Bolton NHS Foundation Trust – Board Meeting July 31st 2014 · 2014-07-28 · 1 Bolton NHS...

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Bolton NHS Foundation Trust – Board Meeting July 31st 2014

Location: Board Room Time: 0900 – 1230 hrs

Time Topic Lead Process Expected Outcome

0900 1. Patient Story Verbal Patient story and learning points noted

2. Apologies for Absence – Trust Sec. Verbal Apologies noted

3. Declarations of Interest Chairman Verbal To note any declarations of interest in relation to items on the agenda

4. Minutes of meeting held 26th June 2014 Chairman Minutes To approve the previous minutes

5. Action sheet Chairman Action log To note progress on agreed actions

6. Matters arising Chairman Verbal To address any matters arising not covered on the agenda

0930 7 Chairman’s Report Chairman Verbal To receive a report on current issues

0940 7.1 CEO Report including reportable issues CEO Report To receive a report on any reportable issues including but not limited to SUIs, never events, coroner reports and serious complaints

Safety Quality and Effectiveness

0950 8. Integrated Performance Report Exec team Report To note and receive the integrated performance report

10.20 9. Mock CQC inspection DoN Presentation To receive a report summarising the findings of the recent mock CQC inspections

10.40 10. Infection Control update DoN Report To receive an update on the implantation of the infection control training programme

Governance

11.00 11. Quarter one compliance declaration Trust Sec Report To approve the Q1 compliance declaration to Monitor

11.10 12. MOU N W Sector CEO Report To approve the MOU with NW Sector Trusts (Healthier Together

Finance and Strategy

11.20 13. Development of a Community Strategy DoF Report

For Information

Chair reports of the following sub-committees will be noted – if any member of the Board wishes to raise a question regarding one of these items they should indicate

2

Time Topic Lead Process Expected Outcome

this before the start of the meeting.

11.50 14. Finance and Investment Committee – Chair Report (meeting held - 17th July 2014)

15. Quality Assurance Committee – Chair Report (meeting held 9th July 2014)

16. Audit Committee – no meeting in reporting period

17. Charitable Funds – Chair report (meeting held 25th June 2014)

18. Any other business

Questions from Members of the Public

To respond to any questions from members of the public that had been received in writing 24 hours in advance of the meeting.

Resolution to Exclude the Press and Public

12.00 To consider a resolution to exclude the press and public from the remainder of the meeting because publicity would be prejudicial to the public interest by reason of the confidential nature of the business to be transacted

Review of meeting Identification of key lines of enquiry for Board visits

Trust Secretary

discussion Board members to identify any concerns and potential lines of enquiry from the papers received in the Board and recent sub committees prior to inspection visits at start of part two meeting.

Board of Directors minutes – June 26th 2014 Page 1 of 10

Meeting Board of Directors Meeting

Time 09.00 a.m.

Date 26th June 2014

Venue Boardroom Royal Bolton Hospital

Present:- Abbv.

Mr D Wakefield Chair DW

Dr J Bene Chief Executive JB

Dr M Harrison Vice Chair MH

Dr E Adia Non-Executive Director EA

Mrs G Ashworth Non-Executive Director GA

Mrs C Davies Non-Executive Director CD

Mr A Duckworth Non-Executive Director AD

Mrs T Armstrong Child Director of Nursing TAC

Mr S Hodgson Medical Director SH

Mr S Worthington Director of Finance SCW

Ms S Woolridge Acting Director Workforce and OD SW

In attendance:-

Mrs E Steel Trust Secretary ES

Dr H Bharaj Head of Division Acute Adult (item 16 only) HB

Ms B Tabernacle Deputy Director of Nursing

Mrs H Edwards Head of Communications

Two members of the Council of Governors, a representative of the CCG and a

representative of the local media in attendance as observers.

1. Patient Story

Kath - a member of the Trust’s nursing staff attended the Board meeting to tell her story of

her experiences and the care received following the death of her husband. Kath returned

home from work having stayed late on a shift to find her husband having difficulties

breathing. Kath’s husband had a diagnosis of muscular dystrophy and was a wheelchair

used requiring breathing support at night, however, despite this, he was still a young strong

man and the sudden deterioration came as a shock.

Initially one paramedic attended meaning that Kath had to continue to provide CPR support

to her husband rather than looking after her children aged 12 and 15. Further paramedic

support arrived and Kath and her husband were taken to hospital.

At some time after arrival in hospital room Kath was informed that her husband had died.

Kath felt that she had been treated well; she had been offered the opportunity to spend

time with her husband with privacy maintained by the use of the butterfly symbol. Kath

later returned home to the upsetting evidence of the paramedics’ attempts to save her

husband, the cleaning up of this area was for Kath the worst aspect of the whole situation.

The following day Kath was contacted by the tissue donation team to discuss eye and

tissue donation in accordance with her husband’s wishes, she later learnt that his eyes had


been donated to two recipients.

Overall, Kath felt the whole thing had been handled well, people had been fantastic and

she had received fantastic support from the bereavement team, the worst thing was

clearing up at home.

Board members thanked Kath for her story and acknowledged the lack of understanding of

the impact of what is left on the scene after providing emergency resuscitation. The

Director of Nursing agreed to raise this with her counterpart at the North West Ambulance

Service.

FT/14/46 TAC to discuss the impact of the patient story and potential actions to ease the situation for

others in this position with the DoN of NWAS

TAC

2. Apologies

A Ennis, G Ashworth

3. Declarations of Interest

None

4. Minutes of The Board Of Directors Meeting Held on 29th May 2014

The minutes of the meeting held on 29th May were approved as an accurate record subject

to the two amendments below

9. The audit of antibiotic stewardship will be reported through the IPCC.

8 - for clarification at its meeting on 22nd May 2014 the Finance Committee

approved in principle the application for the loan for investment in community IT

infrastructure

5. Action Sheet

The action sheet was updated to reflect progress on agreed actions.

FT/14/31 Readmissions - a review of the readmissions metric has identified that

reporting of this target and metric has not been a comparison of like with

like. The 8% target is for avoidable readmissions, the rate of approximately

14% is all readmissions and therefore not comparable.

Admissions classed as avoidable have previously been determined by a

retrospective review of casenotes conducted by primary and secondary care

clinicians. If audit shows a significantly higher or lower percentage than

previously reported this will require a contractual adjustment.

Board members requested a formal proposal for future reporting of

readmission rates to be presented at the July 2014 Board meeting

FT/14/47 Formal proposal for the reporting of readmissions

SCW/

AE


FT/14/27 Better care early warnings. Potential KPIs to monitor the impact of the

Better Care Fund have been considered - existing KPIs including but not

limited to those below will be used.

Delayed discharge

Increased LOS

Increased elderly admissions from Nursing Homes

FT/14/36 There is no backlog of 18 week patients

6. Matters Arising

No matters arising not covered elsewhere on the agenda.

7.1 Chairman’s Report

Accident and Emergency - despite high attendance performance has remained on track.

Activity is up on the previous year - the operational team are looking to understand this

more fully. The continued increase in activity was discussed at the recent Board to Board

with Bolton CCG. Both organisations are aware that there is inappropriate use of A & E

and that addressing this is an area where all members of the health economy can play a

part.

Monitor - the routine performance monitoring call was positive, the continued achievement

of the A&E target was commended and it is now acknowledged that significant process has

been made towards getting out of breach.

Mock CQC - over 100 members of staff and governors participated in a mock hospital

inspection and listening event, the discussion and observation findings are a rich source of

data to work from - a report will be provided to the next Board meeting.

FT/14/48 Report on mock hospital inspection to July board meeting TAC

7.2 CEO report

Overview and Scrutiny Committee - the CEO and Chair attended the Health Overview

and Scrutiny committee along with other NHS partners to present the Trust plans for the

year - the plans were received without comment.

The Chair and CEO met with the Bolton MPs to provide an update on Healthier Together

and the Trust’s plans.

Reportable Issues - although there have been no SUIs since the last Board meeting there

has unfortunately been one never event. The error of the insertion of the wrong lens was

identified immediately while the patient was still in the theatre area under local anaesthetic.

Immediate action was taken to change the lens and the incident was logged and reported.

A root cause analysis was undertaken including a look back exercise to identify any other

similar errors - this exercise identified a second incident reported in April 2014 although

relating to surgery in April 2012.

The new Head of Governance Richard Sachs has taken immediate action including:

Identification of lessons learned

Education with regard to the identification of never events

A paper for the CQC to explain the events


Incident Reporting - As previously discussed, the Trust is a low reporter of incidents in

comparison to other trusts when considered as a ratio of incidents per 100 admissions. In

order to be in the top ten percent of reporting organisations the Trust need to be reporting

13/14 incidents per 100 admissions (almost double the current rate)

Healthier Together - public consultation starts on 7th July 2014.

FT/14/49 Board Development session on incident reporting

8 Integrated Performance Report

Quality

There was one breach of the mixed sex accommodation guidance - one patient

breached the standard while in HDU waiting for a respiratory bed. The situation was

escalated in accordance with the policy and an operational decision made on the basis of

providing the most appropriate care to all patients who could have been impacted by a

move.

Medication incidents - There has been a slight increase in the number of reported

incidents, the terms of reference of a full external review has now been commissioned and

a letter has been sent to the Chief Pharmacist outlining the concerns. The review will

include a two week diagnostic and will include a full review of systems and processes for

medicine management. Following the review the Board will receive the full report.

Although not yet at 100 % the improvement in the completion of the WHO checklist has

continued to improve. Board members agreed there must be zero tolerance for anything

other than 100% effective timeouts - further information will be provided in the QA

Committee on the key things to achieve the final 3%.

A query was raised as to why there had been an increase in the number of pressure

ulcers; the Director of Nursing confirmed that she was aware of this but was not worried

that this represented a new trend. She advised that the review of data and cases showed

a high level of unavoidable cases, particularly in the community. The metrics are

monitored by ward and by health-centre, this monitoring will continue with quarterly

reporting to the QA Committee.

FT/14/50 Report on WHO checklist to QA committee meeting SH

Operational

Operational performance has remained steady with the continued achievement of A&E

18 weeks and all cancer targets.

Workforce

Staff turnover is within tolerance although there is some variation between different areas

of the Trust. A report will be provided to the next QA Committee on the number of leavers

to provide assurance that there are no underlying reasons.

Sickness - there has been a slight improvement in the sickness rate, primarily as a result

of getting people back into the work place after long term sickness.

Appraisal rates have dropped below target - this is thought to be due to the timing of

appraisals in relation to the cascade of annual objectives - performance will recover in the


next month

Finance

At the end of May performance is on plan:

year to date deficit of £0.5m.

CIP £3m in line with plan

Cash position slightly ahead of plan

Capital programme underspent against plan

Within the Finance and Investment Committee assurance is provided that divisions are

operating consistently with the financial management framework driving accountability

through the organisation. Board members agreed that they were assured that concerns

are highlighted and managed.

Resolved: The Board noted the integrated performance report.

9. Staffing levels

The Director of Nursing presented an update in relation to the provision of safe staffing

levels and compliance with the National Quality Board (NQB) recommendations. Previous

reports on staffing levels having been provided to the Board and to the QA Committee with

regular monthly information provided on the ward to board heat maps.

From June 2014 there is a formal requirement to publish planned and actual staffing levels

on the NHS choices web site; this information will also be provided monthly to the Board.

The data published in June 2014 shows an overall shift fill rate of 97%

Following the agreement by the Board to invest in additional nurses there have been some

challenges in relation to recruitment and the impact of high levels of sickness in many

wards and departments. In addition to focusing on the management of sickness and the

retention of staff a commitment has been made to pursue international recruitment. 40

nurses from Spain and Portugal will be commencing in post by the middle of August. In

addition, 27 pre-registration nurses have been recruited to join us on qualification in

September 2014.

Board members discussed the measures taken to recruit new nurses, the recruitment of

nurses from Spain and Portugal was undertaken with the support of a specialist firm to

ensure appropriate registration and checks including language checks are in place. Senior

nurses from the Trust interviewed all nurses recruited in this manner and were satisfied at

the standard of care and were assured that the nurses recruited are of a high calibre.

Some of the nurses recruited have previously worked in the UK and all have undertaken an

additional preregistration training year as required in Spain.

There is still more to do to address levels of sickness absence and retention, there are

some shifts which are not filled but systems are in place to manage and to escalate when

staffing levels are low.

Resolved: The Board accepted the report as assurance in relation to fulfilment of the NHS

England reporting requirements for staffing levels and agreed to receive a six monthly

formal report on staffing commencing June 2014.

FT/14/51 Report back to QA Committee to provide assurance that escalation of unfilled shifts is

working. TAC


10. Reward and recognition of staff

The Acting Director of Workforce and OD presented a proposal to promote the reward and

recognition of staff including an award evening to be held on 23rd October 2014.

The following points were noted:

The awards for employee of the month and the extra mile award have already

started

Awards are aligned to the Trust’s strategic priorities and include recognition of

quality improvements and recognition for all staff who have had a year of full

attendance.

Board members discussed the proposed awards and debated the merits of reward

compared to recognition with regard to whether awards should have a monetary or token

value. The current proposal is for recognition through awards with no monetary value

other than the John Briscoe award which is funded from a bequest and is awarded to fund

specific professional development.

Resolved: The Board noted the proposed reward scheme and asked the Executive team

to give further consideration to the development of rewards in addition to recognition.

FT/14/52 Exec team to give consideration to the presentation of financial reward as well as

recognition

FT/14/53 Over the next few months the other elements of the workforce strategy for staff

engagement, behaviours and standards to be brought together

11 Clinical Waste

In response to a questions raised at the previous Board meeting regarding the position of

designated clinical waste officer, the Director of Nursing confirmed that the Energy and

Environmental Manager is the Trust lead for this area. The Trust receive assurance with

regard to the handling of clinical and other waste through an annual independent audit of

waste. The results of this audit were presented to the QA Committee in January 2014

along with the new policy. Future audits and action plans will be presented to the Health

and Safety Committee with exceptions escalated to the Board through the QA Committee.

Resolved: The Board noted the update to address action FT/14/40

12 Revalidation

The Medical Director provided a summary of the revalidation system in response to the

Board’s queries raised at the previous meeting.

Board members asked the Medical Director for assurance that there was sufficient capacity

to ensure a robust process for sign off in accordance with GMC guidance.

The Medical Director confirmed that he was confident that the systems in place are robust

although further support from the governance and complaints teams would enhance the

process.

Resolved: the Board noted the update and requested a further verbal update in three

months’ time


FT/14/54 Three month update on revalidation to the September 2014 Board meeting

13 Risk Management Strategy

The Director of Nursing presented the revised Risk Management Strategy for consideration

and approval. Although a new strategy was approved in January 2014, changes have

been made as part of the on-going work around risk management including revised

definitions and a new risk grading matrix.

A full training programme has been developed to launch the strategy to nursing, medical

and ancillary staff, this programme is fully booked up to October.

Resolved: The Board approved the new Risk Management Strategy and requested the

provision of a training session specific to Board members

FT/14/55 Risk training session to be included in Board Development programme ES/TAC

14. Corporate Governance Statement

The Trust Secretary presented the June declaration to Monitor covering Corporate

Governance, Governor training and Academic Health Science Centres.

The Board reviewed each clause of the declaration in turn considering the evidence listed

within the report in support of the declaration.

For each statement the Board agreed they would be in a position to declare confirmation of

compliance with the requirements with Monitor’s requirements.

The Trust Secretary asked Board members to consider if they were aware of any future

risks to compliance with the statements; Board members confirmed they were not aware of

any risks to on-going compliance with the provider licence.

Resolved: The Board approved the submission of the declaration to Monitor as part of the

Annual Planning process.

15. Update on Better Care funds

The CEO advised Board members that the development and roll out of the Better Care

Fund continues in line with the national agenda. The five year plan for the Trust has been

developed in collaboration with partners in the Health economy and there is awareness of

the size and scale of the changes this will bring.

Resolved: the Board noted the update on the Better Care Fund

The following agenda items were brought forward to allow Dr Bharaj to attend for item 16 -

development of a Community Strategy

17. Finance and Investment Committee Chair report (17/06/14)

The finance report continues to evolve with the development of narrative to enable

committee members to get to the heard of key issues in advance of the meeting. Future


minutes of the CRIG meetings will include a full account of discussions in relation to capital

expenditure plans to provide further assurance to the Committee and avoid any issues with

capital expenditure as year end approaches.

Further assurance is required regarding aspects of divisional performance, the Exec team

will continue to work with the Elective Care division to ensure the recovery plan is

implemented effectively.

The IT and Estates strategies were discussed at length, a full Board discussion will be

required before these are submitted to Monitor.

Resolved: the Board noted the Finance Committee Chair report

18. Quality Assurance Committee Chair report (11/06/14)

The Committee received a presentation on midwife supervision and asked for a further

report back with recommendations to recruit more supervisors.

Medication incidents remains a priority for this committee, an external review has now

been requested to provide additional assurance of effective management in this area

The Committee discussed the reporting of incidents and the implications of the Trust’s

ambition to be in the top 10% of reporters to develop a culture of reporting near misses in

order to further learning and reduce harm to patients.

Resolved: the Board noted the QA committee Chair report.

19. Audit Committee

No meetings held during the reporting period.

20. Charitable Funds Chair report

No meetings held during the reporting period.

21. Any other business

None

22. Questions From Members of the Public

None

16 Development of a Community Strategy

The Director of Finance and the Head of Division for the Acute Adult Division delivered a

presentation to inform initial discussions for the development of a new Community

Strategy.

Board members acknowledged that having undertaken the transfer of community services

(TCS) in July 2011 the Trust’s move into turnaround had an adverse impact on the

development of an integrated community services and benefit realisation.

It has been recognised that a new Community Services Strategy and implementation plan


should be developed to pull existing strands of work together into a single coherent

strategy. A further update will be provided at the July Board meeting towards the

development of a strategy to deliver on community services through investment,

partnership and growth.

Board members discussed the decision taken at the point of transfer to split community

services across the three clinical divisions rather than operating as a separate entity which

it is now recognised would have been the best approach. Although community services

are split across the three divisions the majority of the services are within the Acute Adult

division, in recognition of this the Acute Adult Division restructure has seen the creation of

a business unit specific to community services to ensure aligned governance and

management.

It is accepted that the original benefits outlined in TCS documentation are now out of date,

appropriate metrics are needed to measure the success or otherwise of community

services. Board members discussed the proposed metrics and the development of a

community dashboard. The following points were noted:

Consideration should be given to the CCGs preferred metrics to measure

community services - discussion with the CCG to date have focused on patient

experience, quality of care and avoidance/deflection of admissions

The chosen metrics need to demonstrate the delivery of the required service

specification; operational measures will be needed in addition to quality indicators.

Deflection is a complex matter for which the responsibility must be shared between

hospital, community and primary care with all parties needing to contribute to the

management of the patient.

Operational elements are captured in the community heat map with sickness rates

and vacancies shown by health centre.

Community services is more than just keeping patients out of hospital, it is about

supporting people in the community.

Dashboards of community trusts have been reviewed as part of the development of

these metrics, contrary to what might be expected these include very similar

metrics to a hospital dashboard with 18 weeks, CDT etc included.

Metrics are needed to evidence a vibrant and effective community service provided

in line with a service specification delivering care closer to home, a positive

experience and good outcomes.

Board members agreed that further development of the strategy with timelines and a

milestone plan should be provided for the next Board meeting.

FT/14/56 Follow up paper on the development of the community strategy including milestones and

timelines to July board meeting SCW

Date And Time Of Next Meeting

31st July 2014 2014 0900

Resolved: to exclude the press and public from the remainder of the meeting because

publicity would be prejudicial to the public interest by reason of the confidential nature of

the business to be transacted.


24 Review of meeting

Board members agreed to focus on the following areas during their visits to wards and

departments:

Incident reporting

Staffing levels

“is this a great place to work”

May Board actionsCode Date Context Action Who Due CommentsFT/13/103 31/10/2013 AHSN update in April 2014 - deferred to June/July 2014 AMS Jul-14 verbal update

FT/14/38 29/05/2014 performance report FFT to be added to apex report TAC Jul-14

FT/14/39 29/05/2014 infection control annual

report

briefing note on evaluation of effectiveness of the infection control

training programme

TAC Jul-14 agenda item

FT/14/46 26/06/2014 patient story TAC to discus the impact of the patient story and potential actions with

the DoN of NWAS

TAC Jul-14 verbal update

FT/14/47 26/06/2014 actions - readmissions Formal proposal for the reporting of readmissions SCW/AE Jul-14 verbal update

FT/14/48 26/06/2014 Chair report report on mock CQC inspections to July Board meeting TAC Jul-14 agenda item

FT/14/50 26/06/2014 performance report Report on WHO checklist to QA Committee meeting SH Jul-14 complete discussed at July QA committee

FT/14/52 26/06/2014 reward and recognition Exec team to give consideration to the presentation of financial reward

as well as recognition

SW Jul-14 verbal update

FT/14/55 26/06/2014 community strategy follow up paper on development of community strategy to include

milestones and timelines

SCW/AE Jul-14 agenda item

FT/14/28 24/04/2014 SUI report data loss report back to QA committee on review of compliance with new

standard operating procedures

AE Aug-14 QA workplan Aug 2014

FT/14/51 26/06/2014 staffing levels report back to QA Comm to provide assurance that escalation of

unfilled shifts is effective

TAC Aug-14

FT/14/17 27/03/2014 performance report TAC to provide update to QA Committee on proposals for volunteers TAC Sep-14 action deferred

FT/14/23 24/04/2014 late night transfers Further report back including three months audit report and

comparison with other Trusts

AE Sep-14 action deferred to allow for results of audit to be collated

FT/14/53 26/06/2014 reward and recognition reports to be provided on engagement, behaviours and standards SW Sep-14

FT/14/54 26/06/2014 revalidation three month update on revalidation SH Sep-14

FT/14/49 26/06/2014 CEO report Board development session on incident and risk reporting ES Oct-14 to be incorporated in Board Development programme

currently being developedFT/14/42 29/05/2014 committee reports review of committee effectiveness as part of wider governance review ES Oct-14

All information provided in this written report was correct at the close of play 21/07/2014 a verbal update will be provided during the meeting if required

Agenda Item No: 7.1

Meeting Board of Directors

Date 31st July 2014

Title Chief Executive Update

Executive Summary

The Chief Executive update includes a summary of key issues since the previous Board meeting, including but not limited to:

Monitor update

reportable issues log

o coroner communications

o Never events

o SUIs

o Red complaints

Board Assurance Framework summary

Next steps/future actions Clearly identify what will follow i.e. future KPI’s, assurance requirements

The Board are asked to note this update

Discuss Receive

Approve Note

This Report Covers (please tick relevant boxes)

Strategy Financial Implications

Performance Legal Implications

Quality Regulatory

Workforce Stakeholder implications

NHS constitution rights and pledges Equality Impact Assessed

For Information Confidential

Prepared by Esther Steel Trust Secretary

Presented by Dr J Bene Chief Executive


Chief Executive Update

1. Stakeholders

1.1 CCG

The Trust have received a letter from Bolton CCG flagging concerns with regard to the

targets stroke patients to be in a designated stroke bed within four hours and the target for

investigation and treatment of high risk TIA patients within 24 hours. An action plans is

being developed, this will be reviewed by the QA committee at its next meeting.

1.2 Monitor

The next performance review meeting with Monitor is scheduled for 8th August 2013. As

requested by Monitor in our last review meeting, we are currently in the process of

completing an application for a certificate of compliance with our enforcement actions.

1.3 Healthier Together

The Healthier Together consultation was launched on 8th July 2014; meetings have been

held for staff on the 11th and 21st July and for the public on 18th July.

The Trust will submit an organisational response, responses can also be submitted by

individuals to express personal views.

1.4 Care Quality Commission

Under the CQC intelligent monitoring, the Trust has moved from band 5 to band 4 mainly as

a result of the addition of an additional risk metric for finance being included in the data.

2. Reportable Issues Log

Issues occurring between 26th June 2014 and 21st July 2014

2.1 Serious Untoward Incidents

There have been no SUIs since the last Board meeting.

2.2 Never Events

There have been no new never events since the last Board meeting.

2.3 Coroner Prevention of future Deaths (PFD) reports

There have been no coroner notices issued since the last report

2.4 Red Complaints

There have been no red rated complaints since the last Board meeting.

2.5 Reputational Issues

None of significance

2.6 Whistleblowing

There have been no concerns raised by whistleblowers

3 Board Assurance Framework

3.1. Introduction


The BAF is the framework setting out how the Board are assured that the Trust will achieve

its strategic objectives - the Annual Plan for 2014/15 builds on the five year strategic plan

submitted in September 2013 - the strategic objectives have not been changed and the

majority of the risks to achieving these objectives also remain and will be carried forwards

onto the new BAF.

The BAF is used by the Board of Directors to ensure that all significant risks have been

identified; information on control, performance and assurance is timely and relevant; and to

provide leadership on risk management.

The BAF is reviewed on a monthly basis by the Executive team who finalise the list of

strategic risks, confirm actions being taken and check assurances

3.2. 2014/15 Assurance Framework

Summary of Risks June 2014

Risk 4- incident reporting has been reduced to reflect the completion of actions and increased

controls

lead May June July

1 Failure to control healthcare acquired infections DoN 10 10 10

2 failure to provide appropriate skill mix for “safe and suitable” staffing DoN 20 20 20

3 non-compliance with CQC standards DoN 12 16 16

4 Failure to ensure the safe management, statutory reporting, internal reporting and learning from incidents

DoN 12 12 9

5 failure to provide an adequate timely response to the deteriorating patient

MD 16 16 16

6 failure to meet the A&E target COO 12 12 12

7 failure to meet the RTT target COO 12 12 12

8 Failure to comply with standards for information governance COO 12 12 12

9 loss of IT access in community settings COO 12 12 12

10 failure to provide efficient fit for purpose estate COO 16 16 16

11 downgrading of RBH scope of services CEO 15 15 15

12 To fail to achieve planned surplus of £1.6m DoF 20 20 20

13 failure to address Monitor concerns and return to green for governance CEO 10 10 10

14 Failure to achieve integrated care in Bolton CEO 15 15 15

15 failure to reduce sickness absence and improve staff health and wellbeing

HR 16 16 16

Safe, High Quality Care, Fit for the Future

Quality and Safety

Valued Provider

Financially viable and sustainable

Great place to work

Fit for the future

Well Governed

Subject Integrated Performance Report – July 2014

Prepared By Performance and Information Team

Approved By Executive Management Team

Presented By Chief Executive – Bolton NHS Foundation Trust

Executive Summary

Please see the High level Executive Summary section at the beginning of the report

Key Recommendations

The Board are asked to receive the report and give approval.

Acronyms/Terms used in Report

TRUST BOARD

Trust Objectives

Purpose

This report sets out the Trust’s integrated performance against leading national and local targets and draws attention to key areas for specific review by the Trust Board. Driven by the Trust’s strategic objectives this report is underpinned by a strong platform of integrated governance and assured data quality controls allowing the Trust Board to make effective decisions and demonstrate its commitment to delivering high quality healthcare for the people of Bolton.

Report

Appendix A

Appendix B

Report change log

1 All Report data correct and verified as of Friday 18th July 2014


Executive Apex Reports High Level Executive Summary High Level Executive Dashboard High Level Executive Report Including Community Services update • Monitor Risk Assessment Framework

Section 1 Improving the Quality of Care and Safety of our patients • Quality and Governance Scorecard • Quality and Governance Charts • Quality and Governance Report • Acquired Infection • Falls • Pressure Damage

Section 2 Valued provider of Integrated Services • Operations Scorecard

• Operations Charts • Operations Report

Contents



Section 3 Financially viable and sustainable • Finance Scorecard • Finance Report Section 4 A great place to work • Workforce Scorecard • Workforce Charts • Workforce Report Section 5 Ward to Board Heat Map

Section 6 Fit for the Future Section 7 Well Governed

Appendix A Acronyms/Terms used in Report

Appendix B Dashboard Change log - in month


Integration - The Better Care Fund

Annual Plan

Independent Review of Data Quality and Board Level Quality Indicators

Cash balance is £6.5m, £5.1m above plan

ICIP delivery is £1.7m in month, which is on plan.

June's in month deficit is as planned at £0.25m

Year end forecast surplus of £1.6m is on plan

Emergency readmissions within 30 days remains above 14% for the second consecutive month.

Natural Staff Turnover remains consistent at 9.3%.

Sickness % days lost continues to improve to 4.81% but is still above the target of 3.75%.

Deterioration in appraisal rates to 77.9%.

Mandatory training has further improved to 85.9%. Target is 100%.

Healthier Together

18 weeks admitted, non-admitted and incomplete pathways have achieved in June.

2 Same Sex Accomodation Breaches.

Who Checklist (emergency) has achieved 100% compliance.

2 Never Events in June.

I level 3 and 1 level 4 pressure damage case reported from community. Both cases were deemed to be unavoidable.

Medication Incidents have slightly raised to 78.

A&E 4 hour target has achieved at 95.7%.

Executive Summary

This executive summary provides an integrated overview of the Trust Board Performance Report. Supporting the Trust's Strategic Objectives it orientates executives quickly to the areas that have been escalated, are of particular note or political significance. The accompanying High-Level Dashboard and narrative gives further analyses. Compliance levels with the Monitor Risk Assessment Framework and CQC (Care Quality Commission) are also shown.

Improving the Quality of Care and Safety of our patients A great place to work

Valued provider of Integrated Services Fit for the future

Financially viable and sustainable Well Governed

Our Patients

The Trust continues to be licensed to carry out regulated activities with no conditions imposed

Monitor Risk Assessment Framework

CQC

Governance Finance ‐ Level 1

All Report data correct and verified as of Friday 18th July 2014

The Trust has been awarded a band 4 weighting by the CQC


Improving The Quality Of Care And Safety Of Our Patients Plan 14/15 Plan YTD

Actual YTD

Monthly Actual

Monthly Change

On Plan Off Plan Financially Viable And Sustainable

Plan 14/15

Plan YTD

Plan Actual YTD

Monthly Actual

Monthly Change

On Plan Off Plan Well Governed Status

Total number of new SUIs received within the month 0 0 2 0 Forecast year end deficit - FYE 1.6 1.6 1.6 0.0 0.0 0.0

Monitor Risk Assessment Framework On Plan

Total Incidents reported on Safeguard

YTD Running

Total 708 18 802 Forecast year end income and cost improvement - FYE 22.2 22.2 22.2 0.0 0.0 0.0 CQC Intelligent Monitoring Report On Plan

Never Event 0 0 2 2 Actual position against plan - YTD 1.6 -0.8 -0.8 -0.3 0.0 0.0CQC Essential Healthcare Standards (5) On Plan

All Patient Falls (Safeguard) 982 246 232 84 Actual Income and Cost Improvement -YTD 22.2 4.8 4.8 1.7 0.3 0.0CQUINS: National Clinical Quality Indicators On Plan

Acute Inpatients acquiring pressure damage (grades 2+) 27 7 22 9 Capital Expenditure YTD -17.5 -2.0 -0.4 -0.1 0.1 1.6 Report to prevent future deaths On Plan

Community patients acquiring pressure damage 76 19 21 7 Cash Position YTD 1.1 1.4 6.5 6.5 3.4 5.1 Litigation On Plan

VTE Assessment Compliance 95.0% 95.0% 96.9% 97.2% Continuity of services rating 2.0 1.0 1.0 1.0 0.0 0.0 Formal Contract Notices On Plan

Total number of medication incidents 636 159 228 78 Formal Performance Notices On Plan

MRSA Bacteraemia Post 48 Hours admission 10 3 0 0 Contract Fines/Penalties Off Plan

C Diff Hospital acquired 48 0 8 3

CHKS RAMI (Rolling 12 months) 100 100 80 81 Local Induction Attendance (starters in the last 12 months) n/a 100% 81.5% 81.3%

SHMI 1.000 1.000 1.078 1.078Substantive Staff Turnover Headcount (rolling average 12 months) <=10% 10% 10% 9.3% 9.3%

Surgical WHO Checklist compliance (Elective) 100% 100% 96% 98% Appraisals completed % 80% 80% 79.7% 77.9% Board Assurance Framework On Plan

Surgical WHO Checklist compliance (Emergency) 100% 100% 98% 100% Sickness days % of days lost 3.75% 3.75% 4.86% 4.6% Annual Plan On Plan

Formal complaints from patients 240 60 144 57 Mandatory Training Compliance % 100% 100% 85.3% 85.9% Patient Experience Strategy On PlanComplaints responded to within the time period % 95% 95% 96% 94% Risk Management Strategy On Plan

Cancer Treatment Targets (7) reported 1 month retrospectivelyPlan 14/15

Plan YTD Actual YTD

Monthly Actual

Monthly Change

On Plan Off Plan

Valued Provider Of Integrated Services Plan 14/15 Plan YTDActual YTD

Monthly Actual

Monthly Change

On Plan Off Plan Patients 2 week wait (all cancers) % 93.0% 93.0% 94.9% 97.8%

A&E 4 hour target 95.0% 95.0% 95.5% 95.7% Patients 2 week wait (breast symptomatic) % 93.0% 93.0% 96.2% 93.2%

RTT Admitted Clock Stops % 90.0% 90.0% 94.9% 94.9% 31 days to first treatment % 96.0% 96.0% 98.8% 95.7%

RTT Non-Admitted Clock Stops % 95.0% 95.0% 97.5% 97.1% 31 days subsequent treatment (surgery) % 94.0% 94.0% 99.5% 100.0%

RTT: Incomplete pathways within 18 weeks % 92.0% 92.0% 94.9% 96.6% 31 days subsequent treatment (anti cancer drugs) % 98.0% 98.0% 100% 100.0%

Diagnostic waits >6 weeks % 1.0% 1.0% 0.5% 0.6% 62 day standard % 85.0% 85.0% 87.0% 92.7%% of patients who spend 90% of their stay on the stroke unit 80.0% 80.0% 86.7% 85.7% 62 day screening % 90.0% 90.0% 93.3% 100.0%

% Readmissions within 30 days of discharge 12.6% 12.6% 12.6% 14.1%

The On Plan / Off Plan Columns represent a projected Year End position. The status columns represents the current status of the initiative detailed

Status

High Level Executive Dashboard

Fit for the Future

Performance improved but off target in month

Performance deteriorated and off target in month

Monthly Change

On Plan Off PlanDeveloping Our Staff

Plan 14/15

Plan YTD Actual YTD

Monthly Actual

Performance improved and on target in month

Performance deteriorated but on target in month

YTD Running Total


No. Area Indicator (All measured Quarterly) Threshold Weighting Apr-14 May-14 Jun-14Quarter 1 Actual

2.05

Maximum time of 18 weeks from point of referral to treatment in aggregate – admitted 90% 1.0 94.0% 95.8% 94.9% 94.9%

2.06

Maximum time of 18 weeks from point of referral to treatment in aggregate – non-admitted 95% 1.0 97.6% 97.7% 97.1% 97.5%

2.07

Maximum time of 18 weeks from point of referral to treatment in aggregate – patients on an incomplete pathway 92% 1.0 96.3% 96.9% 96.6% 96.6%

2.01

A&E: maximum waiting time of four hours from arrival to admission/ transfer/ discharge 95% 1.0 93.6% 97.3% 95.7% 95.5%All cancers: 62-day wait for first treatment from:

2.23 Urgent GP referral for suspected cancer 85% 94.4% 92.7% 93.6%2.24 NHS Cancer Screening Service referral 90% 100% 100% 100%

All cancers: 31-day wait for second or subsequent treatment, comprising:

2.21 Surgery 94% 1.0 100% 100% 100%2.22 Anti-cancer drug treatments 98% 1.0 100% 100% 100%

2.20

All cancers: 31-day wait from diagnosis to first treatment 96% 1.0 100% 96% 98%

Cancer: two week wait from referral to date first seen, comprising:

2.18 All urgent referrals (cancer suspected) 93% 97.4% 97.8% 97.6%

2.19

For symptomatic breast patients (cancer not initially suspected) 93% 97.6% 93.2% 95.4%

1.13

Clostridium (C.) difficile – meeting the C. difficile objective DM* 1.0 3 2 3 8

1.33

Certification against compliance with requirements regarding access to health care for people with a learning disability 100% 1.0 100% 100% 100% 100%

Data completeness: community services, comprising:Referral to treatment information 50% 99.4% 99.4% 99.4% 99.4%

Referral information 50% 100.0% 100.0% 100.0% 100.0%Treatment activity information 50% 100.0% 100.0% 100.0% 100.0%

Acc

ess

1.0

1.0

Monitor Risk Assessment Framework 2014/15

Out

com

es

1.0


High level Executive Report July 2014

Harm Free Care

• There are 2 Never Events reported from Ophthalmology in June 2014. They are currently under investigation.

• Patient incident reporting continues to be reviewed at the Quality Assurance Committee. A new format for reporting is being introduced. The Trust is encouraging a positive culture for reporting incidents. There were a total of 802 incidents reported on Safeguard - an increase in month of 105. The highest numbers of incidents in June are reported from the following 5 areas:

WardNumber of Incidents

Central Delivery Suite 54A&E - Adult 53DN - North/East/West 39Intermediate Care - Residential 30Ward C4 21

• All patient falls have increased in month with 84 reported in June. The table below shows the areas with the highest numbers

of falls:

WardNumber of Falls

Medical ward with 4 step down stroke beds Ward C4 12Medical Respiratory ward Ward D3 9

Intermediate Care - Residential 8Medical Assessment Unit Ward D2 - AMRU - Male 6


• June sees a slight increase in hospital acquired pressure damage cases but at a lesser severity. Community reports 2 cases at levels 3 and 4 which were judged at Panel to be unavoidable. The table below shows the performance over the last 6 months:

Category Performance Indicator Jan-14 Feb-14 Mar-14 Apr-14 May-14 Jun-14

Patients acquiring pressure damage (grade 2) 4 2 3 4 3 9Patients acquiring pressure damage (grade 3) 3 2 0 1 5 0Patients acquiring pressure damage (grade 4) 0 0 0 0 0 0Patients acquiring pressure damage (Total) 7 4 3 5 8 9Patients acquiring pressure damage (grade 2) 2 8 8 3 8 5Patients acquiring pressure damage (grade 3) 3 1 0 0 3 1Patients acquiring pressure damage (grade 4) 2 0 0 0 0 1Patients acquiring pressure damage (Total) 7 9 8 3 11 7

Hos

pita

lC

omm

unity

Medication Incidents

• Medication incidents have slightly risen in June to 78. The external review of medications management has been completed and the report is expected by the end of July 2014. This will be fully shared with the Quality Assurance Committee. This month sees the highest number of incidents being reported from the following areas:

WardNumber of Incidents

District Nursing - North/East/West 6Ward E5 (Children's Unit) 6Pharmacy 5Neonatal Unit 4Ward D1 AMRU-Female 4


Acquired Infection

• No MRSA infections in month.

• 3 C. Diff cases reported in June. We have 8 reported cases for the quarter with an annual tolerance of 48.

Same Sex Accommodation

• Two breaches in month. Unable to single sex owing to full units with little room for manoeuvre and one very ill lady in HDU. The breaches involved were 29.5 hours and 19 hours respectively.

Valued provider of Integrated Services National Targets

• Performance was met for month 3 June at 95.7% and for Quarter 1 at 95.69%. There were 19 out of 28 days of performance above 95% for June.

• All 18 week admitted, non-admitted and incomplete pathway targets have achieved in month.

• Diagnostic waits are sustained at 0.7%.

• The 80% of people receiving 90% of their care on a stroke unit target was met in June at 85.7%.

• Cancer targets are reported one month in arrears. In May the 31 day decision to treat target was not met with 4 patients breaching. One patient was unfit for surgery; one had a complex pathway and two were delayed because of capacity problems. Although not yet validated the most recent performance data for June shows that there have been no further breaches.

• Emergency Re-admissions within 30 days have been over 14% for two consecutive months. A more detailed analysis of all

specialties is being conducted. The target is 12.6%.


1. Executive Dashboard & Commentary


(1.0)

(0.5)

0.0

0.5

1.0

1.5

2.0

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

Surplus / (deficit) £m

Cumulative Actual Cumulative Plan

0.0

0.5

1.0

1.5

2.0

2.5


In month ICIP delivery £m

Acute Adult Elective Care

Family Care Trust wide contingency

Plan

0.02.04.06.08.010.012.014.016.018.0


Cumulative Capital expenditure £m

Cumulative Actual Cumulative Plan Financed Capital Plan

0.0

1.0

2.0

3.0

4.0

5.0

6.0

7.0


Month end cash balance £m

Actual Plan Revised Cash forecast


1. Executive Dashboard & Commentary

Income & Expenditure

Overall the Trust is on plan with a year to date deficit of £0.76m. June 2014 in month position shows a deficit of £0.25m against the planned deficit of £0.26m. The June position is made up of:

• Income overall is better than plan in month at £23.48m compared to a plan of £23.2m, with clinical over achieving by £0.26m.• Pay spend is £16.76m, an over spend of £0.94m.• Non pay spend is £6.58m, an over spend of £0.39m.• The overall position is slightly worse than anticipated and the Trust has used £1.1m of Risk Reserve to date in month. Year to date the maximum

available has been utilised.• ICIPs delivered in June total £1.7m. The year to date delivery is £4.8m, which is in line with plan.

The Trust is still forecasting to deliver the year-end target surplus of £1.6m, however this will require utilisation of the £6.2m risk reserve, £4.8m being used to mitigate financial risk and £1.4m being used to finance developments. There is a risk range of delivery from a deficit of £7.6m to a surplus of £3m and this range will narrow as we go through the year. To manage the risk within the forecast the downside risk management plan has been enacted, consequently the Corporate division has been tasked with bringing forward 2014/15 ICIP schemes to deliver an additional £1.2m and Estates has been tasked with delivering £0.25m in year.


Cash & Capital

• There was a cash balance of £6.5m at the end of the month. This is higher than the £1.4m plan and is in line with the Trust cash management strategy. The cash balance would have been £7.8m had all block payments been received in month. Public Health Commissioning and NHS England amounts totalling £1.3m remained as debtors on 30th June. These outstanding debtors were escalated and all of this has now been received.

• The Capital budget for the year is £6.1m plus £1.7m of financed developments. Dependent on additional finance being agreed, there is potential for a further £9.7m in developments related to the Estates & IT strategy.

• At the end of June the Capital programme is underspent by £1,639k against plan.• The Trust is reviewing the Capital forecast for the year in light of the Estates and IT business cases and steps are also being taken to progress

capital spend for M4.

• The Trust Continuity of Service rating is 1 as planned.


2.1.1 Trust Income & Expenditure position

Trust SummaryAnnual budget £m Budget £m Actual £m Var £m Budget £m Actual £m Var £m

Contract income 254.1 20.9 21.2 0.3 63.4 64.1 0.7Education and Training Income 8.6 0.7 0.8 0.0 2.2 2.2 0.0Other income 17.5 1.5 1.5 (0.0) 4.5 4.7 0.2

Total Income 280.1 23.2 23.5 0.3 70.1 71.0 0.9Direct - Pay (188.8) (15.8) (16.8) (0.9) (47.6) (50.0) (2.4)Direct - Non Pay (74.2) (6.2) (6.6) (0.4) (18.6) (19.2) (0.6)Risk reserve (6.2) (0.6) 0.5 1.1 (2.3) (0.0) 2.3

Total Operational Costs (269.1) (22.7) (22.9) (0.2) (68.5) (69.2) (0.7)

EBITDA 11.0 0.5 0.6 0.1 1.6 1.8 0.2Capital charges (9.4) (0.8) (0.8) (0.1) (2.3) (2.5) (0.2)

Total Costs (278.5) (23.5) (23.7) (0.3) (70.9) (71.7) (0.9)

Surplus / (Deficit) 1.6 (0.2) (0.2) 0.0 (0.8) (0.8) 0.0

In Month Year to Date



2.3.1 Income Summary position

Areas of DeliveryActivity Plan

Activity Actual

Activity Var

Income Plan £m

Income Actual £m

Income Var £m

Activity Plan

Activity Actual

Activity Var

Income Plan £m

Income Actual £m

Income Var £m

Unscheduled Care 13,896 14,692 797 6.6 6.9 0.3 45,088 47,497 2,409 20.6 21.6 1.0Scheduled Care 2,607 2,575 (32) 2.8 2.8 0.0 8,491 8,156 (335) 8.4 7.8 (0.6)Outpatient Care 24,510 25,076 566 3.2 3.3 0.1 76,771 75,075 (1,696) 10.1 9.8 (0.3)Clinical Support Services 763 781 18 0.6 0.6 (0.0) 2,419 2,297 (122) 1.7 1.7 (0.0)Other & Block 10.0 9.8 (0.2) 29.3 30.0 0.8

Total £m 23.2 23.5 0.3 70.1 71.0 0.9

In Month Movement Year to Date


0

10,000

20,000

30,000

40,000


Activity Actual (number) Activity Plan (number)

0.0

5.0

10.0

15.0

20.0

25.0

30.0


Income Actual £m Income Plan £m

Trust Income year to date• Unscheduled care - continues to be above plan for the month and year to date. The

impact of the non-elective marginal rate has also increased significantly with activity being above plan. A&E activity is showing a pattern of sustained increase since March 2014.

• Scheduled care - is on plan for month 3 but remains below plan year to date. Elective activity continues to be below plan, but day cases are above plan in month and now on plan year to date.

• Outpatient care - is above plan in the month, but still below plan year to date. The main area below plan remains antenatal pathways. The main areas of overperformance are our first attendance points of delivery.

• Clinical Support Services - the only area of variation within clinical support services are ECG's that continue to be below plan year to date, but we are reporting above plan in month.

• Other & Block - is below plan in the month, this is mainly due to the cessation of the GP Out of Hours service. Year to date we are still above plan, and this is due to penalties being lower than planned.

• We are reporting 100% achievement of CQUINs at month 3. Detail of some CQUIN schemes remain to be agreed with the CCG, but we remain on plan for the agreed CQUINs.


2.4.1 Pay costs position

Pay category

Annual budget £m

Budget £m

Actual £m Var £m

Budget £m

Actual £m Var £m

Senior Managers (5.2) (0.4) (0.4) 0.0 (1.3) (1.2) 0.1Medical and Dental (47.8) (4.0) (3.9) 0.1 (12.1) (11.6) 0.4Nursing, Midwifery And Health Visiting (71.5) (5.9) (6.0) (0.1) (18.0) (18.2) (0.3)Scientific, Therapeutic and Technical (23.6) (2.0) (1.9) 0.1 (5.9) (5.6) 0.3Professional and Technical (4.9) (0.4) (0.4) 0.0 (1.2) (1.2) 0.0Administrative and Clerical (21.8) (1.8) (1.7) 0.1 (5.5) (5.2) 0.3Healthcare Assistants and Other Support Staff (19.4) (1.7) (1.5) 0.1 (4.9) (4.6) 0.3Agency Staff (2.2) (0.2) (0.8) (0.5) (0.6) (2.1) (1.4)Other Pay Budgets 7.7 0.6 (0.1) (0.8) 1.8 (0.4) (2.2)

Total (188.8) (15.8) (16.8) (0.9) (47.6) (50.0) (2.4)



Pay

In total £16.8m has been spent on pay in June compared to a budget of £15.8m, an overspend of £0.9m.

The main areas of overspend in June are

Agency £0.78m of spend against a budget of £0.23m; Medical £308k – Radiology (£86k), Complex Care (£101k) and A&E (£57k)Nursing £142k – Acute Medicine (£23k), Complex care (£30k) and Endoscopy £20k)Admin £56kOther £37k – Radiographers (£19k) and Lab Med (£10k)

The Other Pay Budgets includes the cost reductions (ICIPs) monies that have all been removed from specific specialty budgets, but not yet allocated to specific staff groups on those statements.


2.5.1 Non Pay costs position

Non Pay category

Annual budget £m

Budget £m

Actual £m Var £m

Budget £m

Actual £m Var £m

Drugs (17.5) (1.5) (1.6) (0.1) (4.4) (4.6) (0.2)Medical & Surgical (10.1) (0.8) (0.8) 0.1 (2.5) (2.5) 0.0Clinical Supplies (9.1) (0.8) (0.8) (0.1) (2.3) (2.2) 0.1

Activity Dependent (36.8) (3.1) (3.1) (0.1) (9.2) (9.3) (0.1)Establishment (10.5) (0.9) (1.0) (0.1) (2.6) (2.8) (0.2)Estates & Premises (11.4) (1.0) (1.0) (0.1) (2.9) (2.8) 0.1Services from other NHS bodies (3.3) (0.3) (0.3) (0.0) (0.8) (0.9) (0.1)Other Non Pay (12.2) (1.0) (1.2) (0.2) (3.1) (3.4) (0.3)

Other Non Pay (37.4) (3.1) (3.4) (0.3) (9.4) (9.9) (0.5)

Total Non Pay (74.2) (6.2) (6.6) (0.4) (18.6) (19.2) (0.6)

Total Risk Reserve (6.2) (0.6) 0.5 1.1 (2.3) (0.0) 2.3



Non Pay

The total non-pay spend at £6.6m is £0.4m worse than plan.

Non pay expenditure against activity dependant items is overspent in month by £0.1m. This is due to expenditure above plan of £0.07m on FP10 drugs (which has an offsetting income increase).

The Trust has utilised £1.1m of the Risk reserve which is the maximum available year to date.


2.6.1 Capital Charges

Trust Position

Annual budget £m

Budget £m

Actual £m Var £m

Budget £m

Actual £m Var £m

Dividends (3.2) (0.3) (0.3) (0.0) (0.8) (0.8) (0.0)Interest Paid (0.9) (0.1) (0.1) 0.0 (0.3) (0.2) 0.1Interest Received 0.0 0.0 (0.0) (0.0) 0.0 0.0 (0.0)Depreciation (5.2) (0.4) (0.5) (0.1) (1.3) (1.5) (0.2)

Total (9.4) (0.8) (0.8) (0.1) (2.4) (2.5) (0.1)

£m Values Apr May Jun Jul Aug Sept Oct Nov Dec Jan Feb Mar YTD

Dividends (0.3) (0.3) (0.3) (0.8)Interest Paid (0.1) (0.1) (0.1) (0.2)Interest Received 0.0 0.0 (0.0) 0.0Depreciation (0.5) (0.5) (0.5) (1.5)

Total (0.8) (0.8) (0.8) (2.5)

Plan (0.8) (0.8) (0.8) (2.4)Variance to Plan (0.0) (0.1) (0.1) (0.2)



Capital charges

Depreciation charges are £40k per month above plan, this is being investigated.

A proportion of the risk reserve has been set aside to cover the increased depreciation on Community IT, the budget transfer will be made in due course.


4.1 Statement of Financial Position year to date

£m Values Mar-14JunePlan £m

JuneActual £m

Var to plan £m

Year end Plan £m

Non-current assetsIntangible assets 0.5 0.3 0.5 0.2 0.3Property, plant & equipment 131.4 125.5 130.3 4.8 137.1Trade & other receivables >1 year 0.7 0.9 0.6 (0.3) 0.9

132.6 126.8 131.4 4.6 138.4Current assets

Inventories 1.6 1.6 1.9 0.3 1.6Trade receivables 5.4 3.1 2.9 (0.2) 2.8Other receivables 0.8 0.8 2.1 1.3 0.8Accrued income 1.8 2.8 3.1 0.3 2.8Prepayment 1.3 1.9 1.7 (0.2) 1.5Cash & cash equivalents 0.4 1.4 6.5 5.1 1.0

11.3 11.5 18.2 6.7 10.5Total assets 143.9 138.2 149.6 11.4 148.9

Current liabilitiesLoans due < 1 year (1.4) (2.8) (1.4) 1.4 (2.8)Trade payables (7.3) (9.2) (10.9) (1.7) (8.8)Accruals (4.6) (5.6) (4.4) 1.2 (4.6)Payments on Account (0.4) (0.6) (0.2) 0.4 (0.6)Leases due < 1 year (0.1) (0.1) (0.1) 0.0 (0.1)Other current liabilities (8.1) (7.3) (12.1) (4.8) (7.7)

(21.9) (25.6) (29.1) (3.5) (24.6)Net Current assets / (liabilities) (10.6) (14.2) (10.9) 3.3 (14.1)Non-current liabilities

Loans due > 1 year (18.5) (16.5) (17.9) (1.4) (25.5)Provisions (0.3) (0.3) (0.3) 0.0 (0.3)Leases due > 1 year (0.1) (0.4) 0.0 0.4 (0.7)

(18.9) (17.2) (18.2) (1.0) (26.5)

Total assets employed 103.1 95.4 102.3 6.9 97.7

Taxpayers Equity:Public dividend capital 102.0 102.0 102.0 0.0 102.0Retained earnings (35.3) (35.7) (36.1) (0.4) (33.3)Revaluation reserve 36.4 29.0 36.4 7.4 29.0

103.1 95.4 102.3 6.9 97.7


Summary

• As at month 3 the Trust had net current liabilities of £10.9m a deterioration from Month 2 of £0.1m but better than plan by £3.3m.

• The Trust's current assets are £6.7m above plan. Payments of tax/NI/Super ann. are in line with due dates (previously an element had been paid in advance)

• The Trust's current liabilities of £29.1m compare with a plan of £25.6m. The variance of £3.5m relates to:-

• Tax (3.4)• Accruals 1.2• Provisions (0.9)• Trade payables (1.7)• Loans* 1.4• Other liabilities (0.1)

* Loans current liability variance is offset by the non- current liabilities variance (1.5m). This is due to a change in repayable term since the plan was submitted.

• The plan was submitted prior to a revaluation of the Trust's assets therefore the property, plant and equipment variance is due to the impact of the revaluation.


5.1 Cashflow Source and Application year to date


JuneActual £m

Var to plan £m

Year end Plan £m

Income 24.4 24.1 25.0 0.9 283.0

PaymentsSalaries / Wages (10.3) (10.0) (9.2) 0.8 (110.2)Tax, NI & Superannuation (4.4) (6.2) (6.0) 0.2 (71.2)Capital (3.3) (0.6) (0.1) 0.5 (15.5)Non Pay (12.2) (6.8) (6.4) 0.4 (90.1)Loan repayment (0.1) 0.0 0.0 0.0 (1.4)Loan interest (0.0) 0.0 0.0 0.0 (0.7)PDC Dividend (1.6) 0.0 0.0 0.0 (3.2)PDC cash support 7.5 0.0 0.0 0.0 9.8

Total payments (24.4) (23.6) (21.8) 1.8 (282.4)

Cashflow (0.0) 0.5 3.2 2.7 0.6Opening balance 0.5 0.9 3.3 2.4 0.4

Closing balance 0.4 1.4 6.5 5.1 1.1


Summary

• In month 3 there was a cash inflow of £3.2m with a closing cash balance of £6.5m.

• Cash is above plan by £5.1m at month 3.

• Block payments from NHS England and Public Health Commissioning of £1.3m relating to month 1 and 3 activity were not received in month 3. All of this has since been received and steps have been taken to ensure escalation process for prompt payment in future.

• The Trusts plan is showing a cash inflow of £0.6m for the year with a planned balance of £1.1m at 31st March 2015 this is based on the approved Budget / Annual plan. The Trust would look to maintain an improved cash balance during the year and improve on the year end position. On the assumption the I&E plan delivers a cash balance of £6.6m should be achievable by the year end.


5.1 Cashflow Source and Application year to date


JuneActual £m

Var to plan £m

Year end Plan £m

Income 24.4 24.1 25.0 0.9 283.0

PaymentsSalaries / Wages (10.3) (10.0) (9.2) 0.8 (110.2)Tax, NI & Superannuation (4.4) (6.2) (6.0) 0.2 (71.2)Capital (3.3) (0.6) (0.1) 0.5 (15.5)Non Pay (12.2) (6.8) (6.4) 0.4 (90.1)Loan repayment (0.1) 0.0 0.0 0.0 (1.4)Loan interest (0.0) 0.0 0.0 0.0 (0.7)PDC Dividend (1.6) 0.0 0.0 0.0 (3.2)PDC cash support 7.5 0.0 0.0 0.0 9.8

Total payments (24.4) (23.6) (21.8) 1.8 (282.4)

Cashflow (0.0) 0.5 3.2 2.7 0.6Opening balance 0.5 0.9 3.3 2.4 0.4

Closing balance 0.4 1.4 6.5 5.1 1.1


Summary

• In month 3 there was a cash inflow of £3.2m with a closing cash balance of £6.5m.

• Cash is above plan by £5.1m at month 3.

• Block payments from NHS England and Public Health Commissioning of £1.3m relating to month 1 and 3 activity were not received in month 3. All of this has since been received and steps have been taken to ensure escalation process for prompt payment in future.

• The Trusts plan is showing a cash inflow of £0.6m for the year with a planned balance of £1.1m at 31st March 2015 this is based on the approved Budget / Annual plan. The Trust would look to maintain an improved cash balance during the year and improve on the year end position. On the assumption the I&E plan delivers a cash balance of £6.6m should be achievable by the year end.


6. Capital Expenditure position

Capital schemes

Annual budget £'000

Budget £'000

Actual £'000 Var £'000

Budget £'000

Actual £'000

Var £'000

Plant and Equipment 2,037 473 8 (465) 695 243 (452)Property - Maintenance 3,350 320 60 (260) 490 98 (392)Plant and Equipment - Information Tec713 290 23 (267) 290 23 (267)Sub Total 6,100 1,083 91 (992) 1,475 364 (1,111)Funded Developments 1,743 176 0 0 528 0 0

Schemes plus funded developments 7,843 1,259 91 (1,168) 2,003 364 (1,639)

Other Developments 9,693 0 0 0 0 0 0GROSS CAPITAL EXPENDITURE 17,536 1,259 91 (1,168) 2,003 364 (1,639)



Capital Expenditure• The Trust Capital plan is £6.1m plus £1.7m of financed developments. The further developments of £9.7m relate to Estates and IT strategy and are

dependent on additional finance being agreed.• At the end of month 3 Capital Expenditure was £1,639k underspent.• The main areas of underspend are Defibs, main walkway duct, lab med servers and windows XP upgrade all of which had a total of £697k spend in the

plan in month 3 but with no actual spend.• The Trust has spent 18% of the year to date Capital plan, this is below the 85% Monitor threshold.• Forecast Capital Expenditure is on plan for year end. The plan assumes £9.7m of the developments will be funded via loans.

(more detailed information on planned capital spend is available at appendix 10.09)


6. Capital Expenditure position

Capital schemes Apr May Jun Jul Aug Sept Oct Nov Dec Jan Feb Mar YTD

Plant and Equipment 245 (10) 8 243Property - Maintenance 7 31 60 98Plant and Equipment - Information Technology 0 0 23 23

Sub Total 252 21 91 364Funded Developments 0 0 0

Schemes plus funded developments 252 21 91 364

Other Developments 0 0 0 0GROSS CAPITAL EXPENDITURE 252 21 91 364

Plan 176 568 1,259 805 714 684 2,208 2,138 2,258 2,142 2,292 2,292 2,003Variance to Plan 76 (547) (1,168) (1,639)



7. Income & Cost Improvement Programme

Division Savings typeFull year target £'000

Forecast £'000


Forecast £'000


Adult Acute Pay 3,646 261 120 (141) 649 199 (450)Non Pay 700 53 (384) (437) 141 (126) (267)Income 2,822 304 77 (227) 829 232 (597)Corporate share 1,394 117 116 (1) 349 348 (1)Contingency (1,184) (148) 148 (518) 518Benefit of Risk reserve usage 0 0 541 541 0 680 680

Total Adult Acute 7,378 587 471 (116) 1,450 1,334 (116)

Elective Pay 1,815 152 50 (102) 456 154 (302)Non Pay 1,017 84 (30) (114) 254 (210) (464)Income 4,720 394 227 (167) 1,180 517 (663)Corporate share 1,277 107 106 (1) 319 319 0Contingency (1,104) (139) 139 (483) 483Benefit of Risk reserve usage 0 0 176 176 0 625 625

Total Elective 7,725 598 528 (70) 1,726 1,404 (322)

Families Pay 3,468 288 57 (231) 871 166 (705)Non Pay 618 51 243 192 150 397 247Income 2,968 247 98 (149) 741 294 (447)Corporate share 955 79 80 1 239 239 (0)Contingency (912) (115) 115 (398) 398Benefit of Risk reserve usage 0 0 141 141 0 507 507

Total Families 7,097 550 619 69 1,603 1,603 (0)

Trust wide Contingency 0 0 116 116 0 437 437

Total ICIP Delivery 22,200 1,735 1,734 (1) 4,779 4,779 (0)



Cost Improvement Programme• The Trust has been able to report on plan delivery of ICIPs planned to date by way of releasing risk reserves in each of the divisions.• The corporate division has generated a surplus against the year to date plan, giving an overall value reported as Trust wide contingency to date.

(more detailed information on Income & Cost Improvement delivery is available at appendix 10.10)


8. Forecast outturn for year

Trust Summary

Annual budget £m

Forecast£m

Contract income 254.1 255.5Education and Training Income 8.6 9.3Other income 17.5 17.0

Total Income 280.1 281.9Direct - Pay (188.8) (193.4)Direct - Non Pay (74.2) (74.6)Risk reserve (6.2) (2.9)

Total Operational Costs (269.1) (270.9)

EBITDA 11.0 11.0Capital charges (9.4) (9.4)

Total Costs (278.5) (280.3)

Surplus / (Deficit) 1.6 1.6


Forecast outturn for year• The Trust is forecasting that the £1.6m planned surplus for 2014/15 can be delivered• Taking into account the Divisional forecast and allowing for 'optimism bias' within the Divisional Forecasts the Trust is forecasting that the £1.6m

planned surplus for 2014/15 can be delivered by fully utilising the risk reserve of £6.2m• To manage the risk within the forecast the Corporate division has been tasked with bringing forward 2014/15 ICIP schemes to deliver an additional

£1.2m and Estates has been tasked with delivering £0.25m in year.


9. Continuity of Service Risk Rating (CSRR)


Capital Service Cover rating 1 1 1Liquidity rating 1 1 1

Continuity of Service Risk Rating - Actual 1 1 1

Continuity of Service Risk Rating - Plan 1 2 2 2


Continuity of Service Risk Rating• Both the Capital Service Cover and the Liquidity ratings are 1, giving an overall Continuity of Service Risk Rating of 1.

This is as per plan for quarter 1.


Workforce

• Labour turnover remains steady and within target.

• Many appraisals are due for renewal and Divisions have been asked to focus on this area.

• The trend of gradually reducing levels of sickness absence continues at 4.6%.

• Mandatory training sees a further rise in compliance. Flexible delivery options have been rolled out although operational pressures still remain an issue in some clinical areas.

Community Services

A new community dashboard report is currently being developed which will assist in triangulating community data across all of the separate services within the three divisions namely Acute, Elective and Families. From an activity point of view the areas which are covered in the new dashboard are:-

• Referrals

• Waiting Times

• Attendances (clinics, contacts and groups)

• DNAs

• DNA Rates

• Complaints


The above areas are all compared to plan. The plans are based on last years’ service out-turn divided by 12. Some children’s services are school term/seasonally affected e.g. school nursing. There are 10 services in total all under family division which are affected. For these 10 services, the plans per month are based on last years’ monthly out-turn, therefore comparing like month with month.

Referral activity is included to highlight the demand within each service. This activity is broken down into referrals from GP and Other sources, again compared to plans as above. All services are working towards collating waiting times activity by time bands.. We are aiming to reduce patients waiting over 12 weeks which at the end of June 14 is at 9.0%. Some services have never collected waiting time activity and we will be working closely with these services.

Alongside the activity and demand, we are also analysing staff sickness per service and turn over together with temperature checks and appraisal rates. A summary will be provided with the dashboard, highlighting not just areas of concern, but also areas that are achieving well.

We are expecting this dashboard to be available in July 2014.

Fit for the Future Healthier Together

Healthier Together proposals for Greater Manchester were launched for public consultation on Tuesday July 8th. These proposals look at the way services are provided across Greater Manchester, particularly in hospitals. It is important that all staff understand the proposals and the Trust’s view and that people respond to the consultation. To this end the consultation documentation and questionnaire are available and the Healthier Together Team are conducting a series of staff briefings across the organisation. Our Chief Executive, Dr Jackie Bene, has set out Bolton Foundation Trust’s viewpoint on the options that are best for our Trust and circulated a paper widely. She has also facilitated forums for staff to discuss the future direction of the Trust. The consultation period is set to run for 12 weeks.


Integration – Better Care Fund

Integration – the Better Care Fund – works with the aim of co-ordinating better care for people and sees the shift of “health” money to social care. This is a national initiative which will mean smaller hospitals and more care provided in the community in different models than at present. Work with our partners is already under way on this locally. Whilst change is challenging, both for organisations and for individuals, as an integrated trust, providing both acute and community services, we are in a strong position to influence and take these initiatives forward.

Annual Plan

The Trust’s 5 year Annual Plan was submitted to Monitor at the end of June 2014.

Well Governed

Independent Review of Data Quality and Board Level Quality Indicators

A follow-up review has been requested by the Trust to give assurance that all of the recommendations around data quality and Board level quality indicators have successfully been implemented. Penalties

Plan Actual£'000 £'000

Penalties (346) (29)C-Diff 0 0TOTAL (346) (29)


• At month 2 we reported a predicted 18 week RTT penalty for non-admitted Plastic Surgery; this has now been validated as

correct. The other predicted penalty in month 2 was the validation reduction. Following actions from the Divisions this position has been improved.

• In month 3 reporting we are predicting the following penalties changes:

• The validation reduction is where we can't charge for any activities that cannot be coded by the deadline, we have included an estimate for month 3, but the overall penalty has improved due to steps taken within the Divisions to minimise the penalty.

• Re-admission penalty is a set amount based on a audit, this value may change once we've completed an new audit of all emergency re-admissions within 30 days of original discharge. The audit looks at a sample of patients and determines how many of them could have been avoided if better primary/social care services existed.

• Mixed Sex Accommodation Breach, within our contract there is a zero tolerance for mixed sex accommodation breaches with a set penalty of £250 per incidence. We have had one validated breach recognised since last month.

• Binding Date within 28 days, when a patient's procedure is cancelled we are required to offer another date with 28 days of the cancellation. The penalty for these breaches is none payment of the procedure, we have had 1 validated breach. An estimate has been reported until the actual penalty can be confirmed.


INDICATORSAcute Frailty

UnitB2 B4 C1 C2 C3 C4 CCU CDU D1 (MAU1) D2 (MAU2) D3 D4 Darley

CourtH3 (Stroke

Unit) HDU ICU DCU (Daycare)

EU (Daycare) E3 E4 F3

F4/F6 (Combined

wards)G3/G3TSU G4 G5 H2

(daycare)UU

(Daycare)

E5 (Paed HDU and

Obs)

F5 (Short Stay Paed Ass Unit)

M1 and Assessment EPU M2 CDS M3 (Birth

Suite) M4/M5 NICU Total

Number of Beds 16 26 26 25 26 26 27 10 14 23 22 27 27 30 24 10 8 15 15 25 25 24 27 23 25 13 10 4 38 7 16 6 16 18 5 44 38 761

Exception indicator

Friends and Family Net Promoter Score 68 80 83.3 81 73 77 75 94 82 73.3 68.6 65 86 N/A 87 85 N/A N/A N/A 87 80 76 67 77 73 100 N/A N/A N/A N/A 100 N/A N/A 91.3 91.3 81.3 N/A 78.6

Safety Express Programme Harm Free Care (%) 100.00% 100.00% 83.33% 100.00% 84.62% 95.83% 88.00% 100.00% NA 95.00% 100.00% 73.08% 85.19% 79.31% 95.45% 100.00% 100.00% NA NA 100.00% 100.00% 88.89% 100.00% 100.00% 100.00% 100.00% NA NA 100.00% NA 100.00% NA 100.00% 100.00% NA 100.00% 100.00% 95.95%

Weekly KPI Audit % 100.00% 97.00% 90.50% 100.00% 94.40% 91.30% 87.00% 97.60% 67.90% 93.20% 92.70% 90.90% 76.30% 89.50% 98.00% 100.00% 100.00% 97.00% 97.00% 99.70% 96.30% 100.00% 100.00% 97.50% 98.80% 100.00% 97.00% 97.00% 95.20% 100.00% 100.00% 100.00% 100.00% 100.00%

Hand Washing Compliance % 66.67%Figures not avail

at present96.00% 98.33% 85.00% 90.00% 100.00% 100.00% 92.33% 90.83% 58.89% 99.00% 100.00% 92.71% 96.33% 99.00% 98.33% 97.22% 100.00% 90.42% 96.33% 95.00% 98.33% 86.00% 96.67% 97.50% 100.00% 87.67% 100.00% 100.00% 100.00% 96.67% 96.25% 96.67%

Figures not avail

at present90.00% 95.00% 97.02%

1.60 - Monthly New pressure Ulcers (Grade 2+) 0 0 0 0 0 1 3 0 0 0 0 2 1 0 1 0 0 0 0 0 0 0 0 1 0 0 0 0 0 0 0 0 0 0 0 0 0 9

1.01 - All Patient Falls (Safeguard) 9 2 3 3 1 3 12 1 3 2 6 9 2 0 3 0 0 1 0 2 1 2 1 1 3 0 0 0 0 0 1 0 0 0 0 0 0 71

1.13 - Infection Control (C. Diff) 0 0 0 0 1 1 0 0 0 0 0 1 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 3

1.39 - MRSA HA aquisitions 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0

1.20 - VTE Assessment Compliance (May 14) 68.57% 50.00% 0.00% 100.00% 75.00% 100.00% 100.00% 100.00% 93.95% 96.88% NA 100.00% 100.00% NA 93.02% 100.00% 100.00% 93.84% 98.20% 100.00% 70.00% 99.55% 96.64% 96.10% 94.29% 97.98% 98.73% 96.55% 97.45% 100.00% 99.29% 100.00% 92.45% 97.19%

ESSA Assessment ** ** * *** ** *** * ** ** ** * *** * * ** *** *** N/A N/A INFORMATION NOT SUBMITTED *** INFORMATION

NOT SUBMITTED * *** *** *** N/A N/A ** N/A *** N/A *** *** *** *** ***1.27 - Number of complaints received 2 1 1 2 1 2 1 1 1 1 1 1 1 16

Budgeted Nurse: Bed Ratio (WTE) 0.00 1.16 1.16 1.21 1.16 1.16 1.22 2.75 1.43 1.72 1.59 1.12 1.12 1.07 1.37 4.10 6.58 1.75 1.96 1.18 1.17 1.62 1.40 1.42 1.48 1.48 2.87 4.02 1.17 1.37

Actual/Current Nurse: Bed Ratio (WTE) 0.06 0.97 1.08 1.25 1.27 1.04 0.89 2.57 1.14 1.63 1.55 1.04 1.02 0.99 1.26 4.03 6.22 1.58 1.93 1.10 0.98 1.43 1.23 1.44 1.09 1.27 2.97 3.47 1.16 1.25

% Qualified Staff (Night)100.0% 95.1% 100.0% 100.0% 100.2% 96.7% 101.8% 100.0% 87.7% 96.0% 90.7% 103.3% 100.0% 100.0% 96.5% 92.7% 95.0% 99.9% 87.4% 88.9% 98.9% 86.7% 92.2% 96.6% 100.0% 98.5% 94.5% 71.1% 97.5% 97.0% 95.50%

% un-Qualified Staff (Night)123.8% 162.5% 152.2% 98.3% 123.2% 211.6% 150.0% 96.7% 103.4% 116.7% 121.4% 119.4% 118.3% 98.3% 27.2% 100.0% 101.7% 127.1% 99.2% 91.6% 123.2% 98.4% 103.9% 110.0% 100.0% 99.7% 111.2% 63.3% 73.0% 56.7% 109.40%

% Qualified Staff (Day)95.0% 100.9% 88.4% 91.7% 103.5% 91.5% 86.4% 100.5% 82.2% 82.2% 79.6% 88.9% 74.1% 93.5% 94.3% 88.8% 83.4% 73.8% 80.4% 78.3% 100.7% 71.5% 90.0% 88.1% 88.0% 92.6% 88.1% 93.9% 91.8% 98.4% 88.68%

% un-Qualified Staff (Day)126.5% 146.9% 122.1% 94.5% 102.1% 154.7% 110.4% 140.8% 98.6% 98.6% 99.7% 113.9% 113.1% 95.0% 88.0% 66.8% 102.2% 111.8% 97.6% 71.9% 130.1% 91.7% 112.2% 84.4% 80.4% 82.0% 78.5% 67.1% 56.5% 101.0% 101.30%

AUKUH Acuity/Dependancy (WTE) INFORMATION NOT SUBMITTED

-2.34 0.40 2.65 -4.41 -0.81 1.84 N/A 6.82 INFORMATION NOT SUBMITTED

INFORMATION NOT SUBMITTED

0.67 INFORMATION NOT SUBMITTED

-9.05 INFORMATION NOT SUBMITTED

N/A N/A N/A N/A -2.08 1.05 12.84 16.98 5.69 -1.62 6.23 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A

1.07 - Total Incidents reported on Safeguard 17 4 10 4 9 10 21 5 9 18 19 20 13 0 9 4 14 18 17 7 3 11 10 8 14 6 0 0 20 4 3 1 5 72 4 8 19 416

SUIs in Month 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0

Current Budgeted WTE (From Ledger) 0 30.22 30.22 30.22 30.22 30.22 32.87 27.51 19.97 39.64 35.05 30.22 30.22 32.02 32.87 40.96 52.62 26.23 29.42 29.4 29.35 38.77 37.9 32.61 37.07 19.23 28.74 16.08 65.21 18.69 109.34 1,043.09

Actual WTE In-Post (From Ledger) 1 25.29 28.11 31.19 32.93 26.99 23.92 25.74 15.99 37.54 34.19 28.17 27.6 29.71 30.35 40.34 49.79 23.66 28.98 27.53 24.5 34.24 33.13 33.02 27.35 16.53 29.66 13.88 59.46 18.58 95.04 954.41

Actual Worked (From Ledger) 9.11 31.26 30.26 31.09 35.4 33.04 26.31 25.89 16.4 39.21 35.28 27.92 29.78 29.85 31.44 39.04 47.49 24.82 28.95 27.68 27.58 40.95 35.17 37.8 32.65 17.69 30.41 15.08 63.21 21.44 89.21 1011.41

Pending Appointment 1 2 1 3 1 4 6 1 4 3 1 3 2 1 2 2 2 6 0.8 3 1 49.80

Current Budgeted Vacancies (WTE) -2.00 2.93 1.11 -0.97 -2.71 0.23 7.95 1.77 3.98 -1.90 -5.14 1.05 -1.38 -0.69 2.52 -0.38 -0.17 2.57 0.44 -0.13 3.85 2.53 4.77 -2.41 7.72 -3.30 -0.92 2.20 4.95 -2.89 0.00 13.30 38.88

Sickness (%) 9.41 2.54 4.64 2.44 4.90 4.06 0.78 1.73 8.12 5.22 4.78 0.24 17.61 7.20 8.19 0.53 3.45 3.30 4.29 6.92 9.31 12.41 17.53 4.45 5.63 6.59 12.14 0.96 1.97 0.61 3.04 0.00 4.02 4.02 4.02 4.02 6.97 5.35

4.02 - Substantive Staff Turnover Headcount (rolling average 12 months)

10.71% 3.45% 14.71% 3.45% 8.57% 20.00% 25.81% 6.90% 41.18% 11.90% 15.15% 16.67% 6.90% 20.59% 11.43% 2.27% 10.91% 4.17% 22.22% 3.33% 9.68% 8.33% 13.16% 5.41% 25.81% 18.18% 6.06% 13.33% 8.57% 20.00% 9.52% 0.00% 7.53% 7.53% 7.53% 7.53% 9.65% 11.84%

12 month Appraisal 92.59% 65.52% 77.42% 60.00% 94.87% 65.52% 82.14% 100.00% 37.50% 60.00% 87.88% 100.00% 17.24% 81.82% 61.76% 69.77% 92.00% 100.00% 76.74% 78.57% 80.00% 47.22% 63.64% 83.33% 89.29% 95.00% 58.06% 57.14% 73.33% 100.00% 65.22% 50.00% 60.44% 60.44% 60.44% 60.44% 78.85% 72.55%

12 month Mandatory Training 92.20% 67.67% 66.67% 89.55% 88.26% 95.28% 62.54% 97.94% 81.82% 70.36% 82.04% 96.11% 71.62% 88.93% 89.01% 86.79% 83.22% 88.28% 78.80% 94.94% 82.09% 88.64% 76.00% 69.13% 79.87% 78.57% 85.89% 89.44% 93.05% 96.23% 86.06% 75.00% 84.54% 84.54% 84.54% 84.54% 98.41% 84.02%

Friends and Family N/A 4.83 3.63 N/A 3.19 N/A N/A 4.38 N/A N/A N/A 4.14 3.45 N/A 3.62 3.83 3.83 N/A N/A 4.11 4.03 N/A N/A N/A N/A N/A N/A 3.88 N/A N/A N/A N/A N/A N/A N/A N/A

Board Assurance Heat Map Staffing June 2014


Date Indicator Code Indicator Description Requested by Change Authorised by

19/11/2013Monitor Compliance Governance 1013-14

Monitor Compliance Governance 1013-14 Report Esther Steel Remove from Report. No longer used. Esther Steel

27/11/20131.07 - Total number of incidents (Clinical and non-clinical)

This metric is everything reported, patient, staff, visitors, contractors, non person. “Clinical & non clinical” infers just patient incidents. Eric Porter

Change to 1.07 - Total Incidents reported on Safeguard Trish Armstrong-Child

04/12/2013

4.02 - Substantive Staff Turnover Headcount (rolling average 12 months)

Labour turnover of substantive contracted employees Kelly King

This metric previously included turnover relating to contrived reductions in workforce over the course of the year, relating to Turnaround schemes, redundancies (voluntary and compulsory) etc. The data for this metric should be based on “natural” turnover in order to demonstrate a representative picture of the workforce. Retrospective figures have replaced the previously reported figures for the current year (2013/14). The 2012/13 figures have not been adjusted. The target remains at 10%. The metric definition has also been changed. Louise Ludgrove

13/12/2013 1.39 ‐ MRSA HA acquisitions N/A Julie Dziobon This is a duplicate of metric number 1.38 - MRSA Bacteraemia post-48 Hours admission Trish Armstrong-Child

13/12/20131.37 - MRSA Bacteraemia pre-48 Hours admission

No of pts identified as having MRSA presenting complaint 48 hrs before admission Julie Dziobon

All pre cases are now the responsibility of the CCG, for both CDT & MRSA bacteraemia cases, so despite having 4 pre cases of MRSA bacteraemia for the current year– none of them have been attributed to the Foundation Trust. Action: To remove this metric . Trish Armstrong-Child

17/01/2014 1.50 Infection Control Level 1 National Qualification David Wakefield Not Reportable David Wakefield17/01/2014 1.51 Infection Control Level 2 National Qualification David Wakefield Not Reportable David Wakefield

14/02/2014

1.36 Surgical WHO Checklist compliance (Emergency)

Checklist to reduce surgical morbidity and mortality Mike Steele Metric added Jill Patterson

19/02/2014

1.10 - pt incidents that resulted in severe harm or death %

Number of incidents involving pts that resulted in severe harm or death

Trish Armstrong-Child Target changed to 0%

Trish Armstrong-Child

19/02/2014 1.27 - complaints receivedTotal number of compliants received into trust


change target to 10% reduction on last years outturn


11/03/2014

1.25 - NICE Guidelines Adoption of Technology Appraisals

% of Technology appraisals applicable to the Trust that are adopted or adopted with caveat Steve Hodgson

Use the percentages based on total adopted technology appraisals Steve Hodgson

03/04/20144.13 - Qualified Nurse to bed ratio

Compares the number of contracted WTE nurses against in the number of occupieed beds in the most recent month Nigel Moloney

Remove from Report. Replaced by ‘Budgeted Nurse: Bed Ratio’ and ‘Actual Nurse: Bed Ratio’ in the Board Staffing Assurance Heat Map Suzanne Woolridge

Report Change log


Date Indicator Code Indicator Description Requested by Change Authorised by

Report Change log

03/04/2014

1.33 - Compliance of 6 access criteria for learning disability %

to ensure equality of access and equity for all people with learning disabilities Mike Steele

After reviewing the 13-14 and 12-13 data there were incorrect figures in (83%). We were 100% compliant in year 12-13 and also in 13-14. Data changed to reflect this Bev Tabernacle

07/05/2014

2.46 - Readmissions within 30 days of discharge % - National

scorecard to have a line to show the national rate of readmissions along with the Trust’s performance. Esther Steel

Added Line to scorecard and series into 2.40 - Readmissions within 30 days of discharge % Chart Simon Worthington

14/05/20141.01, 1.02, 1.03, 1.04, 1.52, 1.56 (All falls and pressure damage grade 2)


a 5% reduction in year 2013/14 target applied to 2014/15 targets Jill Patterson

14/05/20142.40 - Readmissions within 30 days of discharge % Joanna Warburton

Readmission % for Feb14 reported last month has changed from 12.8% to 13.3% due to natural changes in data on LE2.2. The figure has still come within the ranges of previous month’s figures reported. Mike Steele

10/06/20141.13 - Infection Control (C. Diff) Mike Steele Metric duplicated by 1.45 Jill Patterson

13/06/20142.40 - Readmissions within 30 days of discharge % Simon Worthington

Target of 8% replaced by average of last years Readmission data = 12.6% Jill Patterson

02/07/2014

Total number of patient incidents (clinical and non-clinical) Total number of patient incidents

Mike Steele/Richard Sachs Number better represented by metric 1.07 Richard Sachs

15/07/2014

4.13 - Substantive Staff Turnover Headcount (Contrived) (rolling average 12 months)

This includes redundancies and MARS but still excludes junior doctors, flexi retirements and TUPE transfers Nigel Moloney New metric Suzanne Woolridge

17/07/20141.34 - No of CQUIN targets achieved in month

CQUINs are reported Quarterly to the CCG. This metric should reflect this position. Mike Steele Revise from monthly reporting to quarterly. Jill Patterson


Page 1 of 3

Agenda Item No: 10


Date 31st July 2014

Title Overview of IPC Delivered at Mandatory Training

Executive Summary

Why is this paper going to the Board

To summarise the main points and key issues that the Board should focus on including risk, compliance priorities, cost and penalty implications, KPI’s, Trends and Projections, conclusions and proposals

The Infection Control and Prevention Annual Report was presented at the May 2014 Trust Board. A specific request was made by the Chairman that the Trust Board had oversight of how current training is evaluated. The briefing paper attached provides the evaluation feedback of training delivered in 2013/14 and the actions taken as a response.

Next steps/future actions Clearly identify what will follow a Board decision i.e. future KPI’s, assurance requirements

The 2014/15 HCAI forward plan will be monitored quarterly via the Infection Control Committee.

Discuss Receive

Approve Note

Assurance to be provided by:



Performance

Legal Implications

Quality

Regulatory




Prepared by Richard Catlin, Assistant Director of Infection Prevention and Control

Presented by Trish Armstrong-Child, Director of Nursing

Page 2 of 3

Infection Prevention and Control (IPC) Overview of IPC Delivered at Mandatory Training

IPC is currently delivered at induction and annually for all staff in the Trust. At induction, all staff receive one IPC session (clinical and non-clinical staff) which is delivered by the IPC team. In addition clinical staff also get a practical hand hygiene session delivered by the training team. IPC is also covered by the Department staff as part of the staff member’s local induction. The mandatory training is evaluated on an on-going basis. Subject matter experts receive quarterly feedback in order to assist in directing future updates of training material. A review of evaluation forms from training delivered in the last financial year indicates that the session evaluates well with the audience; 95% of evaluations evaluate the session as Very Good or Excellent. Table 1: Summary of 55 Session Evaluations

1 2 3 4 5 Poor Fair Good Very Good Excellent

0% 2% 6% 42% 53%

Looking at the narrative feedback from evaluations, there were consistent themes:

This session covers all of the clinical staff and so some of the staff find some of the topics and language too complex

Community staff found the session lacked relevance to the community services

Staff from paediatrics found the session lacked relevance to their speciality

Some staff found the session to be too focused on targets and numbers and could be more clinically relevant

The session time was short for the topics covered

The session wasn’t interactive enough

In response, the IPC team have made a number of changes based on these comments:

1. The team now delivers a separate session specifically for the community services which is

more fit for purpose. The first session has been delivered in July 2014.

2. Two members of the IPC team have nominated themselves to draw together and lead on the

implementation of a 12-month training strategy.

3. The service is now looking at more department based micro training sessions to be delivered

to individuals or small groups for the team to deliver as they visit the departments to

augment the mandatory/induction training.

4. Training is incorporated in the Trust HCAI Reduction Forward plan 14/15 (see appendix 1).

Further evaluations of training will be undertaken once these actions have been completed.

Page 3 of 3

Appendix 1

Action Timescale Lead Progress RAG

To deliver IPC mandatory and induction training as per training needs analysis 2014/15

Ongoing

IPCT Training delivered

To review IPC training module in line with 2014/15 training needs analysis Ongoing

IPC Matron

Revised training module in place

Divisions to report quarterly on training uptake for staff via TIPCC 13/10/14 Divisional Professional Leads

IPC Training reported via Divisions

Develop, pilot, disseminate and evaluate the use of IPC ‘flash cards’ for planned and opportunistic ward/department learning

01/10/14

ADIPC/IPC team

Development, implementation and evaluation of ‘flash cards’ complete

Agenda Item No


Date 31st July 2014

Title Q1 compliance framework declaration

Executive Summary

As a Foundation Trust regular declarations are required with

regard to compliance with targets and financial performance.

These declarations are made on a template provided by Monitor

which includes worksheets for financial performance,

governance declarations and performance against targets.

The governance and target templates will be uploaded with the

monthly financial templates by 4.00 pm on July 31st 2014

Although the Trust remain red rated for governance the process

to receive a certificate of compliance with the enforcement

actions has been initiated by Monitor.

Next steps/future actions

The Board are asked to approve the Q1 submission to Monitor

Discuss Receive

Approve Note

For Information Confidential y/n N


Strategy Legal Implications

Performance and Quality Regulatory

Financial Implications Stakeholder implications

Workforce Risk

Prepared by Esther Steel Trust Secretary

Presented by Esther Steel Trust Secretary

Compliance Declaration Q1 2013/14

1. PURPOSE

The purpose of this paper is to inform the Board’s consideration of the quarter one

submission to Monitor.

2. BACKGROUND

As a Foundation Trust regular declarations are required with regard to compliance with

targets and financial performance.

These declarations are made on a template provided by Monitor which includes

worksheets for financial performance, governance declarations and performance

against targets.

3. CURRENT POSITION

An update on the current position with regard to operational performance, quality and

finance is included on the Board agenda.

4. RECOMMENDATIONS

Board members are asked to agree that the following proposed statements attached to

this report are signed for submission to Monitor for the Q1 return:

Governance declaration

Targets and indicators

Quality Governance declaration.

Classified as Restricted per Monitor's Information Security Policy

In Year Governance Statement from the Board of Bolton

The board are required to respond "Confirmed" or "Not confiirmed" to the following statements (see notes below)

For finance, that: Board Response

4 Not Confirmed

For governance, that:

11 Confirmed

Otherwise:

Confirmed

Consolidated subsidiaries:

0

Signed on behalf of the board of directors

Signature Signature

Name Name

Capacity [job title here] Capacity [job title here]

Date Date

0

Notes:

A

B

C

The board confirms that there are no matters arising in the quarter requiring an exception report to Monitor (per the Risk Assessment

Framework page 22, Diagram 6) which have not already been reported.

The board anticipates that the trust will continue to maintain a Continuity of Service risk rating of at least 3 over the next 12 months.

The board is satisfied that plans in place are sufficient to ensure: ongoing compliance with all existing targets (after the application of

thresholds) as set out in Appendix A of the Risk Assessment Framework; and a commitment to comply with all known targets going

forwards.

The board is unable to make one of more of the confirmations in the section above on this page and accordingly responds:

The Trust currently has a Continuity of Services rating of 1 and is subject to enforcement and discretionary requirements which are discussed in detail at montly

performance review meetings.

The annual plan submitted at the end of June 2014 projected CSR rating of 1 for Q1 and Q2 increasing to 2 in Q3 and Q4

Number of subsidiaries included in the finances of this return. This template should not include the results of your NHS charitable funds.

Monitor may adjust the relevant risk rating if there are significant issues arising and this may increase the frequency and intensity of monitoring for the

NHS foundation trust.

Monitor will accept either 1) electronic signatures pasted into this worksheet or 2) hand written signatures on a paper printout of this declaration posted

to Monitor to arrive by the submission deadline.

In the event than an NHS foundation trust is unable to confirm these statements it should NOT select 'Confirmed’ in the relevant box. It must provide a

response (using the section below) explaining the reasons for the absence of a full certification and the action it proposes to take to address it.

This may include include any significant prospective risks and concerns the foundation trust has in respect of delivering quality services and effective

quality governance.

BOLTON 1415 Q1 in year reporting template (to issue) - Governance Statement

1 of 1 22/07/2014 17:31

Classified as Restricted per Monitor's Information Security Policy

Worksheet "Targets and Indicators"

Declaration of risks against healthcare targets and indicators for 2014-15 by Bolton

These targets and indicators are set out in the Risk Assessment Framework Key: must complete

Definitions can be found in Appendix A of the Risk Assessment Framework may need to complete

NOTE: If a particular indicator does not apply to your FT then please enter "Not relevant" for those lines. Quarter 1

Actual

Target or Indicator (per Risk Assessment Framework)

Threshold or

target YTD

Scoring

under

Risk Assessment

Framework

Risk declared at

Annual Plan

Scoring

under

Risk Assessment

Framework Performance Achieved/Not Met Any comments or explanations

Scoring

under

Risk Assessment

Framework

Referral to treatment time, 18 weeks in aggregate, admitted patients 90% 1.0 No 94.9% Achieved

Referral to treatment time, 18 weeks in aggregate, non-admitted patients 95% 1.0 No 97.5% Achieved

Referral to treatment time, 18 weeks in aggregate, incomplete pathways 92% 1.0 No 0 92.0% Achieved 00/01/1900

A&E Clinical Quality- Total Time in A&E under 4 hours 95% 1.0 Yes 1 95.5% Achieved 0

Cancer 62 Day Waits for first treatment (from urgent GP referral) - post local breach re-allocation 85% 1.0 No 93.4% Achieved Only 2 months data available

Cancer 62 Day Waits for first treatment (from NHS Cancer Screening Service referral) - post local breach re-allocation 90% 1.0 No 0 100.0% Achieved Only 2 months data available 0

Cancer 62 Day Waits for first treatment (from urgent GP referral) - pre local breach re-allocation 96.0% Only 2 months data available

Cancer 62 Day Waits for first treatment (from NHS Cancer Screening Service referral) - pre local breach re-allocation 100.0% Only 2 months data available

Cancer 31 day wait for second or subsequent treatment - surgery 94% 1.0 No 100.0% Achieved Only 2 months data available

Cancer 31 day wait for second or subsequent treatment - drug treatments 98% 1.0 No 100.0% Achieved Only 2 months data available

Cancer 31 day wait for second or subsequent treatment - radiotherapy 94% 1.0 No0

0.0% Not relevant 0

Cancer 31 day wait from diagnosis to first treatment 96% 1.0 No 0 97.7% Achieved Only 2 months data available 0

Cancer 2 week (all cancers) 93% 1.0 No 97.6% Achieved Only 2 months data available

Cancer 2 week (breast symptoms) 93% 1.0 No0

95.5% Achieved Only 2 months data available0

Care Programme Approach (CPA) follow up within 7 days of discharge 95% 1.0 No 0.0% Not relevant

Care Programme Approach (CPA) formal review within 12 months 95% 1.0 No 0 0.0% Not relevant 0

Admissions had access to crisis resolution / home treatment teams 95% 1.0 No 0 0.0% Not relevant 0

Meeting commitment to serve new psychosis cases by early intervention teams 95% 1.0 No 0 0.0% Not relevant 0

Ambulance Category A 8 Minute Response Time - Red 1 Calls 75% 1.0 No 0 0.0% Not relevant 0

Ambulance Category A 8 Minute Response Time - Red 2 Calls 75% 1.0 No 0 0.0% Not relevant 0

Ambulance Category A 19 Minute Transportation Time 95% 1.0 No 0 0.0% Not relevant 0

C.Diff due to lapses in care 12 1.0 No 0 8 Achieved We are currently working with the CCG to agree aspects of care parameters0

Total C.Diff YTD (including: cases deemed not to be due to lapse in care and cases under review) 8

C.Diff cases under review 0

Minimising MH delayed transfers of care <=7.5% 1.0 No 0 0.0% Not relevant 0

Data completeness, MH: identifiers 97% 1.0 No 0 0.0% Not relevant 0

Data completeness, MH: outcomes 50% 1.0 No 0 0.0% Not relevant 0

Compliance with requirements regarding access to healthcare for people with a learning disability N/A 1.0 No 0 N/A Achieved 0

Community care - referral to treatment information completeness 50% 1.0 No 99.4% Achieved

Community care - referral information completeness 50% 1.0 No 100.0% Achieved

Community care - activity information completeness 50% 1.0 No0

100.0% Achieved 0

Risk of, or actual, failure to deliver Commissioner Requested Services N/A No No

CQC compliance action outstanding (as at time of submission) N/A No No

CQC enforcement action within last 12 months (as at time of submission) N/A No No

CQC enforcement action (including notices) currently in effect (as at time of submission) N/A No No

Moderate CQC concerns or impacts regarding the safety of healthcare provision (as at time of submission) N/A No No

Major CQC concerns or impacts regarding the safety of healthcare provision (as at time of submission) N/A No No

Trust unable to declare ongoing compliance with minimum standards of CQC registration N/A No No

Results left to complete 0 0

Total Score 1 0

Report by Exception

In Year Quality Governance Metrics of Bolton

Actual for

The Risk Assessment Framework (diagram 13) sets out that Monitor will use executive team turnover as one of the

potential indicators of quality governance concerns. Please provide the information requested below and ensure that any

changes are explained in your commentary: units

Quarter

ending 30-

Jun-14

Executive Directors

Total number of Executive posts on the Board (voting) Posts 6

Number of posts currently vacant Posts -

Number of posts currently filled by interim appointments Posts -

Number of resignations in quarter Resignations -

Number of appointments in quarter Appointments -

Agenda Item No : 12


Date 31st July 2014

Title Memorandum of Understanding N W Sector

Executive Summary

The purpose of this MOU is to set out:

the objectives and principles of the partnership between the

organisations listed below,

the governance arrangements for the partnership; and,

the proposed timetable for the development and

implementation of the arrangements.

This MOU is not exhaustive and, with the exception of the

confidentiality clause, is not intended to be legally binding,

between any of the Parties.

Signatories:

Bolton NHS Foundation Trust

Salford Royal NHS Foundation Trust

Wrightington, Wigan And Leigh NHS Foundation Trust

NHS Bolton Clinical Commissioning Group

NHS Salford Clinical Commissioning Group

NHS Wigan Borough Clinical Commissioning Group

Bolton Council

Salford City Council

Wigan Council

Next steps/future actions

The Board are asked to formally approve the signing of the

attached MOU.

Discuss Receive

Approve Note

For Information Confidential y/n


Strategy Legal Implications

Performance and Quality Regulatory

Financial Implications Stakeholder implications

Workforce Risk

Prepared by Dr J Bene Chief Executive

Presented by Dr J Bene Chief Executive

Dated [date to be inserted]

BOLTON NHS FOUNDATION TRUST SALFORD ROYAL NHS FOUNDATION TRUST WRIGHTINGTON, WIGAN AND LEIGH NHS FOUNDATION TRUST NHS BOLTON CLINICAL COMMISSIONING GROUP NHS SALFORD CLINICAL COMMISSIONING GROUP NHS WIGAN BOROUGH CLINICAL COMMISSIONING GROUP BOLTON COUNCIL SALFORD CITY COUNCIL WIGAN COUNCIL

Memorandum of Understanding in relation to Partnership Working to provide a shared, sector-based response that meets the requirements of Healthier Together and improves services for patients in the North West of Greater Manchester

DRAFT 0.7 (07 07 14)

FOR APPROVAL BY THE SPECIFIED PARTIES

FIRST DRAFT, VERSION 0.7: FOR APPROVAL BY THE PROPOSED PARTIES TO THE MOU 2 | P a g e

VERSION CONTROL

No Date Editor Purpose/Change

0.1 18/05/14 J Sharp Consolidate decisions and collective agreements to-date

Propose governance arrangements for NW sector

0.2 20/05/14 J Sharp Change in terminology (‘emergency and high risk elective surgery’ rather than ‘emergency and complex surgery’)

Reworded to clarify initial preference for a JANE JV

Query inserted re cost of new service model

Bury stakeholders to be invited to attend Part 2 of the NW Sector Leadership Board

0.3 25/5/14 J Sharp Timeline inserted

Role description for Project Director inserted

Terms of Reference for Operational Group added

Revision to confidentiality clause to recognise information already in the public domain or required by law

0.4 30/5/14 J Sharp Rewording of sector-based to HT

Rewording of sustainability / cost savings

Inclusion of ‘partnership of equals’ in principles, consensus approach to decision-making and equal votes

Overt that costs and benefits will be shared between parties

Insertion of organisational reporting arrangements within governance section

Removed reference to Pennine Acute, Bury MBC and Bury CCG as members of the Leadership Board – to be revisited if modelling work indicates this is a material consideration

Amended timeline for finalisation of the business case

0.5 09/06/14 J Sharp Revised arrangement for the Leadership Board

Insertion of data sharing clauses to support modelling work

0.6 01/07/14 J Sharp Modification to reflect different roles of FTs, CCGs and LAs

0.7 07/07/14 J Sharp Recognised potential for perceived conflicts of interest

Amended governance section to describe separate FT Project Board and sector Leadership Group


CONTENTS

Clause Heading Pages 1 Status of this MOU 6

2 Purpose of the Partnership 6 3 Principles of the Agreement 7 4 Governance Arrangements 7 5 Provisional Timetable 8 6 Costs 9 7 Data Sharing and Confidentiality 9

Appendix 1 North West Sector Emergency and High Risk Elective Surgery Operational Group

12

Appendix 2 North West Sector Clinical Chair role description 14 Appendix 3 North West Sector Project Director role description 15


THIS AGREEMENT is dated [date be inserted once agreed by all Parties] BETWEEN

(1) BOLTON NHS FOUNDATION TRUST of Trust Headquarters, Royal Bolton Hospital, Minerva Road, Farnworth, Bolton, BL4 0JR (“Bolton FT”);

(2) SALFORD ROYAL NHS FOUNDATION TRUST of Trust Headquarters, Mayo Building, Salford Royal NHS Foundation Trust, Stott Lane, Salford, M6 8HD (“SRFT”);

(3) WRIGHTINGTON, WIGAN AND LEIGH NHS FOUNDATION TRUST of Trust Headquarters, Royal Albert Edward Infirmary, Wigan Lane, Wigan, WN1 2NN (“WWL”);

(4) NHS BOLTON CLINICAL COMMISSIONING GROUP of St Peter's House, Silverwell Street, Bolton, BL1 1PP (“Bolton CCG”);

(5) NHS SALFORD CLINICAL COMMISSIONING GROUP of St James's House, Pendleton Way, Salford, M6 5FW (“Salford CCG”);

(6) NHS WIGAN BOROUGH CLINICAL COMMISSIONING GROUP of Wigan Life Centre, College Avenue, Wigan, WN1 1NJ (“Wigan CCG”);

(7) BOLTON COUNCIL of Victoria Square, Bolton BL1 1RU (“Bolton Council”);

(8) SALFORD CITY COUNCIL of Salford Civic Centre, Chorley Road, Swinton, Manchester, M27 5D (“SCC”); and

(9) WIGAN COUNCIL of Town Hall, Library Street, Wigan, Lancashire WN1 1YN (“Wigan Council”)

together referred to as the “Parties” to the MOU

BACKGROUND (A) The Healthier Together (“HT”) programme has identified that, in Greater Manchester, a

range of acute hospital services (Urgent, Emergency and Acute Medicine, General Surgery and Children’s Services) currently have highly variable standards and outcomes for patients, and are challenged with shortages of specialist staff and constrained resources.

(B) A new model of care has been developed by clinicians from across organisations in Greater Manchester. Quality and safety standards have been developed for each clinical area, incorporating national guidance and recommendations from Royal Colleges. The model and the standards have been endorsed by the National Clinical Advisory Team (“NCAT”) and approved by the twelve Greater Manchester Clinical Commissioning Groups (through its Committees in Common).

(C) The new model of care proposes the formation of shared, single services across larger

geographical footprints, raising the standards in all hospitals, and concentrating the specialist workforce in delivery of the most specialist services into fewer places.


(D) Whilst the majority of care will be provided either in a community setting or in local hospitals, HT proposes that a smaller number of hospitals will be designated ‘specialist sites’, providing centres of excellence for seriously ill patients. These specialist sites will provide care for a larger population and will be staffed by a single multi-disciplinary team from collaborating hospitals (local and specialist sites).

(E) Subject to public consultation, it is likely that there will be 4-5 designated specialist sites in

Greater Manchester. Both SRFT and Central Manchester University Hospitals NHS Foundation Trust have been determined as ‘fixed points’, i.e. in each of the options that will be consulted on they are both designated as specialist sites. Given population volumes and patients flows, it is likely that there will be 1-2 specialist sites in the North West sector.

(F) Dependent on the overall number and distribution of local and specialist sites in Greater

Manchester, the North West sector may need to support a wider geographical area.

(G) Initially concentrating on General Surgery, the three Foundation Trusts within the North West sector have held a series of workshops with clinical and managerial stakeholders to explore options for implementing the standards across Bolton, Salford and Wigan.

(H) The Parties met on 30 April and committed to work together as a partnership to develop a

sector-based response to HT which is consistent with the new model of care and meets the specified quality and safety standards. It was also recognised that the population of Bury access services within the sector and therefore it will be important to engage partners in Bury in the proposed new arrangement.

(I) It is recognised that the Parties to the Memorandum of Understanding (“MOU”) have different roles and responsibilities, namely:

(i) Bolton FT, SRFT and WWL are responsible for developing the new service model

which meets the HT standards and the requirements of commissioners. Subject to the outcome of the public consultation and commissioner approval, the three Foundation Trusts will be responsible for delivering the shared service;

(ii) Bolton CCG, Salford CCG and Wigan CCG are responsible for providing commissioning input into the North West sector response to HT, recognising that collective arrangements have been agreed for pan-Greater Manchester CCG decision-making through the Committees in Common; and

(iii) Bolton Council, SCC and Wigan Council are responsible for ensuring the new service meets the needs of the combined population of the sector and supporting the alignment of adult social care services to support effective discharge from hospital.

(J) The purpose of this MOU is to set out the:

(i) Objectives of the partnership and the principles that will underpin it; (ii) Governance arrangements for the partnership; and (iii) Proposed timetable for the development and implementation of the arrangements.


IT IS AGREED that:

1 Status of this MOU 1.1 This MOU is not exhaustive and, with the exception of the confidentiality clause, is not

intended to be legally binding, between any of the Parties. 2 Objectives of the Partnership 2.1 The Parties agree that the objectives of the partnership will be to:

(a) Support and ensure delivery of the new model of care and the quality and safety

standards that have been established and approved through the HT programme; (b) Develop a service proposal for the reconfiguration of Emergency and High Risk Elective

General Surgery within the North West sector of Greater Manchester; (c) Seek to secure a consistent, shared sector-based response to the HT public consultation; (d) Develop a Business Case on the future configuration of services; (e) Identify further opportunities to collaborate within the North West sector, where this

is in the best interests of patients and the population; and (f) Deliver any additional objectives as determined and agreed by all Parties.

2.2 In developing a service proposal for the reconfiguration of Emergency and High Risk

Elective General Surgery, the Parties agree that it must: (a) Reliably and consistently meet the HT quality and safety standards; (b) Enable the best clinical outcomes and optimise access for the combined population of

Bolton, Salford and Wigan; (c) Be clinically and managerially managed as a single service; (d) Operate within a single system of governance; (e) Support the sustainability of adjacent clinical services; (f) Be supported by effective arrangements for transfer for discharge from hospital and

ongoing rehabilitation and reablement; (g) Enable costs, risks and benefits to be shared between providers; and (h) Be financially sustainable for all Parties and cost no more (and preferably less) than the

current service (accepting that some upfront investment will be required). 2.3 It has been agreed the redesigned surgical service will operate as a Shared Service, through

a Joint Venture (“JV”) model. The proposed model is a Joint Arrangement that is Not an Entity (“JANE”), where the Shared Service is hosted by one of the Foundation Trusts but that the service is governed and held to account through a joint Board of the three Foundation Trusts. (There is an option to move towards a free-standing JV, a Body Corporate JV (BCJV), in the longer term.)

2.4 The Parties recognise that this will require strong relationships and the creation of an environment of trust, collaboration and innovation.


3 Principles of the Agreement 3.1 The Parties agree to the following principles underpinning this MOU and the development

of a sector-led response to HT:

(a) To act in the best interests of service users and the public; (b) To work as a partnership of equals; (c) At all times to act in good faith towards one another; (d) To act in a timely manner and respond accordingly to requests for support; (e) To communicate openly about concerns, issues or opportunities relating to HT and/or

the sector-led response to the new model of care; (f) To seek to develop as a collaborative in order to achieve the full potential of the

partnership; (g) To adopt a positive outlook and to behave in a positive, proactive manner; (h) To focus on the care and experience of service users and potential beneficiaries of the

new model of care; and (i) To promote innovation.

3.2 The Parties agree that decision-making should be by consensus. 4 Governance Arrangements 4.1 Recognising the potential for perceived conflicts of interest, particularly during the public

consultation stage of HT, the Parties have agreed the following governance arrangements: (a) A Project Board will oversee the development of a sector-led response to Healthier

Together and the development of service proposal for the reconfiguration of Emergency and High Risk Elective General Surgery within the sector;

(b) The North West Sector Leadership Group will provide wider senior leadership to partnership working within the sector and will help to address barriers or obstacles that could prevent the achievement of the objectives of this partnership.

4.2 The Project Board will be a vehicle for joint working between the three Foundation Trusts

that are party to this Agreement. The Project Board will be comprised of the three Foundation Trust Chief Executives, lead Executive Directors, the Project Director and independent Clinical Chair. During the public consultation phase of HT, the Project Board will have an independent chair, agreed by the three Foundation Trusts.

4.3 The North West Sector Leadership Group will provide a broader forum for collective decision-making between the three Local Authorities, three CCGs and three Foundation Trusts. It will have Chief Officer / Leader / Board-level representation from the Parties to this Agreement. The Leadership Group will be chaired by Leader of Bolton Council.

4.4 The Project Board will meet on a 4 weekly basis, with a wider Leadership Group meeting on

an 8 weekly basis.


4.5 Wherever possible, both committees will make decisions through consensus. In those circumstances where consensus cannot be reached and a decision must be taken, the issue may be put to a vote, with each Party on the committee having one allocated vote.

4.6 Unless there is specific justification to withhold information, all papers and minutes

associated with both the Project Board and the North West Sector Leadership Group will be deemed suitable to be made available in the public domain. Minutes of the Project Board will be reported to the Boards of the Foundation Trusts, which are held in public.

4.7 The service proposal for Emergency and High Risk Elective General Surgery will be developed by an Emergency and High Risk Elective Surgery Operational Group (“Surgery Operational Group”). The Terms of Reference for this are set out at Appendix 1.

4.8 An independent Clinical Chair and a Project Director will be appointed, on behalf of the

three Foundation Trusts. These roles are set out at Appendices 2 and 3.

4.9 Parallel arrangements will be established should the three Foundation Trusts agree to collaborate in other clinical areas. Revised arrangements are be likely to be required at the point that it is agreed to implement the new model of care.

4.10 These arrangements will be reviewed after the public consultation process has concluded.

5 Provisional Timetable

5.1 The following table sets out a high-level provisional timetable for next 12 months. The timetable is subject to further review by each of the Parties.

Timescale Principal Tasks

May – June 2014

Establish governance structure Appoint Project Director and independent Clinical Chair Commission modelling work (capacity / finances / workforce)

July 2014 Agree outline clinical model Complete modelling work and test this within organisations

August 2014 Agree legal mechanism on how single service will operate Test high level, outline clinical model with key stakeholders (internal

and external) Start drafting joint response to HT

August – September 2014

Sign-off service model and governance arrangements across the three Foundations Trusts

Submit joint response to HT consultation (i.e. sector based model

December 2014

First iteration of business case

February – March 2015

Business case finalised


5.2 A more detailed implementation plan and timetable will be jointly developed between the Parties upon approval of this MOU.

6 Costs

6.1 Each Party shall bear their own costs in relation to this Agreement.

6.2 The costs of the Project Director, Clinical Chair and administrative support shall be borne equally by three Foundation Trusts.

7 Data Sharing and Confidentiality

7.1 The Parties acknowledge and agree that each may be required to disclose to others, information which is regarded as confidential or commercially sensitive. The Parties undertake for themselves and their respective Boards and employees: (a) The disclosing Party shall confirm whether information is to be regarded as

confidential prior to its disclosure; (b) All Parties shall use no lesser security measures and degree of care in relation to any

confidential information received from the other Party than it applies to its own confidential information;

(c) The Parties shall not disclose any confidential information of the other Parties to any third party without the prior written consent of the other Parties; and

(d) On the termination of this Agreement, each Party shall return any documents or other material in its possession that contains confidential information of the other Parties.

7.2 Clause 7.1 shall not apply to any information which is already in the public domain (other

than by a breach of this Agreement), or where disclosure is required by law or in relation to any information which is lawfully requested by government, Monitor or NHS England.

7.3 The Parties have agreed that information will be shared with external advisors to enable modelling work to be undertaken for the sector. For the avoidance of doubt:

(a) The Foundation Trusts, CCGs and Local Authorities that are subject to this MOU agree

to provide in a timely manner and without restriction all information requested and required by the advisors to carry out the work including but not limited to relevant detailed financial, activity, workforce and estates related information;

(b) All Parties agree that publically available information may be shared fully with all other Parties that are subject to this agreement;

(c) Non-publically available information provided to the advisors as part of this project including (but not limited to) relevant financial, activity, workforce and estates related information will be held securely by the advisors and not shared with the other providers, CCGs and Local Authorities connected to this project without the express permission of the relevant originating organisation; and

(d) No information will be shared with parties outside of the project.


7.4 Express permission will be sought from the three Foundation Trusts to share the following information:

(a) All in and out of scope activity information at each hospital site; (b) Whole-time equivalent workforce information for the in-scope sites and services; (c) Estates information in relation to in and out of scope services; and (d) Financial information, including Service Line Reporting information, should be provided

to the advisors for each Trust as a whole (i.e. for both in and out of scope sites and services) but will be shared between the three providers for in scope activity only.


Signed by [insert name once approved] For and on behalf of BOLTON NHS FOUNDATION TRUST We confirm our agreement to the above ………………………………………………………….

Signed by [insert name once approved] For and on behalf of SALFORD ROYAL NHS FOUNDATION TRUST We confirm our agreement to the above ………………………………………………………….

Signed by [insert name once approved] For and on behalf of WRIGHTINGTON, WIGAN AND LEIGH NHS FOUNDATION TRUST We confirm our agreement to the above ………………………………………………………….

Signed by [insert name once approved] For and on behalf of NHS BOLTON CLINICAL COMMISSIONING GROUP We confirm our agreement to the above ………………………………………………………….

Signed by [insert name once approved] For and on behalf of NHS SALFORD CLINICAL COMMISSIONING GROUP We confirm our agreement to the above ………………………………………………………….


Signed by [insert name once approved] For and on behalf of NHS WIGAN BOROUGH CLINICAL COMMISSIONING GROUP We confirm our agreement to the above ………………………………………………………….

Signed by [insert name once approved] For and on behalf of BOLTON COUNCIL We confirm our agreement to the above ………………………………………………………….

Signed by [insert name once approved] For and on behalf of SALFORD CITY COUNCIL We confirm our agreement to the above ………………………………………………………….

Signed by [insert name once approved] For and on behalf of WIGAN COUNCIL We confirm our agreement to the above ………………………………………………………….

Private & Confidential

Appendix 1

North West Sector Emergency and High Risk Elective Surgery Operational Group

Name Emergency and High Risk Elective Surgery Operational Group

Purpose Develop a proposal for the configuration of Emergency and complex general surgery as part of Healthier Together for the North West Sector.

Provide and maintain high quality care to patients and maximise outcomes for patients on all sites and across specialties.

Drive progress forward ensuring all Quality, Performance and Finance standards including those agreed through Healthier Together, are met.

Produce a Business case for the respective Boards on future configuration of services.

Role of the Group

1. To develop clinical pathways across the North West Sector.

2. Work with partners in the Network to ensure high quality of care and outcomes for patients requiring emergency and complex surgery.

3. To ensure that other co-dependent specialties are supported to provide a safe service on all sites.

4. Ensure effective communication within the Departments, between the three Trusts, to the public and other stakeholders.

5. To develop proposals for workforce configuration across three sites.

6. To consider and develop robust financial plans to ensure efficiency gains are maximised.

Principles 1. The status quo is not viable and will not enable us to meet agreed standards for patients

2. We want to develop a single shared service for the population which reliably meets agreed standards and is sustainable into the future

3. The single service will enable the best access and the best outcomes for all patients and it is this, not organizational loyalties, which will drive our decision making

4. We will agree a common governance model with a single source of logistical support (IT, HR, admin etc)

5. The cost of this new service will be demonstrably less than the current cost of the service accepting that some upfront investment may be needed.

Chair Independent Clinical Chair (TBA) – acting A Ennis, COO, Bolton FT


Membership 1. Lead Surgeon from the 3 Trusts & nominated deputy

2. Executive Directors from the 3 Trusts (as standing members may not need always to attend)

3. Divisional Directors from the 3 Trusts

4. Project Manager - TBA

5. Project administration – TBA

6. Chairs of subgroups

Clinical pathways

Workforce and Communications

Finance and Activity Modelling

7. Nominated lead from each Trust for following where appropriate

ICU

Gynae

ED

Paeds

Diagnostics

8. CCG representatives

9. Additional Representatives to be invited in an advisory capacity

Quorum / Attendance expectations

Quorum - minimum of 1 representative from each site and 3 Clinicians.

Attendance - at least 75% meeting attendance required.

3 x successive failures to attend meetings will result in removal from the distribution list.

Frequency & Timing

Monthly

Reporting Arrangements

The Operational Group will provide the North West Sector Leadership Board with regular updates and receive progress updates from the project work streams.


Appendix 2

North West Sector Emergency and High Risk Elective Surgery: Clinical Chair

Key Responsibilities and Outcomes

Chair the North West Sector Emergency and High Risk Elective Surgery Operational Group

Provide independent professional advice on clinical models and standards required to delivered the agreed Healthier Together standards for General Surgery

Support the Clinical Pathway Subgroup to develop an agreed sector-based clinical model

Facilitate joint working across the three Foundation Trusts and with stakeholders

Develop a shared sense of purpose and commitment within the clinical community

Provide clinical advice and support to the Project Director

Accountability and Key Relationships

Accountable to the Medical Directors of the three Foundation Trusts

Other key relationships o The North West Sector Project Director o The nominated General Surgical Leads from the three Foundation Trusts o The nominated Executive Director leads from the three Foundation Trusts

Duration and Time Commitment:

Initial appointment duration of 12 months

Time commitment of 1-2 days per week


Appendix 3

North West Sector Project Director

Key Responsibilities and Outcomes

Deliver the Emergency and High Risk Elective General Surgery objectives and timelines as agreed by the North West Sector Leadership Board

Develop and produce the Business Case for Emergency and High Risk Elective General Surgery, with the support of the Operational Group

Assess the requirement and work with colleagues to formulate an appropriate North West sector response to the two other Healthier Together ‘in scope’ hospital services (Urgent, Emergency & Acute Medicine and Children’s Services)

Work in partnership with appropriate clinical, management and other staff to ensure support and engagement for the agreed project(s)

Use influencing and facilitation skills to encourage staff to approach things differently e.g. deliver services differently, adopt differ ways of working and establish different relationships

Act as an ‘independent’ voice to challenge the member organisations to take a wider view where necessary

Develop a robust project management and assurance framework

Ensure effective performance management of the project

Ensure there are regular project meetings co-ordinating the subgroups to ensure timely delivery of key objectives

Lead other collaborative workstreams, as determined and agreed by the North West Sector Leadership Board

Accountability and Key Relationships

Accountable to the North West Sector Leadership Board

Report to the nominated Executive Director leads from the three Foundation Trusts

Other key relationships o The North West Sector Project Director o The nominated General Surgical Leads from the three Foundation Trusts

Duration and Time Commitment:

Initial appointment duration of 6 months

Full time

Agenda Item No: 13


Date 31st July 2014

Title Community Services Strategy

Executive Summary

• Why is this paper going to the Board of Directors

• To summarise the main points and key issues that the Board of Directors should focus on including risk, compliance priorities, cost and penalty implications, KPI’s, Trends and Projections, conclusions and proposals

To update the Board on progress toward agreeing an updated community services strategy for the Trust by the end of September 2014, so that the Trust can be in the best position possible to respond to the new service specifications being worked up by Bolton CCG.

Next steps/future actions Clearly identify what will follow a Board decision i.e. future KPI’s, assurance requirements

Discuss Receive

Approve Note

Assurance to be provided by:



Performance Legal Implications

Quality Regulatory




Prepared by Simon Worthington Finance Director Presented by Simon Worthington

Finance Director

Community Services Strategy

1. Introduction

1.1 The purpose of this paper is to update the Board on progress toward agreeing an updated community services strategy for the Trust by the end of September 2014, so that the Trust can be in the best position possible to respond to the new service specifications being worked up by Bolton CCG.

2. Progress

2.1 The Executive agreed a plan to develop the strategy in June 2014. The following table shows the current status of these work streams

Work stream RAG Comment Vision Amber Agreement of high level KPI’s to support the vision

is behind plan, see section four below Governance Green On track Service specifications

Green On track – new service specifications are being worked up by the CCG, it is planned that these will be agreed by the 1st October.

IT/Information Green On track – note: £1.7m capital funding secured for IT Performance dashboard now available – see appendix one.

Workforce Green On track Estates Green On track Finance Green On track – note: Detailed service line analysis

presented to the July finance committee. Community services incurred a deficit of £2m in 2013/14.

3. Community Performance Dash Board

3.1 Appendix one shows the community services dashboard. This will continue to be developed, particularly in respect of patient experience, quality and workforce information. The final version will measure performance against all aspects of the service specifications. A summary version of this will be included in the Board integrated dashboard going forward (see below), the detail will be used with the Divisions through the integrated performance framework process.

4. High Level Key Performance Indicators

4.1 At its last meeting the Board discussed what high level KPI’s should be used to monitor the impact community services was having on the Trust services as a whole (i.e. measure the benefits of being an integrated care organisation as opposed to an acute hospital Trust). Following this discussion the Board asked for a further proposal from the Executive, this is set out in the table below:

Measure Rationale Patient Experience There should be a benefit to overall patient

experience of the Trust from being an integrated care provider

Number of patients with a key worker and care plan

This is a key measure for the effectiveness of the work that is being done to deliver integrated health and social care under the auspices of the better care fund. It is expected that as the number of patients with a key worker and a care plan increases (the current number is zero) the number of hospital admissions, length of stay etc will fall.

Community Service Effectiveness – Quality

The Trust should measure the quality of its community services against the requirements of the service specifications.

Community Service Effectiveness – Performance

The Trust should measure the performance of its community services against the requirements of the service specifications.

Community Service Effectiveness – Finance

The Trust should measure the financial contribution that community services are making to the overall financial performance of the Trust.

5. Recommendations

5.1 It is recommended that the Trust Board agree

I. That it has sufficient assurance on the development of the community services strategy

II. The high level KPI’s proposed

Appendices

1. Community services dashboard

Improving the Quality of Care and Safety of our patients

FFT Awaiting guidance around FFT in Community, liaise with Patient Safety regarding collection

Complaints 2 complaints were reported during June 2014, a total of 10 during the financial year to date.

Pressure Ulcers 21 pressure ulcers in community year to date. 7 in June 14, one of which is a grade 4.

Patient Falls 12 falls reported in Community during June 2014, a total of 33 during the financial year to date.

Valued provider of Integrated Services

Attendances 63136 attendances were seen during June 14 against a plan of 68835 (8.3% below plan)

DNA Rates 2425 patients Did Not Attend during June 14 (rate of 3.7%), this is below the planned number of 2546

GP Referrals 2802 GP Referrals were received compared to 2573 the previous year, an increase of 8.9%

12 Week Waiters 9.1% of patients waited over 12 weeks to see a AHP/Nurse/consultant in Community against a plan of 10%.

A great place to work

Staff Turnover

Apprasials

Sickness Sickness rate for June 2014 is 4.8% across Community.

Staff Temp

Community Dashboard 2014_15 Executive Summary

Executive Summary

1 All report data correct and verified as of Thursday 17th July 2014

tmoss

Typewritten Text

Appendix one

Community Dashboard Executive Summary Report

Improving Patient Care in the Community Metric 1.0 Attendances Adult Acute Division is below plan by 2804 attendances (7.5%).

The services that are primarily affecting the percentage below plan are:-

Asylum Seekers:- An average of 111 attendances per month were seen in 2013/14, compared to an average of 40 per month so far

in 2014/15. The monthly actuals are affected by the numbers referred via Border Control.

Dietetics Community Weight Management (CWM):- Activity is 84.6% below plan. In 2013/14 an average of 300 attendances were

seen per month compared to only 140 per month in 2014/15. The Service Lead has been contacted for advice on the low numbers

this year, the plan may need to be revised following discussions.

Tissue Viability:- Activity is 92.0% below plan. An average of 130 attendances were seen per month during 2013/14 compared to

only 9 per month in 2014/15. Colleagues have been contacted for advice on the low numbers this year, the plan may need to be

revised following discussions.

Elective Division are above plan by 1.0%.

MSK Occupational Therapy is above plan by 14.5%.

The other services above plan are Podiatry and Rheumatology Department.

All other services are below plan.


Family Division are below plan by 12.8%.

The services that are primarily affecting the percentage below plan are:-

Childrens Learning Disability:- 38.4% below plan. During 2013/14 an average of 1160 attendances were seen per month compared

to only 800 per month in 2014/15. The plan for this service is term time affected however, it is the actual attendances seen that

has reduced. The Service Lead has been contacted for advice on the low numbers this year, the plan may need to be revised

following discussions.

Paediatric Complex Needs:- 67.7% below plan. An average of 500 attendances per month were seen during 2013/14. In 2014/15

this has reduced to 280. The Service Lead has been contacted for advice on the low numbers this year, the plan may need to be

revised following discussions.

Special School Nursing:- 64.9% below plan. An average of 408 attendances per month were seen during 2013/14. The average

number of attendances seen during 2014/15 has reduced to 280. The plan for this service is term time affected however, it is the

totals seen that have reduced. The Service Lead has been contacted for advice on the low numbers this year, the plan may need

to be revised following discussions.

Paediatric Continuing Care:- 31.6% below plan. During 2013/14 an average of 460 attendances were seen per month. This has

reduced to 333 during 2014/15. The Service Lead has been contacted for advice on the low numbers this year, the plan may need

to be revised following discussions.

Paediatric Physiotherapy:- 31.9% below plan. An average of 440 attendances per month were seen during 2013/14. In 2014/15

this has reduced to an average of 404 attendances per month. The plan for this service is term time affected. The total numbers

seen hasn’t reduced greatly compared to this time last year however, the Service Lead has been contacted for advice on the low

numbers this year, the plan may need to be revised following discussions.


Metric 3.0 DNA Rates

The services with the highest DNA rates within each division are:-

Adult Acute Division – Dermatology – 14.2%.

Elective Division – Rheumatology Therapy – 17.9%.

Family Division – Paediatric Audiology – 17.9%.

Metric 4.0 GP Referrals

GP Referrals received into Adult Acute Division during June 2014 is above plan by 99 referrals.

Elective Division GP Referrals are above plan by 80 referrals during June 2014.

GP Referrals into Family Division during June 2014 are above plan by 50 referrals.

Metric 5.0 Other Referrals

Other Referrals received into Adult Acute Division during June 2014 is below plan by 96 referrals.

Elective Division Other Referrals are above plan by 19 referrals during June 2014.

Other Referrals into Family Division during June 2014 are above plan by 108 referrals.


Metric 7.0 Sickness

The sickness rate during June 2014 is 4.8%. This is the lowest sickness rate reported in Community Year to Date.

Metric 11.0 Complaints

During June 2014 a total of 2 complaints were received. 1 in District Nursing ACM and 1 in Rheumatology Therapy. A total of 10

complaints have been received in Community so far during 2014/15.

Metric 13.0 Pressure Ulcers

A total of 7 Pressure Ulcers were reported in Community during June 2014. 1 of the cases was a Grade 4. All were reported under

the Service District Nursing Domiciliary.

Metric 13.0 Patient Falls

During June 2014 a total of 12 falls were reported in Community. 8 of the falls were reported within the Service IMCR (Intermediate

Care Residential). A total of 33 falls have been reported so far for the financial year 2014/15, 23 belonging to IMCR. A plan is still

to be agreed.


Indicator Data Provider Definition Source Description

1.0 Attendances Lorenzo/LE2 Number of new and followup attendances for clinics/Contacts/Groups SYS122

Count of new and followup clinic attendances + contacts attended + total number of patients

attending groups

2.0 DNAs Lorenzo/LE2 Number of new and followup appointments where patient Did Not Attend SYS122 Count of new and followup clinic DNAs + contacts DNAs

3.0 DNA Rate % Lorenzo/LE2

% of new and followup attendances that DNA their appointment for

clinics/contacts SYS122 Indicator 2.0/(1.0 + 2.0)

3.0 GP Referrals Lorenzo/LE2 Number of GP Referrals received including Choose and Book SYS122

Count of referrals with a received date within the relevant month, received from sources

relating to GP inc. C&B

5.0 Other Referrals Lorenzo/LE2 Number of Other Referrals received SYS122

Count of referrals with a received date within the relevant month, received from sources other

than GP

11.0 Complaints Patient Experience Total no. of complaints received to the Trust DoPSE Total no. of complaints received to the Trust

12.0 Waiting times over 12 Weeks Services manual collection Number of patients waiting over 12 weeks as at month end Service Leads

Patients waiting to be seen with or without a date at the end of the month. Recalculated for

DNAs and pt cancellations.

Service Data Source

The Parallel Blythe Lillie

New Born Hearing

Received via email from Valerie

Walmsley, Manager New Born

hearing Screening Team

Anti-Coag

Received via email from

Michelle Grundy Anticoagulant

service manager / specialist

Emergency Dental

Received via email from

Claudine Pimberly IT Manager

for the OOH / EDS Admin

Family Planning Blythe Lillie

GUM Blythe Lillie

IMCD

Lorenzo/Joyce Tadeusiak /

Intermediate Care at Home

Teams

Smoking Cessation

Bolton Smoking Database BSSCS

- Bolton Stop Smoking Service

Cessation

The plans for the following services are school term time affected. Their plans are based on actual month on month out-turn of the previous Financial Year.

All other plans are based on the previous Financial Year out-turn divided by 12.

School term time affected services:-

Childrens Dietetics Paediatrics

Childrens Learning Disabilities School Nursing

Paediatric Occupational Therapy School Nursing Immunisations

Paediatric Physiotherapy Special School Nursing

Paediatric Respiratory The Parallel

Paediatric Speech Therapy Looked After Children (LAC)

Definitions and Sources - Community Dashboard - Services from Lorenzo/LE2

Manual Metrics - These are services not currently recorded on Lorenzo, the sources are shown below

Plans

Community Dashboard 2014_15 Definitions and Sources


Category Type

Actual

13/14 Target 14/15 YTD Monthly Target Apr-14 May-14 Jun-14 Jul-14 Aug-14 Sep-14 Oct-14 Nov-14 Dec-14 Jan-15 Feb-15 Mar-15

Activity 1.0 Attendances 54993 54993 13418 4583 4622 4477 4319

2.0 DNAs 3527 3527 829 294 299 276 254

3.0 DNA Rate % 6.0% 6.0% 5.8% 6.0% 6.1% 5.8% 5.6%

Referrals4.0 Total Referrals 1023 1023 222 85 60 94 68

Workforce6.0 Staff Turnover Awaiting 10.00% 10.00%

7.0 Staff Sickness 2.09% 3.75% 1.4% 3.75% 1.14% 2.42% 0.57%

8.0 Staff Temperature Check Awaiting 3.68 3.68

9.0 Staff Appraisals Awaiting 80% 80%

Patient Experience11.0 Number of Complaints received 0 0 0 0 0 0 0

Adult Acute Division - Anti-Coag Community Dashboard 2014_15

Improving Patient Care in the Community

Actual

13_144663 4742 4350 4916 4638 4366 4861 4382 4565 5124 4186 4200

Actual

14_154622 4477 4319

Target

14_154583 4583 4583 4583 4583 4583 4583 4583 4583 4583 4583 4583

0

1,000

2,000

3,000

4,000

5,000

6,000

1.0 Attendances

Actual

13_14312 271 273 333 348 285 321 299 274 319 244 248

Actual

14_15299 276 254

Target

14_15293 293 293 293 293 293 293 293 293 293 293 293

0

50

100

150

200

250

300

350

400

2.0 DNAs

Actual

13_1483 91 78 100 84 91 84 87 90 97 55 83

Actual

14_1560 94 68

Target

14_150 0 0 0 0 0 0 0 0 0 0 0

0

20

40

60

80

100

120

4.0 Total Referrals

Actual

13_14

Actual

14_15

Target

14_1510.0% 10.0% 10.0% 10.0% 10.0% 10.0% 10.0% 10.0% 10.0% 10.0% 10.0% 10.0%

0.0%

2.0%

4.0%

6.0%

8.0%

10.0%

12.0%

6.0 Staff Turn-Over

Actual

13_140.00% 0.00% 0.00% 0.87% 3.77% 9.30% 9.00% 1.82% 0.00% 0.00% 0.00% 0.28%

Actual

14_151.14% 2.42% 0.57%

Target

14_153.75% 3.75% 3.75% 3.75% 3.75% 3.75% 3.75% 3.75% 3.75% 3.75% 3.75% 3.75%

0.0%

1.0%

2.0%

3.0%

4.0%

5.0%

6.0%

7.0%

8.0%

9.0%

10.0%

7.0 Staff Sickness


Category Type

Actual



2.0 DNAs 231 231 45 19 12 13 20

3.0 DNA Rate % 8.5% 8.5% 8.5% 8.5% 7.3% 8.0% 9.8%

Referrals4.0 GP 1152 1152 258 96 95 94 69

5.0 Other 644 644 174 54 54 61 59


7.0 Staff Sickness 13.40% 3.75% 15.2% 3.75% 33.07% 12.48% 0.00%




Waiting Times12.0 % waiting over 12 Weeks 6.79% 10.00% 19.9% 10.00% 11.11% 15.38% 33.33%

Numbers of staff in Service actively seeing patients =

Monthly Caseload per member of staff based on Attendances in clinics/contacts/groups

Adult Acute Division - Bladder and Bowel Community Dashboard 2014_15


Actual13_14

280 324 253 194 199 253 172 222 186 142 134 113

Actual14_15

153 150 184

Target14_15

206 206 206 206 206 206 206 206 206 206 206 206

0

50

100

150

200

250

300

350

1.0 Attendances

Actual13_14

40 12 25 16 14 21 17 16 15 18 15 22

Actual14_15

12 13 20

Target14_15

19 19 19 19 19 19 19 19 19 19 19 19

0

5

10

15

20

25

30

35

40

45

2.0 DNAs

Actual13_14

82 74 99 104 107 104 131 151 65 84 71 80

Actual14_15

95 94 69

Target14_15

96 96 96 96 96 96 96 96 96 96 96 96

0

20

40

60

80

100

120

140

160

4.0 GP Referrals

Actual13_14

Actual14_15

Target14_15

10.0% 10.0% 10.0% 10.0% 10.0% 10.0% 10.0% 10.0% 10.0% 10.0% 10.0% 10.0%

0.0%

2.0%

4.0%

6.0%

8.0%

10.0%

12.0%

6.0 Staff Turn-Over

Actual13_14

0.00% 0.00% 0.00% 8.36% 16.02% 20.76% 24.26% 12.08% 15.76% 18.45% 11.84% 33.31%

Actual14_15

33.07% 12.48% 0.00%

Target14_15

3.75% 3.75% 3.75% 3.75% 3.75% 3.75% 3.75% 3.75% 3.75% 3.75% 3.75% 3.75%

0.0%

5.0%

10.0%

15.0%

20.0%

25.0%

30.0%

35.0%

7.0 Staff Sickness

Actual13_14

0.0% 0.0% 0.0% 0.0% 0.0% 0.0% 0.0% 0.0% 0.0% 42.9% 28.6% 10.0%

Actual14_15

11.1% 15.4% 33.3%

Target14_15

10.0% 10.0% 10.0% 10.0% 10.0% 10.0% 10.0% 10.0% 10.0% 10.0% 10.0% 10.0%

0.0%

5.0%

10.0%

15.0%

20.0%

25.0%

30.0%

35.0%

40.0%

45.0%

12.0 % of Patients waiting over 12 weeks


Category Type

Actual



2.0 DNAs 420 420 159 35 44 65 50

3.0 DNA Rate % 11.2% 11.2% 15.0% 11.2% 16.2% 14.9% 14.2%

Referrals4.0 GP 2051 2051 437 171 131 147 159

5.0 Other 123 123 33 10 11 9 13


7.0 Staff Sickness 8.59% 3.75% 7.7% 3.75% 15.41% 6.55% 1.27%




Adult Acute Division - Dermatology Community Dashboard 2014_15


Actual13_14

301 299 231 311 287 327 342 146 272 317 240 251

Actual14_15

227 371 302

Target14_15

277 277 277 277 277 277 277 277 277 277 277 277

0

50

100

150

200

250

300

350

400

1.0 Attendances

Actual13_14

32 38 27 39 37 36 28 24 33 36 37 53

Actual14_15

44 65 50

Target14_15

35 35 35 35 35 35 35 35 35 35 35 35

0

10

20

30

40

50

60

70

2.0 DNAs

Actual13_14

177 178 193 198 172 187 196 129 141 188 168 124

Actual14_15

131 147 159

Target14_15

171 171 171 171 171 171 171 171 171 171 171 171

0

50

100

150

200

250

4.0 GP Referrals

Actual13_14

Actual14_15

Target14_15

10.0% 10.0% 10.0% 10.0% 10.0% 10.0% 10.0% 10.0% 10.0% 10.0% 10.0% 10.0%

0.0%

2.0%

4.0%

6.0%

8.0%

10.0%

12.0%

6.0 Staff Turn-Over

Actual13_14

6.37% 4.09% 2.60% 3.52% 0.00% 2.47% 6.37% 9.86% 13.39% 20.20% 14.71% 19.54%

Actual14_15

15.41% 6.55% 1.27%

Target14_15

3.75% 3.75% 3.75% 3.75% 3.75% 3.75% 3.75% 3.75% 3.75% 3.75% 3.75% 3.75%

0.0%

5.0%

10.0%

15.0%

20.0%

25.0%

7.0 Staff Sickness


Category Type

Actual



2.0 DNAs 97 97 36 8 8 15 13

3.0 DNA Rate % 8.4% 8.4% 11.1% 8.4% 10.0% 11.5% 11.5%

Referrals4.0 GP 0 0 272 0 112 66 94

5.0 Other 236 236 93 20 26 36 31


7.0 Staff Sickness Awaiting 3.75% 3.75%




Adult Acute Division - Dermatology Surgery Community Dashboard 2014_15


Actual13_14

57 107 99 104 71 107 121 95 76 93 73 49

Actual14_15

72 116 100

Target14_15

88 88 88 88 88 88 88 88 88 88 88 88

0

20

40

60

80

100

120

140

1.0 Attendances

Actual13_14

6 7 5 9 9 8 12 8 7 9 11 6

Actual14_15

8 15 13

Target14_15

8 8 8 8 8 8 8 8 8 8 8 8

0

2

4

6

8

10

12

14

16

2.0 DNAs

Actual13_14

0 0 0 0 0 0 0 0 0 0 0 0

Actual14_15

112 66 94

Target14_15

0 0 0 0 0 0 0 0 0 0 0 0

0

20

40

60

80

100

120

4.0 GP Referrals

Actual13_14

Actual14_15

Target14_15

10.0% 10.0% 10.0% 10.0% 10.0% 10.0% 10.0% 10.0% 10.0% 10.0% 10.0% 10.0%

0.0%

2.0%

4.0%

6.0%

8.0%

10.0%

12.0%

6.0 Staff Turn-Over

Actual13_14

Actual14_15

Target14_15

3.75% 3.75% 3.75% 3.75% 3.75% 3.75% 3.75% 3.75% 3.75% 3.75% 3.75% 3.75%

0.0%

0.5%

1.0%

1.5%

2.0%

2.5%

3.0%

3.5%

4.0%

7.0 Staff Sickness


Category Type

Actual



2.0 DNAs 1660 1660 364 138 117 136 111

3.0 DNA Rate % 9.2% 9.2% 9.8% 9.2% 9.3% 11.7% 8.7%

Referrals4.0 GP 2497 2497 513 208 153 178 182

5.0 Other 530 530 16 44 13 0 3


7.0 Staff Sickness 1.82% 3.75% 6.3% 3.75% 7.22% 5.93% 5.85%




Adult Acute Division - Diabetes Community Dashboard 2014_15


Actual13_14

1573 1441 1474 1670 1299 1382 1511 1394 1012 1300 1135 1206

Actual14_15

1144 1027 1161

Target14_15

1367 1367 1367 1367 1367 1367 1367 1367 1367 1367 1367 1367

0

200

400

600

800

1,000

1,200

1,400

1,600

1,800

1.0 Attendances

Actual13_14

180 135 148 171 137 136 153 146 96 128 121 109

Actual14_15

117 136 111

Target14_15

138 138 138 138 138 138 138 138 138 138 138 138

0

20

40

60

80

100

120

140

160

180

200

2.0 DNAs

Actual13_14

153 234 209 289 249 216 224 145 196 165 194 223

Actual14_15

153 178 182

Target14_15

208 208 208 208 208 208 208 208 208 208 208 208

0

50

100

150

200

250

300

350

4.0 GP Referrals

Actual13_14

Actual14_15

Target14_15

10.0% 10.0% 10.0% 10.0% 10.0% 10.0% 10.0% 10.0% 10.0% 10.0% 10.0% 10.0%

0.0%

2.0%

4.0%

6.0%

8.0%

10.0%

12.0%

6.0 Staff Turn-Over

Actual13_14

0.00% 0.00% 0.00% 0.00% 0.00% 0.00% 2.48% 2.76% 0.00% 3.90% 5.68% 6.96%

Actual14_15

7.22% 5.93% 5.85%

Target14_15

3.75% 3.75% 3.75% 3.75% 3.75% 3.75% 3.75% 3.75% 3.75% 3.75% 3.75% 3.75%

0.0%

1.0%

2.0%

3.0%

4.0%

5.0%

6.0%

7.0%

8.0%

7.0 Staff Sickness


Category Type

Actual



2.0 DNAs 728 728 163 61 58 55 50

3.0 DNA Rate % 7.0% 7.0% 6.8% 7.0% 7.6% 6.8% 5.9%

Referrals4.0 GP 731 731 150 61 52 37 61

5.0 Other 1178 1178 277 98 94 100 83


7.0 Staff Sickness 4.75% 3.75% 6.6% 3.75% 5.41% 5.17% 9.10%





Adult Acute Division - Neuro LTC Community Dashboard 2014_15


Actual attendances 13_14 479 529 583 663 556 601 610 650 603 659 635 614

Actual attendances 14_15 624 584 631

0

100

200

300

400

500

600

700

1.0 Attendances

Actual_13_14 14 14 20 14 12 24 17 11 11 11 14 16

Actual 14_15 12 4 13

Target_14_15

0

5

10

15

20

25

30

2.0 DNAs

Actual13_14

32 34 38 35 27 38 41 34 32 52 60 34

Actual14_15

37 41 43

Target14_15

0

10

20

30

40

50

60

70

4.0 GP Referrals

Actual13_14

Actual14_15

Target14_15

0.0%

0.0%

10.0%

20.0%

30.0%

40.0%

50.0%

60.0%

70.0%

80.0%

90.0%

100.0%

6.0 Staff Turn-Over

Actual13_14

2.65% 4.39% 5.64% 2.36% 0.00% 0.17% 0.00% 2.31% 3.97% 0.30% 0.00% 0.00%

Actual14_15

0.00% 0.00% 0.00%

Target14_15

0.0%

1.0%

2.0%

3.0%

4.0%

5.0%

6.0%

7.0 Staff Sickness

Actual13_14

3.3% 0.0% 21.5% 0.0% 0.0% 0.0% 0.0% 0.0% 0.0% 0.0% 2.9% 0.0%

Actual14_15

0.0% 0.0% 6.8%

Target14_15

0.0%

5.0%

10.0%

15.0%

20.0%

25.0%


Actual13_14

939 819 798 861 742 763 949 801 572 888 785 779

Actual14_15

710 750 791

Target14_15

809 808 809 808 809 808 809 809 809 808 809 808

0

100

200

300

400

500

600

700

800

900

1,000

1.0 Attendances

Actual13_14

60 65 73 63 53 51 72 64 48 73 57 49

Actual14_15

58 55 50

Target14_15

61 61 61 61 61 61 61 61 61 61 61 61

0

10

20

30

40

50

60

70

80

2.0 DNAs

Actual13_14

67 65 74 65 47 67 49 70 44 59 48 76

Actual14_15

52 37 61

Target14_15

61 61 61 61 61 61 61 61 61 61 61 61

0

10

20

30

40

50

60

70

80

4.0 GP Referrals

Actual13_14

Actual14_15

Target14_15

10.0% 10.0% 10.0% 10.0% 10.0% 10.0% 10.0% 10.0% 10.0% 10.0% 10.0% 10.0%

0.0%

2.0%

4.0%

6.0%

8.0%

10.0%

12.0%

6.0 Staff Turn-Over

Actual13_14

4.01% 4.88% 7.07% 8.11% 0.53% 0.48% 6.08% 9.43% 5.32% 3.80% 3.01% 4.32%

Actual14_15

5.41% 5.17% 9.10%

Target14_15

3.75% 3.75% 3.75% 3.75% 3.75% 3.75% 3.75% 3.75% 3.75% 3.75% 3.75% 3.75%

0.0%

1.0%

2.0%

3.0%

4.0%

5.0%

6.0%

7.0%

8.0%

9.0%

10.0%

7.0 Staff Sickness

Actual13_14

10.6% 17.4% 28.3% 32.0% 40.8% 45.6% 40.1% 44.6% 53.2% 44.0% 44.5% 25.2%

Actual14_15

20.1% 18.9% 18.7%

Target14_15

10.0% 10.0% 10.0% 10.0% 10.0% 10.0% 10.0% 10.0% 10.0% 10.0% 10.0% 10.0%

0.0%

10.0%

20.0%

30.0%

40.0%

50.0%

60.0%



Category Type

Actual



2.0 DNAs 36 36 5 3 2 2 1

3.0 DNA Rate % 0.7% 0.7% 0.5% 0.7% 0.5% 0.6% 0.3%

Referrals4.0 GP 42 42 17 4 6 7 4

5.0 Other 369 369 93 31 34 34 25


7.0 Staff Sickness 4.08% 3.75% 1.5% 3.75% 0.00% 0.27% 4.30%




Waiting Times12.0 % waiting over 12 Weeks 0.00% 10.00% 10.00% 0.00% 0.00% 0.00%

Adult Acute Division - Stroke Team Community Dashboard 2014_15




0

100

200

300

400

500

600

700

1.0 Attendances

Actual_13_14 14 14 20 14 12 24 17 11 11 11 14 16

Actual 14_15 12 4 13

Target_14_15

0

5

10

15

20

25

30

2.0 DNAs

Actual13_14

32 34 38 35 27 38 41 34 32 52 60 34

Actual14_15

37 41 43

Target14_15

0

10

20

30

40

50

60

70

4.0 GP Referrals

Actual13_14

Actual14_15

Target14_15

0.0%

0.0%

10.0%

20.0%

30.0%

40.0%

50.0%

60.0%

70.0%

80.0%

90.0%

100.0%

6.0 Staff Turn-Over

Actual13_14

2.65% 4.39% 5.64% 2.36% 0.00% 0.17% 0.00% 2.31% 3.97% 0.30% 0.00% 0.00%

Actual14_15

0.00% 0.00% 0.00%

Target14_15

0.0%

1.0%

2.0%

3.0%

4.0%

5.0%

6.0%

7.0 Staff Sickness

Actual13_14

3.3% 0.0% 21.5% 0.0% 0.0% 0.0% 0.0% 0.0% 0.0% 0.0% 2.9% 0.0%

Actual14_15

0.0% 0.0% 6.8%

Target14_15

0.0%

5.0%

10.0%

15.0%

20.0%

25.0%


Actual13_14

505 486 402 491 466 411 490 415 312 396 312 292

Actual14_15

373 346 354

Target14_15

417 417 417 417 417 417 417 417 417 417 417 417

0

100

200

300

400

500

600

1.0 Attendances

Actual13_14

5 3 2 1 4 1 7 4 1 4 1 3

Actual14_15

2 2 1

Target14_15

3 3 3 3 3 3 3 3 3 3 3 3

0

1

2

3

4

5

6

7

8

2.0 DNAs

Actual13_14

1 4 3 5 8 3 3 5 2 2 1 5

Actual14_15

6 7 4

Target14_15

4 4 4 4 4 4 4 4 4 4 4 4

0

1

2

3

4

5

6

7

8

9

4.0 GP Referrals

Actual13_14

Actual14_15

Target14_15

10.0% 10.0% 10.0% 10.0% 10.0% 10.0% 10.0% 10.0% 10.0% 10.0% 10.0% 10.0%

0.0%

2.0%

4.0%

6.0%

8.0%

10.0%

12.0%

6.0 Staff Turn-Over

Actual13_14

0.98% 0.00% 3.43% 10.08% 1.22% 12.39% 1.34% 1.39% 1.20% 5.30% 6.61% 4.98%

Actual14_15

0.00% 0.27% 4.30%

Target14_15

3.75% 3.75% 3.75% 3.75% 3.75% 3.75% 3.75% 3.75% 3.75% 3.75% 3.75% 3.75%

0.0%

2.0%

4.0%

6.0%

8.0%

10.0%

12.0%

14.0%

7.0 Staff Sickness

Actual13_14

0.0% 0.0% 0.0% 0.0% 0.0% 0.0% 0.0% 0.0% 0.0% 0.0% 0.0% 0.0%

Actual14_15

0.0% 0.0% 0.0%

Target14_15

10.0% 10.0% 10.0% 10.0% 10.0% 10.0% 10.0% 10.0% 10.0% 10.0% 10.0% 10.0%

0.0%

2.0%

4.0%

6.0%

8.0%

10.0%

12.0%



Category Type

Actual



2.0 DNAs 908 908 284 76 82 105 97

3.0 DNA Rate % 10.4% 10.4% 13.1% 10.4% 12.3% 15.4% 12.0%

Referrals4.0 GP 1526 1526 401 127 110 145 146

5.0 Other 235 235 45 20 15 14 16


7.0 Staff Sickness 5.6% 3.8% 0.3% 3.8% 0.9% 0.0% 0.0%


9.0 Staff Appraisals Awaiting 80.0% 80.0%



* Referrals are assigned to a specialty of Rheumatology in LE2, we are not able to break down into Department or Therapy. All referrals are assigned to Rheum Department on this report.

* Waiting times as above.

Elective Division - Rheumatology Department Community Dashboard 2014_15


Actual13_14

668 718 747 733 551 552 692 712 598 649 594 585

Actual14_15

587 577 714

Target14_15

650 650 650 650 650 650 650 650 650 650 650 650

0

100

200

300

400

500

600

700

800

1.0 Attendances

Actual13_14

59 60 67 67 54 55 94 99 110 85 82 76

Actual14_15

82 105 97

Target14_15

76 76 76 76 76 76 76 76 76 76 76 76

0

20

40

60

80

100

120

2.0 DNAs

Actual13_14

142 136 142 148 126 128 130 112 95 135 113 119

Actual14_15

110 145 146

Target14_15

128 128 128 128 128 128 128 128 128 128 128 128

0

20

40

60

80

100

120

140

160

4.0 GP Referrals

Actual13_14

Actual14_15

Target14_15

10.0% 10.0% 10.0% 10.0% 10.0% 10.0% 10.0% 10.0% 10.0% 10.0% 10.0% 10.0%

0.0%

2.0%

4.0%

6.0%

8.0%

10.0%

12.0%

6.0 Staff Turn-Over

Actual13_14

1.56% 0.15% 4.91% 6.29% 16.87% 10.99% 2.94% 4.77% 5.34% 2.80% 4.58% 5.71%

Actual14_15

0.91% 0.00% 0.00%

Target14_15

3.75% 3.75% 3.75% 3.75% 3.75% 3.75% 3.75% 3.75% 3.75% 3.75% 3.75% 3.75%

0.0%

2.0%

4.0%

6.0%

8.0%

10.0%

12.0%

14.0%

16.0%

18.0%

7.0 Staff Sickness

Actual13_14

3.6% 5.6% 7.5% 11.7% 14.5% 17.1% 13.9% 12.6% 15.8% 13.3% 26.2% 13.4%

Actual14_15

13.8% 7.9% 10.7%

Target14_15

10.0% 10.0% 10.0% 10.0% 10.0% 10.0% 10.0% 10.0% 10.0% 10.0% 10.0% 10.0%

0.0%

5.0%

10.0%

15.0%

20.0%

25.0%

30.0%



Category Type

Actual



2.0 DNAs 911 911 210 76 84 59 67

3.0 DNA Rate % 19.6% 19.6% 19.0% 19.6% 20.9% 17.8% 17.9%






* Referrals are assigned to a specialty of Rheumatology in LE2, we are not able to break down into Department or Therapy. All referrals are assigned to Rheum Department on this report.

* Waiting times as above.

Elective Division - Rheumatology Therapy Community Dashboard 2014_15


Actual

13_14362 348 320 324 295 355 358 306 205 299 292 279

Actual14_15

317 272 307

Target

14_15312 312 312 312 312 312 312 312 312 312 312 312

0

50

100

150

200

250

300

350

400

1.0 Attendances

Actual

13_1461 56 79 84 85 75 90 106 79 62 59 75

Actual

14_1584 59 67

Target

14_1575 75 75 75 75 75 75 75 75 75 75 75

0

20

40

60

80

100

120

2.0 DNAs

Actual

13_14

Actual

14_15

Target14_15

10.0% 10.0% 10.0% 10.0% 10.0% 10.0% 10.0% 10.0% 10.0% 10.0% 10.0% 10.0%

0.0%

2.0%

4.0%

6.0%

8.0%

10.0%

12.0%

6.0 Staff Turn-Over

Actual13_14

Actual

14_15

Target

14_153.75% 3.75% 3.75% 3.75% 3.75% 3.75% 3.75% 3.75% 3.75% 3.75% 3.75% 3.75%

0.0%

0.5%

1.0%

1.5%

2.0%

2.5%

3.0%

3.5%

4.0%

7.0 Staff Sickness


Category Type

Actual



2.0 DNAs 155 155 25 13 9 7 9

3.0 DNA Rate % 7.9% 7.9% 6.1% 7.9% 6.3% 5.8% 6.1%

Referrals4.0 GP 402 402 105 34 37 28 40

5.0 Other 516 516 164 43 44 64 56


7.0 Staff Sickness 4.5% 3.8% 10.5% 3.8% 10.9% 10.8% 9.8%





Elective Division -Wheelchairs Community Dashboard 2014_15


Actual13_14

155 157 159 185 129 176 150 142 138 142 135 127

Actual14_15

135 113 138

Target14_15

150 150 150 150 150 150 150 150 150 150 150 150

0

20

40

60

80

100

120

140

160

180

200

1.0 Attendances

Actual13_14

4 8 17 23 13 15 18 10 16 9 13 9

Actual14_15

9 7 9

Target14_15

12 12 12 12 12 12 12 12 12 12 12 12

0

5

10

15

20

25

2.0 DNAs

Actual13_14

37 43 33 53 31 33 42 30 24 15 21 40

Actual14_15

37 28 40

Target14_15

34 34 34 34 34 34 34 34 34 34 34 34

0

10

20

30

40

50

60

4.0 GP Referrals

Actual13_14

Actual14_15

Target14_15

10.0% 10.0% 10.0% 10.0% 10.0% 10.0% 10.0% 10.0% 10.0% 10.0% 10.0% 10.0%

0.0%

2.0%

4.0%

6.0%

8.0%

10.0%

12.0%

6.0 Staff Turn-Over

Actual13_14

4.08% 10.10% 14.36% 13.90% 0.45% 0.00% 2.03% 0.52% 0.51% 5.57% 0.00% 2.47%

Actual14_15

10.93% 10.76% 9.83%

Target14_15

3.75% 3.75% 3.75% 3.75% 3.75% 3.75% 3.75% 3.75% 3.75% 3.75% 3.75% 3.75%

0.0%

2.0%

4.0%

6.0%

8.0%

10.0%

12.0%

14.0%

16.0%

7.0 Staff Sickness

Actual13_14

0.0% 0.0% 0.0% 0.0% 0.0% 0.0% 0.0% 0.0% 0.0% 0.0% 6.6% 2.9%

Actual14_15

0.0% 1.3% 4.9%

Target14_15

10.0% 10.0% 10.0% 10.0% 10.0% 10.0% 10.0% 10.0% 10.0% 10.0% 10.0% 10.0%

0.0%

2.0%

4.0%

6.0%

8.0%

10.0%

12.0%



Category Type

Actual



2.0 DNAs 225 225 52 19 19 20 13

3.0 DNA Rate % 7.5% 7.5% 9.0% 7.5% 9.2% 11.5% 6.6%

Referrals4.0 GP 343 343 79 29 22 20 37

5.0 Other 0 0 0 0 0 0 0


7.0 Staff Sickness 3.00% 3.75% 0.6% 3.75% 0.00% 1.75% 0.00%





Adult Acute Division - Dietetics Specialist Weight Management Community Dashboard 2014_15


Actual13_14

283 195 305 258 195 244 236 233 179 251 217 185

Actual14_15

188 154 183

Target14_15

232 232 232 232 232 232 232 232 232 232 232 232

0

50

100

150

200

250

300

350

1.0 Attendances

Actual13_14

9 11 11 18 22 31 14 24 26 22 25 12

Actual14_15

19 20 13

Target14_15

19 19 19 19 19 19 19 19 19 19 19 19

0

5

10

15

20

25

30

35

2.0 DNAs

Actual13_14

46 26 29 32 30 30 24 21 17 29 23 36

Actual14_15

22 20 37

Target14_15

29 29 29 29 29 29 29 29 29 29 29 29

0

5

10

15

20

25

30

35

40

45

50

4.0 GP Referrals

Actual13_14

Actual14_15

Target14_15

10.0% 10.0% 10.0% 10.0% 10.0% 10.0% 10.0% 10.0% 10.0% 10.0% 10.0% 10.0%

0.0%

2.0%

4.0%

6.0%

8.0%

10.0%

12.0%

6.0 Staff Turn-Over

Actual13_14

0.00% 9.37% 9.40% 1.91% 0.00% 0.00% 6.45% 4.07% 4.78% 0.00% 0.00% 0.00%

Actual14_15

0.00% 1.75% 0.00%

Target14_15

3.75% 3.75% 3.75% 3.75% 3.75% 3.75% 3.75% 3.75% 3.75% 3.75% 3.75% 3.75%

0.0%

1.0%

2.0%

3.0%

4.0%

5.0%

6.0%

7.0%

8.0%

9.0%

10.0%

7.0 Staff Sickness

Actual13_14

7.5% 1.7% 77.8% 74.3% 61.5% 68.8% 81.3% 29.5% 64.5% 16.7% 18.8% 51.9%

Actual14_15

63.3% 53.8% 45.2%

Target14_15

10.0% 10.0% 10.0% 10.0% 10.0% 10.0% 10.0% 10.0% 10.0% 10.0% 10.0% 10.0%

0.0%

10.0%

20.0%

30.0%

40.0%

50.0%

60.0%

70.0%

80.0%

90.0%



Category Type

Actual



2.0 DNAs 178 178 29 15 12 4 13

3.0 DNA Rate % 2.4% 2.4% 1.6% 2.4% 1.9% 0.7% 2.0%

Referrals4.0 GP 457 457 121 38 37 41 43

5.0 Other 1653 1653 441 138 132 150 159


7.0 Staff Sickness 1.82% 3.75% 3.75% 0.00% 0.00% 0.00%





Adult Acute Division - Adult Speech and Language Community Dashboard 2014_15


Actual13_14

479 529 583 663 556 601 610 650 603 659 635 614

Actual14_15

624 584 631

Target14_15

598 598 598 598 598 598 598 598 598 598 598 598

0

100

200

300

400

500

600

700

1.0 Attendances

Actual13_14

14 14 20 14 12 24 17 11 11 11 14 16

Actual14_15

12 4 13

Target14_15

14 14 14 14 14 14 14 14 14 14 14 14

0

5

10

15

20

25

30

2.0 DNAs

Actual13_14

32 34 38 35 27 38 41 34 32 52 60 34

Actual14_15

37 41 43

Target14_15

38 38 38 38 38 38 38 38 38 38 38 38

0

10

20

30

40

50

60

70

4.0 GP Referrals

Actual13_14

Actual14_15

Target14_15

10.0% 10.0% 10.0% 10.0% 10.0% 10.0% 10.0% 10.0% 10.0% 10.0% 10.0% 10.0%

0.0%

2.0%

4.0%

6.0%

8.0%

10.0%

12.0%

6.0 Staff Turn-Over

Actual13_14

2.65% 4.39% 5.64% 2.36% 0.00% 0.17% 0.00% 2.31% 3.97% 0.30% 0.00% 0.00%

Actual14_15

0.00% 0.00% 0.00%

Target14_15

3.75% 3.75% 3.75% 3.75% 3.75% 3.75% 3.75% 3.75% 3.75% 3.75% 3.75% 3.75%

0.0%

1.0%

2.0%

3.0%

4.0%

5.0%

6.0%

7.0 Staff Sickness

Actual13_14

3.3% 0.0% 21.5% 0.0% 0.0% 0.0% 0.0% 0.0% 0.0% 0.0% 2.9% 0.0%

Actual14_15

0.0% 0.0% 6.8%

Target14_15

10.0% 10.0% 10.0% 10.0% 10.0% 10.0% 10.0% 10.0% 10.0% 10.0% 10.0% 10.0%

0.0%

5.0%

10.0%

15.0%

20.0%

25.0%



Category Type

Actual



2.0 DNAs 227 227 67 19 20 21 26

3.0 DNA Rate % 7.6% 7.6% 9.8% 7.6% 8.8% 9.1% 11.3%

Referrals4.0 GP 478 478 112 40 48 28 36

5.0 Other 98 98 22 8 9 7 6


7.0 Staff Sickness 3.88% 3.75% 3.7% 3.75% 8.87% 2.28% 0.00%





Adult Acute Division - Dietetic Adults Community Dashboard 2014_15


Actual13_14

293 219 247 301 232 170 262 280 182 207 217 162

Actual14_15

206 209 205

Target14_15

231 231 231 231 231 231 231 231 231 231 231 231

0

50

100

150

200

250

300

350

1.0 Attendances

Actual13_14

15 31 20 26 30 18 26 15 11 11 12 12

Actual14_15

20 21 26

Target14_15

19 19 19 19 19 19 19 19 19 19 19 19

0

5

10

15

20

25

30

35

2.0 DNAs

Actual13_14

58 32 39 38 42 44 38 33 28 55 31 40

Actual14_15

48 28 36

Target14_15

40 40 40 40 40 40 40 40 40 40 40 40

0

10

20

30

40

50

60

70

4.0 GP Referrals

Actual13_14

Actual14_15

Target14_15

10.0% 10.0% 10.0% 10.0% 10.0% 10.0% 10.0% 10.0% 10.0% 10.0% 10.0% 10.0%

0.0%

2.0%

4.0%

6.0%

8.0%

10.0%

12.0%

6.0 Staff Turn-Over

Actual13_14

0.22% 0.00% 0.00% 0.00% 7.84% 9.45% 2.64% 2.14% 3.87% 2.76% 8.68% 8.94%

Actual14_15

8.87% 2.28% 0.00%

Target14_15

3.75% 3.75% 3.75% 3.75% 3.75% 3.75% 3.75% 3.75% 3.75% 3.75% 3.75% 3.75%

0.0%

1.0%

2.0%

3.0%

4.0%

5.0%

6.0%

7.0%

8.0%

9.0%

10.0%

7.0 Staff Sickness

Actual13_14

0.0% 0.0% 0.0% 5.0% 7.3% 3.3% 0.0% 0.0% 0.0% 0.0% 0.0% 0.0%

Actual14_15

0.0% 0.0% 0.0%

Target14_15

10.0% 10.0% 10.0% 10.0% 10.0% 10.0% 10.0% 10.0% 10.0% 10.0% 10.0% 10.0%

0.0%

2.0%

4.0%

6.0%

8.0%

10.0%

12.0%



Category Type

Actual



2.0 DNAs 58 58 22 5 7 6 9

3.0 DNA Rate % 6.0% 6.0% 6.4% 6.0% 6.9% 5.1% 7.1%

Referrals4.0 GP 344 344 104 29 42 23 39

5.0 Other 214 214 43 18 13 17 13


7.0 Staff Sickness 0.20% 3.75% 0.2% 3.75% 0.00% 0.00% 0.73%





Adult Acute Division - Nutritional Support Community Dashboard 2014_15




0

100

200

300

400

500

600

700

1.0 Attendances

Actual_13_14 14 14 20 14 12 24 17 11 11 11 14 16

Actual 14_15 12 4 13

Target_14_15

0

5

10

15

20

25

30

2.0 DNAs

Actual13_14

32 34 38 35 27 38 41 34 32 52 60 34

Actual14_15

37 41 43

Target14_15

0

10

20

30

40

50

60

70

4.0 GP Referrals

Actual13_14

Actual14_15

Target14_15

0.0%

0.0%

10.0%

20.0%

30.0%

40.0%

50.0%

60.0%

70.0%

80.0%

90.0%

100.0%

6.0 Staff Turn-Over

Actual13_14

2.65% 4.39% 5.64% 2.36% 0.00% 0.17% 0.00% 2.31% 3.97% 0.30% 0.00% 0.00%

Actual14_15

0.00% 0.00% 0.00%

Target14_15

0.0%

1.0%

2.0%

3.0%

4.0%

5.0%

6.0%

7.0 Staff Sickness

Actual13_14

3.3% 0.0% 21.5% 0.0% 0.0% 0.0% 0.0% 0.0% 0.0% 0.0% 2.9% 0.0%

Actual14_15

0.0% 0.0% 6.8%

Target14_15

0.0%

5.0%

10.0%

15.0%

20.0%

25.0%


Actual13_14

76 74 125 66 41 70 63 60 67 77 90 106

Actual14_15

95 112 117

Target14_15

77 77 77 77 77 77 77 77 77 77 77 77

0

20

40

60

80

100

120

140

1.0 Attendances

Actual13_14

7 3 6 5 4 4 2 7 1 7 4 8

Actual14_15

7 6 9

Target14_15

5 5 5 5 5 5 5 5 5 5 5 5

0

1

2

3

4

5

6

7

8

9

10

2.0 DNAs

Actual13_14

31 36 26 29 28 27 18 29 24 35 29 32

Actual14_15

42 23 39

Target14_15

29 29 29 29 29 29 29 29 29 29 29 29

0

5

10

15

20

25

30

35

40

45

4.0 GP Referrals

Actual13_14

Actual14_15

Target14_15

10.0% 10.0% 10.0% 10.0% 10.0% 10.0% 10.0% 10.0% 10.0% 10.0% 10.0% 10.0%

0.0%

2.0%

4.0%

6.0%

8.0%

10.0%

12.0%

6.0 Staff Turn-Over

Actual13_14

0.00% 0.00% 0.81% 0.00% 0.00% 0.93% 0.00% 0.00% 0.00% 0.00% 0.00% 0.70%

Actual14_15

0.00% 0.00% 0.73%

Target14_15

3.75% 3.75% 3.75% 3.75% 3.75% 3.75% 3.75% 3.75% 3.75% 3.75% 3.75% 3.75%

0.0%

0.5%

1.0%

1.5%

2.0%

2.5%

3.0%

3.5%

4.0%

7.0 Staff Sickness

Actual13_14

2.9% 16.4% 19.9% 22.6% 39.5% 39.5% 46.0% 42.9% 43.8% 41.9% 31.8% 22.0%

Actual14_15

14.1% 19.6% 18.7%

Target14_15

10.0% 10.0% 10.0% 10.0% 10.0% 10.0% 10.0% 10.0% 10.0% 10.0% 10.0% 10.0%

0.0%

5.0%

10.0%

15.0%

20.0%

25.0%

30.0%

35.0%

40.0%

45.0%

50.0%



Category Type

Actual



2.0 DNAs 590 590 138 49 46 43 49

3.0 DNA Rate % 9.7% 9.7% 10.4% 9.7% 9.3% 10.2% 11.9%

Referrals4.0 GP 2402 2402 658 200 210 227 221

5.0 Other 1814 1814 500 151 161 158 181







Elective Division - Biomechanics Community Dashboard 2014_15


Actual13_14

497 406 404 483 470 565 439 433 403 452 414 504

Actual14_15

448 378 362

Target14_15

455 455 455 455 455 455 455 455 455 455 455 455

0

100

200

300

400

500

600

1.0 Attendances

Actual13_14

48 31 52 69 62 41 47 51 45 47 42 55

Actual14_15

46 43 49

Target14_15

49 49 49 49 49 49 49 49 49 49 49 49

0

10

20

30

40

50

60

70

80

2.0 DNAs

Actual13_14

215 212 193 230 186 230 197 180 152 210 185 212

Actual14_15

210 227 221

Target14_15

200 200 200 200 200 200 200 200 200 200 200 200

0

50

100

150

200

250

4.0 GP Referrals

Actual13_14

Actual14_15

Target14_15

10.0% 10.0% 10.0% 10.0% 10.0% 10.0% 10.0% 10.0% 10.0% 10.0% 10.0% 10.0%

0.0%

2.0%

4.0%

6.0%

8.0%

10.0%

12.0%

6.0 Staff Turn-Over

Actual13_14

Actual14_15

Target14_15

3.75% 3.75% 3.75% 3.75% 3.75% 3.75% 3.75% 3.75% 3.75% 3.75% 3.75% 3.75%

0.0%

0.5%

1.0%

1.5%

2.0%

2.5%

3.0%

3.5%

4.0%

7.0 Staff Sickness

Actual13_14

0.0% 0.0% 0.0% 0.3% 0.7% 0.0% 0.6% 0.8% 0.3% 0.8% 0.5% 0.0%

Actual14_15

2.7% 7.4% 8.7%

Target14_15

10.0% 10.0% 10.0% 10.0% 10.0% 10.0% 10.0% 10.0% 10.0% 10.0% 10.0% 10.0%

0.0%

2.0%

4.0%

6.0%

8.0%

10.0%

12.0%



Category Type

Actual



2.0 DNAs 2538 2538 757 212 262 268 227

3.0 DNA Rate % 4.8% 4.8% 5.4% 4.8% 5.6% 5.7% 4.9%

Referrals4.0 GP 1725 1725 707 144 204 285 218

5.0 Other 2428 2428 565 202 230 135 200


7.0 Staff Sickness 11.5% 3.8% 5.7% 3.8% 6.5% 5.3% 5.4%





Elective Division - Podiatry Community Dashboard 2014_15


Actual13_14

4445 4593 4283 4694 3977 4272 4680 3820 3491 4231 3958 4202

Actual14_15

4381 4393 4381

Target14_15

4220 4220 4220 4220 4220 4220 4220 4220 4220 4220 4220 4220

0

500

1,000

1,500

2,000

2,500

3,000

3,500

4,000

4,500

5,000

1.0 Attendances

Actual13_14

264 213 189 235 176 190 226 200 199 265 174 207

Actual14_15

262 268 227

Target14_15

211 211 211 211 211 211 211 211 211 211 211 211

0

50

100

150

200

250

300

2.0 DNAs

Actual13_14

80 86 89 151 135 102 153 138 172 184 142 293

Actual14_15

204 285 218

Target14_15

143 143 143 143 143 143 143 143 143 143 143 143

0

50

100

150

200

250

300

350

4.0 GP Referrals

Actual13_14

Actual14_15

Target14_15

10.0% 10.0% 10.0% 10.0% 10.0% 10.0% 10.0% 10.0% 10.0% 10.0% 10.0% 10.0%

0.0%

2.0%

4.0%

6.0%

8.0%

10.0%

12.0%

6.0 Staff Turn-Over

Actual13_14

2.05% 1.55% 2.54% 51.00% 39.00% 1.21% 2.60% 7.45% 7.54% 10.66% 8.48% 3.98%

Actual14_15

6.49% 5.27% 5.38%

Target14_15

3.75% 3.75% 3.75% 3.75% 3.75% 3.75% 3.75% 3.75% 3.75% 3.75% 3.75% 3.75%

0.0%

10.0%

20.0%

30.0%

40.0%

50.0%

60.0%

7.0 Staff Sickness

Actual13_14

0.0% 0.0% 0.0% 0.0% 0.0% 0.0% 0.0% 0.0% 0.2% 3.0% 12.1% 6.5%

Actual14_15

2.7% 7.4% 8.7%

Target14_15

10.0% 10.0% 10.0% 10.0% 10.0% 10.0% 10.0% 10.0% 10.0% 10.0% 10.0% 10.0%

0.0%

2.0%

4.0%

6.0%

8.0%

10.0%

12.0%

14.0%



Category Type

Actual



2.0 DNAs 207 207 36 17 15 15 6

3.0 DNA Rate % 11.1% 11.1% 7.6% 11.1% 9.1% 10.3% 3.7%

Referrals4.0 GP 379 379 105 32 34 35 36

5.0 Other 877 877 195 73 71 69 55







Elective Division - MSK Occupational Therapy Community Dashboard 2014_15


Actual13_14

129 94 145 89 104 142 187 132 167 155 139 174

Actual14_15

149 131 158

Target14_15

138 138 138 138 138 138 138 138 138 138 138 138

0

20

40

60

80

100

120

140

160

180

200

1.0 Attendances

Actual13_14

14 19 17 13 13 12 30 18 20 16 18 17

Actual14_15

15 15 6

Target14_15

17 17 17 17 17 17 17 17 17 17 17 17

0

5

10

15

20

25

30

35

2.0 DNAs

Actual13_14

27 31 30 33 36 39 34 30 23 21 29 46

Actual14_15

34 35 36

Target14_15

32 32 32 32 32 32 32 32 32 32 32 32

0

5

10

15

20

25

30

35

40

45

50

4.0 GP Referrals

Actual13_14

Actual14_15

Target14_15

10.0% 10.0% 10.0% 10.0% 10.0% 10.0% 10.0% 10.0% 10.0% 10.0% 10.0% 10.0%

0.0%

2.0%

4.0%

6.0%

8.0%

10.0%

12.0%

6.0 Staff Turn-Over

Actual13_14

Actual14_15

Target14_15

3.75% 3.75% 3.75% 3.75% 3.75% 3.75% 3.75% 3.75% 3.75% 3.75% 3.75% 3.75%

0.0%

0.5%

1.0%

1.5%

2.0%

2.5%

3.0%

3.5%

4.0%

7.0 Staff Sickness

Actual13_14

0.0% 0.0% 0.0% 0.0% 0.0% 0.9% 0.0% 0.0% 0.0% 0.0% 0.0% 0.0%

Actual14_15

0.0% 0.0% 2.7%

Target14_15

10.0% 10.0% 10.0% 10.0% 10.0% 10.0% 10.0% 10.0% 10.0% 10.0% 10.0% 10.0%

0.0%

2.0%

4.0%

6.0%

8.0%

10.0%

12.0%



Category Type

Actual



2.0 DNAs 3781 3781 990 315 372 298 320

3.0 DNA Rate % 11.9% 11.9% 12.6% 11.9% 13.6% 11.9% 12.3%

Referrals4.0 GP 6728 6728 1603 561 579 508 516

5.0 Other 3479 3479 887 290 291 314 282


7.0 Staff Sickness 9.2% 3.8% 8.3% 3.8% 12.2% 6.5% 6.2%





Elective Division - MSK Therapy Community Dashboard 2014_15


Actual13_14

2362 2171 1864 2237 1775 2225 2842 2971 2325 2604 2332 2387

Actual14_15

2362 2216 2287

Target14_15

2341 2341 2341 2341 2341 2341 2341 2341 2341 2341 2341 2341

0

500

1,000

1,500

2,000

2,500

3,000

3,500

1.0 Attendances

Actual13_14

258 283 277 324 293 284 396 424 295 360 292 295

Actual14_15

372 298 320

Target14_15

315 315 315 315 315 315 315 315 315 315 315 315

0

50

100

150

200

250

300

350

400

450

2.0 DNAs

Actual13_14

560 587 504 566 586 527 646 645 430 562 516 599

Actual14_15

579 508 516

Target14_15

560 560 560 560 560 560 560 560 560 560 560 560

0

100

200

300

400

500

600

700

4.0 GP Referrals

Actual13_14

Actual14_15

Target14_15

10.0% 10.0% 10.0% 10.0% 10.0% 10.0% 10.0% 10.0% 10.0% 10.0% 10.0% 10.0%

0.0%

2.0%

4.0%

6.0%

8.0%

10.0%

12.0%

6.0 Staff Turn-Over

Actual13_14

5.44% 4.94% 9.84% 8.96% 8.31% 14.08% 17.88% 10.91% 8.54% 8.63% 7.60% 5.75%

Actual14_15

12.16% 6.52% 6.17%

Target14_15

3.75% 3.75% 3.75% 3.75% 3.75% 3.75% 3.75% 3.75% 3.75% 3.75% 3.75% 3.75%

0.0%

2.0%

4.0%

6.0%

8.0%

10.0%

12.0%

14.0%

16.0%

18.0%

20.0%

7.0 Staff Sickness

Actual13_14

0.0% 5.9% 9.1% 15.8% 19.1% 24.6% 8.2% 1.8% 0.0% 0.0% 0.0% 0.0%

Actual14_15

0.0% 0.0% 0.3%

Target14_15

10.0% 10.0% 10.0% 10.0% 10.0% 10.0% 10.0% 10.0% 10.0% 10.0% 10.0% 10.0%

0.0%

5.0%

10.0%

15.0%

20.0%

25.0%

30.0%



Category Type

Actual



2.0 DNAs 129 129 33 11 10 15 8

3.0 DNA Rate % 2.8% 2.8% 4.0% 2.8% 4.4% 4.9% 2.7%

Referrals4.0 GP 361 361 94 30 28 37 29

5.0 Other 334 334 66 28 19 31 16


7.0 Staff Sickness 8.88% 3.75% 5.1% 3.75% 9.59% 4.77% 1.00%




Adult Acute Division - District Nursing ACM Community Dashboard 2014_15




0

100

200

300

400

500

600

700

1.0 Attendances

Actual_13_14 14 14 20 14 12 24 17 11 11 11 14 16

Actual 14_15 12 4 13

Target_14_15

0

5

10

15

20

25

30

2.0 DNAs

Actual13_14

32 34 38 35 27 38 41 34 32 52 60 34

Actual14_15

37 41 43

Target14_15

0

10

20

30

40

50

60

70

4.0 GP Referrals

Actual13_14

Actual14_15

Target14_15

0.0%

0.0%

10.0%

20.0%

30.0%

40.0%

50.0%

60.0%

70.0%

80.0%

90.0%

100.0%

6.0 Staff Turn-Over

Actual13_14

2.65% 4.39% 5.64% 2.36% 0.00% 0.17% 0.00% 2.31% 3.97% 0.30% 0.00% 0.00%

Actual14_15

0.00% 0.00% 0.00%

Target14_15

0.0%

1.0%

2.0%

3.0%

4.0%

5.0%

6.0%

7.0 Staff Sickness

Actual13_14

376 417 510 513 419 365 411 305 266 358 287 253

Actual14_15

216 292 286

Target14_15

375 375 375 375 375 375 375 375 375 375 375 375

0

100

200

300

400

500

600

1.0 Attendances

Actual13_14

15 19 29 12 10 4 7 4 8 8 7 6

Actual14_15

10 15 8

Target14_15

11 11 11 11 11 11 11 11 11 11 11 11

0

5

10

15

20

25

30

35

2.0 DNAs

Actual13_14

24 27 14 19 20 14 47 27 47 48 38 36

Actual14_15

28 37 29

Target14_15

30 30 30 30 30 30 30 30 30 30 30 30

0

10

20

30

40

50

60

4.0 GP Referrals

Actual13_14

Actual14_15

Target14_15

10.0% 10.0% 10.0% 10.0% 10.0% 10.0% 10.0% 10.0% 10.0% 10.0% 10.0% 10.0%

0.0%

2.0%

4.0%

6.0%

8.0%

10.0%

12.0%

6.0 Staff Turn-Over

Actual13_14

0.98% 9.33% 1.50% 7.12% 19.61% 14.09% 5.10% 7.44% 10.09% 9.89% 12.08% 9.36%

Actual14_15

9.59% 4.77% 1.00%

Target14_15

3.75% 3.75% 3.75% 3.75% 3.75% 3.75% 3.75% 3.75% 3.75% 3.75% 3.75% 3.75%

0.0%

5.0%

10.0%

15.0%

20.0%

25.0%

7.0 Staff Sickness


Category Type

Actual



2.0 DNAs 329 329 101 27 27 48 26

3.0 DNA Rate % 0.1% 0.1% 0.2% 0.1% 0.1% 0.3% 0.2%

Referrals4.0 GP 2040 2040 453 170 188 142 123

5.0 Other 2932 2932 641 244 238 216 187






Adult Acute Division - District Nursing Domiciliary Community Dashboard 2014_15




0

100

200

300

400

500

600

700

1.0 Attendances

Actual_13_14 14 14 20 14 12 24 17 11 11 11 14 16

Actual 14_15 12 4 13

Target_14_15

0

5

10

15

20

25

30

2.0 DNAs

Actual13_14

32 34 38 35 27 38 41 34 32 52 60 34

Actual14_15

37 41 43

Target14_15

0

10

20

30

40

50

60

70

4.0 GP Referrals

Actual13_14

Actual14_15

Target14_15

0.0%

0.0%

10.0%

20.0%

30.0%

40.0%

50.0%

60.0%

70.0%

80.0%

90.0%

100.0%

6.0 Staff Turn-Over

Actual13_14

2.65% 4.39% 5.64% 2.36% 0.00% 0.17% 0.00% 2.31% 3.97% 0.30% 0.00% 0.00%

Actual14_15

0.00% 0.00% 0.00%

Target14_15

0.0%

1.0%

2.0%

3.0%

4.0%

5.0%

6.0%

7.0 Staff Sickness

Actual13_14

19948 20612 18140 19579 18964 19555 20030 19659 17460 18729 16871 18481

Actual14_15

18108 18568 17208

Target14_15

19002 19002 19002 19002 19002 19002 19002 19002 19002 19002 19002 19002

0

5,000

10,000

15,000

20,000

25,000

1.0 Attendances

Actual13_14

45 47 37 31 26 41 30 31 11 11 8 11

Actual14_15

27 48 26

Target14_15

27 27 27 27 27 27 27 27 27 27 27 27

0

10

20

30

40

50

60

2.0 DNAs

Actual13_14

185 170 179 283 204 172 187 101 128 172 114 145

Actual14_15

188 142 123

Target14_15

170 170 170 170 170 170 170 170 170 170 170 170

0

50

100

150

200

250

300

4.0 GP Referrals

Actual13_14

Actual14_15

Target14_15

10.0% 10.0% 10.0% 10.0% 10.0% 10.0% 10.0% 10.0% 10.0% 10.0% 10.0% 10.0%

0.0%

2.0%

4.0%

6.0%

8.0%

10.0%

12.0%

6.0 Staff Turn-Over

Actual13_14

Actual14_15

Target14_15

3.75% 3.75% 3.75% 3.75% 3.75% 3.75% 3.75% 3.75% 3.75% 3.75% 3.75% 3.75%

0.0%

0.5%

1.0%

1.5%

2.0%

2.5%

3.0%

3.5%

4.0%

7.0 Staff Sickness


Category Type

Actual



2.0 DNAs 222 222 44 19 14 16 14

3.0 DNA Rate % 2.4% 2.4% 1.9% 2.4% 1.9% 2.1% 1.7%

Referrals4.0 GP 1210 1210 301 101 100 90 111

5.0 Other 855 855 207 71 71 74 62


7.0 Staff Sickness 2.04% 3.75% 2.9% 3.75% 3.68% 3.57% 1.58%





Adult Acute Division - Falls Community Dashboard 2014_15




0

100

200

300

400

500

600

700

1.0 Attendances

Actual_13_14 14 14 20 14 12 24 17 11 11 11 14 16

Actual 14_15 12 4 13

Target_14_15

0

5

10

15

20

25

30

2.0 DNAs

Actual13_14

32 34 38 35 27 38 41 34 32 52 60 34

Actual14_15

37 41 43

Target14_15

0

10

20

30

40

50

60

70

4.0 GP Referrals

Actual13_14

Actual14_15

Target14_15

0.0%

0.0%

10.0%

20.0%

30.0%

40.0%

50.0%

60.0%

70.0%

80.0%

90.0%

100.0%

6.0 Staff Turn-Over

Actual13_14

2.65% 4.39% 5.64% 2.36% 0.00% 0.17% 0.00% 2.31% 3.97% 0.30% 0.00% 0.00%

Actual14_15

0.00% 0.00% 0.00%

Target14_15

0.0%

1.0%

2.0%

3.0%

4.0%

5.0%

6.0%

7.0 Staff Sickness

Actual13_14

3.3% 0.0% 21.5% 0.0% 0.0% 0.0% 0.0% 0.0% 0.0% 0.0% 2.9% 0.0%

Actual14_15

0.0% 0.0% 6.8%

Target14_15

0.0%

5.0%

10.0%

15.0%

20.0%

25.0%


Actual13_14

741 754 738 684 695 775 806 789 706 871 758 717

Actual14_15

718 750 806

Target14_15

753 753 753 753 753 753 753 753 753 753 753 753

0

100

200

300

400

500

600

700

800

900

1,000

1.0 Attendances

Actual13_14

27 14 15 15 19 16 17 21 20 21 20 17

Actual14_15

14 16 14

Target14_15

19 19 19 19 19 19 19 19 19 19 19 19

0

5

10

15

20

25

30

2.0 DNAs

Actual13_14

106 110 107 120 95 89 77 87 97 114 94 114

Actual14_15

100 90 111

Target14_15

100 100 100 100 100 100 100 100 100 100 100 100

0

20

40

60

80

100

120

140

4.0 GP Referrals

Actual13_14

Actual14_15

Target14_15

10.0% 10.0% 10.0% 10.0% 10.0% 10.0% 10.0% 10.0% 10.0% 10.0% 10.0% 10.0%

0.0%

2.0%

4.0%

6.0%

8.0%

10.0%

12.0%

6.0 Staff Turn-Over

Actual13_14

1.01% 0.11% 2.42% 5.26% 4.25% 1.78% 0.00% 1.48% 3.55% 0.90% 1.08% 2.63%

Actual14_15

3.68% 3.57% 1.58%

Target14_15

3.75% 3.75% 3.75% 3.75% 3.75% 3.75% 3.75% 3.75% 3.75% 3.75% 3.75% 3.75%

0.0%

1.0%

2.0%

3.0%

4.0%

5.0%

6.0%

7.0 Staff Sickness

Actual13_14

0.0% 0.0% 0.0% 0.0% 0.0% 0.0% 0.0% 0.0% 0.0% 0.0% 0.0% 0.0%

Actual14_15

0.0% 0.0% 0.0%

Target14_15

10.0% 10.0% 10.0% 10.0% 10.0% 10.0% 10.0% 10.0% 10.0% 10.0% 10.0% 10.0%

0.0%

2.0%

4.0%

6.0%

8.0%

10.0%

12.0%



Category Type

Actual



2.0 DNAs 136 136 29 11 9 11 9

3.0 DNA Rate % 2.0% 2.0% 1.7% 2.0% 1.5% 2.0% 1.5%

Referrals4.0 GP 67 67 19 6 8 6 5

5.0 Other 843 843 207 70 59 82 66


7.0 Staff Sickness 4.60% 3.75% 3.3% 3.75% 8.24% 1.00% 0.65%




Adult Acute Division - IMCD Community Dashboard 2014_15




0

100

200

300

400

500

600

700

1.0 Attendances

Actual_13_14 14 14 20 14 12 24 17 11 11 11 14 16

Actual 14_15 12 4 13

Target_14_15

0

5

10

15

20

25

30

2.0 DNAs

Actual13_14

32 34 38 35 27 38 41 34 32 52 60 34

Actual14_15

37 41 43

Target14_15

0

10

20

30

40

50

60

70

4.0 GP Referrals

Actual13_14

Actual14_15

Target14_15

0.0%

0.0%

10.0%

20.0%

30.0%

40.0%

50.0%

60.0%

70.0%

80.0%

90.0%

100.0%

6.0 Staff Turn-Over

Actual13_14

2.65% 4.39% 5.64% 2.36% 0.00% 0.17% 0.00% 2.31% 3.97% 0.30% 0.00% 0.00%

Actual14_15

0.00% 0.00% 0.00%

Target14_15

0.0%

1.0%

2.0%

3.0%

4.0%

5.0%

6.0%

7.0 Staff Sickness

Actual13_14

3.3% 0.0% 21.5% 0.0% 0.0% 0.0% 0.0% 0.0% 0.0% 0.0% 2.9% 0.0%

Actual14_15

0.0% 0.0% 6.8%

Target14_15

0.0%

5.0%

10.0%

15.0%

20.0%

25.0%


Actual13_14

522 492 555 558 426 526 566 491 599 722 608 647

Actual14_15

576 534 593

Target14_15

559 559 559 559 559 559 559 559 559 559 559 559

0

100

200

300

400

500

600

700

800

1.0 Attendances

Actual13_14

7 10 6 17 0 11 15 5 7 12 25 21

Actual14_15

9 11 9

Target14_15

11 11 11 11 11 11 11 11 11 11 11 11

0

5

10

15

20

25

30

2.0 DNAs

Actual13_14

3 3 6 2 3 3 6 9 7 9 7 9

Actual14_15

8 6 5

Target14_15

6 6 6 6 6 6 6 6 6 6 6 6

0

1

2

3

4

5

6

7

8

9

10

4.0 GP Referrals

Actual13_14

Actual14_15

Target14_15

10.0% 10.0% 10.0% 10.0% 10.0% 10.0% 10.0% 10.0% 10.0% 10.0% 10.0% 10.0%

0.0%

2.0%

4.0%

6.0%

8.0%

10.0%

12.0%

6.0 Staff Turn-Over

Actual13_14

11.02%

7.32% 4.28% 4.81% 6.02% 2.10% 2.82% 4.40% 8.34% 1.33% 0.40% 2.36% 4.6%

Actual14_15

8.24% 1.00% 0.65%

Target14_15

3.75% 3.75% 3.75% 3.75% 3.75% 3.75% 3.75% 3.75% 3.75% 3.75% 3.75% 3.75%

0.0%

2.0%

4.0%

6.0%

8.0%

10.0%

12.0%

7.0 Staff Sickness

Actual13_14

Actual14_15

Target14_15

10.0% 10.0% 10.0% 10.0% 10.0% 10.0% 10.0% 10.0% 10.0% 10.0% 10.0% 10.0%

0.0%

2.0%

4.0%

6.0%

8.0%

10.0%

12.0%



Category Type

Actual



2.0 DNAs 40 40 13 3 6 4 3

3.0 DNA Rate % 0.6% 0.6% 0.7% 0.6% 0.8% 0.8% 0.5%

Referrals4.0 GP 18 18 14 2 13 1 0

5.0 Other 450 450 109 38 44 29 36


7.0 Staff Sickness 3.00% 3.75% 0.1% 3.75% 0.00% 0.00% 0.30%




Adult Acute Division - Rapid Response Community Dashboard 2014_15




0

100

200

300

400

500

600

700

1.0 Attendances

Actual_13_14 14 14 20 14 12 24 17 11 11 11 14 16

Actual 14_15 12 4 13

Target_14_15

0

5

10

15

20

25

30

2.0 DNAs

Actual13_14

32 34 38 35 27 38 41 34 32 52 60 34

Actual14_15

37 41 43

Target14_15

0

10

20

30

40

50

60

70

4.0 GP Referrals

Actual13_14

568 508 468 660 556 529 664 470 397 499 481 677

Actual14_15

718 521 655

Target14_15

540 540 540 540 540 540 540 540 540 540 540 540

0

100

200

300

400

500

600

700

800

1.0 Attendances

Actual13_14

5 2 2 6 4 4 2 1 2 8 3 1

Actual14_15

6 4 3

Target14_15

3 3 3 3 3 3 3 3 3 3 3 3

0

1

2

3

4

5

6

7

8

9

2.0 DNAs

Actual13_14

2 2 1 4 0 2 0 2 0 1 2 2

Actual14_15

13 1 0

Target14_15

2 2 2 2 2 2 2 2 2 2 2 2

0

2

4

6

8

10

12

14

4.0 GP Referrals

Actual13_14

Actual14_15

Target14_15

10.0% 10.0% 10.0% 10.0% 10.0% 10.0% 10.0% 10.0% 10.0% 10.0% 10.0% 10.0%

0.0%

2.0%

4.0%

6.0%

8.0%

10.0%

12.0%

6.0 Staff Turn-Over

Actual13_14

8.57% 8.57% 2.57% 0.00% 0.28% 0.38% 0.00% 0.38% 2.21% 4.98% 0.97% 7.04%

Actual14_15

0.00% 0.00% 0.30%

Target14_15

3.75% 3.75% 3.75% 3.75% 3.75% 3.75% 3.75% 3.75% 3.75% 3.75% 3.75% 3.75%

0.0%

1.0%

2.0%

3.0%

4.0%

5.0%

6.0%

7.0%

8.0%

9.0%

7.0 Staff Sickness


Category Type

Actual



2.0 DNAs 0 0 0 0 0 0 0

3.0 DNA Rate % 0.0% 0.0% 0.0% 0.0% 0.0% 0.0% 0.0%

Referrals4.0 GP 465 465 114 39 51 34 29

5.0 Other 362 362 58 30 20 16 22


7.0 Staff Sickness 5.90% 3.75% 3.1% 3.75% 6.22% 0.87% 2.09%




Adult Acute Division - Referral and Assessment Team Community Dashboard 2014_15




0

100

200

300

400

500

600

700

1.0 Attendances

Actual_13_14 14 14 20 14 12 24 17 11 11 11 14 16

Actual 14_15 12 4 13

Target_14_15

0

5

10

15

20

25

30

2.0 DNAs

Actual13_14

32 34 38 35 27 38 41 34 32 52 60 34

Actual14_15

37 41 43

Target14_15

0

10

20

30

40

50

60

70

4.0 GP Referrals

Actual13_14

576 595 489 549 421 440 547 549 623 517 343 473

Actual14_15

614 406 436

Target14_15

511 511 511 511 511 511 511 511 511 511 511 511

0

100

200

300

400

500

600

700

1.0 Attendances

Actual13_14

0 0 0 0 0 0 0 0 0 0 0 0

Actual14_15

0 0 0

Target14_15

0 0 0 0 0 0 0 0 0 0 0 0

0

1

2

3

4

5

6

7

8

9

10

2.0 DNAs

Actual13_14

43 39 43 34 38 36 34 36 41 44 39 38

Actual14_15

51 34 29

Target14_15

39 39 39 39 39 39 39 39 39 39 39 39

0

10

20

30

40

50

60

4.0 GP Referrals

Actual13_14

Actual14_15

Target14_15

10.0% 10.0% 10.0% 10.0% 10.0% 10.0% 10.0% 10.0% 10.0% 10.0% 10.0% 10.0%

0.0%

2.0%

4.0%

6.0%

8.0%

10.0%

12.0%

6.0 Staff Turn-Over

Actual13_14

4.76% 10.30% 6.04% 10.69% 7.39% 3.22% 3.35% 0.98% 0.82% 7.74% 6.14% 9.31%

Actual14_15

6.22% 0.87% 2.09%

Target14_15

3.75% 3.75% 3.75% 3.75% 3.75% 3.75% 3.75% 3.75% 3.75% 3.75% 3.75% 3.75%

0.0%

2.0%

4.0%

6.0%

8.0%

10.0%

12.0%

7.0 Staff Sickness


Category Type

Actual



2.0 DNAs 3450 3450 865 288 283 259 323

3.0 DNA Rate % 5.1% 5.1% 5.4% 5.1% 5.5% 4.9% 5.7%

Referrals4.0 GP 515 515 323 43 130 103 90

5.0 Other 14840 14840 3767 1237 1135 1313 1319


7.0 Staff Sickness 12.45% 3.75% 14.4% 3.75% 14.12% 16.07% 12.92%




Adult Acute Division - District Nursing Treatment Room Community Dashboard 2014_15




0

100

200

300

400

500

600

700

1.0 Attendances

Actual_13_14 14 14 20 14 12 24 17 11 11 11 14 16

Actual 14_15 12 4 13

Target_14_15

0

5

10

15

20

25

30

2.0 DNAs

Actual13_14

32 34 38 35 27 38 41 34 32 52 60 34

Actual14_15

37 41 43

Target14_15

0

10

20

30

40

50

60

70

4.0 GP Referrals

Actual13_14

4932 5267 5176 5810 5587 5542 5578 5279 5262 5317 5101 5510

Actual14_15

4909 5068 5298

Target14_15

5364 5364 5364 5364 5364 5364 5364 5364 5364 5364 5364 5364

0

1,000

2,000

3,000

4,000

5,000

6,000

7,000

1.0 Attendances

Actual13_14

253 250 296 361 311 294 272 271 269 295 278 300

Actual14_15

283 259 323

Target14_15

287 287 287 287 287 287 287 287 287 287 287 287

0

50

100

150

200

250

300

350

400

2.0 DNAs

Actual13_14

74 54 59 69 54 32 43 28 9 28 21 44

Actual14_15

130 103 90

Target14_15

43 43 43 43 43 43 43 43 43 43 43 43

0

20

40

60

80

100

120

140

4.0 GP Referrals

Actual13_14

Actual14_15

Target14_15

10.0% 10.0% 10.0% 10.0% 10.0% 10.0% 10.0% 10.0% 10.0% 10.0% 10.0% 10.0%

0.0%

2.0%

4.0%

6.0%

8.0%

10.0%

12.0%

6.0 Staff Turn-Over

Actual13_14

15.74% 13.45% 19.81% 16.81% 10.44% 10.40% 10.04% 5.42% 5.81% 10.50% 14.54% 16.48%

Actual14_15

14.12% 16.07% 12.92%

Target14_15

3.75% 3.75% 3.75% 3.75% 3.75% 3.75% 3.75% 3.75% 3.75% 3.75% 3.75% 3.75%

0.0%

5.0%

10.0%

15.0%

20.0%

25.0%

7.0 Staff Sickness


Category Type

Actual



2.0 DNAs 63 63 1 5 1 0 0

3.0 DNA Rate % 3.8% 3.8% 3.4% 3.8% 6.3% 0.0% 0.0%

Referrals4.0 GP 334 334 49 28 20 18 11

5.0 Other 588 588 87 49 37 25 25


7.0 Staff Sickness 3.10% 3.75% 18.8% 3.75% 14.12% 21.19% 21.19%




Adult Acute Division - Tissue Viability Community Dashboard 2014_15




0

100

200

300

400

500

600

700

1.0 Attendances

Actual_13_14 14 14 20 14 12 24 17 11 11 11 14 16

Actual 14_15 12 4 13

Target_14_15

0

5

10

15

20

25

30

2.0 DNAs

Actual13_14

32 34 38 35 27 38 41 34 32 52 60 34

Actual14_15

37 41 43

Target14_15

0

10

20

30

40

50

60

70

4.0 GP Referrals

Actual13_14

183 197 198 211 180 174 144 130 119 47 2 0

Actual14_15

15 0 13

Target14_15

163 163 163 163 163 163 163 163 163 163 163 163

0

50

100

150

200

250

1.0 Attendances

Actual13_14

10 8 4 5 10 8 2 9 4 3 0 0

Actual14_15

1 0 0

Target14_15

5 5 5 5 5 5 5 5 5 5 5 5

0

2

4

6

8

10

12

2.0 DNAs

Actual13_14

32 35 14 35 37 26 25 17 29 22 30 32

Actual14_15

20 18 11

Target14_15

29 29 29 29 29 29 29 29 29 29 29 29

0

5

10

15

20

25

30

35

40

4.0 GP Referrals

Actual13_14

Actual14_15

Target14_15

10.0% 10.0% 10.0% 10.0% 10.0% 10.0% 10.0% 10.0% 10.0% 10.0% 10.0% 10.0%

0.0%

2.0%

4.0%

6.0%

8.0%

10.0%

12.0%

6.0 Staff Turn-Over

Actual13_14

11.07% 13.60% 0.00% 0.00% 0.00% 0.00% 0.00% 0.00% 3.58% 6.20% 0.00% 2.73%

Actual14_15

14.12% 21.19% 21.19%

Target14_15

0.0%

5.0%

10.0%

15.0%

20.0%

25.0%

7.0 Staff Sickness


Category Type

Actual



2.0 DNAs 26 26 21 2 4 6 11

3.0 DNA Rate % 0.7% 0.7% 2.2% 0.7% 1.4% 1.8% 3.4%

Referrals4.0 GP 24 24 5 2 0 4 1

5.0 Other 713 713 175 59 64 54 57


7.0 Staff Sickness 4.36% 3.75% 1.6% 3.75% 2.21% 2.50% 0.23%





Adult Acute Division - Palliative Care Community Dashboard 2014_15




0

100

200

300

400

500

600

700

1.0 Attendances

Actual_13_14 14 14 20 14 12 24 17 11 11 11 14 16

Actual 14_15 12 4 13

Target_14_15

0

5

10

15

20

25

30

2.0 DNAs

Actual13_14

32 34 38 35 27 38 41 34 32 52 60 34

Actual14_15

37 41 43

Target14_15

0

10

20

30

40

50

60

70

4.0 GP Referrals

Actual13_14

Actual14_15

Target14_15

0.0%

0.0%

10.0%

20.0%

30.0%

40.0%

50.0%

60.0%

70.0%

80.0%

90.0%

100.0%

6.0 Staff Turn-Over

Actual13_14

2.65% 4.39% 5.64% 2.36% 0.00% 0.17% 0.00% 2.31% 3.97% 0.30% 0.00% 0.00%

Actual14_15

0.00% 0.00% 0.00%

Target14_15

0.0%

1.0%

2.0%

3.0%

4.0%

5.0%

6.0%

7.0 Staff Sickness

Actual13_14

3.3% 0.0% 21.5% 0.0% 0.0% 0.0% 0.0% 0.0% 0.0% 0.0% 2.9% 0.0%

Actual14_15

0.0% 0.0% 6.8%

Target14_15

0.0%

5.0%

10.0%

15.0%

20.0%

25.0%


Actual13_14

309 323 320 380 331 320 296 248 234 325 252 276

Actual14_15

281 330 313

Target14_15

302 302 302 302 302 302 302 302 302 302 302 302

0

50

100

150

200

250

300

350

400

1.0 Attendances

Actual13_14

0 4 6 1 1 3 2 3 0 1 0 5

Actual14_15

4 6 11

Target14_15

2 2 2 2 2 2 2 2 2 2 2 2

0

2

4

6

8

10

12

2.0 DNAs

Actual13_14

1 2 5 4 1 2 1 0 1 3 1 3

Actual14_15

0 4 1

Target14_15

2 2 2 2 2 2 2 2 2 2 2 2

0

1

2

3

4

5

6

4.0 GP Referrals

Actual13_14

Actual14_15

Target14_15

10.0% 10.0% 10.0% 10.0% 10.0% 10.0% 10.0% 10.0% 10.0% 10.0% 10.0% 10.0%

0.0%

2.0%

4.0%

6.0%

8.0%

10.0%

12.0%

6.0 Staff Turn-Over

Actual13_14

0.58% 0.35% 1.43% 5.51% 5.74% 6.48% 4.96% 6.72% 6.97% 6.40% 6.46% 0.67%

Actual14_15

2.21% 2.50% 0.23%

Target14_15

3.75% 3.75% 3.75% 3.75% 3.75% 3.75% 3.75% 3.75% 3.75% 3.75% 3.75% 3.75%

0.0%

1.0%

2.0%

3.0%

4.0%

5.0%

6.0%

7.0%

8.0%

7.0 Staff Sickness

Actual13_14

0.0% 0.0% 0.0% 0.0% 0.0% 0.0% 0.0% 0.0% 0.0% 0.0% 0.0% 0.0%

Actual14_15

0.0% 0.0% 0.0%

Target14_15

10.0% 10.0% 10.0% 10.0% 10.0% 10.0% 10.0% 10.0% 10.0% 10.0% 10.0% 10.0%

0.0%

2.0%

4.0%

6.0%

8.0%

10.0%

12.0%



Category Type

Actual



2.0 DNAs 903 903 223 75 76 72 75

3.0 DNA Rate % 18.9% 18.9% 17.9% 18.9% 18.9% 16.9% 17.9%

Referrals4.0 GP 66 66 9 6 8 1 0

5.0 Other 1924 1924 520 160 172 187 161


7.0 Staff Sickness 1.7% 3.8% 2.5% 3.8% 2.0% 0.0% 5.3%




Family Division - Paediatric Audiology Community Dashboard 2014_15


April May June July Aug Sept Oct Nov Dec Jan Feb March

Actual13_14

372 318 296 292 329 311 350 343 270 340 300 345

Actual14_15

327 355 343

Target14_15

323 323 323 323 323 323 323 323 323 323 323 323

0

50

100

150

200

250

300

350

400

1.0 Attendances


Actual13_14

63 96 79 78 103 55 69 73 93 69 56 69

Actual14_15

76 72 75

Target14_15

75 75 75 75 75 75 75 75 75 75 75 75

0

20

40

60

80

100

120

2.0 DNAs


Actual13_14

7 6 2 6 2 5 6 2 2 4 11 13

Actual14_15

8 1 0

Target14_15

6 6 6 6 6 6 6 6 6 6 6 6

0

2

4

6

8

10

12

14

4.0 GP Referrals


Actual13_14

Actual14_15

Target14_15

10.0% 10.0% 10.0% 10.0% 10.0% 10.0% 10.0% 10.0% 10.0% 10.0% 10.0% 10.0%

0.0%

2.0%

4.0%

6.0%

8.0%

10.0%

12.0%

6.0 Staff Turn-Over


Actual13_14

2.20% 2.10% 7.11% 3.82% 0.23% 0.53% 0.00% 0.00% 0.00% 2.55% 1.20% 0.54%

Actual14_15

2.03% 0.00% 5.33%

Target14_15

3.75% 3.75% 3.75% 3.75% 3.75% 3.75% 3.75% 3.75% 3.75% 3.75% 3.75% 3.75%

0.0%

1.0%

2.0%

3.0%

4.0%

5.0%

6.0%

7.0%

8.0%

7.0 Staff Sickness


Category Type

Actual



2.0 DNAs 822 822 162 69 46 61 55

3.0 DNA Rate % 11.8% 11.8% 10.1% 11.8% 8.9% 11.1% 10.4%

Referrals4.0 GP 744 744 200 62 61 76 63

5.0 Other 1512 1512 403 126 134 113 156






Family Division - Paediatrics Community Dashboard 2014_15


Actual13_14

580 544 515 461 372 523 572 521 388 611 447 607

Actual14_15

471 490 475

Target14_15

580 544 515 461 372 523 575 521 389 617 445 610

0

100

200

300

400

500

600

700

1.0 Attendances

Actual13_14

53 65 87 78 76 64 84 62 63 69 61 60

Actual14_15

46 61 55

Target14_15

53 65 87 78 76 64 84 62 63 69 61 60

0

10

20

30

40

50

60

70

80

90

100

2.0 DNAs

Actual13_14

68 50 60 48 54 55 68 53 63 87 64 74

Actual14_15

61 76 63

Target14_15

68 50 60 48 54 55 68 53 63 87 64 74

0

10

20

30

40

50

60

70

80

90

100

4.0 GP Referrals

Actual13_14

Actual14_15

Target14_15

10.0% 10.0% 10.0% 10.0% 10.0% 10.0% 10.0% 10.0% 10.0% 10.0% 10.0% 10.0%

0.0%

2.0%

4.0%

6.0%

8.0%

10.0%

12.0%

6.0 Staff Turn-Over

Actual13_14

Actual14_15

Target14_15

3.75% 3.75% 3.75% 3.75% 3.75% 3.75% 3.75% 3.75% 3.75% 3.75% 3.75% 3.75%

0.0%

0.5%

1.0%

1.5%

2.0%

2.5%

3.0%

3.5%

4.0%

7.0 Staff Sickness


Category Type

Actual



2.0 DNAs 3 3 2 0 0 2 0

3.0 DNA Rate % 1.9% 1.9% 3.4% 1.9% 0.0% 6.7% 0.0%

Referrals4.0 GP 0 0 0 0 0 0 0

5.0 Other 0 0 0 0 0 0 0






Family Division - Looked After Children Community Dashboard 2014_15


Actual13_14

12 9 6 7 23 7 34 5 9 14 21 9

Actual14_15

22 28 6

Target14_15

12 9 6 7 23 7 34 5 9 14 21 9

0

5

10

15

20

25

30

35

40

1.0 Attendances

Actual13_14

0 1 0 0 0 0 0 0 0 0 2 0

Actual14_15

0 2 0

Target14_15

0 1 0 0 0 0 0 0 0 0 2 0

0

1

1

2

2

3

2.0 DNAs

Actual13_14

0 0 0 0 0 0 0 0 0 0 0 0

Actual14_15

0 0 0

Target14_15

0 0 0 0 0 0 0 0 0 0 0 0

0

0

0

0

0

1

1

1

1

1

1

4.0 GP Referrals

Actual13_14

Actual14_15

Target14_15

10.0% 10.0% 10.0% 10.0% 10.0% 10.0% 10.0% 10.0% 10.0% 10.0% 10.0% 10.0%

0.0%

2.0%

4.0%

6.0%

8.0%

10.0%

12.0%

6.0 Staff Turn-Over

Actual13_14

Actual14_15

Target14_15

3.75% 3.75% 3.75% 3.75% 3.75% 3.75% 3.75% 3.75% 3.75% 3.75% 3.75% 3.75%

0.0%

0.5%

1.0%

1.5%

2.0%

2.5%

3.0%

3.5%

4.0%

7.0 Staff Sickness


Category Type

Actual



2.0 DNAs 670 670 219 56 77 68 74

3.0 DNA Rate % 7.8% 7.8% 10.3% 7.8% 12.8% 8.6% 10.2%

Referrals4.0 GP 125 125 53 10 21 14 18

5.0 Other 770 770 230 64 78 105 47


7.0 Staff Sickness 1.4% 3.8% 17.5% 3.8% 18.5% 11.3% 22.7%





Family Division - Child Dietetics Community Dashboard 2014_15



Actual13_14

611 807 758 458 388 618 829 742 495 730 754 733

Actual14_15

523 727 654

Target14_15

611 807 758 458 388 618 829 742 495 730 754 733

0

100

200

300

400

500

600

700

800

900

1.0 Attendances


Actual13_14

31 69 57 54 69 43 59 59 51 51 53 74

Actual14_15

77 68 74

Target14_15

55 55 55 55 55 55 55 55 55 55 55 55

0

10

20

30

40

50

60

70

80

90

2.0 DNAs


Actual13_14

13 10 9 10 12 5 13 10 8 11 7 17

Actual14_15

21 14 18

Target14_15

13 10 9 10 12 5 13 10 8 11 7 17

0

5

10

15

20

25

4.0 GP Referrals


Actual13_14

Actual14_15

Target14_15

10.0% 10.0% 10.0% 10.0% 10.0% 10.0% 10.0% 10.0% 10.0% 10.0% 10.0% 10.0%

0.0%

2.0%

4.0%

6.0%

8.0%

10.0%

12.0%

6.0 Staff Turn-Over


Actual13_14

0.00% 0.00% 0.00% 0.29% 0.00% 0.00% 0.66% 1.36% 1.13% 3.06% 2.87% 7.32%

Actual14_15

18.54% 11.25% 22.71%

Target14_15

3.75% 3.75% 3.75% 3.75% 3.75% 3.75% 3.75% 3.75% 3.75% 3.75% 3.75% 3.75%

0.0%

5.0%

10.0%

15.0%

20.0%

25.0%

7.0 Staff Sickness


Actual13_14

0.0% 0.0% 0.0%

Actual14_15

0.0% 0.0% 0.0%

Target14_15

10.0% 10.0% 10.0% 10.0% 10.0% 10.0% 10.0% 10.0% 10.0% 10.0% 10.0% 10.0%

0.0%

2.0%

4.0%

6.0%

8.0%

10.0%

12.0%

12.0 12% of Patients Waiting over 12 weeks


Category Type

Actual



2.0 DNAs 455 455 75 38 20 30 25

3.0 DNA Rate % 7.9% 7.9% 5.8% 7.9% 4.7% 6.3% 6.5%

Referrals4.0 GP 188 188 21 16 13 7 1

5.0 Other 505 505 80 42 41 31 8







Family Division - Paediatric Physiotherapy Community Dashboard 2014_15


Actual13_14

462 435 524 398 306 468 538 522 317 489 405 440

Actual14_15

407 448 357

Target14_15

462 435 524 398 306 468 538 522 317 489 406 441

0

100

200

300

400

500

600

1.0 Attendances

Actual13_14

30 34 42 45 36 31 31 43 41 44 32 46

Actual14_15

20 30 25

Target14_15

30 34 42 45 36 31 31 43 41 44 32 46

0

5

10

15

20

25

30

35

40

45

50

2.0 DNAs

Actual13_14

22 3 19 14 10 19 20 21 13 12 17 18

Actual14_15

13 7 1

Target14_15

22 3 19 14 10 19 20 21 13 12 17 18

0

5

10

15

20

25

4.0 GP Referrals

Actual13_14

Actual14_15

Target14_15

10.0% 10.0% 10.0% 10.0% 10.0% 10.0% 10.0% 10.0% 10.0% 10.0% 10.0% 10.0%

0.0%

2.0%

4.0%

6.0%

8.0%

10.0%

12.0%

6.0 Staff Turn-Over

Actual13_14

Actual14_15

Target14_15

3.75% 3.75% 3.75% 3.75% 3.75% 3.75% 3.75% 3.75% 3.75% 3.75% 3.75% 3.75%

0.0%

0.5%

1.0%

1.5%

2.0%

2.5%

3.0%

3.5%

4.0%

7.0 Staff Sickness

Actual13_14

0.0% 0.0% 0.0% 0.0% 0.0% 0.0% 0.0% 0.0% 0.0% 0.0% 0.0% 0.0%

Actual14_15

0.0% 0.0% 6.7%

Target14_15

10.0% 10.0% 10.0% 10.0% 10.0% 10.0% 10.0% 10.0% 10.0% 10.0% 10.0% 10.0%

0.0%

2.0%

4.0%

6.0%

8.0%

10.0%

12.0%



Category Type

Actual



2.0 DNAs 101 101 30 8 8 8 14

3.0 DNA Rate % 3.2% 3.2% 4.0% 3.2% 2.8% 4.3% 5.0%

Referrals4.0 GP 8 8 0 1 0 0 0

5.0 Other 347 347 91 29 40 35 16


7.0 Staff Sickness 3.9% 3.8% 10.0% 3.8% 15.5% 7.1% 7.4%





Family Division - Paediatric Occupational Therapy Community Dashboard 2014_15


Actual13_14

321 206 267 261 215 343 282 240 209 237 212 251

Actual14_15

274 176 264

Target14_15

321 206 267 261 215 343 282 240 209 240 243 281

0

50

100

150

200

250

300

350

400

1.0 Attendances

Actual13_14

4 12 3 6 12 12 11 13 15 5 4 4

Actual14_15

8 8 14

Target14_15

4 12 3 6 12 12 11 13 15 5 4 4

0

2

4

6

8

10

12

14

16

2.0 DNAs

Actual13_14

0 0 1 1 2 1 0 0 0 1 1 1

Actual14_15

0 0 0

Target14_15

0 0 1 1 2 1 0 0 0 1 1 1

0

1

2

3

4

5

6

7

8

9

10

4.0 GP Referrals

Actual13_14

Actual14_15

Target14_15

10.0% 10.0% 10.0% 10.0% 10.0% 10.0% 10.0% 10.0% 10.0% 10.0% 10.0% 10.0%

0.0%

2.0%

4.0%

6.0%

8.0%

10.0%

12.0%

6.0 Staff Turn-Over

Actual13_14

0.00% 4.37% 7.68% 6.12% 0.00% 0.27% 0.49% 0.00% 2.65% 0.00% 9.33% 15.43%

Actual14_15

15.51% 7.07% 7.39%

Target14_15

3.75% 3.75% 3.75% 3.75% 3.75% 3.75% 3.75% 3.75% 3.75% 3.75% 3.75% 3.75%

0.0%

2.0%

4.0%

6.0%

8.0%

10.0%

12.0%

14.0%

16.0%

18.0%

7.0 Staff Sickness

Actual13_14

12.1% 9.7% 11.4% 0.0% 5.3% 11.8% 0.0% 0.0% 0.0% 0.0% 0.0% 0.0%

Actual14_15

34.5% 46.3% 41.5%

Target14_15

10.0% 10.0% 10.0% 10.0% 10.0% 10.0% 10.0% 10.0% 10.0% 10.0% 10.0% 10.0%

0.0%

5.0%

10.0%

15.0%

20.0%

25.0%

30.0%

35.0%

40.0%

45.0%

50.0%



Category Type

Actual



2.0 DNAs 848 848 189 71 79 56 54

3.0 DNA Rate % 4.5% 4.5% 4.0% 4.5% 5.7% 3.3% 3.2%

Referrals4.0 GP 95 95 26 8 6 10 10

5.0 Other 1557 1557 429 130 151 143 135


7.0 Staff Sickness 0.7% 3.8% 1.9% 3.8% 0.7% 0.6% 4.3%





Family Division - Paediatric Speech and Language Therapy Community Dashboard 2014_15


Actual13_14

1668 1644 1494 1203 539 1527 1675 1868 1147 1861 1513 1989

Actual14_15

1313 1634 1632

Target14_15

1668 1644 1494 1203 539 1527 1675 1869 1147 1864 1517 1993

0

500

1,000

1,500

2,000

2,500

1.0 Attendances

Actual13_14

85 69 78 85 64 68 97 63 52 76 53 58

Actual14_15

79 56 54

Target14_15

85 69 78 85 64 68 97 63 52 76 53 58

0

20

40

60

80

100

120

2.0 DNAs

Actual13_14

14 9 6 14 8 7 8 8 7 4 3 7

Actual14_15

6 10 10

Target14_15

14 9 6 14 8 7 8 8 7 4 3 7

0

2

4

6

8

10

12

14

16

4.0 GP Referrals

Actual13_14

Actual14_15

Target14_15

10.0% 10.0% 10.0% 10.0% 10.0% 10.0% 10.0% 10.0% 10.0% 10.0% 10.0% 10.0%

0.0%

2.0%

4.0%

6.0%

8.0%

10.0%

12.0%

6.0 Staff Turn-Over

Actual13_14

0.00% 0.00% 0.00% 0.00% 0.00% 1.49% 2.01% 1.62% 1.24% 0.31% 0.00% 1.13%

Actual14_15

0.66% 0.63% 4.34%

Target14_15

3.75% 3.75% 3.75% 3.75% 3.75% 3.75% 3.75% 3.75% 3.75% 3.75% 3.75% 3.75%

0.0%

0.5%

1.0%

1.5%

2.0%

2.5%

3.0%

3.5%

4.0%

4.5%

5.0%

7.0 Staff Sickness

Actual13_14

0.0% 0.0% 0.0% 0.0% 0.0% 0.0% 0.0% 0.0% 0.0% 0.0% 0.0% 0.0%

Actual14_15

0.0% 0.0% 4.8%

Target14_15

10.0% 10.0% 10.0% 10.0% 10.0% 10.0% 10.0% 10.0% 10.0% 10.0% 10.0% 10.0%

0.0%

2.0%

4.0%

6.0%

8.0%

10.0%

12.0%



Category Type

Actual



2.0 DNAs 705 705 170 59 47 64 59

3.0 DNA Rate % 7.0% 7.0% 6.6% 7.0% 5.5% 7.4% 7.1%

Referrals4.0 GP 3276 3276 871 273 288 271 312

5.0 Other 3207 3207 902 267 266 348 288


7.0 Staff Sickness 0.5% 3.8% 0.0% 3.8% 0.0% 0.0% 0.0%




Family Division - Paediatric Acute Nursing Community Dashboard 2014_15



Actual

13_14868 833 692 783 755 746 743 888 730 821 750 794

Actual

14_15806 806 776

Target

14_15784 784 784 784 784 784 784 784 784 784 784 784

0

100

200

300

400

500

600

700

800

900

1,000

1.0 Attendances


Actual

13_1459 93 89 75 33 46 44 50 58 51 63 44

Actual

14_1547 64 59

Target

14_1558 58 58 58 58 58 58 58 58 58 58 58

0

10

20

30

40

50

60

70

80

90

100

2.0 DNAs


Actual

13_14339 292 231 233 202 207 266 269 263 350 282 342

Actual

14_15288 271 312

Target

14_15273 273 273 273 273 273 273 273 273 273 273 273

0

50

100

150

200

250

300

350

400

4.0 GP Referrals


Actual

13_14

Actual

14_15

Target

14_1510.0% 10.0% 10.0% 10.0% 10.0% 10.0% 10.0% 10.0% 10.0% 10.0% 10.0% 10.0%

0.0%

2.0%

4.0%

6.0%

8.0%

10.0%

12.0%

6.0 Staff Turn-Over


Actual

13_140.85% 3.29% 0.84% 1.11% 0.00% 0.00% 0.00% 0.00% 0.00% 0.00% 0.00% 0.00%

Actual

14_150.01% 0.00% 0.00%

Target

14_153.75% 3.75% 3.75% 3.75% 3.75% 3.75% 3.75% 3.75% 3.75% 3.75% 3.75% 3.75%

0.0%

0.5%

1.0%

1.5%

2.0%

2.5%

3.0%

3.5%

4.0%

7.0 Staff Sickness


Category Type

Actual



2.0 DNAs 14 14 2 1 0 1 1

3.0 DNA Rate % 0.2% 0.2% 0.2% 0.2% 0.0% 0.3% 0.6%

Referrals4.0 GP 0 0 0 0 0 0 0

5.0 Other 0 0 0 0 0 0 0


7.0 Staff Sickness 4.3% 3.8% 3.4% 3.8% 4.6% 4.2% 1.4%




Family Division - Paediatric Complex Needs Community Dashboard 2014_15



Actual

13_14778 672 544 642 424 464 485 517 463 440 355 314

Actual

14_15335 354 168

Target

14_15520 520 520 520 520 520 520 520 520 520 520 520

0

100

200

300

400

500

600

700

800

900

1.0 Attendances


Actual

13_142 3 0 3 0 2 2 1 0 0 0 1

Actual

14_150 1 1

Target

14_151 1 1 1 1 1 1 1 1 1 1 1

0

1

1

2

2

3

3

4

2.0 DNAs


Actual

13_140 0 0 0 0 0 0 0 0 0 0 0

Actual

14_150 0 0

Target

14_150 0 0 0 0 0 0 0 0 0 0 0

0

1

2

3

4

5

6

7

8

9

10

4.0 GP Referrals


Actual

13_14

Actual

14_15

Target

14_1510.0% 10.0% 10.0% 10.0% 10.0% 10.0% 10.0% 10.0% 10.0% 10.0% 10.0% 10.0%

0.0%

2.0%

4.0%

6.0%

8.0%

10.0%

12.0%

6.0 Staff Turn-Over


Actual

13_146.13% 4.35% 4.13% 6.16% 4.25% 7.57% 1.43% 1.45% 0.67% 3.19% 6.32% 5.55%

Actual

14_154.63% 4.21% 1.44%

Target

14_153.75% 3.75% 3.75% 3.75% 3.75% 3.75% 3.75% 3.75% 3.75% 3.75% 3.75% 3.75%

0.0%

1.0%

2.0%

3.0%

4.0%

5.0%

6.0%

7.0%

8.0%

7.0 Staff Sickness


Category Type

Actual



2.0 DNAs 17 17 9 1 0 0 9

3.0 DNA Rate % 0.3% 0.3% 0.9% 0.3% 0.0% 0.0% 2.6%

Referrals4.0 GP 2 2 0 0 0 0 0

5.0 Other 84 84 14 7 6 4 4


7.0 Staff Sickness 2.2% 3.8% 11.4% 3.8% 13.2% 9.4% 11.6%




Family Division - Paediatric continuing Care Community Dashboard 2014_15



Actual13_14

532 592 552 584 546 476 485 540 429 429 222 156

Actual14_15

325 335 340

Target14_15

497 497 497 497 497 497 497 497 497 497 497 497

0

100

200

300

400

500

600

700

1.0 Attendances


Actual13_14

4 3 1 0 1 5 1 2 0 0 0 0

Actual14_15

0 0 9

Target14_15

1 1 1 1 1 1 1 1 1 1 1 1

0

1

2

3

4

5

6

7

8

9

10

2.0 DNAs


Actual13_14

0 0 0 0 0 0 0 0 0 2 0 0

Actual14_15

0 0 0

Target14_15

1 1 1 1 1 1 1 1 1 1 1 1

0

1

1

2

2

3

4.0 GP Referrals


Actual13_14

Actual14_15

Target14_15

10.0% 10.0% 10.0% 10.0% 10.0% 10.0% 10.0% 10.0% 10.0% 10.0% 10.0% 10.0%

0.0%

2.0%

4.0%

6.0%

8.0%

10.0%

12.0%

6.0 Staff Turn-Over


Actual13_14

0.62% 0.59% 0.70% 0.41% 0.00% 7.02% 2.27% 2.34% 5.80% 0.00% 0.56% 5.54%

Actual14_15

13.23% 9.44% 11.57%

Target14_15

3.75% 3.75% 3.75% 3.75% 3.75% 3.75% 3.75% 3.75% 3.75% 3.75% 3.75% 3.75%

0.0%

2.0%

4.0%

6.0%

8.0%

10.0%

12.0%

14.0%

7.0 Staff Sickness


Category Type

Actual



2.0 DNAs 150 150 48 13 10 22 16

3.0 DNA Rate % 5.9% 5.9% 8.7% 5.9% 5.2% 11.8% 9.2%

Referrals4.0 GP 24 24 7 2 2 2 3

5.0 Other 392 392 120 33 43 41 36






Family Division - Paediatric Respiratory Community Dashboard 2014_15


Actual13_14

258 269 162 233 202 162 232 200 153 215 193 115

Actual14_15

182 164 157

Target14_15

258 269 162 233 202 162 232 200 153 215 193 158

0

50

100

150

200

250

300

1.0 Attendances

Actual13_14

16 18 12 13 15 11 5 2 13 13 14 18

Actual14_15

10 22 16

Target14_15

16 18 12 13 15 11 5 2 13 13 14 18

0

5

10

15

20

25

2.0 DNAs

Actual13_14

2 2 2 2 1 2 1 6 6

Actual14_15

2 2 3

Target14_15

2 0 2 2 2 0 1 2 1 0 6 6

0

1

2

3

4

5

6

7

4.0 GP Referrals

Actual13_14

Actual14_15

Target14_15

10.0% 10.0% 10.0% 10.0% 10.0% 10.0% 10.0% 10.0% 10.0% 10.0% 10.0% 10.0%

0.0%

2.0%

4.0%

6.0%

8.0%

10.0%

12.0%

6.0 Staff Turn-Over

Actual13_14

Actual14_15

Target14_15

3.75% 3.75% 3.75% 3.75% 3.75% 3.75% 3.75% 3.75% 3.75% 3.75% 3.75% 3.75%

0.0%

0.5%

1.0%

1.5%

2.0%

2.5%

3.0%

3.5%

4.0%

7.0 Staff Sickness


Category Type

Actual



2.0 DNAs 277 277 49 23 23 10 16

3.0 DNA Rate % 1.9% 1.9% 2.0% 1.9% 3.0% 1.2% 1.8%

Referrals4.0 GP 0 0 13 0 4 6 3

5.0 Other 340 340 73 28 25 21 27


7.0 Staff Sickness 4.5% 3.8% 4.2% 3.8% 6.3% 5.3% 1.1%




Family Division - Child Learning Disabilities Community Dashboard 2014_15



Actual13_14

1583 1308 1418 1223 776 1116 1331 1187 898 1430 983 723

Actual14_15

740 794 874

Target14_15

1585 1309 1418 1226 775 1113 1331 1187 898 1430 983 723

0

200

400

600

800

1,000

1,200

1,400

1,600

1,800

1.0 Attendances


Actual13_14

24 20 30 22 30 25 24 20 16 31 18 17

Actual14_15

23 10 16

Target14_15

23 23 23 23 23 23 23 23 23 23 23 23

0

5

10

15

20

25

30

35

2.0 DNAs


Actual13_14

0 0 0 0 0 0 0 0 0 0 0 0

Actual14_15

4 6 3

Target14_15

1 1 1 1 1 1 5 1 3 12 14 2

0

2

4

6

8

10

12

14

16

4.0 GP Referrals


Actual13_14

Actual14_15

Target14_15

10.0% 10.0% 10.0% 10.0% 10.0% 10.0% 10.0% 10.0% 10.0% 10.0% 10.0% 10.0%

0.0%

2.0%

4.0%

6.0%

8.0%

10.0%

12.0%

6.0 Staff Turn-Over


Actual13_14

0.00% 0.67% 2.97% 4.46% 4.50% 4.96% 2.29% 2.44% 2.82% 8.50% 9.14% 10.75%

Actual14_15

6.27% 5.33% 1.10%

Target14_15

3.75% 3.75% 3.75% 3.75% 3.75% 3.75% 3.75% 3.75% 3.75% 3.75% 3.75% 3.75%

0.0%

2.0%

4.0%

6.0%

8.0%

10.0%

12.0%

7.0 Staff Sickness


Actual13_14

Actual14_15

Target14_15

10.0% 10.0% 10.0% 10.0% 10.0% 10.0% 10.0% 10.0% 10.0% 10.0% 10.0% 10.0%

0.0%

2.0%

4.0%

6.0%

8.0%

10.0%

12.0%



Category Type

Actual



2.0 DNAs 5 5 0 0 0 0 0

3.0 DNA Rate % 0.1% 0.1% 0.0% 0.1% 0.0% 0.0% 0.0%

Referrals4.0 GP 0 0 0 0 0 0 0

5.0 Other 309 309 56 26 54 2 0


7.0 Staff Sickness 11.30% 3.75% 27.5% 3.75% 28.15% 34.19% 20.11%




Adult Acute Division - Dietetic CWM Community Dashboard 2014_15


Actual13_14

451 395 128 550 288 105 443 287 118 327 262 149

Actual14_15

199 176 45

Target14_15

292 292 292 292 292 292 292 292 292 292 292 292

0

100

200

300

400

500

600

1.0 Attendances

Actual13_14

0 0 2 0 0 0 3 0 0 0 0 0

Actual14_15

0 0 0

Target14_15

1 1 1 1 1 1 1 1 1 1 1 1

0

1

2

3

4

5

6

7

8

9

10

2.0 DNAs

Actual13_14

0 0 0 0 0 0 0 0 0 0 0 0

Actual14_15

0 0 0

Target14_15

0 0 0 0 0 0 0 0 0 0 0 0

0

1

2

3

4

5

6

7

8

9

10

4.0 GP Referrals

Actual13_14

Actual14_15

Target14_15

10.0% 10.0% 10.0% 10.0% 10.0% 10.0% 10.0% 10.0% 10.0% 10.0% 10.0% 10.0%

0.0%

2.0%

4.0%

6.0%

8.0%

10.0%

12.0%

6.0 Staff Turn-Over

Actual13_14

18.10% 15.57% 0.00% 0.00% 0.00% 4.69% 3.89% 0.00% 16.86% 20.11% 20.11% 36.32%

Actual14_15

28.15% 34.19% 20.11%

Target14_15

3.75% 3.75% 3.75% 3.75% 3.75% 3.75% 3.75% 3.75% 3.75% 3.75% 3.75% 3.75%

0.0%

5.0%

10.0%

15.0%

20.0%

25.0%

30.0%

35.0%

40.0%

7.0 Staff Sickness


Category Type

Actual








Family Division - Family Planning Community Dashboard 2014_15



Actual13_14

864 876 785 757 722 656 693 673 577 726 638 744

Actual14_15

719 677 754

Target14_15

726 726 726 726 726 726 726 726 726 726 726 726

0

100

200

300

400

500

600

700

800

900

1,000

1.0 Attendances


Actual13_14

Actual14_15

Target14_15

10.0% 10.0% 10.0% 10.0% 10.0% 10.0% 10.0% 10.0% 10.0% 10.0% 10.0% 10.0%

0.0%

2.0%

4.0%

6.0%

8.0%

10.0%

12.0%

6.0 Staff Turn-Over


Actual13_14

Actual14_15

Target14_15

3.75% 3.75% 3.75% 3.75% 3.75% 3.75% 3.75% 3.75% 3.75% 3.75% 3.75% 3.75%

0.0%

0.5%

1.0%

1.5%

2.0%

2.5%

3.0%

3.5%

4.0%

7.0 Staff Sickness


Category Type

Actual




7.0 Staff Sickness 7.5% 3.8% 1.2% 3.8% 3.7% 0.0% 0.0%




Family Division - The Parallel Community Dashboard 2014_15


Actual13_14

931 779 587 851 508 682 466 503 607 842 620 691

Actual14_15

595 516 548

Target14_15

931 779 587 851 508 682 466 503 607 842 620 691

0

100

200

300

400

500

600

700

800

900

1,000

1.0 Attendances

Actual13_14

Actual14_15

Target14_15

10.0% 10.0% 10.0% 10.0% 10.0% 10.0% 10.0% 10.0% 10.0% 10.0% 10.0% 10.0%

0.0%

2.0%

4.0%

6.0%

8.0%

10.0%

12.0%

6.0 Staff Turn-Over

Actual13_14

5.20% 4.20% 4.42% 4.20% 4.96% 11.66% 22.91% 7.10% 5.81% 4.44% 4.34% 11.20%

Actual14_15

3.66% 0.00% 0.00%

Target14_15

3.75% 3.75% 3.75% 3.75% 3.75% 3.75% 3.75% 3.75% 3.75% 3.75% 3.75% 3.75%

0.0%

5.0%

10.0%

15.0%

20.0%

25.0%

7.0 Staff Sickness

Actual13_14

Actual14_15

Target14_15

10.0% 10.0% 10.0% 10.0% 10.0% 10.0% 10.0% 10.0% 10.0% 10.0% 10.0% 10.0%

0.0%

2.0%

4.0%

6.0%

8.0%

10.0%

12.0%



Category Type

Actual



2.0 DNAs 147 147 15 12 2 3 10

3.0 DNA Rate % 1.5% 1.5% 0.7% 1.5% 0.3% 0.5% 1.2%






Family Division - GUM Community Dashboard 2014_15



Actual13_14

909 855 794 853 831 849 905 777 797 706 671 750

Actual

14_15630 560 836

Target

14_15808 808 808 808 808 808 808 808 808 808 808 808

0

100

200

300

400

500

600

700

800

900

1,000

1.0 Attendances


Actual

13_1416 16 23 15 8 12 19 5 4 8 9 12

Actual

14_152 3 10

Target

14_1512 12 12 12 12 12 12 12 12 12 12 12

0

5

10

15

20

25

2.0 DNAs


Actual13_14

Actual14_15

Target

14_1510.0% 10.0% 10.0% 10.0% 10.0% 10.0% 10.0% 10.0% 10.0% 10.0% 10.0% 10.0%

0.0%

2.0%

4.0%

6.0%

8.0%

10.0%

12.0%

6.0 Staff Turn-Over


Actual

13_14

Actual14_15

Target

14_153.75% 3.75% 3.75% 3.75% 3.75% 3.75% 3.75% 3.75% 3.75% 3.75% 3.75% 3.75%

0.0%

0.5%

1.0%

1.5%

2.0%

2.5%

3.0%

3.5%

4.0%

7.0 Staff Sickness


Category Type

Actual



2.0 DNAs 338 338 82 28 33 29 20

3.0 DNA Rate % 0.7% 0.7% 0.8% 0.7% 0.9% 0.8% 0.6%

Referrals4.0 GP 15 15 4 1 2 1 1

5.0 Other 2618 2618 495 218 150 167 178


7.0 Staff Sickness 5.9% 3.8% 3.0% 3.8% 2.9% 3.2% 2.8%




Family Division - School Nursing Community Dashboard 2014_15


Actual13_14

4723 3400 4452 2112 892 2294 6379 5374 3746 4772 3912 5362

Actual14_15

3825 3534 3366

Target14_15

4723 3400 4452 2112 892 2294 6379 5374 3746 4772 3912 5395

0

1,000

2,000

3,000

4,000

5,000

6,000

7,000

1.0 Attendances

Actual13_14

21 31 48 26 18 29 36 32 28 27 21 21

Actual14_15

33 29 20

Target14_15

21 31 48 26 18 29 36 32 28 27 21 21

0

10

20

30

40

50

60

2.0 DNAs

Actual13_14

2 2 1 0 0 3 1 4 1 1 0 0

Actual14_15

2 1 1

Target14_15

2 2 1 0 0 3 1 4 1 1 0 0

0

1

2

3

4

5

6

7

8

9

10

4.0 GP Referrals

Actual13_14

Actual14_15

Target14_15

10.0% 10.0% 10.0% 10.0% 10.0% 10.0% 10.0% 10.0% 10.0% 10.0% 10.0% 10.0%

0.0%

2.0%

4.0%

6.0%

8.0%

10.0%

12.0%

6.0 Staff Turn-Over

Actual13_14

8.47% 10.68% 7.52% 4.33% 4.50% 5.93% 6.63% 3.52% 4.89% 5.20% 5.53% 3.85%

Actual14_15

2.92% 3.19% 2.75%

Target14_15

3.75% 3.75% 3.75% 3.75% 3.75% 3.75% 3.75% 3.75% 3.75% 3.75% 3.75% 3.75%

0.0%

2.0%

4.0%

6.0%

8.0%

10.0%

12.0%

7.0 Staff Sickness


Category Type

Actual



2.0 DNAs 3 3 6 0 0 0 6

3.0 DNA Rate % 0.1% 0.1% 0.7% 0.1% 0.0% 0.0% 2.7%

Referrals4.0 GP 0 0 0 0 0 0 0

5.0 Other 145 145 12 12 6 6


7.0 Staff Sickness 15.5% 3.8% 3.8% 0.0% 0.0% 0.0%




Family Division - Special School Nursing Community Dashboard 2014_15


Actual13_14

587 483 616 417 2 469 356 340 260 536 332 509

Actual14_15

250 377 216

Target14_15

587 483 616 417 2 469 356 340 260 536 333 510

0

100

200

300

400

500

600

700

1.0 Attendances

Actual13_14

0 0 0 3 0 0 0 0 0 0 0 0

Actual14_15

0 0 6

Target14_15

0 0 0 3 0 0 0 0 0 0 0 0

0

1

2

3

4

5

6

7

2.0 DNAs

Actual13_14

0 0 0 0 0 0 0 0 0 0 0 0

Actual14_15

0 0 0

Target14_15

0 0 0 0 0 0 0 0 0 0 0 0

0

0

0

0

0

1

1

1

1

1

1

4.0 GP Referrals

Actual13_14

Actual14_15

Target14_15

10.0% 10.0% 10.0% 10.0% 10.0% 10.0% 10.0% 10.0% 10.0% 10.0% 10.0% 10.0%

0.0%

2.0%

4.0%

6.0%

8.0%

10.0%

12.0%

6.0 Staff Turn-Over

Actual13_14

20.77% 20.20% 20.20% 20.20% 20.20% 20.77% 21.07% 20.20% 20.20% 2.38% 0.00% 0.00%

Actual14_15

0.00% 0.00% 0.00%

Target14_15

3.75% 3.75% 3.75% 3.75% 3.75% 3.75% 3.75% 3.75% 3.75% 3.75% 3.75% 3.75%

0.0%

5.0%

10.0%

15.0%

20.0%

25.0%

7.0 Staff Sickness


Category Type

Actual


Activity 1.0 Actual 4 Week Quitters 1176 1176 68 100 49 19

Elective Division -Smoking Cessation Community Dashboard 2014_15


Actual13_14

139 129 96 94 115 98 109 84 61 109 62 80

Actual14_15

49 19

Target14_15

100 100 100 100 100 100 100 100 100 100 100 100

0

20

40

60

80

100

120

140

160

1.0 Actual 4 week quitters


Category Type

Actual


Activity 1.0 Actual Attendances 4541 4541 1242 379 387 444 411

Adult Acute Division - Emergency Dental Community Dashboard 2014_15


Actual13_14

405 419 374 359 383 378 381 349 352 363 353 425

Actual14_15

387 444 411

Target14_15

379 379 379 379 379 379 379 379 379 379 379 379

0

50

100

150

200

250

300

350

400

450

500

1.0 Actual Attendances


Category Type

Actual



2.0 DNAs 3743 3743 919 312 412 252 255

3.0 DNA Rate % 4.0% 4.0% 3.8% 4.0% 4.7% 3.3% 3.3%

Referrals4.0 GP 0 0 67 0 33 17 17

5.0 Other 7737 7737 1926 645 719 604 603


7.0 Staff Sickness 5.6% 3.8% 2.7% 3.8% 2.3% 2.2% 3.6%




Family Division - Health Visiting Community Dashboard 2014_15



Actual13_14

7869 7591 6441 7916 7158 7651 8419 7900 5491 9388 7267 7581

Actual14_15

8307 7300 7481

Target14_15

7564 7564 7564 7564 7564 7564 7564 7564 7564 7564 7564 7564

0

1,000

2,000

3,000

4,000

5,000

6,000

7,000

8,000

9,000

10,000

1.0 Attendances


Actual13_14

343 313 236 372 308 259 351 373 252 330 306 300

Actual14_15

412 252 255

Target14_15

311 311 311 311 311 311 311 311 311 311 311 311

0

50

100

150

200

250

300

350

400

450

2.0 DNAs


Actual13_14

0 0 0 0 0 0 0 0 0 0 0 0

Actual14_15

33 17 17

Target14_15

0 0 0 0 0 0 0 0 0 0 0 0

0

5

10

15

20

25

30

35

4.0 GP Referrals


Actual13_14

Actual14_15

Target14_15

10.0% 10.0% 10.0% 10.0% 10.0% 10.0% 10.0% 10.0% 10.0% 10.0% 10.0% 10.0%

0.0%

2.0%

4.0%

6.0%

8.0%

10.0%

12.0%

6.0 Staff Turn-Over


Actual13_14

6.77% 8.26% 6.62% 5.94% 6.36% 4.52% 8.25% 6.50% 4.49% 3.47% 3.26% 2.54%

Actual14_15

2.31% 2.16% 3.62%

Target14_15

3.75% 3.75% 3.75% 3.75% 3.75% 3.75% 3.75% 3.75% 3.75% 3.75% 3.75% 3.75%

0.0%

1.0%

2.0%

3.0%

4.0%

5.0%

6.0%

7.0%

8.0%

9.0%

7.0 Staff Sickness


Actual13_14

Actual14_15

Target14_15

10.0% 10.0% 10.0% 10.0% 10.0% 10.0% 10.0% 10.0% 10.0% 10.0% 10.0% 10.0%

0.0%

2.0%

4.0%

6.0%

8.0%

10.0%

12.0%



Category Type

Actual



2.0 DNAs 0 0 0 0 0 0 0

3.0 DNA Rate % 0.0% 0.0% 0.0% 0.0% 0.0% 0.0% 0.0%

Referrals4.0 GP 0 0 0 0 0 0 0

5.0 Other 0 0 0 0 0 0 0


7.0 Staff Sickness 7.8% 3.8% 10.9% 3.8% 11.4% 11.4% 9.7%




Family Division - School Nursing Immunisations Community Dashboard 2014_15


Actual13_14

1042 877 779 145 90 852 1030 1172 619 1269 991 462

Actual14_15

619 651 617

Target14_15

1042 877 779 145 90 852 1030 1172 619 1269 991 561

0

200

400

600

800

1,000

1,200

1,400

1.0 Attendances

Actual13_14

0 0 0 0 0 0 0 0 0 0 0 0

Actual14_15

0 0 0

Target14_15

0 0 0 0 0 0 0 0 0 0 0 0

0

1

2

3

4

5

6

7

8

9

10

2.0 DNAs

Actual13_14

0 0 0 0 0 0 0 0 0 0 0 0

Actual14_15

0 0 0

Target14_15

0 0 0 0 0 0 0 0 0 0 0 0

0

1

2

3

4

5

6

7

8

9

10

4.0 GP Referrals

Actual13_14

Actual14_15

Target14_15

10.0% 10.0% 10.0% 10.0% 10.0% 10.0% 10.0% 10.0% 10.0% 10.0% 10.0% 10.0%

0.0%

2.0%

4.0%

6.0%

8.0%

10.0%

12.0%

6.0 Staff Turn-Over

Actual13_14

0.38% 0.00% 1.29% 0.00% 1.56% 7.37% 12.90% 14.29% 14.29% 13.03% 11.43% 17.62%

Actual14_15

11.43% 11.43% 9.71%

Target14_15

3.75% 3.75% 3.75% 3.75% 3.75% 3.75% 3.75% 3.75% 3.75% 3.75% 3.75% 3.75%

0.0%

2.0%

4.0%

6.0%

8.0%

10.0%

12.0%

14.0%

16.0%

18.0%

20.0%

7.0 Staff Sickness


Category Type

Actual



2.0 DNAs 49 49 15 4 6 3 6

3.0 DNA Rate % 0.8% 0.8% 1.0% 0.8% 1.3% 0.6% 1.3%


7.0 Staff Sickness 5.6% 3.8% 2.7% 3.8% 2.3% 2.2% 3.6%




Family Division - New Born Hearing Community Dashboard 2014_15



Actual

13_14505 521 475 512 516 525 561 495 553 538 438 494

Actual14_15

459 513 471

Target

14_15511 511 511 511 511 511 511 511 511 511 511 512

0

100

200

300

400

500

600

1.0 Attendances


Actual

13_146 5 3 2 5 3 4 3 6 3 5 4

Actual

14_156 3 6

Target

14_154 4 4 4 4 4 4 4 4 4 4 4

0

1

2

3

4

5

6

7

2.0 DNAs


Actual

13_14

Actual14_15

Target

14_1510.0% 10.0% 10.0% 10.0% 10.0% 10.0% 10.0% 10.0% 10.0% 10.0% 10.0% 10.0%

0.0%

2.0%

4.0%

6.0%

8.0%

10.0%

12.0%

6.0 Staff Turn-Over


Actual

13_140.00% 0.00% 13.74% 19.84% 3.60% 5.84% 0.00% 0.64% 5.09% 0.75% 0.00% 0.00%

Actual

14_1512.89% 4.03% 0.00%

Target14_15

3.75% 3.75% 3.75% 3.75% 3.75% 3.75% 3.75% 3.75% 3.75% 3.75% 3.75% 3.75%

0.0%

5.0%

10.0%

15.0%

20.0%

25.0%

7.0 Staff Sickness


Category Type

Actual



2.0 DNAs 4 4 1 0 0 1 0

3.0 DNA Rate % 0.3% 0.3% 0.8% 0.3% 0.0% 3.6% 0.0%

Referrals4.0 GP 2 2 0 0 0 0 0

5.0 Other 61 61 9 5 5 2 2


7.0 Staff Sickness 8.53% 3.75% 3.75% 0.00% 0.00% 0.00%




Adult Acute Division - Asylum Seekers Community Dashboard 2014_15


Actual13_14

78 73 113 179 65 127 191 97 85 153 111 46

Actual14_15

82 27 11

Target14_15

111 111 111 111 111 111 111 111 111 111 111 111

0

50

100

150

200

250

1.0 Attendances

Actual13_14

0 0 0 1 0 0 0 0 0 0 3 0

Actual14_15

0 1 0

Target14_15

0 0 0 0 0 0 0 0 0 0 0 0

0

1

2

3

4

5

6

7

8

9

10

2.0 DNAs

Actual13_14

2 0 0 0 0 0 0 0 0 0 0 0

Actual14_15

0 0 0

Target14_15

1 1 1 1 1 1 1 1 1 1 1 1

0

1

2

3

4

5

6

7

8

9

10

4.0 GP Referrals

Actual13_14

Actual14_15

Target14_15

10.0% 10.0% 10.0% 10.0% 10.0% 10.0% 10.0% 10.0% 10.0% 10.0% 10.0% 10.0%

0.0%

2.0%

4.0%

6.0%

8.0%

10.0%

12.0%

6.0 Staff Turn-Over

Actual13_14

0.00% 0.00% 0.00% 0.00% 0.00% 0.00% 0.00% 4.00% 13.55% 25.68% 33.33% 25.81%

Actual14_15

0.00% 0.00% 0.00%

Target14_15

3.75% 3.75% 3.75% 3.75% 3.75% 3.75% 3.75% 3.75% 3.75% 3.75% 3.75% 3.75%

0.0%

5.0%

10.0%

15.0%

20.0%

25.0%

30.0%

35.0%

7.0 Staff Sickness


Category Type

Actual



2.0 DNAs 8 8 3 1 0 2 1

3.0 DNA Rate % 3.1% 3.1% 4.1% 3.1% 0.0% 11.1% 3.0%

Referrals4.0 GP 0 0 13 0 1 6 6

5.0 Other 164 164 42 14 18 13 11






U

Adult Acute Division - Elderly Medicine Community Dashboard 2014_15




0

100

200

300

400

500

600

700

1.0 Attendances

Actual_13_14 14 14 20 14 12 24 17 11 11 11 14 16

Actual 14_15 12 4 13

Target_14_15

0

5

10

15

20

25

30

2.0 DNAs

Actual13_14

32 34 38 35 27 38 41 34 32 52 60 34

Actual14_15

37 41 43

Target14_15

0

10

20

30

40

50

60

70

4.0 GP Referrals

Actual13_14

12 25 28 29 13 21 28 17 25 27 18 11

Actual14_15

23 16 32

Target14_15

22 22 22 22 22 22 22 22 22 22 22 22

0

5

10

15

20

25

30

35

1.0 Attendances

Actual13_14

1 0 0 1 0 1 1 1 0 3 0 0

Actual14_15

0 2 1

Target14_15

1 1 1 1 1 1 1 1 1 1 1 1

0

1

1

2

2

3

3

4

2.0 DNAs

Actual13_14

0 0 0 0 0 0 0 0 0 0 0 0

Actual14_15

1 6 6

Target14_15

0 0 0 0 0 0 0 0 0 0 0 0

0

1

2

3

4

5

6

7

4.0 GP Referrals

Actual13_14

Actual14_15

Target14_15

10.0% 10.0% 10.0% 10.0% 10.0% 10.0% 10.0% 10.0% 10.0% 10.0% 10.0% 10.0%

0.0%

2.0%

4.0%

6.0%

8.0%

10.0%

12.0%

6.0 Staff Turn-Over

Actual13_14

Actual14_15

Target14_15

3.75% 3.75% 3.75% 3.75% 3.75% 3.75% 3.75% 3.75% 3.75% 3.75% 3.75% 3.75%

0.0%

0.5%

1.0%

1.5%

2.0%

2.5%

3.0%

3.5%

4.0%

7.0 Staff Sickness


Committee Chair Report

Name of Committee: Finance & Investment Committee

Date of Meeting: 17th July 2014

Report to: Board of Directors

Chair: Allan Duckworth

Key Issues Discussed

Month 3 financial performance

Community Services – Financial Position

Divisional Financial Management Framework

Planning assumptions and process to update medium term efficiency plan

Healthier Together impact review

Review of quarterly risk rating forecast to Monitor

Estates & IT Strategy – Business Case Update

Risks Identified/Further Assurance

The Executive provided the Committee with assurance that the planned £1.6m outturn is still on track to be achieved. It will not, however, be achieved in line with the original plan, and the potential impact of this needs to be understood. A “deep dive” review will be undertaken in October once the first six months’ results are known and an assessment made of the impact on subsequent years of the longer term financial plan.

The Estates & IT Strategy business cases will be submitted to Monitor at the end of July as previously agreed, on a business continuity basis. Phase 2 for the Digital Trust will be produced at a date to be decided and will consider various options, including outsourcing and/or shared services with neighbouring Trusts.

Apologies received from: No apologies received.

Date of next meeting Tuesday 19th August at 9.30am in the Boardroom


Name of Committee: Quality Assurance Committee

Date of Meeting: 9th July 2014


Chair: Ebrahim Adia


Medical Devices audit

CAMHS update on actions taken and KPI’s

Quality Strategy Update

Leavers and Turnovers

Medication Report

Quality Dashboard and heat map

Patient experience update

WHO checklist

Quarterly divisional assurance report

Comparative incident data

Ophthalmic wrong implant never event – immediate steps paper

Learning from incidents, claims, HM coroners and complaints

Responding to abnormal test results

Decisions/Approvals

Approved revised format of divisional quality reports.


A further assurance report on medication will be provided at the next meeting.

Apologies received from: Gina Ashworth, David Wakefield, Brian Smith, Caroline

Greenhalgh, Bev Tabernacle, Michelle Redgard, Linda Woods and Cheryl Casey.

Date of next meeting: 13th August 2014


Name of Committee: Charitable Fund Committee

Date of Meeting: 25th June 2014


Chair: Ebrahim Adia


It was agreed that the Committee would support the bid for a Portable Ultrasound Scanner subject to the clarification of a few queries. The job description and person specification for the Fundraising Co-ordinator was approved. The Committee’s Terms of Reference were reviewed and approved with minor changes. The committee agreed to appoint KPMG as the auditors for the Charitable Funds. The Committee endorsed the decisions made by the Staff Awards Planning group.


Apologies received from: Linda Woods

Date of next meeting: Wednesday 24th September at 3pm in the Boardroom

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