to the 150 incidents reported in October 2017.

The overall use of restraint as a response to violent incidents has continued to decrease with 16% of violent incidents ending in restraint,

compared to 19% in October 2017.

Elmridge ward has seen a significant reduction in the number of restraints from 40 incidents in October to 5 in November.

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

resulting in Restraint


The service is looking at recruiting to a new post that will support teams in

the use of restraint and debriefs.

End of

Quarter 3

Care Group

Manager New Quality Lead in post.

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31

CPA Reviews within 6 Months:

In November, all 146 eligible service users have had a CPA within the last 6 months.

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

Within 6 Months


Review the process for arranging CPA reviews. End of Quarter

3

Performance

Analyst This is continuing.

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32

Local Care Coordinator:

In November, there was 1 Secure Inpatient admitted who is awaiting allocation of a Local Link worker. This is currently being investigated

by the CMHT and has also been escalated to the Flow and Capacity Manager and Care Group Manager.


2.1 Performance Activity Mental Health (Secure Services) – Local Care Coordinator

allocated within 2 weeks

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33

Attendance of CPA reviews:

The attendance of Local Care Co-ordinators at secure inpatient CPA Reviews has increased significantly to 72% in November.

There were a total of 25 CPA Reviews planned, of which 18 were attended by Local Care Co-ordinators. It is noted that 1 Local Care

Coordinator sent apologies, but that 6 did not attend. The DNA's have been followed up Line Manager to Line Manager.

Work continues to flag forthcoming CPA dates with Service Managers in order to allocate attendees to all Secure Inpatient CPA Reviews.

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

CPA reviews


1. All teams have been asked to forward the names of attendees for

all planned CPAs until the end of December 2017. 10-Nov-17

Care Group

Manager

Ongoing monthly.

2. Outlook invites are now being included within the invite process

and the secretaries will be following up all invites where apologies or

the name of the attendee have not been received.

10-Nov-17 Admin

Manager Ongoing monthly.

Attended Apologies DNA

21 17 1 3

4 1 0 3

Breakdown of LCCNo of CPA

reviews

LCFT LCC

Non LCFT LCC

Nov-17

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25hr Meaningful Activity:

In November, 5 of the 15 wards failed to meet the 100% set target relating to meaningful activity uptake. It is noted that the improvement

across most wards has continued to increase slightly from 85.2% in October to 86.4% for November.

There are wards that continue to experience high acuity which has resulted in a static level of activity uptake. There is ongoing work being

undertaken to improve engagement and opportunities of activity both on and off the ward. The accuracy of recording has improved and the

wards continue to work with staff to record activity.

2.1 Performance Activity Mental Health (Secure Services) – 25hr Meaningful Activity

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35

2.1 Performance Activity Mental Health (Secure Services) – 25hr Meaningful Activity


1. Ward Managers and Team Leaders on Fairoak Ward and

Mallowdale Ward to ensure that 25hr activity is discussed with staff at

the end of each shift to improve the recording of activity and the

promotion for service user wellbeing.

End of Q3 Ward

Manager

2. Following the work with the service users on Marshaw ward to

understand what activities they would like to do, staff to purchase new

games and introduce new activities to improve uptake. End of Q3

Ward

Manager

3. The ward manager of Fairoak Ward to send a recurring email to

shift leaders to promote accurate recording of activities. End of Q3

Ward

Manager

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36

% of FCMHT Caseload >12 months:

There are currently 51 service users on the FCMHT case load; 36 of these service users have been on the FCMHT caseload for over 12

months.

The team will be discussing the clinical appropriateness of this target with the Commissioner in January 2018.

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

Caseload >12 months


1. The service manager will continue to work with the team to

review pathways and the continued need for intensive input by the

FCMHT.

End of

Quarter 3

Care Group

Manager

Continued FCMHT input is dictated by a

balance of risk, legal status and psychological

need and now reviewed on a weekly basis.

2. A meeting is taking place with the commissioner and the

percentage of caseload being carried over 12 months will be

discussed with a suggestion for a more clinically appropriate target.

Oct-17

revised to

Jan-18

FMCT Care

Group

Manager

This discussion has been rescheduled for the

January 2018 meeting date yet to be

confirmed.

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37

Attendance of CPA Reviews within Community Services:

Attendance of Local Care Co-ordinators at Forensic Community CPA Reviews has significantly increased to 45.45% for November. There

were 11 scheduled CPAs in total. 5 of these had link worker attendance, apologies were received from a further 3 link workers and 3 did

not attend.

Within this number, 9 cases involved LCFT link workers, of which 4 attended, 2 sent apologies and 3 did not attend.

Of the 2 CPAs which did not involve LCFT link workers, 1 sent apologies and 1 attended

Work continues to flag forthcoming CPA dates with Service Managers in order to allocate attendees to all Forensic Community CPA

Reviews. Further measures have been put in place to compliment the introduction of the FCMHT admin staff sending a letter out 6-8

weeks prior to a review. An invite to the meeting is now placed in the care co-ordinator's electronic calendar and the admin team are

calling the care co-ordinator a week before the review to ensure they are attending. If the care co-ordinator is unable to attend they are

being asked to identify a contingency plan in terms of skype, telephone call or sending another representative. Following any non-

attendance the FCMHT are contacting the team to identify reasons why so that these can be addressed.

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

CPA Reviews within Community Services


Admin staff to contact local care co-ordinators in week prior to planned CPA to

increase levels of attendance at CPA reviews and identify an alternative

representative if care co-ordinator is unable to attend due to leave or sickness.

End of Q3 Service Manager

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

Incidents exceeding PACE Clock

38

Number of Incidents exceeding PACE Clock:

There has been an increase in PACE breaches in November. Of the 9 breaches that took place, one was in excess of 95 hours, one 55,

47, 45, 41, 26, 22, 19 and one 17 hours longer held in Police custody than the PACE Limit of 24hrs. Four occurred in Preston, three at

Blackpool, one at Lancaster and one at Blackburn Custody.

One was due to communication issues relating to the bed required causing a delay waiting for a PICU bed. One was matters arising to

an informal admission and use of MHA with the grey area to be discussed at the next managers meeting. Seven related to no beds

being available and the escalation process being followed, with two of these being out of area.


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HMP Liverpool – HJIP Indicators:

GP Waiting Times:

As of the beginning of December there were 90 patients on the GP waiting list and the longest wait was 10 working days. This is a

significant improvement (14 days) on last month. The DNA rate of 37% is only slightly improved but there were 40 more patients seen by

the Nurse Practitioner which has contributed to the improvement.

Enablement issues are highlighted below.

NHS Health Checks:

At the start of the month six men were eligible for the NHS Health Check. Two Health Checks were completed and following a month's

intake of new receptions, the eligible total for December was again six. These six men have been offered an appointment on the 5th

December. We are looking at the possibility of offering the NHS Health Checks to patients and adding these on to the end of the

Therapeutic Monitoring Clinic one at a time and this would enable staff to remove the need for a dedicated NHS Health Check Clinic.

Wellman Screening:

The Wellman screenings target has slipped slightly due to staff annual leave. The NICE Guidance "Physical Health for people in prison"

now stipulates that the Wellman Screen should be completed in seven days and we are within these guidelines.

Immunisations and Vaccinations:

Due to staffing issues and a shortage of vaccinations there were only 50 appointments offered in November and 22 of those DNA.

The seasonal Influenza campaign is going well with only 23 eligible patients still outstanding. We now have secured some more

vaccinations and the clinics will be starting again week commencing 11/12/17.

DNA - Enablement Issues:

Following the recent HMIP / CQC inspection the following reporting structure has been put in place to try to resolve the current issues,

Enablement being amongst that list. Local Delivery Group (LDG) is Governor led and attended by Head of Healthcare and NHSE. Prison

Healthcare and Operational Group (PHOG) is a joint Healthcare and Prison meeting to resolve operational issues, including Enablement.

This is attended by Head of Healthcare and John Carroll and Vicky Price from the Prison. The first meeting is scheduled for the 8th

December.

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

HJIP Indicators

39

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HJIP Indicators

40


1. Enablement issues. 08-Dec-17 Care Group

Manager

New escalation structure in place. The PHOG forum to

meet on 8/12/17 with the initial meeting to discuss

Healthcare issues.

2. NHS Health Checks:

Primary Care manager has been tasked by Head of

Healthcare with targeting NHS Health Checks.

30-Dec-17 Care Group

Manager

The NHS Health Check is now a manageable total (6).

Outpatients Manager is to look at adding these

appointments to the Therapeutic Management clinics.

3. Wellman Screening:

To have contingencies in place for staff annual leave

to maintain NICE standards. 30-Dec-17

Care Group

Manager

Continue to monitor and liaise with Mental Health Lead

K.G.

4. Immunisation and Vaccination:

Continue to offer as many appointments as possible

for Men C and MMR but the current emphasis will be

on Influenza vaccinations.

30-Dec-17 Care Group

Manager

Vaccinations now sourced and clinics to start again w/c

11/12/17.

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HJIP Indicators

41

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

276 307 375 261 336 358 422 359 307 274 285

269 292 335 196 211 117 406 432 301 341 237

97.46% 95.11% 89.33% 75.10% 62.80% 32.68% 96.21% 120.33% 98.05% 124.45% 83.16%

Wellman Checks

No. of new receptions

No. of Wellman checks completed

% completed


5 6 7 8 9 10 11 27 44 16 28

27 49 41 19 18 39 54 28 35 37 25

41 59 35 52 31 45 47 69 57 33 48

127 169 165 80 23 0 27 96 103 70 31

GP Waits

0-2 days

3-7 days

8-14 days

14+ days


248 260 296 261 336 358 422 359 307 274 285

23 12 3 27 35 35 99 55 24 43 29

7 3 0 1 0 3 0 0 1 0 0

29 13 7 31 61 72 53 54 24 60 26

30.43% 25.00% 0.00% 3.70% 0.00% 8.57% 0.00% 0.00% 4.17% 0.00% 0.00%

Total vaccinations in month

% patients accepting within 4 wks

Hep B Vaccinations

No. of new receptions

No. of patients accepting Hep B

Patients vaccinated >4wks


134 258 247 103 14 14 21 31 22 6 6

26.12% 13.18% 8.91% 1.94% 57.14% 28.57% 14.29% 22.58% 0.00% 33.33% 33.33%

28 18 19 23 11 11 6 14 51 17 9

14.29% 33.33% 5.26% 13.04% 27.27% 63.64% 100.00% 21.43% 13.33% 17.65% 11.11%

41 41 38 41 38 38 19 26 28 31 24

12.20% 4.88% 2.63% 2.44% 21.05% 44.74% 5.26% 7.69% 7.14% 19.35% 4.17%

27 25 21 21 225 132 129 203 241 222 198

11.11% 0.00% 14.29% 23.81% 3.56% 2.27% 2.33% 0.99% 1.66% 4.05% 3.03%

0 5 2 6 2 2 4 1 2 3 1

- 100.00% 100.00% 100.00% 100.00% 100.00% 100.00% 100.00% 100.00% 0.00% 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

% Recieved

Total Eligible

% Recieved

Total Eligible

% Recieved

Patients Screened for

Chlamydia

Total Eligible

% Screened

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2.1 Performance Activity Community & Wellbeing – Improving Access to

Psychological Therapies (IAPT) Prevalence

42

IAPT - Prevalence:

• Greater Preston have not met the contractual target of 15% by 3 patients, or the 16.2% internal cumulative target.

• St Helens have not met the contractual target of 15% by 15 patients.

A cumulative prevalence model is in place to direct and support teams to achieve the 16.8% prevalence target set by NHS England in

quarter 4. The quarter 3 contractual target remains at 15% (BwD is 14.2%), however teams have been working towards an internal

cumulative target of 16.2% in preparation. St Helens CCG have agreed that prevalence will stay at 15% as they have not received any

national LTC funding. Blackburn with Darwen CCG's prevalence target has been confirmed as 14.2% with an expectation that this will

increase and funds will be re attributed to this locality next year.

The service is aware that December has historically been a lower month for referrals and prevalence. In preparation for December, the

teams have been working to increase referrals and assessments in October and November. This is reflected in some of the high

prevalence figures in month 8.

The leadership team, including the recently appointed interim team leaders and admin leads have daily oversight of performance across all

teams. Performance data is examined daily to enable teams to respond quickly to areas of deficit in prevalence and, in conjunction with

team members, directs resources within each specific locality. Deficits and risk areas to achieve prevalence are highlighted at team and

management level and are escalated to the Leadership team and the Network managers immediately in order to expedite actions.

The team continues to increase 'Taster' and awareness sessions to improve prevalence. In addition, the leadership team are exploring

other options to increase prevalence, such as direct referral into groups and the use of technology.

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2.1 Performance Activity Community & Wellbeing – IAPT Prevalence

43


1. West Lancs additional taster sessions planned for

Aug, Sept, Oct. 31-Dec-17 Team Leader

Taster sessions continue alongside exploring

direct referral options

2. Action plan developed with Preston and St Helens to

increase prevalence. 31-Dec-17 Service Manager Action plan remains in place.


1.27% 1.38% 1.20% 1.09% 1.60%

1.31% 1.45% 1.38% 1.40% 2.10%

1.42% 1.22% 1.30% 1.38% 1.36%

1.44% 1.35% 1.37% 1.33% 1.88%

1.41% 1.07% 1.24% 1.67% 1.24%

1.46% 1.32% 1.27% 1.03% 1.75%

1.07% 1.09% 1.43% 1.56% 1.20%

1.08% 1.48% 1.21% 1.33% 1.67%

1.28% 1.22% 1.26% 1.30% 1.45%

CWB IAPT Prev CCG (Monthly)









NHS St Helens CCG

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44

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45

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2.1 Performance Activity Community & Wellbeing – IAPT Waits

46

IAPT - Waits:

Waiting times have increased across the service in Month 8; 59 people have been waiting of treatment over 26 weeks.

• 1 person has been waiting over 26 weeks for CBT in BwD, this is the same number as in October

• 11 people have been waiting over 26 weeks for CBT in East Lancs, this is an increase since October when no one was waiting over

26 weeks

• 5 people have been waiting over 26 weeks for CBT in Greater Preston, this is an increase of 4 since October

• 10 people have been waiting over 26 weeks in Fylde and Wyre for CBT, this is an increase of 1 since October

• 18 people have been waiting over 26 weeks in Morecambe Bay for CBT, this is an increase since October when no one was waiting

over 26 weeks

• 14 people have been waiting over 26 weeks in St Helens for CBT, this is an increase since October when no one was waiting over 26

weeks

All people waiting over 26 weeks have been reviewed, and their individual circumstances. An action has been identified for each person

which may involve an appointment letter, attendance at a group or offer of alternative interventions. The main reasons for the increase

in waiting times are:

• staff vacancies and difficulties in recruitment, in terms of attracting suitable candidates

• staff sickness, measures in place to mitigate against loss of capacity

• noted reduction in activity with the sub contract partner Lancashire Women’s Centre, this is being managed monthly through a

formal contract and performance meeting.

• A service focus on increasing prevalence in quarter 1, 2 and 3, which has led to more people accessing Mindsmatter

A service based action plan is in development for each CCG. This action plan will be shared with each CCG individually, focusing

specifically on local team concerns and actions to mitigate against each concern. The action plans will focus on both clinical and

operational concerns and will be led by the Mindsmatter Leadership team.

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2.1 Performance Activity Community & Wellbeing – IAPT Waits

47


Internal performance reporting increased and reviewed to closely

monitor waiting times across the teams.

30-Sep-17

revised to

31-Dec-17

Service

Manager

This will remain in place as there is a large

amount of staff movement in Quarter 3 which

will have an impact on waiting times.

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

48

Early Intervention in Psychosis (EIP):

The position at the end of M8 is that 23.9% of service users received treatment within 2 weeks. There have been 46 clocked stopped in

M8, compared to 21 in M7.

The number of service users waiting at the end of M8 has reduced from 68 to 51. This review leading to a decision for many service users

has changed the distribution of those waiting and has moved the average wait from 8-12 weeks to 3-4 weeks. This changed distribution is

shown in the comparison between October and November completed pathways in the graph and allows the teams to begin December with

less potential fails through those waiting over 2 weeks.

Oct-17 Nov-17

16.7% 9.1%

0.0% 0.0%

0.0% 50.0%

0.0% 27.8%

0.0% -

0.0% 0.0%

50.0% 50.0%

0.0% 100.0%

9.5% 23.9%

CYP 2ww EIP CCG




NHS Blackpool CCG






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

49


1. Review and amend SOP to ensure clarity and triangulation

with most recent national Guidance Jan-18 Deputy Director Underway.

2. Appoint to vacant Band 8a Manager post Jan-18 Deputy Head of

Operations Complete - secondment in place.

3. Review of referral processes to ensure timely receipt by

service, including a review of impact of Bluelight 71 Dec-17

Deputy Head of

Operations

In the interim, contact being made

daily with SPoA and AMH teams in

each locality. This is being extended

to include AMH admission wards

4. Review of allocation processes for telephone and first face

to face with case manager to plan for sufficient timely first face

to face treatment appointments. Dec-17

Deputy Head of

Operations and

Lead Psychologist

Complete via daily call - process

agreed and telephone call stops clock

as per guidance. Formalisation of face

to face appointment within subsequent

7 days after telephone call (as a local

measure) to be reviewed at 6 months

once performance stabilised.

5. Establish an operational team to clear long term EIS case

backlog Dec-17

Head of

Operations

Complete - legacy group reduced to 8

and all in progress within current

capacity.

6. Training update for staff and team leaders on NCRS, EDMS

and records management Jan-18

Deputy Head of

Operations Under review as training not

necessary at present.

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

50

Child Psychology (Total Network Performance):

In M8, overall service performance decreased to 86.3%, from 89% in M7. The total number of SUs on the waiting list in M8 reduced to 270 from

290 in M7, of which 37 are waiting over 18 weeks – an increase of 5 from M7. Four out of the six team’s performance are now above the target

of 92% (BwD/EL; Preston Community; Blackpool; Fylde & Wyre) and two teams under the target (Preston Hospital and Lancaster).

Issues affecting performance:

Preston Hospital

8 out of 21 service users are waiting under 18 weeks (38.1%); this is a 34% reduction from M7 (64.7%). The longest waiter is 35 weeks.

The Royal Preston Hospital service has a contractual requirement for inpatients to be seen at very short notice, so the Clinical Psychologist may

see 2-3 inpatients in any given week which impacts on their capacity for out-patient/community work. Currently these short notice requests are

not logged on the waiting list and the processes to reflect that activity are being reviewed so that capacity can be better understood.

Preston Community

Performance in the team is above the 92% target for three consecutive months, at 96.7%. One SU out of 30 is waiting over 18 weeks for

treatment and has an appointment booked in December 17. The next longest waiter is at 14 weeks.

Lancaster

Performance in Lancaster increased slightly in M8 to 59.6% - from 55.6% in M7. This equates to 34 out of 57 service users. 8 SUs waiting over

18 weeks have TCIs in December, and one in January 17. The current longest waiter is at 27 weeks. The new Principal Clinical Psychologist

took up post on 20th November and after a week of Trust induction they are now starting their clinical work which will have a positive impact on

service delivery. There are two clinical psychologists off long term sick that are being appropriately managed.

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

51


In Lancaster CPS, a request for extra capacity in the team will be

discussed with the Care Group Manager. 30-Nov-17

Service

Manager

Delayed – capacity not yet available to

look in-depth at issues.

Continue to manage sickness appropriately. 31-Dec-17 Service

Manager

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

52

CAMHS Tier 3

Overall service performance increased by 3.9% from 56.9% in M7 to 60.8% in M8 (353 SUs). This equates to 228 out of 581 waiting over

18 weeks for treatment – which represents a 21% decrease from M7. The total number of SUs on the waiting list also decreased in M8

from 671 to 581. Two out of the five team’s performance remains above the target of 92% (West Lancashire and Fylde & Wyre) and three

teams under the target. 86% (197) of SUs waiting over 18 weeks relate to Chorley & South Ribble Team.

Issues affecting service level performance:

Chorley & South Ribble performance increased slightly for the second consecutive month in M8 to 43.2% from 40.2% in M7. There are

currently 197 out of 347 SUs waiting over 18 weeks. 20 SUs have TCI dates in December, of which 12 are waiting over 18 weeks. The

longest wait is currently 44 weeks – a reduction from 52 weeks in M7. The team continues to send validation letters to the longest

waiters in order of referral date and are currently at 33 weeks. This process continues to have a positive impact on the waiting times.

Twelve Initial Assessment appointments are now being offered by the Team each week which will also improve waiting times. There are

still a number of substantive vacancies which are having an impact on the teams’ capacity; interviews for vacancies have been organised

for January 2018.

Preston performance reduced to 80% in M8 from 85.6% in M7. There are currently 23 out of 115 SUs waiting over 18 weeks. 11 SUs

have TCI dates. The longest waiter is 25 weeks. Through SITREP review, the team are being requested to increase capacity of initial

assessments to improve throughput.

Lancaster performance remained the same in M8 at 57.9%. There are currently 8 out over 19 SUs waiting over 18 weeks. 8 SUs have

TCI dates. The longest waiter is 24 weeks. 2 staff currently on long term sickness (1.7 WTE) and there are 2 vacancies (1 x B5 and 1

Psychology 0.4) affecting the teams’ capacity. Sickness is being managed appropriately and posts are being recruited to. The longest

wait at 24 weeks was offered an appointment during December but was unable to attend; a further appointment has been negotiated. All

families next in line for an appointment are being contacted by phone to confirm their need for an appointment remains and to offer a

choice of appointment to encourage attendance.

When performance is expected to meet the target:

The impact of the validation process in Chorley & South Ribble is having a positive effect on the waiting list size, with an overall reduction

from 671 to 581. Over 60 validation responses are still required by the end of M9, and along with the revised appointment booking

procedure now in place in C&SR Team, further improvements should be realised by the end of M10.

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

53


1. HR still supporting the long term sickness absence. 31-Dec-17 Service

Manager Complete.

2. Admin processes are being reviewed in the Referral Assessment

Centre (RAC). Options paper to be drafted regarding future functioning of

the RAC.

23-Oct-17

revised to

30-Nov-17

Service

Manager Complete.

3. 25 validation letters a week to be sent to waiters down to 36 weeks for

CSR. 30-Nov-17

Service

Manager Complete.

4. 12 Initial Appointments each week to be arranged. 30-Nov-17 Performance

Analyst Complete.

5. Waiting list reduction trajectory spreadsheet developed and populated

ready for RAC to use. 30-Nov-17

Performance

Analyst Complete.

6. Vacancies to be recruited to. 31-Jan-18 Service

Manager

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

54

Occupancy:

In M8, bed occupancy performance at The Cove increased to 90.6% from 78.9% in M7, against the target of 85%. The CAMHS Outreach

Team received 28 referrals at The Cove, and 11 of these referrals resulted in admission, of which one was an emergency admission.

There were 12 discharges from The Cove in November 2017.

Length of stay of discharges during August 2017 was 38.8 days against the national benchmark of 83 days.

Issues affecting performance:

The Cove was open to admissions through November and was running at full capacity. Bed occupancy remains reflective of demand for

beds throughout the North West.


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

55

ADHD:

The proportion of new referrals to the ADHD service waiting under 18 weeks for treatment was 35.1% as at the end of M8, down

marginally from 36.7% last month. This equates to 111 out of 316 new referrals waiting under 18 weeks. In November, there were 44

referrals (new and transition) as opposed to 33 in October; an increase of 30%.

Issue affecting performance:

• Staffing – one NMP has recently joined the service and is now prescribing independently under supervision which has improved

capacity. The service still has one vacant NMP post.

• A review of the administration systems has resulted in improvements in data processes maximising our ability to provide timely,

accurate and appropriate reporting of performance.

• In M7, a presentation was delivered to Mental Health Quality and Performance Group describing lessons learnt from the delivery of

Adult ADHD Service. The presentation included the analysis of New and Transitional referrals, and highlighted strategies to improve

the service offer going forward. CSU advised further discussion would occur between Trust and Commissioners. There is a meeting

planned for 22/12/17.


1. A new service model to be developed, focusing on effective gatekeeping

and triage alongside robust efficiency of treatment. 30-Nov-17

Service

Manager

Meeting with

commissioners 22/12/17.

2. Change the referral route process. 30-Nov-17 Service

Manager

Meeting with


3. Validate existing waiting lists. 31-Dec-17 Service

Manager Complete.

4. Set up a virtual neuro-development assessment team. 31-Jan-18 Service

Manager

Meeting with


5. Review all service users who are stable and also open to Adult Mental

Health (AMH) with aim to transfer to AMH. 31-Mar-18

Service

Manager

6. A second NMP has been in post for 3 months and training is still in

process. There will be a gradual improvement to the waiting list following this

preceptorship.

30-Sep-17 Service

Manager Complete.

7. Consider the opportunities to review approach across neuro-

developmental assessment to improve the offer 31-Jan-18

Deputy Head

of Operations

More effective service

provision.

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

56

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Patient Flow

Section 2.2

57

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2.2 Patient Flow Summary – Patient Flow

58


Sparkline

Patient Flow

Average Number of Patients (OAPS) Commissioner 15 27.42 22.48 23.29 23.42 24.27 25.52 25.67 24.23 23.68 26.17 24.58 29.93

OAPS Occupied Bed Days Commissioner 460 850 697 652 726 728 791 770 751 734 785 762 898

LCFT and OAPS Occupancy % (Total Network Performance) Commissioner 85% 100.6% 101.1% 98.2% 96.8% 105.7% 106.1% 106.4% 105.4% 107.4% 107.6% 107.9% 109.6%

Number of LCFT and OAPS Occupied Bed Days (Total Network

Performance)Commissioner 9519 10880 10667 10009 10927 10593 10988 10665 10917 11120 10777 11171 10982

LCFT and OAPS Occupancy % (AMH) 101.0% 102.9% 102.8% 101.2% 108.6% 107.9% 108.0% 107.7% 107.6% 108.9% 108.3% 109.4%

Number of LCFT and OAPS Occupied Bed Days (AMH) 8297 7799 7630 8317 8148 8364 8097 8349 8340 8167 8394 8206

LCFT and OAPS Occupancy % (OA) 99.2% 96.5% 85.8% 85.0% 97.0% 100.8% 101.9% 98.6% 106.8% 103.6% 106.6% 110.2%

Number of LCFT and OAPS Occupied Bed Days (OA) 2583 2868 2379 2610 2445 2624 2568 2568 2780 2610 2777 2776

LCFT only Occupancy % (Total Network Performance) NHSE 85% 96.9% 98.7% 100.1% 98.5% 98.5% 98.5% 98.8% 98.7% 100.3% 101.9% 100.5% 100.6%

Number of LCFT only Occupied Bed Days (Total Network Performance) Stretch 9519 10030 9970 9357 10201 9865 10197 9895 10216 10386 10212 10409 10084

LCFT only Occupancy % (AMH) 96.1% 99.6% 99.9% 99.1% 99.2% 98.3% 99.0% 98.7% 98.9% 99.9% 99.5% 99.2%

Number of LCFT only Occupied Bed Days (AMH) 7447 7102 6990 7679 7437 7622 7426 7648 7665 7492 7715 7441

LCFT only Occupancy % (OA) 99.2% 96.5% 100.6% 96.9% 96.3% 98.9% 98.0% 98.6% 104.5% 107.9% 103.5% 104.9%

Number of LCFT only Occupied Bed Days (OA) 2583 2868 2367 2522 2428 2575 2469 2568 2721 2720 2694 2643

Secure Overall Gross Occupancy NHSE 93% 90.2% 91.8% 93.3% 93.7% 97.2% 95.9% 96.0% 94.2% 91.3% 91.0% 92.4% 91.3%

Average Episode Length of Stay (LOS) (AMH) Bench 31 31.20 29.72 40.23 33.00 34.70 36.10 46.40 47.60 29.60 33.30 38.80 43.90

Average Ward Length of Stay (LOS) (PICU) 45.08 58.50 55.20 37.80 39.90 35.10 38.80 30.10 27.60 38.10 34.00 34.00

Average Episode Length of Stay (LOS) (OA) 144.50 123.56 95.35 115.60 122.30 135.50 97.90 104.50 86.90 95.00 129.80 119.00

Re-Admission Rates - 30 Days (AMH) % NHSE <8.7% 16.7% 7.8% 12.6% 9.5% 15.3% 13.8% 14.8% 11.5% 6.9% 6.7% 8.6% 7.5%

Re-Admission Rates - 30 Days (AMH) Number of patients NHSE 15 36 18 24 22 31 30 30 24 14 13 16 13

Re-Admission Rates - 30 Days (OA) % NHSE <8.7% 4.5% 0.0% 0.0% 3.4% 8.0% 0.0% 4.0% 0.0% 3.7% 0.0% 0.0% 0.0%

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

Re-Admission Rates - 90 Days (AMH) % NHSE 15% 25.0% 16.5% 23.0% 19.0% 20.7% 22.6% 22.2% 18.7% 17.3% 12.9% 15.1% 17.9%

Re-Admission Rates - 90 Days (AMH) Number of patients NHSE 26 54 38 44 44 42 49 45 39 35 25 28 31

Re-Admission Rates - 90 Days (OA) % NHSE 15.0% 4.5% 0.0% 0.0% 13.8% 0.0% 10.3% 4.0% 5.3% 7.4% 0.0% 0.0% 4.0%

Re-Admission Rates - 90 Days (OA) Number pf patients NHSE 4 1 0 0 4 - 3 1 1 2 0 0 1

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2.2 Patient Flow Out of Area Placements (OAPS)

59

OAPS:

The average number of OAPs increased in November by 5.35 alongside an increase in the OAP OBD in November with a position of

898, an increase of 136 from October.

The overall number of OAPs again remains relatively static against an assumed fall in the trajectory. It is anticipated that the

operationalization of the Integrated Discharge Team in December will begin to reduce the number of 180+ day length of stay patients,

ensuring that they access a more appropriate care environment. There is system-wide acknowledgement that this cohort of patients are

the key factor on flow and reducing the number of out of area placements. The patient cohort have chronic mental health presentations

with slow responses to treatment. Typically, their presentations fall short of the threshold for a secure services bed, but will not be

accepted by independent providers. As reported previously, from the current inpatient cohort, zero 180+ day cases would result in zero

OAPs and LCFT occupancy on acute wards below 100%. The Network will use LCFT beds made available through the Integrated

Discharge Team to repatriate current OAPs, improving care through bringing these patients closer to families and community care

teams.

No actions provided.

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2.2 Patient Flow OAPS

60

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2.2 Patient Flow OAPS Trajectory

61

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2.2 Patient Flow Occupancy – Mental Health

62

Occupancy:

LCFT and OAPs Occupancy position in November decreased from the October position at 102.87%. The occupancy for LCFT beds in

November was 108.27%, thus the requirement for OAP beds.


1. MCAP standardisation workshop for defining non-qualified bed days

consistently across Trust Wards Dec-17

Deputy Head

of Operations

2. Integrated Discharge Team to become operational Dec-17 Head of

Operations

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2.2 Patient Flow Occupancy – Mental Health Total

63

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2.2 Patient Flow Occupancy – Adult Mental Health

64

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2.2 Patient Flow Occupancy – Older Adults

65

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

66

Average Ward Length of Stay - PICU:

The Network is reporting an average length of stay of 34 days. This is above the Trust set target of 30 days and is equivalent to

October's position.

The Network has maintained a LOS under 40 days for nine 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.

Average LOS in PICU skewed by use of PICU to provide medium/long-term placement for patients with high dependency needs and no

identified available suitable placement.


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2.2 Patient Flow Mental Health – Average Episode LOS – Adult

67

Average Ward Length of Stay - Adult:

The Network is reporting an average LOS of 43.9 days for November, an increase from October's position. PICU LOS is included within

the Average Network LOS.


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

68

Average Episode Length of Stay – Older Adult:

M8 has seen a decrease in the average length of stay, reporting an average LOS 119 days.

Continued efforts in proactive discharge management across all wards and an additional member to the discharge facilitator team has

added support across the wards, working towards timely discharge .


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2.2 Patient Flow Mental Health – Readmission Rate (90 days)

69

Re-Admission Rate (90 Days):

The Network failed to achieve compliance with the 90 day re-admission rate this month with16.16% for M8. This includes Older Adult

ward data. The underlying position with Adult Wards has declined from M7 with a position of 17.92%. Older Adults had one re-admission

in M8.

32 cases were re-admitted within 90 days. These include the 13 cases re-admitted within 30 days. 19 cases were re-admitted 31-90 days

after discharge.


1. Team Leaders to ensure to review in CMHT/CRHTT

Clinical Discussion Meetings.

Nov-17 revised

to Jan-18

Team

Leaders

Target date revised, this process will be

designed within sectorisation process, and

delayed timescale to ensure appropriate process

has been decided on given that the target is

being met currently and so there is no urgent

pressure on this indicator.

2. Re-admission data to be routinely reviewed in Locality

Governance groups.

Nov-17 revised

to Jan-18

Team

Leaders

Target date revised, this process will be

designed within sectorisation process, and

delayed timescale to ensure appropriate process

has been decided on given that the target is

being met currently and so there is no urgent

pressure on this indicator.

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2.2 Patient Flow Mental Health – Readmission Rate (90 days)

70

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Data Quality

Section 2.3

71

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2.3 Data Quality Summary – Data Quality

72

Note: Allocated patients report is back online after re-build. Network re-alignment has meant that some results have changed but does not completely mask a growth in

unallocated cases.

Indicators achieved Target Dec-16 Jan-17 Feb-17 Mar-17 Apr-17 May-17 Jun-17 Jul-17 Aug-17 Sep-17 Oct-17 Nov-17 Sparkline

PBR Clustering

Trust PBR Clustering 95% 96.28% 96.75% 96.37% 96.43% 96.45% 96.66% 96.64% 96.44% 95.70% 95.90% 95.00% 95.30%

Mental Health PBR Clustering 95% 96.43% 96.78% 96.37% 96.48% 96.47% 96.63% 96.65% 96.44% 95.70% 95.90% 95.10% 95.40%

Children & Young People's Wellbeing PBR Clustering 95% 93.60% 96.16% 96.31% 95.35% 95.99% 97.17% 96.35% 96.51% 95.10% 95.30% 95.10% 93.90%

Allocated Patients (within 2 weeks)

Trust Allocated Patients 0 454 461 413 443 430 300 228 242 223 - - 708

Mental Health Allocated Patients 0 307 313 255 260 267 255 211 233 203 - - 152

Community Wellbeing Allocated Patients 0 11 12 12 7 15 13 2 7 19 - - 43

Children & Young People's Allocated Patients 0 14 8 18 29 23 5 4 2 2 - - 99

Manual Overrides

Trust NHSI Manual Overrides 0 16 21 11 13 2 2

MR01 NHSI Manual Overrides 0 4 6 8 1 0 2

MR07 NHSI Manual Overrides 0 11 6 3 8 0 0

Other NHSI Manual Overrides 0 1 9 0 4 2 0

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2.3 Data Quality Data Quality – PbR Clustering

73

PbR Clustering:

Overall the trust is meeting the PBR target, however the Children and Young People's Network have dipped slightly below the 95%

target. This will be addressed directly by the Network Performance Lead.

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2.3 Data Quality Data Quality – Manual Overrides

74

Manual Overrides:

A combination of better recording, checking and reporting has seen manual overrides greatly reduce. Meetings have been diarised

aimed at addressing those that remain.

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75

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:- Contract Activity

• Community & Wellbeing – Network Line Totals

• Community & Wellbeing – Service Line Totals

• Community & Wellbeing – Total Activity Split by CCG

• Community & Wellbeing – Activity Exception Reports by CCG

• Children & Young People’s Wellbeing – Service Line Totals

• Children & Young People’s Wellbeing – Exception Reports by Service

• Children & Young People’s Wellbeing – Total Activity Split by CCG

• Mental Health – Total Activity Split by CCG

• Mental Health – Activity Totals

Section 3.3:- Commissioning for Quality & Innovation

• CQUIN Executive Summary

3. Finance and Contracting

138 of 255


Financial Activity

Section 3.1

76

139 of 255


Use of Resources rating (UoR)

The improved I&E position now yields a rating of 3 and a Capital Service rating of 3 improving the overall UoR to a 2 ( 3 at

Month 7). Assuming current pressures and risks are addressed through the recovery plan and I&E performance achieves

(or exceeds) forecast the Trust will achieve a UoR of 2 in line with the plan. However, though forecast would achieve the

overall target rating, Capital Service is based on EBITDA and since part of the Trusts recovery plan is based on disposals

(which are excluded from EBITDA) the Trust is not forecast to achieve planned Capital Service. The Trust is also forecast to

exceed its liquidity and slip against it's planned Agency target.

3.1 Financial Activity Use of Resources (UoR) Risk Rating

77

FINANCE AND USE OF RESOURCES RATING

Plan Actual Plan Forecast

Capital service cover rating 2 3 2 3

Liquidity rating 2 1 2 1

I&E margin rating 2 3 2 2

I&E margin: distance from financial plan 1 3 1 1

Agency rating 1 2 1 2

Overall 2 2 2 2

Year to Date Annual

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Sustainability

After adjusting for impairments of £0.2m the adjusted deficit for month 8 is a -£1.9m which excludes year to date planned

Sustainability and Transformation Funding of c£1.1m, against a plan surplus to date of £0.9m. Performance is therefore

£2.9m behind the plan and £1.6m behind the control total (excluding STF). The position continues to be driven by staffing

pressures in ward and prison areas and the slow start to delivery against planned cost improvement programmes. In

addition, expenditure is exceeding funding on OAPs resulting in current and forecast pressures. Performance does however

show an improvement on the Month 7 in month position of £0.5m and an in month surplus over plan of £0.3m.

Unmitigated projections indicate a gap of c£4.6m (£6.8m including STF), which again shows an improvement over the month

7 position (c£0.2m).

Though improvements in performance are evident, continued delivery will require sustained and coordinated responses with

robust management and oversight.

3.1 Financial Activity Summary I&E Position

78

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 204,350 203,405 -945 304,889.3 305,459 570

5,728.9 5,639.0 Clinical Services -153,129 -158,666 -5,536 -229,152 -237,571 -8,419

771.0 719.4 Corporate Services -35,076 -35,022 55 -53,404 -52,863 542

Reserves and Capital Charges -15,245 -11,804 3,441 -20,163 -12,981 7,182

6,499.9 6,358.3 899 -2,086 -2,985 2,170 2,045 -125

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3.1 Financial Activity Summary of Clinical Services

79

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

2,952.7 3,045.5 ADULT PAY 78,066.6 84,125.6 -6,059.0 -7.8 117,650.1 125,991.5 -8,341.4

NON PAY 7,624.8 8,749.2 -1,124.4 -14.7 10,203.9 11,904.4 -1,700.5

PATIENT RELATED INCOME -497.8 -1,001.8 504.1 -101.3 -626.7 -1,202.4 575.8

NON PATIENT RELATED INCOME -1,377.7 -1,526.6 148.9 10.8 -2,066.6 -2,278.8 212.2

2,952.7 3,045.5 TOTAL 83,815.9 90,346.4 -6,530.5 -7.8 125,160.6 134,414.7 -9,254.0

1,618.6 1,527.6 ADULT COMMUNITY PAY 37,175.2 37,841.2 -666.1 -1.8 55,968.2 56,402.8 -434.5

NON PAY 8,221.9 7,909.5 312.4 3.8 12,390.9 12,508.9 -117.9

PATIENT RELATED INCOME -5,939.3 -6,093.3 154.0 -2.6 -9,175.7 -9,451.8 276.1

NON PATIENT RELATED INCOME -1,765.8 -1,740.2 -25.7 -1.5 -2,571.5 -2,549.9 -21.6

1,618.6 1,527.6 TOTAL 37,691.9 37,917.2 -225.3 -0.6 56,612.0 56,910.0 -298.0

1,102.5 1,014.1 CHILDREN AND FAMILY PAY 28,245.3 27,329.6 915.7 3.2 42,164.8 41,306.2 858.6

NON PAY 3,387.0 2,864.7 522.3 15.4 4,830.0 4,336.1 493.9

PATIENT RELATED INCOME -1,321.0 -781.5 -539.5 40.8 -1,696.2 -1,071.8 -624.4

NON PATIENT RELATED INCOME -821.1 -926.1 105.0 12.8 -1,116.4 -1,250.0 133.6

1,102.5 1,014.1 TOTAL 29,490.2 28,486.6 1,003.6 3.4 44,182.2 43,320.6 861.7

55.2 51.7 PHARMACY PAY 1,790.2 1,631.1 159.1 8.9 2,685.3 2,450.3 235.0

NON PAY 341.1 288.1 52.9 15.5 511.6 481.0 30.6

NON PATIENT RELATED INCOME 0.0 -3.7 3.7 No Budget 0.0 -5.6 5.6

55.2 51.7 TOTAL 2,131.3 1,915.5 215.8 10.1 3,196.9 2,925.7 271.2

5,728.9 5,639.0 TOTAL 153,129.3 158,665.7 -5,536.4 -3.6 229,151.8 237,570.9 -8,419.1142 of 255


Cost Improvement Programmes

At £8.5m in month 8 the Trust is c£1.3m behind the plan of £9.8m. The adverse variance is attributable to a lack of

performance on Run Rate Reduction Programmes on staffing pressures. The Trust continues to invest significant time

and effort in managing and developing compensating CIPs and network management are being supported to implement

measures aimed at improving the position.

Currently the Trust anticipates it will achieve its annual target of £15.1m.

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

being finalised.

3.1 Financial Activity CIPs

80

Plan Actual Variance Plan Forecast Variance

£'m £'m £'m £'m £'m £'m

Cost Improvement Programmes 7.10 7.71 0.61 11.10 13.10 2.00

Run Rate Reduction Programmes 2.67 0.80 -1.87 4.00 2.00 -2.00

Total 9.77 8.51 -1.26 15.10 15.10 0.00

Year to Date Annual

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Capital Expenditure

Progress against the capital programme has been slow to date with expenditure at £2.1m against the original profile of

£6.6m. With the resolution of a number of issues the Trust is working with contractors to minimise the impact of delays on

the programme though the initial work indicates some slippage on 2017/18 Inpatient and Perinatal scheme expenditure is

now inevitable. Draft forecasts suggest significant slippage on 2017/18 expenditure of 6-8 weeks on Inpatients and x weeks

on Perinatal and though the Trust is working with contractors to ensure both schemes go live on time delays would now

appear likely on Perinatal (c1-3 weeks subject to further discussions with the contractors). Though the programme is behind,

outturns for the remainder of the capital programme are currently expected to be managed in line with overall plan and

funding.

3.1 Financial Activity Capital Expenditure

81

YTD Plan YTD Act Annual Forecast

Nov 2017 Nov 2017 Variance Plan Out-turn Variance

£000 £000 £000 £000 £000 £000

IT Schemes 1.015 0.591 -0.424 1.900 1.900 0.000

Estate and infrastructure Schemes

Large Schemes

MH Inpatient Schemes 3.194 0.537 -2.657 4.580 4.300 -0.280

Perinatal 0.000 0.138 0.138 0.000 2.270 2.270

Places of Safety 0.000 0.138 0.138 0.000 0.138 0.138

High Priority Schemes 0.697 0.147 -0.550 1.263 1.260 -0.003

Maintenance and Replacement 0.620 0.310 -0.310 0.930 0.956 0.026

Other (inc. contingency) 0.463 0.247 -0.216 0.918 0.947 0.029

Total 5.989 2.108 -3.881 9.591 11.771 2.180

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Contract Activity

Section 2.2

82

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83

2017-18 M8 Activity

Following the submission of 3 months variances and trajectories, LCFT have met with Midlands and Lancashire CSU to discuss the quality of the

exception reports being provided as there are concerns that in certain cases LCFT are not providing trajectories that will bring services back to within a

-10% variance.

LCFT Performance have explained that the trust is not prepared to provide unrealistic trajectories and this approach has been agreed by Midlands and

Lancashire CSU and therefore when LCFT feel that a -10% variance is unachievable they will invite the Commissioners to discuss the issues faced by

the service with a view to setting an action plan to improve activity over the remainder of the year.

LCFT have 12 services overperforming by +10% and 14 underperforming by -10%. However, this over and underperformance means that the overall

variance for the Community contract is 0.0% as shown above.

Concerns have been raised by the Midlands and Lancashire CSU that a resolution has not been sought for the Central Lancashire Paediatric Liaison

services to have sight of all the children that are triaged by the ‘Go to Doctor’ service and subsequently deflected away from A&E. This is due to an

outstanding information sharing agreement which LCFT are working to put in place with both the GTD Service and the CSU.

The CWB Network is 2.1% ahead of targeted activity contacts YTD. There are two areas of concern; the first being BwD Treatment Rooms and the

second being Community Matrons who are supporting the CHESS Service in Central Lancashire, both of which have plans in place for redesign to

address service needs.

A number of services have submitted exception reports this month which include recovery trajectories were applicable. All have action plans in place to

recover their monthly position. For those service lines that will not be in a position to make up their negative variance by year end, discussions will

need to take place with the Commissioners.

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

Network17-18 Monthly

PlanApr-17 May-17 Jun-17 Jul-17 Aug-17 Sep-17 Oct-17 Nov-17 YTD 17-18

YTD 17-18

Variance

YTD 17-18

Variance (%)

Planned YTD

17-18

Community & Wellbeing Total 91,093 90,069 94,927 98,778 90,684 91,640 90,102 95,739 96,699 748,638 15,481 2.1% 733,157

Children and Young People's

Wellbeing Total 10,898 6,830 9,676 8,101 7,920 7,188 8,855 9,549 9,568 67,687 -15,216 -18.4% 82,903

Trust Total Against Plan 101,991 96,899 104,603 106,879 98,604 98,828 98,957 105,288 106,267 816,325 265 0.0% 816,060

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84

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

Service17-18

Monthly PlanApr-17 May-17 Jun-17 Jul-17 Aug-17 Sep-17 Oct-17 Nov-17 YTD 17-18

YTD 17-18

Variance

YTD 17-18

Variance (%)

Planned YTD

17-18

Adult Learning Disability Service Total 2,554 1,646 2,345 2,312 2,017 2,080 1,985 2,028 2,482 16,895 -1,708 -9.2% 18,603

Adult Speech and Language Therapy Total 256 349 298 375 415 368 311 352 390 2,858 809 39.5% 2,049

CHESS Total 389 307 427 300 96 213 133 246 153 1,875 -875 -31.8% 2,750

Children's Learning Disability Service Total 1,319 1,235 1,660 1,655 1,363 1,214 1,585 1,594 1,651 11,957 2,348 24.4% 9,609

Community IV Service BwD Total 201 84 97 66 118 92 62 145 177 841 -1,131 -57.4% 1,972

Community Matrons Total 1,548 1,264 1,199 1,293 1,236 1,093 879 868 543 8,375 -3,489 -29.4% 11,864

Community Neuro Team Total 1,090 1,067 1,245 1,254 1,246 1,260 1,123 1,081 1,406 9,682 1,161 13.6% 8,521

Community Respiratory Service Total 1,836 1,968 2,074 1,933 1,918 2,110 1,798 2,267 2,280 16,348 2,834 21.0% 13,514

Community Stroke Service Total 469 339 359 382 431 467 399 558 510 3,445 -532 -13.4% 3,977

Complex Case Management Total 465 413 395 385 321 294 543 641 588 3,580 97 2.8% 3,483

Continence Service Total 352 227 304 223 234 287 290 272 300 2,137 -252 -10.5% 2,389

Dermatology Service Total 477 455 489 400 333 433 276 423 388 3,197 -361 -10.1% 3,558

DESMOND Total 81 65 78 64 75 68 94 124 73 641 25 4.1% 616

Diabetes Specialist Nursing Total 1,183 847 956 974 1,038 1,152 1,081 1,200 1,135 8,383 -818 -8.9% 9,201

District Nursing Total 37,766 40,895 40,999 39,943 37,898 38,888 37,705 39,928 39,278 315,534 11,181 3.7% 304,353

Domiciliary Physiotherapy Total 557 701 610 708 704 784 800 920 1,087 6,314 2,775 78.4% 3,539

Falls Team Total 418 425 658 656 685 667 727 810 585 5,213 2,219 74.1% 2,994

Heart Failure Service Total 544 147 249 261 213 220 251 276 276 1,893 -1,985 -51.2% 3,878

Intermediate Care Total 3,896 2,804 3,168 3,223 2,779 2,747 2,900 2,822 2,420 22,863 -7,072 -23.6% 29,935

Nutrition & Dietetics Total 259 269 262 251 289 211 265 353 375 2,275 355 18.5% 1,920

Oxygen Service Total 332 237 269 313 445 371 333 291 300 2,559 -3 -0.1% 2,562

Phlebotomy Total 15,809 16,855 16,160 22,004 17,610 16,671 17,630 18,013 20,596 145,539 16,328 12.6% 129,211

Podiatry Total 4,884 4,396 5,455 5,071 5,009 5,083 4,848 5,059 5,087 40,008 -963 -2.4% 40,971

Pulmonary Rehabilitation Total 547 441 598 680 618 790 597 631 585 4,940 937 23.4% 4,003

Rapid Assessment Team Total 1,637 1,527 1,735 1,659 1,730 1,700 1,479 1,504 1,365 12,699 511 4.2% 12,188

Rheumatology Total 1,560 1,306 1,587 1,729 1,440 1,684 1,641 1,757 1,855 12,999 1,468 12.7% 11,531

Specialist Nurse TB Total 303 618 381 525 471 481 533 428 451 3,888 831 27.2% 3,057

Tissue Viability Service Total 252 228 247 267 296 297 247 282 214 2,078 -301 -12.7% 2,379

Treatment Room Total 10,055 8,862 10,500 9,768 9,574 9,895 9,446 10,789 10,138 78,972 -9,096 -10.3% 88,068

Viral Hepatitis Service Total 54 92 123 104 82 20 141 77 11 650 188 40.7% 462

Community & Wellbeing Total 91,093 90,069 94,927 98,778 90,684 91,640 90,102 95,739 96,699 748,638 15,481 2.1% 733,157

Please note that the 2016-17 Community Baselines have been produced incorporating seasonal variations for each individual Service where appropriate and so unlike last year the

monthly plans are not determined by dividing the Annual plan by 12. 147 of 255


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

Community & Wellbeing - Total Activity split by CCG17-18


YTD 17-18

Variance

YTD 17-18

Variance

(%)

Planned

YTD 17-18

Central Lancs Locality Total 15,809 16,855 16,160 22,004 17,610 16,671 17,630 18,013 20,596 145,539 16,328 12.6% 129,211

NHS Blackburn with Darwen CCG Total 23,322 21,957 24,654 23,309 23,422 23,699 22,170 24,453 23,506 187,170 -3,926 -2.1% 191,096

NHS Blackpool CCG Total 56 150 120 142 97 108 139 72 89 917 354 62.9% 563

NHS Chorley and South Ribble CCG Total 23,169 26,116 26,299 26,278 24,088 25,577 24,647 25,514 25,625 204,144 19,609 10.6% 184,535

NHS East Lancashire CCG Total 858 649 948 772 668 647 887 815 998 6,384 137 2.2% 6,247

NHS Fylde & Wyre CCG Total 489 322 330 478 391 430 464 588 526 3,529 -126 -3.4% 3,655

NHS Greater Preston CCG Total 26,556 23,281 25,375 24,630 23,500 23,637 23,388 25,429 24,600 193,840 -17,802 -8.4% 211,642

NHS Morecambe Bay CCG Total 429 341 486 584 456 396 373 432 421 3,489 265 8.2% 3,224

NHS West Lancashire CCG Total 405 398 555 581 452 475 404 423 338 3,626 642 21.5% 2,984

Community & Wellbeing Totals 91,093 90,069 94,927 98,778 90,684 91,640 90,102 95,739 96,699 748,638 15,481 2.1% 733,157

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3.2 Contract Activity – Variance to Plan Community & Wellbeing – Activity Exception Reports by CCG

Community & Wellbeing Planned Contract Activity M7

The Community & Wellbeing Network has provided the following explanations as to why certain services are underperforming by more than 10% against the baseline.

Commissioner: NHS Blackburn with Darwen CCG

Under Performance Exception Reporting:-

Adult Learning Disability Service 55%-

The ongoing deep dive into the service data has continued to increase data capture and therefore led to an increase in activity in M8. There continues to be staffing

pressures in M8 with Long term sickness for the clinical psychologist and a number of short term sickness absences throughout the month.

Current position and issues: The current position has been improving however the impact of Transforming Care agenda on contacts with clinicians attending the

required CPA and CTR meetings has been identified as having a significant impact on activity as these have equated to 10 days alone in M8.

Recovery Action Plan: Recording issues will continue to be addressed and work continues on the identified gaps. M11 will see the service roll out their group sessions

on Managing Health and Emotional Regulation topics with the aim of providing an early intervention. This will have a more positive impact on activity levels.

Trajectory:

Dec: 350 contacts

Jan: 350 + 10% groups = 385

Feb : 350 + 10% from groups = 385

March: 350 + 10% from groups = 385

Activity has increased by 40% in M8 however is still well under the monthly plan. Continuing at this increased level for the remainder of this financial year would have a

more positive impact on our baseline figures although at this position in the year, achieving the above proposed monthly trajectory will improve the current position by a

further 14%.

Forecast: Increased focus on accurate data recording along with the change in the delivery of services through increasing the numbers of group sessions will help to

support our proposed trajectory.

Service17-18


YTD 17-18

Variance

YTD 17-18

Variance (%)

Planned YTD

17-18

Adult Learning Disability Service 473 135 189 178 160 143 178 240 342 1,565 -1,881 -55% 3,446

Children's Learning Disability Service 95 106 121 179 109 140 144 124 141 1,064 370 53% 694

Community IV Service BwD Total 201 84 97 66 118 92 62 145 177 841 -1,131 -57% 1,972

Community Respiratory Service 498 644 596 578 570 621 566 670 663 4,908 693 16% 4,215

Community Stroke Service 469 339 359 382 431 467 399 558 510 3,445 -532 -13% 3,977

DESMOND (Completed Courses) 32 28 25 6 19 11 35 42 30 196 -42 -18% 238

Diabetes Specialist Nursing 492 274 387 265 305 429 414 362 380 2,816 -1,013 -26% 3,829

District Nursing 7,908 8,822 9,327 8,991 9,193 8,795 8,197 9,036 8,972 71,333 7,611 12% 63,722

Intermediate Care ACS 1,120 866 1,066 1,068 970 1,002 946 957 777 7,652 -961 -11% 8,613

Pulmonary Rehabilitation 547 441 598 680 618 790 597 631 585 4,940 937 23% 4,003

Tissue Viability Service 79 105 119 111 121 97 92 126 94 865 132 18% 733

Treatment Room - Non-Serious Injury 98 141 195 189 184 144 166 169 134 1,322 281 27% 1,041

Treatment Room Total 6,419 5,590 6,359 5,721 5,659 6,008 5,686 6,405 6,097 47,525 -8,755 -16% 56,280

Treatment Room - Ulcer & Vascular 168 164 260 330 270 272 195 200 192 1,883 575 44% 1,308

149 of 255





Community IV Service BwD 57%-

Current position and issues:

In M8 the IV team has the highest number of contacts this financial year. The team continue to work closely with East Lancashire Teaching Hospitals to ensure step down

referrals are captured. The IV team currently has capacity to accept new referrals and support the acute hospitals during the winter pressures.

In M8 there was a staff member on short term sickness which has had an impact upon our on-going promotions. However the service is now back up to full establishment

in M8.

The service continues to support the nursing element of IHSS to ensure all service needs and demands are delivered in a timely way to provide acute responses.

Recovery action plan:

We will continue to promote the IV service in ELHT and other acute sites and liaise with the OPAT nurse at ELHT daily regarding potential patients to try and increase

acute step down referrals into the service.

Trajectory:

From October 1st 2017 the service stopped accepting step up referrals from primary Care so this will have a further impact on referrals to the service.

Forecast:

The IV service continues to work with stakeholder colleagues to promote and identify patients for Community IV therapy. We plan to meet with commissioners in M9 to

discuss future IV work and how we can develop the service. Consider if this service forms part of the task and finish group, meeting planned with the CCG on Monday 18th

December to discuss plans for proposed trajectories.

Community Stroke Service 13%-


The teams monthly plan was to achieve 469 contacts. For M8 this target was exceeded however previous months positions left us with a 13.4% negative variance. This

has been due to a number of factors. Long term sickness has impacted on our capacity for a number of months but we have also had some short term sickness in M8.

We expect these staff to return to work in M9.


The recovery trajectory has been set at plan plus 10% so with staff returning to work in M9 we expect that will end on a negative variance of -5% although this will be with

our 10% tolerance range at year end.

Forecast:

As part of the recovery action plan we have examined the way contacts have been recorded on ECR. We have identified that there are inconsistencies in the way that the

team records their weekly multidisciplinary team discussions.

We will continue to build on our working relationships and promoting the service within the acute trust to facilitate timely discharges. 150 of 255




Under Performance Exception Reporting continued:

DESMOND (Completed Courses) 18%-


M8 is showing a total of 30 attendances which was close to the monthly plan although not enough to recover our position in M8. There still remains a deficit of 17.6%

against the plan. This however is an improvement on the previous months position by 1.8%.

The service continues to experience long term sickness, although the staff member was originally due to return in M9 is now not due to return until at least M11. Long

term sickness throughout 17/18 has reduced the amount of courses the service has been able to offer.


The team contacts all Desmond referrals by phone to give more detail of the value of the course and to book patients in.

Increase the number of people trained in Desmond to be able to cover for staff sickness. We have identified people to could be part of a DESMOND bank for Pennine

Lancashire. This will not provide immediate improvement but will future proof the service to ensure courses can take place.

Forecast:

There are 2 courses planned for Month 9 which should maintain our recovery trajectory which we have set at 10% above monthly plans and if achieved will leave us in a

year end position of around -7% which is within 10% tolerance.

Diabetes Specialist Nursing 26%-


The monthly plan was 492 contacts and the team achieved only 380 in M8 leaving us with a variance of -26.5%. Due to unplanned levels of sickness within our Diabetes

Education Programme (DESMOND) Diabetes Specialist Nurses supported the education courses so that patients did not have to be cancelled. This however has had a

negative impact on our own Diabetes Baseline figures.


By identifying staff that will be able to cover the DESMOND Courses will allow the DSN trained staff to return to work within Diabetes Services.

Forecast:

The trajectory was set in M6 which aimed for a recovery back to within -5% tolerance, however an additional vacancy from the end of M8 is likely to further impact on our

activity levels. It is unlikely that the service will be fully recruited to before M11 and this will further impact on activity with a projected end of year variance of -22%.

We plan to meet with commissioners in M9 to discuss our recovery trajectory. Consider if this service forms part of the task and finish group, meeting planned with the

CCG on Monday 18th December to discuss plans for proposed trajectories.

151 of 255




Under Performance Exception Reporting continued:

Intermediate Care 11%-


The community rehabilitation team have been supporting the RAT team who are experiencing high levels of long term sickness. This is to ensure the acute trust are able

to refer early supported discharges and the patients are seen within a timely manner to help prevent hospital admissions.

Treatment Room 16%-


We are currently below our planned activity in treatment rooms . In previous months we have had vacancies, but all posts are now recruited to. In addition we have

experienced long term sickness within the team which is being managed in line with policy.


Set up weekly task and finish group to consider service delivery, access and waiting times. This has identified a number of issues. A project plan has been developed

which has been shared across both organisations, this includes:-

* Venepuncture - transition to drop in clinics.

* Review of clinic utilisation across all sites

* Deep dive into DNA's and cancellations

* Communications with all stakeholders

* Consideration of best practice in other localities

* Consideration of patients who attend Non Serious injury, Ulcer and vascular Clinic and visited by the District Nursing Services who's care could be more appropriately

provided in treatment rooms

Trajectory:

On Monday 18th Dec we are meeting with the CCG to discuss recovery trajectories in line with our recovery action plan.

Forecast:

We anticipate that movement to walk-in venepuncture clinics in M11 will reduce DNA' s and maximise clinic capacity.

152 of 255




Over Performance Exception Reporting:-

Children's Learning Disability Service 53%+


The increased numbers of Group sessions contribute to this over performance in BwD

Community Respiratory Service 16%+


We continue to see high referral numbers which is expected during the months of winter pressures. The team are continuing to meet the service demands

District Nursing 12%+


The team continue to meet the need and demands of the service which is reflected in increased activity levels, leaving us at a YTD positive variance of 12%

We are currently reviewing district nursing caseloads to see if there are patients that could be seen in the treatment rooms

Pulmonary Rehabilitation 23%+


The current position in maintaining activity over plan is due to the numbers of patients attending and successfully completing their course. This is due to intensive work

contacting patients, building relationships within the service/stakeholders which has resulted in more patients completing a six week course.

Tissue Viability Service 18%+


The service have seen an increasing number of referrals from district nursing services for patients with more complex presentations. This has led to an increase in activity

levels over the past year which has left us in a YTD positive variance of 18% above the agreed baseline.

Treatment Room – Non-Serious Injury 27%+


Full exception report has been submitted which covers the treatment room total for BwD.

Treatment Room – Ulcer & Vascular 44%+


Full exception report has been submitted which covers the treatment room total for BwD.

153 of 255



Commissioner: NHS Blackpool CCG


Specialist Nurse TB 63%+


Increased numbers of referrals over several months has contributed to a positive in month variance against plan

Commissioner: Central Lancs Locality


Community Matrons 29%-


Referrals into the matron service have decreased over the last three months which has impacted on activity linked to new face to face contacts and associated reviews.

A reduction in WTE linked to vacancy, sickness and implementation of the action plan to support the CHESS service has also impacted on matron activity.

All patients referred have been seen and care plans formulated. New care pathways are being developed between matrons and specialist teams to ensure seamless care

across pathways are in place and to ensure capacity to manage new referrals. This has seen a reduction in follow up activity for matrons during November as, moving

forwards, suitable patients are managed along specialist pathways.

The team has recently had an increase in turnover due to retirements, staff leaving for posts nearer home and also leaving for more lucrative contracts with local providers.

This will continue to impact on the ability of the team to meet its activity targets.

A sustainability model has been developed in discussion with the CCG and recruitment to vacancies for matrons and case managers is now in place but it is unlikely that we

will see full recruitment to posts until March 2018.

Service17-18


YTD 17-18

Variance

YTD 17-18

Variance (%)

Planned YTD

17-18Specialist Nurse TB 56 150 120 142 97 108 139 72 89 828 321 63% 507

Service17-18


YTD 17-18

Variance

YTD 17-18

Variance (%)

Planned YTD

17-18

Adult Speech and Language Therapy Total 256 349 298 375 415 368 311 352 390 2,858 809 39% 2,049

Community Matrons Total 1,548 1,264 1,199 1,293 1,236 1,093 879 868 543 8,375 -3,489 -29% 11,864

Community Neuro Team Total 1,090 1,067 1,245 1,254 1,246 1,260 1,123 1,081 1,406 9,682 1,161 14% 8,521

Community Respiratory Service Total 1,338 1,324 1,478 1,355 1,348 1,489 1,232 1,597 1,617 11,440 2,141 23% 9,299

Continence Service Total 352 227 304 223 234 287 290 272 300 2,137 -252 -11% 2,389

DESMOND (Completed Courses) Total 49 37 53 58 56 57 59 82 43 445 67 18% 378

Domicillary Physiotherapy Total 557 701 610 708 704 784 800 920 1,087 6,314 2,775 78% 3,539

Falls Team Total 418 425 658 656 685 667 727 810 585 5,213 2,219 74% 2,994

Intermediate Care ACS Total 2,776 1,938 2,102 2,155 1,809 1,745 1,954 1,865 1,643 15,211 -6,111 -29% 21,322

Nutrition & Dietetics Total 259 269 262 251 289 211 265 353 375 2,275 355 18% 1,920

Phlebotomy 15,809 16,855 16,160 22,004 17,610 16,671 17,630 18,013 20,596 145,539 16,328 13% 129,211

Tissue Viability Service Total 90 49 50 48 53 57 53 50 27 387 -443 -53% 830

154 of 255




Under Performance Exception Reporting continued:-

Community Matrons – Continued:-

Forecast

Based on the forecasted recruitment timescales, it is unlikely that the service will recover its position by end Q4. It is estimated that it is unlikely that the service will be fully

recruited to before January and this will further impact on activity with a projected negative variance of approx -40%.

Continence 11%-


Activity has increased in M8 following a phased return. However this sickness has impacted on activity in previous months leading to the under performance negative

variance of -11%

Intermediate Care ACS 29%-


Activity in Intermediate Care needs to be taken in the context of Falls and Community Therapies. These are collectively above baseline and delivered as one overall

service specification. Taking account of the overall activity of the combined Community Therapy teams the overall position is of over-performance.

New Discharge to assess pathways for Broadfield and Meadowfield has increased number of patients not requiring rehab within the units and this will have negatively

impacted on activity.

Recovery Action Plan

Staff are flexed across all areas within the Integrated Rehabilitation Team to respond according to clinical demand. Performance of the combined team shows well above

activity taking into account the Intermediate Care, Domiciliary Physio and Falls data. It is proposed that a combined report is created to address this issue.

Trajectory

As new starters begin in post across December and January it is envisaged that this will increase monthly actual figures although the Discharge to Assess pathway

continues to negate rehab need as patients discharged into longer term care. Will mean overall Intermediate Care activity unlikely to return to levels seen in May or June

Forecast

YTD variance (when looking at Intermediate Care and not wider Therapy context) will be approximately -30%. This needs to be taken in context across all therapy

services.

155 of 255




Under Performance Exception Reporting Continued:-

Tissue Viability Service 53%-


During M8 the team had planned annual leave and then some unplanned long term sickness which has further impacted on our activity levels which has left us in a

negative variance of 53%. We have attempted to recruit extra staff but due to the nature of this teams work and the small number of existing staff we have been

unable to recruit. We will continue to attempt to recruit to this post. After delving into the data further it has appeared that the team stopped recording any non face to

face activity with patients in Q3 -Q4 15-16 which has impacted on our activity levels with approximately a 50% drop in contacts. We are still experiencing some sickness

but plans are in place to ensure visits are covered.


Discussions have taken place with the team to ensure they record all their activity including their non face to face activity with patients.

Baselines will be monitored weekly.

Trajectory

We have set a recovery trajectory of baseline plus 1% which should leave us at a year end position of around negative 30% YTD variance.

Forecast

If recording takes place as anticipated for the non face to face contacts from M9/10 onwards including some historical recording on to the electronic system although we

wont end year end within the 10% tolerance we will be in a more positive position at the year end and into the new financial year.

Over Performance Exception Reporting :-

Adult Speech and Language Therapy 39%+


The service have increased their use of non face to face reviews to work more efficiently which continues to have a positive impact on activity levels. There has also

been a significant increase in referrals over the last 2 quarters of the year. New staff have commenced employment and have full caseloads.

Community Neuro Team 14%+


Additional temporary staffing commenced in M7 which will have had a positive impact on our activity levels.

Community Respiratory Service 23%+


The number of in month referrals remains high, this combined with increased acuity of caseload has contributed to increased activity in month and YTD positive

variance. 156 of 255




Over Performance Exception Reporting :-

DESMOND (Completed Courses) 18%+


The service currently has an action plan in place to increase uptake of diabetes structured education. This is continuing to deliver improvements in attendance and

contributing to a positive in month and YTD positive variance.

Domiciliary Physiotherapy 78%+


Domiciliary Physiotherapy over-performance needs to be taken in conjunction with all other community therapy activity (as part of one combined service specification

for Central Lancs Community Rehabilitation Team). This combines Domiciliary Physiotherapy, Intermediate Care and Falls Team data and the exception narrative

provided on line 47 also applies here. Whilst Intermediate Care is showing an underperformance, collectively the rehabilitation team is overperforming. Note, Falls data

does not include that of Steady On which is reported separately to LCC.

Falls Team 74%+


Falls over-performance needs to be taken in conjunction with all other community therapy activity (as part of one combined service specification for Central Lancs

Community Rehabilitation Team). This combines Domiciliary Physiotherapy, Intermediate Care and Falls Team data and the exception narrative provided on line 47

also applies here. Whilst Intermediate Care is showing an underperformance, collectively the rehabilitation team is overperforming. Note, Falls data does not include

that of Steady On which is reported separately to LCC.

Nutrition & Dietetics 18%+


A high demand for the service combined with increasing numbers of patients requiring ongoing follow up reviews continues to place the service under pressure and

contributes to higher than planned activity.

Phlebotomy 13%+


The service flexes staff across localities to meet demand. The number of diagnostic blood test requests are increasing across both localities. The number of outpatients

attending community clinics for their blood test remains high and is also contributing to the positive variance. This needs to be taken in the context of the fact that most

clinics are dropping and we will be unable to manage the increased demand on the service.

157 of 255



Commissioner: NHS Chorley & South Ribble CCG


CHESS 13%-


The number of referrals into the service has decreased quarter on quarter which has had a negative impact on our activity levels.


Children's Learning Disability Service 50%+


The team run a high number of groups for parents named 'Riding the Rapids' and 'Incredible Years' which contribute to the over activity. They also receive a large number

of referrals for ASD children which has increased activity this year as they have a commissioned a project for pre-school children which started in M6 and ends in M12 so

activity is expected to remain higher than the planned baseline.

Diabetes Specialist Nursing 16%+


The service in reach onto LTH wards, the activity associated with this is unpredictable and therefore may have contributed to the in month and YTD positive variance.

Rheumatology 17%+


Increasing numbers of referrals is contributing to increased activity and both positive in month and YTD variance against plan.



Increased numbers of referrals over several months has contributed to a positive in month variance against plan.

Service17-18


YTD 17-18

Variance

YTD 17-18

Variance (%)

Planned YTD

17-18

CHESS 144 156 205 107 33 143 77 96 69 886 -133 -13% 1,019

Children's Learning Disability Service 301 351 504 462 408 273 421 391 483 3,293 1,104 50% 2,189

Diabetes Specialist Nursing 168 167 161 182 185 197 170 238 209 1,509 203 16% 1,306

Rheumatology 638 579 677 745 631 695 703 719 770 5,519 805 17% 4,714

Specialist Nurse TB 21 35 6 0 39 5 93 62 76 316 108 52% 208

158 of 255



Commissioner: NHS East Lancashire CCG


Children's Learning Disabilities Service 52%+


The team run a high number of groups for parents 'Riding the Rapids' and 'Incredible Years' which contribute to the over activity.

Commissioner: NHS Fylde and Wyre CCG



Exception Narrative: The ongoing work regarding data capture has identified errors with under reporting which has been addressed. Analysing clinical time has

identified the amount of meeting time increasing as clinicians Transforming Care caseloads expand. This time will be monitored to assess how it can be mitigated in

future months. Clinicians have been consolidating caseloads & completing caseload closure reports which has impacted on clinical time of which has not been

recorded against patient activity.

Current position and issues: The current position has been improving month on month since an initial slow start to the year. The impact of the Transforming Care

agenda has required clinicians to attend ongoing CPA and CTR meetings. This has had a significant impact on activity levels as these meetings equated to 9 days

alone in M8. Those patients placed out of area continue to be a challenge for the service which has significantly impacted on activity levels due to increased travel time

and patient allocations.

Recovery Action Plan: Recording issues will continue to be addressed and work continues on the identified areas. In M11 the team are intending to run at least 2

groups per month on Staying Well, Improving Communication and Emotional Regulation topics. The aim is to provide an early intervention to prevent any deterioration

in mental and/or physical health and prevent admissions. This will support the monthly recovery plan by increasing activity by approximately 70 contacts per month

whilst delivering services to those who may not receive an intervention until their situation has deteriorated.

Service17-18


YTD 17-18

Variance

YTD 17-18

Variance (%)

Planned YTD

17-18

Adult Learning Disability Service 339 168 184 268 210 284 268 417 322 2,121 -352 -14% 2,473


Service17-18


YTD 17-18

Variance

YTD 17-18

Variance (%)

Planned YTD

17-18

Children's Learning Disability Service 268 200 281 280 179 208 349 362 356 2,215 108 52% 1,951

159 of 255



Commissioner: NHS Fylde and Wyre CCG


Adult Learning Disabilities Service:

Trajectory: A recovery trajectory would require monthly contacts of 457 which is unlikely taking into consideration the current achieved monthly figures. The monthly

recovery plan will provide a year end negative out turn to be within the 10% tolerance.

Forecast: Activity increased in M7 but was not maintained in M8, although this was still higher than previous months in year. The increase in activity can be attributed

to more accurate recording on the clinical system and along with the change in delivery of services through increasing the numbers of group sessions will help to

support our proposed recovery trajectory.

Over Performance Exception Reporting:




160 of 255



Commissioner: NHS Greater Preston CCG


CHESS 43%-

Current Position and Issues

The CHESS service has recently been experiencing reduced numbers of referrals in Greater Preston locality. This coupled with additional annual leave for M8 has

impacted on activity for new and follow ups. This needs to be considered within the context that this small niche service which operates across the Central Lancashire

locality was significantly understaffed earlier in the year and activity was impacted in Q2.

Actions

Staffing has been bolstered by flexing community matron staff with the necessary knowledge and skills to support the two care homes and to provide further support from

the wider teams in respect of care home work plans.

A sustainability model has been developed in discussion with the CCG and recruitment to vacancies is now in place but it is unlikely that we will see full recruitment to

posts until March 2018 which will continue to impact activity into Q4.

Forecast

Based on the forecasted recruitment timescales it is unlikely that the service will recover its position by end Q4- estimated that It is unlikely that the service will be fully

recruited to before January and this will further impact on activity with a projected negative variance of approx. -37 % . However this needs to be considered in the

context that the team also works across CSRCCG and overall there should be a reduced combined – variance.

Service17-18


YTD 17-18

Variance

YTD 17-18

Variance (%)

Planned YTD

17-18

Adult Learning Disability Service 262 185 298 351 381 430 292 206 278 2,421 510 27% 1,911

CHESS 245 151 222 193 63 70 56 150 84 989 -742 -43% 1,731

Children's Learning Disability Service 266 232 271 275 242 246 327 317 314 2,224 285 15% 1,939

Heart Failure Service 272 133 228 233 192 201 226 235 241 1,689 -250 -13% 1,939

Viral Hepatitis Service 33 70 96 91 62 14 34 37 11 415 138 50% 277

161 of 255





Heart Failure Service -13%-

Current Position and Issues

Unfilled vacancy in month 1 followed by period of induction of new member of staff from May to July together with summer holiday period has contributed to the overall

YTD negative variance. Staffing of clinics in CDGH from October to support heart failure expansion into CSR has further contributed to a negative variance. There is

currently a new vacancy in the team which will continue to impact on the service activity overall until filled. Since the service expansion into CSR the teams work across

both localities and flexes staff across both CSR and GP.


A gradual increase in monthly activity is delivering a positive shift in negative variance against plan. Staff will continue to try and meet demand despite recent vacancy.

Recruitment to this vacancy is likely to be in the new year.

Trajectory

It is likely the service will have a monthly actual for December of approx. -10% against monthly plan due to holidays. In January and February we are likely to deliver

approx +6% above monthly plan. Early Easter holidays are likely to impact on activity in March with the service achieving expected monthly planned activity.

Forecast

This is likely to deliver an end of YTD variance of approx -9%


Adult Learning Disability Service 27%+


The team have started carrying out joint assessment appointments between different disciplines to assess the needs of the patient at the point of referral with a view to

improving outcomes. This has resulted in an increase in activity. We also have a trainee psychologist commence in M8 who now has a caseload.

Children’s Learning Disabilities 15%+


The team deliver a large number of groups and have a number of children on the Dynamic Risk Register requiring intensive input which increases the numbers of

contacts for the service.

Viral Hepatitis Service 50%+


Increases in group activity continues to contribute to a positive in month variance. 162 of 255



Commissioner: NHS Morecambe Bay CCG




There has been a nurse and AHP vacancy in the team for the past 2 months however a nurse has now been appointed and will start in M9. The AHP post remains vacant.

There has also been a significant number of absences due to long term sickness but the majority of these staff are due to return this month.


Children’s Learning Disability Service 220%+


Additional activity for Tranche 1 & 2 has impacted on our baseline activity figures. Activity has continued to increase month on month in an upward trend leaving us in a

220% positive variance position YTD.




Service17-18


YTD 17-18

Variance

YTD 17-18

Variance (%)

Planned YTD

17-18

Adult's Learning Disability Service 361 184 321 384 300 248 271 255 245 2,208 -419 -16% 2,627

Children's Learning Disability Service 34 91 128 99 80 74 69 114 132 787 541 220% 246


163 of 255



Commissioner: NHS West Lancashire CCG


Children’s Learning Disability Service 11%-


The team have a vacancy which has equated to being under establishment by 30% resulting in a reduction in activity.


Adult Learning Disability Service 68%+


The team run weekly group sessions which is generating multiple patient contacts. A complex case has also had an impact on our activity figures until year end.




Viral Hepatitis Service 98%+


Although no in month referrals combined with no vaccinations being due has resulted in nil contacts for the month of November there is still a YTD positive variance due to

an increase in the amount of group activity in previous months.

Service17-18


YTD 17-18

Variance

YTD 17-18

Variance (%)

Planned YTD

17-18

Adult Learning Disability Service 154 230 292 324 187 273 184 199 191 1,880 759 68% 1,121

Children's Learning Disability Service 237 160 238 233 233 182 180 184 134 1,544 -185 -11% 1,729


Viral Hepatitis Service 5 2 14 13 5 6 18 25 0 83 41 98% 42

164 of 255


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

102

Children & Young People's Wellbeing -

Total Activity split by CCG

17-18


YTD 17-18

Variance

YTD 17-18

Variance (%)

Planned YTD

17-18

NHS Blackburn with Darwen CCG Total 809 561 753 718 591 535 766 787 794 5,505 -296 -5% 5,801

NHS Chorley and South Ribble CCG Total 2,016 1,011 1,339 1,310 1,178 830 1,198 1,229 1,316 9,411 -5,642 -37% 15,053

NHS East Lancashire CCG Total 4,492 3,448 5,028 4,026 3,971 3,779 4,438 4,979 4,895 34,564 -783 -2% 35,347

NHS Greater Preston CCG Total 2,839 1,399 1,994 1,524 1,751 1,575 1,876 2,021 2,006 14,146 -7,194 -34% 21,340

NHS West Lancashire CCG Total 742 411 562 523 429 469 577 533 557 4,061 -1,301 -24% 5,362

Children & Young People's Wellbeing

Total 10,898 6,830 9,676 8,101 7,920 7,188 8,855 9,549 9,568 67,687 -15,216 -18% 82,903

165 of 255


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

103

Service17-18 Monthly


YTD 17-18

Variance

YTD 17-18

Variance (%)

Planned YTD

17-18

Children's Occupational Therapy Total 1,068 618 835 851 610 550 799 836 785 5,884 -2,883 -33% 8,767

Children's Physiotherapy Total 929 574 645 632 580 518 648 694 678 4,969 -1,530 -24% 6,499

Children's Speech & Language Therapy Total 3,617 1,960 2,859 2,573 2,361 1,938 2,772 3,102 2,850 20,415 -4,792 -19% 25,207

Paediatric Liaison Total 5,284 3,678 5,337 4,045 4,369 4,182 4,636 4,917 5,255 36,419 -6,011 -14% 42,430

Children and Young People's Wellbeing

Total Against Plan10,898 6,830 9,676 8,101 7,920 7,188 8,855 9,549 9,568 67,687 -15,216 -18% 82,903

166 of 255


3.2 Contract Activity – Variance to Plan Children & Young People’s Wellbeing – Exception Reports by Service

104

Commissioner: NHS Chorley & South Ribble CCG


Children’s Occupational Therapy 37%-


The service is not meeting the baseline activity target. On review of how this was established for 2017/2018, it is noted that they were set based on 100% staff capacity,

so no slippage has been factored in for sickness, maternity leave, recruitment etc. throughout the monitoring year add it is of note that many of the teams are not running

at 100%. There is also an ongoing awareness that the teams use paper records and electronic activity noting so the data collection for these teams is not as robust as

we would like. A paper is being prepared for complete electronic records as the concern is that recording is under actual levels. It is also noted that the service is working

to shorter episode lengths which is positive and could indicate better self help strategies being promoted. This was part of the redesign in CITNS and is demonstrated

by waiting lists now within RTT target.

In order to support the understanding of the activity achieved throughout the year to date, we are providing below the current staffing capacity and the YTD position for

this team.

For C&SR the current staff capacity is at 90%, with the YTD calculated as at 83%.

Forecast

The service continue to work hard to maximise all the capacity in the service. These issues are to be discussed at Community Q&P in December 2017.

Children’s Physiotherapy 24%-

The manual position reported through Schedule 6 is -4.2% therefore the service has not been asked to provide exception narrative.

Paediatric Liaison 62%-


The service receives 100% of its referrals from the Emergency Department (ED), and have no control over the number of children attending however the activity is lower

than expected as we are currently unable to identify the activity that is deflected through the Go To Doctor Service.



YTD 17-18

Variance

YTD 17-18

Variance (%)

Planned YTD

17-18

Children's Occupational Therapy 19 115 155 172 142 92 154 151 154 1,135 -672 -37% 1,807

Children's Physiotherapy 345 257 266 271 213 190 204 226 198 1,825 -579 -24% 2,404

Paediatric Liaison 900 261 434 311 366 291 366 277 366 2,672 -4,322 -62% 6,994

167 of 255



105









to shorter episode lengths which is positive and could indicate better self help strategies being promoted. This was part of the redesign in CITNS and is demonstrated by

waiting lists now within RTT target.


this team.

For East Lancashire the current staff capacity is at 86%, with the YTD calculated as at 84%.

Forecast




YTD 17-18

Variance

YTD 17-18

Variance (%)

Planned YTD

17-18


Children's Speech & Language Therapy 1,358 634 1,012 887 792 665 916 1,101 884 6,891 -2,573 -27% 9,464

Paediatric Liaison 2,786 2,586 3,684 2,818 2,967 2,928 3,233 3,564 3,732 25,512 2,490 11% 23,022

168 of 255



106



Children’s Speech & Language Therapy 27%-










this team.

For East Lancashire the current staff capacity is at 90%, with the YTD calculated as at 83%.

Forecast



Paediatric Liaison 11%+




169 of 255



107












this team.

For Greater Preston the current staff capacity is at 90%, with the YTD calculated as at 84%.

Forecast




YTD 17-18

Variance

YTD 17-18

Variance (%)

Planned YTD

17-18



Children's Speech & Language Therapy 648 270 401 272 361 305 411 451 422 2,893 -1,616 -36% 4,509

Paediatric Liaison 1,598 831 1,219 916 1,036 963 1,037 1,076 1,157 8,235 -4,179 -34% 12,414

170 of 255



108





The service is not meeting the baseline activity target. On review of how this was established for 2017/2018, it is noted that they were set based on 100% staff capacity, so

no slippage has been factored in for sickness, maternity leave, recruitment etc. throughout the monitoring year add it is of note that many of the teams are not running at

100%. There is also an ongoing awareness that the teams use paper records and electronic activity noting so the data collection for these teams is not as robust as we

would like. A paper is being prepared for complete electronic records as the concern is that recording is under actual levels. It is also noted that the service is working to

shorter episode lengths which is positive and could indicate better self help strategies being promoted. This was part of the redesign in CITNS and is demonstrated by


In order to support the understanding of the activity achieved throughout the year to date, we are providing below the current staffing capacity and the YTD position for this

team.


Forecast


Children’s Speech and Language Therapy 36%-









team.


Forecast


171 of 255



109



Children’s Paediatric Liaison 34%-















team.

For West Lancashire the current staff capacity is at 94%, with the YTD calculated as at 67%.

Forecast




YTD 17-18

Variance

YTD 17-18

Variance (%)

Planned YTD

17-18

Children's Occupational Therapy 154 72 101 107 64 98 92 92 99 725 -529 -42% 1,254


Children's Speech & Language Therapy 384 243 335 277 247 250 323 283 246 2,204 -476 -18% 2,680

172 of 255



110





The services is not meeting the baseline activity target. On review of how this was established for 2017/2018, it is noted that they were set based on 100% staff capacity,




to shorter episode lengths which is positive and could indicate better self help strategies being promoted. This was part of the redesign in CITNS and is demonstrated

by waiting lists now within RTT target.


this team. For West Lancashire the current staff capacity is at 95%, with the YTD calculated as at 77%.

Forecast


Children’s Speech and Language Therapy -18%


The manual position reported through Schedule 6 is -4.9% therefore the service has not been asked to provide exception narrative.

173 of 255


3.2 Contract Activity – Variance to Plan Mental Health – Total Activity split by CCG

Demand Metrics Apr-17 May-17 Jun-17 Jul-17 Aug-17 Sep-17 Oct-17 Nov-17 YTD 17-18

Adult/PICU Ward Admissions Total 169 195 180 187 175 171 167 153 1,397

Adult/PICU Ward Discharges Total 167 187 177 165 168 163 160 147 1,334

CMHT Adult - Accepted Referrals Total 153 171 167 153 212 189 187 196 1,428

CMHT Older Adult - Accepted Referrals Total 90 139 131 120 142 134 129 142 1,027

Community Restart Teams - Accepted Referrals Total 130 176 178 165 163 122 158 127 1,219

CRHT Teams - Referrals Total 720 793 870 806 769 822 806 742 6,328

Eating Disorder Service - Referrals Total 73 86 93 79 69 69 94 96 659

Hospital Liaison Referrals Total 149 171 155 158 175 152 154 153 1,267

MAS Teams - Referrals Total 492 565 627 607 617 580 605 624 4,717

Older Adult (Dementia) Inpatient Ward Admissions Total 7 12 6 7 7 9 5 6 59

Older Adult (Dementia) Inpatient Ward Discharges Total 10 6 8 8 5 6 8 6 57

Older Adult (Functional) Inpatient Ward Admissions Total 11 9 11 12 9 11 4 8 75

Older Adult (Functional) Inpatient Ward Discharges Total 12 10 9 14 9 11 7 8 80

PICU Wards - Transfers In Total 16 27 24 26 21 17 24 22 177

RITT Referrals Total 169 154 168 151 204 154 145 163 1,308

174 of 255


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

Mental Health - Total Contacts Activity split by CCG Apr-17 May-17 Jun-17 Jul-17 Aug-17 Sep-17 Oct-17 Nov-17 YTD 17-18

NHS BLACKBURN WITH DARWEN CCG 2,665 3,162 2,928 2,848 2,838 2,775 2,963 2,737 22,916

NHS BLACKPOOL CCG 2,751 3,225 2,915 2,991 2,991 3,030 3,207 2,800 23,910

NHS CHORLEY AND SOUTH RIBBLE CCG 2,339 2,584 2,341 2,219 2,307 2,279 2,543 2,387 18,999

NHS EAST LANCASHIRE CCG 4,870 5,770 5,560 5,834 5,612 5,195 5,447 5,305 43,593

NHS FYLDE & WYRE CCG 2,398 2,589 2,699 2,549 2,599 2,408 2,404 2,432 20,078

NHS GREATER PRESTON CCG 2,898 3,659 3,494 3,389 3,460 3,322 3,694 3,506 27,422

NHS MORECAMBE BAY CCG 2,584 2,757 2,823 2,879 2,901 2,863 2,918 2,669 22,394

NHS WEST LANCASHIRE CCG 1,419 1,677 1,664 1,676 1,766 1,607 1,531 1,601 12,941

Grand Total 21,924 25,423 24,424 24,385 24,474 23,479 24,707 23,437 192,253

Please note that the 2016-17 Mental Health Baselines have been produced incorporating the number of working days per month, and so unlike last year ,the monthly plans are not

determined by dividing the Annual plan by 12.

Productivity Metrics Apr-17 May-17 Jun-17 Jul-17 Aug-17 Sep-17 Oct-17 Nov-17 YTD 17-18

ADHD Contacts Total 371 253 390 454 315 268 329 212 2,592

CMHT AD - Contacts Total 8,189 9,706 9,627 9,171 9,015 8,881 9,178 8,650 72,417

CMHT OA Contacts Total 2,584 2,846 2,815 2,754 2,862 2,766 3,049 2,884 22,560

CRHT Face to Face Contacts - Below 18 Total 123 242 153 171 130 137 145 156 1,257

CRHT Face to Face Contacts - 18 to 65 Total 3,667 4,042 3,766 3,921 3,874 3,657 3,716 3,638 30,281

CRHT Face to Face Contacts - Over 65 Total 65 74 43 73 39 9 19 32 354

CRHT Telephone Contacts - Below 18 Total 66 128 96 69 80 96 101 98 734

CRHT Telephone Contacts - 18 to 65 Total 2,130 2,487 2,148 2,404 2,508 2,518 2,560 2,415 19,170

CRHT Telephone Contacts - Over 65 Total 37 106 47 40 41 40 35 20 366

Criminal Justice Liaison - Contacts Total 571 667 587 580 648 576 631 479 4,739

Eating Disorder Service - Contacts Total 692 869 964 1,139 1,114 1,043 1,183 1,228 8,232

Hospital Liaison Contacts Total 372 410 387 363 470 368 432 312 3,114

MAS Teams - Contacts Total 2,899 3,399 3,206 3,097 3,268 2,958 3,149 3,142 25,118

RITT Contacts Total 1,921 2,265 2,270 2,571 2,742 2,640 2,530 2,453 19,392

Mental Health Productivity Total 23,687 27,494 26,499 26,807 27,106 25,957 27,057 25,719 210,326

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113

2017-18 Baseline Proposal

Following the Audit of Patient ‘Notes’ LCFT have identified that in some instances the Patient Note does constitute a relevant contact but in most

cases it does not. The 4 services involved are MAS, Eating disorders, Hospital Liaison and ADHD and in all there have been 23,025 over reported

Non-Patient contacts for the period of Apr-17 to Oct-17.

LCFT have also identified that for the above 4 Services and the RITT Service, 4,606 Non-Patient contacts have been reported in error as Face to Face

Contacts making a total of 27,631 over reported Patient Contacts as shown in the table below.

In both cases above this is a historic issue going back to 2012 and so this issue has been inflating numbers for some time and so recent trends of

changes of activity in recent years are not related to this issue. Consequently, activity baselines have been inflated as a result.

LCFT will seek for a decision to be made at the LCFT MH Contracts Meeting on 20th December, whether to reconcile the contacts at year end or to

make the necessary adjustments to both the Baselines and the reported activity ASAP.

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

Quality Metrics Apr-17 May-17 Jun-17 Jul-17 Aug-17 Sep-17 Oct-17 Nov-17 YTD 17-18

Adult Ward Occupied Bed Days Total 5,744 5,835 5,676 5,885 5,904 5,784 5,935 5,741 46,504

Eating Disorder Service DNA's - Follow Up Contacts 94 98 76 123 129 93 95 119 827

Eating Disorder Service DNA's - New Contacts 7 8 14 14 19 3 6 12 83

PICU Ward Occupied Bed Days Total 817 849 846 893 952 897 878 836 6,968

Older Adult (Dementia) Ward Occupied Bed Days Total 812 850 854 909 945 924 938 895 7,127

Older Adult (Functional) Ward Occupied Bed Days Total 1,034 1,104 1,081 1,102 1,154 1,101 1,119 1,090 8,785

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

Older Adult (Functional) Inpatient 90 Day ReAdmissions 1 1 0 1 0 0 0 0 3

Adult Inpatient 30 Day ReAdmissions Rate (8% Target) 9.58% 7.49% 9.04% 9.09% 6.55% 7.36% 9.38% 6.12% 8.08%Adult Inpatient 90 Day ReAdmissions Rate (15% Target) 14.97% 13.90% 16.38% 12.12% 7.74% 7.36% 9.38% 6.12% 11.00%

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

as at w/c 27th November 2017

114

• Revised planned attendances full year are 27,344. Actual attendances during November 2017 was 1,802 – 1,222 below

the planned total of 3,024

• Initial income for the 17/18 monitoring year shows a provisional increase in M7 and 8, with the total income as at end of

November 2017 at £974,498.

(* estimates)

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115

3.3 CQUIN Executive Summary

CQUIN Executive Summary:

Quarter 2 submissions for 2017/18 schemes have taken place for the Mental Health & Community contracts. The staff flu scheme is currently

behind plan but it expected to meet the 70% target by the end of February 18. Discussions are ongoing with acute trusts regarding the A&E

scheme, however we are working towards the targets for the scheme with commissioner support. Some further work needs to be done

regarding the Physical Health schemes to achieve the required increase in targets for future quarters. An audit is currently under way.

The Trust has not been successful in achieving the required targets for the preventing illness through risky behaviours scheme. The total loss

across the schemes is now £56k relating to Mental Health and £10k for Longridge. Work needs to focus on referrals to the stop smoking

services and training of staff to ensure Qtr. 3 and Qtr. 4 targets are achieved.

Qtr2 schemes for Southport & Formby contract have been submitted in line with the agreed milestones. Further discussions to take place with

Commissioners around future quarterly submissions.

£1,033k CQUIN funding across CCG contracts is agreed based on the trust meeting it's control total in 2016/17, however there are ongoing

discussions between NHSE and NHSI regarding the payment mechanism.

A further £1,033k CQUIN funding across CCG contracts is agreed based on the Trust's engagement and commitment to the STP process.

Confirmation has been received via BWD CCG that this element of funding has been agreed by the STP.

The Trust is waiting feedback from NHS England regarding the Cumbria Liaison & Diversion scheme submission but are not expecting any

issues.

There are not expected to be any issues with the submission for the Specialist Services schemes for Q2.

Measures are expected to be put into place to ensure that the Trust achieves the

remaining CQUIN funding available and no further losses are seen than those identified in Qtr2.

Executive Summary

Contract Actual

Loss/

concern Expected

Loss/

concern Expected

Loss/

concern Expected

Loss/

concern % Met Expected

Loss/

concern

Mental Health 100% £652,503 £0 90% £502,074 £56,210 100% £515,457 £0 100% £1,842,663 £0 98% £3,512,697 £56,210

Southport 100% £45,584 £0 100% £48,657 £0 100% £33,294 £0 100% £128,513 £0 100% £256,048 £0

Community 100% £238,378 £0 96% £244,404 £10,042 100% £174,107 £0 100% £672,046 £0 99% £1,328,935 £10,042

NHS England - Spec Comm MH 100% £193,941 £0 100% £193,941 £0 100% £193,941 £0 100% £193,941 £0 100% £775,762 £0

NHS England - Liaison & Diversion 100% £5,201 £0 100% £5,201 £0 100% £5,201 £0 100% £5,201 £0 100% £20,803 £0

NHS England - Imm & Vacc 100% £3,675 £0 100% £3,675 £0 100% £7,350 £0

Qtr. 4

100%Expected

Position

Full Year

99%£2,842,363 £0 £5,901,596 £66,253£0Expected

Position£922,000 £0100%

Nov 2017 CQUIN Position

Expected

PositionTotal

Expected

Position100%

Qtr. 2Qtr. 1

£1,139,282 94% £997,951 £66,253

Qtr. 3

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Quality

Section 4

116

179 of 255


117

Section 4:- Quality

• Quality and Safety Tile

• Quality Surveillance – Safe

• Quality Surveillance – Effective

• Quality Surveillance – Caring

• Quality Surveillance – Responsive

• Quality Surveillance – Well Led

• Audits

• Delivering the Strategy

4. Quality

180 of 255


4. Quality Quality & Safety Tile

118

17521 95.28%

91 8789

37

1

9 1635

3943 306

13 52%

2664

2236

90.42%

95% N/A

83% 13

Good

Completed within agreed

timeframe (%)

RESPONSIVE

Complaints

Upheld/partially upheld

complaints

WELL LED

Trust CQC rating

As a result of 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.


Physical Health HFC Rate (%) Appraisals (%)

Mental Health HFC Rate (%) Concerns raised

EFFECTIVE

Never Events


(inpatients only)

Core Skills (%)

SAFE

Physical violence to staff from

patients

Serious HCAI incidents

Use of restraint

Potentially avoidable grade 3 and

4 pressure ulcers

QUALITY AND SAFETY TILE

CARING

Compliments

F&F Test

RIDDOR incidents

Incidents

STEIS-reportable serious

incidents

As a result of 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.


181 of 255


4. Quality Safe

119


total

12 months


Incidents n/a 1867 2094 2345 2358 2168 2090 2329 2270 17521 2190.1

Incidents with harm n/a 404 436 487 547 437 473 535 462 3781 472.6


incidentsn/a 6 7 9 4 9 8 10 4 11 8 10 5 91 7.6

RIDDOR incidents n/a 6 2 0 3 4 5 2 6 1 6 1 1 37 3.1

Never Events 0 0 0 0 0 0 1 0 0 0 0 0 0 1 0.1

Medication incidents n/a 127 149 177 150 148 183 186 9 1129 141.1

Infection control Serious HCAI incidents 0 4 1 0 1 1 0 1 0 0 1 0 0 9 0.8

Use of restraint n/a 252 189 263 308 329 300 400 461 335 346 398 362 3943 328.6

Use of seclusion n/a 85 65 73 68 66 64 65 93 579 72.4

Safeguarding alerts n/a 100 158 138 129 130 95 152 116 1018 127.3

Potentially avoidable grade 3

and 4 pressure ulcersn/a 0 0 2 0 2 0 5 1 2 0 1 0 13 1.1

Number of instances of 1 or less

qualified on duty (inpatients)0 207 192 170 145 139 197 140 132 177 132 84 74 1789 149.1


(inpatients only)n/a 261 260 268 221 195 270 227 228 258 228 137 111 2664 222.0

Staff safetyPhysical violence to staff from

patients n/a 137 140 129 151 155 150 218 268 220 223 219 226 2236 186.3

Legal Regulation 28 Notices received n/a 0 0 0 1 0 0 1 1 0 0 0 0 3 0.3

QUALITY AND SAFETY SURVEILLANCE - Safe

Incidents

Patient safety

Staffing

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4. Quality Effective

120

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

Pressure ulcers (%) - 3.96% 2.72% 2.91% 5.27% 3.45% 3.45% 4.04% 3.05% 3.12% 2.55% 2.72% 2.57%

Falls with harm (%) - 1.29% 1.28% 1.64% 1.55% 1.55% 0.60% 0.75% 1.21% 0.64% 0.93% 0.53% 0.53%

Catheter and UTI (%) - 0.18% 0.64% 0.27% 0.26% 0.43% 0.45% 0.27% 0.21% 0.07% 0.23% 0.15% 0.08%

VTE (%) - 0.55% 0.08% 0.36% 0.35% 0.35% 0.15% 0.69% 0.43% 0.43% 0.93% 0.38% 0.23%

Physical Health HFC Rate (%) 95% 94% 95% 95% 93% 94% 96% 94% 95% 96% 96% 96% 97%

Self harm (%) - 3.35% 4.04% 3.55% 3.43% 3.56% 3.76% 3.75% 4.37% 4.63% 3.71% 3.59% 4.22%

Victim of violence (%) - 1.89% 1.62% 2.71% 1.07% 2.30% 1.46% 2.50% 1.66% 1.89% 1.75% 3.17% 2.53%

Feel unsafe (%) - 9.22% 6.26% 8.35% 9.01% 9.62% 10.65% 7.08% 7.90% 10.53% 8.08% 11.21% 7.81%

Omission of medication (%) - 18.87% 13.74% 16.08% 17.17% 17.99% 18.37% 23.54% 20.37% 19.79% 20.09% 24.10% 19.62%

Restraint (%) - 6.29% 4.65% 4.80% 3.65% 5.23% 5.43% 7.08% 6.86% 7.16% 5.68% 4.86% 5.91%

Mental Health HFC Rate (%) 90% 83% 86% 84% 85% 83% 83% 84% 81% 80% 84% 80% 83% 83.0%

Physical Health

Harm Free Care

Mental Health

Harm Free Care

0.4%

19.1%

5.6%

95.1%

3.8%

2.0%

8.8%

QUALITY AND SAFETY SURVEILLANCE - Effective12 months

average

3.3%

1.0%

0.3%

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4. Quality Effective

121

N/L/R*

L

L

R

R

R

L

L

L

L

R

L

L

L

L

R

R

R

REducation, Health and Care Plans 89% Nov-17

Use of restrictive practices within LD 93%

Acupuncture - Rheumatology & Physiotherapy 97%

79%

85%Learning Disability

Clozapine

Antibiotics in dentistry

80%

94%

85%

70%

Risk Assessments

Cerebral Palsy in under 25's (NICE) 82%

83%

Nutrition 77%

Consent to Treatment 94%

Completion of Waterlow risk assessments

Wound assessment documentation

Care of Dying

Carers 54% Oct-17

Diabetes 65% Sep-17

Nursing Management of Clozaril 60% Oct-17

Absent Without Leave 55% Oct-17

Compliance (%)Clinical Audits Date

Prevention of Dehydration 54% Sep-17

Compliance Date

96% 5.12.17

NetworkNICE Baseline Assessments

NG74 Reablement CWB

* N/L/R - National Audit, Local Audit, Re-Audit (if re-audit, the previous compliance figure will be included).

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4. Quality Caring & Responsive

122


total

12 months


F&F Test 95% 87% 96% 96% 96% 96% 97% 95% 97% 97% 97% 95% 95.28%

F&F Test - Response Rate n/a 1744 1659 2042 1562 1263 1815 1218 1241 1652 923 1669 1526.2

Compliments Compliments n/a 529 678 1031 788 593 987 697 774 819 537 549 807 8789 732.4

QUALITY AND SAFETY SURVEILLANCE - Caring

Friends & Family -

Patients

The Friends and Family Test real time reporting is locked and nationally reported on the 19th of each month and will therefore be reported in arrears most months


total

12 months


Complaints n/a 150 114 111 167 95 108 152 134 173 149 145 137 1635 136.3


complaintsn/a 26 22 21 31 26 23 19 24 22 21 43 28 306 25.5


timeframe (%)n/a 54.0% 50.0% 104.0% 52.0%

Reopened complaints n/a 3 3 4 2 4 4 7 5 0 0 3 3 38 3.2

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

MP enquiries n/a 7 13 9 15 7 8 5 9 11 5 12 8 109 9.1

Environment Mixed Sex Breaches 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0.0

QUALITY AND SAFETY SURVEILLANCE - Responsive

Complaints

185 of 255


4. Quality Well Led

123


total

12 months


Trust CQC rating Good RI Good Good Good Good Good Good Good Good Good Good Good

Regulatory inspections/visits n/a 4 5 4 3 4 3 2 1 2 1 4 33 3

CQC notifications n/a

Core Skills (%) 85% 88.24% 89.07% 89.41% 90.68% 90.33% 89.26% 91.06% 91.55% 90.81% 90.87% 91.64% 92.12% - 90.42%

Supervision (%) n/a

Appraisals (%) n/a



Overdue incident actions 0 94 150 - 122

Duty of candour breaches 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0.00%

Overdue safety alerts 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0.00%

Concerns raised n/a 9 17 26 13

Quality Plan priorities off track 0 0 0 0 0 5 - 1

Quality assurance visits n/a 1 0 0 0 2 1 4 0.67

Assurance

QUALITY AND SAFETY SURVEILLANCE - Well Led

Regulatory

People

Good

Learning and

candour

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124

4. Quality Audits 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

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125

4. Quality Delivering the Strategy

Annual

Performance

Plan (£000)

Annual

Forecast

Performance

Actual (£000)

15,100

15,100

12,843 12,828

791

Risks

15

2,272 a+b+c

791 d

1,481 (a+b+c)-d

464 a+b+c

Value of schemes at Feasibility

Slippage Against Annual Performance

Gross Risk of Delivery Against Overall DTS

Baseline

Additional Programme Reporting

2017/18

Overall Target

Value of approved schemes

Mitigation

Net Risk of Delivery Against Overall DTS

Value of non-recurrent schemes

Exec SRO Sue Moore

Programme SRO Joanne Moore

Programme Manager Carly SteerReporting Period November 2017 (Month 8)

Report date 13-Nov-17

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.

Programme Description

DTS Programme Report

Overview

Across each network portfolio, for all schemes that have been initiated, work is ongoing to develop detailed delivery plans where this is not already in

place status summarised for each scheme in Programme assurance heat maps.

Complex packages of care within C&YP has not launched, however the tender was submitted to go on the Framework to provide Complex Packages of

Care for Children and Young People was submitted on the 17th November. Transformation of Secure Services , Core 24 and Core Home Treatment 24/7.

Further work required to establish benefit trackers for each programme, to enable leads to measure performance and provide robust assurance on

delivery.

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126


Programme SRO Goal (£000) MonthTransacted

(£000)Narrative

Q2 511,585

Oct (07) 95,750

Nov (08) 95,750

Q2 2,664,285

Oct (07) 494,822

Nov (08) 471,731

Q2 857,715

Oct (07) 115,812

Nov (08) 115,812

Organisational

reset

Joanne

Moore

Savings delivered through this programme will be reported through the relevant

Network or Corporate services.

Mobilisation &

DemobilisationLouise Giles

Savings delivered through this programme will be reported through the relevant

Network or Corporate services.

Q2 2,317,248

Oct (07) 386,225

Nov (08) 386,225

Children &

Young PeopleSteve Tingle 2,142,770

Support

Services

Community

Wellbeing

Mental Health

£1.42m is registered on the CIP system, £1,168k approved and £258k at feasibility.

Current splippage against approved schemes of £85,645, which is an improving

position on last month leaving an in year gap of £924,030. However, further work has

progressed on the gap and pipeline schemes with current schemes rated green to the

value £305k with further pipeline schemes anticicpated to convert. CIP plans and

additional pipeline schemes are monitored weekly.

£5.5m of schemes are registered as approved leaving a gap of £2.3m. This position

includes £3.4, of schemes related to cost reduction including temporary staffing and

OAPs. This a static position on last month, with schemes worth £384k still in the

pipeline. Further recovery schemes are underway whilst expenditure reduction

schemes are being tested in order to determine the underlying recurrent position. CIP

plans, additional pipeline schemes and recovery plans are being monitored weekly.

£1.55m of schemes are registered on the system, all of which are approved leaving a

gap of £590k. Pipeline schemes to the value of £590k are in train- and if all schemes

are approved this will meet 17/18 target. CIP plans and additional pipeline schemes

are monitored weekly.

Schemes to the value of £4.64m are registered at approved stage. In addition there is

£612k of schemes at feasibility. If delivered, this will give an over-acheivement of

£2.4m which is offsetting gaps elsewhere. There are £100k worth of pipeline schemes

that are being monitored weekly

Dominic

McKenna2,801,600

Tanya

Hibbert2,265,460

Lisa

Moorhouse7,869,522

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127

PROGRAMME RESOURCE

PMO Lead assigned Dawn Killey Dawn Killey Dawn Killey Dawn Killey Dawn Killey Dawn Killey Dawn Killey Dawn Killey

Transformation Lead

assignedSarah Neve Helena Owen Sarah Neve Sarah Neve

Natalie Hilton/Fran

RileySarah Neve Sarah Neve Sarah Neve

Clinical Lead assigned Lorraine Chadwick Lorraine ChadwickLorraine Chadwick/Claire

BensonGuz Singh Jeremy Tudway TBC

Lorraine

Chadwick

Lorraine

Chadwick

Full resource plan agreed n/a currently n/a currently

PROGRAMME

DOCUMENTATION

Programme initiation

documentScoping In Progress n/a currently

Scope

changed

n/a

Currently

Programme Governance n/a currently

In Progress

Nov-17

Regular meetings n/a Currently n/a Currently n/a currently

Benefit trackerIn progress- met

with PerformanceStarted to map benefits n/a Currently In development n/a currently

On cost

Project Lead assignedLorraine McDonald-

JohnsonBev Liddle Joe Crocock Phil Horner Pauline Cullen

Crisis House eastASSURANCE CRITERIONMental Health

Access Line

Inpatient Reconfiguration

programme

Mental Health DTS Portfolio

MHDU

North

Phil Horner Bev Liddle

Richard Morgan

Scoping In Progress n/a currentlyUpdate In

progress

n/a currently

n/a currently

Core Home

Treatment 24/7 Core 24

Programme Plan Scoping

Quality Impact AssessmentSTAR Chambers for sign

off 8th December

S136 New Models of

Care?

Dawn Killey

Sarah Neve

Phil Horner

Transforming Secure

Services

In Progress

Awaiting

Sign off

Joe Crocock

On time( from

dashboard)

TOR n/a currently

Risks and Issues log

Not currently assessed

Project Element not in place

Project Element in place but requires update or further

work

Project Element in place and fit for purpose

Project Element not required

Project Element not in place

Key

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128

ASSURANCE CRITERION LD IAPT CPSR South Ribble Central BwD Dental CPOC

ASSURANCE CRITERION LD IAPT CPSR South Ribble Central BwD Dental CPOC

PROGRAMME RESOURCE

Programme Lead assigned Stuart Sheridan Deborah Bretherton Julie Nowell Julie Nowell Tanya Hibbert Tanya Hibbert Andy Jones

Transformation Lead

assignedDeborah Howe

Clinical Lead assigned Mahesh Odiyoor Janine Williams Tracy Cook- Scowen Tracy Cook- Scowen Sarah Procter

Full resource plan agree

PROGRAMME

DOCUMENTATIONProgramme initiation

document

Quality Impact Assessment

Programme Plan Plans to be finalisedTo be updated in line

with new governance

structure

High-level – plan in

place further detail

required.

Risks and Issues log

Programme Governance

TOR

Regular meetings Fortnightly

Benefits Tracker

PROJECT PERFORMANCE

On time

On cost

Community and Wellbeing DTS Portfolio

MCP

Mark Wardman

MCP Prime Provider

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129

ASSURANCE CRITERIONComplex Packages of Care

(CPOC)

CAMHS Tier 4

Transformation

0-25 Clinical Pathway

including integration of

Child psychology and

LCC contract for Health

Visiting and School

Nursing

PROGRAMME RESOURCE

Project Manager assigned Janet Thorpe Janet Thorpe Janet Thorpe Janet Thorpe

Transformation Lead

assignedTBC Nicola Adams Nicola Adams Michael Orchard

Project Lead assigned TBC Paul AndertonSarah Wright/Anita

DemariaCathy Allen

Clinical Lead assigned Lorna Taylor Debbie Yoxall Julie Ross Debra Wilson

Full resource plan agreed

PROGRAMME

DOCUMENTATION

Programme initiation

document

Revised PID to be

confirmed at

Steering Group

meeting 14 Dec

Revised PID to be

confirmed at Steering

Group meeting 12 Dec

Not required for tender

Move to the Cove –

in place

Transformation work

Programme PlanHigh level plan in

place. Will be

Programme plan will be

finalised depending on

Plan to be developed

following confirmation of

Risks and Issues log In place In place In place

Programme Governance In place In place To be reviewed

TOR In place In place To be reviewed

Regular meetings 1st meeting 13 June 1st meeting 13 June 1st meeting 13 June

PROJECT PERFORMANCE

On time

On cost

Benefits tracker in place Not applicable

Quality Impact AssessmentNot required – quality is

addressed within tender

documentation

Children & Young People's Wellbeing DTS Portfolio

QIA to be revised for

phase 1 once confirmed

at BDT 8 Dec

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Workforce

Section 5

130

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5. Workforce

131

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

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132

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 19,043,638 1,332,951 6.3% 319,252 1.5% 384,288 1.8% 2,036,491 21,080,129 9.66%

M ental Health 8,644,409 1,057,354 10.4% 190,804 1.9% 272,381 2.7% 1,520,539 10,164,948 14.96%

Community &

Wellbeing4,351,245 151,765 3.2% 128,028 2.7% 122,524 2.6% 402,316 4,753,561 8.46%

Children & Young

People3,222,362 70,831 2.1% 20,261 0.6% 54,270 1.6% 145,363 3,367,725 4.32%

Corporate 2,825,622 53,001 1.9% -19,841 -0.7% -64,887 -2.3% -31,727 2,793,895 -1.14%

Flexible

Labour

Reliance %Business Area

Core

Workforce

Spend £

Bank Agency M edical AgencyTotal Spend

£

2017 11

Total

Peripheral

Workforce

Spend £

Actual Workforce Costs compared to

Budget:

Overall spend on peripheral labour has

decreased slightly in the month of November,

when compared to the October position.

MHN and C&WBN continue to be the highest

spenders.

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:

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.

195 of 255


5. Workforce Sickness Absence Rates

133

Trust 12 Month, Year on Year Trend

Sickness Absence Breakdown

Rate Rate Rate Trend

2017 09 2017 10 2017 11

% Long

Term

Absence

% Short

Term

Absence

12mths

Trust 6.35% 6.88% 6.84% 53.77% 46.23%

Mental Health 7.70% 8.52% 8.22% 61.49% 38.51%

Community & Wellbeing 6.48% 6.25% 6.58% 40.99% 59.01%

Children & Young People 4.77% 5.53% 5.48% 51.10% 48.90%

Support Services 3.04% 3.75% 3.94% 43.13% 56.87%

2017 11

Sickness Absence Rates:

Sickness Absence has decreased slightly in the month of

November, reporting 6.84%. The Trust decrease this month

is attributable to the decrease in sickness experienced in

MHN.

Actions:


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.


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:

Q3 & Q4 will see the HRBP’s focus the Network on the

management of Short Term repetitive Absence

Management.

Network has agreed a Sickness Absence trajectory to

support its achievement of the Trust Target of 4.5% by the

end of Q4.

196 of 255


5. Workforce Appraisals and Mandatory Training Compliance

134

Appraisals and Mandatory Training Compliance:

Networks continue to work closely with Quality Academy and focus on improvement in this key performance measure and continue to focus on those

training courses where compliance is still to meet the Trust target of 85%. Appraisal Compliance for Q3 is calculated using the number of employees

who have objectives and who have completed a PDR review.

E&D

3yr

Fire

Saf

ety

1yr

Hea

lth

& S

afet

y 3

yr

Info

rmat

ion

Go

vern

ance

1yr

Infe

ctio

n C

on

tro

l

Clin

ical

1yr

Bas

ic L

ife

Sup

po

rt

1yr

Imm

edia

te L

ife

Sup

po

rt 1

yr

Co

nfl

ict

Res

olu

tio

n

3yr

Safe

guar

din

g

Ch

ildre

n L

2 3

yr

Safe

guar

din

g

Ch

ildre

n L

3 3

yr

Men

tal C

apac

ity

Act

L1

3yr

Man

ual

Han

dlin

g

L2 3

yr

Man

ual

Han

dlin

g

L3 2

yr

Infe

ctio

n C

on

tro

l

L1 2

yr

Safe

guar

din

g

Ch

ildre

n L

1 3

yr

Safe

guar

din

g

Ad

ult

s L1

(+P

REV

ENT)

3yr

Men

tal C

apac

ity

Act

L1

(O

ne

Tim

e

Co

mp

leti

on

)

Man

ual

Han

dlin

g

L1 3

yr Appraisal

Compliance

Trust 98% 92% 97% 95% 91% 80% 79% 89% 93% 85% 90% 85% 86% 96% 95% 96% 90% 97% 92% 49%

MHN 99% 93% 98% 94% 91% 76% 77% 89% 93% 79% 91% 79% 80% 95% 98% 96% 92% 98% 91% 31%

C&W 99% 90% 96% 95% 90% 79% 89% 88% 93% 80% 88% 92% 90% 95% 94% 96% 88% 95% 92% 65%

C&YP 98% 91% 96% 95% 91% 90% 86% 89% 0% 94% 89% 89% 90% 96% 94% 94% 89% 94% 93% 58%

SS 98% 93% 98% 95% 94% 88% 67% 93% 97% 100% 90% 86% 0% 97% 95% 95% 89% 97% 95% 66%

All Staff Medical, Clinical & Clinical Support Staff Admin, Clerical & Estates

Total

197 of 255


5. Workforce Vacancy Management and Active Recruitment

135

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 6499.97 5701.67 798.30 12.28% 63.34% 505.61 742 39.44

Mental Health 2952.68 2599.52 353.16 11.96% 59.64% 210.63 331 44.15

Community & Wel lbeing 1618.60 1465.24 153.36 9.48% 99.93% 153.25 226 43.35

Chi ldren & Young People 1102.47 992.88 109.59 9.94% 65.17% 71.42 92 42.70

Support Services 826.22 644.03 182.19 22.05% 38.59% 70.31 93 27.55

2017 11

Establ ishment Vacancies Vacancies in Active Recruitment

Vacancy Management and Active Recruitment:

The Budgeted Establishment Vacancy Rate has increased slightly in November and reports a closing rate of 12.28%. The number of those vacancies

being actively recruited has also increased, moving from 57.49% in October to 63.34% in November.

Actions:


• 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.


• Vacancy clarity and management continues to be high on the Network agenda.

Children & Young People Wellbeing Network:

• Health Visitor Vacancies, held in in light of the Universal 0-19 contract Tender exercise, will be released through Q3 and actively recruited to as the

Trust is now in receipt of the new Service Specification that we are bidding against.

• The Network continue to hold a number of vacancies across Tier 3 Services as a result of the financial variation to contract removal of the CAHMS

Grant.

Support Services

• A refresh of the Support Services Organisational Structure has been undertaken. The ESR system updates are complete and Financial EFIN system

updates are underway. The refresh has seen a move of ‘Hosted Services’ out of the Trust main workforce information data set and the temporary

non alignment of the ESR and EFIN systems (due to update timing differences) has resulted in a reported increase in BEVR for Support Services in

November.

198 of 255


5. Workforce Core Workforce Headcount

136

Core Workforce

Network Headcount FTE Headcount FTE

Trust 6385 5646.96 6348 5621.29

Mental Health 2795 2582.51 2777 2567.93

Community & Wellbeing 1753 1445.07 1734 1435.76

Children & Young People 1145 983.54 1143 979.28

Support Services 692 635.85 694 638.33

2017 10 2017 11

199 of 255


5. Workforce Workforce Turnover

137

200 of 255


138

6. Risks Board Assurance Framework 17/18 Quarter 2

BOARD ASSURANCE FRAMEWORK DASHBOARD 2017/18 – Q2

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

12

High

16

Significant

8

High

8

Close Monitoring

4

Moderate

12

Significant

1.2 If we do not create a culture of

learning then we will be unable to

provide high quality care.


Significant

16

Significant 16 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

16

Significant

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

12

High

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.

Business Dev &

Delivery COO

12

High

12

High

12

High

8

High

4

Tolerable

4

Moderate

8

Close Monitoring

SP

3 E

xcell

en

ce

3.1 If we do not engage with our

patients and service users we cannot

achieve excellence and quality.


High

12

High

12

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.

Business Dev &

Delivery COO

16

Significant

16

Significant

16

Significant

12

High

4

Tolerable

4

Moderate

12

Significant

SP

4

Peo

ple

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

20

Significant

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

9

High

12

High

6

Moderate

6

Close Monitoring

3

Low

9

Close Monitoring

SP

5

Mo

ney

5.1 If we do not meet financial

objectives we will not be able to provide

sustainable services.

Finance CFO 15

Significant

20

Significant

20

Significant

10

High

10

Concern

10

High

10

Concern

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

15


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 16

Significant

12

High

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 16

Significant

16


8

High

8

Close Monitoring

4

Moderate

12

Significant 201 of 255


Southport & Formby

Appendix 1

139

202 of 255


1. Performance Activity Southport & Formby – Summary

140

Southport & Formby - Summary:

All the team have had their initial visit from Performance except the Stoma team whom has a single clinician out of a team of two and is

understandably not able to commit time at the moment.

Due to sickness within the EMIS team, refresh training which is supporting the deep dive has not been undertaken. It is expected the team

will return to full strength In the New Year when the Audits for Continence and Treatment rooms will be undertaken and the scheduling for

the remaining team can be planned.

Performance is actively engaging with the specific teams to help them to undertake the review of their caseloads. The aim of which is to

remove patients who are not actively engaging with the service and to give a better understanding of caseload and waiting lists demands.

Due to the size of the caseload this is an extensive piece of work for podiatry.

Analysis of all team’s activity, waiting times and data quality issues continues to be carried out by the performance lead and fed back to

the team to support caseload and waiting list management.

Treatment room activity slide is included for the first time in this report, with an expectation of including Adult Therapies, Chronic Care and

Community Matrons in next months report.

Patient level data is still to be received from St Helens and Knowsley FTs Pathology Department to enable Performance to validate the

Phlebotomy activity.

203 of 255


1. Performance Activity Southport & Formby – Summary

141

204 of 255


1. Performance Activity Southport & Formby – Referrals Summary

142

Unvalidated Figures

Validated Figures

Service CCG May-17 Jun-17 Jul-17 Aug-17 Sep-17 Oct-17 Nov-17 Total

Adult Therapies - MS NHS Southport and Formby CCG 1 1 1 2 1 0 0 6

Adult Therapies - Neurology NHS Southport and Formby CCG 51 40 39 48 62 45 48 333

Adult Therapies - Non Neuro NHS Southport and Formby CCG 154 162 140 163 169 148 142 1078

Adult Therapies - SALT NHS Southport and Formby CCG 3 5 3 9 7 9 11 47

Adult Therapies - Vestibular NHS Southport and Formby CCG 11 10 6 12 4 12 13 68

CERT NHS Southport and Formby CCG 103 119 85 105 98 137 139 786

Chronic Care Coordinators NHS Southport and Formby CCG 155 117 141 134 127 119 122 915

Community Matrons NHS Southport and Formby CCG 35 47 49 35 40 52 48 306

Continence NHS South Sefton CCG 62 84 77 92 98 118 86 617

NHS Southport and Formby CCG 68 93 90 150 104 99 110 714

Diabetes NHS Southport and Formby CCG 81 97 97 73 90 97 113 648

Dietetics NHS Southport and Formby CCG 251 215 208 208 194 207 216 1499

District Nurses NHS Southport and Formby CCG 543 683 632 669 770 775 691 4763

District Nurses OOH NHS Southport and Formby CCG 183 170 207 182 195 231 211 1379

Falls Service NHS Southport and Formby CCG 81 88 60 72 65 60 61 487

Leg Ulcer NHS Southport and Formby CCG 6 13 3 6 10 8 2 48

Pain Management NHS Southport and Formby CCG 29 71 46 33 70 23 67 339

Phlebotomy NHS Southport and Formby CCG 1738 2216 2234 2261 2091 2315 2301 15156

Podiatry NHS Southport and Formby CCG 368 391 316 366 291 353 315 2400

Psychology NHS Southport and Formby CCG 18 14 20 26 20 21 26 145

Stoma NHS Southport and Formby CCG 19 24 70 28 13 25 25 204

Treatment Rooms NHS Southport and Formby CCG 843 1036 1020 1006 937 1100 973 6915

Grand Total 4804 5700 5549 5682 5459 5955 5721 38870

205 of 255


1. Performance Activity Southport & Formby – Contacts Summary

143

Unvalidated Figures

Validated Figures

Service CCG May-17 Jun-17 Jul-17 Aug-17 Sep-17 Oct-17 Nov-17 Total

Adult Therapies - MS NHS Southport and Formby CCG 6 5 4 5 8 6 5 39

Adult Therapies - Neurology NHS Southport and Formby CCG 309 248 280 293 324 301 350 2105

Adult Therapies - Non Neuro NHS Southport and Formby CCG 384 424 397 421 480 573 622 3301

Adult Therapies - SALT NHS Southport and Formby CCG 13 9 7 12 24 22 27 114

Adult Therapies - Vestibular NHS Southport and Formby CCG 29 40 39 40 33 50 43 274

CERT NHS Southport and Formby CCG 2146 2528 2567 2495 2393 3154 2914 18197

Chronic Care Coordinators NHS Southport and Formby CCG 478 445 409 320 389 356 376 2773

Community Matrons NHS Southport and Formby CCG 256 387 370 361 279 405 367 2425

NHS South Sefton CCG 87 92 120 240 235 173 164 1111

NHS Southport and Formby CCG 66 156 254 296 224 206 206 1408

Diabetes NHS Southport and Formby CCG 452 447 378 484 469 481 513 3224

Dietetics NHS Southport and Formby CCG 405 442 440 452 455 438 330 2962

District Nurses NHS Southport and Formby CCG 6272 8227 7702 8139 7695 8351 7529 53915

District Nurses OOH NHS Southport and Formby CCG 553 481 603 494 546 683 796 4156

Falls Service NHS Southport and Formby CCG 109 91 95 172 160 152 215 994

Leg Ulcer NHS Southport and Formby CCG 51 84 97 80 94 101 93 600

Pain Management NHS Southport and Formby CCG 245 289 279 206 353 318 323 2013

Phlebotomy NHS Southport and Formby CCG 1337 2215 2063 2128 2004 2128 1929 13804

Podiatry NHS Southport and Formby CCG 1891 2208 2126 2270 2008 2279 2258 15040

Psychology NHS Southport and Formby CCG 250 290 292 376 262 332 302 2104

Stoma NHS Southport and Formby CCG 95 99 118 107 69 87 95 670

Treatment Rooms NHS Southport and Formby CCG 2090 2618 2454 2569 2119 2371 2424 16645

Grand Total 17524 21825 21094 21960 20623 22967 21881 147874

Continence

206 of 255


1. Performance Activity Southport & Formby – Continence

144

Southport & Formby - Continence:

Improvements in data recording and waiting list management continue to improve the waiting list profile for the Continence Service. The

latest snapshot from 11th December 17 shows a slight increase (4 patients) in the overall number of patients waiting. The team continue to

reduced patients waiting 19-24 and the profile of the waiting list is front loaded, decreasing in numbers moving through the longer wait

bands.

Due to staff sickness within the EMIS team, the Continence service scheduled audit for November 17 has been rescheduled until January

18.

207 of 255


1. Performance Activity Southport & Formby – Treatment Rooms

145

Southport & Formby – Treatment Rooms:

Performance has reviewed the service and after identifying a training need, the EMIS Trainer re-training all of the clinical staff to record

contacts accurately.

Due to staff sickness within the EMIS team, the Treatment room service scheduled audit for November 17 has been rescheduled until

January 18.

208 of 255


2.1 Finance Activity Southport & Formby

Detail for Southport and Formby can be found in the Trust's main QPR Finance and Contracting Section.

209 of 255


147

2.2 Contract Activity Queens Court – Palliative Care subcontract

CNS MAY JUNE Q1 JULY AUG SEP Q2 OCT NOV Q3 Total

Number of referrals received 88 84 172 83 93 76 252 69 81 69 317

% appropriate referrals (SEEN BY SERVICE)80% 79% 79% 78% 78% 74% 77% 91% 84% 91% 82%

Primary health care team (GP) 20 15 35 16 19 22 57 23 20 23 115

Specialist nurse / team (internal) 9 13 22 9 4 10 23 7 8 7 52

Other hospital staff (internal) 47 46 93 36 50 30 116 31 39 31 240

Internal Referral (QCH & SPCS) 11 10 21 21 20 14 55 8 13 8 84

Other(other) 1 0 1 1 0 0 1 0 1 0 2

Not recorded 0 0 0 0 0 0 0 0 0 0 0

Pain/Symptom Control 83 76 159 81 86 66 233 68 74 68 460

Psychological Support 44 48 92 39 60 40 139 13 37 13 244

Social/Financial 0 0 0 2 0 0 2 0 0 0 2

Family Support 0 1 1 1 0 1 2 0 0 0 3

Other 0 1 1 0 0 0 0 0 0 0 1

Number of patients 'active' 364 363 727 383 390 390 1163 390 320 390 2280

82 41 123 37 43 46 126 45 70 45 294

19 18 37 18 20 20 58 6 11 6 101

Inappropriate 1 0 1 1 1 2 4 1 3 1 6

Died within 24hrs of referral 2 2 4 2 4 1 7 1 2 1 12

Declined 0 1 1 1 1 1 3 0 0 0 4

Unable to contact (includes admissions)1 0 1 0 0 4 4 0 2 0 5

Contact made, appointment arranged12 11 23 11 10 8 29 3 4 3 55

Other 3 3 6 5 3 4 12 1 0 1 19

Unknown 0 1 1 0 1 0 1 0 0 0 2

Number 70 66 136 65 73 56 194 63 68 63 393

New and re-referred as % of

all patients seen in month41% 39% 40% 36% 39% 33% 58% 35% 55% 35% 44%

Cancer 42 44 86 42 49 34 125 32 43 32 243

Non-malignant 28 22 50 23 24 22 69 31 25 31 150

Not recorded 0 0 0 0 0 0 0 0 0 0 0

% Primary Diagnosis of Cancer 60% 67% 63% 65% 67% 61% 64% 51% 63% 51% 59%

Total (New Non F2F) 82 84 166 83 93 76 252 69 81 69 487

Within 48 hours 69 69 138 67 74 54 195 50 68 50 383

% target achieved 84% 82% 83% 81% 80% 71% 77% 72% 84% 72% 78%

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)

210 of 255


148



New assessment with patient (New F2F)54 64 118 59 70 49 178 66 66 66 362

OPD 0 20 44 22 34 21 77 30 32 30 151

Current place of residence 54 44 74 37 39 28 104 36 34 36 214

Review FU with patient (face-to-face)251 266 578 263 220 252 735 303 186 303 1616

OPD 0 78 139 53 63 49 165 44 56 44 348

Current place of residence 312 188 439 210 157 203 570 259 130 259 1268

Review FU with patient (telephone) 270 270 540 301 203 187 691 305 242 305 1536

Advice & Support relative/carer F:F 185 171 356 166 175 190 531 212 126 212 1099

Advice/support to a Professional F:F168 173 341 162 179 145 486 175 125 175 1002

Advice & Support relative/carer Tel 222 232 454 217 240 231 688 281 158 281 1423

Advice/support to a Professional Tel 147 184 331 158 207 152 517 166 115 166 1014

Bereavement visit with relative / carer 0 0 0 1 0 1 2 2 1 2 4

Bereavement Telephone with relative / carer11 16 27 17 24 12 53 16 26 16 96

Bereavement Letter to relative / carer14 17 31 18 15 9 42 16 55 16 89

DNA (Total DNA) NR NR NR NR NR NR NR NR NR NR NR

0 31 23 54 33 37 22 92 22 29 22 168

1 15 14 29 10 7 9 26 16 7 16 71

2 5 3 8 0 5 2 7 4 4 4 19

3 1 5 6 7 4 5 16 1 2 1 23

4 4 6 10 4 5 6 15 3 6 3 28

5 1 3 4 2 3 1 6 4 5 4 14

6 2 1 3 0 6 0 6 4 4 4 13

7 1 4 5 3 1 4 8 0 1 0 13

8-14 6 6 12 5 2 6 13 7 8 7 32

15-21 3 0 3 0 3 1 4 1 2 1 8

22-28 0 0 0 1 0 0 1 1 0 1 2

29-41 0 0 0 0 0 0 0 0 0 0 0

> 42 0 0 0 0 0 0 0 0 0 0 0

Total 69 65 134 65 73 56 194 63 68 63 391

Primary healthcare team 24 15 39 22 18 13 53 9 38 9 101

Internal referral 1 3 4 2 2 0 4 3 2 3 11

Died 57 21 78 12 19 31 62 33 30 33 173

Other 0 2 2 1 4 2 7 0 0 0 9

Not recorded 0 0 0 0 0 0 0 0 0 0 0

Discharged to (of those seen)

Time from Referral to Assessment

in days (seen)

Contacts

(related to caseload)

211 of 255


149



Average time 119 21 32 19 34 45 33 35 53 35 33

Shortest time 0 0 0 0 0 0 0 0 0 0 0

Longest time 1898 154 1898 279 315 572 572 939 358 939 1136

63% 33% 55% 25% 42% 55% 45% 42% 57% 42% 48%

Home 16 3 19 2 5 6 13 8 9 8 40

Hospital 21 14 35 9 11 14 34 19 13 19 88

Hospice 13 0 13 0 1 1 2 4 2 4 19

Care home 7 4 11 1 2 10 13 2 6 2 26

Prison 0 0 0 0 0 0 0 0 0 0 0

Other 0 0 0 0 0 0 0 0 0 0 0

Unknown 0 0 0 0 0 0 0 0 0 0 0

PPC achieved 29 9 38 5 7 13 25 19 16 19 82

PPC not achieved 14 3 17 0 3 7 10 2 0 2 29

PPC unknown 14 9 23 7 9 11 27 12 6 12 62

Not recorded 0 0 0 0 0 0 0 0 8 0 0

0 - 5 57 54 111 56 61 45 162 50 53 50 323

6 - 14 9 11 20 8 9 10 27 11 13 11 58

15 - 21 3 0 3 0 3 1 4 1 2 1 8

22 - 28 0 0 0 1 0 0 1 1 0 1 2

29 - 42 0 0 0 2 0 0 2 2 0 2 4

> 42 0 0 0 0 0 0 0 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)

212 of 255


150


Activity perfomance indicator Report frequency May June Q1 July Aug Sept Q2 Oct Nov Q3 Annual total

SERVICE USER EXPERIENCE

1. Complaints received Monthly 0 0 0 0 0 0 0 0 0 0 0

2. Compliments Monthly 6 9 15 3 4 1 8 3 4 3 26

3. Incidents reported (about the service) Monthly 0 0 0 0 0 0 0 0 0 0 0

4. Incidents reported (by the service) Monthly 1 0 1 0 2 0 2 1 0 1 4

5. Iwantgreatcare (number of returns) Annually 0 0

STAFF TURNOVER /ATTENDANCE

1. Left employment Quarterly 1 0 0 1

2. Recruited Quarterly 0 0 0 0

3. Sickness % per establishment Quarterly 10.60% 1.59% TBC 0.00%

STAFF TRAINING / DEVELOPMENT

1. Annual apprisals completed 100% Annually 0

2. Mandatory training completed 100% Annually 0

3. Clinical supervision (hours) 100% Monthly 0 0 0 1.5 0 1.5 3 1.5 1.5 1.5 4.5

GSF Attendance Monthly 6 6 12 8 7 11 26 11 12 11 49

213 of 255


3. Quality Southport & Formby

151

KLOE Domain Indicator Target Dec Jan Feb Mar Apr May Jun Jul Aug Sep Oct Nov12 months

total

12 months


Incidents n/a 20 50 58 56 53 44 82 363 52


incidentsn/a 0 1 0 0 0 1 0 2 0

RIDDOR incidents n/a 1 0 0 1 0 0 0 0 0 0 0 0 2 0

Fall incidents n/a 0 0 1 0 1 1 0 3 0

Pressure ulcer incidents n/a 4 20 20 18 15 11 32 120 17

Potentially avoidable grade 3

and 4 pressure ulcersn/a 0 0 0 0 0 0 0 0 0 0 0 0 0 0

Safeguarding alerts n/a 1 3 4 3 1 7 10 29 4

Staff safetyViolence or aggression to staff

from patients n/a 0 0 1 0 0 0 2 3 0

Pressure ulcers (%) - 1.06% 5.15% 1.09% 1.59% 4.23% 1.95% 3.33% - 2.63%

Falls with harm (%) - 0% 0% 0% 0% 0% 0% 0% - 0.00%

Catheter and UTI (%) - 0% 0% 0% 0% 0% 0% 0% - 0.00%

VTE (%) - 0.53% 1.47% 1.46% 1.27% 0.94% 0.98% 0.74% - 1.06%

Physical Health HFC Rate (%) 95% 99% 94% 98% 97% 96% 97% 96% - 96.76%

F&F Test 95% 99.2% 100.0% 100% - 99.73%

F&F Test - Response Rate n/a 126 113 3 242 81

Compliments Compliments n/a 0 5 16 45 54 25 51 56 252 32

Complaints n/a 0 1 2 12 11 1 7 7 41 5


complaintsn/a 0 0 0 6 6 3 2 17 2


timeframe (%)n/a

Reopened complaints n/a

Overdue 3 day reviews 0 2 4 6 3

Overdue 7 day reviews 0 12 13 25 13

Overdue incident actions 0 0 0 0 0

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

Assurance Concerns raised n/a 0 0 0 0 0 0 0 0 0

Learning and

candour

Patient safety

Incidents

FOCUSED QUALITY AND SAFETY SURVEILLANCE - Southport & Formby Services

Safe

Effective

Caring

Responsive

Well Led

Physical Health

Harm Free Care

Friends & Family -

Patients

Complaints

214 of 255


152

Actual Workforce Costs Compared to Budget - Quarterly Trend

Peripheral Workforce Spend and Usage

4. Workforce Actual Workforce Costs Compared to Budget

Spend £ % Spend £ % Spend £ %

Southport & Formby 649,757 5,163 0.7% 34,521 5.0% 0 0.0% 39,684 689,441 5.76%

Flexible

Labour

Reliance

%Business Area

Core

Workforce

Spend £

Bank Agency Medical Agency

Total Spend

£

2017 11

Total

Peripheral

Workforce

Spend £

215 of 255


4. Workforce Sickness Absence Rates

153

Trust 12 Month, Year on Year Trend

Sickness Absence Breakdown

Rate Rate Rate Trend

2017 09 2017 10 2017 11

% Long

Term

Absence

% Short

Term

Absence

12mths

Southport & Formby 5.08% 6.70% 5.07% 45.25% 54.75%

2017 11

216 of 255


4. Workforce Appraisals and Mandatory Training Compliance

154

E&D

3yr

Fire

Saf

ety

1yr

Hea

lth

& S

afet

y 3

yr

Info

rmat

ion

Go

vern

ance

1yr

Infe

ctio

n C

on

tro

l Clin

ical

1yr

Bas

ic L

ife

Sup

po

rt 1

yr

Imm

edia

te L

ife

Sup

po

rt 1

yr

Co

nfl

ict

Res

olu

tio

n 3

yr

Safe

guar

din

g C

hild

ren

L2

3yr

Safe

guar

din

g C

hild

ren

L3

3yr

Men

tal C

apac

ity

Act

L1

3yr

Man

ual

Han

dlin

g L2

3yr

Man

ual

Han

dlin

g L3

2yr

Infe

ctio

n C

on

tro

l L1

2yr

Safe

guar

din

g C

hild

ren

L1

3yr

Safe

guar

din

g A

du

lts

L1

(+P

REV

ENT)

3yr

Men

tal C

apac

ity

Act

L1

(On

e Ti

me

Co

mp

leti

on

)

Man

ual

Han

dlin

g L1

3yr

Ap

pra

isal

Co

mp

lian

ce

S&F 98% 96% 85% 95% 93% 84% x 76% 89% x 92% 95% 50% 93% 98% 97% 95% 94% 91% 78%

All Staff Medical, Clinical & Clinical Support Staff Admin, Clerical & Estates

Total

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

Southport & Formby 224.22 207.42 16.80 7.49% 69.05% 11.60 13.00 N/A

2017 11

Establ ishment Vacancies Vacancies in Active Recruitment

Vacancy Management and Active Recruitment

Core Workforce

Network Headcount FTE Headcount FTE

Southport & Formby 260 204.75 261 207.42

2017 10 2017 11

Core Workforce Headcount

217 of 255


155

4. Workforce Workforce Turnover

218 of 255

Summary

Actual Plan Var Forecast Plan VarSustainability

EBITDA 6,820 9,696 -2,876 15,860 17,745 -1,885 Operational Deficit -2,255 610 -2,865 2,194 2,167 27Deficit after Impairment* -3,358 -1,274 -2,084 -1,359 -1,390 31

CIPs (against Trust Plan) 7,386 8,440 -1,054 15,100 15,100 0Cash and Liquidity 11,441 11,829 -388 24,601 10,989 13,612Capex 1,834 5,989 -4,155 13,661 9,591 4,070UOR

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

Sustainability

CIPs

Liquidity

Summary continued overleaf

The cash position remains strong but shows a minor adverse variance from plan of £0.4m. The capital position continues to offset the I&E position. High debtors are placing some pressure on working capital though this is considered transient. Forecast cash is currently expected to exceed plan, a combination of an improved opening position, capital funding, and anticipated disposals. - see Cash and Liquidity for more details.

Current Out-Turn

At month 7 with CIPs of c£7.4m against a plan of c£8.4m the Trust is £1.1m behind plan, a deterioration of £0.1m on month 6 (£1.0m behind plan). The adverse variance is mainly due to a lack of performance on Run Rate Reduction Programmes on staffing pressures. Compensating schemes have, and continue to be, developed and confirmation of transactions are expected in month 8. Networks continue to create and implement measures aimed at improving the position.

Month 7 sees a year to date operating deficit of -£2.3m, excluding planned Sustainability and Transformation funding of £0.9m, against a planned surplus to date of £0.6m. This shows an improvement on month 6 and represents a small budgetary surplus in month and nearly £0.2m when excluding STF monies. The position remains driven by staffing pressures in ward and prison areas and consequential impact on cost improvement programmes (rising agency costs will also impact Use of Resources targets). Additionally OAPs expenditure continues to exceed funding - see Out Of Area Activity for more details. The forecast assumes current pressures and risks are addressed or mitigated in line with the recovery plan (see forecasting) and financial performance achieves (or exceeds) plan but the unmitigated projection indicates a gap of c£4.8m, c£6.9m without STF monies. This is represents an improvement on month 6 forecasts (£6.2m), and is driven by excess OAPs of c£0.8m (all be that significantly below last month), prisons (see also Bank and Agency section) and additional mental health pressures. Delivery of the recovery plan and financial targets will required a significant and coordinated response with robust management and oversight. After taking in to account £1.7m of disposals, which are accounted for after EBITDA, EBITDA is broadly in line with I&E Margin. 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.

Capital and Financing

Use of Resources (UoR) risk ratings

Forecasting

Recovery Plan

#

Whilst it would appear that the gap can be bridged through the plan, this is not without significant risk. Delivery will only be achieved with a considerable coordinated and sustained effort across the organisation. The plan will continue to be refined and presented in more detail to the Financial Recovery Group along with the actions required.

Progress against the capital programme has been slow to date with expenditure at £1.8m against the original profile of £6.0m. The scheduling profile of many schemes was dependent on a number of tendering exercises (the last of which, Perinatal, has now been completed), agreements with third parties (now substantially resolved) and final funding approval (Inpatient schemes approval now received from NHSI, awaiting final confirmation of funds and timing from DH). Schedules for these and related/dependant schemes are now being finalised through discussions with the incumbent contractors and the Trust is pushing forward with work on the affected projects. Discussions with contractors indicate the delays will cause slippage, mainly on the Inpatients (Chorley site - c5 weeks) though a risk of slippage on the Perinatal scheme remains and is being worked on. Impacts on the respective projects have yet to be finalised and incorporated in to forecasts.

Revised year end control totals are being provided to networks in line with the recovery plan and will require:• Progress and delivery of ward staffing actions• Implementation of the recovery plan.• Agreement of OAPs mitigations with commissioners.• Progress on land sales.

Though slightly improved the current I&E position continues to give a rating of 4 and a Capital Service rating of 4 constraining the current overall UoR to a 3. Assuming current pressures and risks are addressed through the recovery plan and I&E performance achieves (or exceeds) forecast the Trust will achieve a UoR of 2 in line with the plan. However, though forecast would achieve the overall target rating, Capital Service is based on EBITDA and since part of the Trusts recovery plan is based on disposals (which are excluded from EBITDA) the Trust is not forecast to achieve planned Capital Service. The Trust is also forecast to exceed its liquidity and slip against it's planned Agency target. Should conditions persist and costs not be managed within the control total then the resulting deterioration might trigger a review of our segmentation.

Forecast ForecastYTD YTD Out-turn Out-turn

Oct 2017 Sep 2017 at Oct 2017 at Sep 20177 6 Note 12 12 Note

Plan 0.610 0.321 Plan 2.167 2.167

Major Variances Major VariancesCIP Slippage -1.054 -0.982 - See CIP section CIP Slippage 0.000 0.000 - See CIP sectionOAPs -0.773 -0.773 - See OAPs section OAPs -1.792 -1.792 - See OAPs sectionStaffing -5.471 -5.000 - See also Bank and Agency section Staffing -8.139 -8.201 - See also Bank and Agency sectionOther Bud Vars 1.708 1.791 - See Services section Other Bud Vars 1.929 0.601 - See Services sectionReserves 3.210 3.040 - See Reserves section Reserves 7.231 8.899 - See Reserves sectionIncome -0.699 -0.688 - See Reserves section Income 0.584 0.514 - See belowMinor Variances 0.000 0.000 Minor Variances 0.000 0.000

Variance -3.079 -2.612 Variance -0.187 0.021

Actual -2.469 -2.291 Actual Forecast 1.980 2.188

----

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

This month sees an operating deficit of £2.5m, £2.3m after adjusting for impairments, £2.9m behind plan. Of this £0.9m relates to STF funding leaving a net gap from plan of £1.9m.

YTD income variance relates mainly to STF funds which are assumed in forecast along with additional funds re NCAs and R&D

Staffing variance has increased in part due to phasings of development funding in mental health, but more materially due to ward pressures.The full year projection is a surplus of £2.0m, £2.2m after adjusting for impairments. The position models an upside of c£7.0m and includes profit on disposals of c£1.7m.

-10,000.0

-8,000.0

-6,000.0

-4,000.0

-2,000.0

0.0

2,000.0

4,000.0

Plan CIP Surplus OAPs Staffing Other BudVars

Reserves Addl Income MinorVariances

2,167.0 0.0 -1,792.0 -8,139.1 1,928.8 7,231.4 584.1 0.0

-8,000.0

-7,000.0

-6,000.0

-5,000.0

-4,000.0

-3,000.0

-2,000.0

-1,000.0

0.0

1,000.0

Plan CIP Shortfall OAPs Staffing Other BudVars

Reserves Addl Income MinorVariances

610.0 -1,054.2 -773.0 -5,471.3 1,708.2 3,209.9 -698.53 0.0



Plan 193.922 166.144 Plan 332.908 332.908

Major Variances Major VariancesCommunity Services 1.073 0.659 - Note 1 Community Services 2.232 2.172 - Note 1Mental Health 2.956 2.380 - Note 2 Mental Health 2.704 2.598 - Note 2Specialist Services -0.355 -0.196 - Note 3 Specialist Services -1.160 -1.145 - Note 3Non NHS Healthcare Income-1.018 -0.835 - Note 4 Non NHS Healthcare Income-1.804 -1.758 - Note 4R&D 0.274 0.180 R&D 0.389 0.600ETR 0.204 0.167 - Student Income ETR 0.356 0.297 - Student IncomeMiscellaneous -0.047 0.209 - Note 5 Miscellaneous 2.260 1.529 - Note 5STF -0.939 -0.730 STF 0.000 0.000

Minor Variances 0.000 -0.039 Minor Variances 0.000 0.015

Variance 2.148 1.794 Variance 4.978 4.308

Actual 196.070 167.938 Actual Forecast 337.886 337.216

12

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

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

Major decrease due to Southport commencing in May and not April offset by minor gains in other services including 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 in respect of lower than planned activity in Sexual Health services and forecasts for Sexual Health and Offender Health later in the year.

0.000

5.000

10.000

15.000

20.000

25.000

30.000

35.000

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



Budget 164.955 141.407 Budget 281.644 281.506

Major Variances Major VariancesMental Health -6.479 -5.654 - Note 1 Mental Health -9.257 -9.961 - Note 1Community & Wellbeing -0.216 -0.274 - Note 2 Community & Wellbeing -0.401 -0.489 - Note 2Children & Young People 0.844 0.705 - Note 3 Children & Young People 0.824 0.866 - Note 3Pharmacy 0.188 0.169 - Note 4 Pharmacy 0.260 0.265 - Note 4Property Services 0.000 0.000 - Note 5 Property Services 0.000 0.000 - Note 5Corporate 0.073 0.089 - Note 6 Corporate 0.571 -0.073 - Note 6

Variance -5.590 -4.965 -8.002 -9.392

Actual 170.545 146.372 Actual Forecast 289.646 290.898

1

23

456 Corporate services are slightly ahead of plan year to date, with overspends in IM&T currently met by underspends in Medical and Human Resources.

Mental Health in year overspend is driven more acutely by excess staffing costs, primarily on wards, (£3.9m). 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, though risk remains until this is enacted. There is also significant CIP slippage, as all CIPS have been withdrawn but some schemes are still in development (c£1.9m). The Network's position is diminished further by ward overspends in Secure Services wards (c£1.2m). OAPs are now manifesting as overspends (£0.8m for the year)

Community's position is impacted by undelivered CIPs to date (£0.35m). 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(£0.25m) and Sexual Health activity shortfall (£0.2m) 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, with some underspends on staffing.Property Services are performing in line with plan and are expected to remain so.

-£7,000

-£6,000

-£5,000

-£4,000

-£3,000

-£2,000

-£1,000

£0

£1,000

£2,000Mental Health

Community &Wellbeing

Children &Young People Pharmacy

PropertyServices Corporate Total

Service Forecast Variance

-£10,000

-£8,000

-£6,000

-£4,000

-£2,000

£0

£2,000Mental Health

Community &Wellbeing

Children &Young People Pharmacy

PropertyServices Corporate Total

Service Year to Date Variance

CIP Achievement (£)Notes

Year to Date PerformanceAt month 7 with CIPs of £7.4m against a plan of £8.4m the Trust is c£1.1m behind plan, a deterioration of £0.1m on month 6 (£1.0m behind plan). The adverse variance is mainly due to the continued lack of performance on Run Rate Reduction Programmes on staffing pressures. Compensating schemes have, and continue to be, developed and network management team are being supported by to implement measures aimed at improving the position.

Schemes to be Transacted£0.9m of schemes are yet to be transacted at month 7 leading to year to date slippage of c£0.5m. There is a good degree of confidence in the delivery of these schemes.

Schemes In Process£1.5m of additional schemes identified are not yet sufficiently detailed to transact and after allowing for slippage factored into plan this results in slippage of c£0.6m. There is some confidence in the delivery of these schemes.

Schemes to be IdentifiedIncluding pipeline schemes plan totals exceed target and though not without risk forecast continues to be broadly in line with plan requirements.

ForecastThe programme is currently expected to achieve the Annual Plan however risk of slippage, particularly on mental health and community schemes, remains.


£'m £'m £'m £'m £'m £'m

Cost Improvement Programmes 6.11 6.69 0.58 11.10 13.10 2.00

Run Rate Reduction Programmes 2.33 0.70 -1.63 4.00 2.00 -2.00

Total 8.44 7.39 -1.05 15.10 15.10 0.00


£'m £'m £'m £'m £'m £'m

Monitored Schemes 7.31 7.39 0.07 12.74 12.73 -0.01

Schemes to be transacted 0.52 -0.52 0.89 0.89 0.00

Schemes in Process 0.61 -0.61 2.12 1.51 -0.61

Slippage/Schemes to be identified 0.00 -0.65 -0.03 0.62

Total 8.44 7.39 -1.05 15.10 15.10 0.00

Year to Date Annual

Year to Date Annual

Month Month Month MonthOct 2017 Sep 2017 Oct 2017 Sep 2017

7 6 Note 7 6 Note

Agency Spend 774 863 Note 1 Bank Spend 1,388 1,813

Network Analysis Network AnalysisMental Health 564 554 - Note 2 Mental Health 1086 1484 - Note 2Children & Young Peoples 11 64 - Note 3 Children & Young Peoples 81 80 - Note 3Community & Wellbeing 282 215 - Note 4 Community & Wellbeing 160 197 - Note 4Corporate Services -83 30 - Note 5 Corporate Services 60 52 - Note 5

Actual 774 863 Actual 1,388 1,813

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 7, the Trust is -£758k, or 17% above it'strajectory. The new Use of Resources rating measures agency against target and containstrigger points. Key trigger points are a requirement for 50% and 25% or better for ratings of3 and 2 respectively. An individual rating of at least 3 is required to obtain an overall ratingof 2 (see also 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.

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

A high level of vacancies is supported by bank and agency, though increased levels of recruitment mean overall staffing costs remain high. Agency costs have decreased from last month as well as bank costs.Mental Health Networks bank and agency costs are primarily due to the level of acuity on inpatient wards being beyond the level established although the in month decrease in bank is almost entirely attributable to staffing on Adult and Secure wards.Children and Young Peoples temporary staffing remains relatively minor and consistent.Community and Wellbeing sees an increase in both Agency but a fall in Bank, with the major agency change being the with regard to Learning Diability, and bank recovering in Integrated Teams and Southport.


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 1365 1481 1813

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

2017/18 647 691 711 704 825 863

0

200

400

600

800

1000

1200

1400

Agency Ceiling Apr May Jun Jul Aug Sep Oct Total Projection

Actual 647 691 711 704 825 863 774 5,216 8,353Plan 639 639 639 636 636 636 633 4,458 7,695Variance -8 -52 -72 -68 -189 -227 -141 -758 -658% of Plan -17% -9%

Month Month YTD ForecastOct 2017 Sep 2017 Oct 2017 Out-turn

7 6 Note 7 12 Note

Plan 0.2 -3.6 Plan 11.8 11.0

Major Variances Major VariancesI&E -0.3 -0.6 - Note 2 I&E -3.1 -2.1 - Note 2Capital & financing 0.6 0.8 - Note 2 Capital & financing 4.4 11.8 - Note 2Contract Vars and Adjs 0.2 -1.1 Note 3 Contract Vars and Adjs -2.7 Note 3Debtors -1.7 1.2 - Note 4 Debtors -3.7 -0.3 - Note 4Timing of settlements to suppliers -0.3 2.9 - Note 4

Timing of settlements to suppliers 0.0 0.5 - Note 4

Provisions and deferred income 0.6 0.0 - Note 5

Provisions and deferred income 1.4 0.4 - Note 5

Opening cash 0.0 0.0 Opening adjustment 2.7 2.7

Minor Variances 0.2 0.3 Minor Variances 0.5 0.6

Variance -0.7 3.4 Variance -0.4 13.6

Actual -0.5 -0.2 Note 1 Forecast Actual/Forecast 11.4 24.6 - Note 1

1

2

34

56 Provisions and Deferred Income are currently generating gains of c£1.9m over plan. Crystallisation of income and redundancy settlements are expected to reduce gains and this is

factored into forecasts.

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

Timing of settlements to suppliers are broadly in line with 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, that PDC for the inpatients Programme is in line with expectations, and that the disposal of Westfields, Ridge Lea and Ribbleton take place in 2017/18.

Late payments by CCGs (£1.0m) and local authorities (£2.1m) coupled with outstanding CQUIN (£0.5m) have lead to a large adverse position on debtors. Late payments were largely settled in early November and the issues are being addressed accordingly (as problems over payment timing rather than disputes). CQUIN payments are a national issue and payment is expected by March.

Forecast cash is ahead of plan by c13.6m partly due to the change in opening position c2.7m, but mainly due to assumptions around disposals (net improvement c£5.75m - Westfields, Ribbleton and Ridge Lea) and the assumed external cash funding of a substantial part of the Inpatient Scheme (net improvement £4.6m). The forecast assumes that proposed management action to bring financial performance back in to line is achieved (including profit on disposals), that capital receipts are in line with expectations, and that the Trust maintains eligibility for Sustainability Funding (achieves the control total).

Cash shows an adverse variance from plan of £0.4m. The capital position continues to offset the I&E position and pressures on working capital have been reduced - see below.

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

-10.000

-5.000

0.000

5.000

10.000

15.000


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

30.000


Forecast

Plan

YTD Plan YTD Act Annual ForecastOct 2017 Oct 2017 Variance Plan Out-turn Variance

£000 £000 £000 £000 £000 £000

IT Schemes 1.015 0.664 -0.351 1.900 1.900 0.000 - Note 1

Estate and infrastructure SchemesLarge Schemes

MH Inpatient Schemes 3.194 0.401 -2.793 4.580 5.700 1.120 - Note 2

Perinatal 0.000 0.113 0.113 0.000 2.470 2.470 - Note 3

Places of Safety 0.000 0.100 0.100 0.000 0.490 0.490 - Note 4

High Priority Schemes 0.697 0.147 -0.550 1.263 1.260 -0.003 - Note 5

Maintenance and Replacement 0.543 0.310 -0.233 0.930 0.930 0.000Other (inc. contingency) 0.541 0.099 -0.442 0.918 0.911 -0.007

Total 5.989 1.834 -4.155 9.591 13.661 4.070

12

3

4

5

6 The underspend largely relates to contingency and reserves. Some delays as a result of dependencies/focus on large schemes and fire safety have resulted in slippage rather than the expected pressures on contingency. Transfers between revenue and capital transacted are as required.

Note 6-

£3.5m of external cash funding was allocated for the Perinatal project, £2.5m in 2017/18. Again issues with third parties have caused some delays and whilst it was hoped this can be managed, some slippage may be likely. The impact has yet to be finalised and incorporated in to forecast.

£0.5m of external cash funding was allocated for Places of Safety. Funding currently exceeds planned work and should spend not be required this year then funding will be retained by DoH.

Capital Expenditure

Progress against the capital programme has been slow to date with expenditure at £1.8m against the original profile of £6.0m. The scheduling profile of many schemes was dependent on a number of tendering exercises (the last of which, Perinatal, has now been completed), agreements with third parties (now substantially resolved) and final funding approval (Inpatient schemes approval now received from NHSI, awaiting final confirmation of funds and timing from DH). Schedules for these and related/dependant schemes are now being finalised through discussions with the incumbent contractors and the Trust is pushing forward with work on the affected projects. Discussions with contractors indicate the delays will cause slippage, mainly on the Inpatients (Chorley site - c5 weeks) though a risk of slippage on the Perinatal scheme remains and is being worked on. Impacts on the respective projects have yet to be finalised and incorporated in to forecasts.

IT programme is expected to be delivered on forecast.External cash funding was provisionally allocated to the Inpatient project through the STP and was approved by NHSI in October. DH have requested additional information, including additional governance requirements, and final approval remains to be confirmed. Work has commenced though delays in relation to the Chorley site, primarily caused by third parties, have meant that works have started later than originally intended and whilst it was hoped this could be managed, slippage of c5 weeks now appears likely. The impact has yet to be finalised and incorporated in to forecast.

Schemes are underway and despite some delays, partly as a result of inpatient development, schemes are expected to be completed in line with planned outturns.

Use Of Resource Metric

unitsPlan

YTD ending 31-Oct-2017

Actual YTD ending 31-

Oct-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 1.803 1.208 (0.594) 1.909 1.647 (0.262) Variance from plan 0.00% -1.00% -2.00% <=-2%

Capital service rating Rating 2 4 2 3 Agency 0.00% 25.00% 50.00% >=50%

Liquidity Metric Weighting

Capital Service Cover rating 20.00%

Liquidity metric £m (1.062) 3.807 4.869 (0.433) 13.631 14.064 Liquidity rating 20.00%

Liquidity rating Rating 2 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 % 0.31% (1.15%) (1.46%) 0.65% 0.65% (0.00%)

I&E Margin rating Rating 2 4 2 2

I&E Variance From Plan

I&E Variance from plan metric % (1.46%) (0.00%)

I&E Variance from plan rating Rating 3 2

Agency

Agency metric % (0.65%) 16.24% 16.88% (0.95%) 7.87% 8.82%

Agency rating Rating 1 2 1 2

Use Of Resources Rating

Overall rating unrounded Rating 2.80 2.00 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.

Though slightly improved the current I&E position continues to give a rating of 4 and a Capital Service rating of 4 constraining the current overall UoR to a 3. Assuming current pressures and risks are addressed through the recovery plan and I&E performance achieves (or exceeds) forecast the Trust will achieve a UoR of 2 in line with the plan. However, though forecast would achieve the overall target rating, Capital Service is based on EBITDA and since part of the Trusts recovery plan is based on disposals (which are excluded from EBITDA) the Trust is not forecast to achieve planned Capital Service. The Trust is also forecast to exceed its liquidity and slip against it's planned Agency target. Should conditions persist and costs not be managed within the control total then the resulting deterioration might trigger a review of our segmentation.

• Capital Service is currently a 4 against a plan of 2, an increase in operating performance of c£0.2m would be required to increase the rating to 3.

• Liquidity is currently a 1 against a plan of 2, a deterioration in the liquidity metric of c£3.8m would be required to reduce the rating to 2.

• I&E Margin rating is currently 4 against a plan of 2, an increase in operating performance of c£0.3m would be required to increase the rating to 3 - Note that the adjusted deficit of -£2.3m is £2.9m behind the RCT (£1.9m exc STF)).

• I&E Variance from Plan is currently 3, an increase in operating performance of c£0.3m would be required to increase the rating to 2.

Reserves

Reserve Budget Actual £ Annual Projected £

To Date To Date Variance Budget Actual Variance Narrative

£'000 £'000 £'000 £'000 £'000 £'000

Capital Charges £8,966 £9,168 -£202 £15,546 £13,852 £1,694 Anticipated Profit on Disposals offset by var due to revaluation of estate

Pay Reserve £1,166 £566 £600 £1,529 £969 £559 Charge for Apprentice LevyPressures Reserve £293 £117 £176 £503 £201 £302 Funds to be applied to servicesCIP Reserve £1,028 -£47 £1,075 £1,834 -£80 £1,914 Gain on CIP to be applied to service pressuresEmerging Pressures -£315 £0 -£315 -£2,261 £0 -£2,261 Utilisation of Reserves to meet Emerging PressuresDevelopments £729 £280 £449 £934 £250 £684 Costs to be applied as incurredContracts £168 £0 £168 £227 £0 £227 Minor contract gains to be applied to servicesOrganisational Reset £1,017 £235 £782 £1,734 £573 £1,162 Funds to be returned to Networks, with some staffing chargesAgency & Direct Engagement -£350 -£343 -£7 -£600 -£612 £12 Premium for using non-contracted staffNon Clinical Development £4 £0 £4 £22 £0 £22 Premium for using non-contracted staffSavings to be Identified £0 -£2 £2 £0 -£2,420 £2,420 Additional savings required to deliver control total

Non Pay Inflation £638 £162 £477 £794 £216 £578 Funds to be applied for inflationary pressures

Total £13,346 £10,136 £3,210 £20,263 £12,949 £7,313

MATTERS

ID Meeting DatePaper Status

2017/01 Jul-17 VerbalPartial




2017/05 Jul-17 Verbal

Excluded

2017/06 Jul-17 VerbalExcluded

2017/07 Jul-17 Verbal Excluded

2017/08 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: The process of reclaiming VAT in relation to older developments continues. Communications with HRMC progressthough timing and amounts remain uncertain. Treatment is being discussed with external audit but initial indications are positive. Thevalue may be up to £2m, though less than half this amount is included in plans and forecasts. Our advisors are actively engaged inbringing this to a final resolution.

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

NHSI is currently clarifying the position around elements of the national contingency reserve, £0.5m of which is now outstanding.

The forecast trajectory with regard to Out of Area Placements (OAPs) is currently projected to £1.6m, with the assumption that the50% risk share applies.

Provision for charges incurred as a result of the organisational reset have been made, the process is largely complete, but somechallenges remain and these may have financial consequences.

STF monies have been included in forecasts on the assumption that the Trust will achieve its revenue control total. Should this not bethe case £2.1m of funding would be lost.The Trust is assessing the impact of recent court decisions around pay for sleepover in Learning Disabilities care placements.

OUT OF AREA ACTIVITY

NetworkActual/ Forecast Apr May Jun Jul Aug Sep Oct Nov Dec Jan Feb Mar TotalAcute OAPs (places) 15 11 14 13 10 11 13 15 9 9 9 9 138PICU OAPs (places) 9 13 9 12 12 11 9 9 8 8 8 8 116Total Beds 24 24 23 25 22 22 22 24 17 17 17 17 254Acute OAPs (£'000) 244 185 228 218 168 179 218 244 151 151 137 151 2274PICU OAPs (£'000) 206 308 206 284 284 252 213 206 189 189 171 189 2697Total £'000 450 493 434 502 452 431 431 450 340 340 308 340 4971

1

23

4

567

The Trust has written to commissioners about the pressure caused by patients awaiting alternative placements.The Trust has opened negotiations with commissioners about the financial impact of patients inappropriately occupying our beds in excess of 180 days.

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. After this fund is exhausted, any additional OATs are accounted for on the basis of 50:50 split between the Trust and CCGs.

Current projection suggest there will be expenditure of £5.0m for OAPs in 2017/18., though slippage on developments takes the net impact to £4.8m as reported elsewhere.

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

If the current trajectory persists this would present pressure in the order of £2.3m (net).

ForecastActuals

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