Board of Directors - LSCFT Board/Trust Board Documents/2020... · BOARD OF DIRECTORS Minutes of the...

Board of Directors Thursday 06 February 2020

09:30am

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

Board of Directors

Quality Committee

Finance & Performance Committee

Nomination Remuneration

Committee

Audit Committee

Board of Directors Meeting Board of Directors Meeting

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

Date Thursday 06 February 2020

Time 09:30am

Reference Item Lead Action Enc.

PART ONE (PUBLIC MEETING)

TB 031/20 Welcome and opening comments Chair Verbal

TB 032/20 Apologies for absence and confirmation of quoracy Chair Verbal

TB 033/20 Declarations of Interest Chair Verbal

TB 034/20 Minutes of the previous meeting Chair Decision Paper

TB 035/20 Action Tracker Chair Decision Paper

SCRUTINY & ASSURANCE (PUBLIC MEETING) TB 036/20 Trust Chair’s Report Chair Decision Paper

TB 037/20 Chief Executive’s Report Chief Executive Noting Paper

TB 038/20 Finance & Performance Committee Chair’s Report Committee Chair Assurance Paper

TB 039/20 Audit Committee Chair’s Report Committee Chair Assurance Paper

TB 040/20 South Cumbria Assurance Committee Chair’s Report Committee Chair Assurance Paper

TB 041/20 Improvement Board Update Report Chief Executive Noting Paper

TB 042/20 Mental Health Improvement Plan Director of Operations Noting Paper

TB 043/20 Patient Story Director of Nursing and Quality Noting Presentation

TB 044/20 Quality and Performance Report (QPR)

Interim Director of Partnerships & Strategy Noting Paper

TB 045/20 CQC Update Director of Improvement

and Compliance Noting Paper

TB 046/20 Finance Report Chief Finance Officer Noting Paper

TB 047/20 Nurse Safe Staffing Report Director of Nursing and Quality Assurance Paper

Any Other Business TB 048/20 Chair Verbal

Declarations of Interest – Board of Directors

Name Role Description Date Inputted Comments

David Eva Chairman

1. Employed by Union Learn as National Manager2. Trustee of national Association of Racing Staff3. Non-Executive Director Liverpool Media Academy4. Independent Chair of the Wirral Integrated Care Partner

20/02/2019

Louise Dickinson Non-Executive Director

1. Director at Talegar Limited2. Consultancy Services at Talegar Limited3. Foundation Governor and Finance Chair at St. Vincent’s primary School

20/02/2019

Isla Wilson Non-Executive Director

1. NED - Progress Housing Group2. Shareholder - FSquared Ltd3. Shareholder - Ruby Star Associates Ltd4. Consultancy/Advisory Work Ruby Star Associates5. NED - Healthier Lancashire & South Cumbria ICP6. Chair - Borough Care7. Director - Life In Colour Ltd8. Innovation Agency

24/09/2019

David Curtis Non-Executive Director Director at Clinical and Corporate Governance Limited 29/04/2019

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Bill Gregory Chief Finance Officer

1. Trustee of Healthcare Financial Management Association 2. Co-opted member of Lancaster University Financial and General Purpose Committee 3. Director of HSIS 4. Director and shareholder of Healthcare Business Partnerships Limited (HBP). 5. Strasys Associate Liaison Group NED Advisor

15/01/2020

HBP will not be providing any services to the Trust

Shazad Sarwar Non-Executive Director

1. Director Msingi Research Ltd 2. Lay Member Lord Chancellors Advisory Committee for Cumbria & Lancashire 3. Independent Member Joseph Rowntree Foundation Audit & Risk Management Committee 4. Community Representative Pendle Community Safety Partnership

30/08/2019

Debbie Francis Non-Executive Director Managing Director at Direct Rail Services 01/09/2019

Richard Morgan Acting Medical Director Nil Declaration 02/04/2019

Caroline Donovan Chief Executive Nil Declaration 29/04/2019

Russell Patton Director of Operations Nil Declaration 28/06/2019

Maria Nelligan Director of Nursing and Quality

1. CQC Executive Reviewer 2. Honorary Senior Lecturer – Chester University 3. Company Secretary at National Mental Health & Learning Disability Director of Nursing Forum

10/10/2019

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Nicky Ingham Interim Director of HR 1. Chief Executive – Nicky Ingham and Associates Ltd 2. Executive Director – Healthcare People Management Association (HPMA)

25/09/2019

Ursula Martin Director of Compliance and Improvement Nil Declaration 01/10/2019

Paul Farrimond Non-Executive Director

1. Managing Director of P.F. Consultancy Ltd 2. Facilitate meetings and conferences for the CEOs of the nine mental health Trusts in North East and Yorkshire and Humber 3. Specialist mental health advisor to NHS Providers

24/12/2019 No conflict with LSCFT

Peter Williams Non-Executive Director 1. Secondary Care Doctor Manchester Health and Care Board 2. Non Executive Director NHS transformation unit.

01/01/2020

Phil Evans Interim Director of Partnerships & Strategy Nil Declaration 31/01/2020

Declaration of Interest Presented to the Board of Directors on 06 February 2020

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BOARD OF DIRECTORS

Minutes of the Part One Board of Directors meeting held on 09 January 2020 Boardroom, Sceptre Point

PRESENT: David Eva, Trust Chair (Chair)

Caroline Donovan, Chief Executive David Curtis, Non-Executive Director Debbie Francis, Non-Executive Director Shazad Sarwar, Non-Executive Director Julia Possener, Non-Executive Director Isla Wilson, Non-Executive Director Paul Farrimond, Non-Executive Director Peter Williams, Non-Executive Director Maria Nelligan, Executive Director of Nursing and Quality Ursula Martin, Executive Director of Compliance and Improvement Russell Patton, Interim Executive Director of Operations Bill Gregory, Chief Finance Officer Richard Morgan, Acting Medical Director Nicky Ingham, Interim Director of HR Shelley Wright, Director of Communications

IN ATTENDANCE: Natalie Gauld, Executive PA (minutes) Bev Howard, Head of Communications

Louise Guss, Interim Company Secretary OBSERVERS: Paul Faulkner, Lancashire Post

TB 001/20 WELCOME AND OPENING COMMENTS

The Chair welcomed everyone to the meeting and introductions were made.

TB 002/20 APOLOGIES FOR ABSENCE AND CONFIRMATION OF QUORACY Apologies from Louise Dickinson and David Curtis will be leaving early.

Confirmation of quoracy was provided.

TB 003/20 DECLARATIONS OF INTEREST Non-Executive Director, David Curtis declared that he had commenced as a Non-Executive Director at Tameside NHS Trust. There were no conflicts to declare regarding this today. There were no other declarations of interest declared.

TB 004/20 MINUTES OF THE PREVIOUS MEETINGS The minutes of the previous meeting held on the 05 December 2019 were agreed as a true and accurate record.

UNCONFIRMED

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TB 005/20 ACTION TRACKER The Board reviewed the action tracker and received updates in respect of the two open actions. The Board also noted the actions scheduled for future meetings. There were no further matters arising.

TB 006/20 TRUST CHAIRS REPORT The Chair presented his monthly report which included an overview of the activity of Non-Executive Directors and Governors. The report was noted by the Board.

TB 007/20 CHIEF EXECUTIVE’S REPORT The Chief Executive presented her report and provided an update on the work regarding the Care Quality Commission (CQC) Plan which was being led by the Executive Director of Improvement and Compliance. The Mental Health Plan was highlighted with the Executive Director of Operations leading the continued work jointly with Northumberland, Tyne and Wear (NTW). Clinical teams had also been partnering with NTW, particularly regarding rehab. The South Cumbria merger with Lancashire Care was going well, with a successful recruitment event taking place and more to come. The Staff Survey had closed and it was noted that the Trust had received a higher response rate than previous years. The Trust had, unfortunately, been unable to reach the national target and was currently awaiting publication of the national headlines. Listening into Action (LiA) was continuing at pace with good work being noted, In particular, the advent calendar had been well received over the Christmas period. An update was provided regarding the Integrated Care System (ICS). The revised plans for the 5 year joint plan work were continuing of which mental health was a key part. The Trust would be re-submitting its part of the plan again this week which outlines additional work. Work regarding the Clinical Strategy was still ongoing with a Board development session held before Christmas. “2020 Year of the Nurse” would be celebrated within the Trust. Plans had been identified, along with activities that would take place each month. Senior Nurses met yesterday to look at events and also the possibility of partnerships with other organisations. Sarah Green, Pharmacy Technician had been awarded “Pharmacy Tech of the Year” nationally, with Michelle Walker coming second in the awards. The work the Trust was carrying out in respect of inclusion and diversity had been recognised with the Trust being placed third nationally.

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With regards to the external environment, the Chief Executive confirmed that there were five new MPs within the Trust’s footprint and that John Lawler had been appointed as the National Children’s Lead for LD and Autism. The importance of building relationships was highlighted.

TB 008/20 SOUTH CUMBRIA ASSURANCE COMMITTEE CHAIR’S REPORT A Non-Executive Director presented the Chair’s Report on behalf of the Committee Chair following the meeting held on 20 December 2019. Key highlights included recruitment successes, OAPS, agreed expenditure to improve the environment and risks around Kentmere. Significant workforce data gaps were noted. A meeting was due to take place next week to gain assurance and reassurance; however, should assurance not be gained this would be escalated to the Board. It was highlighted that work was continuing in respect of the action plans and the locality model, which was moving in the right direction. Kentmere remained the main concern due to the capital needed as it was not fit for purpose and required transformation around the unit. The team was hoping to make an assessment next week and make a decision and would confirm the ‘must dos’ in terms of safety and these would be progressed. A query was raised as to whether staff concerns had been included within the lessons learnt report. The Chair of the Committee would confirm at the next meeting. ACTION The Board noted the content of the Chair’s Report.

TB 009/20 QUALITY PERFORMANCE REPORT 9.50am – Phil Horner, Head of Business Intelligence joined the meeting. The Executive Director of Operations presented the report for month 8 and confirmed that the Trust was compliant with 8 of the 11 current NHSI metrics. Inappropriate OAPs continued to exceed the current trajectory (which was agreed at the start of 18/19). The number of OAPs occupied bed days had increased in month 8 coinciding with increased demand for inpatient admissions and following the trend started the previous month. 14% higher and admissions 3% higher – closure of MHDU. Actions to improve the OAPs position were being progressed as part of the system-wide action plan developed to respond to the NTW review. IAPT Recovery had returned to above the target of 50%. Whilst this was reported at Board on a monthly basis, it was a quarterly target so there was an opportunity to achieve the Quarter target with early indications for December suggesting that this would be achieved. The latest position available (August 2019) of the Data Quality Maturity Index (DQMI), reported by NHS Digital, showed the Trust was non-compliant against the 95% standard (and the 90%-95% for the CQUIN achievement). The DQMI measures the Trust’s performance against data submission to 36 fields. Due to lack of overall alignment with the Trust’s systems to the national dataset, and the

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partial roll out of RiO (RiO PAS rolled out only), this was proving to be a complex, challenging piece of work. South Cumbria services failed on 7 day follow up, however month on month improvements were being made. It was noted that much of the data in the report had management issues for actions that had been identified. It was confirmed that conversations had taken place with NHSE regarding concerns about long term and sustainability of sector colleagues, along with financial viability concerns. Key tasks of the bed management service were to carry out regular reviews of the providers used by the Trust, with quality assurance assessments being carried out. Part of next year’s internal audit plan was to review these contracts. The improved position regarding 12 hour breaches was noted and management actions were in place in order to continue to improve the figures. Section 136 breaches had improved from previous months and it was noted that the figures in 2018 at this time of year were 41.9% compared to 16.3% in 2019. The 4hr compliance target in A&E was discussed and the figure recorded in November was 96.4% in comparison to 2018 which was 80.9%. 1hr compliance was not as positive but still an improvement on 2018. Superstranded and stranded patients were discussed. The number of superstranded and stranded patients represented around 6% of all admissions and was as a result of structural issues rather than clinical issues. It was requested that the QPR be integrated within the Mental Health report for future meetings. ACTION It was noted that 20 fields were currently reported at 90% or above in relation to the Mental Health Data Quality CQUIN 5a which requires achieving a score of 95% in the mental health services data set quality maturity index. Actions were in place to address each area, and based on the current assumptions of the impact of the Trust’s interventions, it was expected that the minimum CQUIN standard may be achieved from Q3 onwards; however, payment mechanisms were such that there was a risk to financial achievement for the year. HR workforce data information to be presented was noted. There were issues regarding the level of vacancies that the organisation was carrying and these were being actively reviewed. It was reported that sickness had increased, but improvements were being made. Training and appraisal data was recorded as being the highest to date. The Board noted the content of the report.

TB 010/20 MENTAL HEALTH IMPROVEMENT PLAN The Executive Director of Operations presented his report. It was reported that two deep dive reviews had been completed.

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Updates were given which highlighted a substantial number of patients receiving rehab care; however, the organisation’s bed shortfall was reported as problematic and this contributed to a high number of OAPS. Avondale and Wesham sites were being considered as possible options to help elevate the pressure within the service on beds and alternative models were being considered. In the short term, it was reported that 11 patients would move to Avondale in the Spring of 2020. A census was completed on in-patient wards which highlighted that 67 patients on acute wards would have been more appropriately placed on an inpatient rehab facility. Regarding throughput on treatment wards, it was reported that 10 facilities remained a challenge and it was clear that the Trust needed assurance that the most efficient and effective processes and delivery models were in place. Conversations had taken place with NHSE and NHSI and a representative had been involved and was working with the networks to drive forward changes. It was reported that a workshop was to be held next month to look at and review possible changes. An additional crisis house had now been commissioned which would provide 24hr support in the centre of Blackpool. The unit would be operational in late Spring 2020. The Executive Director reported that pathway redesign work in Pennine was continuing via the Trust’s partnership with Cumbria Northumberland, Tyne and Wear. Two workshops had already taken place, one regarding access and the other on assessment. A Mental Health liaison pathway in eating disorders was also being reviewed. In relation to Learning Disability (LD), NHSE had commissioned Moorhouses Consultancy to review current commissioned provision of LD services in Lancashire and South Cumbria in order for them to be assured that the transforming care programme (TCP) could be effectively and safely delivered in the system. The next stage of the review would be respective CEOs discussing roles going forward in terms of LD within Lancashire and South Cumbria. Intensive support teams were reported as an area of concern with Merseycare providing this service currently. An LD improvement Board was being developed and Amanda Doyle, Integrated Care System Lead for Lancashire and South Cumbria would be chairing this. The Board noted the contents of the report. 10.48 – Phil Horner, Head of Business Intelligence left the meeting.

TB 011/20 FINANCE REPORT The Chief Finance Officer presented the finance report and confirmed that the organisation was reporting a deficit. It was reported that significantly, stranded patients would result in £1.5m costs. It was reported that conversations had taken place with commissioners regarding funding and these would continue. However, the organisation would still be required to deliver improvements in the financial position.

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The Executive Director reported that the cash position and aged debt had improved and cash would run to plan for year end. It was noted that the Academic Health Science Network (AHSN) would be transferred to another organisation on 31 March 2020. The Board was advised that in relation to the Sharoe Green site, contracts had been exchanged and a completion date of January 2020 had been agreed. It was reported that negotiations were progressing well regarding the Wesham site and a business case would be presented to the Board in March 2020. Bank and agency costs were noted by the Board and improvements to the use of bank over agency staff was also noted.

TB 012/20 NURSE SAFE STAFFING REPORT

The Executive Director of Nursing and Quality presented her report which provided the Board with an update on LSCFT nurse staffing and set out of actions being taken to improve safety and quality in the delivery of care to people who use our services. It was noted that the reports now included nursing associates and nurses that cover additional hours to ensure safe clinical practice was continued. The Harbour and Guild had daily staffing briefings to ensure staffing was maintained. The Executive Director noted that bed occupancy was at 92% in November 2019 with a number of challenges, which included the lack of a seclusion facility on Calder ward. It was noted that staff experience saw an improvement in the period in relation to the number of breaks taken and clinical supervision had increased to 81%. It was noted that recruitment and vacancies had seen an improvement, however there continued to be significant vacancies. The Board noted the challenges in delivery of safer staffing together with the mitigations and action plans in place.

TB 013/20 BOARD ASSURANCE FRAMEWORK (BAF)

The Executive Director of Improvement and Compliance presented the Quarter 3 BAF. It was reported that there was one amendment to note, this being an increase in risk 16. An exception report was also included in the papers. The Board noted the next steps regarding the completion of the Well Led review and action plans to be brought to Board in February 2020. The Board noted the content of the Q3 Board Assurance Framework.

TB 014/20 CQC UPDATE The Executive Director of Improvement and Compliance presented her report which provided the Board with an update in relation to the Trust’s response to the

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CQC Warning Notices. Exception reporting against the CQC action plan and an update relating to the governance arrangements in place was highlighted. It was noted that a considerable amount of activity was being maintained and reported periodically to the regulator. The Executive Director reported that a meeting would take place the following week with the CQC to discuss the level of assurance provided on the issues contained in the warning notices and a date for a further inspection. The Board noted the update provided in relation to activity linked to the CQC inspection and the associated governance arrangements.

TB 015/20 MENTAL HEALTH BENCHMARKING REPORT 2019 The Acting Medical Director presented his report which provided an overview of the 2019 mental health benchmarking project findings. The Medical Director reported that the organisation did need to ensure that data quality was good and a team would be created to help with data quality and the interpretation. A working group was to be established to focus on this area. It was agreed that workforce lead should be included within this working group. ACTION The Board noted the content of the report.

TB 016/20 ANY OTHER BUSINESS

The Executive Director of Nursing and Quality reported to the Board that the flu CQUIN uptake figures were currently at 75% and that Southport and Formby was currently reporting an 82% uptake. The target deadline was noted as February 2020.

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BOARD OF DIRECTORS – ACTION TRACKER – PART ONE

DATE ACTION REF NO

ACTION OWNER ACTION

KEY DATES/FORECAST

COMPLETION STATUS IMPLEMENTATION STATUS/CLOSE

OUT ACTION

October 2019

TB 254/19 RP

Quality and Performance Report - ADHD A deep dive would be undertaken to review the ADHD data and to discuss future commissioning intentions.

January 2020 Closed This action is closed and will be discussed within the agenda item TB 005/20

November 2019

TB 283/19 MN

Finance and Performance Chairs Report An updated paper regarding lessons learnt on making buildings safe will be discussed at Execs/SLT meeting following on from the Health and Safety Forum. The Board will receive an update in January 2020.

January 2020 Closed This action is closed due to an update paper now being completed regarding lessons learnt.

November 2019

TB 286/19 NI

Patient Story HR to undertake a review of all long term health conditions. To ensure we are accurately understanding all reasons for absence and what additional support can be provided if necessary.

February 2020 Open

A report will be submitted to People and Quality Committee in January 2020 and an update to be received at the February 2020 Board meeting.

November 2019

TB 288/19 NI

Quality Improvement Report Workforce section of the QPR to be reviewed and additional information to be provided which outlines the establishment against vacancies.

December 2019 Closed

At the 05 December 2019 Board meeting it was noted that there was further work to be undertaken on the workforce section and therefore the action would remain open until January 2020. Update – 09.01.2020 – Action closed. The Workforce section has now been updated and includes more detail and narrative.

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BOARD OF DIRECTORS – ACTION TRACKER – PART ONE

DATE ACTION REF NO

ACTION OWNER ACTION

KEY DATES/FORECAST

COMPLETION STATUS IMPLEMENTATION STATUS/CLOSE

OUT ACTION

January 2020

TB 008/20 LD

South Cumbria Assurance Committee Chair’s Report The Committee Chair to confirm if staff concerns had been included within the lessons learnt report.

February 2020 Closed

The staff concerns have been added to the lessons learnt work programme for oversight by the Committee.

January 2020

TB 015/20 RM

Mental Health Benchmarking A working group was suggested to analyse the quality and interpretation of the data. A workforce lead is to be included in the membership of the group.

February 2020 Open

RM confirmed that Phil Connolly has been invited to join the group, which is established and next meeting 12.02.20

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Board of Directors Agenda Item TB 036/20 Date: 06/02/2020

Report Title Trust Chair’s Report

Prepared By Umme Batan, Corporate Governance Support and PA to Chair & Non-Executive Directors

Presented By David Eva, Trust Chair

Action Required Decision

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 1.0 The Trust does not protect the people who use its services from avoidable harm and fails to comply with the CQCs standards for the quality and safety of services

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. In addition to the usual Board business, Non-Executive Directors (NEDs) have been involved in their areas of special interest during the period 03 January 2020 – 31 January 2020:

Louise Dickinson

Attended the Board of Directors Meeting Attended the Board Development Session Attended the Trusts Clinical Strategy Attended the Director of Digital Stakeholder Group Attended the South Cumbria Assurance Committee Meeting

Julia Possener

Attended the Board of Directors Meeting Attended the Review of Hospital Managers Hearing meeting Attended the Quality Committee Meeting

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David Curtis Attended the Board of Directors Meeting Attended the Quality Committee Meeting Attended the NHS NW Leadership Academy Board Meeting Attended the Audit Committee Meeting

Isla Wilson Attended the Board of Directors Meeting Attended the Board Development Session Had a tele-call with the STP Lead for Lancashire and South Cumbria Attended the ICS Board meeting Chaired the Finance and Performance Committee Meeting Attended the Governance Task and Finish Group Had the monthly catch up with the Chair Attended the KPI’s SLI Workshop Session Attended the formal panel interviews for the Director of Digital

Shazad Sarwar

Attended the Board of Directors Meeting Attended the Board Development Session Attended the Council of Governors to the Board of Directors Meeting Participated in the formal panel interviews for the Director of People and Organisation

Development Attended the Director of Digital Stakeholder Group

Debbie Francis

Attended the Finance and Performance Committee Meeting Attended the Board of Directors Meeting Attended the HSIS Board Meeting Met with the Internal Auditors Attended the Board Development Session Chaired the Audit Committee Meeting Attended the Northern Care Alliance NHS Group’s Audit Committee Meeting to observe Attended the KPI’s SLI Workshop Session

Paul Farrimond

Attended the Board of Directors Meeting Attended the Quality Committee Meeting

Peter Williams

Attended the Board of Directors Meeting

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2.0 CHAIR’S ACTIVITY Had the weekly catch ups with the Chief Executive Had the monthly catch up with the Deputy Chair Chaired the Board of Directors Meeting Attended the shortlisting for the People and Organisational Development post Attended the shortlisting for the Director of Digital post Attended the shortlisting for the Chief Finance Officer post Had the quarterly meeting with the Lead Governor Attended the CoG Nomination Remuneration Committee Attended the formal panel interviews for the Director of People and Organisation

Development Attended the session with Sir David Dalton re: Provider Collaborative Had a tele-call with the internal auditors Attended the Board Development Session Attended the Executive and Chair lunch with Saffron Cordery, NHS Providers Attended the formal panel interviews for the Director of Digital

3.0 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, there has not been a Council of Governors meeting. However, there was a Council of Governors with the Board of Directors meeting held on 18 December 2019 of which the minutes can be seen at appendix one. The Board of Directors are asked to approve the minutes of the Council of Governors with the Board of Directors meeting which took place on 18 December 2019.

4.0 USE OF THE COMMON SEAL

To inform the Board that the Common Seal has been applied as below since the Board of Directors meeting on 05 December 2019.

Disposal agreement of former Sharoe Green Hospital Lease relating to ATOS premises

5.0 BOARD ACTION

The Board of Directors is asked to:

Note the content of the Trust Chair’s Report Approve the minutes of the Council of Governors with the Board of Directors meeting held

on 18 December 2019.

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UNCONFIRMED

COUNCIL OF GOVERNORS WITH THE BOARD OF DIRECTORS

Minutes of the Council of Governors Meeting with the Board of Directors Held on Wednesday, 18 December 2019, Garden Room, St. Catherine’s Hospice, Preston

Present: David Eva, Trust Chair

Caroline Donovan, Chief Executive David Curtis, Non-Executive Director Isla Wilson, Non-Executive Director Louise Dickinson, Non-Executive Director Shazad Sarwar, Non-Executive Director Ursula Martin, Director of Compliance and Improvement Richard Morgan, Acting Medical Director Maria Nelligan, Executive Director of Nursing and Quality Jo Moore, Director of Partnerships and Strategy Phil Curwen, Public Governor (Lead) Chris Johnson, Public Governor Lorena Dumitrache, Public Governor John Walden, Public Governor Mary Jackson, Public Governor Julia Kay Horn, Public Governor Hamad Saleem, Public Governor Steph Holmes, Public Governor Lesley Davison, Public Governor Kate Eggleston-Wirtz, Public Governor Sally-Ann Walker, Staff Governor Helen Scott, Staff Governor Judy Laing, Staff Governor Emma Allen, Staff Governor Vicky Shepherd, Age UK, Nominated Governor Paul Howes, Ncompass, Nominated Governor Shaun Turner, Lancashire County Council, Nominated Governor

In Attendance: Cath Hill, Director, AQuA

Dominic McKenna, Financial Management Director Fiona Ritchie, Company Secretary Viv Prentice, Deputy Company Secretary (Minutes)

COG/TB 001/19 WELCOME & OPENING COMMENTS

The Chair welcomed everyone and outlined the format of the meeting which was to share the findings of the well-led developmental review and was an opportunity to look ahead and to consult with the governors about the organisation’s vision and strategic objectives going forwards.

COG/TB 002/19 APOLOGIES FOR ABSENCE Apologies were received from Non-Executive Directors: Debbie Francis, Julia Possener and Louise Dickinson; Interim Director of HR: Nicky Ingham; Director of Operations: Russell Patton; Chief Finance Officer: Bill Gregory (Director of Operational Finance, Dominic McKenna deputising); Public Governor: Ken Lowe; Staff Governors: Yvonne Guilfoyle and Gina Gasson; and Nominated Governor: Joanne Keeling.

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UNCONFIRMED

COG/TB 003/19 DECLARATIONS OF INTEREST There were no declarations of interest.

COG/TB 004/19 WELL LED: MOVING TO GOOD The Chair introduced Cath Hill, Director of AQuA who was in attendance to provide high-level feedback following the recent well-led developmental review and advised that this would be an opportunity for governors to provide their input.

In terms of setting the context to the report, the Director referred to the Care Quality Commission’s (CQC) overall core service ratings for 2018-19 where 65% of NHS organisations were rated as ‘Good’ whilst those rated as ‘Requires Improvement’ had marginally reduced. In respect of the Trust’s position, the Trust had been rated as ‘Requires Improvement’ for the well-led domain which was expected given the current organisational challenges. In terms of how regulatory bodies looked at well-led, the Director advised that the CQC used the well-led framework in their inspections and regulatory activity whilst NHS Improvement used it in their oversight/regulation and to support improvement in trusts. In terms of how a developmental review was distinctive, the Director confirmed that it was considered good practice to have an externally facilitated review every three years. Rather than assessing current performance, these reviews should identify the areas of leadership and governance of organisations that would benefit from further targeted development work to secure and sustain future performance. As part of the review, three reports had been produced: report findings, committee review report findings and a summary of development themes. The Director provided an overview of the Key Lines of Enquiry (KLOE) that were covered during the developmental review using the well led framework and also provided some of the feedback received from external stakeholders. It was noted that whilst the Trust faced tremendous challenge it was felt that it was moving in the right direction. KLOE 1 – Leadership, Capacity and Capability: The Director confirmed that there were some roles still to be recruited to and consideration would need to be given to more clinical representation on the Board. In addition, a leadership development programme for clinical leadership and non-clinical management was essential. The Director confirmed that there was an understanding of the importance of visibility of the Board and a commitment to improving the current mechanisms by which visibility was delivered. Lorena Dumitrache, Governor, joined the meeting KLOE 2 – Vision and Strategy: It was recognised that the Trust was developing a new Corporate Strategy and there was recognition that the alignment of mental health and community services had not been fully exploited. Tensions were also identified at network and system level regarding the pressure that the strategic lack of clarity was creating.

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UNCONFIRMED

The Director referred to the Trust’s values and confirmed that the Board and network leaders believed that the values were not well understood and embedded and was an opportunity for these to be to refreshed. KLOE 3 – Responsibility, Roles and System Accountability: Board meetings were well chaired with evidence of good behaviours. A review of issues being presented to the private Board would, however, be beneficial. It was noted that committees of the Board were not working effectively and there was limited challenge in meetings. Feedback also indicated that there were too many meetings and inconsistency with how the governance structure of each network was currently established. Following observation of the Council of Governors, there was a range of good practice with regard to the involvement and engagement of governors, particularly with the Chairman. However, there were opportunities for improvement including more private session time and enabling of engagement with external constituencies. It was noted that Governors attended Part One of the Board meetings but also remained for Part Two, which was inconsistent with other organisations. A change in this area was therefore recommended as this was not considered common practice. KLOE 5 – Information: It was noted that the Trust had been awarded Global Digital Exemplar (GDE) funding and was building on the new integrated performance management report. Areas still be strengthened included the timeliness and flow of information between committees and the Board. Some of the workforce reporting was also problematic in terms of multiple systems and inaccurate reporting. One of the unintended consequences of this was the overreliance on local and manual systems. KLOE 6 – Risk and Performance: Leaders were able to describe the key risks that related to their areas of work and whilst the Board Assurance Framework (BAF) and corporate risk registers were routinely reviewed, this needed strengthening further. It was also recommended that due to the changes at Board level the Board should re-visit the concept of a risk appetite and signal it’s level of acceptance across its strategic risks. KLOE 7 – Engagement: An external communication and engagement plan for 2019/20 was in place, Listening into Action (LiA) was being well received but there was also recognition that stronger relationships needed to be established with the Third Sector. In respect of the staff survey, the Director highlighted that it was important upon receipt of the results that staff helped to inform the actions. In addition, there was significantly more focus required to change historic perceptions, although feedback received to date had been positive.

KLOE 8 - Learning and Improvement: There was a real commitment to be a learning organisation, a number of external reviews had already been commissioned and there was evidence of lessons learnt being applied. Areas to be strengthened included the use of benchmarking and embedding a quality improvement approach. Finally, the Director felt it important to highlight that organisations rated as ‘Outstanding’ also received a number of recommendations following well-led reviews and it was therefore important that that Trust did not lose sight of this.

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UNCONFIRMED

The Chair thanked the Director for presenting and confirmed that progress was already being made in some areas. Two new Non-Executive Directors were due to commence with the Trust in January 2020, one of which was extremely knowledgeable of mental health services whilst the other Non-Executive was a doctor who had also led at systems level. Following a question from a Public Governor regarding how the actions from the development review would be addressed, the Director advised against turning the recommendations into a single action plan but to embed the actions into already established action plans. The Director of Improvement and Compliance confirmed that there would be an opportunity to align some of the work that would need to be undertaken with the Council of Governors forward plan for 2020/21 and agreed to liaise with the Lead Governor in this respect. ACTION Following a comment from a Staff Governor regarding the dangers of solely focussing on the previous CQC action plan, the Chief Executive highlighted the importance of pulling actions together to ensure there was no duplication. The Director also highlighted the importance of prioritising what could be done before the CQC re-inspected the Trust.

The Director responded to a question from a Public Governor regarding AQuA’s view of service user input and highlighted the importance of engaging service users when undertaking service change and re-design. The Chief Executive also highlighted that the Trust wanted to move from engagement to real integration and was therefore considering having a service user and carer counsel and a bridge between the governing body and the Board. The Executive Director of Nursing also added that a number of discussions would be held with service users and carers and consideration given to what meaningful co-production would look like. Following the previous suggestion that Governors should not be in attendance during the private part of the Board meeting, the Director highlighted that the private part provided an opportunity to have some early debate around certain issues. The agenda should not be huge and the only people in attendance should be Board members. The Chair agreed to discuss this further with the Director of Improvement and Compliance prior to presenting a proposal to the Council of Governors outlining what would be considered private and public. ACTION A Public Governor raised concerns regarding the accessibility and timings of future Board meetings and requested that further consideration be given to this. ACTION

Cath Hill, Director left the meeting

Prior to the next agenda item, the Chief Executive took the opportunity to provide an update following the recent review of commissioning that had been undertaken by PriceWaterhouseCoopers (PWC). Whilst this was not yet in the public domain, verbal feedback had not been particularly complimentary. The Chief Executive confirmed that a new commissioner had been appointed on secondment from Blackpool and Fylde CCG with responsibility for commissioning Learning Disability (LD) and Mental Health. In terms of re-design, the Pennine Lancs pathway review had commenced and was progressing well.

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UNCONFIRMED

An update was provided regarding the provision of LD beds and it was noted that the Crisis Home Treatment Team were now providing a 24/7 service. The Trust had also committed to developing a small number of Frequent Attender Care Teams to manage frequent attenders and negotiations were underway to provide a further crisis house in Blackpool. There had been a reduction in Out of Area Placements (OAPs); however, during August and September this had increased again following the closure of the Mental Health Decision Units (MHDUs). Until the new bed provision was in place this would continue to remain a challenge for the Trust. In terms of LD services, the Chief Executive confirmed that NHSE had commissioned Moorhouses Consultancy to review current commissioned provision of LD services in Lancashire and South Cumbria, the findings of which had been shared with the key system stakeholders. In respect of the Trust’s model of clinical delivery, the Trust had been consulting and engaging with people with regards to moving to an ICP locality framework so that local services could be provided for local people. The Chair provided an update on recruitment and confirmed that in 2020 the Trust would be recruiting a Chief Operating Officer, a Director of People and OD, a Director of Digital and a Chief Finance Officer. It was noted that there was considerable improvement work taking place within the Trust which would result in the establishment of an Improvement Board from January 2020 which would obtain assurance with regard to the improvement activity across the Trust and would ensure that embedded improvements were sustained. Following a question from a Staff Governor regarding how the changes would be communicated to staff, the Chief Executive highlighted the various communication channels. These included ‘Chat with Caroline’, Listening into Action (LiA) and locality model re-design workshops. In addition, the newly appointed Director of Communications was due to commence with the Trust on the 06 January 2020 bringing a wealth of experience and energy. The Director of Improvement and Compliance responded to a question from a Public Governor regarding feedback from the Improvement Board and confirmed that a timeline of improvement would be presented to a future meeting of the Council of Governors. ACTION

COG/TB 005/19 VISION, STRATEGIC OBJECTIVES 2020-2021 The Chief Executive presented the proposed vision and strategic objectives and confirmed that the Board had spent time considering the Trust’s vision which should be quite inspirational and should be something that staff, stakeholders etc recognised as the direction of travel. Two options were presented for consideration: ‘to serve our local communities by excelling in everything we do together’ or ‘to be outstanding in serving our local communities’. A discussion ensued and a number of suggestions were put forward by the governors. The Chief Executive thanked the governors for their input and confirmed that further feedback would continue to be obtained.

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UNCONFIRMED

The Chief Executive drew attention to the Trust’s current strategic priorities and went on to provide an overview of the proposed strategic objectives (6S’s). The Chief Executive outlined the deliverables of each objective. David Curtis, Non-Executive Director joined the meeting In respect of the objective ‘service users will be at the heart of everything we do’, the Chief Executive confirmed that the Trust would strive for the highest standards of quality across the organisation and would deliver safe care, ensuring lessons were learnt to continually improve and innovate. With regards to the objective relating to staff, a People Strategy would be developed and health and wellbeing would be promoted across staff within the Trust. The Chief Executive referred to the objective ‘striving for the highest standards of quality across all of our services’ and highlighted the importance of this in respect of multi-disciplinary team working. With regards to ‘collaborating effectively with system partners’ a lot of work had been undertaken to develop the detail of when and how this would be measured. In respect of the final objective ‘we will be sustainable and deliver real value in everything we do’ the Chief Executive confirmed that the Trust was investing significantly in digital and highlighted that the Trust needed to move away from short term cost improvement programmes to long term transformation programmes. The next steps were outlined which included the agreement of the Trust’s vision and strategic objectives, the LiA work in developing values, the development of a brand, communicating across the Trust so people were clear on the Trust’s vision, values and strategic objectives, alignment with the Clinical strategy and enabling strategies and development of the Board Assurance Framework (BAF) to ensure visibility and scrutiny at Board. Following a question from a Public Governor regarding recruitment, the Chief Executive confirmed that the Trust had recently conducted a recruitment campaign in Cumbria which had gone fairly well. The Executive Director of Nursing and Quality was also conducting a staffing review of the wards which would be completed by the middle of 2020. The Interim Medical Director highlighted that nationally there was a challenge with recruitment; however, it was particularly challenging within the North West. It was unlikely that the Trust would fill all of its consultant posts but work was underway to improve the Trust’s reputation as a training trust for medics. There was also a focus on overseas recruitment.

COG/TB 006/19 CLINICAL STRATEGY UPDATE

The Director of Partnerships and Strategy alongside the Acting Medical Director were in attendance to provide an update on the Clinical Strategy. The Director of Partnerships and Strategy outlined a summary of the approach that would be taken that included understanding the context, consulting with the Trust’s stakeholders, articulating aspirations, delivery, and communication and engagement. An overview of the challenges, strategic aspirations, priorities and impact was also provided. In respect of engagement, the Board had received regular updates and two workshops had been held with the Trust’s clinical staff, which had been really well attended. Commissioners and GP leads had also been in attendance alongside service user

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UNCONFIRMED

representation, although it was recognised that further work was required to ensure true co-production with service users. Wider staff engagement was via an online platform (tricider) and social media. There would also be regular updates within ‘Team Talk’. Vicky Shepherd, Nominated Governor left the meeting It was noted that an update was due to be provided at January’s ‘Engage’ session and there were links with the LiA work. A final Big Engage event was also planned. In terms of engagement with wider partners, the intention was to engage with ICS leaders, Healthwatch, the voluntary sector, Public Health Directors and the Police. The Acting Medical Director presented the draft principles of service delivery and drew attention to staff development and how staff would work differently in the future. There would be a move to conditional roles that the Trust currently did not have, ie nurse consultants. The Trust would also ensure that staff were sufficiently supported so they had time to reflect and were resilient and had coaching and mentoring. Interaction with services users had been a big theme and in respect of developing the Trust’s care pathways, work was underway with NTW commencing in East Lancs. There needed to be a strong focus on prevention and whilst the Trust was not commissioned to provide a prevention programme, it was still considered really important. The next steps were outlined which included engaging external support to develop the intent and vision for our clinical services.

A summary of the engagement conversations with Non-Executive Directors was provided alongside the strategy development timeline.

Following a question from a Public Governor regarding funding, the Acting Medical Director confirmed that the Chief Executive had been in discussions with commissioners in respect of additional funding. The Director of Partnerships and Strategy also highlighted that additional funding was set out nationally in the Long Term Plan. The Chair thanked the Director of Partnerships and Strategy and Acting Medical Director for presenting to the Council of Governors.

COG/TB 007/19 ANY OTHER BUSINESS The Chair noted that both the Interim Company Secretary and the Director of Partnerships and Strategy would shortly be leaving the Trust and on behalf of the Board and the Council of Governors, thanked them both for their valued contributions to the Trust and wished them well in the future. There was no other business to be discussed.

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Report Title Chief Executive’s Report

Prepared By Caroline Donovan, Chief Executive

Presented By Caroline Donovan, Chief Executive

Action Required Noting


PURPOSE OF THE REPORT: Report Purpose The purpose of this report is to provide Board members with

an overall summary of the Trust position and highlight areas for further discussion and celebration.


To provide high quality services

Board Assurance Framework Risk 2.0 The Trust does not deliver safe, appropriate and therapeutic environments to deliver high quality services

CQC Domain Well-led INTRODUCTION

This report updates the Board on activities undertaken since the last meeting and draws the Board’s attention to any other issues of significance or interest.

Local Updates BOARD ACTION: Noting

1. CQC UPDATE

The Trust continues to prioritise delivery against the CQC actions and a focused Steering Group continues to meet monthly to ensure that assurance is gained against actions. This is supported by the quality review process that has been put in place by the Director of Improvement and Compliance. The CQC Action Plan report on the Board agenda provides more information on the current position against the plan. We responded to the CQC enforcement notices on 30 December 2019 and positive feedback has been received from them about significant progress being made. The CQC has requested additional information and an unannounced visit was carried out at the Health Based Place of Safety at The Harbour in Blackpool in January. We are expecting formal feedback about this and will update the Board in due course.

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2. LEARNING DISABILITY (L&D) FOCUS AND IMPROVEMENT PLAN

The Board will be aware that NHS England commissioned Moorhouses to review provision of L&D services in Lancashire and South Cumbria. This work continues to support the system. Additional funding has been secured to work in collaboration with Merseycare to pilot an intensive support function to help reduce admissions. Whilst the pilot is a joint venture, the Trust maintains a clear aspiration to be the prime provider of learning disability services in Lancashire and South Cumbria. The first meeting of the Learning Disability Improvement Board took place on Friday 31 January and will provide regular updates to the Board on progress. The Trust and the system continues to be under significant scrutiny from NHS England and Improvement in relation to inappropriate out of area placements for mental health and learning disability patients. Dialogue will continue at a system level in the short to medium term until sustained improvements are obtained. Representatives for the Trust and the system also attended the regional and national meeting for mental health and learning disabilities on 29 January 2020 to discuss a broad range of strategic system issues. The following key issues remain at the forefront of our work: • We have no commissioned specialist rehabilitation beds within the Trust • We have no commissioned assessment and treatment L&D beds within the Trust • This factor is having a significant impact on our use of out of area (OAPS) treatment beds In addition the following improvement should be noted: • We continue to invest heavily in community alternatives and have made significant progress in a number crisis pathways, in particular 24/7 crisis/HBT teams, expanded Mental Health Liaison Services, an expanded mental Health Advice line and bolstering of the work of Frequent Attenders Teams – which are all contributing towards a more robust community offer • Plans are in place to increase bed capacity with the development of a new rehabilitation facility at the Avondale Unit. We are also working with the Richmond Fellowship to provide more Crisis House provision within Blackpool (see item 3 below). We have also seen improvements in the following areas: • A reduction in 12 hour breaches • A reduction in section 136 breaches • We are focusing on patient ‘flow’ to ensure people don’t stay in beds longer than they need and that they can be discharged into appropriate alternatives in a timely way. 3. CRISIS CAFÉ & CRISIS HOUSE Supporting people in mental health crisis continues to be a priority and, as noted above, there have been developments within the last six months for those in need of urgent help. In addition to increasing staffing and the operating hours of our home treatment teams to run 24/7 we have also continued to work with partners to put innovative solutions in place.

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The Trust’s on-going partnership with Richmond Fellowship will see another crisis house opening and a new crisis café has also opened. Both of these developments are in Blackpool. The Light Lounge café opened in January and is located at Blackpool Centre for Independent Living on Whitegate Drive, Blackpool. The Trust is working with Richmond Fellowship to provide the service from 4pm until midnight with the Home Treatment Team also providing input. The café will provide a safe environment for people requiring emotional and psychological support that may or may not be attributed to a mental health need. Following the ‘soft launch’ of the service in January it will continue to be reviewed to inform future development and expansion of its operating hours. The Blackpool crisis house will be open from April 2020 and will be delivered by Richmond Fellowship in a centrally located residential property, staffed by a team of mental health support workers and a service manager. The service will offer a holistic support package that considers the individual’s housing, employment, educational, physical, social and emotional needs, supported by appropriate medical intervention from the Crisis Team. The Trust already has two crisis houses, which have proved to be very effective in supporting people, therefore this additional facility in Blackpool is a welcome addition. The crisis house model provides short-term (up to seven days) intensive 24 hour, specialist mental health support to people who are assessed by the local Crisis Intervention and Home Treatment Teams as needing additional support to avoid admission to hospital. 4. SOUTH CUMBRIA UPDATE

A report from the Chair of the South Cumbria Assurance Committee is included on the agenda but work continues to implement the Post Transaction Implementation Plan (PTIP). New actions are being added to utilise it as a service development plan. The CQC actions continue to be delivered and there is a regular weekly meeting that takes place to maintain focus on the actions. The CQC actions and the PTIP have been cross checked to ensure consistency.

Positive and safe training is planned for all inpatient staff Additional clinical role of Interim Matron has been agreed for South Cumbria Agreement to commence schedule of works across inpatient sites from 24 February 2020,

ensuring minimal disruption to patients New Adult Psychiatrist commenced for Kendal with another psychiatrist planned to start in

March and discussions ongoing regarding the appointment of a third psychiatrist CAMHS psychiatry continues to be fragile

Good relationships with the Clinical Commissiong Group (CCG) and other stakeholders continue to be developed. The Trust has agreed to a Bay Development Group that will focus on the services within The Bay and prepare for the new Bay Locality. 5. LISTENING INTO ACTION In January all LiA triumvirate leads were asked to attend an event marking the ‘half-way’ point to share the progress made so far in the delivery of our priority actions. The passion, pride and

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enthusiasm displayed for the improvements shown by all teams shone through and feedback has been really positive about this initiative. Plans for the ‘Pass It On’ event scheduled for March 23 are under way and Board members will be invited to this. The LiA team have welcomed feedback from the triumvirates on what has worked well within sponsor groups and what challenges they have faced. This feedback will inform the information pack that is being developed to support the next wave of LiA teams. It serves to provide clear guidance on the role of the triumvirates to support sponsor groups to run and provide clarity on what we are setting out to achieve. Monthly drop in sessions have been established to enable triumvirates to share good practice and learn from each other which are proving to be beneficial. One area that received support and positive feedback was the ‘advent’ campaign highlighting the positive impact that the new equipment has had on care delivery. On-going engagement continues with the fortnightly newsletter and LiA change champions continue to support clinical leads to embed staff led change. The third Change Champions event took place at the end of January. Planning for wave 2 of LiA is underway and the teams that will join the programme from April are being identified. Discussions are also on-going with Optimise as we approach the end of their contracted 12 months and determine the future delivery of LiA. 6. ICS & TRUST STRATEGY UPDATE

We have contributed to the final Lancashire and South Cumbria ICS five-year strategic plan which was submitted to the ICS Senior Leadership Executive (SLE) in December. The SLE acknowledged the need for a consistent and robust approach to working together to plan and address the structural and operational inefficiencies that span both health and social care, and which are largely responsible for driving the system’s financial deficit, at their meeting in December. National operational planning guidance for 2020-21 from NHSE/I is expected to be published imminently and the Trust has preparations in hand to meet the requirements of this guidance. Operational planning for 2020-21 will form the basis for delivery of the ICS 5-year strategy. The Trust has previously stated its expectations in relation to both the Mental Health Investment Standard, as well as national funding that is to be distributed to each ICS for mental health as part of the Long Term Plan, these will continue as part of the 2020-21 planning round. Aligned to this is the continuing work to the refresh of the Trust strategy and we have appointed Elliott Blanchard to support delivery of this, with an initial focus on the development of our Clinical Services Strategy.

7. FLU UPDATE

The Trust’s Infection and Prevention Control Team continues to vaccinate our teams to ensure staff wellbeing and patient safety over winter. There has been a significant increase in cases of flu in recent weeks affecting schools, care homes and hospitals.

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Within the Trust, there has been some ward closures due to flu which have been well managed by frontline colleagues. It is vitally important that as many frontline employees as possible are vaccinated as a means of preventing infection in our services and ensuring that we are keeping the most vulnerable members of the population safe. Evidence to date shows that the vaccine this year is a good match for the circulating strain in the community. Every effort has been made to ensure that employees can get their vaccination flexibly at various locations and these have been well advertised. Peer to peer vaccination is also in place and flu vouchers have been issued so people can get vaccinated in their own time too. Over 76% of frontline staff have been vaccinated and 3,330 (63% of all staff) in total. The target set by CQUIN and agreed with commissioners is 80% which was achieved in Southport & Formby. 8. NATIONAL EARLY INFLAMMATORY ARTHRITIS AUDIT An internal audit against the standards of the national early inflammatory arthritis audit indicates significant improvement in quarter three, with an improvement from 41% compliance to 76%. It is worth noting that the service was flagged as a national outlier in quarter one this year, reaching a compliance rate of just 8% at the time. This in year progress gives assurance that the agreed improvement plan has been effective. 9. MOVING WELL SERVICE SHORTLISTED FOR NATIONAL AWARD The Central Lancashire Moving Well Service has been shortlisted in the British Society for Rheumatology’s 2020 Best Practice Awards. The service provides an integrated model of care with a special focus on prevention and early intervention. The team prides itself on involving patients in discussions about their care and their nomination demonstrates how the team has embedded a method of shared decision making across the service. Shared decision making ensures that individuals are supported to make decisions that are right for them. It is a collaborative process through which a clinician supports a patient to reach a decision about their treatment. The conversations bring together the clinician’s expertise, such as treatment options, evidence, risks and benefits and what the patient knows best, their preferences, personal circumstances, goals, values and beliefs. 10. HIGH PERFORMING EATING DISORDER SERVICE

The Trust’s All Age Eating Disorder Service scored very positively in a national assessment carried out by the Quality Network for Community Child and Adolescent Mental Health Services (QNCC). The peer review found that the Trust’s Eating Disorder Services scored high on all 10 sections of the QNCC service standards at over 95%. This is a great achievement and the team are rightly very proud. The QNCC is run by the Royal College of Psychiatrists to assess Child and Adolescent

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Mental Health Services and Eating Disorder Services across the country with the aim of improving service quality. The review involved staff, young people and their parents and found that the service has a well-structured, organised team that works cohesively to meet the demands of people. The staff team work well together and are driven to support the needs of young people. Parents and carers also said that staff will go above and beyond to support them and that the team will make every effort to ensure parents and carers are supported by phone and email. 11. GOLD STANDARD FOR BABY FRIENDLY INITIATIVE The Trust’s Blackburn with Darwen 0-19 universal service has achieved the Gold Standard for the Unicef Baby Friendly Initiative. The verbal feedback was that the service is exemplary at a national level. This is a fantastic achievement and the team should be very proud of the work they are doing.

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National Updates BOARD ACTION: Noting

12. MENTAL HEALTH FUNDING & INVESTMENT

A new briefing has been published, Mental health funding and investment: A digest of issues, which explores the financial and investment challenges facing mental health trusts, including their current financial position, the impact of stigma on investment in mental health provision, how mental health services are commissioned, contracted and paid for, and the transparency and governance of funding flows. It sets out a number of solutions to the financial problems mental health trusts face. The report highlights that whilst there has been increased investment in recent years to deliver on aspirations to improve quality and access, many mental health leaders still face significant challenges that need to be addressed. The briefing sets out what the sector needs to address the financial problems and deliver better outcomes for service users including: improved and transparent mechanisms that guarantee that mental health funding reaches

frontline services that need it most clear expectations around delivering on national investment and initiatives for

CCGs/STPs/ICSs to deliver against, which are tightly monitored and enforced meeting capital investment needs so that urgent improvements can be made to estates further progress on data collection and data quality to give a better understanding of mental

health activity, access and outcomes that can then enable better commissioning greater understanding within STPs/ICSs/systems of the mental health and wellbeing needs of

local populations to ensure mental health service delivery is prioritised accordingly national policy must focus on increased support for both mental health and public health less fragmented approaches to commissioning and a reduction in the frequency of retendering expansion and roll out of mental health new care models that are adequately funded and

resourced.

The full briefing can be accessed here. As referenced earlier in this report, the Trust has previously stated its expectations in relation to both the Mental Health Investment Standard and national funding. During 19/20 the Trust has received £10.9 million of additional funds, including £5m from the Integrated Care System. This has enabled some of the key elements of our mental health improvement plan and we continue to have constructive dialogue with system partners to secure the on-going funding to fully deliver the plan and sustain the improvements. Funding for next year is still to be confirmed with the plan including additional income of £30m across a number of programmes.

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https://nhsproviders.org/media/689015/mental-health-funding-and-investment.pdf?utm_campaign=240156_Mental%20health%20funding%20briefing&utm_medium=email&utm_source=NHS%20Providers%20%28Policy%20and%20networks%29&Organisation=Lancashire%20and%20South%20Cumbria%20NHS%20Foundation%20Trust&dm_i=52PX,55B0,13C7J6,IJNK,1

13. SOCIAL CARE REFORM STRATEGY Prime Minister Boris Johnson has committed to publish a social care reform strategy this year, with the caveat that its impact may not be felt for five years. He has committed to bringing forward a proposal later this year and "getting it done" by the end of the current parliament. This announcement has been welcomed by NHS Providers with Deputy Chief Executive, Saffron Cordery welcoming the planned proposal. She has commented about the strain the social care system has been under this winter which in turn has an impact on the health service with patients then paying the price. NHS Providers have urged the Government to make social care reform a top priority, emphasising that the NHS and social care are "two sides of the same coin". 14. EXTRA FUNDING PLEDGE Health and Social Care Secretary, Matt Hancock has set out the NHS Long Term Plan Funding Bill to Parliament. The bill will protect in law an extra £33bn every year by 2024 for the NHS to transform care. The bill will contain a 'double-lock' commitment that places legal duty on both the secretary of state and the Treasury to uphold this minimum level of NHS revenue funding over the next four years. 15. WINTER PRESSURES

Figures released by NHS England and NHS Improvement indicate that the acute sector has been under increasing pressure in its emergency departments during the winter months. In December, 79.8% of patients were seen within four hours in A&E last month compared with 81.4% in November. Nationally, the pressure is also being felt across mental health trusts, community services and the ambulance sector with ambulances responding to more incidents than ever before in December. Within the Trust, the delivery of the mental health improvement plan serves to ensure that the Trust is providing a responsive service to mental health patients that present in A&E. We have seen an overall reduction in the number of breaches and the number of people being taken to a place of safety (136 suite) has reduced due to improved partnership working with the police and extended services to support people in crisis going live. Within our community wellbeing network, teams continue to work really hard to support people at home, avoiding hospital admittance when possible. 16. QUARTER OF YOUNG PEOPLE WITH MENTAL HEALTH REFERRAL REJECTED

Research by the Education Policy Institute (EPI) estimated that more than 130,000 of those referred to specialist services in 2018-19 were "rejected". This represents one in four children and young people referred to mental health services in England last year not being accepted for treatment. This has raised concerns that many are failing to get vital support at an early stage.

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The EPI has asserted that rejection rates have remained unchanged over the last four years, despite government commitments to address shortages in child and adolescent mental health services. NHS England has challenged the analysis undertaken by EPI and countered that it cannot be assumed that every referral should result in NHS treatment, when support might be provided elsewhere, for example from schools and local authorities. Since April the Trust has received 3837 referrals to our CAMHS teams of which 2866 (74.7%) were accepted. We have also supported the development of the Thrive model across Lancashire and South Cumbria to improve access for children, young people and their families.

17. HEALTHWATCH REVIEW OF COMPLAINTS Healthwatch England has undertaken an analysis of complaints across 149 hospitals which has resulted in a recommendation for a new national organisation with powers to set standards on the handling of patient complaints. Under current legislation every hospital is required to collect and report on the number of complaints they receive, what they were about and what action has been taken. However, only 12% of Trusts were found to be compliant. This has led to Healthwatch flagging that a lack of transparency on what Trusts are doing means it is impossible to judge how well complainants were being treated. At LSCFT we are committed to ensuring that all complaints are handled thoroughly and appropriately with any learning shared. A review of the Trust’s complaints handling has been undertaken and more detail is provided in this pack. 18. FESTIVAL OF HEALTH

A ‘Festival of Health’ is to take place in Manchester during September. Organised by Dods, it will be the UK's largest population health event. It is being supported by NHS Providers with the intention of providing a platform for health and care providers across the whole system to come together, share learning and overcome challenges. Increasingly Trusts are using collaboration and innovation to progress shared agendas in relation to integrated care, improving health outcomes and empowering people. This event serves to bring providers together to network and share goals across the NHS, government, local authorities and the wider system.

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Report Title Finance and Performance Committee Chairs Report

Prepared By Natalie Gauld, Executive Personal Assistant

Presented By Isla Wilson, Chair of Finance and Performance Committee

Action Required Assurance


PURPOSE OF THE REPORT: Report Purpose To provide an outline of the activity undertaken by the

Finance and Performance Committee on the 17 January 2020, highlight assurance received and risks identified.



Board Assurance Framework Risk 3.0 The Trust does not have the ability to address and meet service demands which is affected by uncertain and limited commissioning arrangements

7.0 The Trust does not achieve financial performance sufficient to maintain resilience and sustainability

8.0 The Trust does not achieve the required efficiency savings whilst delivering and improving quality

9.0 The Trust does not exploit the full capabilities of technology and fails to achieve the desired benefits to improve quality of care and data

10.0 The Trust does not identify and maximise new innovations to transform services and improve care

CQC Domain Well-led 1.0 INTRODUCTION

This Chair’s Report outlines the activity undertaken by the Board level Finance and Performance Committee held on the 17 January 2020.

2.0 BOARD ACTION The Board of Directors is asked to note the content of the Chair’s Report for assurance

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MEETING: Finance and Performance Committee DATE: 17 January 2020

RISKS: (including actions to address gaps in controls rated red) RISK

SCORE 3.0 The Trust does not have the ability to address and meet service demands which is affected by uncertain and limited commissioning arrangements

12

7.0 The Trust does not achieve financial performance sufficient to maintain resilience and sustainability 15

8.0 The Trust does not achieve the required efficiency savings whilst delivering and improving quality 15

9.0 The Trust does not exploit the full capabilities of the new EPR system and fails to achieve the desired benefits to improve quality of care

12

10.0 The Trust does not identify and maximise new innovations to transform services and improve care 16

AGENDA ITEM COMMITTEE ACTION IMPACT ON

BAF RISK (If applicable)

Chairs Reporting Board Assurance Framework No new risks were noted and the risk scores remain appropriate. Positive improvements in assurance against risks was noted, however it did not feel appropriate to change the scores, and monitoring of progress will continue.

No action noted. All BAF risks

Infrastructure Sub-Committee Chairs Report The report contents were noted by the Committee. The chair received assurance in relation to the Nicotine Management Action Plan, which is reviewed monthly at the Nicotine Management Group, however it was felt more appropriate for this to be monitored within the Quality Committee for oversight.

The Committee noted the update. The Nicotine Management Action Plan to be monitored by the Quality Committee.

BAF risk 12.0

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AGENDA ITEM COMMITTEE ACTION IMPACT ON BAF RISK (If applicable)

HSIS Board Chairs Report The report contents were noted by the Committee. Key issues were highlighted which included OCS and equal pay which may arise at the contract renewal date of July 2020. A further conversation at Board is to take place regarding changing the terms and conditions of the contract.

The Committee noted the update.

n/a

Finance and Performance CIP Update It was noted that 3 of the networks have delivered less than 70% of the schemes identified and additional support is being given. The networks have started to review 2020/2021 figures with the first draft being submitted to NHSI in January 2020. The internal target agreed is £12m with costings so far of £11.2m identified. Moving forward the CIPs will become a transformational plan with a structured timescale, and producing network outputs.

The Committee noted the contents of the report. The Executive Director of Partnerships and Strategy to update in due course to the committee.

BAF risk 7.0, 8.0

CQUINS Delivery A short term action plan have been completed and will be reported to the executive team on a monthly basis following a review of the delivery of CQUINS process. A loss of £273k has been reported, however other improvements have been made. Issues were noted with regards to RiO and the collation of data required. A contract discussion will be taking place with the whole team to gain understanding of the issues.

The Committee noted the contents of the report.

BAF risks 7.0 and 8.0

Cash Flow Reporting The Committee was assured that the cash position has improved, but there remain significant risks in the mid/long term position if we fail to improve financial performance.


BAF risk 7.0

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Aged Debts The Committee was assured that the aged debts position had improved, following a deterioration in the last quarter largely due to OAPS and stranded patients. Discussions are underway with Commissioners.

The Committee noted the contents of the report and will be updated at the next meeting following commissioner discussions.

BAF risk 7.0

IFSR16 Impact The Committee were updated on a change relating to operating lease rules. A further update will be given at the Audit Committee once more information is received.

The Committee noted the information.

BAF risks 7.0

Use of Resources Plan Progress Assurance was received regarding the work being progressed with OAPS and bank and agency usage. It was agreed that the report is useful to prompt departments and is also discussed at the Audit Committee.


BAF risks 7.0

Health Informatics Update The Committee received assurance regarding progress with the GDE programme, following on from a formal funding assurance review which recently took place. The Trust has now moved from an amber plus rating to green and our report will be submitted to NHS Digital. A figure of £2.2m will be drawn down at the end of this month. Committee noted assurance on current delivery, and notes risks highlighted. Outstanding actions relating to the pace of Digital, the transformation potential and the level of resourcing remain, but will be picked up following appointment of a new Director of Digital Work is ongoing with the clinical networks regarding the go live of RiO in Pennine Lancashire and readiness assessment are in place to ensure we are clinically safe for the system to transfer.


BAF risks 9.0 and 10.0

ICS Financial Framework As a collective system, the control total is being reported as being achievable, however an £18m issue has been flagged and there is a £52.5m gap from the combined control total. Conversations


BAF risk 7.0 and 8.0

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are taking place with provider trusts and we are expecting more oversight and governance going forward. HR Overpayments The workforce system is not being completed in time which is therefore causing a delay in the system, resulting in overpayments to staff. Improvements have been made with the systems and training to staff. A report will be circulated for feedback from committee members.

The members of the Committee were asked to provide feedback on the workforce report and its usefulness.

BAF risk 9.0

Pensions Assurance A verbal update was provided regarding the cost implications of recruiting members of staff who are due to retire in 3-5 years. A discussion took place regarding the legality of this and it was agreed there was no further actions that could be taken by the Trust.

No action noted. BAF risk 9.0

Social Value Assurance was provided regarding progress with the Trust’s social value account. Research has been completed regarding how services report social value and a structure is being looked into of how to present the information with themes. A workshop is to be arranged to work through information and focus on what we want to publish next year. An update will be presented to the next Finance and Performance Committee.

Committee members agree to structure the social value reporting on the TOMS model, taking in Political, social, economic and ecological impact, and with a focus on where we make the largest impacts.

BAF risk 5.0

Carbon Reduction Progress Assurance was provided regarding our achievement of the Trust’s carbon reduction target and the 1% gap to achieving next year’s target. A training package will be pulled together for managers so that we can encourage reduction. Space utilisation has impacted on improvement and also the LED lighting funding achieved will also help improve our figures.


BAF risk 8.0

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Report Title Audit Committee Chairs Report

Prepared By Viv Prentice, Deputy Company Secretary

Presented By Debbie Francis, Chair of Audit Committee



PURPOSE OF THE REPORT: Report Purpose To provide an outline of the activity undertaken by the Audit

Committee on the 24 January 2020, highlight assurance received and risks identified.



Board Assurance Framework Risk N/A


This Chair’s Report outlines the activity undertaken by the Board level Audit Committee held on the 24 January 2020.


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MEETING: Audit Committee DATE: 24 January 2020

PART ONE AGENDA ITEM COMMITTEE ACTION CLINICAL, INTERNAL AND EXTERNAL AUDIT Internal Audit Progress and Follow Up Reports The following internal audit reports had been finalized during Q3: CQC Warning Notice Action Plan, HR KPIs, Risk Relapse Plans, Sickness Management and EPR Programme. HR Key Performance Indicator: Moderate/Limited Assurance A split opinion was issued. In relation to KPI data production, consistency, timeliness and validation, the Trust received moderate assurance. In relation to governance and the control, management and monitoring of HR KPIs, the Trust received limited assurance. To address the issues identified, the following actions would be taken:

Migration of several systems to ESR and work was being undertaken with finance to align establishments.

The People and Culture Strategy was under development and would align to the Trust Strategy and Clinical Strategy.

The People & Culture Committee had been established with the first meeting due to take place on the 24 February 2020.

Sickness Management Review: Limited Assurance There was four high risk recommendations identified. A key issue identified was the need for robust management of short term/frequent absences and of long term sickness. A Managing Attendance Policy was in place but this was not consistently applied and communications around this was required. The Managing Attendance Policy was under review and further training was being considered in order to refresh manager’s responsibilities.

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AGENDA ITEM COMMITTEE ACTION Regular audits would be undertaken to spot check where there was frequent long term sickness absence. Reports with limited assurance, particularly where there was an operational impact, would be presented to the SLT meeting in order to triangulate some of these issues at operational level. CQC Warning Notice: All actions validated as completed. MIAA had undertaken a review of a sample of the CQC warning notice actions that had been agreed and had confirmed all actions validated as complete by the Trust, completed. There was, however, scope for additional action to be taken to improve assurance and sustainability and mitigate further risk. Risk Relapse Plans: Limited Assurance Following management approval of the report, it was identified that some records had not been reviewed by the auditors which could possibly change the outcome. An additional review taking into account the additional information would therefore be undertaken and reported to the next meeting. EPR Programme: Substantial Assurance The review identified a number of areas of good practice and received substantial assurance with three medium recommendations which related to the availability of key personnel and implementing lessons learnt, which management had taken on board. 2019/20 Audit Plan Changes The Committee agreed that the risk management internal audit was deferred to 2020/21 as a large proportion of the work had been covered by the AQuA Well-Led Review. The Policy Framework System had been identified as a priority and would replace the risk management audit for 2019/20.

The Committee noted the findings and it was agreed that the recommendations from the initial report would be acted upon until the revised report was received, thereby avoiding delay. The Committee agreed to the proposed audit plan change.

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AGENDA ITEM COMMITTEE ACTION Internal Audit Follow-Up Summary Report In respect of the outstanding 2017/18 Clinical SLA audit recommendations, it had been agreed that the implementation of the Contract and SLA management system would support the completion of these actions. Internal Audit Effectiveness Review The Committee received an overview of the findings of the 2019/20 MIAA internal audit effectiveness review. Lots of areas of good practice had been identified; however, further visibility at the Committee was needed as to how both auditors worked together to carry out the audit work for the organisation.

The Committee noted the findings of the review.

Anti-Fraud Update The Committee received an update regarding the National Fraud Initiative (NFI). Matches were being investigated, the results of which would be input into the NFI portal. The revised Code of Conduct was currently awaiting final sign off. The Anti-Fraud Bribery and Corruption Policy had also been updated. MIAA had provided advice in response to five queries regarding potential fraud during the quarter, none of which had resulted in investigation. The Trust was required to comply with the requirements set out in the NHS CFA’s Standards for Providers which would be completed at the end of April. It was anticipated that the Trust would be rated as compliant against each area.


Draft External Audit Plan 2019-20 The Committee received the draft audit plan. The Committee received an overview of the significant risks in the audit plan and received assurance that these were being managed. There would also be a focus on the transfer of services from South Cumbria, Healthcare Support and Infrastructure Services (HSIS) and IFRS 16 Accounting for Leases.


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AGENDA ITEM COMMITTEE ACTION External Audit Technical Update The Committee received the update with no concerns to raise.


External Audit Effectiveness Review The Committee received an overview of the findings. Overall the Committee were satisfied with the service provided by the external auditors in line with the requirements outlined within the HFMA Audit Committee Handbook.

The Committee noted the findings of the review.

Clinical Audit Report The Committee received the Q3 update. Further improvement was required in relation to seclusion and risk assessments. The seclusion audit would be shared with the Care Quality Commission. It was noted that the risk assessment piece aligned to the risk relapse work that MIAA were concluding and that these two items would be tracked through the Quality Committee.

The Committee noted the level of assurance offered by the network priority audit programme and national audits. The Committee approved the un-amended Clinical Audit Policy and Procedure.

FINANCIAL MATTERS AND REPLATING REPORTING Breaches and Waivers Q3 There were no breaches noted during the quarter. Eight waivers were reported, none of which required further analysis.

The Committee noted the breaches and waivers reported for the quarter to 31 December 2019.

Losses and Special Payments Q2 There had been 19 losses and 12 special payments during the period. All the payments were within delegated limits and all payments had been made in accordance with Standing Financial Instructions.

The Committee noted the losses and special payments for the quarter to 31 December 2019.

IFRS 16 Leases – Implementation Progress Report The IFRS 16 is a new accounting standard which is being introduced for the reporting period commencing 01 April 2020/21.

The Committee noted the progress made and the plans in place to ensure the implementation of IFRS 16.

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AGENDA ITEM COMMITTEE ACTION In respect of the impact assessment (first cut), the Trust had submitted this to NHSE/I in accordance with the 15 January deadline and had reported it to the Finance and Performance Committee. Use of Resources Plan Progress The Committee were informed that the contracts had not been audited and KPMG would therefore ensure this was undertaken as part of the audit plan.


GENERAL CONTROLS AND COMPLIANCE CQC Action Plan Process The Committee received the updated position and noted that next year’s audit calendar would include a sense check of the process, scrutiny of the evidence and the ‘so what’. It was anticipated that this year’s inspection would take place in September 2020 and work was underway to ensure that actions had been embedded. In May/June 2020 services across the organisation would also be asked to undertake a self-assessment in readiness.

The Committee noted the implementation of the robust CQC processes in place and associated governance arrangements.

Outcome of the Niche Review The Committee received the findings and recommendations of the independent review together with an update on next steps. This included the commissioning of an external review of serious incident and safety processes, and also of the complaints processes within the Trust. The recommendations from this review would be considered in line with the other two reviews that had been commissioned and an integrated action plan developed and reported to the Quality Committee.

The recommendations from the review would be monitored by the Quality Committee.

Cyber Security Arrangements In October 2018 the Trust gained accreditation to the ISO27001 Standard for Information Security and in October 2019 successfully completed its annual “surveillance audit” in order to maintain the standard. The Health Informatics Department has also been working towards accreditation to the Cyber Essentials Plus (CE+) Standard.

The Committee noted the current assurance provided.

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AGENDA ITEM COMMITTEE ACTION The Trust is required to complete an annual Information Governance Self-Assessment via the Data Security and Protection Toolkit (DSPT). The Committee received significant assurance via MIAA that the 2018/19 submission met the required standard, and as part of the normal audit work plan, the 2019/20 DSP Submission would also be assessed.

An update on the progress with Cyber Security would be presented to each meeting of the Audit Committee.

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Report Title South Cumbria Assurance Committee Chairs Report

Prepared By Marion Fountain, Executive Personal Assistant

Presented By Louise Dickinson, Chair of South Cumbria Assurance Committee



PURPOSE OF THE REPORT: Report Purpose To provide an outline of the activity undertaken by the South

Cumbria Assurance Committee on the 29 January 2020, highlight assurance received and risks identified.



Board Assurance Framework Risk 4.0 The Trust does not ensure safe and effective transfer of mental health, CAMHS and learning disability services into the Trust


This Chair’s Report outlines the activity undertaken by the Board level South Cumbria Assurance Committee held on the 29 January 2020.


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MEETING: South Cumbria Assurance Committee DATE: 29th January 2020

RISKS: RISK

SCORE 4.0 The Trust does not ensure safe and effective transfer of mental health, CAMHS and learning disability services into the Trust 16

AGENDA ITEM COMMITTEE ACTION IMPACT ON

BAF RISK 4.0 (if applicable)

Action Tracker and Matters Arising A potential risk was previously identified in relation to historic Coroners’ cases. All Coroners’ cases are being monitored closely and there are currently 2 outstanding. External reviews have been commissioned by the Trust on the conduct of serious incidents and complaints. Visibility around governance and incident data for South Cumbria is required. Conclusions on Lessons Learnt and a review of the resulting Action Plan has been rescheduled to March 2020 to allow for feedback from staff The Committee will receive a comprehensive report in February on progress in improving the quality of key services The Committee did not receive the requested assurance of executive review of environment safety assessments and approval of associated capital risk mitigation plans. This will be provided in February.

The Committee is to receive highlighted SI and complaint themes and trends and be provided with an update of any historical issues at the next meeting in February 2020. The Committee rescheduled several actions to support improved assurance

4.0

Workforce Report The amended report was presented to understand headcount and budgets, highlighting the work being undertaken to mitigate the gaps and addressing the data gap previously identified.

The Committee will receive an updated report at the next meeting

4.0

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AGENDA ITEM COMMITTEE ACTION IMPACT ON BAF RISK 4.0 (if applicable)

The report is to be further broken down by staff group and position title for the next meeting. A summary table is to be produced capturing key themes and providing narrative where there are any hotspots. Average turnaround times for recruitment are also to be included. Pleasing to report the appointment of a psychiatrist. Disappointing that there are significant gaps in the CAMHS medical workforce – recruitment is ongoing and the redesign of THRIVE is being discussed with the commissioners. Ongoing issues with e-rostering with extra training undertaken. A lead nurse is guiding and supporting the teams and giving dedicated time to help sign off rosters 6-8 weeks in advance.

in February, with a breakdown of staff group and position title, a summary table capturing key themes and narrative together with average turnaround times.

Post Transfer Assurance Report Extensions for 8 out of the 14 CQC actions had been requested, mainly in relation to Kentmere. A number of Health and Safety Risk Assessments and Ligature Assessments have been repeated in this context. Clarification around the risk rating of 15 in relation to Risk 9973 (failure to see all services/records for a CYP caused by split of services 01.10.10 resulting in no oversight of child’s care) was sought. A risk meeting is to be held on 30th January to review all risks and re-grade, where appropriate. Issues were raised around the workforce data and training. The Trust’s Executive Group will receive a report highlighting the mandatory training data discrepancies requesting acceptance of the due diligence training records as a baseline position.

The Committee will receive an update on the PTIP at each meeting and on the decision regarding baseline training data

4.0

Performance Report The performance report had been presented to the Executive Group via the monthly performance meeting. A one page summary/exception report is to be included in the future,

The Committee will receive a one page summary, highlighting any

4.0

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highlighting any actions which have been addressed at the performance meeting. Performance across several indicators are below target (e.g. DTOC) and there remains a number of data gaps, particularly in relation to workforce matters (appraisals, supervision, mandatory training)

actions which were addressed at the performance meeting.

Estates and Capital Spend Update Disappointed to note that the works will take longer than originally planned and that the completion is now anticipated in July 2020. The works at Kentmere are now due for completion in March 2020. A review of the baseline assessment is to be undertaken by the repeated risk assessments noted above and short term strategies to mitigate the risks. Assurance was sought from the Director of Nursing and Quality that she is comfortable with the amended plan and new phased approach. A revised Gantt chart will be presented at the next meeting.

The Committee will receive the updated internal risk assessments and amended implementation Gantt chart together with confirmation that the Director of Nursing and Quality is assured of the amended plan and new phased approach.

4.0

Integration into the Bay Locality model An integration Board has been established to support progression with integration into the locality model.

The Committee would receive a comprehensive update on the integration into the locality model in February 2020.

4.0

South Cumbria Mobilisation Board Update The Director of Improvement and Compliance had attended the South Cumbria Mobilisation Board in December and provided assurance on the work undertaken by the Trust via the South Cumbria Assurance Committee Chair’s report to the Board. The Chair of the Mobilisation Board had requested “real time” information but she was comfortable with the progress made.


4.0

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Board Assurance Framework The Board Assurance Framework risk 4.0 would be updated as follows: Highlight the gap in the extension of the environmental deadlines to July 2020. Note the challenges around workforce, recruitment and mitigation. The Director of Improvement and Compliance has requested a trust-wide dormitory risk

assessment

The Committee agreed the additions.

4.0

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Report Title Improvement Board Update Report

Prepared By Louise Giles, Head of Transformation

Presented By Caroline Donovan, Chief Executive


Supporting Executive Director Director of Improvement and Compliance

PURPOSE OF THE REPORT: Report Purpose To set out the background to the formation of the

Improvement Board


To become recognised for excellence

Board Assurance Framework Risk 3.0 The Trust does not have the ability to address and meet service demands which is affected by uncertain and limited commissioning arrangements

CQC Domain Responsive to people's needs

1.0 Introduction This Board paper sets out the background to the formation of the Improvement Board and provides detail on its role and purpose. 2.0 Background There is a large agenda for the Improvement Board, over the coming year. There is a lot of different programmes of work currently being undertaken across the Trust and it is important that there is a forum to bring this work together to prevent duplication and ensure alignment with our developing strategies. The first meeting of the Improvement Board has been held and one of the first tasks was to ensure that everyone was clear about our approach to transformation and understands the activity currently underway. We are in a critical point of development within LSCFT with significant reputational, quality and workforce challenges. Following the Cumbria, Tyne and Wear (CNTW) system wide review and the CQC report, our transformation programme requires attention and focus as a matter of urgency; this is fundamental to address and ensure alignment to the clinical strategy and enabling strategies. Whilst a lot of work is currently underway, more needs to be done to bring it together and reduce the duplication and also to be able to articulate to our service users, their carers’, our staff and stakeholders what the future looks like and how we are going to get there. It is equally important that we recognise the ongoing operational and resource pressures across our organisation and, therefore, prioritise our activity to best effect. The current improvement work underway is outlined in Appendix 1.

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3.0 The purpose of the Improvement Board The Improvement Board has been set up to oversee the transformation of our services through a Quality Improvement (QI) methodology, including steering the Trust through the organisational and cultural development needed to support a culture of QI and learning, directing the implementation of training and development of staff; and overseeing key transformation projects. Please see Appendix 2 for the Terms of Reference.

It is our intention to use the Improvement Board as the vehicle to take the range of work undertaken to date and shape it in to a coherent strategy for our services.

The Board will gain assurance on the relevant improvement action plans that fall within the remit of the Board, which include:

Pathways Redesign: this will include the Mental Health Improvement Plan, Bed Management work, community access and treatment pathway redesign, Getting It Right First Time (GIRFT) and Digital Transformation.

Listening into Action: oversight on the initial programmes selected by staff at the Trust and next steps.

Quality Improvement: reviewing the Trust’s Quality Improvement agenda, overseeing agreed Quality Improvement collaboratives across the Trust.

CQC Action Plan: oversight of delivery of the CQC action plan, and the improvements required.

The Improvement Board will, therefore, be responsible for:

• Shaping and directing our approach to working with CTNW to implement a QI methodology across our Trust, overseeing the structure, timing and scope of the training roll out.

• Shaping and directing our approach to organisational and management development to support a culture of QI throughout the Trust.

• Overseeing our major transformation projects, making sure we are prioritising capacity to best effect, including oversight of our partnership with CTNW.

• Ensuring that implementation of both training and transformation projects is as fast as it can be whilst making sure we fully engage staff, service users, carers and other stakeholders to get it right.

• Overseeing our major trust wide projects of work supporting strategic change and QI. • Ensuring there is a robust communication and staff engagement plan in place to support our QI

and transformation projects.

4.0 Decision required The Board are asked to note the establishment of the Improvement Board and will receive updates throughout the year.

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Appendix 1- Improvement and Transformation work underway within the Trust

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Appendix 2: Improvement Board Terms of Reference

PURPOSE

The purpose of the Improvement Board is to obtain assurance with regard to all the improvement activity across the Trust and ensure that we have sustained embedded improvements that are delivered in line with the Trust’s Clinical Strategy. The Board will gain assurance on the relevant improvement action plans that fall within the remit of the Board, which include:

Pathways Redesign – this will include the Mental Health Improvement Plan, Bed Management work, community access and treatment pathway redesign, Getting It Right First Time (GIRFT), Digital Transformation and any associated cost improvement programmes.

Listening into Action - oversight on the initial programmes selected by staff at the Trust and next steps.

Quality Improvement – reviewing the Trust’s Quality Improvement (QI) agenda, overseeing agreed Quality Improvement collaboratives across the Trust.

CQC Action Plan - oversight of delivery of the CQC action plan and the improvements required.

The Improvement Board will submit regular reports to the Board of Directors and Executive Directors Group, reporting progress and risks to successful implementation of relevant plans and any areas that require further action.

The Improvement Board will oversee transfer of programme and project outputs to ensure they are transferred from the relevant plans to the Trust’s ‘business as usual’ management and governance structure. The Improvement Board will ensure that associated improvements and learning are embedded and will support the ongoing development and improvement of the Trust on a longstanding and sustainable basis.

DUTIES AND RESPONSBILITIES

Overseeing all major transformation projects, making sure we are prioritising our improvement capacity to best effect, including oversight of the Trust’s strategic partnership with Cumbria Northumberland, Tyne and Wear NHS Trust (CNTW).

Shaping and directing our approach to implement a continuous improvement strategy across the Trust, overseeing the structure, timing and scope of the training roll out.

Shaping and directing the approach to organisational and management development to support a culture of improvement throughout the Trust.

Ensuring that implementation of both training and transformation projects is implemented at pace whilst making sure we fully engage staff, service users, carers and other stakeholders to ensure the improvements are effective and sustained.

Ensuring there is a robust communication and staff engagement plan in place to support all our improvement projects.

Identifying and reviewing key issues and risks that may prevent or delay the achievement of associated action plans, gaining assurance that they are being appropriately logged, managed and mitigated.

Receiving escalation reports where viability of key deliverables is considered to be at risk and advice on contingencies.

Co-ordinating with other internal action plans to ensure consistency and that there are no conflicts or duplications.

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Utilising benchmarking data to improve our services, to understand and compare services and their outcomes and to promote best practice by using a range of comparative information to compare key aspects of performance, identify gaps, identify opportunities for improvement and monitor progress.

FREQUENCY

The Improvement Board shall meet bi-monthly.

REPORTING

The Improvement Board will report to Executive Directors via an aggregated Chair’s Report. Reporting will be established to the Board of Directors. In addition, as requested, an aggregated Chair’s report will be provided to the future locality governance meetings and Quality Committee. An additional external report relating to the mental health improvement plan is in place, reporting to the Integrated Care System.

LSCFT

Executive Directors

Meeting

LIA Sponsor Group

Improvement Board

Mental Health

Improvement Steering

Group

CQC Steering Group

Exception reporting to

Board pf Directors and

Quality Committee

Exception reporting

to Board, Quality

Committee and

Audit Committee

Exception reporting to

Board of Directors and

externally to ISC MH

Improvement Board

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MEMBERSHIP (including quorum) The membership of the Committee will be comprised as follows:

Chief Executive (Chair) Director of Improvement and Compliance (Vice Chair) Director of Nursing and Quality Director of Partnerships and Strategy Director of Operations/Chief Operating Officer Director Of Communications Medical Director Director of Digital Director of Workforce and Organisational Development Director of Operational Finance Director of Healthcare Support and Infrastructure Services Service User representative Staffside representative Technical Director, Trust Innovation Cumbria Northumberland Tyne and Wear (CNTW) Head of Transformation LiA Clinical Lead Clinical Director Leads Head of Performance

The Chief Executive shall Chair the Board - in her absence, a nominated deputy, the Director of Improvement and Compliance, or a nominated Executive Director, will Chair the meeting.

A quorum will be 10 members, to include at least 3 Executive Directors.

Members are expected to attend at least 75% of meetings annually. Other representatives will attend on invitation. ADMINISTRATION The administrative support aligned to the Improvement Board will circulate a request for papers 10 working days prior to submission deadline and collation of papers. The agenda and papers will be circulated 5 working days prior in advance of the meeting. The administrator will ensure that minutes of the meeting are taken, including a record of decisions taken, matters arising and that issues to be carried forward are kept in a rolling log. All papers must be approved by the Chair and/or Vice Chair REVIEW

The Terms of Reference will be reviewed annually to ensure effective delivery of the duties set out within this document.

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Board of Directors Agenda Item TB 042/20 Date 06/02/2020 Report Title Mental Health Improvement Plan

Prepared by Louise Giles, Head of Transformation

Presented by Russell Patton, Director of Operations

Action required Noting

Supporting Executive Director Director of Operations

PURPOSE OF THE REPORT: Report purpose To provide an update for the Board on the Mental Health

pathway developments.



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

1.3 If we do not provide integrated physical and mental health services we will lose opportunities to improve patient outcomes

2.2 If we do not deliver new models of care we will cease to be a creditable lead provider

CQC domain Well-led

1.0 Introduction This paper provides an overview to the Board of Directors on a range mental health issues including key performance metrics, recent service developments, the Pennine Lancs Transformation programme and the latest iteration of the Mental Health Improvement Plan – appendix 1 2.0 Performance Update There is continued focus on the mental health urgent care pathway at both a local and national level. The agreed data sets below monitor’s key metrics within the urgent care pathway. It helps to identify current performance trends and to gauge the impact of actions taken to date to develop more efficient, effective and sustainable services that meets the needs of key stakeholders including service users, carer’s, the Trust and the wider ICS system

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2.1 Home Treatment Team Caseload & Activity

*Data excludes South Cumbria due to separate reporting arrangements for this financial year

Home Treatment Team caseloads equate to circa 26 wards of patients being home treated There is an emerging theme that teams are operating in a range of between 427 to 486 cases, but

with a notable exception of the period around New Year. While this may be related to increased general demand, it is noted that this time of year has a general reduction of available support services across the range of provision from both third sector to statutory

There is a marked variance in the ratios of patients to staff in teams

Total team activity continues on an overall upward trend. While activity in December was lower than the previous two months, the cumulative total activity April – December 2019 is 11.1% higher than the same period in 2018

The increase in activity does not appear to be driven by a corresponding increase in Face To Face activity, which has increased by 4.5% in the same period

Caseload Tracker Clinical Staff in Post 06/11/2019 13/11/2019 20/11/2019 27/11/2019 04/12/2019 11/12/2019 18/12/2019 25/12/2019 01/01/2020 08/01/2020 15/01/2020

Trust Total 160.3 463 427 475 448 457 465 474 486 566 442 474

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Cumulative face-to-face activity has increased compared to last year from last month, when the cumulative total was 3.1% higher than the same period in 2018

Work continues to increase compliance with recording face-to-face contacts as clinical contacts rather than clinical notes, and for multiple contacts within a day to be recorded separately, though it is noted that this can be more onerous for clinical staff

2.2 Mental Health Liaison Activity

Full team activity presented (A&E and ward-based activity) Increased activity evident in line with expectations of increased investment This reflects the liaison role with patients admitted to acute Trust wards requiring more frequent

MHLT input for safe clinical management Improved 1 hr performance over this period (37.0% compliance Dec 2018 to 77.2% in December

2019, a further increase from 72.1% in Nov 2019) There was a slight fall in 4 hr performance with 96.0% in December 2019 compared to 96.4% in

November 2019, though this still compares favourably to December 2018’s 84.0% 824 patients were seen within 4 hours in December 2019 compared to 804 in November 2019

indicating that MHLTs are improving in responsiveness

2.3 12 hour breaches

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The total number of 12 hour breaches linked to Lancashire and South Cumbria fell in December to 21, compared to 33 in November

This is despite an increase in presentations at A&E, with the second highest number of presentations in the year

This data includes: o All LSC patients who breach 12 hours in an LSC Acute Trust A&E o All non-LSC patients who breach 12 hours in an LSC Acute Trust A&E o All LSC patients who breach 12 hours in a non-Lancashire Acute Trust A&E

2.4 Bed Utilisation

Reporting of the total daily bed demand by bed type has been extended back to April 2019 The above graph reflects every Lancashire resident either in an adult mental health bed or awaiting

admission The bed types are:

o LSCFT Assessment Bed o LSCFT Acute Adult Mental Health Bed o LSCFT PICU o Contracted Priory Bed o Acute OAP o PICU OAP o An out of area NHS Bed o People waiting admission to a bed (solid red bars at top of stacked columns)

This latter group represent a key clinical risk to be managed for the organisation The black horizontal line reflects the total bed capacity that LSCFT (excluding South Cumbria)

would have if inpatient capacity was commissioned at the population-weighted national average for Adult Acute, PICU, Long Term Complex Care, HDU and LD Admission & Assessment beds

o This equates to 390 beds o Average Trust bed demand since April 2019 has been 345 patients (88.5% occupancy at

national average bed capacity) o Trust bed demand peaked on 3 November at 386 patients (99.0% occupancy at national

average bed capacity) o The dotted red horizontal line shows LSCFT capacity if commissioned to the same level as

CNTW for population size This is shown as CNTW manage the total population inpatient requirements for the Trust footprint

(i.e. zero use of independent rehabilitation facilities)

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OAP numbers reflect average of daily midnight bed state

OAP numbers reflect average of daily midnight bed state There is a clear downward trend from the earl November peak, which was driven by high October

demand There is a visible increase in OAPs at the end of November at the time of three LSCFT wards being

closed due to influenza, and a similar pattern is seen after the closure of two Chorley Wards in early January

2.5 Trust Bed Flow

NHSE are requesting that Acute Ward Length of Stay data is presented as Median Lengths of Stay rather than Mean Length of Stay, as this is considered a more reliable indicator of underlying performance, less subject to skew from large outliers (e.g. discharge of a very long length of stay patient) Monitoring of the Median Length of Stay on Trust Wards has therefore commenced:

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The median LOS for 2019 was 17 days, which is in line with the National Average (Mean length of stay is notably higher than national average, though is skewed by Long-Term Complex Care cases on Acute Wards)

Notably, median LOS moved below the national average in Q2 and Q3, with a consequent increase in numbers of discharges/patients per bed

2.6 Stranded and Super Stranded Cases

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The year to date has seen a falling trend in numbers of 180+ day Length of Stay (‘Super Stranded’) cases, though this is becoming less pronounced as a trend with a third successive month of c.60 cases, a similar figure to April and May, suggesting that this is typical figure for 2019/20

Conversely, the number of 120-179 day Length of Stay (‘Stranded’) cases is seeing an increasing trend over the year but with four successive months of falling numbers

The Head of Operations for the Mental Health Network has now expanded the weekly review with commissioners of all Stranded and Super Stranded cases to include all ICS CCGs

2.7 Access Line and 136 Usage

November saw a slight increase in police calls to the Mental Health Access Line compared to the previous month, with 144 calls

This compares to an average monthly police call rate of 124.5 for the months June to September, so reflects a sustained increase in use of the Mental Health Access Line by police

The number of s136 detentions decreased in December to 119, suggesting that the November fall in detentions was an exceptional month

2.8 136 Usage and Breaches

Jun Jul Aug Sep Oct Nov Dec

Police calls to MHAL 124 137 124 113 193 139 144

Total Number of s136 Detentions 123 116 127 136 124 82 119

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There was an increase in detentions under s136 and s135 in December, increasing by 37 from the previous month to 119 (a 45.1% increase)

The number of s136 & s135 breaches decreased to 8, of which 6 were in Trust s136 Suites (with 2 in A&E Departments)

This means that 6.7% of all detentions breached in December compared to 15.9% in November The primary reason for breaches was bed availability

3.0 Updates 3.1 Crisis Teams – Board members will be aware that one of the most significant concerns identified in the NTW review of the Urgent Care pathway was the limited availability of the trusts Crisis/ HBT services. Following the receipt of additional resources and a successful recruitment campaign we now provide 24-7 cover in all of the Lancashire teams. This is not the case in South Cumbria where the South Lakes team is operational 9am - 8pm 7 days a week. The Furness team works as a hybrid in the urgent care pathway providing input into Liaison, s136 cover and HBT. This Crisis team shortfall will figure prominently in the emerging Bay locality work programme. These teams provide intensive support at home for individuals experiencing an acute mental health crisis, with the aim being to reduce both the number and length of hospital admissions. 3.2 136 Usage – The use of s136 MHA remains a key focus for the trust and the broader mental health system. Meetings have taken place with senior representatives of the Police and L.A. to try and develop more pragmatic approaches to dealing with:

• the excessive use of s136 within Lancashire • the use of least restrictive approaches.

The trust has responded to concerns re the limited availability of advice and support by increasing the availability of the Mental Health Advice Line, and we have communicated widely with the police to encourage their continued use of this resource. Trust and LA representatives have also met to discuss practical approaches to dealing with patients whose mental health presentations and clinical risk change during their time detained under s136. Anecdotal evince would suggest that on a number of occasions a re-assessment by the AMP may well result in the rescinding of the s136. This is positive for the individual concerned and may also have a positive impact on the number of s136 breaches. Further work is proposed between the trust the police and the Local Authorities to progress this work. 3.3 Partnership with Cumbria Newcastle Tyne and Wear (CNTW) The Trust continue to work with CNTW’s Innovations team to re-design and improve our community mental health pathways. Following the completion of the clinical pathway workshops in Pennine Lancs two planning events have been arranged for early and mid-February to identify and agree the key enablers and timescales for implementation across the Locality. To ensure a broader cohort of staff are engaged in the process and updated on progress to date, a number of engagement sessions have also been planned. These will take place in the following locations on the following dates. • Balladen House, 6the February 2020 • Daisyfield Mill, 13the February 2020

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• Pendle House, 14the February 2020 In addition we have drafted an initial plan with CNTW to commence the diagnostic for the remaining localities and have condensed workshops in each locality to ensure completion by the end of May 20 4.0 Deep Dive Position Crisis House/Crisis Café Crisis houses provide a short-term alternative to hospital admission for those with individuals with mental illness who are experiencing a crisis. In addition they may also be utilised to facilitate an early discharge from hospital. The exclusion criteria includes patients who are detained under the Mental Health Act and those posing a significant clinical risk. Following the NTW review and as part of the mental health improvement plan a number of alternatives to admissions have been identified. This service supports the principle, of care in the least restrictive environment. Lancashire & South Cumbria NHS Trust in partnership with the national mental health charity Richmond Fellowship (RF) have run two crisis houses based in Central and East Lancashire, providing a therapeutic environment to support people during a time of mental health crisis. This service offers short term placements for up to seven days. Individuals will work with the team of experienced Recovery Workers on a tailored support plan to help manage their mental health and develop effective coping strategies. 4.1 Willow House Chorley Willow House is a 6 bedroom en-suite service situated in the village of Coppull, Chorley. The house has a communal kitchen, lounges and large garden area for guests to enjoy. The service has a dedicated member of staff on site 24 hours a day, seven days a week.

Contract Value £350k.

Average Bed Occupancy and Length of stay

Willow House, Chorley Bed Occupancy Average Length of Stay

76% 6 days 5.2 Oak House, Burnley Oak House is a 5 bedroom en-suite service situated in East Lancashire. The house has a communal kitchen, lounges and garden area for guests to enjoy. The service has a dedicated member of staff on site 24 hours a day, seven days a week.

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There was a particularly positive outcome for one service user who is now employed as a full time member if staff within the unit.

Contract Value £350k.

Average Bed Occupancy and Length of stay

Oak House, Burnley Bed Occupancy Average Length of Stay

67% 5 days 5.3 Challenges with the current model

There is occasion where the HTT feel the person is appropriate for the crisis house, although RF have declined for various reasons

Up to November 2019, the RF KPI’s demonstrated that bed occupancy was low within the houses, although there were actions agreed with RF to increase the occupancy and to accept referrals and transfer into the houses 24/7, as in the past transfers into the houses rarely occurred after 8pm

The HTT’s have raised concerns that the sleep in staff member through the night has caused transfers into the houses out of hours to be rare occurrences. If a person is declined by the Crisis House, a clear rationale of why they were not accepted must be clearer documented with ECR following discussion with relevant HTT regarding this decision.

5.4 Development of the Blackpool Crisis House: The Trust have met with Richmond Fellowship who are developing the crisis house in Blackpool (6 beds). The crisis house will provide short-term (up to seven days) intensive 24 hour, specialist mental health support to people who are assessed by the local Crisis Intervention and Home Treatment Teams as needing support to avoid admission to hospital. The additional crisis house is located in the centre of Blackpool and plans are drawn up to begin the mobilisation phase in February 2020 with a view to being operational July 2020. Further work is planned with Richmond Fellowship to review the ‘system wide model’ and align pathways to increase occupancy linking in with the mobilisation of the Blackpool crisis house. 5.5 Crisis Café 5.5.1 Haven Crisis Café Preston The Haven is a new community mental health service in Preston accessible to anyone in Central Lancashire from age 16 years. The service is being delivered by RF in partnership with n-compass and provides crisis support. The Haven will provide a safe and welcoming place for people to go at times of mental health crisis. The Trust provides a crisis worker that supports the Haven. 5.5.2 Blackpool crisis café A crisis café opened in Blackpool on the 7th January 2020.The café is based at the Blackpool Centre for Independent Living (BCIL) on Whitegate Drive. We have worked with our colleagues at Blackpool Council, Public Health, CCG & Patient and Family groups to develop an appropriate model that will provide a crisis

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café to support the members of the Fylde Coast community. The café will be run by our colleagues at Richmond Fellowship with daily support into the café from Blackpool Council Social Workers and LSCFT Home Treatment Team Following receipt of additional national resources further opportunities exist to look at expanding the model of crisis house/ cafe’s into other ICP areas. 6.0 Decision Required

The Board is asked to note the contents of the report.

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KEY – Blue – delivered and evidenced Green – on track for delivery Amber – some slippage Red – slippage and concerns about delivery MENTAL HEALTH IMPROVEMENT PROGRAMME

Version 17 31.01.2020 – please note amendments/additions to themes and actions from previous version are highlighted in yellow

SECTION 1 - SHORT TERM OPEN ACTIONS

Theme Action Lead Organisation/s

Executive Lead Operational Support

Transformation Support Other Stakeholder Input

Deadline Extended Deadline

Progress Feb 2020 Update

Impact of Completed

Action

Assurance

Method

1. CRISIS PATHWAY

1.1 Strengthen Clinical Pathways in adult services (Pennine & BFW)

Review & strengthen Crisis/Home Based Treatment Teams operating model, including bringing teams together in Pennine Lancs and ensuring robust 24/7 operating.

LCFT/CCG’s

Russell Patton – LCFT Exec Pauline Cullen – LCFT Ops

Sarah Neve – LCFT Transformation

30.01.19

30.03.19

The review of the clinical pathways is being undertaken in conjunction with colleagues from CNTW. As such it has been agreed that the status quo will be maintained to enable a full review of the key enablers e.g. Staff accommodation, travel etc to be carried out. All Crisis/HBT Teams now provide 24-7 care.

1.2.2 Operationalise modular buildings within Royal Blackburn Hospital LCFT Russell Patton – LCFT Exec

Pauline Cullen - Ops 31.03.20

Tenders received and contract has been let, awaiting further clarity on construction and timescales. The liaison team will work closely with Royal Blackburn A&E team to consider the most effective working practices.

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https://www.healthierlsc.co.uk/









Impact of Completed

Action

Assurance

Method

1.5.1 Crisis House Explore options for additional crisis houses/crisis cafes within all ICP areas LCFT

Russell Patton – LCFT Exec Lorraine McDonald-Johnson – Ops

Sarah Neve - Transformation 31.03.20

Blackpool crisis café opened (on the 7th Jan. The Crisis house Blackpool– 8 bedded facility operated by RF to open June/July 2020.

1.6.1 Frequent Attenders

Recruit to model and operationalise Frequent Attenders Care Enhanced Team) in all localities

LCFT

Paul Hopley - ICS Russell Patton – LCFT Exec

Lorraine McDonald-Johnson– Ops Sarah Neve - Transformation

1.01.20

1.04.20

Central and Pennine are now established. Recruitment partially completed for Fylde & The Bay, estimated to be fully recruited by the end of March 2020

We have a register of

defined frequent

attenders with locality system

oversight & ownership

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Impact of Completed

Action

Assurance

Method

4. SYSTEM REDESIGN

4.1 Clinical Pathways

Review primary and secondary care interfaces and consider this against the developing Mental Health Strategy e.g. span from Primary Care/Crisis/Suicide

ICS

Paul Hopley - ICS Stuart Sheridan – Transformation

Dr Tom Phillips Dr Leon Leroux Ops

01.09.19

01.04.20

A meeting took place on the 10th October with GP MH leads. An

approach to primary and secondary care interfaces along

with consideration against developing Mental Health

Strategy. This will include linking into the Pennine Transformation

work. GP leads meeting now takes

place the 3rd Tuesday of every month. Discussions planned for December 19 with PCN Clinical

Leads( Pennine Lancs) and L&SC Director to discuss a

broad range of interface issues.

4.2.2 Street Triage Following evaluation to agree potential model to rollout to ICS footprint

ICS / LA / Police / LCFT

Arif Rajpura – Blackpool LA / Blackpool ICP

Russell Patton – LCFT Exec Nicola Evans – Lancashire

Constabulary

01.04.20

On competition of proposal,

this would need to be presented to relevant ED Delivery Boards and ICS

MHIB

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Impact of Completed

Action

Assurance

Method

5. SUBSTANCE MISUSE

5.1 Substance Misuse Map current provision and develop gap analysis ICS

Louise Taylor – LA Chris Lee – LA / PH

Russell Patton - Exec Phil Horner – Ops

Stuart Sheridan – Transformation Paul Hopley - PH

31.05.19

01.07.20

Good progress made, pockets of good practice identified across the county which we can standardise i.e. MDT forums, in reach & training. Key gaps identified in community crisis access 24/7 for D&A use, rapid access to inpatient detox beds & PC support for the homeless. Second workshop planned for June 2020 to develop more appropriate models to bridge the current gap in provision.

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SECTION 2 - OPEN LONG TERM PROPOSALS


Executive Lead Operational

Support Transformation

al Support


Progress- Feb 2020 Update

Impact of Action

Assurance Method

C. Undertake a wholesale redesign of the MH Clinical Pathway within Pennine Lancs ICP.

C.1 Develop a transformation programme in partnership with NTW, Service Users, Commissioners and other k e y partners.

All

Russell Patton Louise Giles

Tanya Hibbert Pauline Cullen Paul Hopley

Stuart G (NTW)

Oct 19 Complete and Delivered

C.2 Undertake a full current state analysis building on the full NTW review. LCFT/NTW

Oct 19 Complete and Delivered

C.3 Review drivers of demand and consider against current capacity. LCFT/NTW

Oct 19 April 20 The Pennine Transformation workshops have taken place in December 2019 and January

2020, on the following areas: Access to Services, Assessment Pathway, Psychosis

Pathway, Non- Psychosis Pathway, Cognitive Pathway. Planning events are being held on the 4th and the 11th February to set out next steps.

C.4 Develop a full range of evidenced based clinical pathways, in conjunction with key internal and external partners.

LCFT/NTW Nov-Feb 20

April 20

C.5

Undertake development sessions with the local teams on the concept of standard work as a means of improving safety, reducing waste and increasing productivity.

LCFT/NTW Nov-Feb 20

April 20

C.6 Develop a robust set of benefits criteria to measure progress against current state. LCFT/ICS Nov 19

March 20

C.7 Support the local teams to operationalise the new Pennine Lancs Model. LCFT/NTW May 20

C.8 Reflect and review the process and outcomes of the programme of work. LCFT/NTW May 20

D. Service Users co-production & involvement in care – Pennine Lancashire

D.1 Ensure that the principles of service user co-production is embedded within all levels of the organisation.

LCFT

Maria Neligan

Louise Giles

Jan 20

March 20 This is one of the Trusts LIA Workstreams

D.2

Ensure high levels of engagement and involvement with service users and their representatives in the service developments/transformational changes taking place throughout the Trust.

LCFT Jan 20

April 20

Significant input from service users/ carers in the development of the new mental health pathways This co production will continue.

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al Support



Impact of Action

Assurance Method

E. Clinical risk-taking

E.1 Develop ‘home first’ approach LCFT Richard Morgan Rachel Domone

Russell Patton

March 20

Speakers invited to address the consultant

body and this work will be incorporated into one of the LiA streams (title: Avoiding Harm and

Risk Aversion).

E.2 Optimise SU leave planning LCFT March 20

E.3 Reduce restrictive practices LCFT March 20

G. In patient Services

G.3

Work with commissioning colleagues to secure the most appropriate number of beds for MH Rehabilitation, LD assessment and treatment and substance misuse beds.

LCFT

Feb 20 Engaging with commissioners regarding long term plan for these discrete areas.

H. Partnerships

H.1 To work with all stakeholders to collectively develop whole system ICS strategy for mental health ICS/All Andrew Bennett

Caroline Donovan

March 20

H.2

To work with Police Liaison Officer to develop the role and implement SOP with Police to ensure appropriate

detentions

LCFT/Police

Tanya Hibbert Neil Smith

Nicola Evans

Nov 2019

March 2020

Discussions taken place at a senior level with representative from the police on system

pressures. The next phase of work will be to establish locality relationships between the

police for support of a number of initiatives e.g. frequent attenders Changes in management of Lancashire Police, have extended the deadline

for completion.

H.3 Enhance working relationships with Voluntary sector.

To include engagement with commissioners/providers to understand what further roles/services they could undertake

LCFT/VFCS

Paul Hopley

A number of third sector organisation attended a workshop in the Summer of 2019 to inform what added value / service they could add in particular to the urgent care pathways.

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al Support



Impact of Action

Assurance Method

H.4 Review partnership working with AMHPs and Social

Workers, inclusive of section 12 app and rota.

LCFT/LA

Louise Taylor

I. CCG and Local Authority Commissioner Recommendations

I.1

The ICS and ICP Leads to collaboratively review, and where needed to increase, the capability and expertise around Mental Health within those staff that commission services - working together with providers, learning from one another, and exploring together what good looks like from other organisations both nationally and internationally.

ICS Andrew Bennett Dec 2019

Initial meeting held with MH Commissioners on

the 2nd July 2019 and a further meeting has been planned.

The ICS have commissioned an external

provider to undertake a diagnostic, this will commence on the 23rd September. This piece

of work is expected to last 14 weeks.

J. Social Care Recommendations

J.1

All Local Authority Partners to work collaboratively on Skills Integration - Build on the approach to refocus and further enhance the skills and competencies of Social Workers and AMHPs, while maintaining the integration approach with Health and Social Care in a well-defined and well-led system in all areas

LA

Sakthi Karuntha/Louise Taylor/ Other LA

reps tbc

LCC capacity in place to manage referrals and performance reporting in situ. LCC AMHP

working to and applying National standards of practice for AMHPs

J.2

Quality Improvement - Facilitation of a Quality Improvement programme to review the drivers for demand and to understand capacity in all Social Work/AMHP teams, and the transitions between those and Health/VCS, at great depth

Sept 2019

2 QCIM Quality Improvement Managers in place monitoring SW/AMHP

Agreement in place to manage this interface by end of Sept 2019

J.3

Build understanding of where ‘waste’ can be removed from the Social Care system so professional resource and skills can be focused on designing and delivering a new system for the highest quality of service delivery, in collaboration with partners

Oct 2019

Discussions and roles clarified with agreed actions in place between LCC and LCFT to

reduce duplication New Care Programme Approach policy drafted

and is in consultation

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al Support



Impact of Action

Assurance Method

J.4 Ensure a focus on prevention wherever possible, with a cohesive strategy for Public Health and early intervention across Lancashire.

TBC

SAR reported in relation to individuals with substance misuse issues as system wide

response is in development

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SECTION 3- COMPLETED ACTIONS & IMPACT






Impact of Action

Assurance

Method

Crisis Pathway

1.1 Strengthen Clinical Pathway in adult services (Adult & BFW)

Implement new leadership posts across liaison/MHDU/Crisis/HTT LCFT

Russell Patton – LCFT Exec Complete

Delivered and evidenced

The service now has in place a more robust

operational management structure with greater

oversight.

One service manager overseeing the urgent care pathway across each locality

1.2 A&E Liaison Relocate liaison team to A&E in Blackburn ELHT/LCFT

Russell Patton – LCFT Exec Pauline Cullen – LCFT Ops


Complete


More timely access to the E.D. which benefits both the patients and urgent

care system.

One and 4 hour compliance against target

1.2 A&E Liaison

Increased staffing in line with new national models (13 Qualified+2 Medical Consultants). Other members of the MDT are also employed within this model.

ICS / LCFT

Russell Patton – L CFT Exec Laura Walsh – LCFT Ops


Complete

Ongoing recruitment but all sites now have 24 hour provision in

place.

Increased staffing in place to enable A&E

liaison teams to operate 24/7, so that practitioners

are more accessible.

Reduction in 4 hour and 1 hour breaches and

reduction in % of bed referrals

1.2.1 Identify and obtain funding options for a sustainable long term building solution for liaison service in Blackburn E.D.

LCFT Russell Patton – LCFT Exec Pauline Cullen - Ops

Complete

A modular building proposal has been identified as the optimum solution. Capital funding has

been identified and the planning process from an

estates and operational/ clinical perspective is ongoing.

Refer to action above

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Impact of Action

Assurance

Method

Crisis Pathway 1.2.3 Review the clinical suitability of facilities within all ED within our sphere of reasonability. LCFT Russell Patton – LCFT Exec

Laura Walsh - Ops 01.09.19

Model agreement by 01.11.19

Initial estates review complete. Work has now commenced

with local operation teams to agree the most appropriate

operating model.

Optimal model for each discreet service. fall E.Ds within the e

ICS have ha

This impact of the action we have a clearer

understanding of clinical requirements and what is

achievable.

1.3 S136 / Place of Safety

Implement a substantive dedicated staffing model CCG’s/LCFT

Russell Patton – LCFT Exec Paul White – Ops



A dedicated staff team is now available for the 136 suite’s supporting more timely assessments and

reducing staffing pressures on other

elements of the acute pathway.

Consistent 136 approach Ring fenced team for each locality Adherence to 136 escalation process

1.4 MHDU Review clinical acceptance criteria LCFT

Richard Morgan - Exec Joanne Greenwood – Ops



All 3 MHDU’s will be

closed by the 8th October 2019.

Develop operational SOP for function of MHDU LCFT

Russell Patton – LCFT Exec Lorraine McDonald-Johnson – Ops Sarah Neve – Transformation

31.05.19

Delivered and evidenced All 3 MHDU’s will be

closed by the 8th October 2019.

1.4.1

Undertake staffing review of Blackpool MHDU LCFT BVH

Russell Patton – LCFT Exec Laura Walsh – Ops

Berenice Groves - ICS 01.09.19

The trust is currently enacting an MHDU closure programme. It is

anticipated that Richmond Fellowship staff will work in other

areas of the Urgent Care pathway to support patents in

various settings

Following closure of the MHDU the Richmond Fellowship staff were

reallocated to other roles within the Urgent Care

pathway.

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Impact of Action

Assurance

Method

Crisis Pathway 1.5 Crisis Houses Review acceptance criteria including time of day for admission LCFT

Russell Patton – LCFT Exec Lorraine McDonald-Johnson –

Ops Sarah Neve - Transformation

01.07.19


Following this review, patients can now get

more timely and appropriate access to this

valuable resource.

Assurance contracting report provided quarterly to ensure the crisis house has optimal usage. Community teams are accessing crisis house when appropriate as an alternative to an acute admission.

1.6 Frequent Attenders

Develop a proposal for the establishment of a Frequent Attenders Clinical Team taking into account National Good Practice

CCG’s

Paul Hopley - ICS Russell Patton – LCFT Exec Joanne Greenwood – Ops

Sarah Neve - Transformation

01.07.19

Business case produced, to be discussed with Commissioners in

September 2019

The Frequent Attenders Team when established

will contribute to meeting the needs of patients who currently make excessive use of

ED or are regularly detained under section 136 of the Mental Health

Act.

Establish locality frequent attender teams in place that provide support and oversight of people who are identified as frequent users of services (as defined by system).

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Impact of Action

Assurance

Method

1.7 Gatekeeping Function

Ensure that the gatekeeping function is always undertaken by the crisis team as per policy guidance

LCFT Russell Patton – LCFT Exec

Pauline Cullen – Ops Sarah Neve - Transformation

01.08.19

The Bed Management Service have reviewed the routes of admission as there is a view that not all patients have been seen or reviewed by the Crisis Team prior to a request for a bed. All services have been informed of the need to utilise the crisis team prior to seeking an admission. The crisis teams have now been supplied with robust gatekeeping protocol that include ‘critical indicators.’

Enhanced gate-keeping supports a more robust management of the Trusts Inpatient beds. The Gatekeeping assessment is now completed at the earliest opportunity to ensure. All options are considered prior to an admission into a mental health bed.

Gatekeeping function undertaken by HTT in all circumstances. Ongoing monitoring of compliance. Consistent approach to bed requests, which ensures a home first approach, giving assurance that admissions are clinically necessary

Bed Management 2.1 Short-term bed capacity

Ensure 50/50 risk share of excess OAPs with CCGs is within LCFT contract

CCGs Paul Hopley - ICS

Lisa Moorhouse – Ops Sarah Neve - Transformation

31.05.19


Clearer understanding about the cost associated

with OOA within both organisations.

Undertake a review of patient population/available bed stock and staff competencies to develop short term solutions to meet the needs of the current Learning Disability and Rehab patients currently in receipt of inpatient care.

LCFT

Russell Patton – LCFT Exec Laura Walsh – Ops



Gaps in LD and Rehab provision have been identified. Identified

cohort of patients who require a different

packages of care which is not currently commissioned

Weekly locality discharge planning meetings

Confirm with NHSI Priory beds are not defined as OAP’s LCFT

Joanne Moore – LCFT Exec Laura Walsh – Ops


Delivered and evidenced More accurate reflection of OAPs

Constant reporting of true OAPs

Identify additional mental health acute bed capacity within the Lancashire system to reduce the reliance on OAPs

LCFT

Russell Patton – LCFT Exec

Laura Walsh – Ops Sarah Neve – Transformation

01.07.19

Delivered and evidenced Reduce OAPs usage

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Impact of Action

Assurance

Method

2.2 Assessment wards

Review length of stay to obtain baseline. Work with community services to ensure facilitated early discharge where appropriate

LCFT Russell Patton - Exec

Joanne Greenwood – Ops Sarah Neve - Transformation

01.08.19


This is a key metric of success we will be

revisiting this action due to current bed pressures.

Strengthen clinical leadership LCFT Richard Morgan - Exec


01.08.19

The Chief Executive and

Medical Director have attended the joint

R.C.Psyc. and A& E Faculty at the end of July 2019. The

purpose of this workshop being to consider a broad range of

clinical, modes that with support could be potentially utilised within

the Lancashire Care system.

Discussions are taking place within the Trust to review the

clinical leadership/management model.

A greater understanding of mental health models

within key senior managers

2.2 Assessment Wards

Implement red to green enabling appropriate discharge planning

LCFT Russell Patton - Exec


01.08.19

Feedback on review of process from a patient and service perspective 01.12.19

All wards within the Mental Health Network have now

adopted the methodology of Red to Green. A full

programme of review and audit is been developed to capture patient and system

benefits. Further work required to embed the procedure.

Red to green procedure in place that will enable

more timely and appropriate discharges

Reduced length of stay

and improved patient

experience

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Impact of Action

Assurance

Method

3. COMMUNITY TEAMS

3.1 Community Teams

Support investment in CMHT staffing in line with MHIS LCFT

Russell Patton – LCFT Exec Laura Walsh– Ops

Louise Giles - Transformation 01.11.19

An additional £1.3m has been identified for investment following

the 2019/20 contract round. Recruitment has been successful with candidates from within and

out with Lancashire. Staff to transition into post from 1st Sept. –complete – Majority of roles are now in post – with some posts yet

to be filled in the Fylde coast

This will reduce allocation of care coordinator,

decrease care coordinator caseload

within each team which will enhance the input

with service users reducing possibility of

relapse and subsequently admission into mental health hospital. Overall improvement of service

user experience

Evidence of additional staff in post, stabilising of caseload and reduction in unallocated.

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Impact of Action

Assurance

Method

4. SYSTEM REDESIGN

4.1 Clinical Pathways Develop system-wide Mental Health Risk Register ICS

Paul Hopley - ICS Laura Walsh – Ops Stuart Sheridan - Transformation

01.08.19

First version completed and presented at the Mental Health Improvement Board meeting in

September.

Multiple ownership of system wide mental

health risks which will support much needed

developments of mental health community and

inpatient services.

The version presented to Board in September was not meeting the purpose

of the group. RP / PH have discussed how to take this forward whilst

ensuring multiple ownership and are proposing a single meeting with key

stakeholders from PMO / organisations to agree

key risks in delivering the MHIP.

17.10.19 – Development

of a one-off task and finish group is being

arranged to finalise risks on the risk register in

order to capture key risks across the system.

A further stakeholder meeting was requested in December 2019, however had ppor attendance, ICS to review on how to take

this forward.

4.1 Ensure all previously developed SOP’s are circulated and implemented

ICS/LCFT Richard Morgan LCFT Exec 01.08.19


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Impact of Action

Assurance

Method

4.1

Analyse data driving the increase in demand for MH services ICS

Paul Hopley - ICS Phil Horner – Ops

01.08.19

01.12.19

MHIB meeting took place on the 6th November and the report

received positive feedback. The MHIB paper for November is

currently underway and a more collaborative approach has been

taken with LSCFT and NHSE. Further work is currently

underway to expand sections of the report relating to; Reasons

for 12-hour breaches, out of area placements, stranded and

super-stranded patients and suicide prevention

The ICS board has a level of assurance that actions and associated

performance is reviewed on a regular basis

ICS Mental Health

Improvement board receive the

report.

4.1 Develop SOP for admission thresholds for adults and older people into the Acute sector

ICS/LCFT

Richard Morgan / Russell Patton – LCFT Exec Paul Hopley - ICS

Laura Walsh – Ops Stuart Sheridan – Transformation

01.08.19

The SOP has been agreed by all Acute trusts and is expected to

be implemented from 1 December.

Whilst the legality of detention to Acute trusts was thought to

have been established and agreed final clarification has

been requested and is expected before the implementation date

SOP in place Reduction of 12 hour breaches and increased

patient satisfaction

4.2 Street Triage Undertake initial evaluation of Blackpool pilot ICS/Police

Russell Patton – LCFT Exec Cathy Gardner

Berenice Groves Laura Walsh – Ops Stuart Sheridan - Transformation

31.05.

19

Initial evaluation paper completed. Agreement to continue for 12 months in

Blackpool to end March 2020.

This provides ongoing Street Triage to

identify people who would normally have been detained under

section 136 or presented themselves

to ED, providing Mental Health

intervention and signposting at crisis

point

Reduced conveyance to A&E by police and NWAS. People sign

posted to most appropriate service to

ensure they receive the service they

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Impact of Action

Assurance

Method

4.3 System Redesign

Agree a system wide plan regarding the review of the current commissioning arrangements of adult rehabilitation beds

ICS Paul Hopley - ICS

01 Oct

19

Following the initial scoping meeting, the group met again in

July to collate and review the available intelligence from

MLCSU and LCC. Information from the other local authorities

and the Blackpool Complex Cases Team is expected by the

28th August 2019. Once this intelligence gathering exercise is complete, the information will be

clinically validated and triangulated with NHS

benchmarking data to inform a system wide commissioning plan, which is expected for the October 2019 MH System Improvement

Board.

17.10.19 – A task and finish group is now established with a terms of reference, project plan and risk log. A refreshed, refined and cleansed ICS-wide dataset of current locked rehab activity has now been established and a clinical review of MLCSU activity has also taken place. This has allowed some further analysis to take place and for initial modelling of future provision to begin 30.01.20 Commissioners with support from CSU / LSCFT data have now completed rehab mapping, a meeting has been planned for the 7th February to be followed by leader workshop to agree findings / actions required. Overview presentation will be presented on 7th Feb for comments / agreement which will form basis for leader

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Impact of Action

Assurance

Method

4.3.1 To agree a system wide approach to the commissioning of LD beds

ICS Rachel Snow Miller - ICS 30.06.19

There is now a plan in place to commission crisis residential

places and LD beds from another NHS provider, this is coupled with

improvements to community services and pathways

A. Mental Health Investment standard A.1

Ensure appropriate funding is secured via the national MHIS for the delivery of a comprehensive mental health pathway. This should be based on an analysis of the needs of the local population we serve, with proposals being transparent in nature in terms of anticipated outcomes and remaining service gaps.

CCG’s/ICS Bill Gregory Roger Parr

June 2019

Specific funding linked to CMHT and crisis teams has been

received

Identified staffing model for CMHT and HTT which reflects additional investment.

Improved access to CMHT and HTT teams. Ability to support safe, early discharges from inpatient services.

B. Mental Health Act

B. 1

Review clinical practices in respect of current legal frameworks – particularly the use of 136 facilities.

LCFT Russell Patton Oct 19

A review of high users of s136

has taken place and a broader range of interventions

have been put in place to more appropriately manage this

element of the pathway. These include more robust medical

rota’s , interagency reviews of 136 applications, greater use of the mental health Access line

These approaches will be reviewed throughout QTR 4 to

gauge levels of success. –

Processes for review and amendments are in place.

Fewer number of people accessing 136 from EDs.

Reduction in actual number in 136 applications

Review data from previous months to see

reduction in 136 applications and

admissions.

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Impact of Action

Assurance

Method

F. Develop and implement a robust, effective and enhanced bed management system within the Trust

F.1 Implement immediate changes to the team/service that will have a positive impact on the enhanced gate keeping/patient flow and effective OAT’s Management.

LCFT Russell Patton

Laura Walsh

Sarah Neve

Euan Robertson

June 2019

The first phase of the (enhanced flow team) has been completed.

Review and expansion of this team will take place through a

Keisen event.

Greater flow through inpatient system and a

reduced reliance on OAP placement

Review of data

will confirm reduced length of stay, increased flow and reduce headcount and occupancy. All

leading to a reduced

occupancy, with the aspiration

being 85% F. Develop and implement a robust, effective and enhanced bed management system within the Trust

F.2

Undertake a 5 day Kaizen event with service and transformation colleagues to design the most effective and sustainable model.

LCFT/NTW

Russell Patton

Phil Horner

Sarah Neve

Euan Robertson Sep 19

Jan 20

A full write up of the Kaizen event is currently being undertaken and a costed model is currently being completed for consideration for exes

A discreet team tasked with managing out of area placements has commenced from the 4th November.

G. In patient services G.1 Review current management and leadership roles to ensure clarity in relation to roles/responsibility and accountability.

LCFT

Russell Patton Maria Neligan

Russell Patton

Phil Horner Louise Giles

Oct 2019

Reporting arrangements have now been confirmed.

Greater clarity on authority and responsibility

Effective and timely decision

making.

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Impact of Action

Assurance

Method

G. In patient services

G.2 Review bed capacity against current demand

and review short term commissioning arrangements accordingly.

LCFT

Russell Patton

Paul Lumsdon

Laura Walsh

Louise Giles

June 2019

Bed capacity will be kept under constant review and amended

accordingly.

This provides a focus as to where there are gaps in current bed stock and what services need to be

developed.

Additional 17 beds identified within the system for acute. Additional step down complex capacity in the system (12 beds currently occupied).

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Report Title Quality and Performance Report (QPR)

Prepared By Phil Evans, Interim Director of Partnerships and Strategy

Presented By Phil Evans, Interim Director of Partnerships and Strategy


Supporting Executive Director Director of Partnerships and Strategy

PURPOSE OF THE REPORT: Report Purpose To appraise the Board of Directors of key elements and

themes from the Month 9 QPR



Board Assurance Framework Risk 2.0 The Trust does not deliver safe, appropriate and therapeutic environments to deliver high quality services

CQC Domain Well-led 1.0 INTRODUCTION The Board of Directors are asked to note the QPR for month 9 with the following comments below:

The Trust is compliant with 9 of the 11 current NHSI metrics in month 9:

o Inappropriate OAPs continues to exceed the current trajectory (which was agreed at the start of 18/19). The number of OAPs occupied bed days decreased in month 9 coinciding with a decreased demand for inpatient admissions and increased repatriation of inpatients who were in OAPs. Indications from weekly monitoring suggest that the reduction in demand seen in month 9 is continuing into January. Actions to improve the OAPs position are being progressed as part of the system-wide action plan developed to respond to the NTW review. The Mental Health Improvement Plan Update paper, presented by the Executive Director of Operations, provides the detailed update on the action plan

o The latest position available (September 2019) of the Data Quality Maturity Index (DQMI), reported by NHS Digital, shows the Trust is non-compliant against the 95% standard (and the 90% - 95% for the CQUIN achievement) at 86.2% but is showing a 10 percentage point improvement on the previous month and a 15 percentage point improvement on July position. The DQMI measures our performance against data submission to 36 fields. Due

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to lack of overall alignment with our systems to the national dataset, and the partial roll out of RiO (RiO PAS rolled out only) this is proving to be a complex, challenging piece of work. Currently there are 23 fields at 90% or above. Actions are in place to address each area, and based on the current assumptions of the impact of our interventions, it is expected that the minimum CQUIN standard may be achieved from Q3 onwards, however payment mechanisms are such that there is a risk to financial achievement for the year.

As agreed with the regulator and Trust Board, South Cumbria metrics are presented separately in

a dashboard under the Summary Dashboard section (page 10) and the combined performance for Lancashire and South Cumbria is presented in dashboards on page 12.

In line with the planned introduction of SPC methodology into the HR section of the QPR, SPC icons are now available on the Sickness and Training run charts. Alongside the introduction of SPC, a review of the content has been undertaken with positive feedback received. In response to feedback, references have been added at the side of the summary dashboards as to where additional narrative can be found. Further work will be undertaken with the new interim Executive Director Workforce and the new Executive Director for Nursing.

In line with comments received, the Quality section of the Summary Dashboards, now includes the

18-19 National Benchmarking mean in the ‘Target’ column, not so much as a target but to provide context to the number of incidents and to gauge the current performance against the mean of last year’s national average. These are only available for selected measures, and the National mean has been used to calculate the equivalent monthly value for the Trust based on bed numbers (or other unit) used to calculate the specific Benchmarking metric.

There is an increase in the number of reported Delayed Transfers of Care (DTOC) from the

Inpatient units in December. The Mental Health Network have been working closely with Commissioners coordinating reviews of all long stay patients, and it has been decided that whilst inpatient rehabilitation beds are not provided by the Trust but that there is an identified need for this for a patient, that they should be identified as a DTOC

The Mental Health Improvement Plan metrics, which have previously been included in the Mental

Health Improvement Plan Update paper, are now incorporated into the QPR and should be referenced in the context of the Mental Health Improvement Plan Update paper.

2.0 RECOMMENDATIONS The Board of Directors are asked to:

Note the content of the QPR Agree how actions are to be addressed as appropriate to LSCFT.

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Quality & Performance ReportMonth 9 – December 2019

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Section 1:- Summary Dashboards

• Statistical Process Control - Key• Trust Monthly Metrics Dashboards

2

Section 3:- Quality

• Quality – Safe• Quality – Effective• Quality – Experience

Section 3.1:- Commissioning for Quality & Innovation

• CQUIN Executive Summary

Section 4:- 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

Quality & Performance ReportContents

Section 2:- Performance Activity

• Key Exceptions

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Summary DashboardsSection 1.

3

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1. Summary DashboardsStatistical Process Control - Key

4

Are we improving, declining or staying the same? (Variation)

Icon Variation Definition ActionSpecial Cause Improving Variation

Unexpected variation that results from unusual circumstances in a system or process i.e. assignable.(Blue = significant improvement/low pressure,H = high numbers, L = low numbers).

External cause should be identified andunderstood.Analyse whether change is attributable to service redesign or not.

Special Cause Concerning Variation

Unexpected variation that results from unusual circumstances in a system or process i.e. assignable.(Orange = significant concern/high pressure, H = high numbers, L = low numbers).

Process is unstable and unpredictable.External cause should be identified and tackled.Develop contingency plans.

Common Cause Variation

A natural or expected variation in a system or process i.e. random.(Grey = no significant change)

Process is stable and predictable.If the current performance is acceptable, do nothing. If it is not acceptable, redesign your processes.

Can we reliably hit the target? (Assurance)

Icon Assurance Definition ActionConsistently hitting target

The current target is outside the process or control limits in the direction to improvement. (Blue = will reliably hit target)

Be assured that without significant change, the system would be expected to continue to hit the target, regardless of natural variation.

Consistently failing target

The current target is outside the process/control limits in the opposite direction to improvement. (Orange = system change required to hit target)

Be aware that without significant change, the system would be expected to consistently miss the target, regardless of natural variation.

Hitting and missing target

The current target is in between the process/control limits. (Grey = subject to random)

Without significant change, the system would be expected to inconsistently hit the target in future. The difference between success and failure may be down to the natural variation of the system and may have no underlying significance.

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1. Summary DashboardsTrust Monthly Metrics Dashboard

5

Note: Exception reports are not included for those measures associated with the acute care pathway, as information is included within the Mental Health Improvement Plan paper instead.2019/20 Cardiometabolic Audit only included Inpatient Wards. To be re-audited in 2020 to include EIP and Community MH Services

NHS Improvement Indicators

Indicator Target Q1 19-20 Q2 19-20 Q3 19-20 Oct-19 Nov-19 Dec-19 Variation Assurance Narrative Location

MR01 - 7 Day Follow Up 95% 97.3% 96.1% 96.6% 96.3% 97.1% 96.4% N/A

MR03 - Delayed Transfers of Care ≤ 7.5% 0.98% 0.61% 1.80% 0.50% 0.59% 4.35% N/A

MR06 - RTT - Consultant Led (Incomplete Pathway) 92% 96.9% 96.3% 97.4% 97.4% 97.6% 97.1% N/A

MR13 - 2 week wait for Treatment for EIP Programme 56% 47.2% 70.4% 78.9% 82.4% 71.1% 87.0% N/A

MR14 - RTT - IAPT 6 Weeks 75% 95.6% 96.8% 97.2% 97.1% 97.0% 97.5% N/A


MR16 - Inappropriate AMH OAPs OBDs (monthly target) 215 5284 2534 4976 1654 1851 1471 Mental Health Improvement

Plan

MR19 - IAPT Recovery 50% 50.7% 51.1% 52.0% 49.8% 54.0% 53.1% N/A

MR20 - Under 16s Admissions to Adult Facilities 0 0 0 0 0 0 0 N/A

MR21 - MSK Diagnostics (DM01) 99% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% N/A

The below NHSI indicator is reported 3 months in arrears N/A N/A N/A Jul-19 Aug-19 Sep-19

MR17 - DQMI Dataset Score (NHS Digital) 95% - - - 71.1% 77.6% 86.2% N/A

The below NHSI indicator is reported Annually N/A N/A N/A 2017/18 2018/19 2019/20MR18 - Cardiometabolic Assessments (Annual) a. Inpatient Wards 90% - - - 89.0% 79.0% 95.0% N/A

b. EIP Services 90% - - - 63.0% 79.0% N/A N/A

c. Community Mental Health Services 65% - - - 73.0% 83.0% N/A N/A

SPC Not Applicable

SPC Not Applicable

SPC Not Applicable

SPC Not Applicable

SPC Not Applicable

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6Note: Exception reports are not included for those measures associated with the acute care pathway, as information is included within the Mental Health Improvement Plan paper instead.

National / Contractual Indicators

Indicator Target Q1 19-20 Q2 19-20 Q3 19-20 Oct-19 Nov-19 Dec-19 Variation Assurance Narrative Included

Gatekeeping - Access to Crisis Res. Home Treatment (%) 95% 100.0% 100.0% 99.1% 100.0% 98.8% 98.3% N/A

CPA 12 Month Reviews (%) 95% 96.5% 96.3% 96.3% 96.6% 95.8% 96.4% N/A

MHLT: 1 Hour Compliance (%) 95% 61.4% 67.7% 71.9% 67.2% 72.1% 77.2% Mental Health Improvement

Plan

MHLT: 4 Hour Compliance (%) 95% 90.2% 94.1% 94.5% 91.6% 96.4% 96.0% Mental Health Improvement

Plan

MHLT: Number of 12 Hour Breaches (includes S&O) 0 109 96 91 37 33 21 Mental Health Improvement

Plan

MHLT: % of 12 Hour Breaches (includes S&O) 0% 4.5% 4.1% 3.4% 3.8% 4.0% 2.4% Mental Health Improvement

Plan

MHLT: Longest Stay 12 Hour Breach N/A 221:14 213:06 216:16 91:38 74:47 49:51 Mental Health Improvement

Plan

MHLT: Average Length of Stay 12 Hour Breach N/A 87:01 83:17 70:54 30:12 21:03 19:39 Mental Health Improvement

Plan

Number of Section 135 Breaches (24 hrs) 0 7 3 2 2 0 0 Mental Health Improvement

Plan

% of Section 135 Breaches (24 hrs) 0% 58.3% 17.6% 20.0% 40.0% 0.0% 0.0% Mental Health Improvement

Plan

Number of Section 136 Breaches (24 hrs) 0 130 67 43 21 13 9 Mental Health Improvement

Plan

% of Section 136 Breaches (24 hrs) 0% 35.3% 18.5% 13.7% 17.6% 16.3% 7.8% Mental Health Improvement

Plan

Longest Stay Section 136 Breach N/A 808:36 519:39 262:28 114:50 70:28 77:10 Mental Health Improvement

Plan

Average Length of Stay Section 136 Detentions N/A 285:52 214:27 134:24 50:45 42:27 41:12 Mental Health Improvement

Plan

SPC Available March 2020






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National / Contractual Indicators (continued)


Occupancy % - Mental Health Network (LCFT only) 85% 99.9% 98.1% 96.6% 97.1% 96.9% 95.9% Mental Health Improvement

Plan

Occupancy % - Perinatal Mental Health 85% 73.1% 92.4% 96.3% 93.5% 97.5% 98.0% Mental Health Improvement

Plan

Occupancy % - The Cove >70% <85% 91.2% 47.6% 60.2% 49.5% 65.7% 65.4% N/A

Readmission Rates % - 30 days <8.7% 7.4% 5.0% 6.6% 5.9% 8.0% 5.9% N/A

Readmission Rates % - 90 days <15% 15.7% 9.1% 9.7% 7.6% 13.2% 8.3% N/A

Eating Disorders: Percentage of Under 19s seen in 1 week (Urgent) 75% 61.5% 50.0% 100.0% 100.0% 100.0% 100.0%

Eating Disorders: No. of Under 19s seen over 1 week (Urgent) 0 5 5 0 0 0 0 N/A

Eating Disorders: Percentage of Under 19s seen in 4 weeks (Routine) 85% 72.2% 95.2% 96.1% 90.9% 100.0% 100.0%

Eating Disorders: No. of Under 19s seen over 4 weeks (Routine) 0 15 2 2 2 0 0 N/A

Acute & PICU OAPs OBDs 465 5299 2624 4977 1654 1851 1472 Mental Health Improvement

Plan

Children and Young People's OAPs OBDs N/A 121 92 23 23 0 0 N/A N/A

CYP Improving Access to CAMHS: No. of CYP receiving Treatment (Total number of CCG's compliant/Total number of CCG's)

8/8 8/8 8/8 8/8 8/8 8/8 8/8 N/A

SPC Available November 2020

SPC Not Applicable

Slide 23

Slide 23

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National / Contractual Indicators (continued)


Children's Community RTT (combined CITNS) 92% 80.7% 75.4% 78.7% 77.4% 77.3% 81.5%

Children's Mental Health RTA (combined CAMHS and CPS) 92% 91.3% 82.9% 84.6% 83.5% 83.3% 87.0%

ADHD - All < 18 Weeks 92% 27.8% 27.5% 27.3% 25.8% 26.3% 29.7%

ADHD - Number of Actual Referrals (Cumulative) 417 269 566 866 673 779 866

IAPT Prevalence - Cumulative Target (End of Quarter 4 target is 19.0%) 14.25% 4.1% 8.3% 11.8% 9.6% 10.7% 11.8%

Adult Community Services - AHP RTT 92% 99.7% 99.7% 99.9% 99.8% 99.8% 100.0% N/A

Southport & Formby - AHP RTT 92% N/A N/A N/A 99.0% 99.0% 99.0% N/A

PBR Clustering - Any Cluster 95% 94.3% 93.4% 93.1% 93.3% 93.1% 92.8% N/A

Contract Variance: Mental Health Contract ±10% N/A N/A N/A -8.4% -8.8% -8.8% N/A

Contract Variance: Community Contract ±10% N/A N/A N/A 3.0% 3.0% 3.0% N/A

Contract Variance: Community Contract (Southport & Formby) ±10% N/A N/A N/A 10.0% 9.0% 5.0% N/A

Contract Variance: Children's Community Contract (baselines to be agreed for 19/20) ±10% N/A N/A N/A - - - N/A


SPC Not Applicable

SPC Not Applicable

SPC Not Applicable

SPC Not Applicable

SPC Not Applicable


Slide 24

Slide 24

Slide 23

Slide 23

Slide 22

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9

Note: IAPT Waits (>26 week waits) quarterly positions are a snapshot figure at the end of the quarter Exception reports are not included for those measures associated with the acute care pathway, as information is included within the Mental Health Improvement Plan paper instead;

MHDU Breaches no longer being reported. These beds have now closed in response to the CQC

Slide 22

Trust Indicators


% MHLT Referrals known to service (currently open) N/A N/A 42.5% 64.4% 62.5% 58.9% 71.9% Mental Health Improvement

Plan

% MHLT Referrals Where Alcohol/Substance Misuse is a Factor N/A N/A 20.2% 17.7% 36.4% 40.0% 40.9% Mental Health Improvement

Plan

Crisis/HTT - Open Referrals to Service in Month (All Teams) N/A 2456 2084 2201 776 709 716 N/A

Crisis/HTT - Total Number of Contacts N/A 23,993 25,009 25,086 8,091 8,403 8,592 N/A

Delayed Discharges (Number of Formal Delays) 39 2 2 24 3 4 24 N/A

Number of Ward Discharges (Acute Only) N/A 224 291 341 96 125 120 Mental Health Improvement

Plan

Stranded Patients (120-150 days) - Mental Health Network N/A 74 90 71 24 21 26 N/AMental Health Improvement

Plan

Stranded Patients (150-180 days) - Mental Health Network N/A 57 53 57 23 19 15 N/AMental Health Improvement

Plan

Superstranded Patients (180+ days) - Mental Health Network 10 197 122 181 58 62 61 Mental Health Improvement

Plan

IAPT Waits (>26 week waits) 0 100 124 81 68 42 81


SPC Available July 2020

SPC Available July 2020




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1. Summary DashboardsSouth Cumbria Monthly Metrics Dashboard

10

NHS Improvement IndicatorsIndicator Target Q1 19-20 Q2 19-20 Q3 19-20 Oct-19 Nov-19 Dec-19 Variation Assurance Narrative Included

MR01 - 7 Day Follow Up 95% 100.0% 89.9% 90.7% 80.0% 94.1% 100.0%





MR16 - Inappropriate AMH OAPs OBDs (monthly target) 1.66 1045 465 161 9 78 74 N/A

MR17 - DQMI Dataset Score (Self Assessment) 95% 91.3% 92.3% 92.9% 92.9% 81.6% 82.3% N/A


MR20 - Under 16s Admissions to Adult Facilities 0 0 0 0 0 0 0 N/ASPC Not Applicable

N/A

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1. Summary DashboardsSouth Cumbria Monthly Metrics Dashboard

11



CPA Reviews Within 12 Months 95% 95.6% 97.3% 97.4% 98.0% 98.9% 95.2% N/A


CPA 3 Day Follow Up 80% - - 83.1% 90.0% 88.9% 71.4% N/A

IAPT Prevalence - Cumulative Target (End of Quarter 4 target is 16.8%) 12.60% 5.18% 9.72% 13.37% 10.88% 12.27% 13.37% N/ASPC Not Applicable

SPC Not Applicable

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1. Summary DashboardsLancashire & South Cumbria Monthly Metrics Dashboard

12

Note: DQMI Combined Unavailable for September 2019. This was due to a reporting issue when adding in the new measures,

NHS Improvement Indicators


MR01 - 7 Day Follow Up 95% 97.6% 95.4% 96.1% 94.8% 96.9% 96.7%





MR16 - Inappropriate AMH OAPs OBDs (monthly target) 217 6329 2999 5137 1663 1929 1545 N/A


MR20 - Under 16s Admissions to Adult Facilities 0 0 0 0 0 0 0 N/ASPC Not Applicable

N/A

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1. Summary DashboardsLancashire & South Cumbria Monthly Metrics Dashboard

13



CPA Reviews Within 12 Months 95% 96.4% 96.3% 96.3% 96.7% 95.9% 96.4% N/A


CPA 3 Day Follow Up 80% - - 84.1% 84.6% 86.4% 81.5% N/A

IAPT Prevalence - Cumulative Target (End of Quarter 4 target is XX %) N/AData not available for Lancashire & South Cumbria

SPC Not Applicable

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1. Summary DashboardsTrust Quality Monthly Metrics DashboardSafety

14

Note: The figures taken from the NHS benchmarking report for use as a national target are for the full year 2018/2019. These will be updated in November 2020 following publication of the 2019/2020 report

Slide 26

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15


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16


Slide 27

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17


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1. Summary DashboardsTrust Quality Monthly Metrics DashboardEffectiveness

18


Slide 28

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1. Summary DashboardsTrust Quality Monthly Metrics DashboardExperience

19


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1. Summary DashboardsTrust Quality Monthly Metrics DashboardExperience

20


Slide 29

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Performance ActivitySection 2.

21

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2. Performance ActivityCommunity Wellbeing – IAPT Prevalence & IAPT Waits

22

IAPT: Actions:IAPT PrevalenceOnly Chorley South Ribble achieved the access target in December. The total number of referrals into the service has reduced again in December and also remains lower than the required amount in month. 2,052 new assessments were undertaken in December, against a target of 2562 new assessments per month.

Service wide: The year to date target is 25,609, to date the service have undertaken 23,137 new assessments, a shortfall of 2472.

Issues uncovered in lower number of referrals month on month, yet the impact on waits does not correlate with this. Requirement for centralised wait management role under discussion.

IAPT WaitsWaits over 26 weeks have increased and additional measures have been put in place to recover performance including weekly reporting on actions taken to address long waits. Centralised mechanism required for booking appointments being investigated to ensure consistency. Waits over 26 weeks at 81 at the end of month 9. Total Waits including Non-IAPT at 118 at the end of month 9.

• Communication, media and promotional materials are in development. Co-design session is booked in January and all promotional materials will be ready in February. Mindsmatter Twitter account now set up and website is live and being reviewed and updated.

• A targeted piece of work to review the number of referrals per GP practice has been shared with CCGs, teams have now reviewed the 5 lowest referring areas to target some promotional activities.

• Refine SOPs for DNAs and cancellations to avoid ambiguity and to ensure standardised practice across teams

• Create a SOP to ensure a standardised number of new appointments per week, per modality to ensure effective client flow

• Implement a screening tool to aid clinician's decision making and ensure that only clients who will benefit from an IAPT intervention are accepted in to the service

• Formalise "community" offer with other third sector mental health community providers• Review alternatives to 1:1 therapy offer to include an increased group offer, consistent across

localities• Review number of sessions which exceed the recommended standard for each modality, with a

view to implementing a consistent offer.• To maintain contact with clients whilst they are waiting for treatment to understand their status

and potential changing requirements• To address disparities in pay between LSCFT and other IAPT providers. (This has had an

impact on waiting times as the service has struggled to recruit to posts and to retain staff, meaning capacity has not been maximised)

• To increase the digital offer to release some of the estates burden.

Note: IAPT Waits – St Helens is not included in the SPC charts as going forward we will no longer report these numbers

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2. Performance Activity Children & Young People’s Wellbeing – Eating Disorders and ADHD

23

Narrative: Actions:Fourteen young people under the age of 19 were seen for non-urgent input in Month 9 and all were seen within 4 weeks. This has resulted in a rolling 3 month position of 96.1%.

The ADHD service continues to underperform against the RTT. In M9, 29.7% of patients are currently waiting less than 18 weeks for assessment.

There have been 87 referrals in M9, this is a total of 866 so far in 2019/20 compared to the contracted number of 556 per annum.

Further to the Trust Board paper submitted in January 2020 we have had informal contact from the lead CCG to confirm that commissioners are in agreement to terminate the current contract by mutual agreement, with a notice period to be agreed and the CCG are likely to tender the service out at the current financial envelope going forward.

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2. Performance ActivityChildren & Young People’s Wellbeing – CITNS RTT & CAMHS Referral to Assessment

24

Narrative: Actions:

In month 9, the CITN service continues to underperform against the 92% target.

Workforce challenges remain the primary driver for performance in occupational therapy, alongside some increase in demand Staffing challenges, turnover, delays due to some (on occasion repeated) unsuccessful attempts at recruitment, internal promotion and maternity leave. This is exacerbated by slow recruitment processes which can take 6 to 8 weeks to progress individual requests to recruit.

The recovery trajectory has been updated for Month 9

In month 9 the referral to assessment performance for CAMHS/CPS teams did not achieve the 92% target. The number of service users waiting over 18 weeks has decreased in month 9 by 33 but the overall waiting list has also increased by 33. Of the 7 teams within the Emotional Wellbeing service, 6 are currently achieving the 92% 18 week RTT standard. The teams which are not achieving 92% is: Chorley, South Ribble (CSR) at 72.3%.

The network is in the process of implementing the age increase in community CAMHS services to achieve a 0-19 offer, but recruitment is proving challenging in relation to meeting the original timescale of February 2020

The network is in discussion with Healios, an online service which can offer the whole CAMHS pathway (for those children and young people suitable for this method of delivery) or specific therapies such as CBT and family therapy. Healios already work with BTH and have a pilot scheme for CBT in Morecambe bay. A pilot with Healios is currently under negotiation having been the subject of engagement with clinicians in the network over recent weeks

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QualitySection 3

25

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3. Quality Safety – Exception

No. of Incidents with Harm

26

No. of Incidents with Harm

There has been an increase in reported incidents of low harm and a decrease in incidents of no harm. Incidents of moderate, severe and catastrophic harm have all reduced in December, possibly due to greater scrutiny of moderate harm and above incidents on the daily safety call and staff education re levels of harm. Overall month on month incident reporting is relatively static

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3. Quality Safety – Exception

Physical Violence (with harm) to Staff From Patients

27

Physical Violence (with harm) to Staff From Patients

The majority of these are low harm incidents with a slight reduction in the total number of incidents of moderate and severe harm. Approximately half of all the incidents occur in 6 wards with Wordsworth ward reporting twice as many incidents as other 5 wards. The second highest reporter for the quarter is Ramsey Ward, also a ward for older adults.

There appears to be a gradual increase in reporting across a number of areas with no particular hotspot for December.

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3. Quality Effective – Exception

Section 132 rights attempted in 24 hours

28

Section 132 rights attempted in 24 hours

Work is ongoing to improve compliance with Section 132 rights in inpatient services. This is being reported to the Mental Health Network SLT on a weekly basis and via the Inpatient Practice Development Group.

S132 compliance for inpatients is monitored on NerveCentre. Currently a report is being developed by the BI team in collaboration with the Mental Health Law Team to ensure that information is able to be extracted in a practical way. The Mental Health LawTeam also provide daily compliance reports to the ward managers and matrons/lead nurses.

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3. Quality Experience – Exception

Complaints Completed Within Agreed Timeframe (%)

29

Complaints Completed Within Agreed Timeframe (%)

Compliance below expected range – this is again due to a concerted effort to reduce the number of cases that have been overdue for some time. This has now reduced significantly and we can expect a continued trajectory of improvement. To achieve this, the Hearing Feedback Team are continuing to work collaboratively with the Investigation Leads in the Networks, with an increased focus on moving responses forwards within the process.

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30

3.1 CQUINExecutive Summary

Note: Once the outcome of submissions have been formalised, the values will turn red for confirmed loss and green for confirmed funding. Schemes that have been risk rated as Amber in the Quality & Safety Sub-Committee report are assumed to be achieved and included in the expected CQUIN values.

CQUIN scheme Summary 2019/20

Dec-19

Scheme Plan % expected £ expected

£ Loss/

concern £ Total % expected £ expected

£ Loss/

concern £ Total

2Staff Flu Vaccinations £786,762 0% £0 £0 £0 0% £0 £0 £0

3aAlcohol and Tobacco a) Screening £212,299 100% £53,075 £0 £53,075 100% £53,075 £0 £53,075

3bAlcohol and Tobacco b) Tobacco Brief Advice £212,299 100% £53,075 £0 £53,075 100% £53,075 £0 £53,075

3cAlcohol and Tobacco c) Alcohol Brief Advice £212,299 100% £53,075 £0 £53,075 100% £53,075 £0 £53,075

472hr Follow up Post Discharge £485,696 0% £0 £0 £0 0% £0 £0 £0

5aMental Health Data: Data Quality Maturity Index £222,136 0% £0 £0 £0 0% £0 £74,045 £74,045

5bMental Health Data: Interventions £222,136 0% £0 £0 £0 0% £0 £0 £0

6Use of Anxiety Disorder Specific Measures in IAPT £421,127 0% £0 £0 £0 71% £99,867 £40,508 £140,376

SP1Southport & Formby Local CQUIN - CHC/PHB £79,541 0% £0 £0 £0 100% £26,514 £0 £26,514

7Three high impact actions to prevent Hospital Falls (Longridge only) £221,525 100% £55,381 £0 £55,381 100% £55,381 £0 £55,381

IMSK1Shared Decision Making £90,913 100% £22,728 £0 £22,728 100% £22,728 £0 £22,728

L&D1Personalised Care and Support Planning within Liaison & Diversion Services. £57,356 100% £14,339 £0 £14,339 100% £14,339 £0 £14,339

NHSE1Secure – Healthy Weight in Adult Services £363,078 100% £90,770 £0 £90,770 100% £90,770 £0 £90,770

NHSE2CAMHS PSS Inpatient Staff Training £50,757 100% £12,689 £0 £12,689 100% £12,689 £0 £12,689

NHSE3Perinatal £28,494 0% £0 £0 £0 100% £9,498 £0 £9,498

Total £3,666,420 100% £355,132 £0 £355,132 81% £491,011 £114,554 £605,565

Network Plan % expected £ expected

£ Loss/


£ Loss/

concern £ Total

Mental Health £1,973,543 100% £210,390 £0 £210,390 78% £219,888 £62,852 £282,740

Community Wellbeing £1,336,313 100% £132,052 £0 £132,052 85% £258,433 £44,366 £302,799

South Cumbria £129,138 £0 £0 £0 £0 £0 £0

Children & Young People £227,426 100% £12,689 £0 £12,689 63% £12,689 £7,336 £20,025

Total £3,666,420 100% £355,132 £0 £355,132 81% £491,011 £114,554 £605,565

Qtr 2Qtr 1

Qtr 1 Qtr 2

119 of 188

31

3.1 CQUINExecutive Summary

Narrative:• The schemes and profiling for 2019/20 have been split to network level as summarised above. South Cumbria is now included in the above with a

CQUIN value of £129k split between CQUIN 2 and 4 and full payment is expected.• For all other contracts:• Current achievement for flu vaccinations is 72% and to ahieve full payment reaching above 80% is required before the end of the financial year, this is

currently on target to achieve. • Scheme 5a is a challenge and leads are working on how this can be achieved, early indications would indicate full loss for the year of £222k. The clinical

networks need to complete the data set provided by the BI report which will lead to an improved position. The current reporting is achieving 79% to recieve full payment over 95% is required. BI review found a number of fields that require manual population with actions to achieve this in place.

• Scheme 6 Use of Anxiety Specifc Measures in IAPT is at risk of not being fully achieved with current reports indicate that we would receive a partial loss in Q2 & Q3. The remainder of the financial year it is assumed that the targets will be met.

CQUIN scheme Summary 2019/20

Dec-19

Scheme Plan % expected £ expected

£ Loss/


£ Loss/


£ Loss/

concern £ Total

2Staff Flu Vaccinations £786,762 0% £0 £0 £0 100% £786,762 £0 £786,762 100% £786,762 £0 £786,762

3aAlcohol and Tobacco a) Screening £212,299 100% £53,075 £0 £53,075 100% £53,075 £0 £53,075 100% £212,299 £0 £212,299

3bAlcohol and Tobacco b) Tobacco Brief Advice £212,299 100% £53,075 £0 £53,075 100% £53,075 £0 £53,075 100% £212,299 £0 £212,299

3cAlcohol and Tobacco c) Alcohol Brief Advice £212,299 100% £53,075 £0 £53,075 100% £53,075 £0 £53,075 100% £212,299 £0 £212,299

472hr Follow up Post Discharge £485,696 100% £242,848 £0 £242,848 100% £242,848 £0 £242,848 100% £485,696 £0 £485,696

5aMental Health Data: Data Quality Maturity Index £222,136 0% £0 £74,045 £74,045 0% £0 £74,045 £74,045 0% £0 £222,136 £222,136

5bMental Health Data: Interventions £222,136 100% £111,068 £0 £111,068 100% £111,068 £0 £111,068 100% £222,136 £0 £222,136

6Use of Anxiety Disorder Specific Measures in IAPT £421,127 91% £128,344 £12,032 £140,376 100% £140,376 £0 £140,376 88% £368,587 £52,541 £421,127

SP1Southport & Formby Local CQUIN - CHC/PHB £79,541 100% £26,514 £0 £26,514 100% £26,514 £0 £26,514 100% £79,541 £0 £79,541

7Three high impact actions to prevent Hospital Falls (Longridge only) £221,525 100% £55,381 £0 £55,381 100% £55,381 £0 £55,381 100% £221,525 £0 £221,525

IMSK1Shared Decision Making £90,913 100% £22,728 £0 £22,728 100% £22,728 £0 £22,728 100% £90,913 £0 £90,913

L&D1Personalised Care and Support Planning within Liaison & Diversion Services. £57,356 100% £14,339 £0 £14,339 100% £14,339 £0 £14,339 100% £57,356 £0 £57,356

NHSE1Secure – Healthy Weight in Adult Services £363,078 100% £90,770 £0 £90,770 100% £90,770 £0 £90,770 100% £363,078 £0 £363,078

NHSE2CAMHS PSS Inpatient Staff Training £50,757 100% £12,689 £0 £12,689 100% £12,689 £0 £12,689 100% £50,757 £0 £50,757

NHSE3Perinatal £28,494 100% £9,498 £0 £9,498 100% £9,498 £0 £9,498 100% £28,494 £0 £28,494

Total £3,666,420 91% £873,403 £86,077 £959,481 96% £1,672,198 £74,045 £1,746,243 93% £3,391,744 £274,676 £3,666,420

Network Plan % expected £ expected

£ Loss/


£ Loss/


£ Loss/

concern £ Total

Mental Health £1,973,543 89% £502,721 £62,852 £565,573 93% £851,988 £62,852 £914,840 90% £1,784,988 £188,555 £1,973,543

Community Wellbeing £1,336,313 95% £292,696 £15,890 £308,585 99% £589,020 £3,857 £592,877 95% £1,272,201 £64,113 £1,336,313

South Cumbria £129,138 100% £32,285 £0 £32,285 100% £96,854 £0 £96,854 100% £129,138 £0 £129,138

Children & Young People £227,426 86% £45,702 £7,336 £53,038 95% £134,336 £7,336 £141,673 90% £205,417 £22,009 £227,426

Total £3,666,420 91% £873,403 £86,077 £959,481 96% £1,672,198 £74,045 £1,746,243 93% £3,391,744 £274,676 £3,666,420

Full YearQtr 4Qtr 3

Qtr 3 Qtr 4 Full Year

120 of 188

WorkforceSection 4

32

121 of 188

4. Workforce

33

Section 4:-

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

122 of 188

KPI PERFORMANCE OVERVIEW

The HR and L&OD Key Performance Indicators have been devised to update the Trust Board on the Trusts current performance against the agreed key workforce indicators and highlight any areas of concern and provide assurance by identifying the action taken to mitigate risk and improve performance.

Key Performance Indicators Trust Target 2019 11 2019 12

Trend

(Against

Previous

Month)

Total Workforce Expenditure£22,296,679

Budget£22,348,746 £22,449,164 p

Peripheral Workforce Reliance (Bank, Agency & Locum spend % of Total Pay Spend)

6.0% 11.51% 12.55% p

Operational Gap 5.0% 2.71% 2.56% q

Sickness Absence 4.5% 6.93% 7.52% p

Vacancy Rate 5.0% 8.82% 9.51% p

Turnover Rate 10.0% 15.61% 15.96% p

Appraisal Performance 80.0% 85.33% 86.91% p

Mandatory & Statutory Training

Compliance 80.0% 83.79% 89.52% p

Key Performance Indicators Trust Target 2019 Q1 2019 Q2

Trend

(Against

Previous

Quarter)

Engagement 7.40 7.00 6.80 q

Wellbeing 51.19% 50.63% q123 of 188

WORKFORCE EXPENDITURE

Total Workforce Expenditure against Established Budget

The HR and L&OD Key Performance Indicators have been devised to update the Trust Board on the Trusts current performance against the agreed key workforce indicators and highlight any areas of concern and provide assurance by identifying the action taken to mitigate risk and improve performance.

Workforce Expenditure against Established Budget

0

5

10

15

20

25

2019 10 2019 11 2019 12

£ m

illio

ns

Medical Agency

Agency

Bank

Core

Budget

Source Data: EFIN FinanceLedger

Business Area Established Budget £'sSpend on Core

Workforce £'s

Spend on Peripheral

Workforce £'s

Total Spend on

Workforce £'s

Budget & Expenditure

Variance £'s

Trend

(Against

Previous

Month)

Trust 22,296,679 19,630,675 2,818,489 22,449,164 152,484 q

Mental Health 11,179,075 9,344,075 2,023,474 11,367,549 188,474 p

Community & Wellbeing 4,715,538 4,415,915 361,408 4,777,324 61,786 q

Children & Young People 2,439,395 2,275,517 161,809 2,437,326 -2,069 q

South Cumbria 1,453,040 1,199,841 193,041 1,392,882 -60,158 q

Support Services 2,509,631 2,395,326 78,757 2,474,083 -35,548 q

124 of 188

Bank & Agency Pay Spend by Business Area

Agency & Bank spend is calculated as a percentage ofthe total salary spend.

Usually, a link can be seen between the level ofexpenditure on peripheral workforce (Bank, Agency andLocum), the Vacancy Rate, Sickness Absence andOperational Gap.

PERIPHERAL WORKFORCE RELIANCE

Spend £ % Spend £ % Spend £ %

Trust 19,400,483 1,679,741 7.6% 561,743 2.5% 428,434 1.9% 2,669,917 22,070,400 12.10%

Mental Health 9,181,594 1,437,410 12.9% 256,233 2.3% 230,677 2.1% 1,924,321 11,105,915 17.33%

Community & Wellbeing 4,459,621 150,818 3.1% 173,544 3.6% 79,169 1.6% 403,531 4,863,152 8.30%

Children & Young People 2,287,717 6,724 0.3% 11,690 0.5% 59,242 2.5% 77,656 2,365,373 3.28%

South Cumbria 1,197,702 23,344 1.7% 115,320 8.3% 59,345 4.3% 198,009 1,395,711 14.19%

Support Services 2,273,848 61,444 2.6% 4,957 0.2% 0 0.0% 66,401 2,340,249 2.84%


Trust 19,776,471 1,714,533 7.7% 479,713 2.1% 378,029 1.7% 2,572,275 22,348,746 11.51%

Mental Health 9,431,253 1,391,935 12.5% 204,154 1.8% 133,024 1.2% 1,729,114 11,160,367 15.49%



South Cumbria 1,141,421 68,392 5.0% 63,927 4.7% 100,750 7.3% 233,069 1,374,490 16.96%


Total Core

Workforce

Spend £

2019 10

Flexible

Labour

Reliance %Business Area

Bank Agency Medical AgencyTotal

Peripheral

Workforce

Spend £

Total Spend £

Total Core

Workforce

Spend £

2019 11

Flexible

Labour



Peripheral

Workforce

Spend £

Total Spend £

125 of 188

Bank, £2,156,

200

Agency, £385,19

0

Medical Agency, £277,09

8





Bank & Agency Pay Spend

Overview:Spend on Peripheral Workforce has increased in December, when compared withOctober and November performance and closes the month with a 12.55% reliancerate. Not all areas have experienced an increase in use, with Community andWellbeing and South Cumbria Networks reporting a reduction in spend. The MentalHealth Network have predominantly engaged LSCFT Bank Workforce and report asignificant reduction in spend on Medical Agency Locums. The remaining Networkspresent a more varied picture in respect of the balance in use of Bank and Agencyworkforce, with the highest spend on Medical Agency in South Cumbria and Childrenand Young People.


Trust 19,630,675 2,156,200 9.6% 385,190 1.7% 277,098 1.2% 2,818,489 22,449,164 12.55%

Mental Health 9,344,075 1,788,258 15.7% 207,345 1.8% 27,870 0.2% 2,023,474 11,367,549 17.80%



South Cumbria 1,199,841 54,638 3.9% 48,080 3.5% 90,323 6.5% 193,041 1,392,882 13.86%


Total Core

Workforce

Spend £

2019 12

Flexible

Labour



Peripheral

Workforce

Spend £

Total Spend £

126 of 188





Mental Health Network: Peripheral workforce reliance has increased inDecember.

No Network Information Provided

Children and Young Peoples Wellbeing Network: Decemberreports a n increase in Peripheral workforce reliance for a secondmonth, this increase is attributed, in part, to the use of a Medic in EIS,who commenced work in November, and an increase in thedeployment of Bank Nursing workforce in Community CAMHS.

Increase in Bank Workforce deployment in Community CAMHS isin place to cover new substantive Nursing Vacancies within theservice. There are 15FTE vacancies to be filled, linked to theincrease in age range for CAMHS to 19. Recruitment to fill isactive.

Network Hot Spot Analysis:

Community & Wellbeing Network: Overall spend on PeripheralWorkforce reports a reduction in spend in December for the network.This decrease is attributable to decrease in the use of Agency workforcefor Clinical, Non-Medical workforce in month. Both Pennine and Mindsmatter are overachieving target for peripheral

workforce reliance and this is attributable to the filling of vacancies andreduction in Sickness Absence.

Significant increase in use of agency sessional Dentists, in place toreduce wait lists.

Whilst Moving Well Service usage continues to remain high in thenetwork, this month has seen improvement and this is attributable to areduction in Rheumatology Agency and Clinical Admin.

Rheumatology continues to overspend due to Locum Consultant coverand an increase in spend on Diagnostics . The overspend is being metby underspend in other services.

Reduction in Podiatry Agency Usage. Reduction in bank use in SPoA and District Nursing in Southport

127 of 188

OPERATIONAL GAPOperational Gap is the measure of absences that affect operational performance otherthan Sickness and Annual Leave.This section of the report considers employees who are absent from operational workfor the following reasons: Career Break, Maternity & Adoption, Paternity, Out onExternal Secondment (Paid), Out on External Secondment (Unpaid), Suspend No Pay,Suspend With Pay.

Source Data: ESR

0.00

50.00

100.00

150.00

200.00

2019 01 2019 02 2019 03 2019 04 2019 05 2019 06 2019 07 2019 08 2019 09 2019 10 2019 11 2019 12

FTE

Mental Health Community & Wellbeing Children & Young People Support Services

Operational Gap by Business Area – 12 Month Trend

Indicator Heads FTE

Total Workforce 6536 5834.80

Mat / Adoption Leave 125 112.12

Career Break 11 9.77

Secondment 4 4.20

Suspension 4 3.29

Sickness Absence 472 416.64

Annual Leave 1102 984.55

Total Workforce Gap 1718 1530.56

Active76.1%

Annual Leave15.4%

Sickness Absence

6.5%

Mat / Adoption

Leave 1.8%

Career Break0.2%

Secondment0.1%Other

0.4%

Total Operational Gap Analysis, by Reason – Position at Month End

128 of 188

OPERATIONAL GAP

Source Data: ESR Operational Gap by Business Area – Monthly Actuals by Business Area

Operational Gap is the measure of absences that affect operational performance otherthan Sickness and Annual Leave.This section of the report considers employees who are absent from operational workfor the following reasons: Career Break, Maternity & Adoption, Paternity, Out onExternal Secondment (Paid), Out on External Secondment (Unpaid), Suspend No Pay,Suspend With Pay.

FTE

(Average in

Month)

Average No

Absent

Employees

Gap FTE

(Average in

Month)

Average No

Absent

Employees

Gap FTE

(Average in

Month)

Average No

Absent

Employees

Gap

Trust 5463.69 158.00 2.89% 5831.59 149.12 2.56% 5825.36 143.63 2.47%

Mental Health 2668.77 53.00 1.99% 2683.39 49.55 1.85% 2669.15 49.00 1.84%

Community & Wellbeing 1445.82 50.00 3.46% 1425.97 50.55 3.55% 1427.02 45.45 3.19%

Children & Young People 669.79 26.00 3.88% 673.71 22.66 3.36% 678.81 24.73 3.64%

South Cumbria - - - 355.41 10.91 3.07% 351.71 9.91 2.82%

Support Services 679.31 17.00 2.50% 693.11 15.44 2.23% 698.68 14.53 2.08%

Business Area

2019 10 2019 11 2019 12

129 of 188

Vacancy Management Network Rates and 3 Month Performance Comparison

The Vacancy Rate presents the % difference between the Trusts budgeted establishmentand its actual spent establishment. This measurement has been based on FTE and isone of the measures referenced when assessing core workforce stability.

To enhance this measure, the Active Vacancy Rate has been supplied. This ratehighlights the % of budgeted establishment vacancies that are being actively recruited toby the organisation.

VACANCY RATE

Source Data: EFIN and ESR

0.00%

5.00%

10.00%

2019 10 2019 11 2019 12

Vac

ancy

Rat

e

Vacancy Rate & WTE – Monthly Actuals by Business Area

BE FTE FTE In Post BE VR AVR BE FTE FTE In Post BE VR AVR BE FTE FTE In Post BE VR AVR

Trust 6388.65 5836.30 8.65% 184.88% 6399.05 5834.71 8.82% 188.09% 6441.17 5828.75 9.51% 179.48%

Mental Health 3024.32 2673.54 11.60% 157.21% 3049.92 2685.19 11.96% 165.16% 3060.11 2670.95 12.72% 160.50%

Community & Wellbeing 1553.88 1447.67 6.84% 221.53% 1528.78 1425.97 6.73% 219.52% 1526.16 1427.02 6.50% 226.79%

Children & Young People 681.80 669.79 1.76% 1041.57% 686.91 673.45 1.96% 909.29% 713.90 678.81 4.92% 378.39%

South Cumbria 390.42 364.40 6.66% - 393.42 355.41 9.66% 52.09% 398.22 351.71 11.68% 54.35%

Support Services 738.23 680.90 7.77% 164.57% 740.02 694.70 6.12% 201.11% 742.78 700.26 5.72% 215.73%

Business Area2019 10 2019 11 2019 12

130 of 188

Vacancy Management

VACANCY RATE

Source Data: EFIN and ESR

Network Hot Spot Analysis:Children & Young People's Wellbeing Network: The BudgetedEstablishment Vacancy Rate has significantly increased in Decemberfor the Network. This is due to the release of new funding (26.70FTE)into CAMHS 16-19 services related to the increase in age range to 19. The Network continues to experience significant challenges in

recruiting and retaining CAMHS practitioner and Clinical Psychologist populations. The network is considering the use of attraction packages / methods with the Employment Services team to address these and, alongside this, engagement and partnership opportunities with Further Education Colleges.

The Vacancy Rate presents the % difference between the Trusts budgeted establishmentand its actual spent establishment. This measurement has been based on FTE and isone of the measures referenced when assessing core workforce stability.

To enhance this measure, the Active Vacancy Rate has been supplied. This ratehighlights the % of budgeted establishment vacancies that are being actively recruited toby the organisation.

Community & Wellbeing Network: The Budgeted EstablishmentVacancy Rate has continued to improve through December. Mind,delivered through a commitment to recruit to turnover in Network targetareas. The Network continue to carry some long standing, hard to fill,vacancies in therapy and admin workforce. Two Network areas continue to exceed Trust targets for

recruitment and retention. Pennine and North report success this month with their recruitment

to District Nursing Posts Recruitment challenges remain within Dental services and a number

of vacancies are not being replaced due to live tenders for Specialistand Urgent Care services.

Central and West are experiencing challenges in recruitingtherapies, especially Physio and S&L therapists, Frailty ANP’s andDN Team Leaders.

Vacancies in Admin in Central and West remain high and contributeto increase sickness absence and bank spend.

Podiatry Vacancies continue to present a challenge across thenetwork – Apprenticeships in podiatry are being explored as a wayto respond to this challenge.

Mental Health Network: The Budgeted Establishment Vacancy Ratehas increased against the November position and reports 12.72% inDecember. This is due to introduction of extra funding into theestablishment and a reduction in FTE in post


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Turnover – 12 Month Trend

The Turnover Rate is one of the indicators used to assess employee satisfaction with theTrust. It is presented as a rolling 12 month figure, calculated at the end of each reportingperiod and is calculated as follows:Total number of leavers ÷ total number of contracted employees.To provide the Board with a true picture of turnover activity in the Organisation, threemeasures of turnover are reported: Overall Trust Turnover, BAU Turnover and TUPETransfer Turnover.

TURNOVER

Source Data: ESR

Resignation52.9%

TUPE20.3%

Retirement19.6%

End of FTC4.6%

Dismissal2.0%

Ill Health Retirement

0.7%

BAU Turnover, 7.48%

TUPE Turnover, 8.47%

All Turnover, 15.96%

0.00%2.00%4.00%6.00%8.00%

10.00%12.00%14.00%16.00%18.00%20.00%

2019 01 2019 02 2019 03 2019 04 2019 05 2019 06 2019 07 2019 08 2019 09 2019 10 2019 11 2019 12

BAU Turnover TUPE Turnover All Turnover

Business AreaHeadcount

2019 122019 10 2019 11 2019 12

Trust 5,805 15.39% 15.61% 15.96%

Mental Health 2,669 5.24% 5.38% 5.93%

Community & Wellbeing 1,427 15.86% 16.70% 16.71%

Children & Young People 679 65.12% 64.01% 62.76%

South Cumbria 352 1.40% 3.12% 4.15%

Support Services 679 10.14% 9.95% 10.62%

132 of 188

The Turnover Rate is one of the indicators used to assess employee satisfaction with theTrust. It is presented as a rolling 12 month figure, calculated at the end of each reportingperiod and is calculated as follows:Total number of leavers ÷ total number of contracted employees.To provide the Board with a true picture of turnover activity in the Organisation, threemeasures of turnover are reported: Overall Trust Turnover, BAU Turnover and TUPETransfer Turnover.

TURNOVER

Source Data: ESR

Leaving Reasons for Month

Leavers in Quarter by Staff Group

Business Area

Add Prof

Scientific and

Technic

Additional

Clinical Services

Administrative

and Clerical

Allied Health

Professionals

Estates and

Ancillary

Healthcare

Scientists

Medical and

Dental

Nursing and

Midwifery

Registered

Students

Trust 5 11 13 3 0 0 2 10 0

Mental Health 0 7 4 1 0 0 1 4 0

Community & Wellbeing 1 3 3 1 0 0 1 4 0

Children & Young People 1 0 0 0 0 0 0 0 0

South Cumbria 3 1 0 0 0 0 0 0 0

Support Services 0 0 6 1 0 0 0 2 0

Business Area Dismissal End of FTC Resignation Retirement Grand Total

Trust 2 2 31 9 44

Mental Health 1 0 11 5 17

Community & Wellbeing 1 0 10 2 13

Children & Young People 0 0 1 0 1

South Cumbria 0 1 6 2 9

Support Services 0 1 3 0 4

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Sickness Absence

SICKNESS ABSENCE

Source Data: ESR

The Sickness absence rate is calculated as follows:FTE Days Lost in Period/FTE Days Available in Period *100

Previous Year

Reduction Target

Upper Control Limit

Lower Control Limit

Trust Target

Actual, 7.52%

0.00%

1.00%

2.00%

3.00%

4.00%

5.00%

6.00%

7.00%

8.00%

9.00%

10.00%

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

2018 2019 2020

2019 10 2019 11 2019 12Rolling 12

Mths

% Long

Term

Absence

% Short

Term

Absence

Trust 6.07% 6.93% 7.52% 6.17% LT ST 179,745 13,520 1,161,809

Mental Health 7.22% 8.01% 9.38% 7.12% 66.86% 33.14% 82,706 7,762 641,451

Community & Wellbeing 6.11% 7.27% 7.08% 6.46% 64.45% 35.55% 43,736 3,095 275,374

Children & Young People 3.89% 4.48% 5.16% 4.36% 49.47% 50.53% 20,841 1,074 98,100

South Cumbria 5.09% 6.37% 5.96% 5.80% 48.49% 51.51% 10,908 650 52,700

Support Services 4.12% 4.66% 4.35% 3.99% 52.79% 47.21% 21,555 939 94,184

Business Area

Rates 2019 12 Total

Available FTE

Days in

Month

Total FTE Days

Lost To

Sickness in

Month

Estimated

Contracted

Salary Lost in

Month £

Trend

12mths

134 of 188

Sickness Absence

SICKNESS ABSENCE

Source Data: ESR

The Sickness absence rate is calculated as follows:FTE Days Lost in Period/FTE Days Available in Period *100

Hot Spot Analysis:Children & Young People's Wellbeing Network: Sickness Absencehas increased slightly in December to 5.16%. This increase reflectsthe seasonal trend for this period. The rate is slightly higher than lastyears reported rate for the same period. Long and short term sickness absence is proactively monitored via

monthly case conference meetings providing increased visibility toCare Group Managers with Service Managers leading on actionplan development supported by HR.

The Engagement and Wellbeing Agenda is firmly embedded withinthe Network.

Community & Wellbeing Network: Sickness Absence has decreasedin December, reporting 7.08% at the months close. The majority of theNetwork report a reduction in absence in month, most notably, Pennineand LDS. Whilst an improvement is reported against the Novemberposition, December 2019’s absence rates are higher that for the sameperiod in 2018. Five our of 8 areas in the Network report an improved Sickness

Absence position this month, despite continuing challenges inservices.

Pennine and North report the highest reduction, with a 1.39 pointreduction

Treatment Rooms and District Nursing in BwD remain the outliers inperformance and a deep dive has commenced in line with therecently developed wellbeing and absence management actionplan.

Return to Work completions are 100% A wellbeing & absence management strategy and action plan is

being developed to support managers in Pennine & North. This willfacilitate a deeper analysis of hot spot areas, provide a targetedsupport plan and will contribute to the development of a programmeof wellbeing and engagement activities.

Drop in engagement sessions are to start in January, to supportengagement with the Locality Wellbeing champions. These arebeing supported by the Trust Health and Wellbeing Lead.

Mental Health Network: Sickness Absence has increased in theNetwork in December, closing the period at 9.38%. This takes theNetwork rate above 8% for the second consecutive month and is thehighest rate since January 2018 (9.59%). This rate is higher thanreported for the same period in 2018.


Overview:Sickness Absence has continued its upward trend through December and closes the month at 7.52%. An increase in sickness related absence isusual for this time of year and is in line with normal seasonal trends, but this trend was not experienced by LSCFT in the same period last year.Absence has increased within two of the Networks this month, in line with the trust upward trend - Mental Health and Children's and Young People’sNetwork. South Cumbria, Community and Wellbeing and Support Services has seen a slight decrease on their November positions.

135 of 188

Mandatory & Statutory Training

Mandatory Training covers 21 courses.These have been selected by LCFT as the mandatory trainingcourses to be published and shared with our commissionersand external stakeholders and are indicative of the safety andquality of our services.

MANDATORY TRACKED TRAINING

Source Data: Training Tracker and ESR

Equ

alit

y &

Div

ers

ity

3yr

Fire

Saf

ety

1yr

He

alth

& S

afe

ty 3

yr

Info

rmat

ion

Go

vern

ance

1yr

Infe

ctio

n C

on

tro

l 1yr

Bas

ic L

ife

Su

pp

ort

1yr

Imm

ed

iate

Lif

e S

up

po

rt 1

yr

Co

nfl

ict

Re

solu

tio

n 3

yr

Po

siti

ve &

Saf

e P

rogr

amm

e 1

yr

Safe

guar

din

g C

hild

ren

L2

3yr

Safe

guar

din

g C

hild

ren

L3

3yr

Safe

guar

din

g A

du

lts

L2 3

yr

Me

nta

l Cap

acit

y A

ct L

1 3

yr

Me

nta

l Cap

acit

y A

ct L

2 3

yr

Man

ual

Han

dlin

g L1

B 3

yr

Man

ual

Han

dlin

g L2

A 3

yr

Man

ual

Han

dlin

g L2

B 2

yr

WR

AP

3yr

Safe

guar

din

g C

hild

ren

L1

3yr

Safe

guar

din

g A

du

lts

L1 3

yr

Man

ual

Han

dlin

g L1

A 3

yr

Trust 96% 91% 96% 93% 92% 84% 75% 84% 73% 96% 93% 95% 97% 93% 92% 84% 82% 87% 89% 88% 89% 91.15%

Mental Health 97% 92% 96% 93% 93% 84% 76% 83% 73% 96% 93% 96% 97% 93% 93% 84% 84% 86% 89% 88% 89% 91.39%

Community & Wellbeing 97% 91% 96% 91% 90% 84% 79% 84% x 95% 94% 96% 96% 93% 91% 85% 80% 87% 92% 90% 92% 91.32%

Children & Young People 96% 92% 95% 94% 94% 85% 62% 88% 69% 97% 96% 96% 97% 94% 92% 79% 84% 87% 94% 94% 94% 92.60%

Support Services 91% 83% 91% 93% 87% 79% x 77% x 100% 86% 86% 93% 88% 85% 71% x 85% 87% 85% 86% 87.34%

Business Area

All Staff Medical, Clinical & Clinical Support StaffAdmin, Clerical &

Estates

Total

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Mandatory Training

Mandatory Training covers 20 core skills courses.These have been selected by LCFT as the core training thatare to be published and shared with our commissioners andexternal stakeholders and are indicative of our service qualityand safety.

MANDATORY TRACKED TRAINING

Source Data: Training Tracker and ESR

Hot Spot Analysis:

Children & Young People’s Wellbeing Network: The Networkcontinue to achieve an overall compliance rate above the Trust Target of80%.There are four hotpot courses in the Network at the close of December –Information Governance (at 94% and very close to target), ImmediateLife Support, Positive and Safe and Manual Handling L2A. Subjects highlighted as below compliance targets are discussed with

the relevant team leader and service manager during the weeklyoperational meetings and areas for improvement and actions areagreed.

Support is available to managers to achieve and maintain compliancerates.

The Network has reported to the Mandatory Training Team someareas where mandatory training mapping to position appears to beinaccurate.

Mental Health Network: The Network are achieving the Trusts overallTraining compliance rate of 80%, reporting 91.39%. The networkreports an improved position when reviewing performance by subject,and has moved from 4 underperforming subjects to 3 in month. Thefollowing subjects remain below trust target: Information Governance (at93% and very close to target), Immediate Life Support (76%) andPositive and Safe (73%). Improvements continue to be reported intraining compliance within the Mental Health Network.


Community & Wellbeing Network: The Network continues to exceedthe Trust target for overall mandatory training compliance and has thefollowing hotspot areas at the close of December: InformationGovernance (91%) and Immediate Life Support. December has seen a historic Hotspot area for the Network achieve

target – Manual handling Level 2b. IG Training compliance continues to improve and is nearing the

compliance target of 95% The Network has been working closely with the Quality Academy to

target hotspot areas and area specific courses have been held tosupport more rapid improvement.

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Overall Appraisal Performance

Source Data: ePDR System & Doctors Appraisal System

The Appraisal data presented has been designed to highlight the % initiation of AnnualPerformance Objectives (Appraisal) for the relevant Performance Review Year anddemonstrate the PDR process is ‘live’ through the measurement of periodic PDR reviewand performance year end PDR closure.

APPRAISAL RATE

86.77%

13.23%

Overall Appraisal Compliance

% Compliant % Non Compliant

Business AreaActive

HeadcountCompliant % Compliant

Trust 5949 5162 86.77%

Mental Health 2838 2527 89.04%

Community & Wellbeing 1626 1441 88.62%

Children & Young People 751 671 89.35%

Support Services 734 537 73.16%

0

1000

2000

3000

4000

5000

6000

Trust Mental Health Community &Wellbeing

Children & YoungPeople

Support Services

Activ

e H

eadc

ount

Overall Appraisals

Compliant Non Compliant

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Appraisal Rate – Non Medical & Dental PDR Appraisals Source Data: ePDR System


APPRAISAL RATE

86.62%

13.38%



0100020003000400050006000

Trust Mental Health Community &Wellbeing

Children & YoungPeople

Support Services

Activ

e He

adco

unt

PDR Appraisals

Signoff With Objectives & Review Taken Place With Objectives

Not Compliant With PDR Process New Starters Not Registered on PDR New Starters Registered on PDR

Business AreaActive


% Non

Compliant

12mth

Rolling %

Compliant

Trust 5777 5004 86.62% 13.38% 86.91%

Mental Health 2704 2393 88.50% 11.50% 88.79%

Community & Wellbeing 1608 1423 88.50% 11.50% 88.74%

Children & Young People 733 653 89.09% 10.91% 89.22%

Support Services 732 535 73.09% 26.91% 73.63%

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Appraisal Rate – Doctors Appraisals Source Data: Doctors Appraisal System


APPRAISAL RATE

100.00%

0.00%



Business AreaActive


Trust 172 172 100.00%

Mental Health 134 134 100.00%

Community & Wellbeing 18 18 100.00%

Children & Young People 18 18 100.00%

South Cumbria 2 2 100.00%

0

50

100

150

200

Trust Mental Health Community & Wellbeing Children & YoungPeople

Support Services

Activ

e H

eadc

ount

Doctors Appraisals

Completed Medical Appraisal Process Exempt

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Source Data: ESR, Staff Friends & Family Survey

Staff Friends & Family Test – Quarter 2 Performance

ENGAGEMENT & WELLBEING

The Staff Friends and Family Test (FFT) provides NHS Trusts with an internalService Improvement Tool that uses the knowledge and experience of itsEmployees. The Staff FFT provides our employees with an opportunity to,anonymously, feedback their views on us, as their employer. The test runs fourtimes a year in LCFT and is open to all employees.

Network HeadcountTotal

Responses

Response

Rate %Trend

Question 1

Performance(Target 70%)

TrendQuestion 2

Performance(Target 70%)

TrendEngagement

Score(Target 7.40)

TrendWellbeing

Score Trend

Overall 6032 1101 18.25% q 70.30% q 54.50% q 6.8 q 50.63% q

Children & Young People 770 160 20.78% p 81.25% p 60.00% q 7.4 q 55.97% q

Community & Wellbeing 1747 326 18.66% q 77.91% p 54.91% q 6.9 q 49.35% q

Mental Health 2772 403 14.54% q 60.79% q 49.38% q 6.5 q 48.44% q

Support Services 743 212 28.53% q 68.40% q 59.43% p 6.8 q 52.73% q

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Source Data: ESR, Staff Friends & Family SurveyEngagement– Quarter 2 Performance



Agree Neither Agree or Disagree Disagree

Negative response target (15%) Positive response target (70%)

Trend

1101

762

195

144

1101

726

254

121

1101

598

241

262

1101

636

277

188

1101

907

133

61

1101

870

172

59

1101

777

186

138

1101

734

220

147

1101

631

292

178

Inv

olv

em

en

t

I am able to make

suggestions to improve the

work of my team /

department.

There are frequent

opportunities for me to show

initiative in my role

I am able to make

improvements happen in my

area of work.

Response Performance

Ad

vo

cacy

Care of patients / service

users is my organisation’s

top priority

If a friend of relative needed

treatment, I would be happy

with the standard of care

provided by this

organisation.

I would recommend my

organisation as a place to

work.

Mo

tiv

ati

on

I look forward to going to

work.

I am enthusiastic when I am

working.

Time passes quickly when I

am working.

69.21%

65.94%

54.31%

57.77%

82.38%

79.02%

70.57%

66.67%

57.31%

17.71%

23.07%

21.89%

25.16%

12.08%

15.62%

16.89%

19.98%

26.52%

13.08%

10.99%

23.80%

17.08%

5.54%

5.36%

12.53%

13.35%

16.17%

0.00% 20.00% 40.00% 60.00% 80.00% 100.00%

6.8

Engagement Score

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Source Data: ESR, Staff Friends & Family Survey

Wellbeing – Quarter 2 Performance



Negative response target (15%) Positive response target (70%)

Qw1

Qw2-3

No Yes, definitely Yes, to some extent

Yes No

Disagree Neither Agree or Disagree AgreeQw4-7

Trend

1101

317

602

182

1101

806

295

1101

598

503

1101

860

151

90

1101

882

169

50

1101

805

192

104

1101

767

214

120

1101

299

348

454

Response Performance

Does Lancashire Care NHS

Foundation Trust take

positive action on health and

wellbeing?

In the last 12 months have

you experienced

musculoskeletal problems

(MSK) as a result of work

activities?

During the last 12 months

have you felt unwell as a

result of work related stress?

Wel

lbei

ng

My Line Manager, or someone

at work, seems to care about

me as a person

I receive the respect I deserve

from my colleagues at work

My immediate manager

encourages me at work

I have a choice in deciding

how to do my work

I have unrealistic time

pressures

28.79%

73.21%

54.31%

78.11%

80.11%

73.12%

69.66%

27.16%

54.68%

13.71%

15.35%

17.44%

19.44%

31.61%

16.53%

26.79%

45.69%

8.17%

4.54%

9.45%

10.90%

41.24%

0.00% 20.00% 40.00% 60.00% 80.00% 100.00%

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Report Title CQC Update

Prepared By Julie-Ann Bowden, Associate Director of Effectiveness Shannon Higginbotham, Governance Manager

Presented By Ursula Martin, Director of Improvement and Compliance


Supporting Executive Director Director of Improvement and Compliance

PURPOSE OF THE REPORT: Report Purpose To provide the Board with an update in relation to:-

Response to the CQC visit to the HBPoS on the 10 January 2020;

Exception reporting against the CQC Action Plan; Update relating to the governance arrangements in

place to ensure robust monitoring and reporting of the process to meet CQC requirements.



Board Assurance Framework Risk 1.0 The Trust does not protect the people who use its services from avoidable harm and fails to comply with the CQCs standards for the quality and safety of services

CQC Domain Well-led 1.0 INTRODUCTION 1.1 This paper provides the Board of Directors with an update in relation to the organisational response to the

2019 CQC inspection. 1.2 The single CQC action plan is monitored and reviewed within the CQC Steering Group which currently

meets on a monthly basis. Where action leads have requested a target date extension, this is discussed and agreed at the CQC Steering Group as part of a robust governance process.

1.3 The quality assurance process is now embedded, with action forms completed by the action lead and signed

off by the lead Director. The forms and associated evidence are reviewed by the CQC Governance Team for approval and reported to the CQC Steering Group.

1.4 The exception report provides the current position in relation to the CQC action plan. Where actions have

reached their due date, the action forms and evidence are being collated and reviewed as a matter of urgency. The exception report is issued to the Director of Improvement and Compliance on a weekly basis and is reported across the governance structure as necessary to provide assurance on progression with the plan.

1.5 The exception report now includes an additional section (Section 7.0 Completed actions with assurance

narrative) which provide assurance narrative on the impact of the completed action and answers the ‘So what?’ question. Detail of this can be seen at Appendix 1.

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2.0 RESPONSE TO THE CQC FOLLOWING THE VISIT TO THE HBPOS 10 JANUARY 2020 2.1 The CQC inspected the Health Base Place of Safety (HBPoS) at the Harbour, as part of an unannounced

visit on the 10 January 2020. This visit is part of the CQC’s approach to following up on the enforcement notices issued on the Trust following the visit last year.

2.2 Following the visit, the CQC asked the Trust to provide some additional information. All these requests have

now been responded to. This included confirmation of the S136 register as CQC felt they had identified some anomalies in the data. This point was clarified with them and data provided that included further information to provide an explanation.

2.3 A summary of the information requests that the CQC has asked the Trust to respond to are as follows:

The number of S136 breaches that were reported as incidents on Datix; Explanation of the Trust’s bed management arrangements; Confirmation of whether the Trust has approached commissioners in respect of the lack of acute beds

available; Copies and explanations of findings of any S136 suite audits; Information relating to HBPoS complaints; Copies of AMHP Forum minutes; The date of the opening of the Crisis House in Blackpool; The date of the opening of the Crisis Café; Percentage increase of enhancement of Crisis Team establishments; Percentage increase of enhancement of CMHT establishments; Information relating to the Out of Hours (24/7) service provision; Whether any beds in any of the HBPoS across the trust are designated ‘swing’ beds for the acute wards; Information relating to the ‘Frequent Attenders’ group.

2.4 The Trust submitted the formal response to the information requests on 23 January 2020. 3.0 OVERVIEW OF THE CQC ACTION PLAN PROGRESS 3.1 There are 197 actions within the CQC action plan as at 29 January 2020, 70 are completed, with 43 not yet

due, and one action which has passed its target date. This can be further broken down by core service to evident the spread of the actions required and the current performance at the time of writing this paper.

Action Validated

(Complete)

Additional Evidence

Requested

Awaiting Director Sign Off

Awaiting QA

Overdue Action not yet

due

Target Date Extension

Agreed

Total

Must Do 47 23 11 3 0 26 20 130

Should Do 23 8 5 0 1 17 13 67

Total 70 31 16 3 1 43 33 197

A further detailed exception report can be reviewed in Appendix 1. 4.0 BOARD ACTION

The Board are requested to note the update provided in relation to the CQC processes in place and associated governance arrangements.

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Appendix 1: CQC Exception Report

1.0 LCFT CQC Exception Report (as at 29.01.2020)

Core Service

Action Validated

(Complete)

Additional Evidence

Requested

Awaiting Director Sign

Off Awaiting QA Overdue

Action not yet due


Agreed

Target Date

Extension Requested

Total

LCFT Trust-wide

11 (must do)

1 (must do) 0 0 0 8

(must do) 1

(must do) 0 21

LCFT Adult Acute wards

and PICU

14 (10 must do, 4 should o)

7 (must do)

7 (5 must do, 2

should do)

2 (must do) 0

5 (2 must do, 3

should do)

16 (10 must do, 6 should do)

0 51

LCFT MH Crisis services and

HBPoS


2 (must do)

5 (4 must do, 1

should do)

1 (must do) 0

7 (4 must do, 3

should do)


0 36

LCFT Adult Community based MH services

3 (must do)

4 (must do) 0 0 1

(should do) 6

(5 must do, 1 should do)

5 (4 must do, 1

should do) 0 19

LCFT Child and adolescent MH

wards

5 (should do) 0 1

(should do) 0 0 3 (should do) 0 0 9

*The overdue action is due to be discussed at the mental health CQC meeting on Monday 03 February 2020

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2.0 CPFT CQC Exception Report (as at 29.01.2020)

Core Service Action Validated

(Complete)

Additional Evidence

Requested

Awaiting Director Sign

Off Awaiting QA Overdue

Action not yet due


Agreed

Target Date Extension Requested

Total

South Cumbria Trust-wide 7

(2 must do, 5 should do)

3 (2 must do, 1

should do) 0 0 0 2

(must do) 0 0 12

South Cumbria Adult Acute Wards and PICU

7 (2 must do, 5

should do)

7 (3 must do, 4

should do)

1 (must do) 0 0

7 (4 must do, 3

should do)

6 (3 must do, 3

should do) 0 28

South Cumbria MH Crisis Services and HBPoS

4 (2 must do, 2

should do)

7 (4 must do, 3

should do)

1 (must do) 0 0 4

(should do)

2 (1 must do, 1

should do) 0 18

South Cumbria MH Wards for older people

1 (must do) 0 1

(should do) 0 0

1 (must do) 0 0 3

3.0 Completed actions with assurance narrative

Core Service

Ref CQC Action Trust Action Assurance and ‘So What’ Narrative

Trust wide

MD1a Must ensure that effective governance systems are in place to assess, monitor and improve the quality and safety of services

Commission AQUA to undertake a Governance Well Led Review

AQuA review completed and reported to the Board. Action plan developed for approval by the Board in February 2020.

MD2a Must ensure that the trust policies relating to Mental Health Act and the Mental

Provide accurate guidance to staff that underpins the Mental Health Act code of

S136 checklist developed and implemented with full training provided to staff. Reduction in S136 and the length of stay evidence in the weekly reporting figures.

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Capacity Act reflect current legislation

practice in relation to s136

MD2b Multi agency 135/136 protocol to be amended to reflect compliance with legislation, presented at ICS Multi Agency Oversight Group for approval and Mental Health Law Sub-Committee for ratification

The term ‘best interests’ was removed from the protocol and staff have been advice as part of the training in S136 checklist regarding how to explain a detention to people who are in the HBPoS.

MD2c Review of LCFT MCA Policy CL048 to ensure definition of capacity is included.

The change to the policy (inclusion of the definition of capacity) was drawn out for inclusion in communication to staff via the Pulse. Team managers were also required to discuss the changes in their team meeting.

MD2d Training Needs Analysis on the MHA Code of Practice to be reviewed

Mental Health Act training compliance is tracked across all Acute Wards and PICUs. A training schedule has been developed and is monitored weekly. For those staff who are non-compliant or due to become non-compliant, they are booked onto an upcoming course which is documented on the schedule.

MD2e Provide accurate guidance to staff that underpins the Mental Health Act code of practice in relation to s136 - development of

The section 135/136 checklist has been reviewed and updated to reflect the MHA Code of Practice. This includes key emergency contacts. Reduction in S136 and the length of stay evidence in the weekly reporting figures.

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the S136 checklist, roll out and training

MD3a Must ensure that the acute care pathway operates effectively

Take immediate action to significantly reduce S136 breaches

The number of breaches in Trust HBPoS has decreased since May 2019, and this is in the context of increased utilisation of Trust HBPoS to manage Section 136 demand, and closure of all three of the Trust’s Mental Health Decision Units between August and October 2019.

MD3b Conversion of a section 136 suite to a temporary treatment bed to cease in the 136 suites at the Orchard and Scarisbrick unit

The Trust did explore the potential to implement this but a decision was subsequently taken not to implement temporary treatment beds.

MD3c Implement Contingency Beds on the male and female assessment wards as first phase of Mental Health improvement plan.

Two male and two female contingency beds were put in place in September 2019 to support timely admission from A&E and reduce the impact on the Trust’s HBPoS. This has supported the decrease in S136 breaches.

MD3d Additional beds to be sourced to reduce need for OAP beds

The Trust has increased acute mental health bed capacity within Lancashire, with these beds now subcontracted from an independent sector provider. In Spring 2020, the Trust will be opening 11 ‘moving on’ beds on the Royal Preston Hospital site.

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MD3e Investment in 24/7 Crisis Team service

The Trust has invested in the Crisis Care services and service provision is 24/7 across all localities, from December 2019. Early indications of this improvement show reduced admissions including to HBPoS with bed requests and actual admissions reducing over the time period.

SCMD2a The trust must ensure it continues to make progress against the trust risk register and board members and members of staff understand the process of escalating risks to the board through the board assurance framework.

South Cumbria services/teams/portfolios incorporated into the LSCFT Datix system.

Full South Cumbria service structure became available on Datix from 01 October 2019, and is now being monitored under the “South Cumbria” Network via the Trust’s datix team. South Cumbria staff are reporting incidents and risks through Datix via their desktops, and managers have appropriate permissions to receive notifications, and manage and extract data.

SCMD2b Training provided to staff as part of the induction on the DATIX system and use and recording of Risks.

Datix functionality training sessions were provided specifically for South Cumbria staff for recording risks, incidents, and managing complaints and compliments. South Cumbria sites are now included in the routine face to face risk management training programme over the year, which includes Datix instruction.

SCSD1 The trust should ensure it continues to review the capacity of the leadership team to ensure it has capacity to effectively manage the services and changes to the trust.

New Leadership team with sole responsibility for South Cumbria services.

The Trust has embedded a leadership team across the South Cumbria services, which is aligned to the locality model for April 2020.

SCSD2 The trust should ensure the fit and proper person’s process is updated to meet the guidance for carrying out regular

Undertake an assessment of Trust fit and proper persons requirements and how this aligns to the S

The Trust has ensured that the Fit and Proper Persons process is consistent across all networks, in particular South Cumbria following the recent transfer of services. On the one occasion that a Fit and Proper Person review was appropriate for a senior member of staff in South Cumbria, this has been evidenced and stored on the Trust’s databases in line with the Trust’s internal Fit and Proper Persons process.

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checks of board members.

Cumbria transactional process

SCSD3 The trust should ensure that staff understand the role of the freedom to speak up guardian, how to contact them and have confidence in their independence.

All staff who transferred are aware of the Speak up Guardian and how to contact them as per their induction to LSCFT

The role of the Trust’s Freedom to Speak Up guardian was included within the Trust induction to South Cumbria staff on the 01 October 2019. A booklet was also provided to all South Cumbria staff which detailed this role and how to contact them.

SCSD4b The trust should ensure it continues to develop and embed the governance around the Mental Health Act.

Extend Terms of reference of the Mental Health Law Sub-Committee

The Trust’s Mental Health Law Sub-Committees terms of reference were updated and approved on the 20 December 2019 to include South Cumbria staff on the attendance.

SCSD4c Develop locality MH Law group as per LSCFT structure with a view to future integration with Lancashire MH Law operational group

Representatives from South Cumbria now attend the Mental Health Law Group for the Mental Health Network and South Cumbria. The Mental Health Law Team met with the Lead Nurse, and Service Leads for South Cumbria on 9 January 2020 and agreed to meet monthly in order to embed systems and processes with this meeting feeding into the South Cumbria governance meetings and the Mental Health Law Group as appropriate.

Adult Acute

wards and PICU

MD27b Must ensure that medicines are prescribed with the appropriate legal authority.

Business case to be developed and MHA module on medicines purchased

A business case was prepared and executive support agreed to purchase this module. Following a recent upgrade to the EPMA system, the MHA module is now in the live system. Functionality is not yet accessible to clinicians because of issues raised during end user testing of the module, however there is another action (MD27e) on the CQC action plan which ensures that the module is functional by the end of March 2020.

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This will support improved awareness of and compliance medicines management regulations.

MD27c Weekly compliance check in place by MH Law team to review T2/T3/S62 paperwork and pharmacy

Compliance has increased in relation to Consent to Treatment and continues to be monitored on a weekly basis. Introduction of the Mental Health Act module on ePMA during Q4 will further support compliance and the monitoring of compliance.

MD27d Junior Doctors training to highlight the transfer process moving from S62 to T2/T3

Junior Doctors training was updated to provide additional education on the transfer process from S62 to T2 and T3. CTT compliance has increased and continues to be monitored weekly.

MD28a Must ensure there are enough qualified nursing staff to provide the level of care necessary for each ward.

Weekly meeting established, led by director of Nursing and Quality and attended by all ward managers and matrons to review staffing.

The Director of Nursing has led on a further Safer Staffing review of Acute Wards and PICUs. The outcome will be reported to Board in February 2020. A Staffing for Safety and Quality Action plan has been developed which outlines the improvement actions required in relation to staffing, recruitment and retention. This is led by the Director of Nursing and Quality. A number of initiatives to improve RN staffing are in place.

MD31a Must ensure patients’ privacy and dignity are protected, including in their

Review dormitory arrangements across the Trust and take specific action on

A review of all dormitories across the Trust has been carried out by Property Services with an options appraisal for each site presented to the Executive Group. Immediate works has commenced at Scarisbrick which is due for completion in April 2020, with full occupation in May 2020.

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bedroom, seclusion and the bathrooms.

Scarisbrick Ward (Ormskirk)

MD31b Vistomatic review and replacement programme to be undertaken for Avenham, Duxbury, Worden, Calder, Ribble A, Edisford, Darwin and Hyndburn Wards

Vistamatics which can be opened from both sides have been installed at Calder, Ribble, Darwen and Hyndburn wards. Post completion inspection sign-off form for all vistamatics were provided which were approved by the lead from Property Services and the appropriate Modern Matron. Avenham, Duxbury, Worden and Edisford already had the correct vistamatics and therefore were not required.

MD31c Privacy curtains and anti-ligature curtains rails to be installed as required in Avenham, Edisford and Worden Wards

A privacy curtain rail at Worden, Avenham and Edisford wards has been fitted and a curtain is in place.

MD31f Undertake risk assessment of the dormitory environment in the Scarisbrick unit to establish appropriate mitigation is in place and whether there are any immediate improvements that can be made.

A risk assessment was carried out in the SIPU at Scarisbrick in relation to the dormitory accommodation there highlighted by the CQC during the recent inspection. Immediate works has commenced at Scarisbrick to address all issues highlighted within the risk assessment. The work is due for completion in April 2020, with full occupation in May 2020.

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MD34a Must assess and care plan for patients with specific needs including epilepsy and moving and handling to ensure staff know how best to meet their needs.

CQC gave specific examples of patients - ensure all patients are reviewed and care plans are in place

All individual patients highlighted in the original warning notice letter were been reviewed and action taken to address the issues raised. A care planning workshop was undertaken in September 2019 which provided guidance to staff on quality care plans and the importance of them.

MD37 Must ensure there is oversight and monitoring of the implementation of the Mental Health Act and Deprivation of Liberty Safeguards and that action is taken following audit findings.

Ensure there is a monitoring framework for the implementation of the Mental Health Act and Deprivation of Liberty Safeguards audits that are undertaken within and external to the organisation

The Mental Capacity Act and Deprivation of Liberty Safeguard policies have been amended and ratified at MHL Sub-Committee in September 2019. The MHA Action Plan is also monitored in the MH Network CQC meeting every Monday morning and the CQC Inpatient meeting held every other Thursday afternoon where ward managers attend. Consent to Treatment is monitored weekly by the Trust’s pharmacy team and this was escalated to the CQC Action Planning meeting as part of the requirement notice response. Mental Capacity Act mandatory training compliance has increased to 96% as at January 2020.

SD11a Should ensure staff are aware of where the emergency medicines are, that clinic room storage and temperature readings reflect the trust’s policy, that patients’ allergies are noted on prescription cards.

Clarity with regard to storage arrangements for emergency medicines and requirements to monitor clinic room temperatures including actions required to be shared across all acute adult wards and PICUs

Posters have been placed on the cupboards where emergency medicines are stored to ensure it is easy to identify for staff and there is a procedure outlining expectations with clinic temperature monitoring. Checks of clinic temperature monitoring are undertaken during the safe and secure handling of medicines audits conducted by the pharmacy team. Quarterly audit reports which include compliance with clinic temperature monitoring are produced and issued to the networks. Areas for improvement are highlighted with clear recommendations where necessary. Audit reports are also considered in the Trust Medicines Safety Group.

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SD11b Development of audit and scrutiny framework and regular reports relating to storage arrangements for emergency medicines and review of clinic room temperatures

There is a procedure outlining expectations with clinic temperature monitoring. Checks of clinic temperature monitoring are undertaken during the safe and secure handling of medicines audits conducted by the pharmacy team. The safe and secure handling of medicines audit tool has been updated to include a check that posters are in situ supporting staff to easily identify where emergency medicines are held and an audit schedule is in place with quarterly reporting.

SD16 Should ensure the plans to eliminate dormitory sleeping arrangements are implemented.

Review dormitory arrangements across the Trust and take specific action on Scarisbrick (Ormskirk)

A review of all dormitories across the Trust has been carried out by Property Services with an options appraisal for each site presented to the Trust. A project has been signed off for removing dormitories at Scarisbrick to address the issues raised by the CQC and is due to be completed in April 2020 with full occupation in May 2020.

SD17 Should ensure there is signage at Chorley for people to locate the wards

Signs to be ordered and fitted at Chorley site

The appropriate signage was ordered and fitted at the Chorley site imminently. Staff and patients are now able to identify the wards clearly.

SCMD6a The provider must maintain premises in good condition and suitable for the purpose for which they are being used.

Full estates evaluation as part of the Due Diligence in place.

A full estates evaluation was undertaken as part of the due diligence prior to South Cumbria services transferring. A capital plan was subsequently developed outlining the works required across an 18-month period. A safety prioritisation review has been undertaken against this action plan and has been agreed by the Director of Nursing and Quality, Trust Estates Director and Associate Director of Safety. This is reported to the South Cumbria Assurance Committee and Trust Executive Group.

SCMD6b Estates action plan in place as part of the PTIP - S Cumbria

Estates actions are clearly reported as part of the Post Transfer Implementation Plan (PTIP). Two actions were recently added in relation to the long term solutions, and the other actions were part of the FBC and subsequent assurance

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Assurance Group to determine prioritisation linked to risk

committee actions. The PTIP is presented to the South Cumbria Assurance Committee on a monthly basis and a member of Estates attends the Committee to provide assurance on the estates and capital work.

SCSD6 The trust should ensure entries are clear and complete in seclusion records.

Staff issued with clear guidance of the policies and procedures to follow during segregation episodes - seclusion policy and record keeping

The Trust’s seclusion policy has been shared with all South Cumbria staff. However, there are no seclusion facilities in South Cumbria and the policy is only applicable in respect of segregation.

SCSD11 The trust should ensure that all staff consistently receive and record appropriate supervision.

Adopt LSCFT supervision systems and practices

Supervision guidance has been communicated to all teams together with trajectories and current compliance figures. Performance reviews will be completed in line with the Trust-wide supervision policy and this will be monitored at team level and non-compliant areas will be escalated through to South Cumbria SLT.

SCSD13 The trust should ensure staff provide information on patients’ legal position and rights in line with the Mental Health Act code of practice at the frequency required.

Staff will be provided with clear guidance of the legal framework aligned to the 136, clearly defining the options available at the 24 hour point and escalations required throughout the 24 hour Section 136 process in line with

The development of the S136 Checklist for the former LCFT 136 suites has now been implemented across those Trust services. This revised checklist is currently in the processes of being implemented within the South Cumbria 136 suites.

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the Mental Health Act and code of practice.

SCSD15 The trust should ensure that all staff have awareness of the trust’s visions and values and who the freedom to speak up guardian is and how to contact them.

All staff provided with details of the Speak up Guardian and how to contact them


SCSD16 The trust should ensure they have a policy regarding the arrangements for children and young people who visit patients in hospital.

LSCFT Policy to be implemented across South Cumbria

The Trust policy has been shared with all South Cumbria staff working on wards.

Child and adolescent mental health wards

SD18a Should make sure that staff record that parents or carers are informed of each seclusion episode.

Reinforce importance of informing parents and carers of seclusion and documenting of this, at governance meetings and staff meetings.

Awareness was and continues to be raised via the Networks Governance Meeting to ensure these requirements are met. The networks local seclusion audit was updated to ensure that the requirement to inform parents and carers of seclusion, and to ensure this contact is documented.

SD18b Seclusion audit checklist to be updated to included

The networks local seclusion audit was updated to ensure that the requirement to inform parents and carers of seclusion, and to ensure this contact is documented.

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CQC recommendations

SD20 Should make sure that patients’ detention papers are checked by a doctor (known as medical scrutiny) to make sure the clinical grounds for detaining patients were made out.

Administrative scrutiny processes in place to ensure that medical scrutiny is completed in line with Trust Policy.

An audit was undertaken in June 2019 of the MHA law documentation for all young people at the Cove to obtain assurance on this. All documentation was subsequently updated. The Mental Health Law Team have implemented an escalation SOP in relation to the receipt of medical scrutiny and a clear escalation process provided for when this is not received. This has been communicated to staff. A random monthly audit is undertaken to check and ensure medical scrutiny is in place.

SD21 Should make sure patients’ religious needs are fully reflected in relevant patients’ care plans.

Monthly care plan audit to be amended to include whether the care plans include details of religious needs and the young person’s educational status and needs

The care plan audit standards have been reviewed and updated to ensure that the quality of care plans in relation to religious needs are monitored and improved on care plans if necessary. A care plan audit has been developed and implemented and is undertaken on a regular basis against care plans for children and young people at the Cove. This explicitly refers to the need for the care plan to highlight the young person’s religious needs.

SD22 Should make sure patients care plans provide more detailed information about patients’ education status and needs, working in conjunction with staff from the education team

Education plan on a page to be devised and shared with nursing staff on a weekly basis from September 2018

The care plan audit standards have been reviewed and updated to ensure that the quality of care plans in relation to educational needs are monitored and improved on care plans if necessary. A care plan audit has been developed and implemented and is undertaken on a regular basis against care plans for children and young people at the Cove. This explicitly refers to the need for the care plan to highlight the young person’s educational needs.

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Mental health crisis

services and

health based

places of safety

MD10 Must ensure patients’ privacy and dignity are protected in relation to mental health decision units.

Ensure Mental Health Decision units are closed

All three Trust MHDU’s were closed during the period October – December 2019.

MD12b Must ensure that staff receive annual appraisal in line with the trust’s policy.

Ensure trajectories in relation to Appraisal are monitored on a weekly basis.

Appraisal compliance against trajectories are monitored on a weekly basis at the Trusts Executive Group.

MD13a Must ensure that patients are detained with the appropriate legal safeguards in place.

Development and implementation of S136 checklist

The section 135/136 checklist has been reviewed and updated to reflect the MHA Code of Practice including the reading of patients’ rights (S132). This includes key emergency contacts. There were 119 S135/136s in December. Of these, 98 had their rights read which represents a compliance figure of 82%.

MD13b Revise and update patient section 136 leaflets

All patient information leaflets in relation to S136 have been updated by the MH Law Team. Wording relating to ‘best interests’ has now been removed. Development and training for new checklist for s136 clinical management includes giving updated Patient Rights leaflet.

MD13d Development of Section 136 Audit Framework

A S136 audit framework tool has been developed and implemented which provides a tool for audits to be undertaken where S136 detention occurs. This provides a robust assessment tool to assess compliance. S136 reporting and breach data is also reported to the MH network CQC meeting on a weekly basis to monitor compliance. The most recent data highlights that there is a clear downward trend in s136 breaches both as a total number and proportion of admissions.

MD14b Must ensure there is oversight and monitoring of the section136 timescale.

Manual validation of 136 breaches and bed hub data to support reporting to Weekly Exec Performance meeting for oversight

Reduction in S136 and the length of stay evidence in the weekly reporting figures. The weekly reporting provides oversight to Director’s through the Mental Health Network weekly performance report.

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of 136 numbers and breaches, with review of any breaches

MD16 Must ensure there is oversight and monitoring of the 23 hour timescale for admissions to mental health decision units



MD17 Must ensure patients are only admitted to mental health decision units for a maximum of 23 hours.



MD18 Must ensure that admissions of patients under the age of 18 to mental health decision units are reported.



MD19a Must ensure that incidents are reported as per the mental health decision unit standard operating procedure and the section 136 policy.



MD19b Must ensure that incidents are reported

All Section 136 breaches are reported

The requirement for datix reporting has been enforced through the refreshed 136 checklist and training programme.

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as per the mental health decision unit standard operating procedure and the section 136 policy.

on Datix and weekly monitoring of Section 136 data reviews this

Compliance against the networks reporting of datix is monitored and reported weekly through the weekly network CQC meetings and to Director’s in the Mental Health Network weekly performance report. Data related to incident reporting of 136/135 breaches is now being collated as part of the 136 checklist maintained by the Hub.

MD20a Must ensure there is oversight and monitoring of medicines management in section 136 suites and mental health decision units.

Schedule to be put in place to ensure that the date checking of medicines is done regularly both on the 136 suite and across the whole unit.

Guidance for checking of medicines expiry date has been produced for the pharmacy team. The frequency of audits has been reviewed across the Trust and a schedule of audit frequencies produced. Expiry date checking is including in the pharmacy storage of medicines audit tool and performance against the storage audits are reported quarterly to the networks.

MD20b Must ensure there is oversight and monitoring of medicines management in section 136 suites and mental health decision units.

Greenlight alert to be issued with regard to storing unlabelled medicines and out of date stock not only in Section 136 suites but across relevant areas of the Trust.

A greenlight alert was issued Trust-wide via a newsflash in November 2019, and is also available to staff on the intranet. Pharmacy audit checks this position and reports to the CQC Steering Group.

MD23 Must review the management of complaints and actions in relation to mental health decision units.


All three MHDUs were closed between October and December 2019.

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MD24 Must ensure that the showering facilities in the Preston 136 suite are fit for purpose.

Ensure refurbishment of Section 136 Suite undertaken and ensure shower facilities are improved

A review of the S136 Suite at Preston was undertaken to assess the issues identified. There was no evidence of mould in the shower, however the mastic was replaced and a deep clean was also carried out. The ventilation has now been made operational in the room which has provided an improvement. Further ventilation improvement works are being implemented as part of the 136 suite refurbishment works.

MD25 Must ensure that environmental issues at the Ormskirk home treatment team are addressed.

Ensure refurbishment of reception area in Ormskirk HTT is undertaken

A review of the reception area in Ormskirk HTT was undertaken to assess the issues identified and all required repairs were undertaken. A full replacement heating system is required and is being submitted as a Capital Bid for 2020 to ensure further improvements.

SD5a Should review the establishment staffing levels across home treatment teams.

Review staffing establishments in line with provision of 24/7 crisis team services

There has been an increase in establishments across the Home Treatment Teams to enable 24/7 service provision. Additional funds have been secured recurrently to enable the increase in staffing across Lancashire.

SD5b Ensure staff are consulted for this review

Consultation would only be required if there was a contractual change in base, hours or terms and conditions of staff working, and the increase in staffing did not impact on existing contracts, therefore there was no need for a consultation.

SCMD13 The trust must ensure there is always a dedicated member of staff to observe patients in the health-based places of safety.

Review staffing in Section 136 suites to ensure that staffing 136 suites does not impact on in patient staffing.

Staffing has been reviewed to include additional staffing for 136 suites. Staffing within the Inpatient facility at Kentmere (Kendal HBPoS) has been increased to a minimum of 4 additional members of staff on a shift to ensure sufficient staffing in place to cover the HBPoS.

SCMD19 The trust must ensure they take action in response to regulatory

Development of an external recommendations

Since the inspection in May 2019, the Trust has reviewed and implemented a robust governance and monitoring process to respond to regulatory feedback. This is inclusive of:

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requirements and the findings of external bodies.

policy and ensure appropriate governance and tracking mechanisms in place to adhere to regulatory feedback

The development and monitoring of a Trust-wide CQC action plan The development and monitoring of a MHA Visit action plan Underpinned by robust quality assurance processes Establishment of a CQC Steering group that receives exception reporting

on the progression with the action plan and provides a forum for escalation Establishment of a CQC meeting in the mental health network (weekly) to

discuss progress against actions Regular reporting to the Board, its Committees and Executives Group

An external recommendations policy is under development.

SCSD21a The trust should ensure staff feel supported, respected and valued and are able to speak to senior managers.

On-boarding and Inductions sessions for all staff introducing senior and corporate support services

A full Trust induction took place on the ‘On Boarding’ day on the 01 October 2019 for all South Cumbria staff transferring to the Trust, attended by senior management. An information booklet was also provided to all South Cumbria staff which includes information on the Board and senior management across the Trust.

SCSD22 The trust should ensure that all staff are aware of the Freedom to Speak Up Guardian.

All staff provided with details of the Speak up Guardian and how to contact them during the recent on-boarding/ induction sessions


Community based

MH services for adults

of

MD6b Ensure that all service users on Community Treatment Orders are given information on their rights under the Mental Health Act at

Develop audit tool to monitor whether CTOs are compliant with MHA Code of Practice and ensure is

A weekly compliance with CTO’s report is provided to all Team Managers and Care Coordinators. Compliance is monitored at the Mental Health Law Group via the quality tile surveillance report. CTO rights are documented on ECR and a communications was shared with all staff to escalate within their teams to ensure this was happening.

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working age

regular intervals. This includes when service users have declined their rights.

in place monthly going forward

MD6c Review the governance and assurance processes in relation to mental Health Act audits

A review has been undertaken against the MHA audit process. This has resulted in the mental health act CQC visit action tracker now managed via an excel spreadsheet, alongside a robust quality assurance validation process, reflective of the overall CQC action plan process. There is now monthly reporting on the delivery of the plan to the CQC Steering Group and quarterly to the MH Law Sub-committee.

MD7a Must ensure that the legal authority relating to service users on Community Treatment Orders are kept with medicine cards.

Devise educational plan to ensure that clinicians are aware of the need to ensure that consent to treatment and capacity to consent to treatment certificates are kept with a patient’s medicine chart.

The medicines management module on training tracker has been updated to reflect the requirement. Compliance with this training is tracked via the Trust’s overall mandatory training compliance report. A greenlight has been produced reinforcing staff responsibilities around consent to treatment. Training for junior doctors has been updated to reinforce the responsibilities and requirements. Quarterly audits are undertaken to assess compliance with CTT.

Mental Health

wards for Older

People

SCMD10a The provider must ensure that all section 17 leave forms are individually completed for each patient and show consideration of patient need and risks

Review MHA S17 leave docs for CPFT and cross reference for compatibility with LSCFT and make any changes as appropriate. (Relates to Ramsey Ward)

An audit was undertaken to assess compliance with MHA Section 17 documentation. All patients included in the audit had the required documentation completed. A number of recommendations were shared with the networks for implementation. This included a need for improvement with the standard of recording risks and rationale.

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Report Title Finance Report

Prepared By Shannon Carroll, Financial Services Director

Presented By Bill Gregory, Chief Finance Officer


Supporting Executive Director Chief Finance Officer

PURPOSE OF THE REPORT: Report Purpose To summarise and analyse actual and forecast financial

performance and standing of the Trust, the implications and any proposed management action.


To provide excellent value for money in a financially sustainable way

Board Assurance Framework Risk 7.0 The Trust does not achieve financial performance sufficient to maintain resilience and sustainability

CQC Domain Effective

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Summary

Actual Plan Var Forecast Plan VarSustainability

EBITDA 9,494 11,044 -1,550 15,207 17,121 -1,914 Operational Deficit -1,959 -1,790 -169 -322 -0 -322 Surplus/(Deficit) (inc Technical Adj) 6,436 -1,790 8,226 8,073 -0 8,073

CIPs (against Trust Plan) 6,756 6,968 -212 10,169 10,073 96Cash and Liquidity 28,285 19,573 8,712 19,312 17,493 1,819Capex 6,382 7,135 -753 13,903 12,863 1,040UOR

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

The year to date position is in line with plan at £1.8m deficit, if the PSF loss is excluded of £0.2m (associated with the whole system’s financial performance). The technical adjustment relates to the previously described absorption of south Cumbria (See the Matters Section).Whilst the above table maintains a forecast for delivery of the control total (after allowing for the loss of system PSF) the reality is that a significant year end deficit of c£4.0m, excluding the loss of system PSF, is developing which will manifest without further mitigation. Again this relates to the current OAP position and ward staffing pressures. The Trust has brought a number of upsides into the base position (£0.3m NHSE funding for A&E, £0.6m NHSE/I pay relief and £0.2m of land disposal). Conversely, the Trust has removed c£1.6m of income for stranded patients from the base position, more appropriately reflecting the risk to this. Therefore, of the c£4m deficit identified, nearly half of the recovery upside actions are attributable to system costs on stranded patients and the CCGs directly.All parts of the Trust have been challenged to deliver additional savings, but as yet there has been little traction realised. There is further financial risk in the position associated with anything resulting from implementing the CQC action plan and income from stranded patients from CCGs. Unless an improvement in the position can be delivered in the near future, we will need to consider modification of our forecast reported to the ICS and NHSE/I in future months.The Use of Resources (UoR) metric is rated at 3, in line with plan at this stage, but should the Trust meet its financial plans and targets, as currently expected, the Trust will have a rating of 2.

Current Out-Turn

Sustainability

The Trust is currently reporting an outturn in line with plan. This is contingent on a number of matters and the Trust needs to retain focus on these (see below).• Review of flow to ensure stranded patients are correctly identified, are placed in the correct facility, this is evidence appropriately and funding secured where they are "stranded" in our care.• Ensure current CIP schemes are delivered and significant additional programmes identified• Ensure CQUIN is delivered and the identified slippage recovered where off plan• Ensure implementation of MHIS schemes• Recruit to establishment on ward to avoid additional charges for bank and, in particular, agency staff.• Deliver additional savings to address the base case position and provide contingency.• Ensure no further unplanned expenditure is incurred.

Forecasting and Key Actions

KeyMajor ConcernsMinor concerns, within toleranceIn line with planNHSI RatingNo evident concernsMinor concern, potentially requiring scrutinyMajor concern, requiring scrutinySignificant Risk, action required

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Summary (continued)

e

This table shows the current range of outturns for the Trust• If we take system failure of the control as a given, the Trust will lose £424k.• In addition, the Trust was given an additional £101k of PSF money in 19/20.• The net impact is that the Trust can only now secure a maximum PSF of £2.7m (£2,660k in best case).• If the Trust manages to achieve it's control total of -£3m, it's PSF payments will take it to £0.3m deficit.• The Trust would not be expected to make good any system failing to claim its own PSF• The PSF value of £1,821k assumes the Trust claims PSF up to and including Quarter 3.• The Trust has a likely forecast of £4.0m behind it's control total, the gap within our control to address.• The range is £5.7m from target to £1.9m from target.• Stranded Patient income has been removed from the base case and is now viewed as an upside.• A number of upsides identified last month have been transacted into the base case.

Capital and Financing

Cash continues to benefit from working capital gains, PSF bonus monies and capital phasing. more than compensating for increases to capital and financing requirements. As a result the Trust is remains significantly ahead of plan (c£8.7m). This will reduce as transient working capital gains reduce and capital and financing align, but assuming the Trust achieves its revenue targets for the year cash the forecast is still expected to exceed plan.

CIPs

Cash and Liquidity

CIPS are slightly behind on delivery now at month 9 (year to date) and but in line for the forecast. This is built into the position and the Trust is reviewing schemes and supporting networks to drive through more savings, reduce waste and deliver further contingency for the position.

Overall year to date capital continues to be slightly behind plan, though within acceptable financial tolerance. Spending is expected to accelerate and though forecast capital expenditure continues to increase funding has increased to compensate. While the position is not without risk, with the disposal of Sharoe Green the position is considered manageable and the Trust expects to remain within its resource envelope.

With the return of I&E to plan the UoR also returns to plan with a rating 2 against a plan of 2. Though the agency rating is behind plan, much of this is attributable to Cumbria and and though an adjustment to the Trusts ceiling has been requested from NHSEI to compensate this is now expected to only be implemented from 2020/21 onward. Assuming current pressures and risks are addressed and I&E performance achieves (or exceeds) forecast the Trust will achieve a UoR of 2 in line with the plan.

Use of Resources (UoR) risk ratings

ScenariosWorst Case Forecast Best Case

Sensitivities £000s £000s £000s

Base Outturn Position (excl PSF) -6,973 -6,973 -6,973PSF 1,821 1,821 2,660Outturn incl PSF -5,152 -5,152 -4,312Target -1,160 -1,160 -321Gap to claim LSCFT specific PSF -3,991 -3,991 -3,991

OAPs / Stranded Patients Slippage -1,500Estates CIP 76LD funding 179Super stranded 1,642Renegotiation of pharmacy contract 40EPR consultancy costs 200CQUIN Slippage -200

Residual Gap to Bridge -5,691 -3,991 -1,854

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Statement of Comprehensive Income

Year to Date Statement of Comprehensive Income (Actual v Plan)

Month 8Actual Plan Variance Variance

£'m £'m £'m £'m

Income 266.7 255.9 10.9 7.4

Pay (197.3) (196.5) (0.8) 0.3Non Pay (59.9) (48.3) (11.6) (10.1)Total Costs (257.2) (244.8) (12.4) (9.8)

EBITDA 9.5 11.0 (1.6) (2.5)

Capital Charges (10.3) (11.6) 1.3 1.2Financing (1.1) (1.2) 0.1 0.0

Operational surplus / (deficit) (2.0) (1.8) (0.2) (1.2)

Gain on Transfer by Absorption 8.4 0.0 8.4 8.2

Surplus/(Deficit) (inc Technical Adj) 6.4 (1.8) 8.2 7.0

Forecast Statement of Comprehensive Income (Unmitigated Forecast v Plan)Base

Unmitigated Annual Month 8Forecast Plan Variance Variance

£'m £'m £'m £'m

Income 362.0 343.5 18.5 18.7

Pay (268.4) (262.9) (5.6) (5.1)Non Pay (82.7) (63.5) (19.2) (20.5)Total Costs (351.1) (326.4) (24.8) (25.6)

EBITDA 10.9 17.1 (6.2) (6.9)


Net surplus / (deficit) (4.6) (0.0) (4.6) (5.3)



Forecast Statement of Comprehensive Income (Forecast v Plan) Unmitigated Forecast to Upside Recovery BridgeUpside

Month 8Forecast Plan Variance Variance

£'m £'m £'m £'m

Income 365.2 343.5 21.7 21.0

Pay (268.4) (262.9) (5.6) (5.1)Non Pay (81.5) (63.5) (18.0) (17.8)Total Costs (350.0) (326.4) (23.6) (22.9)

EBITDA 15.2 17.1 (1.9) (1.9)


Net surplus / (deficit) (0.3) (0.0) (0.3) (0.3)



Year To Date (Current)

Annual

-5,000

-4,500

-4,000

-3,500

-3,000

-2,500

-2,000

-1,500

-1,000

-500

0

Gap

PSF

(Ups

ide)

PSF

(Sys

tem

)

Rene

gotia

tion

ofPh

arm

acy

Cont

ract

#

EPR

cons

ulta

ncy

cost

s

Esta

tes

CIPs

Supe

rstr

ande

d

LD fu

ndin

g

Oth

er

-4,301 897 423 40 200 76 1,642 179 844

Income – Year to date income is ahead of plan due to some minor commissioner developments and funding of additional OAPs. Cumbria income is now included for the last three months.The year end base position is £18.5m ahead plan. The is mainly attributable the transfer of Cumbria services, but also to additional commissioner developments, and funding for OAPS. Additional funding has been allocated nationally of c£3m to support the urgent care pathway, plus £2m of more local funding.The upside includes the balance of the PSF income to take it to the full amount due from delivering the control total and some minor gains.

Pay - The year to date pay is now over plan by £0.8m. The investments in mental health were expected to be higher than was finally agreed but the Cumbria pay for three months bridges the gap to plan.The base year-end variance of £5.1m is dominated by the lower than planned development funding agreed in this years settlement, but more than offset by the pay in the Cumbria transfer.The upside is consistent with the base position

Non-Pay - Year to date non-pay is £10.1m beyond plan, dominated by OAPs and Priory , some phasing of pressures funding and some slippage of charges from the previous year's agreement. Additionally, we have now seen three months of Cumbria costs.The base outturn is £20.5m above plan for non-pay driven in the main by subcontracted healthcare (OAPs, although some income compensates), slippage on CIPs, additional estates costs and Cumbria costs.The upside assumes significant delivery of some additional CIP and cost curtailment.

Capital Charges and Financing are at this stage expected to be c£1.6m underspent due to estate revaluation.

Gain on Transfer by Absorption relates to transfer of Cumbria assets.

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Statement of Financial Position

Year to Date Statement of Financial Position (Actual v Plan)

Actual Plan Variance£'m £'m £'m

Fixed Assets 218.7 231.0 -12.3Other Long Term Assets 0.2 0.4 -0.2Non Current Assets 218.9 231.4 -12.5

Stock 0.1 0.1 0.0Trade Debtors 24.0 20.7 3.4Other Current Assets 1.5 2.1 -0.6Cash 28.3 19.6 8.7Current Liabilities -44.3 -33.1 -11.2Current Assets and Liabilities 9.6 9.3 0.4

Provisions and other Long Term Liabilities -1.7 -1.6 -0.1Loans -47.7 -47.6 -0.1Non Current Liabilities -49.4 -49.2 -0.2

Total Net Assets Employed 179.1 191.4 -12.3Financed By:PDC 112.9 114.3 -1.4 External funding to be drawn when revised milestones achieved)I&E Reserve 1.2 6.6 -5.4Other Reserves 65.0 70.5 -5.5

Taxpayers Equity 179.1 191.4 -12.3

Forecast Year End Statement of Financial Position (Forecast v Plan)

Forecast Plan Variance£'m £'m £'m

Fixed Assets 223.7 233.2 -9.5Other Long Term Assets 0.2 0.4 -0.2Non Current Assets 223.9 233.6 -9.7

Stock 0.1 0.1 0.0Trade Debtors 21.1 19.5 1.6Other Current Assets 0.5 0.0 0.5Cash 19.3 17.5 1.8Current Liabilities -32.5 -28.9 -3.5Current Assets and Liabilities 8.5 8.1 0.4

Provisions and other Long Term Liabilities -1.5 -1.6 0.0Loans -46.4 -46.4 0.0Non Current Liabilities -47.9 -48.0 0.0

Total Net Assets Employed 184.5 193.7 -9.2Financed By:PDC 116.7 114.8 1.8I&E Reserve 3.3 8.8 -5.6Other Reserves 64.6 70.1 -5.5

Taxpayers Equity 184.5 193.7 -9.2

Forecast in line with plan.

Annual

With additional capital funding provisionally agreed, the gain attributable to cash as a result of 2018/19 PSF bonus produces gains in underling cash. This is reduced by deferred receipt of AHfS disposals and capital charges changes (See also Cash Flow and Liquidity).

In year I&E performance is forecast to be broadly in line with plan, differences mainly due to impact of Cumbria transfer and differences/transfers on reserves as a result of the impact of brought forward revaluations not included in plan.

Includes allocations for Energy efficiency (£0.4m), an estimate re Integrated Acute MH Hub (£0.2m), Cumbria GDE (£0.2m) and Avondale (£1m).

Forecast capex is higher than original plan with £1.8m additional expenditure and funding provisionally agreed. The primary difference is due to impacts of brought forward revaluations not included in plan and the impact of associated depreciation savings offset by the Cumbria transfer of £8.4m.


In line with plan

Capex is £0.7m behind plan. The primary difference is due to impacts of brought forward revaluations not included in plan and the impact of associated depreciation savings offset by an increase of c£8.4m in relation to the Cumbria transfer.

Mainly due to impact of Cumbria transfer and differences/transfers on reserves due to impact of brought forward revaluations not included in plan. Impact for in year I&E operating performance being behind plan is marginal (c£0.2m).

Overall liquidity is broadly in line with plan with bonus PSF gains offset by timing differences. Cash remains high due to working capital gains with higher than planned levels creditors and deferred income offset to some degree by higher than planned levels of debtor/accrued income(see also Cash Flow and Liquidity).

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Statement of Cash Flow

Year to Date Statement of Cash Flow (Actual v Plan)


Opening cash balance 30.3 20.0 10.3 Opening cash levels high (see WC below)

Surplus/(deficit) after tax 6.4 -1.8 8.2Non Cash Flows 3.1 12.8 -9.8

Operating Cash Flows before WC 9.5 11.0 -1.6

Changes to WC -0.7 -1.2 0.5

Reversal of the temporary gains in 2018/19 accounts are being temporarily masked by transient gains from high levels of creditors/accrued income, offset to some degree by higher than planned debt/accrued income (see liquidity).

CF from operations 8.8 9.8 -1.1

Capital and Investment Activities -6.1 -6.0 -0.1Financing and Other -4.8 -4.3 -0.5

Capital and Financing -10.8 -10.3 -0.5

Net cash inflow/outflow -2.1 -0.5 -1.6

Closing cash balance 28.3 19.6 8.7

Forecast Statement of Cash Flow (Forecast v Plan)


Opening cash balance 30.3 20.0 10.3 Opening cash levels high (see WC below)

Surplus/(deficit) after tax 8.1 0.0 8.1Non Cash Flows 7.1 17.1 -10.0

Operating Cash Flows before WC 15.2 17.1 -1.9

Changes to WC -8.3 -2.5 -5.8

Main variance from plan is due to timing: temporary gains in 2018/19 resulted in a high cash balance, these reverse in 2019/20 returning balances and cash to normal levels (some opening gains remain, mainly as a result of 2018/19 PSF bonus monies).

CF from operations 6.9 14.6 -7.7

Capital and Investment Activities -12.5 -8.5 -4.0Financing and Other -5.5 -8.6 3.2

Capital and Financing -17.9 -17.1 -0.8

Net cash inflow/outflow -11.0 -2.5 -8.5

Closing cash balance 19.3 17.5 1.8

Main differences on capital is due to an increase of £1.8m in externally funded capital spend and deferral of receipts from AHfS including the phasing of the Junction (transacted in 2018/19 and therefore opening cash), with financing benefiting from additional funding and the changes in capital charges as a result of the revaluation (see non cash above).


Annual

After removing system PSF forecast I&E operating performance is slightly behind plan. There is also a negative impact of changes to capital charges as a result of revaluations, but these manifest as gains in financing (see also forecast).

Capex slightly behind plan and planned sale of junction ahead of plan (in 2018/19) impacts negatively on capital. Utilisation of external funding is also behind plan but this is largely offset by reduction in PDC Dividend.

After removing system PSF forecast I&E performance is slightly behind plan. There is also a negative impact of changes to capital charges as a result of revaluations, but these manifest as gains in financing (see below).

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Cash and Liquidity

Actual Plan Variance Forecast Plan Variance£'m £'m £'m £'m £'m £'m

£28.3m £19.6m £8.7m £19.3m £17.5m £1.8m

Debt Analysis*

Invoice Age 1-30 31-90 90+ Total

Local Authorities £0.3m £0.1m £0.6m £1.0mNon NHS £0.4m £0.5m £0.1m £1.0mNHS £3.9m £3.9m £3.2m £11.0m

Total £4.6m £4.6m £3.9m £13.1m

Local Authorities £0.1m £0.4m £0.6m £1.1mNon NHS £0.1m £0.5m £0.1m £0.8mNHS £4.1m £2.4m £3.1m £9.6m

Total Last Month £4.3m £3.4m £3.8m £11.5m

Year To Date (Current) Annual

*Note that phasing adjustments, contract variations, accruals and PSF monies are uninvoiced and therefore excluded from Debt Analysis.

0.000

5.000

10.000

15.000

20.000

25.000

30.000

35.000

1 2 3 4 5 6 7 8 9 10 11 12

Cash Forecast

Strategic Headroom Operating Headrooom Minimum Threshold

Actual/Forecast Plan

Debt Movement

The Trade Debt position £1.6m is higher than that at month 8, once again this largely as a result of the billing of significant receivables with overall debt being broadly in line with plan. This mainly relates to the billing of AHSN, recharges and OAPs with super stranded being the major element of aging from month 8. After the progress of last month 90+ debt has remained relatively stable:

• 1-30 day debt has remained high mainly due to the aforementioned invoicing of AHSN, recharges and OAPs.

• 31-90 has increased as result of some aging within NHS debt. Though significant elements were settled in December, aging of 1-30 debt and in particular OAPs and super stranded have increased the overall. Meetings have been arranged with commissioners to resolve issues with super stranded.

• 90+ day, progress made last month has been maintained with debt level remaining similar to last month.

While work on all areas will continue, focus in currently on the NHS and month 9 agreement exercise.

Note 90+ debt is now reported in detail to the Finance and Performance Committee including thematic and risk analysis.

Cash Variances

Cash levels show a decrease on last month of £1.2m, and are £8.7m ahead of plan (£9.9m last month). This remains largely due to the transient gains on working capital with accruals and deferred income generating gains of (c£10.3m) offset by higher than planned debt/accrued income (c£3.3m), together with the bonus monies from 18/19 PSF (£2.5m) . The cash impact of the operating position and capital and financing changes is relatively minor.

Forecast cash balance is currently expected to be slightly ahead of plan:

• Risks to cash as a result of I&E performance are currently assumed to be managed and the forecast assumes management actions to maintain plan are achieved.

• Given overall revenue and capital positions underlying cash balances are expected to exceed plan for the remainder of the year.

More detailed Cash flows are presented quarterly to Finance and Performance Committee, but even downside scenarios indicate cash levels will give the required headroom.

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Finance Use Of Resource Metric

FINANCE AND USE OF RESOURCES RATING

Plan Actual Plan Forecast 1 2 3 4 Weighting

Capital service cover rating 3 3 3 3 2.5 1.75 1.25 <1.25 20%

Liquidity rating 1 1 1 1 0 -7 -14 <-14 20%

I&E margin rating 3 3 2 3 1.00% 0.00% -1.00% <=-1% 20%

I&E margin: distance from financial plan 1 2 1 2 0.00% -1.00% -2.00% <=-2% 20%

Agency rating 2 3 2 3 0.00% 25.00% 50.00% >=50% 20%

Overall 2 2 2 2 100%

Year to Date Annual

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.

Under the Single Oversight Framework a score of 1 is 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.

With the return of I&E to plan the UoR also returns to plan with a rating 2 against a plan of 2. Though the agency rating is behind plan, much of this is attributable to Cumbria and and though an adjustment to the Trusts ceiling has been requested from NHSEI to compensate this is now expected to only be implemented from 2020/21 onward. Assuming current pressures and risks are addressed and I&E performance achieves (or exceeds) forecast the Trust will achieve a UoR of 2 in line with the plan.

• Capital Service is currently a 3 against a plan of 3, a deterioration in operating performance of c£1.1m would be required to decrease the rating to 4.• Liquidity is currently a 1 against a plan of 1, a deterioration in the liquidity metric of c£8.6m would be required to reduce the rating to 2. • I&E Margin rating is currently 3 against a plan of 3, a deterioration in operating performance of c£0.7m would be required to decrease the rating to 4.• I&E Variance from Plan is currently 2, an improvement in operating performance of c£0.1m would increase the rating to 1.• Agency is currently 3 against a plan of 2, a decrease in agency costs of c£1m would be required increase the rating to 2.

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Income and Expenditure - Services

Year to Date Income and Expenditure - Services (Actual v Plan)


Mental Health Services 113.5 109.4 -4.1Staffing is underspending in most non-inpatient areas. Inpatients and in particular, Secure, are experiencing pressures. OAPS is overspent.

Community Services 46.5 46.9 0.4There is some slippage on CIPs more than compensated for by additional income and non-pay underspends.

Children And Family Services 22.3 21.4 -0.9The Network is struggling to convert prior years savings into it's recurrent position.

Cumbria 4.2 4.4 0.2 There is a £0.2m underspend after two months.

Corporate and Reserves 43.6 46.3 2.7Impacted by holding reserves still to be applied and increased costs due to the Cumbria transfer.

Net Network Position 230.1 228.3 -1.7

Forecast Income and Expenditure - Services (Forecast v Plan)


Mental Health Services 151.2 145.5 -5.7Staffing pressures, and OAPs overspends, partly offset by gains on income for stranded patients. New developments recruited to.

Community Services 62.2 62.5 0.3Some pay pressures from CIP slippage, but compensated for by non-pay underspends and additional income.

Children And Family Services 29.7 28.7 -1.0There is an expectation that the service continues to struggle to shed costs associated with Universal and CIP slippage

Cumbria 8.5 8.8 0.3Direct clinical costs for Cumbria are at this point expected to be in line with the funding agreed for the transfer.

Corporate and Reserves 59.4 63.4 4.0Some gains on reserves, but most pressures now fully distributed. Corporate and estate costs for Cumbria introduce additional costs.

Net Network Position 311.0 308.8 -2.1

Note Service figures do not include Healthcare Income and Capital Charges.


Annual

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Staffing

0

200

400

600

800

1,000

1,200

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

Agency Spend by Type

Medical and Dental Nursing, midwifery and health visiting staff

Scientific, therapeutic and technical staff Health care assistants and other support staff

Managers and infrastructure support Other

Agency Ceiling

12,000

14,000

16,000

18,000

20,000

22,000

24,000


Staffing Spend by Category

Substantive Bank Agency Plan Total

Staffing Spend

• The ward pressures were addressed by funding to align with the Hurst work. There is some pressure on wards still and the Hurst work is being revisited.

• The Trust plan assumed very significant investment from commissioners. This has started to filter through and significant recruitment has taken place to the extent that staffing costs are now exceeding plan.

• We have seen some an overall increase in the use of temporary staffing as development roles are recruited to and backfill used.

Agency Spend

• Agency expenditure continues to be dominated by medical and dental expenditure although this has decreased significantly on previous month. Nursing costs on have again increased in December as recruitment continues on developments

• Cumbria staffing increases the overall agency spend by over £138k, a large increase over November.

• The Trust has revised its agency plan to £9.1m per annum to acknowledge the additional medic costs and Cumbria. The Agency Ceiling is £6.3m and is not expected to be revisited in year.

• Overall expenditure is expected to exceed the agency ceiling by c£2.7m for the year, 43%.

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Month Month Month MonthDec 2019 Nov 2019 Dec 2019 Nov 2019

9 8 Note 9 8 Note

Agency Spend 661 758 Note 1 Bank Spend 2,168 1,727

Network Analysis Network AnalysisMental Health 235 337 - Note 2 Mental Health 1,788 1,392 - Note 2Children & Young Peoples 89 77 - Note 3 Children & Young Peoples 73 49 - Note 3Community & Wellbeing 196 272 - Note 4 Community & Wellbeing 166 143 - Note 4Cumbria 138 104 - Note 4 Cumbria 55 68 - Note 4Corporate Services 2 -33 - Note 5 Corporate Services 86 75 - Note 5

Actual 661 758 Actual 2,168 1,727

1

2

3456

The Trust has been given a ceiling by NHS Improvement for agency spend. This target is £6.3m for the year. At the end of period 9, the Trust is £1.8m, or 39% above it's ceiling, and £0.9m above plan. A revision to the target to account for Cumbria will not occur this year so pressure remains. The new Use of Resources rating measures agency against target and contains trigger points. Key trigger points are a requirement for 50% and 25% or better for ratings of 3 and 2 respectively. An individual rating of at least 3 is required to obtain an overall rating of 2 (see also Use of Resources section). We expect of exceed our plan and control total by some distance.

Corporate Services is net of the charge levied for agency staff. Agency spend is negligible with the exception of minor amounts in Health Informatics.

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

High vacancy levels are being supported by bank and agency, which when added to acuity and occupancy levels on wards, mean overall staffing costs remain high. Temporary staffing has increased this month, however we have seen a shift from agency to bank.Mental Health Networks bank and agency costs are primarily due to the level of acuity and vacancies on inpatient wards which are being recruited to, and from filling medical posts with agency. Temporary staffing has increased on the previous month across most areas due to pressures from backfill for the newly commissioned developments.Children and Young Peoples temporary staffing remains relatively minor, with some bank increase in medics.Community and Wellbeing sees a slight increase in temporary staffing. This is mainly agency staff to dental and iMSK.Cumbria are currently making significant use of medics and nursing agency to cover vacancies. There has been increased agency on the previous month.

Agency Ceiling Apr May Jun Jul Aug Sep Oct Nov Dec YTD Total ProjectionCeiling 527 527 527 527 527 527 527 527 527 4,743 6,323Actual 531 563 664 795 677 866 1,070 758 661 6,586 9,055Plan 627 627 627 627 626 625 617 617 617 5,610 7,462Variance Act to Plan 96 64 -37 -168 -51 -241 -453 -141 -44 -976 -1,593% of Ceiling 139% 143%% of Plan 117% 121%

Apr May Jun Jul Aug Sep Oct Nov Dec Jan Feb Mar2017/18 1312 1268 1625 1365 1481 1813 1388 1322 1795 1266 1488 1963

2018/19 1556 1825 1601 1527 2081 1814 1627 1972 1584 1410 2035 1679

2019/20 1884 1554 1931 1704 1692 2001 1693 1727 2168

0

500

1000

1500

2000

2500


2017/18 647 691 711 704 825 863 774 706 809 790 672 703

2018/19 609 692 642 718 579 607 745 534 588 550 500 1041

2019/20 531 563 664 795 677 866 1070 758 661

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400

600

800

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- Forecast Shortfall - Forecast Achievement - YTD Shortfall - YTD Achievement

CIP Achievement (£)

Notes

Overall delivery of CIPs continues to be broadly in line with plan at month 9, albeit much reliant on non-recurrent schemes.

The forecast outturn is now also in line with plan. This is built into the overall financial position.

Compensatory schemes are being formulated to cover failing schemes and this needs to continue in addition to developing long term transformational programmes.

Additionally, the Trust needs to convert pipeline schemes into real and tangible gains.

The Trust has challenged all services and departments to achieve additional in year savings and targets have been communicated.

Work is progressing on identifying transformational programmes for next year, however it is already a stretch for them to be effective from 1st April.

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

Scheme Annual YTD Plan YTD Actual Variance Outturn YE Variance RecurrentWard Premium £400 £400 £400 £0 £400 £0 £400Ward Skill Mix £450 £338 £0 -£338 £0 -£450 £450OAPs Reduction £500 £250 £0 -£250 £0 -£500 £0Other Mental Health £1,266 £873 £763 -£110 £1,223 -£43 £1,160District Nursing £800 £600 £16 -£584 £22 -£778 £22Other Community £399 £299 £258 -£41 £348 -£51 £332Children & Young Peoples £1,195 £826 £673 -£153 £793 -£402 £325Corporate £1,278 £919 £1,310 £391 £2,528 £1,250 £1,222Estates £396 £296 £312 £16 £423 £27 £423Land Disposals / Non Rec £1,500 £750 £375 -£375 £900 -£600 £00-19 £1,768 £1,326 £1,449 £123 £1,932 £164 £1,932Procurement Savings £121 £91 £375 £284 £500 £379 £500New Schemes £0 £0 £825 £825 £1,100 £1,100 £1,100Total £10,073 £6,968 £6,756 -£212 £10,169 £96 £7,866

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OUT OF AREA ACTIVITY

12

3

4

5

6 The Trust believes it has secured a commitment from commissioners regarding liability for LD and Rehab patients who no longer benefit from our interventions and invoices in respect of these stranded patients have now been raised. This arrangement is currently being tested with some push back on the appropriateness of charging by commissioners. The Trust has arranged meetings with commissioners and appraised NHSE of the position, but has not included c£1.5m in this regard in the base case.

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

The Trust has incurred additional pressure on services. The original plan assumes a large drop in OAPs aligned to the appropriate placement of stranded LD and Rehab patients. This has slipped significantly exposing the Trust to financial pressure.

The current position indicates the Trust will spend c£16.6m on OAPs, £4.1m in excess of LCFT funding after accounting for the recharge of stranded patients. The forecast is being reviewed as it has been suggested that it lacks robustness and is overly pessimistic given current bed occupancy.

There is a fund of c£5m for OAPs, financed 50:50 by the Trust and Lancashire CCGs. The commitment from CCGs is however open ended on a 50:50 basis.

We are including figures for the additional activity at the Priory (Cottam) where it is above commissioner funding.

19/20 Beds beyond Commissioned Capacity

April May June July August September October November December January February March TotalAcute 47 47 51 40 37 53 70 71 66 57 57 57PICU 13 12 17 15 9 7 9 11 7 12 12 12Priory 11 11 11 11 11 11 11 18 17 17 17 17Total Beds 71 70 79 66 57 71 90 100 90 86 86 86Acute £773 £757 £812 £688 £573 £829 £1,209 £1,006 £900 £1,042 £938 £1,042 £10,569PICU £315 £302 £416 £333 £229 £160 £216 £261 £165 £298 £269 £298 £3,262Cottam Ward above trajectory £161 £167 £161 £167 £167 £161 £167 £264 £258 £258 £241 £258 £2,430Calico £81 £106 £112 £300Total Cost (£'000s) £1,330 £1,332 £1,501 £1,188 £969 £1,150 £1,592 £1,531 £1,323 £1,598 £1,448 £1,598 £16,560Charge to CCGs (incl stranded) £500 £662 £838 £500 £709 £702 £1,209 £795 £1,032 £807 £1,143 £1,027 £9,923Charge to LCFT £830 £670 £663 £688 £260 £448 £383 £736 £291 £791 £305 £571 £6,637

Trajectory

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Plan Actual Plan ForecastDec 2019 Dec 2019 Variance Out-turn Variance

£'m £'m £'m £'m £'m £'m

Integrated AMH 0.00 0.03 0.03 0.20 0.84 0.64

IT Schemes (inc GDE and RTCs) 2.96 3.18 0.22 4.20 4.39 0.19

Estate and infrastructure Schemes 3.88 3.13 -0.75 7.03 7.24 0.21

Energy Efficiency Schemes 0.00 0.00 0.00 0.44 0.44 0.00

Contingency and Other 0.30 0.05 -0.25 1.00 1.00 0.00

Total 7.14 6.38 -0.75 12.86 13.90 1.04

Capital Expenditure

Overall year to date capital expenditure remains slightly behind plan, and though well within acceptable tolerance, several pressures and risks are being managed within the programme (see below). The plan and forecast now includes additional external funding of £1.8m for expected allocations re the Energy Efficiency Fund (£0.4m, subject to conditions), estimates of spend on the Wave 4 bid for the Fylde Coast (£0.2m, subject to confirmation), additional cover to support capital pressures re Avondale (£1m, secured through dialogue with NHSEI) and additional GDE monies for Cumbria (£0.2m, subject to milestones). Despite this additional cover several issues underpinning capital management present pressures and risks to the capital programme. Most notably the incorporation of pressures on the programme as a result of the accommodation of the refurbishment of ward at Royal Preston Hospital Avondale Unit to provide mental health rehabilitation beds (£2.2m, now part funded), A&E Liaison builds (£0.7m in 19/20) and the capital investment required for Cumbria (c£1.2m) has presented significant challenges to capital management. When combined with additional pressures as well as pressures/opportunities around AMH schemes, it was considered unlikely that the additional monies would be sufficient to support all of the Trusts requirements within the originally envisaged timescales. However, the additional support provided by the sale of Sharoe Green means that key programmes and objectives can likely now be managed within the overall envelope.

AnnualYTD

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MATTERS

ID Meeting DatePaper Status

2017/01 Jul-17 VerbalIncluded

2019/02-01 Jul-19 Verbal Included

2019/02-02 Jul-19 VerbalPartial


2019/02-04 Jul-19 VerbalIncluded

2019/02-05 Jul-19 VerbalIncluded

2019/03-01 Jul-19 VerbalExcluded


2019/03-02 Jul-19 Verbal

Excluded

2019/03-03 Jul-19 Verbal

Excluded

2019/03-04 Oct-19 Verbal

Included

2019/03-05 Jan-20 Verbal

Excluded

It was reported in July that Julian Kelly (Chief Financial Officer for NHS England and NHS Improvement) wrote to Trusts about the overcommitment of NHS capital and a proposed reduction to capital spend of c20% across the NHS. This is now considered unlikely to takeplace and has been excluded from capital forecasts.

Increased scrutiny by HM Revenue and Customs on the NHS, and in particular those with arm’s length vehicles has led to a challenge byHMRC as to LCFTs VAT treatment on transactions with RRCS. With the assistance of its VAT advisors the Trust has presented itsresponse a and is currently awaiting a reply from HMRC (expected late January). The Trust has asked its VAT advisors to help assess andquantify the risks involved when information allows.

The capital receipts for Ridge Lea are excluded from forecasts. Though the disposal and associated capital receipt for Sharoe Green iscurrently included in forecasts, profits have been excluded while the position is being finalised.

The mental health contract for 19/20 is agreed and the developments are being introduced into the position as they commence

The Trust has been notified that there will be a further PSF distribution to the Trust in relation to 2018/19 of c£100k. This increase isincluded in forecasts but is excluded from control total calculations.

SubjectA number of disputes require resolution and have been submitted for mediation, these include West Lancs and Fylde Coast CCGs. TheTrust is awaiting responses from the commissioners. Though some debt remains in mediation the expected exposure/risk has beenaccounted for appropriately and has been discussed at FRG.

15% of PSF funding is contingent on the Lancashire and South Cumbria health system achieving it's control total. There is nowsignificant uncertainty around delivery of this given the issues being flagged in the health economy and it has been removed from theposition (£423k is currently assumed to be non-recoverable in the forecast). Whilst this impacts the Trusts financial position it does notimpact on the Trusts performance against the control total.

2018/19 PSF monies were paid in July.OAPs trajectories have been revised and shared with commissioners. These include assumptions on stranded patients. Costs forpatients identified as stranded are now being charge to CCGs. Income for this is not in the base position, but modelled as an upside.

The Trust has taken over the services of South Cumbria for mental health. £8.4m of assets transferred as part of this. Guidance fromNHSE/I is that this should be accounted for on an absorption basis. The Trust therefore has a (below the line) non-cash backed credit toincome and expenditure of that amount , and a debit to fixed assets of that value on the balance sheet.

The Trust is conducting a full revaluation of its estate. This will result in changes to fixed asset values and their expected lives at theyear end. Asset values may increase or decrease as a result, impairments will impact the I&E position but will represent technicaladjustments and not impact underlying performance against plan and control total. Whilst changes to values and asset lives will impacton 2020/21 capital charges it will not impact 2019/20.

Given the demands on the capital programme, and with particular regard to pressures re Avondale, A&E Liaison and Cumbria, we are incontinued dialogue with NHSEI. Additional funding of c£1m has been provisionally agreed for Avondale and is now reflected inforecasts.

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Board of Directors

Agenda Item TB 047/20 Date: 06/02/2020

Report Title Nurse Safe Staffing Report (December 2019)

Prepared By Shamine Hall, Nurse Staffing Manager

Presented By Maria Nelligan, Executive Director of Nursing and Quality


Supporting Executive Director Director of Nursing and Quality

PURPOSE OF THE REPORT:

Report Purpose To provide Board with: An update on LSCFT nurse staffing Assurance of actions being taken to improve safety

and quality in the delivery of care to people who useour services

The report provides assurance that all efforts arebeing made to ensure detailed internal oversight andscrutiny is in place to ensure safer staffing levels aremaintained

Proposed next steps.



Board Assurance Framework Risk 1.0 The Trust does not protect the people who use its services from avoidable harm and fails to comply with the CQCs standards for the quality and safety of services 2.0 The Trust does not deliver safe, appropriate and therapeutic environments to deliver high quality services 6.0 The Trust does not have sufficient leadership to deliver the transformational change required to address the cultural changes, improve wellbeing and to empower staff and widen the diversity of our workforce

CQC Domain Safe

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1. Introduction

The National Quality Board (NQB) has described the importance of organisations supporting their staff to

provide high quality compassionate care. Lancashire and South Cumbria NHS Foundation Trust (LSCFT)

is committed to developing a nursing workforce, which is highly skilled and resilient to deliver safe and

effective care.

This report details the in-patient daily staffing levels during the month of December 2019 following the

reporting of the planned and actual hours of Registered Nurses, Registered Nursing Associates (RNAs)

and Health Care Support Workers (HCSW) to NHS Digital. Additionally, as required the Trust has also

reported Care Hours per Patient Day (CHPPD) to NHS Digital. The CHPPD calculation is based on the

cumulative total number of patients daily over the month divided by the total number of care hours.

2. Background

The monthly reporting of safer staffing levels is a requirement of NHS England and the National Quality

Board (NQB) in order to inform the Trust Board and the public of staffing levels within in-patient units.

In addition to the monthly reporting requirements the Executive Director of Nursing and Quality is required

to review ward staffing on a 6 monthly basis (comprising of a comprehensive annual review and 6 month

follow-up) and report the outcome of the review to the Trust Board of Directors. The comprehensive annual

safer staffing review report for 2018 was presented to February 2019 Board by the Interim Director of

Nursing and this staffing review utilised the Hurst methodology.

The new Executive Director of Nursing and Quality commenced the 2019 annual safer staffing review,

prioritising the adult acute mental health wards, in December 2019. The review is utilising the Telford

model which takes into account professional judgement and includes nursing practice, leadership, finance

and estate. The findings from the review will be presented to the Board in February 2020. The

recommendations relating to safer staffing reviews will be progressed and monitored through the Staffing

for Safety and Quality Group. The group has representatives from Nursing and Quality, Networks,

Workforce Information and the Quality Academy who are responsible for progressing the Safer Staffing

recommendations agreed by Board. The group reports to the Quality and Safety Sub-Committee directly

and People and Quality Committee in the form of a Chairs report.

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3. Trust Performance

During December, across 43 in-patient settings, the Trust achieved an average day fill rate for registered

nurses (RNs) of 76% and 128% for health care support workers (HCSW’s). For night shifts the average fill

rate has increased to 98% for registered nurses and 154% for HCSW. Taking skill mix adjustments into

account an overall fill rate of 106.1% on days and 130.5% on nights was achieved. This demonstrates an

increase in fill rates on both days and nights.

Where 100% fill rate was not achieved for RN’s, safety was maintained by the deployment of nurses

working additional hours, RNA’s and HCSW’s covering shifts and cross cover by ward and senior nurses.

Wards are also supported by ward managers, matrons and MDT colleagues. The current staffing review

has identified that throughout days there are additional clinical staff that are supernumerary and these

provide additional support for the wards. Night duties are supported by a duty matron who is based

centrally at the Harbour. A breakdown of ward fill rates can be found in appendix 1.

4. Care Hours per Patient Day (CHPPD)

The Trust is required to report CHPPD to NHS Digital on a monthly basis. The CHPPD calculation is based

on the cumulative total number of patients daily over the month divided by the total number of care hours.

The CHPPD metric has been developed by NHSI to provide a consistent way of recording and reporting

deployment of staff providing care in inpatient units. The aim being to eliminate unwarranted variation in

nursing and care staff distribution across and within the NHS provider sector by providing a single means

of consistently recording, reporting and monitoring staff deployment.

For the Trust CHPPD (appendix 1) continues to be highest within specialist services that have a greater

staff to patient ratio, for example perinatal and PICUs. As reported via NHS Digital overall the Trust

averaged 14.3 hours in December per patient day per day on the wards.

5. Impact of Safe Staffing Levels

Ward managers report the impact of unfilled shifts on a shift by shift basis. Staffing issues contributing to

fill rates are summarised in appendix 2.

5.1 Impact on Patient Safety

The Trust utilises HealthRoster to monitor and report on staffing, within HealthRoster the SafeCare module

includes a census 3 times a day to enhance the ‘real time’ oversight and response to staffing. The

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SafeCare module now includes a red flag summary. Red flag events are locally and nationally determined

early indicators that safer staffing levels on a ward may be of concern and therefore have a potential impact

on the safety of patients. These are identified via the SafeCare module on HealthRoster and enable an

early response to issues as they arise; they are utilised in daily staffing huddles by matrons and by site

managers for this purpose.

During December the majority of red flags related to incidences of there being 1 RN on duty of which there

were 212 occurrences. In terms of themes the one area where there was a significant number of

occurrences (138) was within Guild Secure Services, all of which were on days. To maintain safe staffing

modern matrons and lead nurses use clinical judgement and visible support and leadership to maintain

safe staffing and further support is provided by MDT colleagues. Additionally, Guild Lodge have a

supernumerary senior nurse on site to co-ordinate staffing, provide clinical leadership and maintain safety.

In addition to the red flag summary in SafeCare the Trust also monitors incidents in relation to staffing

through Datix, the Trust incident reporting system. A total of 6 Datix incidents were recorded in December

2019 for inpatient wards in relation to staffing, all of which resulted in ‘no harm’. These incidents were:

Site/Ward Staffing Incident Guild Two preceptees on duty, one from another ward

Guild Lack of Positive and Safe trained staff on duty

Stevenson Reduced staffing levels due to patients requiring care at the local acute hospital

Byron Bank cancellations and high levels of observations; this is being followed up by

the Temporary Staffing Manager

Scarisbrick Prolonged incident on the Lathom Suite required a number of staff to support

Cove High levels of observations and clinical need

5.2 Impact on Patient Experience

Staff prioritise patient experience and direct patient care. During December 2019 there were 8 occasions

when therapeutic leave had to be cancelled as a result of shortfall in nursing staff. All leave was rearranged

at the earliest opportunity.

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5.3 Impact on Staff Experience

In order to maintain safe staffing levels a total of 468 staff breaks were cancelled on inpatient wards in

December; this is approximately 3.39% of breaks and this is a reduction of 204 in month. Any time accrued

due to missed breaks is taken back as time-off in lieu (TOIL) with agreement of the ward manager.

Breaks should only be missed breaks in order to maintain patient and staff safety and must be approved

on HealthRoster by the level 1 approver (band 7 or above). Missed breaks are monitored via HealthRoster

and staff are allocated time owed in lieu. This is being monitored at a local level by the Heads of Nursing.

5.4 Mitigating Actions

Ward managers and members of the multi-disciplinary team have clinically supported day shifts to ensure

safe patient care. Additionally, skill mix may be altered to maintain safe staffing, in December a total of 89

RN shifts were covered by HCSW where RN temporary staffing was unavailable and there were 61

instances of RNs covering HCSW shifts. Additionally, as outlined in section 5.3 staff breaks have been

shortened or cancelled and wards have crossed covered to support safer staffing levels. Both the Harbour

and Guild Lodge have daily safety huddles with senior nursing staff. Further oversight is provided by a

daily safety teleconference between services. Additionally, Temporary Staffing was utilised to backfill

vacant shifts with a total of 461.94 WTE supplied on average each week during December, with the

breakdown as follows:

Role Bank WTE average

per week

Agency WTE average per

week

Registered 78.28 20.99

Support Workers 329.90 32.78

Total 408.18 53.76

6. RN Staff Vacancies and Recruitment

In comparison to November, vacancies for RN within inpatients rose during December 2019 however at a

Trust wide level the RN vacancy rate remained reasonably static in December at 15.78%, from 15.52% in

November 2019. This corroborates reports that a number of RNs transferred to community teams within

the mental health network and therefore they did not leave the Trust however highlights the need to have

attractive career opportunities within the in-patient wards; this is being addressed through the Annual Safer

Staffing Review currently being undertaken by the Director of Nursing and Quality.

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Recruitment of registered practitioners continues to be a priority for LSCFT. Innovative approaches

includes the employment of Learning Disability nurses and Global Learners within mental health settings.

Two global learners commenced in December 2019 following a period of pastoral support, with a further

eight commencing in January 2020.

The newly registered practitioners (RNs, AHPs and Nursing Associates) who commenced within the Trust

continue to be supported by the Preceptorship Academy Pathway. Currently 85 preceptorship RNs plus

11 Nursing Associates being supported.

The Harbour held a successful recruitment event on the 17th January 2020 with 22 offers of employment

made to RNs and pre-registration students.

Following a meeting with Guild staff the shift consultation has been put on hold until June 2020 due to

concerns relating to the impact on staffing. This speciality has been prioritised for the second phase of the

safer staffing review which is planned for February 2020.

RN Nursing

Vacancies

(Inpatients)

April

2019

May

2019

June

2019

July

2019

August

2019

September

2019

October

2019

November

2019

December

2019

All inpatient wards

excluding South

Cumbria

167.12 257.91

(Hurst

included)

262.2 270

275

272.75

227.8 227.2 253.48

South Cumbria –

Kentmere, Dova

and Ramsey

14.1 14.1 13.9

7. Summary

This report provides an update on LSCFT nurse staffing for December 2019. During the reporting period

staffing challenges remain evident, which also reflects the current national picture. Despite these

challenges, ward managers and clinical teams have maintained safer staffing levels. Particularly to note

is an improvement in the fill rates for RNs and the reduction in the number of occurrences of 1 registered

nurse on duty. The improvement in fill rates in December has been as a result of new RN’s recruited in

October and utilisation of RNA’s. The Director of Nursing and Quality is currently overseeing the annual

staffing review and will lead the safer staffing action plan to ensure recruitment, retention and skill mix of

staffing on wards is maximised.

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8. Recommendations

The Board is asked to:

Receive the report;

Note the challenges in delivery safer staffing;

Note the mitigations and action plans in place;

Be assured that safe staffing levels have been maintained during December with the support of

rostered and non-rostered nursing and MDT staff.

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2019 December

Ward

Day

Establishment Day Actual

Night

Establishment Night Actual

Day

Establishment Day Actual

Night

Establishment Night Actual Day Fill Rate % Night fill rate Day Fill Rate

Night Fill

Rates Overall RN%

Overall Care

Staff %

Overall

Staffing

Longridge Ward (C) 900 1110.25 600 650 1125 883.25 600 559.25 123.4% 108.3% 78.5% 93.2% 115.8% 85.9% 100.9%

The Orchard 964.8 1011.8 660 591.56 1608 1908.95 1320 1403.75 104.9% 89.6% 118.7% 106.3% 97.3% 112.5% 104.9%

Fairsnape Ward (S) 990 727.34 322.5 387.75 660 682.26 645 989.17 73.5% 120.2% 103.4% 153.4% 96.9% 128.4% 112.6%

Greenside Ward (S) 990 600.25 322.5 359.67 1320 1181.09 645 1030.42 60.6% 111.5% 89.5% 159.8% 172.2% 124.6% 148.4%

L2063 Calder Ward (S) 990 683 322.5 382.75 1320 2654.51 645 3114.83 69.0% 118.7% 201.1% 482.9% 93.8% 342.0% 217.9%

Fairoak Ward (S) 990 589.68 322.5 379.25 990 986.01 645 779 59.6% 117.6% 99.6% 120.8% 88.6% 110.2% 99.4%

Forest Beck Ward (S) 660 438.85 322.5 418.75 660 783.07 645 688.59 66.5% 129.8% 118.6% 106.8% 98.2% 112.7% 105.4%

Whinfell Ward (S) 990 669.49 322.5 374.59 990 1248.91 645 1045.75 67.6% 116.2% 126.2% 162.1% 91.9% 144.1% 118.0%

Marshaw Ward (S) 990 601.92 322.5 437.75 1320 1161.27 645 1034.92 60.8% 135.7% 88.0% 160.5% 98.3% 124.2% 111.2%

Elmridge Ward (S) 1320 603.42 322.5 362.01 990 2204.92 967.5 2856.81 45.7% 112.3% 222.7% 295.3% 79.0% 259.0% 169.0%

Bleasdale Ward (S) 990 748 322.5 400.67 990 1831.42 645 2065.42 75.6% 124.2% 185.0% 320.2% 99.9% 252.6% 176.3%

Mallowdale Ward (S) 660 522.42 322.5 359.75 330 748.98 645 701.75 79.2% 111.6% 227.0% 108.8% 95.4% 167.9% 131.6%

Dutton Ward (S) 1320 442.84 322.5 362.07 990 1631.18 1290 1784.58 33.5% 112.3% 164.8% 138.3% 72.9% 151.6% 112.2%

Langden Ward (S) 1320 644.92 322.5 452.75 990 1714.03 967.5 1217.55 48.9% 140.4% 173.1% 125.8% 94.6% 149.5% 122.1%

Fellside East Ward (S) 990 457.1 322.5 345.5 660 1446.91 645 1609.22 46.2% 107.1% 219.2% 249.5% 76.7% 234.4% 155.5%

Fellside West Ward (S) 660 590.92 322.5 381.25 660 861.27 645 429.42 89.5% 118.2% 130.5% 66.6% 103.9% 98.5% 101.2%

Hermitage Ward (S) 660 583.1 322.5 353 330 520.53 322.5 365.5 88.3% 109.5% 157.7% 113.3% 98.9% 135.5% 117.2%

Ribble Assessment 1608 1811.77 990 648.32 1286.4 1314.56 660 1089.53 112.7% 65.5% 102.2% 165.1% 89.1% 133.6% 111.4%

Worden Ward 1286.4 1011.08 660 635.82 1286.4 1672.55 1320 1338.93 78.6% 96.3% 130.0% 101.4% 87.5% 115.7% 101.6%

Hyndburn Ward 1286.4 1399.71 660 653.44 1286.4 1819.24 1320 1341.12 108.8% 99.0% 141.4% 101.6% 103.9% 121.5% 112.7%

Darwen Ward 1286.4 1142.56 660 622.04 1286.4 1810.02 1320 1394.72 88.8% 94.2% 140.7% 105.7% 91.5% 123.2% 107.4%

PICU Calder 964.8 881.7 660 633.32 1286.4 2025.36 990 2067.48 91.4% 96.0% 157.4% 208.8% 93.7% 183.1% 138.4%

PICU Avenham 964.8 778.19 660 672.88 1286.4 2399.75 990 2342.27 80.7% 102.0% 186.5% 236.6% 91.3% 211.6% 151.4%

Edisford Assessment 1608 1547.48 990 568.41 1286.4 1383.18 660 1062.78 96.2% 57.4% 107.5% 161.0% 76.8% 134.3% 105.6%

Hurstwood 964.8 833.74 660 643.76 1608 2329.91 1320 2102.3 86.4% 97.5% 144.9% 159.3% 92.0% 152.1% 122.0%

Duxbury Ward 1286.4 746.42 660 603.97 1286.4 1804.37 1320 1366.81 58.0% 91.5% 140.3% 103.5% 74.8% 121.9% 98.3%

Shakespeare 1395 867.61 664.64 643.2 2061.5 1581.48 996.96 1254.5 62.2% 96.8% 76.7% 125.8% 79.5% 101.3% 90.4%

Stevenson Ward 1350 807.21 643.2 639.32 1995 1955.2 1159.8 1665.62 59.8% 99.4% 98.0% 143.6% 79.6% 120.8% 100.2%

Churchill Ward 1350 699.54 643.2 632.48 1350 1221.85 964.8 964.8 51.8% 98.3% 90.5% 100.0% 75.1% 95.3% 85.2%

Orwell Ward 1350 627.46 643.2 430.08 1350 1922.83 964.8 1314.87 46.5% 66.9% 142.4% 136.3% 56.7% 139.4% 98.0%

PICU Byron Ward 1350 774.38 643.2 611.04 1995 3316.07 1159.8 2897.4 57.4% 95.0% 166.2% 249.8% 76.2% 208.0% 142.1%

PICU Keats Ward 1350 751.94 643.2 581.44 1350 1367.5 964.8 1136.32 55.7% 90.4% 101.3% 117.8% 73.0% 109.5% 91.3%

Austen Ward 1350 750.58 643.2 599.8 1800 2217.38 964.8 1911.98 55.6% 93.3% 123.2% 198.2% 74.4% 160.7% 117.6%

Dickens Ward 1350 798.37 643.2 623.48 1800 1469.22 964.8 1245.08 59.1% 96.9% 81.6% 129.1% 78.0% 105.3% 91.7%

Bronte Ward 900 710.74 643.2 589.48 1800 1691.63 964.8 1657.84 79.0% 91.6% 94.0% 171.8% 85.3% 132.9% 109.1%

Wordsworth Ward 900 709.01 643.2 577.38 1800 2976.3 964.8 2851.52 78.8% 89.8% 165.4% 295.6% 84.3% 230.5% 157.4%

Scarisbrick 1286.4 1048.04 660 634.04 1286.4 1547.97 1320 1501.23 81.5% 96.1% 120.3% 113.7% 88.8% 117.0% 102.9%

PICU Lathom 643.2 637.05 660 582.66 964.8 1571.68 990 1491.76 99.0% 88.3% 162.9% 150.7% 93.7% 156.8% 125.2%

CAMHS The Cove 665 806 682 708.72 1288 1252.17 1652 1594.19 121.2% 103.9% 97.2% 96.5% 112.6% 96.9% 104.7%

Perinatal 1206 806 664.43 655 964.8 707.5 332.22 353.76 66.8% 98.6% 73.3% 106.5% 82.7% 89.9% 86.3%

Kentmere Ward 690 725.25 290.88 380.9 883 1182.5 804.88 957.47 105.1% 130.9% 133.9% 119.0% 118.0% 126.4% 122.2%

Dova Ward 921 989.3 325.5 239.5 1043 1473 907.5 828 107.4% 73.6% 141.2% 91.2% 90.5% 116.2% 103.4%

Ramsey ward 806.5 1424.5 281 374.67 1691.5 1896.75 814.9 1058.43 176.6% 133.3% 112.1% 129.9% 155.0% 121.0% 138.0%

Totals 46503.9 35110.93 22714.75 22184.22 53255.2 68358.53 39354.16 60466.64 75.5% 97.7% 128.4% 153.6% 92.50% 145.50% 119.00%

Register Nurse Care StaffRegistered Nurses Care Staff Total Nursing Staff

Appendix 1 Safer Staffing December 2019

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Appendix 1 cont’d

188 of 188

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