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Board of Directors Thursday 01 February 2018

08:30am

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

Board of Directors

Quality Committee

Finance & Performance Committee

Nomination / Remuneration

Committee

Audit Committee

Board of Directors

Meeting Board of Directors Meeting

Location Boardroom, Sceptre Point

Date Thursday, 01 February 2018

Time 08:30am Formal Public Board meeting

13:30pm – 14:30pm Board Development Session

Reference Item Lead Action Enc. FOIA

PART ONE (PUBLIC MEETING) 08:30 AM

TB 019/18 Apologies for absence and confirmation of quoracy

Chair Verbal

TB 020/18 Declarations of Interest Chair Verbal

TB 021/18 Minutes of the previous meetings Chair Decision Paper

TB 022/18 Action Tracker Chair Decision Paper

SCRUTINY & ASSURANCE

TB 023/18 Trust Chair’s Report Chair Noting Paper

TB 024/18 Chief Executive’s Report Chief Executive Discussion Paper

TB 025/18 Audit Committee Chair’s Report Committee Chair Noting Paper

TB 026/18 Quality Committee Chair’s Report Committee Chair Noting Paper

TB 027/18 Finance and Performance Committee Chair’s Report

Committee Chair Noting Paper

TB 028/18 Quality Report Director of Nursing Decision Paper

TB 029/18 Finance Report Chief Finance Officer Noting Paper

TB 030/18 Performance Report Chief Operating Officer Noting Paper

TB 031/18 Patient Story Director of Nursing Noting Pres

TB 032/18 GDPR Chief Finance Officer Noting Paper &

Pres

TB 033/18 Quarterly Workforce Report Director of HR Noting Paper

TB 034/18 Board Assurance Framework Associate Director of Risk and Assurance

Decision Paper

TB 035/18 Any Other Business Chair Verbal

PART TWO (PRIVATE MEETING)

TB 036/18 Minutes of the last meeting Chair Decision Paper

TB 037/18 Chief Executive Report Chief Executive Noting Paper to

follow

TB 038/18 Mental Health and New

Models of Care Chief Operating Officer

Discussion Pres.

TB 039/18 Disposals Update Chief Finance Officer Decision Paper

TB 040/18 Any Other Business Chair Verbal

TB 041/18 Date & Time of the Next Meeting

01 March 2018, 8.30am

Chair Verbal

CLOSE OF BOARD MEETING

Reference Item Lead Action Enc. FOIA

BOARD DEVELOPMENT

TB 042/18 Mental Health Act Development Session

Externally Facilitated Session

Discussion

Declaration of Interest – Board of Directors

Date of Declaration Surname First

Name Job Title Nature of Interest

Do you envisage a conflict of interest between outside employment and

your NHS employment?

Nil Declaration

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

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

06/02/2017 Tierney-Moore Heather Chief Executive

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

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

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

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

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

Progress Housing Group called Concert Living Limited

5. Director of Red Rose Corporate Services

No

29/03/2017 Dickinson Louise Non-Executive Director

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

St.Vincents Primary School

No

03/02/2017 Wilson Isla Non-Executive Director

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

Associates 5. Non Exec Director for Healthier Lancashire &

South Cumbria STP

No

Declaration of Interest – Board of Directors

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

Limited 2. Clinical Associate at MIAA (Advisory Section)

No

07/02/2017 Gregory Bill Chief Finance Officer

1. Trustee of Healthcare Financial Management Association

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

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

No

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

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

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

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

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

06/02/2017 Marshall Max Medical Director

06/02/2017 Moore Sue Chief Operating Officer

07/02/2017 Gallagher Damian Director of HR

BOARD OF DIRECTORS

Minutes of the Part One Board of Directors Meeting held on 04 January 2018 Training Rooms 1 & 2, The Harbour

PRESENT: David Eva, Trust Chair (Chair) Heather Tierney Moore, Chief Executive Gwynne Furlong, Deputy Chair Max Marshall, Medical Director Bill Gregory, Chief Finance Officer Sue Moore, Chief Operating Officer Louise Dickinson, Non-Executive Director Isla Wilson, Non-Executive Director David Curtis, Non-Executive Director Jo Alker, Company Secretary

IN ATTENDANCE: Steve Tingle, Head of Operations, Children and Young People Network Matthew Joyes, Associate Director of Safety & Quality Governance

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

TB 001/18 WELCOME & OPENING COMMENTS

The Chair welcomed everyone to the meeting.

TB 002/18 APOLOGIES FOR ABSENCE & CONFIRMATION OF QUORACY Apologies for absence were received from Julia Possener, Non-Executive Director, Damian Gallagher, Director of HR and Dee Roach, Director of Nursing.

It was noted that apologies were also received from Teresa Jennings, Nominated Governor and Deborah Cox, Deputy Director of HR who was due to deputise for the Director of HR. Matthew Joyes was also in attendance, deputising for the Director of Nursing.

Confirmation of quoracy was provided.

TB 003/18 DECLARATIONS OF INTEREST There were no declarations of interest. However, Non-Executive Director, Isla Wilson confirmed that an updated declaration of interest had been submitted following her recent appointment as Non-Executive Director of Healthier Lancashire and South Cumbria STP. It was also noted that the declaration of interest for Gwynne Furlong, Non-Executive Director required updating to note his position as Director of Red Rose Corporate Services. Finally, the declaration of interest for Peter Ballard required removal following his departure from the Trust.

TB 004/18 MINUTES OF THE PREVIOUS MEETING

The minutes of the previous meeting held on 07 December 2017 were approved as a true and accurate record.

TB 005/18 ACTION TRACKER

The Board reviewed the action tracker and provided updates in respect of the open actions.

TB 006/18 TRUST CHAIR’S REPORT The Chair presented his report which included an overview of the activity of both Non-Executive Directors and Governors. The Chair drew the Board’s attention to

UNCONFIRMED

the recommendation from the Audit Committee that the counter fraud contract provided by MIAA be extended for a further two years with effect from 01 April 2018. The Board noted the content of the Chair’s Report and approved the extension of the MIAA contract for a further two years in line with the Decision Rights Framework, ref 5.5.

TB 007/18 CHIEF EXECUTIVE’S REPORT The Chief Executive introduced her report, a key highlight of which included the improvements following reporting issues identified in the Early Intervention Service (EIS). Following a question from a Non-Executive Director in respect of the timings of the fact finding review, the Company Secretary confirmed that this would be finalised within the next two weeks, following which any actions and recommendations would be presented to Board. ACTION The Chief Executive provided an update in respect of the LCIA Test Bed and confirmed that Philips UKI had decided to withdraw the Motiva telehealth product. This means that it will close its existing UK customer accounts, and would not be extending its contract with the Lancashire and Cumbria Innovation Alliance within the NHS England test-bed programme beyond 31 March 2018. The Chief Executive confirmed that the impact of this was currently being discussed with both NHS England and Philips. The Chief Executive drew the Board’s attention to the immense pressure that the NHS continued to experience and reflected on previous discussions at Board regarding winter preparedness. The work that had taken place within the networks was highlighted, including the implementation of both Gold Command and the integrated discharged team, which had enabled the Trust to address the challenges over the Christmas period.

TB 008/18 QUALITY REPORT

The Associate Director of Safety and Quality Governance introduced the report and drew the Board’s attention to the continued challenge in respect of violence on inpatient units and the increase in the use of restraint, which highlighted a clear correlation. Whilst various improvement initiatives were underway, the ABI service had seen particular success following the introduction of positive behaviour plans. In recognition of the need to take stock of the continuing challenge to deliver improvement, the Associate Director confirmed that he had commissioned a full review of the total approach to violence reduction and management within the Trust with a view to a refreshed programme being launched in April 2018. In addition, the Quality and Safety Sub-committee were receiving a series of deep dive presentations into violence and restrictive practices across inpatient units utilising an internal benchmarking format. The Board noted the slight increase in the number of serious incidents. This was against the backdrop of a sustained reduction over recent years and likely reflected a plateau of that reduction with a new average of eight serious incidents per month. The Mental Health Harm Free Care rate remained below the Trust aspiration and correlated with the high levels of violence and aggression on the inpatient wards.

Whilst there had been a notable increase in complaints, this position is reflected nationally, and is also considered to be partly attributable to the new hearing feedback model where the Trust has been actively seeking out feedback from people who use services, their families and carers. There remained a challenge around the timing of responses; however, this piece of work was being closely monitored by the Nursing and Quality Directorate and work was underway to improve the level of response rate. In relation to mandatory training, there remained areas of under-performance in some core skills and essential skills subjects and whilst the number of overdue incident reports was increasing there was focussed pieced of work underway to address this. The Board’s attention was drawn to the quality plan and the work that was underway to address the areas reported as off track, in particular the development work to capture supervision. The Associate Director confirmed that the reduction in pressure ulcers had been a particular area of focus within the Trust and as a result had seen significant reductions. The Trust had also seen a reduction in red flag incidents following increased scrutiny and the Friends and Family Test results had also remained positive. The Chair raised concern in respect of the percentage of patients being given their rights within 24 hours of admission. The Associate Director re-assured the Chair that patients were always given a written copy of their rights; however, they were not always provided with them verbally within the 24 hour period or recorded as such. Work was currently underway with the lead nurses in each area to understand what the barriers were. The Associate Director agreed to explore the potential of the NerveCentre to support team’s compliance. ACTION The Board noted the content of the Quality Report.

TB 009/18 PERFORMANCE REPORT

The Chief Operating Officer presented the Performance Report for month 8 and confirmed that the Trust was compliant with all NHS Improvement indicators with the exception of performance against the Early Intervention in Psychosis (EIS) two week target. Whilst the Trust was actively monitoring new patients, there was a legacy of patients that impacted on the overall position. Key highlights from the report were outlined which included the development over future months of the Board Balanced Scorecard to include a summary of the 5YFV dashboard of performance metrics. Work had been conducted on the new NHSI measure for inappropriate Out of Area Placements. A trajectory had been submitted by the STP and the performance against trajectory would be included in the QPR from next month. Discussions had taken place with NHSI and NHSE regarding the application of the definition to ensure appropriate interpretation and reporting. Following the request at the previous Board meeting to review IAPT waiting times, the Chief Operating Officer confirmed that a deep dive into service users waiting over 26 weeks had been undertaken and was therefore confident that the number of patients waiting over 26 weeks would be recovered. This was therefore not raised as an issue.

The Chief Operating Officer provided an update in relation to the improvement seen in the four hour target which demonstrated the positive contribution the Trust was making as a result of the early investment that had been secured around Core 24. Additionally, the introduction of the Integrated Discharge Team has resulted in a number of avoided admissions. Whilst there had been improvement in the attendance of Local Care Co-ordinators at Secure Inpatient CPA Reviews, this still remained an issue. However, work was ongoing with Service Managers in order to allocate attendees to all Secure Inpatient CPA Reviews. Following a query from a Non-Executive Director in respect of the 5YFV dashboard, the Chief Operating Officer confirmed that the first three metrics were as a result of the changes to the Single Oversight Framework and linked to the Children and Young People Transition Board. The target for Inappropriate OAPs was a new target; however, in respect of the MHSDS Data Quality Maturity Index target, the Chief Operating Officer would need to ascertain further detail.

The Chief Operating Officer responded to Non-Executive Director, Louise Dickinson’s concern regarding the number of PACE breaches and confirmed that a meeting was due to be held with the Police to discuss the breaches and the number of late referrals the Trust had received. In addition, the team from the Hub would be visiting the custody suites to appreciate the environment in which people were waiting. Following concern from Non-Executive Director, Louise Dickinson in respect of the increase in sickness rates within the Trust, it was agreed that this would be discussed further at a future Board meeting when the Director of HR was present. ACTION The Chief Operating Officer confirmed that this was a key domain within the Business Development & Delivery meeting. The Board noted the Performance Report for month 8.

TB 010/18 FINANCE REPORT

The Chief Finance Officer presented the Finance Report for month 8 which highlighted a year to date operating deficit of -£1.9m, excluding planned Sustainability and Transformation funding of £1.1m, against a planned surplus to date of £0.9m. Whilst there had been further improvements in month of £300k the position continued to be driven by staffing pressures, particularly within secure services. Other key highlights included the new Use of Resources (UoR) metric which was rated at 2 and saw an improvement from month 7 (rated at 3). The Chief Finance Officer confirmed that progress against the capital programme had been slow to date. With the resolution of a number of issues, the Trust was working with contractors to minimise the impact of delays on the programme. External cash funding was provisionally allocated to the Inpatient project through the STP and was approved by NHSI in October. Additional information and governance requirements were subsequently added by and provided to DH, and final approval remains to be confirmed. The Chief Finance Officer drew the Board’s attention to the Financial Recovery Plan and highlighted the key risks that related to delivery and timing. The plan would continue to be refined and presented in more detail to the Financial Recovery Group along with any actions.

The Chief Finance Officer highlighted a risk in respect of invoicing for non-contracted activity. Having previously received mediation, the CCGs had since raised concerns in respect of the legitimacy of doing this. Following a question from a Non-Executive Director regarding winter monies, the Chief Finance Officer confirmed that the Trust had been successful in securing additional funding. The Chief Operating Officer confirmed that the money was held centrally and would be released once the names and additional hours worked within the network had been obtained. A discussion followed in respect of the control total. The Chief Finance Officer confirmed that whilst next year’s control total was set, a discussion had been held with NHSI following the loss of the universal services tender and the Trust had been requested to write formally to NHSI to outline the issues and request that the control total be reviewed. The Board noted the month 8 finance position.

TB 011/18 ANY OTHER BUSINESS There was no other business to discuss.

TB 012/18 DATE AND TIME OF NEXT MEETING 01 February 2018, 08:30am Training Rooms 1 & 2, The Harbour

Board of Directors Agenda Item TB 023/18 Date: 01/02/2018

Report Title Trust Chairs Report

FOIA Exemption No Exemption

Prepared by Louise Dole, Corporate Governance Support

Presented by David Eva, Trust Chair

Action required Noting

Supporting Executive Director Chief Executive PURPOSE OF THE REPORT: Report purpose The purpose of the report is to provide the Board with an

overview of the activity undertaken by the Board and Non-Executive Directors in addition to the Board of Director meetings and Council of Governor meetings.

Strategic Objective(s) this work supports

To become recognised for excellence

Board Assurance Framework risk 1.1 If we do not meet regulatory standards for quality and safety we will not be fit for purpose as a care provider.

CQC domain Well-led 1.0 NON-EXECUTIVE DIRECTOR ACTIVITY

The Non-Executive Directors have been attending the Board Committee meetings of which they are a member (including the Financial Recovery Group) and apologies have been given where they were unable to attend. In addition to the usual Board business, Non-Executive Directors (NEDs) have been involved in their areas of special interest during the period of January 2018 – February 2018 Gwynne Furlong Attended the Quality Committee Meeting Met with the HR Recruitment Manager to discuss accommodation for international

candidates Attended the Financial Recovery Group Attended an ALC Shadow Board Meeting Attended the Land Committee Meeting Met with the Finance and Performance Committee Board Attended the RRCS Board Meeting Met with the Director of Finance Attended a meeting regarding STP Estates Proposition Attended the Quality Committee effectiveness review meeting

Louise Dickinson Attended the Finance Recovery Group Attended the Audit Committee Meeting Met with MIAA to discuss the Audit Plan

Julia Possener Met with the Company Secretary and Deputy Company Secretary to discuss the Quality

and Assurance Committee Met with the Trust Chair Attended a staff briefing within the Children and Young People’s Wellbeing Network with

the Head of Operations Attended the Quality Committee effectiveness review meeting Attended the Audit Committee Met with MIAA to discuss the Audit Plan

David Curtis Met with the Director of Nursing Attended the Serious Incidents Learning Panel Chaired the Quality Committee Met with a member of staff Attended the Financial Recovery Group Attended an event which was held around patient safety Attended the Quality Committee effectiveness review meeting Met with MIAA to discuss the Audit Plan

Isla Wilson Telephone discussion with the Chief Operating Officer Attended the Quality Committee Attended a meeting to discuss STP Strategy Attended the Financial Recovery Group

2.0 CHAIRS ACTIVITY

Attended January’s Board meeting Held several internal meetings with the Chief Executive, Company Secretary, Board

members and other senior colleagues Attended external meetings including the Partnership Leader’s meeting Continues to meet with MPs and local authority members Attended the STP/Strategy Meeting Attended locality meeting for Pennine and North and Central and West Attended the induction day for the newly appointed governors

3.0 COUNCIL OF GOVERNORS UPDATE

This section has been added to the Chair’s Report in order to keep the Board updated on Council of Governor activity, recognising that since 01 April 2017, Board members have been attending meetings on an invitation basis. GOVERNOR ELECTIONS The Governor Election process has now closed and the following governors have been elected;

Public Governors Constituency Christine Cartwright Central Lancashire

Paul Graham Pennine Lancashire Chris Burgess West Lancashire

Ken Lowe West Lancashire Mary Jackson North Lancs and South Cumbria John Walden North Lancs and South Cumbria Michael Helm North Lancs and South Cumbria

Staff Governor Constituency

Gina Gasson Class 5 - Admin & Clerical

Judy Laing Class 3 – Nursing professions and support staff

Sallyann Walker Class 2 - Other clinical and social care professionals and clinical support staff

The newly elected Governors attended an induction day that was held on the 24 January, chaired by the Trust Chair.

4.0 USE OF THE COMMON SEAL To inform the Board that the Common Seal has been used as follows since the Board of Directors meeting on the 04 January 2018. 18/01/2018 – Supplemental Lease of car park. Fylde Road Industrial Estate, Between

Limeoak Properties and Lancashire Care

18/01/2018 – Collective funding agreement to cover the costs of GVA if they were to go into bankruptcy – over seen by Director of Finance

18/01/2018 – Lease of part of Ashton Health Centre, Pedders Lane, Ashton, Preston between NHS Property Services LTD and Lancashire Care

18/01/2018 – Licence for alterations of part of Ashton Health Centre, Pedders Lane, Ashton, Preston

18/01/2018 – Lease of unit 7, Astra Business Centre between Astra Business Centr and Lancashire Care

22/01/2018 – Deed of release and overage relating to the former Garth House now comprising part of the former Ribbleton Hospital between Lancashire Care and Lancashire County Council

5.0 RAISING CONCERNS

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

The use of an external venue for a Board meeting given the restriction on using external venues;

Failure of the alarm system in the Scarisbrick Centre; Staff unaware of the PICU policies and procedures; Bullying by a line manager; No hand drying facilities in a toilet; Payments for overnight “sleep in” shifts; Concerns about caseload size; Behaviour of a staff member towards a patient; Two concerns around heating systems not working.

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

6.0 BOARD ACTION

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

Board of Directors

Agenda Item TB 024/18 Date: 01/02/2018

Report Title Chief Executive’s Report

FOIA Exemption Part Exemption Business Development Section

Prepared by Heather Tierney-Moore, Chief Executive

Presented by Heather Tierney-Moore, Chief Executive

Action required Discussion/Decision

Supporting Executive Director Chief Executive

PURPOSE OF THE REPORT:

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


To provide high quality services

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

CQC domain Well-led

Introduction This report aims to give Board members an overview of the activity undertaken since the last Board meeting, both within the Trust and externally.

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

Inquest has returned a verdict of suicide)

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

Death (suspected suicide) of a patient under the care of the Mindsmatter Service in St Helens.

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

Significant health and safety incidents During December 2017, the following incidents were reported to the Health and Safety Executive and Care Quality Commission under the Reporting of Injuries, Diseases and Dangerous occurrences Regulations (RIDDOR):

(brief information is provided to protect confidentiality)

QUALITY AND SAFETY

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

Injury to a staff member’s hand during restraint resulting in an absence from work of over seven days;

Injury to a staff member from a slip on icy ground resulting in a fracture to the foot.

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

The use of an external venue for a Board meeting given the restriction on using external venues;

Failure of the alarm system in the Scarisbrick Centre; Concerns about a restraint; Staff unaware of the PICU policies and procedures; Bullying by a line manager; No hand drying facilities in a toilet; Payments for overnight “sleep in” shifts; Concerns about caseload size; Behaviour of a staff member towards a patient; Two concerns around heating systems not working; Bullying of staff and culture; Staff sleeping on night shift.

In all cases a review of proportionate scale has been commissioned. The findings from each review are individually fed back to the person raising the concern if they have provided their name. The findings from every concern is summarised in the Quality Matters bulletin.

Care Quality Commission (CQC) Inspection The Care Quality Commission began its inspection of the Trust in January 2018. This process will run through January and February. The draft reports will be expected up to 12 weeks after the Well Led Review, which is planned for week commencing 19 February 2018. During the Well Led Review, the CQC will be holding interviews with the Trust Chair, Executive Directors, and the Raising concerns Guardian. The CQC will also be holding focus groups with Non-Executive Directors, Governors, Commissioners and Staff Side.

Registration with the Health and Safety Executive (HSE) As a result of changes in legislation, the Trust has now registered with the HSE under the Ionising Radiations Regulations 2017. This covers the use of x-ray equipment in dental services. In submitting the registration, the following has been confirmed:

A risk assessment has been completed which identifies the main radiological risks associated with the work with ionising radiation and identifies any reasonably foreseeable radiation accident;

Steps have been taken to measure or estimate employees’ exposure to ionising radiation and appropriate action taken;

Actions identified in the radiation risk assessment that will restrict employees’ and other persons’

exposure to ionising radiation so far as is reasonably practicable have been completed;

Contingency plans have been drawn up for all reasonably foreseeable radiation accidents identified in the radiation risk assessment and, where appropriate, rehearsals will be carried out at suitable intervals;

• A suitable radiation protection adviser (RPA) has been appointed and consulted; Appropriate training, information and instruction is provided to all employees engaged in or

affected by work with ionising radiation and will be repeated at appropriate intervals; Controlled and/or supervised areas have been correctly designated and demarcated (where

required); Written local rules have been drawn up, where required, and radiation protection supervisor(s)

are appointed for all work in controlled areas and, where appropriate, supervised areas.

Infection Prevention and Control:

Flu Campaign The current uptake for the 2017/18 staff flu campaign is 59.5% (63% for frontline staff). 30 staff have been trained to administer the vaccine to their colleagues and the Infection Prevention and Control (IPC) Team have attended team meetings and educational sessions to encourage uptake. Around seventy drop-in sessions have been provided and staff have also been issued with free flu vouchers should they wish to have the vaccine elsewhere. The campaign has been well supported by the Communications Team and the Pulse and social media are used to highlight where staff can obtain the flu vaccine.

Outbreak - iGAS Bronte Ward at The Harbour is currently closed to admissions due to a suspected outbreak of Group A Streptococcus (iGAS). 2 patients identified as having invasive Gp A Strep (iGAS) have been admitted to acute hospitals within a 7 day period and a further patient has been treated for suspected infection, along with two staff members identified as carrying the infection. Regular meetings are being held to plan and update key stakeholders and the ward remains closed to admissions until the infection has been eradicated.

HMP Liverpool Audit The Infection Prevention and Control Team recently carried out an audit of the inpatient Unit at the healthcare facility in HMP Liverpool. This identified significant issues with the environmental cleanliness throughout the facility. There were also a significant number of maintenance issues that were identified and reported to Amey (provider of cleaning services) which required immediate attention to ensure that the environment was safe for staff & patients.

Following the audit, the Head of IPC worked with members of the nursing team to introduce cleaning schedules, decluttering of equipment stores and IPC education. IPC also met with the Service Manager and cleaning provider (Amey) to identify the key issues within the facility and develop recommendations. Further audits by LCFT IPCT and NHS England have identified some progress with the cleanliness but there remain some outstanding actions, which IPC are working to address with the staff.

FINANCE AND PERFORMANCE

Finance Report After adjusting for impairments of £0.2m the deficit for month 9 is a -£1.3m which excludes year to date planned Sustainability and Transformation Funding of c£1.4m, against a plan surplus to date of £1.2m. Performance is therefore £2.5m behind the control total and £1.1m behind with STF. The

position continues to be driven by staffing pressures in ward and prison areas which is also impacting on delivery against planned cost improvement programmes, particularly ward staffing. In addition, expenditure is exceeding funding on OAPs resulting in current and forecast pressures. Performance does however show an improvement on the Month 8 in month position of £0.6m and an in month surplus over plan of £0.3m. Unmitigated projections indicate a gap of c£4.2m (£6.4m without STF), which again shows an improvement of c£0.5m over the month 8 position. Though improvements in performance are evident, continued delivery will require sustained and coordinated responses with robust management and oversight. After taking in to account £1.7m of disposals, which are accounted for after EBITDA, EBITDA is broadly in line with I&E Margin. The new Use of Resources (UoR) metric is rated at 2, consistent with month 8, should the Trust meet its financial plans and targets the Trust will achieve a rating of 2.

Performance Report & Quality Report The Quality Report can be viewed under TB 028/18 and the separate Performance Report can be viewed under item TB 030/18.

Early Intervention Service (EIS) Update Further to the update at January Board regarding the actions to address EIS performance, the fact finding investigation commissioned by the Chief Operating Officer has concluded. The final report has been shared with the Chief Executive, Chief Operating Officer and Head of Operations for the Children & Young People’s Wellbeing Network. The report provides eight recommendations to mitigate against the issues identified as part of the fact finding, both specific to the EIS team and also wider learning. These are drawn out below;

Standard Operating Procedure (SOP) 1. Review the SOP taking into account the comments regarding conflicting statements. 2. When multiple guidance is available in relation to a performance target, ensure the regulatory

guidance is the one used to develop the Trust’s SOP. 3. Discuss the possibilities of an internal audit being added to the 2018/19 Audit Plan that would

support the work being undertaken around SOP development particularly in relation to performance targets with multiple data sources.

System 4. Review the timescales around the rollout of the new EPR system in relation to EIS and

whether there would be any benefit in prioritising this.

Leadership 5. Hold an engagement event with the EIS team and consider ongoing engagement processes. 6. Enhance the role of the HR Business Partner in supporting the Networks Senior

Management team when issues such as large amounts of change in teams arise.

Education 7. There is a need for an educational piece of work to be undertaken to ensure staff across the

organisation understand the requirements of the EIS two week wait target and the obligations on those teams to support compliance with the target.

Other 8. During the investigation, the Company Secretary requested that a random sample of data

from 2016/17 be validated. This identified the same issues as identified with the 2017/18 data. A full review of the 2016/17 data has now been commissioned.

The existing action plan around the EIS performance has been updated with these recommendations which will continue to be monitored by the Corporate Governance & Compliance Sub-Committee.

CAMHS Transformation Preparation (CIC) Subsequent to the discussions at last month’s Board meeting, advice was taken regarding Change Talks and employment options etc. In this instance it was agreed that a fixed term appointment be made with support from UnLtd Foundation. Business and risk development support will be given by the Head of Operations for CYP. A meeting has been set up with relevant parties to agree how we can mainstream this type of approach in the event of future opportunities.

Changes to the Local NHS Improvement Team The Trust has been advised that Anne Gibbs, the Delivery and Improvement Director for Greater Manchester and Lancashire is leaving NHS Improvement. The interim arrangements put in place by NHSI for the next few months see Linda Buckley acting as the interim Delivery & Improvement Director. As Linda is Manchester based and due to resourcing at NHSI the support to Lancashire will be further enhanced with Stephen Downs taking a lead on the Lancashire STP development. Lesley Neary will also be joining the sub regional team to provide further delivery support.

Memorandum Of Understanding (MoU) for Learning Disability Providers To extend our collaboration with Cheshire Wirral Partnership (CWP) around learning disabilities, an MoU has been developed between LCFT, CWP and also Merseycare and North West Boroughs. The MoU sets out the arrangements for a collaborative partnership approach and the establishment of a Provider Board to deliver the vision as set out in Building the Right Support – a national plan to

develop community service and close inpatient facilities for people with learning disabilities and/or

autism who display behaviour that challenges, including those with a mental health condition.

This approach provides an opportunity to revisit the work streams allocated to the North West region of the Transforming Care Programme through the Operational Delivery Network. This will potentially allow for the key elements of development to be undertaken at the appropriate scale, for example, future workforce for learning disabilities on a regional basis. This will also reduce the duplication of work that has been generated at local STP level.

Practically, the MoU also enables closer working on all aspects of learning disability pathways and this has been welcomed by Commissioners and the STP Programme Board.

The Board is asked to approve the MoU which can be seen here.

Communications & Engagement KPI Q3 The Quarter Three KPI report for Communications and Engagement is provided here.

Innovation Agency Assurance Report Q3 The Quarter Three Assurance Report for the Innovation Agency is provided here.

NHS Providers Briefing NHS Providers have issued a background briefing on Sustainability and Transformation Partnerships (STPs), Accountable Care Systems (ACSs) and Accountable Care Organisations (ACOs) as part of a new programme of work they are doing on how national policy has evolved to promote system-based

BUSINESS DEVELOPMENT

https://www.lancashirecare.nhs.uk/media/Trust%20Board/Trust%20Board%20Documents/Memorandum%20Of%20Understanding_MoU_for%20Learning%20Disability%20Providers%20-%2025_01_2018.pdf

collaboration, including the development of STPs, ACSs and ACOs. The briefing is shared with the Board for information here and covers;

the national policy story so far, as plans evolved into partnerships definitions of key terms associated with STPs, accountable care, and new care models five conditions for success based on conversations with trusts NHS Providers’ position and information on the support trusts can access from NHS Providers


Report Title Audit Committee Chairs Report


Prepared by Shannon Higginbotham, Corporate Governance Manager

Presented by Louise Dickinson, Chair of Audit Committee


Supporting Executive Director Chief Executive PURPOSE OF THE REPORT: Report purpose To provide an outline of the activity undertaken by the Audit

Committee, highlight assurance received and risks identified.



Board Assurance Framework risk N/A

CQC domain Well-led

1.0 INTRODUCTION This Chairs Report outlines the activity undertaken by the Board level Audit Committee on 23 January 2018

2.0 BOARD ACTION

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

CHAIRS REPORT

CHAIRS REPORT OF: Audit Committee

DATE OF MEETING: 23 January 2018

AGENDA ITEMS DISCUSSION, ASSURANCE, RISK OR FURTHER ACTION

Outcome of Committee effectiveness review

The Committee noted the robust process adopted to complete the annual Committee effectiveness review. Several areas of good practice were outlined within the paper. Areas for improvement were noted as a full review of the Terms of Reference to include the enhanced oversight of the Board Assurance Framework, further input into the Internal Audit plan, horizon scanning with increased awareness of amended or emerging regulations or risks, integration with other Board Committees and improved meeting efficiency in relation to the prioritisation of agendas. The Committee members met with Internal Audit following the meeting to discuss the Internal Audit plan for 2018/19 and the revised Terms of Reference and Cycle of Business would be presented at the April Committee.

Internal Audit Reporting

Internal Audit Follow-up and Progress report The Committee noted both the internal audit follow-up and progress report, including four completed reviews:

1. Mobilisation, Demobilisation and Transition of service; High, Significant and Limited assurance (relating to CaSH).

2. Agency Cap; Limited assurance. 3. Cyber Security; Significant assurance 4. Financial Systems; High/Significant assurance.

A discussion was raised regarding the limited assurance level following the audit of the transition of CaSH services; a high risk recommendation to improve the assurance was identified as the implementation of a performance monitoring and reporting mechanism. The significant issue within the CaSH transition was highlighted as the complexity of the service and geography and the absence of implementation of the appropriate controls. Three high risk recommendations were identified within the Agency Cap audit; it was noted that controls had not operated effectively and therefore enhanced controls were required to ensure guidance was clear and communicated effectively to staff. Updates on progress against the recommendations had been provided by the Trust and audits were being undertaken internally within the Trust to monitor the effectiveness of the controls.

MIAA were satisfied with the progression of work to address the challenges. Significant assurance around the tight and effective controls in place for both Cyber Security and Financial Systems were noted by the Committee, highlighting the on-going commitment of the Trust to mitigate any risks. The Cyber Security Internal Audit identified a ‘should’ recommendation relating to the strengthening of the firewall between the Trust and COIN and work has been undertaken to close this gap and strengthen the Trust’s protection. The progress report highlighted an amber rating; of which matters had been escalated and responded to and MIAA were satisfied that the programme would be delivered. Internal Audit Anti-fraud update The Committee received assurance on the delivery of the work-plan and progression of investigations. There were no concerns regarding the activity underway and 5 outstanding actions remained which were not yet due. Evidence was readily available in a timely manner and the Trust was pro-actively providing regular updates. The Committee’s attention was drawn to two cases where the investigation had been completed with convictions of fraud. Information on these cases would be disseminated There had been an issue regarding contract performance, however the Committee received assurance that strengthened support was addressing this gap and the reasonableness of the FIRST reporting SLA was being raised nationally with NHS Protect.

External Audit draft plan

The Committee noted the content of the plan and the additional specific risk relating to evaluation of land and buildings which remained significant due to the high figures and degree of estimation required. Guidance on the Quality Account has not yet been issued. It is anticipated that new indicators will be assessed. The guidance will be circulated to the Committee as soon as it is available. KPMG would remain in close liaison with the Finance department around the issues relating to provisions and guidance around STF funding, which was noted as a key risk towards year-end.

External Audit Non-Audit Performance Update

There had been no change to the non-audit performance update.

Clinical Audit Reporting

The Committee received assurance that progress against the Clinical Audit Plan and prior year action plans was good, with one outstanding action to be completed relating to eating disorders. A deep diver had been undertaken by the Medical Director for all failed re-audits (carer’s re-audit, Clozaril re audit, Diabetes re audit) and Quality Improvement Plans developed, which would be discussed at the Quality and Safety Sub-Committee. The Committee asked that a progress report against these plans be included in its Clinical Audit

Report going forward. The revised Standard Operating Procedure identified the enhancement of the Clinical Audit framework and reflected the changes in protocol to strengthen the outcomes. The Committee was assured that the postponement of the lone working audit was not increasing any risk and that it was still a priority for completion in 18/19.

Corporate Governance + Compliance Chairs Report

Further work was being undertaken to enhance the Sub-Committee’s assurance of the Trust’s achievement of the guidance regarding community rapid response times as set out by NHSI; the Committee noted that this was not a reporting requirement but an internal reporting request for best practice. An issue was raised regarding attendance at the SIRO and Caldicott Guardian meeting which had been addressed with a number of assigned actions; an update would be provided at the next Sub-Committee and reported to the Audit Committee. An investigation had taken place to explore the EIS failure with an action plan assigned, and an update paper would be provided to the Trust Board.

Financial Matters and Related Reporting

Breaches and Waivers Q3 The Committee received the report for noting purposes and there were no risks or concerns identified. Losses and Special Payments Q3 The Committee received the report with no particular issues to note. Comparable benchmarking data from previous years was noted within the report as requested. An additional piece of benchmarking work was to be undertaken against Mental Health and Community Trusts.

Cyber Security The paper provided an update in response to the Audit Committee guidance issued by the National Audit Office in September 2017. The paper complemented the Internal Audit report and provided the Audit Committee with additional assurance regarding its Cyber Security activity. The Committee noted that the formal ISO 27001 assessment will take place in March 2018 and asked for a report on the outcome of this assessment at its next meeting. Discussions took place around the training of staff to support the reduction of potential threats, which was incorporated into the mandatory IG training tool. A new IG toolkit with the inclusion of Cyber Security was being developed by NHS Digital.

Outcome of Internal Audit review

A recommendation was made by the Committee to extend the contract with MIAA for a further two years and this was supported by the Committee. An updated improvement plan for the Internal Audit services would come back to the April Committee following discussions with the Associate Director of Risk and Assurance and MIAA lead.


Report Title Quality Committee Chairs Report


Prepared by Shannon Higginbotham, Governance3 Manager

Presented by David Curtis, Non-Executive Director


Supporting Executive Director Executive Director of Nursing and Quality PURPOSE OF THE REPORT: Report purpose To provide an outline of the activity undertaken by the

Quality Committee.



Board Assurance Framework risk 1.1 The Trust does not protect services users from avoidable harm and fails to comply with the CQC standards for the quality and safety of services

1.2 The Trust does not deliver safe, appropriate and therapeutic environments to deliver high quality services

3.1 The Trust fails to deliver the benefits of being a Health and Wellbeing provider.

4.1 The Trust is unable to attract, recruit and retain high quality staff impacting on a continued dependency on temporary staffing levels, affecting quality of care and financial costs

4.2 The Trust does not deliver effective education, training and leadership opportunities resulting in a workforce who are unable to deliver high quality, safe care

7.3 The Trust does not comply with Mental Health Legislation

CQC domain Well-led 1.0 INTRODUCTION This Chairs Report outlines the activity undertaken by the Quality Committee held on the 11 January 2018. 2.0 COMMITTEE ACTION The Trust Board is asked to note the content of the Chairs Report for assurance.

CHAIRS REPORT

CHAIRS REPORT OF: Quality Committee


BOARD ASSURANCE FRAMEWORK RISKS ALIGNED TO SUB-COMMITTEE:

1.1 The Trust does not protect services users from avoidable harm and fails to comply with the CQC standards for the quality and safety of services

1.2 The Trust does not deliver safe, appropriate and therapeutic environments to deliver high quality services

3.1 The Trust fails to deliver holistic whole person care (Physical and Mental Health)

4.1 The Trust is unable to attract, recruit and retain high quality staff impacting on a continued dependency on temporary staffing levels, affecting quality of care and financial costs

4.2 The Trust does not deliver effective education, training and leadership opportunities resulting in a workforce who are unable to deliver high quality, safe care

7.3 The Trust does not comply with Mental Health Legislation

AGENDA ITEMS BAF RISK DISCUSSION, ASSURANCE, RISK OR FURTHER ACTION Board Assurance Framework (BAF)

1.1, 1.2, 1.3, 3.1, 4.1, 4.2

The Committee noted the Q2 BAF risks aligned to the Committee and would consider any impact on the risks throughout the meeting. This would be incorporated into the Q3 report presented to the Board in February.

Emerging issues 1.1 The Committee received an update regarding HMP Liverpool; continuing work to address issues following the quality inspection was noted. The response to the CQC Report and the update to the action plan were to be signed off by the Director of Nursing. Scrutiny of the action plan would continue to be monitored by the Quality & Safety Sub-Committee and any escalations to this Committee as necessary until the contract end date. A discussion was held around the challenges at The Cove relating to staffing and challenging admissions; on-going conversations with the Commissioners were underway to agree a joint way forward. There had been an outbreak of Strep A on Bronte Ward. Immediate steps taken were outlined to the Committee and assurance provided on the well skilled staff managing the situation.

Quality Plan Bi-Annual Report

1.1 The significant work underway and the detailed plan to manage quality improvement following key themes from the inspection were noted, including the progress around appraisals and core skills, additional information would be provided following the findings of the benchmarking data. Concerns relating to Mental Health Law compliance were highlighted and were discussed in further depth under the Mental Health Law Sub-Committee item.

Safer Staffing Bi-Annual Report

1.1, 4.1, 4.2, 5.1, 6.1, 7.2

The on-going staffing challenges recognised that there was still an increase in leavers in comparison to new recruits. On-going work was underway to understand and address barriers, noting the operational challenges as well as high levels of acuity and bed occupancy. A key factor increasing the levels of acuity was highlighted as the impact of service users with complex and challenging needs. Some risks within the networks required additional scrutiny to ensure appropriate plans were in place and that scoring was appropriate; this work would be reported back to the Committee. The hot spot areas within bank and agency challenges had been identified and the 8 highest spending areas were being targeted for improvement which had been well received. Significant work had been undertaken around efficient rostering and scrutiny of requests for additional staff and the recognition of acceptance of patients being a continued challenge of activity. A key finding for contribution to spending was noted as the impact to staff sickness due to significantly challenging patients where staff were not equipped to respond in the appropriate way; this was largely relevant within Guild and the Trusts dementia services. The ability to seek alternatives to admission was having a positive impact to the Trust and supported the reduction in inappropriate admissions. Progress had been made to reduce rates of admissions; despite this there was a continuing high rate which was impacting the overall figure. The next steps to address staffing issues were outlined and an update would be provided to the Committee; in particular around the focus on triangulation regarding the impact of violence reduction training. Following the Trust Chair’s visit to the Harbour, the improvements within inpatient units following the implementation of zonal observations were noted. The Trust is considering rolling this out across other areas, initially within older adults and PICU.

Serious Incidents Bi-Annual Report

1.1 Attention was drawn to 2 particular areas; serious incidents and suicides. There had been a notable decrease in serious incidents within the 6 month-period in comparison to last year’s data; there had been a similar decrease in suicides however a minor increase in avoidable pressure ulcers, this had improved in areas where community staff were undertaking this work. The majority of suicides were not within the inpatient areas.

The suicide prevention plan had been shared with the Board and an update on progression would be brought back to the Committee. The Serious Incident Learning Panel continued to seek assurance on improvement plans ensuring that actions had been embedded. This report would be provided on a quarterly basis in the future.

Quality & Safety Surveillance Reports

1.1 The Clinical Audit report and Mental Health harm free care showed some improvements; however was still below the Trusts 90% target, which was primarily due to violence and medical incidents. The Friends & Family test were receiving positive responses; however an issue around completed responses was currently being addressed. The Committee received assurance that the Trusts framework was being refreshed following the extensive surveying of the school health population. A deep dive had been undertaken by the Medical Director for each re-audit with an amber rating; quality improvement activity was underway to address the varying issues for each re-audit. A particular issue was raised relating to 3 female service users in Elmridge ward causing challenges relating to self-harm and staff sickness within the ward, further increasing the inconsistent use of bank and agency staffing. Conversations with Commissioners were focussed around early intervention opportunities to begin to manage this issue differently. The figure of upheld complaints had stayed the same whilst the number of complaints alone had increased; recognising that not all complaints were required to be upheld. Whilst improvement to core skills compliance was noted, there was still a requirement for further progression. An improvement plan from the Mental Health network would be reported to the Sub-Committee at the earliest opportunity and an update provided through the Chairs report.

People Plan 4.1, 4.2 Positive assurances relating to greater engagement with the Networks were noted as an improved process highlighting their contribution to the plan. Positive works that had been introduced had a positive impact of the delivery of the plan, in particular celebrating success across the Trust. The staff engagement survey would be completed on a 2-monthly basis moving forward for relevance and consistency. The positive increase in contribution to the Trusts staff survey was noted, in particular within Southport & Formby services which had resulted in lower levels of sickness; the opportunity to adopt this across all areas was highlighted. Concerns around the content of the staff survey response were outlined; a focussed action plan was to be targeted linking into the relevant areas within the People Plan. A feeling of a lack of

engagement with Liverpool prisons services due to the considerable tendering within this service was noted. The consideration of a clear engagement strategy was discussed and the Quality Committee would keep oversight of staff engagement going forward. Positive intelligence was being received through the good practice visits and the importance of escalating any issues following these was noted. A discussion was had around the Trust’s requirement to put further work into reviewing service challenges at greater depth to gain the required improvements. A key area to focus attention upon with 2018/19 is the focus of attention of support to the Trust’s workforce. The Committee positively noted a discussion around requirement for focus on early intervention for the specific cohort of service users with complex needs as work was being undertaken by the Chief Operating Officer to support staff in understanding their contribution to the pathway.

Apprenticeship Levy 4.1 Assurance was received around the delivery of the apprenticeship levy programme and detailed plans had been developed, confirming the significant opportunities and benefits within nursing associates and degrees. The opportunity to utilise the levy monies for highly skilled posts such as consultants was outlined. The programme had seen positive engagement with the networks. The need for pace around the delivery of the apprenticeship programme was highlighted. The risk regarding not gaining the impact from this programme following the input of £1.2m had been minimised through the development of various apprenticeships and an opportunity was noted to use the quality improvement methodology for a rapid programme to inform how to utilise the levy. This was noted as a positive vehicle for innovation within services.

Quality and Safety Sub-Committee Chairs report

1.1, 1.2, 3.1 Recovery plans were in place relating to complaints from the Networks which would be reported to the next Committee. Positive assurance was noted relating to complaints at Guild, highlighting that there had been no outstanding complaints reported to the last Sub-Committee. The Director of Nursing had requested a recovery plan to improve the position around overdue 3 and 7 day Datix incident reviews and an updated was expected at the next Sub-Committee.

Mental Health Law Sub-Committee Chairs Report

1.1 Concerns were raised relating to compliance with datasets and remedial work was underway to improve the Mental Health Act compliance, in particular around the recording of when rights have been verbally read to patients. This would be reported back to the next Sub-Committee.

People Sub-Committee Chairs Report

4.1, 4.2 The Sub-Committee had seen significant improvement following the effectiveness review, in particular with the Networks approach to key issues within the remit of HR. On-going challenges were noted around the roll-out of e-rostering and an update would be provided at the next Committee following the meeting between the HR Director and Finance to address this.

Reducing Restrictive Practice

1.1 The Committee noted the positive assurance received around the Trusts process in place to monitor and increase quality surveillance. A deep dive was being undertaken in this area as part of a planned series; PICU and Older Adult mental health wards were being addressed within this review. Differences between genders were noted as an outcome of the data review; and considerations around quality improvements to address this in a different way were being considered. Positive assurance was noted around the low number of prone restraints. Assurance was noted around the next steps following this review, in particular quality improvement programme relating to perception of restrictive intervention. A further report would be brought back to the Committee.

Risk Assurance 1.1, 1.2, 3.1, 4.1, 4.2, 7.3

Positive assurance was received in a number of areas, in particular around the delivery of the Apprenticeship Levy, the People Programme and the Trust’s processes that were in place to monitor and increase quality surveillance in respect of reducing restrictive practice. Limited assurance was noted around the compliance with Mental Health Law and monitoring by the Committee would continue.


Report Title Finance and Performance Committee Chairs Report

FOIA Exemption Part Exemption Section 43: Commercial Interests

Prepared by Shannon Higginbotham, Corporate Governance Manager

Presented by Isla Wilson, Chair of Finance & Performance Committee


Supporting Executive Director Chief Finance Officer PURPOSE OF THE REPORT: Report purpose To provide an outline of the activity undertaken by the

Finance & Performance Committee.



Board Assurance Framework risk 2.1 The Trust does not receive assurance of the accuracy, timeliness and consistency of data andreporting with the potential to compromise decision making and service quality 2.2 The Trust's ability to address and meet service demands is affected by uncertainty and inconsistency of commissioning arrangements. 5.1 The Trust does not have in place effective financial controls which could affect long term financial viability and sustainability 6.1 The Trust is unable to reposition in the marketplace to become established as a provider of choice achieving excellence 6.2 The Trust does not implement a transformational IT programme that ensures transition to a new intuitive clinical system across all services

CQC domain Well-led 1.0 INTRODUCTION

This Chairs Report outlines the activity undertaken by the Board level, Finance & Performance Committee held on 18 January 2018.

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

CHAIRS REPORT

CHAIRS REPORT OF: Finance & Performance Committee


BOARD ASSURANCE FRAMEWORK RISKS ALIGNED TO SUB-COMMITTEE:

2.1 If we do not work collaboratively with partners we will not be able to influence system wide transformation

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

3.2 If we fail to project our achievements then our reputation will not improve

5.1 If we do not meet our financial objectives we will not be able to provide sustainable services

5.2 If we do not work with partners to deliver system wide efficiencies this will undermine our own financial position and that of the STP

6.1 If we do not develop and maintain infrastructure, we will not be able to deliver safe , responsive and efficient care

6.2 If we not exploit the full capabilities of the new EPR system and wider technology to redesign services we will miss important opportunities to improve care

AGENDA ITEMS BAF RISK

DISCUSSION, ASSURANCE, RISK OR FURTHER ACTION

Infrastructure Sub-Committee Chairs Report

6.1

6.2

Strong assurance was noted that the risk relating to the use of non-clinical rooms for non-clinical purposes following the Southport & Formby services transition had not occurred anywhere else within the Trust due to the tight framework of controls. A longer term solution to address fire safety assessments of shared properties was considered outlining a contractual requirement and penalties if this was not adhered to. A breakdown of the risk detail would be taken to the Sub-Committee to review the level of risk. 3 anti-ligature audits remained outstanding which was being addressed by Network leads; assurance was noted around a robust process in place for next year.

The risk regarding the achievement of the delivery of the perinatal unit was noted; the Chief Executive assured that this had been discussed with the Chief Executive at LTH and barriers would be addressed to continue with full access. There was limited assurance relating to the Carbon Reduction target being achieved due to the changes with national targets; a briefing paper would be provided to the Director of Finance to make a judgement on whether this would be achieved. The Committee was assured that the amendment to some of the EPR programme dates had no contractual implications for the wider programme and were due to staff capabilities and the Trust was still intending to ‘Go Live’ on the agreed date. The Committee was assured that a very minor risk was posed relating to a cyber security threat within new mobile phone contract chips and the Trust was happy with the assurance around this. An agreement had been made to extend the EMIS contract with Southport + Formby Trust. The Shadow Board had met and was due to meet again; the establishment of the name of the company had been agreed by the Chief Executive and Trust Chair following Trust Board and significant work was progressing to finalise budget allocation, the completion of the TUPE transfer and HR issues, in particular around the NHS Pension Scheme. The importance of a financial replacement agreement was highlighted.

Business Development And Delivery Sub-Committee Chairs Report

2.1

2.2

3.2

The Committee was assured that the Trust had reported compliance with all NHSI indicators in the month with the exception of EIS, of which appropriate measures was being complied with, and NHSI remained supportive of the recovery. The Trust was intending to achieve the Q4 EIS target. Issues around contractual performance were being discussed and managed through a deep dive activity by the Board, in particular relating to ADHD, CAMHS Tier 3 and the Psychology SLA with LTH. Assurance on the action plans would be reported to the Sub-Committee. Discussions around the mitigation of the risk to the financial position continued within the networks and a particular risk relating to the Mental Health networks achievement of stretch targets was noted regarding staffing and OAP’s issues. The 0-19 decision had posed a significant impact to the network structure and the financial implications of this. Assurance was noted around the Trusts improvement to 89.4% in December in the 4-hour target in relation to patients requiring Mental Health assessment which outlined an improvement of over 20%. The Committee noted the positive momentum in the process for the demobilisation of the HMP Liverpool contract however a potential risk was identified regarding the implications of the TUPE.

There had been an increase in complaints and responses to complaints within the Mental Health Network which were being reviewed against the positive good practice work at Guild where the Trust was compliant with complaint response times which the Trust intended to replicate across the Network. A key theme to discuss within the effectiveness review of the Sub-Committee was noted as the tightening of attendance to ensure valuable contribution and ability to hold key discussions.

Delivering The Strategy (DTS)

5.2 There was a risk to some schemes which were RAG rated as red, in particular the mental health schemes. The PMO team was supporting the teams to develop Quality Impact Assessments. Additional work was to be undertaken within benefit tracking activity; a benefits realisation tracker would be launched in the new financial year and would be tracked throughout the programme. The Committee received assurance in the enhancement of the Quality Assessment process and a further focus on identifying benefits from the outset. Against the 15.1million target; current schemes identified expected to deliver £13.9m with a gap in year of £1.2m; the pipeline schemes that mitigate this gap have some concerns regarding the ability for delivery. The 201819 DTS programme had been reported to the Business Development and Delivery Sub-Committee and assurance on the framework to align CIP’s to this programme would be provided once the scale of the CIP challenge was known. The gap in the CIP was factored into the fore-cast for the year-end position. A paper would go to SLT to review the projection of the 2 year financial plan and the content of what would be explored, in particular sickness and OAPS. The Trust was expecting a Board Development session to discuss the shaping of the plan. The Committee received assurance in the reduction of the OAP’s figure in month from 21 to 19.

Workforce Performance Reporting

4.1 Work continued to enforce compliance with relevant legislation around safer recruitment. Work was underway to continue to improve recruiting timescales, which had positively decreased from 60 days to 41 to recruit. The Committee was assured that there was no loss of money to the Trust however there had been no improvement in figures for overpayments within the financial year following the introduction of updated policies and training. The issue remained as compliance with timely ESR reporting and the Trust was satisfied that it had the appropriate controls in place to mitigate this issue. There had been an improvement within the Networks regarding ESR performance which had not been reflected in the report but confidence in the ability to improve the position moving forward was highlighted.

The remedial actions to address challenges were being reported to the Board through the workforce quarterly report and discussions at the People Sub-Committee and Network Leadership groups continued. The Trust expected an improvement following the introduction of the longer notice period staff required to provide.

STP Accountability update

5.2 A discussion was had around the impact of the STP on the Committee and how the STP Board would hold the Trust to account, in particular relating to the impact and complexity of agreeing and maintaining a shared control total, and the additional pressures to the Trust following this. There was a potential risk that transformational funding would not be provided if all organisations did not agree a control total. If the whole system agreed sign-off for a control total and this was successful, accountability would commence from April 1st 2018 and the ACS partnerships and organisations would be held to account collectively for the delivery of improved quality and financial performance. A piece of work would be considered by the Chief Finance Officer to understand the total spend relating to Mental Health services, and the consideration of areas the Trust could drive improved outcomes, recognising the funding challenges.

Risk Assurance All There were a number of risks elevated which would be reflected in the next Board Assurance Framework.

Positive assurances raised throughout discussions were noted, in particular the Trusts improvement up to 89.4% in the

4-hour target relating to patients requiring mental health assessments, the controls evidenced within the DTS programme

and the continued progress to ensure compliance with safe recruitment legislation.

The key risks and gaps in assurances identified from the discussions and papers presented were agreed by the committee in particular as the site assessments issues within estates, understanding the risks regarding the RRCS transition and replacement arrangements, the potential absence of VAT recoveries landing in year and the impact of this on the achievement of the control total, the Mental Health’s contribution to the year-end position regarding OAP’s and staffing issues and the limited assurance relating to the delivery of the CIP programmes within year.


Report Title Quality and Safety Report

FOIA Exemption No Exemption Not Applicable

Prepared by Matthew Joyes Associate Director of Safety and Quality Governance

Presented by Dee Roach Executive Director of Nursing and Quality and Professor Max Marshall Executive Medical Director

Action required Decision

Supporting Executive Director Executive Director of Nursing & Quality PURPOSE OF THE REPORT: Report purpose To provide the Trust Board with latest version of the Quality

and Safety Report



Board Assurance Framework risk 1.1 If we do not meet regulatory standards for quality and safety we will not be fit for purpose as a care provider

CQC domain Well-led

1.0 Introduction The Quality and Safety Report is a new report, in its fourth iteration, submitted to the Trust Board to provide information and assurance.

2.0 Headline areas

Safe

In the Safe domain, attention is drawn to the decrease in serious incidents. This change in trend is due to a noticeably lower reported number of incidents in December 2017. The regular thematic review of serious incidents was received by the Quality Committee in January 2018. The second area of focus in this domain is violence to staff and restraint (which are linked issues). The Quality and Safety Sub-committee is receiving a series of deep dive presentations into violence and restrictive practices across inpatient units utilising an internal benchmarking format. The Quality Committee received two of these presentations in January 2018. In recognition of the need to take stock of the continuing challenge to deliver improvement, the Associate Director of Safety has commissioned a full review of the total approach to violence reduction and management within the Trust with a view to a refreshed programme being launched in April 2018 (the next quarter being taken to fully review the programme and involve clinical staff fully in the review). Effective In the Effective domain, attention is drawn to the clinical audit report which highlights current progress of the programme. The Mental Health Harm Free Care rate remains below the Trust aspiration and this is linked to violence, restraint and medication incidents. Caring In the Caring domain, attention is drawn to the positive Friends and Family Test results which have been above the target since January 2017. Responsive In the Responsive domain, attention is drawn to the notable increase in complains. This position is reflected nationally, and is also considered to be partly attributable to the new hearing feedback model where the Trust has been actively seeking out feedback from people who use services, their families and carers. The CQC Community Mental Health Survey was published in November 2017, and will be scrutinised at the Quality and Safety Sub-committee alongside the quarter three Hearing Feedback Report. Well Led In the Well Led domain, attention is drawn to the areas of under-performance in some Core Skills and Essential Skills subjects. Concern also exists around the compliance level for appraisals. Further detail on these areas will be included in the Workforce Report. The number of overdue incident reports is increasing; Networks have been instructed to take action on this through the Quality and Safety Sub-committee.

3.0 Conclusion

The Trust Board is asked to receive and note this report.

Quality and Safety Report

February 2018 (data from January 2017 to December 2017)

Prepared by: Presented to the Trust Board by:

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

Max Marshall, Executive Medical Director

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

Appendix 1 – Extracts from the Quality and Safety Surveillance Report and Mental Health Law Surveillance Report ............................................................................. 30

Quality and Safety Tile

19780 96.08%

90 9016

39

1

5 1585

4101 309

15 53%

2403

2281

90.74%

95% 42.14%

83% 13

QUALITY AND SAFETY TILE

CARING

Compliments

F&F Test

RIDDOR incidents

Incidents

STEIS-reportable serious incidents

EFFECTIVE

Never Events

Number of red flag incidents (inpatients only)

Core Skills (%)

SAFE

Physical violence to staff from patients

Serious HCAI incidents

Use of restraint

Potentially avoidable grade 3 and 4 pressure ulcers

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

Physical Health HFC Rate (%) Appraisals (%)

Mental Health HFC Rate (%) Concerns raised

Good

Completed within agreed timeframe (%)

RESPONSIVE

Complaints

Upheld/partially upheld complaints

WELL LED

Trust CQC rating

Lancashire Care NHS Foundation Trust Quality and Safety Report

Page 4 of 35

Executive Summary

This is the fourth Quality and Safety Report for the Trust Board. Prior to review by the Board, the Quality and Safety Sub-committee receives the report for further scrutiny and challenge to Networks and Support Services. In the Safe domain, attention is drawn to the decrease in serious incidents. This change in trend is due to a noticeably lower reported number of incidents in December 2017. The regular thematic review of serious incidents was received by the Quality Committee in January 2018. The second area of focus in this domain is violence to staff and restraint (which are linked issues). The Quality and Safety Sub-committee is receiving a series of deep dive presentations into violence and restrictive practices across inpatient units utilising an internal benchmarking format. The Quality Committee received two of these presentations in January 2018. In recognition of the need to take stock of the continuing challenge to deliver improvement, the Associate Director of Safety has commissioned a full review of the total approach to violence reduction and management within the Trust with a view to a refreshed programme being launched in April 2018 (the next quarter being taken to fully review the programme and involve clinical staff fully in the review). In the Effective domain, attention is drawn to the clinical audit report which highlights current progress of the programme. The Mental Health Harm Free Care rate remains below the Trust aspiration and this is linked to violence, restraint and medication incidents. In the Caring domain, attention is drawn to the positive Friends and Family Test results which have been above the target since January 2017. In the Responsive domain, attention is drawn to the notable increase in complains. This position is reflected nationally, and is also considered to be partly attributable to the new hearing feedback model where the Trust has been actively seeking out feedback from people who use services, their families and carers. The CQC Community Mental Health Survey was published in November 2017, and will be scrutinised at the Quality and Safety Sub-committee alongside the quarter three Hearing Feedback Report. In the Well Led domain, attention is drawn to the areas of under-performance in some Core Skills and Essential Skills subjects. Concern also exists around the compliance level for appraisals. Further detail on these areas will be included in the Workforce Report. The number of overdue incident reports is increasing; Networks have been instructed to take action on this through the Quality and Safety Sub-committee.


Page 5 of 35

Safe

CQC Rating: Requires Improvement

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


Page 6 of 35

Serious Incidents A serious incident is defined as “acts or omissions in care that result in; unexpected or avoidable death, unexpected or avoidable injury resulting in serious harm - including those where the injury required treatment to prevent death or serious harm, abuse, Never Events, incidents that prevent (or threaten to prevent) the ability to continue to deliver healthcare services and incidents that cause widespread public concern resulting in a loss of confidence in healthcare services.” The number of serious incidents fell throughout 2014-2016, however the long term reduction has now plateaued over the rolling 12 month period through 2017 with a noticeable decrease in the last month of the year. There is no theme or trend to this sudden decrease, it is believed to be an exceptional occurrence. During December 2017, the following serious incidents were reported:

• Death (suspected suicide) of a patient under the care of the Community Mental

Health Team (CMHT) in Blackburn; • Death (suspected suicide) of a patient under the care of the Mindsmatter Service in

St Helens. In all cases, a formal investigation is now underway and the incidents have been reported as required under the NHS Serious Incident Framework. Work is underway to improve the action planning process following incidents. During January workshops will be held to explore improvements to recommendation writing with discussions ongoing internally and with commissioners around different approaches to action planning, by taking a greater quality improvement approach where appropriate.

0

2

4

6

8

10

12

14

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

Serious Incidents - Rolling 12 Months


Page 7 of 35

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

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

• Injury to a staff member’s hand during restraint resulting in an absence from work of over seven days;

• Injury to a staff member from a slip on icy ground resulting in a fracture to the foot.

0

1

2

3

4

5

6

7


RIDDOR Incidents - Rolling 12 Months


Page 8 of 35

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

Serious HCAI Incidents A serious HCAI incident is considered to be an avoidable incident of Clostridium Difficile (C.Diff), Meticillin-Resistant Staphylococcus Aureus (MRSA), Methicillin-Susceptible Staphylococcus Aureus (MSSA), Gram-negative bacteria, Carbapenemase-Producing Enterobacteriaceae (CPE), or another infection control incident resulting in a ward closure. The number of HCAI incidents remains low with no exceptions to report. The Infection Prevention and Control Team continue to drive improvements in reporting and compliance with the Essential Steps Hand Hygiene Audit and to drive forward the annual staff flu vaccination campaign. At the time of writing, the flu vaccination uptake was 66.4% for frontline staff & 62.3% for all staff (the target is 70% for frontline staff by end of February 2018). It should be noted that during January 2018 a number of HCAI incidents occurred resulting in ward closures to admissions and discharges; details will be included in the next report.

0

1

2


Never Events - Rolling 12 Months

0

1

2


HCAI Incidents - Rolling 12 Months


Page 9 of 35

Pressure Ulcer Incidents – Potentially Avoidable Grade 3 and Grade 4 Pressure ulcers are injuries to the skin and underlying tissue, primarily caused by prolonged pressure on the skin. Pressure ulcers can affect any part of the body that's put under pressure. They're most common on bony parts of the body and often develop gradually, but can sometimes form in a few hours. In a grade three pressure ulcer, skin loss occurs throughout the entire thickness of the skin and the underlying tissue is also damaged. A grade four pressure ulcer is the most severe type of ulcer. The skin is severely damaged and the surrounding tissue begins to die (tissue necrosis). The underlying muscles, or bone, may also be damaged. People with grade four pressure ulcers have a high risk of developing a life-threatening infection The number of pressure ulcer incidents increased over the summer period but has declined. There have been no reported potentially avoidable incidents in the last month. In December there has been a significant reduction in all reported pressure ulcers of 53%. The Safety Senate model has rolled out in 2 or the 3 localities and Southport and Formby roll out is planned for February 2018. The Safety Cross is fully implemented and Longridge Community Hospital are celebrating over 150 days pressure free (all grades on existing patients).

Physical Violence to Staff Incidents Physical violence to staff includes any degree of harm, including near miss incidents, where staff are physical assaulted. Incidents are recorded by staff on the Trust’s quality governance system (Datix). The number of incidents of physical violence to staff increased notably in 2014 and remained increased since, with a further increase during 2017/18 which appears to have levelled during the last few months. Hot spots have been identified in older adult wards and psychiatric intensive care units (PICUs). A deep dive into the data for PICUs and older adult wards has been presented to the Quality and Safety Sub-committee and Quality Committee. Further deep dives are planned for early 2018 covering adult wards and forensic wards. Details of the improvement work underway is covered in the Quality Plan Update later in this report.

0

1

2

3

4

5

6


Potentially Avoidable G3 and G4 Pressure Ulcer Incidents - Rolling 12

Months

0

50

100

150

200

250

300


Physical Violence to Staff Incidents - Rolling 12 Months


Page 10 of 35

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

Suicide (Reported as a Serious Incident) The overall rate of suicide incidents (deemed to meet the criteria for a serious incident) shows a static position rolling 12 months with April 2017 and October 2017 seeing the highest reported number over that period. An emerging area of potential concern is suicide soon after discharge; the Mental Health Network is undertaking exploration of this with support from the Safety and Quality Governance Department. This will be reported here when complete (expected at the Quality and Safety Sub-committee in March 2018).

050

100150200250300350400450500


Use of Restraint - Rolling 12 Months

0

1

2

3

4

5

6

7


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


Page 11 of 35

Staffing Incidents – One or Less Qualified Staff on Duty Instances of one qualified staff on duty are reported and escalated in accordance with the Staffing for Quality and Safety Escalation Procedure. This allows managers to put into place mitigations by moving staff, supporting the area with senior nurses or using bank and agency staff. There has been a notable decrease in reported incidents which is a reflection of the increased scrutiny led by the Executive Director of Nursing and Quality through the Staffing for Quality and Safety Group and a task and finish group led by the Executive Director looking at specific wards. Networks continue to produce monthly reports to this group on progress. All reported incidents occurred on mental health wards (none in Longridge Community Hospital). The predominance (over 50%) of incidents occurred in three wards at Guild Lodge: Fellside Ward (28), ABI Step Down (19) and Forrest Beck (16).

Staffing Incidents – Red Flags All staff are encouraged to use the Red Flag facility on the eRostering Safe Care system to alert managers to staffing incidents such as low staffing numbers, missed breaks, etc. The majority of Ref Flag incidents relates to the above issue of one or fewer qualified staff on duty. All reported incidents occurred on mental health wards (none in Longridge Community Hospital). The predominance (over 50%) of incidents occurred in three wards at Guild Lodge: Fellside Ward (28), ABI Step Down (19) and Forrest Beck (16) and the Orchard Unit at Lancaster (18). Staffing pressures continue to exist. In the Community and Wellbeing Network, the Pennine and North locality is experiencing challenges with district nursing staffing which is being mitigates by cross-team support. The Central locality Dietetics and Podiatry services are also experiencing challenges which is being mitigated by bank and agency. The Mental Health Network is also experiencing challenges in recruiting allied health professional roles for inpatient services.

0

50

100

150

200

250


One or Less Qualified Staff on Duty - Rolling 12 Months

0

50

100

150

200

250

300


Red Flags - Rolling 12 Months


Page 12 of 35

Safer Staffing – Wards with over 40% hours worked by bank staff The teams on the graph reported bank staff usage of greater than 40%. Dunsop, Byron PICU, Elmridge and Marshaw, Dutton, Calder and Scarisbrick Wards all reported over 40% usage in the last report. The Executive Director of Nursing and Quality is continuing the task and finish group to review particular challenges on inpatient wards. Focused support from Matrons and Senior Nurses is being provided to the wards at Guild Lodge with particular challenges including Elmridge and Dutton (which experienced a serious incident of violence during January 2018).

Safer Staffing – Wards with over 10% hours worked by agency staff The teams on the graph reported bank staff usage of greater than 10%.

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

Dunsop WardEastleigh

Byron PICUElmridge WardMarshaw Ward

Dutton WardStock Beck PICU

Calder WardKeats PICU

Scarisbrick UnitCalder PICU

Townley CSU

Wards with over 40% hours worked by bank staff

0% 5% 10% 15% 20%

Shakespeare Ward

Stevenson Ward

Sefton District Nursing

Teams with over 10% hours worked by agency staff


Page 13 of 35

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

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

0

20

40

60

80


Numbers of Deaths and Mortality Reviews - Rolling 12 Months

SCJ Reviews SI Reviews Deaths

0

20

40

Jul Aug Sep Oct Nov Dec

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

2017)

Expected Natural Expected Unnatural

Unexpected Natural Unexpected Unnatural

Not Yet Known


Page 14 of 35

Effective

CQC Rating: Good

This section of the report looks at the domain of effectiveness – that care, treatment and support achieves good outcomes, helps people to maintain quality of life and is based on the best available evidence. The following indicators are covered in the report:


Page 15 of 35

Mental Health Harm Free Care The Mental Health Harm Free Care rate remains below the aspirational goal of 90%. The overall rate is made up of several individual measures. The area’s most impacting the overall measure includes victim of violence (3.2%), self-harm (4.48%) omission of medication (21.54%) and feeling unsafe (8.96%). The individual measures are detailed in the quality surveillance tables later in this report.

Physical Health Harm Free Care The Physical Health Harm Free Care rate has achieved the target in 9 of the last 12 months with an improving picture seen over recent months. The overall rate is made up of several individual measures. The individual measures are detailed in the quality surveillance tables later in this report.

74%76%78%80%82%84%86%88%90%92%


Mental Health Ham Free Care - Rolling 12 Months

91%

92%

93%

94%

95%

96%

97%

98%


Physical Health Harm Free Care - Rolling 12 Months


Page 16 of 35

Local Clinical Audit

Clinical Audits Network Compliance (%) Date

Prevention of Dehydration MHN 54% Q2

Absent Without Leave MHN 55% Q2

Section 132 Rights (Secure MH) MHN 90% Q3

Completion of Waterlow risk CWN 85% Q1

Wound assessment documentation CWN 70% Q2

Care of the Dying CWN 79% Q1

Learning Disability CWN 85% Q2

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

Risk Assessments CYPWN 83% Q2

Nutrition (NICE) CYPWN 77% Q1

Clozapine CYPWN 80% Q2

Pressure ulcers (Southport and Formby) CWN 54% Q3

Restrictive Practices CYPWN 62% Q3

Local Clinical Re-Audit

Clinical Audits Network Original

Compliance (%)

Standards Re-audited

Re-audit Compliance

(%) Nursing Management of Clozaril MHN 63% 3 60%

Rehabilitation Accommodation MHN 66% 4 84%

Consent to treatment MHN 32% 2 94%

Diabetes MHN 57% 5 65%

Acupuncture - Rheumatology & Physiotherapy CWN 86% 1 97%

Antibiotics in dentistry CWN 88% 1 94%

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

Carers CYPWN 45% 5 54%

Safeguarding supervision CYPWN 82% 1 87%

Education, health and care plans CYPWN 71% 1 89%


Page 17 of 35

National Clinical Audit

Audit Start Quarter End Quarter 2016/17 Compliance

2017/18 Compliance

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

possible

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

possible

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

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

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


Page 18 of 35

Clinical Audit Summary Report Completed Q3 priorities Community & Wellbeing, Pressure Ulcer (Southport & Formby): 54% compliance. A legacy pressure ulcer action plan was developed by the previous provider (Southport and Ormskirk NHS Trust) following a CQC inspection of their organisation in April 2016. This action plan has been reviewed and it was identified that to provide assurance against the action plan in relation to risk assessment and management of pressure ulcers, a clinical audit was required. The baseline audit found there was little consistency with the records for each team and therefore a review is currently underway within the Network to ensure they are fit for purpose. Children & Young People Wellbeing, Restrictive Practices - 62% compliance. The audit provides partial assurance that the guidance has been implemented within the Children’s Integrated Therapies and Nursing teams of the Children & Young People’s Wellbeing Network. Further work is required regarding the documentation of individualised risk assessments. Deep Dive Process If full compliance (80%) is not achieved following the full audit cycle, a more intense piece of work is undertaken by the Medical Director, Head of Clinical Audit and Head of Quality Improvement. This is to ensure the correct support is given to services to improve the quality of care delivered. Actions from this are tracked through the Quality and Safety Sub-committee. During quarter 2, this affected the Carers Re-audit, Clozaril Re-audit, Diabetes Re-audit and Rapid Tranquilisation Audit as part of the POMH national programme. A quality improvement plan is currently in draft for all these programmes and will be reported through in detail to the Quality and Safety Sub-committee.


Page 19 of 35

Caring

CQC Rating: Good

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


Page 20 of 35

Friends and Family Test – Results A key part of the Trust’s real time feedback process is the Friends and Family Test (FFT). The Friends and Family Test is a tool that supports the fundamental principle that people who use NHS services should have the opportunity to provide feedback on their experience. It asks people if they would recommend the services they have used and offers a range of responses. When combined with supplementary follow-up questions, the FFT provides a mechanism to highlight both good and poor patient experience. The Friends and Family Test overall response rate has been at or above the target of 95% for 11 of the last 12 months with the target achieved and maintained since January 2017. Data is available one month in arrears due to national reporting dates.

Friends and Family Test – Submissions The number of submissions has decreased over the long term, with a noticeable increase in November. This is likely to be an exceptional month father than any emerging trend. Data is available one month in arrears due to national reporting dates.

82%84%86%88%90%92%94%96%98%

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

Friends and Family Test Results - Rolling 12 Months

0

500

1000

1500

2000

2500

3000


Friends and Family Test Submissions - Rolling 12 Months


Page 21 of 35

Compliments The number of compliments shows a noticeable decrease with March, September, October and December showing lower submissions.

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

0

200

400

600

800

1000

1200


Compliments - Rolling 12 Months

13579

Workers

Organising care

Planning care

Reviewing care

Staff changes

Crisis care

Treatments

Support andwellbeing

Overall views

Overallexperience

CQC Community Mental Health Survey


Page 22 of 35

Responsive

CQC Rating: Good

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


Page 23 of 35

Complaints The number of complaints has noticeably increased over the 12 months. This reflects a national picture and the work done within the Trust to increase access to the feedback process for patients in services with typically low complaint levels (such as prison healthcare and secure mental health). The predominant themes (from the latest quarterly hearing feedback report) are in relation to access to treatment or drugs (22%), admission and discharge (17.5%), communication (14%), appointments including delays and cancellations (10%) and clinical treatment (9%). Despite the overall increase, the number of upheld or partially upheld complaints remains consistent although there is a noticeable increase in October which is likely to be an exceptional month. The Quality and Safety Sub-committee will review the quarter three Hearing Feedback Report in February 2018.

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

0

50

100

150

200


Complaints - Rolling 12 Months

Complaints Upheld Complaints

0

1


Mixed Sex Breaches - Rolling 12 Months


Page 24 of 35

Well Led

CQC Rating: Good

This section of the report looks at the domain of well les – that the leadership, management and governance of the organisation make sure it's providing high-quality care that's based around individual needs, that it encourages learning and innovation, and that it promotes an open and fair culture. The following indicators are covered in the report:


Page 25 of 35

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

Core Skills The overall Core Skills rate is above the Trust target of 85% however performance remains below target in several individual subjects and in some individual teams. There has been significant and sustained improvement to Core Skills compliance over the past 18 months. Networks continue to take action to improve compliance in those subjects still underperforming, which predominantly relate to courses that require face-to-face attendance away from the workplace.

70%

75%

80%

85%

90%

95%


Core Skills - Rolling 12 Months


Page 26 of 35

Overdue Incident Reviews The number of overdue incident reports (particularly 7 Day Reviews for incidents categorised as Level 1, 2 or 3) remains high with no improvement over the last 12 months. Targeted work has taken place within the Networks and has seen improvement in both the Community and Wellbeing Network and Children and Young People’s Network. The Mental Health Network accounts for the vast predominance of overdue incidents. The Network continue to seek a recovery to this position. The Safety and Quality Governance Department continue to scrutinise all Level 4 and Level 5 incidents daily and track the completion of 3 Day Reviews, which offers assurance that the more serious incidents are being progressed in a timely manner.

Accreditations This section is currently under development.

0

1000

2000

3000

Mar Apr May Jun Jul Aug Sep Oct Nov Dec

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

2017)

7 Day Reviews 3 Day Reviews


Page 27 of 35

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

• The use of an external venue for a Board meeting given the restriction on using external venues;

• Failure of the alarm system in the Scarisbrick Centre; • Concerns about a restraint; • Staff unaware of the PICU policies and procedures; • Bullying by a line manager; • No hand drying facilities in a toilet; • Payments for overnight “sleep in” shifts; • Concerns about caseload size; • Behaviour of a staff member towards a patient; • Two concerns around heating systems not working; • Bullying of staff and culture; • Staff sleeping on night sift.

In all cases a review of proportionate scale has been commissioned. The findings from each review are individually fed back to the person raising the concern if they have provided their name. The findings from every concern is summarised in the Quality Matters bulletin. The themes from concerns over the year to date are management culture and conduct, demand, staffing and violence. The Mindsmatter service has reported a number of concerns, mainly through Dear David, over the year and support is being provided to the Network to help them identify and address more concerns locally.

0

10

20

May Jun Jul Aug Sep Oct Nov Dec

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


Page 28 of 35

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

Priority Lead QI Plan CQC Requirements

Process Measures

Outcome Measures

Balancing Measures

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


Page 29 of 35

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

• Reducing violence and aggression – significant work is underway however the outcome of a reduction is not being realised across all services. Detailed deep dive presentations are underway to the sub-committee and have also been reported to the Quality Committee. The Associate Director of Safety and Quality Governance has commissioned a review of the totality of the Trust approach to preventing and managing violence and aggression. A refreshed Trust-wide programme will be developed, drawing on the best practice in these programmes and replace all existing initiatives and training with one single and consistent model.

• Staffing for Quality and Safety – significant work is underway as reported separately, however challenges remain in many services. • Appraisal – there is no information in Life QI. Overall performance is 42.14%. • Core Skills - overall performance is 92.07% however the Trust is below target in several subjects. • Supervision – work is underway to develop and implement the long term and interim technical solutions; however, data provided to the CQC shows

overall supervision at 71% with some services as low as 41% (Community Mental Health Services for Adults). • Mental Health Law – the programme has delivered its improvement work however compliance remains low; percentage of patients given rights

within 24 of admission (31%), percentage of CTO patients with rights in place at the begging of the month (70%). The Executive Director of Nursing and Quality and Associate Director of Safety and Quality Governance will be holding confirm and challenge meetings with each priority lead in January 2018 to ascertain progress.


Page 30 of 35

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

The Quality and Safety Surveillance Report is designed to provide the Committees and Subcommittee of the Trust Board with a range of indicators that provide assurance and/or early warning escalation of risk. Risk indicators are used to draw attention to areas of focus. Green flags indicate a measure that is on target or where performance is in-line with accepted levels. Yellow flags indicate a measure for close watch (perhaps because of a worsening position) or where a measure is off target but has no immediate risk. Red flags indicate a measure that presents an immediate and/or high level risk. The Quality and Safety Tile, in the front of this report, is a headline summary of key indicators.

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

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


Page 31 of 35

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

total12 months

averageSparkline Risk

Incidents n/a 1867 2095 2342 2362 2175 2097 2357 2285 2200 19780 2197.8

Incidents with harm n/a 404 436 486 549 439 474 542 470 450 4250 472.2

STEIS-reportable serious incidents n/a 7 9 4 9 8 10 4 13 8 9 7 2 90 7.5

RIDDOR incidents n/a 2 0 3 4 5 2 6 1 6 5 2 3 39 3.3

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

Medication incidents n/a 127 149 176 151 148 183 186 159 157 1436 159.6

Infection control Serious HCAI incidents 0 1 0 1 1 0 1 0 0 1 0 0 0 5 0.4

Use of restraint n/a 189 263 308 329 301 400 462 335 344 401 361 408 4101 341.8

Use of seclusion n/a 85 65 73 68 66 64 67 93 67 648 72.0

Safeguarding alerts n/a 100 158 138 129 131 96 156 117 96 1121 124.6

Potentially avoidable grade 3 and 4 pressure ulcers

n/a 0 2 0 2 0 5 1 2 0 1 2 0 15 1.3

Number of instances of 1 or less qualified on duty (inpatients)

0 192 170 145 139 197 140 132 177 132 84 74 1582 143.8

Number of red flag incidents (inpatients only)

n/a 260 268 221 195 270 227 228 258 228 137 111 2403 218.5

Staff safetyPhysical violence to staff from

patients n/a 140 129 151 155 150 218 268 220 221 218 226 185 2281 190.1

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

QUALITY AND SAFETY SURVEILLANCE - Safe

Incidents

Patient safety

Staffing


Page 32 of 35

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

Pressure ulcers (%) - 2.72% 2.91% 5.27% 3.45% 3.45% 4.04% 3.05% 3.12% 2.55% 2.72% 2.57% 3.22%

Falls with harm (%) - 1.28% 1.64% 1.55% 1.55% 0.60% 0.75% 1.21% 0.64% 0.93% 0.53% 0.53% 1.00%

Catheter and UTI (%) - 0.64% 0.27% 0.26% 0.43% 0.45% 0.27% 0.21% 0.07% 0.23% 0.15% 0.08% 0.57%

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

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

Self harm (%) - 4.04% 3.55% 3.43% 3.56% 3.76% 3.75% 4.37% 4.63% 3.71% 3.59% 4.22% 4.48%

Victim of violence (%) - 1.62% 2.71% 1.07% 2.30% 1.46% 2.50% 1.66% 1.89% 1.75% 3.17% 2.53% 3.20%

Feel unsafe (%) - 6.26% 8.35% 9.01% 9.62% 10.65% 7.08% 7.90% 10.53% 8.08% 11.21% 7.81% 8.96%

Omission of medication (%) - 13.74% 16.08% 17.17% 17.99% 18.37% 23.54% 20.37% 19.79% 20.09% 24.10% 19.62% 21.54%

Restraint (%) - 4.65% 4.80% 3.65% 5.23% 5.43% 7.08% 6.86% 7.16% 5.68% 4.86% 5.91% 5.33%

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

QUALITY AND SAFETY SURVEILLANCE - Effective12 months average

3.3%

1.0%

0.3%

82.9%

Physical Health Harm Free Care

Mental Health Harm Free Care

0.4%

19.4%

5.6%

95.2%

3.9%

2.2%

8.8%


Page 33 of 35


total12 months


F&F Test 95% 96% 96% 96% 96% 97% 95% 97% 97% 97% 95% 96% 96.08%

F&F Test - Response Rate n/a 1659 2042 1562 1263 1815 1218 1241 1652 923 1669 2736 1616.4

Compliments Compliments n/a 678 1031 788 593 988 697 777 851 606 614 921 472 9016 751.3

QUALITY AND SAFETY SURVEILLANCE - Caring

Friends & Family - Patients

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


Page 34 of 35


total12 months


Complaints n/a 114 111 167 95 109 152 133 172 147 147 136 102 1585 132.1

Upheld/partially upheld complaints n/a 22 21 31 26 23 19 24 22 21 51 28 21 309 25.8

Completed within agreed timeframe (%)

n/a 54.0% 50.0% 54.0% 158.0% 52.7%

Reopened complaints n/a 3 4 2 4 4 7 5 1 2 3 4 1 40 3.3

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

MP enquiries n/a 13 9 15 7 8 5 9 11 5 12 8 13 115 9.6

Environment Mixed Sex Breaches 0 0 0 0 0 0 0 0 1 0 0 0 0 1 0.1

QUALITY AND SAFETY SURVEILLANCE - Responsive

Complaints


Page 35 of 35


total12 months


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

Regulatory inspections/visits n/a 4 5 4 3 4 3 2 1 2 1 4 0 33 2.75

CQC notifications n/a 2 2 2

Core Skills (%) 85% 89.07% 89.41% 90.68% 90.33% 89.26% 91.06% 91.55% 90.81% 90.87% 91.64% 92.12% 92.07% - 90.74%

Supervision (%) n/a

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

Overdue 3 day reviews 0 105 80 71 65 77 82 74 59 97 103 96 909 82.64


Overdue incident actions 0 94 150 142 - 128.67

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

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

Concerns raised n/a 9 17 13 39 13

Quality Plan priorities off track 0 0 0 0 0 5 6 - 2

Quality assurance visits n/a 1 0 0 0 2 1 4 8 1.14

Assurance

QUALITY AND SAFETY SURVEILLANCE - Well Led

Regulatory

People

Good

Learning and candour

Board of Directors


Report Title Finance Report


Prepared by Shannon Carroll, Financial Services Director

Presented by Bill Gregory, Chief Finance Officer


Supporting Executive Director Chief Finance Officer


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


To provide excellent value for money in a financially sustainable way

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

CQC domain Effective

Summary

Actual Plan Var Forecast Plan VarSustainability

EBITDA 10,261 12,869 -2,608 15,920 17,745 -1,825Operational Deficit -1,293 1,187 -2,480 2,240 2,167 73Deficit with Impairment -1,507 1,187 -2,694 2,026 2,167 -141

CIPs (against Trust Plan) 10,045 11,099 -1,054 15,100 15,100 0Cash and Liquidity 13,630 13,637 -7 20,703 10,989 9,714Capex 3,007 7,297 -4,290 7,741 9,561 -1,820UOR

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

Recovery Plan

Whilst it would appear that there is potential for the gap to be bridged through the plan, this is not without significant risk. Delivery will only be achieved with a considerable coordinated and sustained effort across the organisation. The plan will continue to be refined and presented in more detail to the Financial Recovery Group along with the actions required.

Revised year end control totals are being provided to networks in line with the recovery plan and will require:• Progress and delivery of ward staffing actions• Implementation of the recovery plan.• Continuing to pursue VAT reclaims and consider alternatives.• Progress on land sales.• Satisfactory resolution of disputes.

Forecasting

After adjusting for impairments of £0.2m the deficit for month 9 is a -£1.3m which excludes year to date planned Sustainability and Transformation Funding of c£1.4m, against a plan surplus to date of £1.2m. Performance is therefore £2.5m behind the control total and £1.1m behind with STF. The position continues to be driven by staffing pressures in ward and prison areas which is also impacting on delivery against planned cost improvement programmes, particularly ward staffing. In addition, expenditure is exceeding funding on OAPs resulting in current and forecast pressures. Performance does however show an improvement on the Month 8 in month position of £0.6m and an in month surplus over plan of £0.3m. Unmitigated projections indicate a gap of c£4.2m (£6.4m without STF), which again shows an improvement over the month 8 position of c£0.5m. Though improvements in performance are evident, continued delivery will require sustained and coordinated responses with robust management and oversight. After taking in to account £1.7m of disposals, which are accounted for after EBITDA, EBITDA is broadly in line with I&E Margin. The new Use of Resources (UoR) metric is rated at 2, consistent with month 8, should the Trust meet its financial plans and targets the Trust will achieve a rating of 2, see below.

Current Out-Turn

Sustainability

KeyMajor ConcernsMinor concerns, within toleranceIn line with plan

NHSI RatingNo evident concernsMinor concern, potentially requiring scrutinyMajor concern, requiring scrutinySignificant Risk, action required

Summary (continued)

Progress against the capital programme has begun to accelerate with expenditure at £3.0m against the original profile of £7.3m. Despite the resolution of a number of issues a reduced level of spend on the 17/18 programme would now appear inevitable, particularly on the Inpatient and Perinatal schemes. Forecasts are in line with reported delays and NHSI have been notified with regard to potential underspends and PDC implications. The Trust continues to work with contractors to ensure the planned endpoint for these important schemes remains on track.

The improving I&E position yields a rating of 3 and a Capital Service rating of 3 maintaining the overall UoR to a 2 ( 2 at Month 8). Assuming current pressures and risks are addressed through the recovery plan and I&E performance achieves (or exceeds) forecast the Trust will achieve a UoR of 2 in line with the plan. However, though forecast would achieve the overall target rating, Capital Service is based on EBITDA and since part of the Trusts recovery plan is based on disposals (which are excluded from EBITDA) the Trust is not forecast to achieve planned Capital Service. The Trust is also forecast to exceed its liquidity and slip against it's planned Agency target. The risks presented by the current financial position and the impact on our outturn use of resources risk rating will be modelled alongside the liquidity position for the FRG.Should conditions persist and costs not be managed within the control total then the resulting deterioration might trigger a review of our segmentation, although NHSI have confirmed that there is no change at present.

Use of Resources (UoR) risk ratings

Capital and Financing

The capital position continues to offset the I&E position and pressures on working capital leaving, cash broadly in line with plan. Assuming that proposed management action to bring financial performance back in to line is achieved, given current capital forecasts, the external funding anticipated for the inpatients programme and the anticipated disposals the cash forecast is significantly better than plan (£9.7m) - see SoCF and Liquidity. Given the risks a more detailed assessment of the short term cash position will be presented to the next FRG.

CIPs

Liquidity

At month 9 with CIPs of £10.0m against a plan of £11.1m the Trust is c£1.1m behind plan, an improvement of £0.2m on month 8 (£1.3m behind plan). The adverse variance is mainly due to the continued lack of performance on Run Rate Reduction Programmes on staffing pressures. Compensating schemes have, and continue to be, developed and with c£1.4m of schemes transacted in December confidence in forecasts is increasing. The network management team continue to be support to implement measures aimed at improving the position. These risks are reflected in the forecasts.

Statement of Comprehensive Income

Year to Date Statement of Comprehensive Income (Actual v Plan)

Month 8Actual Plan Variance Variance

£'m £'m £'m £'m

Income 253.3 249.4 3.9 2.9

Pay (192.6) (187.0) (5.5) (5.2)Non Pay (50.7) (49.5) (1.2) (0.8)Total Costs (243.3) (236.5) (6.7) (6.0)

EBITDA 10.0 12.9 (2.8) (3.1)

Capital Charges (10.2) (10.3) 0.2 0.1Financing (1.4) (1.4) (0.0) (0.0)

Net surplus / (deficit) (1.5) 1.2 (2.7) (3.0)

Forecast Statement of Comprehensive Income (Unmitigated Forecast v Plan)Base

Unmitigated Annual Month 8Forecast Plan Variance Variance

£'m £'m £'m £'m

Income 336.6 332.8 3.9 3.4


EBITDA 10.6 17.7 (7.2) (7.7)

Capital Charges (13.1) (13.7) 0.6 0.9Financing (1.8) (1.8) 0.1 0.1

Net surplus / (deficit) (4.3) 2.2 (6.5) (6.8)

Forecast Statement of Comprehensive Income (Forecast v Plan) Unmitigated Forecast to Forecast Recovery BridgeUpside

Month 8Forecast Plan Variance Variance

£'m £'m £'m £'m

Income 339.0 332.8 6.2 5.9


EBITDA 15.7 17.7 (2.0) (2.0)

Capital Charges (11.9) (13.7) 1.8 1.8Financing (1.8) (1.8) 0.1 0.1

Net surplus / (deficit) 2.0 2.2 (0.1) (0.1)

Year To Date (Current)

Annual

-7,000

-6,000

-5,000

-4,000

-3,000

-2,000

-1,000

0Gap Additional

IncomePay Savings NonPay Savings VAT Land Sales STF

-6,346 271 1,540 500 750 1,200 2,085

Income – Year to date changes from plan are dominated by OAPs (£0.9m), STF monies (-£1.4m), and contract variancies (Mental Health - £3.0m, Community - £1.6m, with reduction in NHSE -£0.7m, Councils - £1.4m). There are also increases in AHSN (£0.4m) and R&D (0.5m) income.

These issues also dominate the base year-end position with STF rising to -£2.1m and net contract variations of £2.6m, plus OAPs of £1.1m. AHSN increases to £1.7m above plan.The upside assumes the £2.1m STF monies and an additional £0.3m of income.

Pay - The year to date pay exceeds plan by £5.5m. £3.2m of this is adult ward staffing, with £1.1m on Secure Wards. There is £0.6m of under recovered pay CIPs offset by £1.4m of reserves. Contract variations add £2.2m to pay, compensated in part by Corporate underspends of £0.8m.

The base year-end variance of £6.2m reflects the same issues, adult wards (£4.2m), Secure (£1.5m), CIP slippage (£0.8m) and commissioner developments (£2.8m), partly offset by reserves of £1.7m and corporate vacancies of £1.1m.The upside assumes £1.6m of the recovery measure modelled through pay costs, which are outside of ward areas.

Non-Pay - Year to date non-pay is £1.2m overspent, dominated by OAPs (£1.8m), with developments being offset by reserves underspends (£0.8m).

The base outturn is £4.9m above plan for non-pay. OAPS is £2.1m of this but we see significant increases in non-pay on the back of developments £1.4m, and an increase in AHSN spend of £0.8m as its programmes are back loaded.The upside position brings in £1.3m of non-pay recovery measures into the position.

Capital charges are in line with plan, with the exception of £0.5m for land sales in the base outturn forecast. This increases to £1.7m in the upside.

Statement of Financial Position

Year to Date Statement of Financial Position (Actual v Plan)

Actual Plan Variance£'m £'m £'m

Fixed Assets 207.2 196.2 10.9Other Long Term Assets 0.1 0.6 -0.5Non Current Assets 207.3 196.8 10.5

Stock 0.0 0.3 -0.2Trade Debtors 21.7 16.4 5.3Other Current Assets 1.5 0.0 1.5Cash 13.6 13.6 0.0Current Liabilities -30.9 -30.2 -0.7Current Assets and Liabilities 5.9 0.1 5.8

Provisions and other Long Term Liabilities -1.7 -2.0 0.3Loans -53.5 -53.4 -0.1Non Current Liabilities -55.2 -55.4 0.2

Total Net Assets Employed 158.0 141.5 16.4Financed By:PDC 102.9 102.7 0.1I&E Reserve 0.8 2.6 -1.7Other Reserves 54.3 36.2 18.0

Taxpayers Equity 158.0 141.5 16.4

Forecast Year End Statement of Financial Position (Forecast v Plan)

Forecast Plan Variance£'m £'m £'m

Fixed Assets 205.7 196.2 9.4Other Long Term Assets 0.1 0.6 -0.5Non Current Assets 205.8 196.8 9.0

Stock 0.0 0.3 -0.2Trade Debtors 19.6 16.0 3.7Other Current Assets 1.5 0.0 1.5Cash 20.7 11.0 9.7Current Liabilities -29.1 -27.3 -1.7Current Assets and Liabilities 12.8 -0.1 12.9

Provisions and other Long Term Liabilities -1.6 -2.0 0.3Loans -52.2 -52.2 0.0Non Current Liabilities -53.8 -54.2 0.3

Total Net Assets Employed 164.7 142.5 22.2Financed By:PDC 106.1 102.7 3.3I&E Reserve 4.3 3.7 0.6Other Reserves 54.4 36.1 18.3

Taxpayers Equity 164.7 142.5 22.2


Broadly in line with Plan

Working Capital is £5.8m ahead of plan primarily due to gains on opening position of £2.7m, capex underspend £4.3m and unplanned transfers to assets held for sale £0.9m offset by I&E position -£2.5m. Higher than planned debtors and accrued income levels are suppressing cash (see liquidity)

2016/17 revaluation changes c£16.1m, capex under plan -£4.3m, unplanned transfers to assets held for sale -£0.9m. The remainder being minor unplanned changes re depreciation, disposals and impairments.

2016/17 opening position changes to I&E including 2016/17 bonus STF monies, plus current I&E position (£2.7m behind plan).

Broadly in line with Plan

Annual

Working Capital is £12.9m ahead of plan, this is primarily due to gains on Cash (£9.7m - see SoCF) plus increases to forecast Trade Debtors (£3.7m - £2.1m re STF), increases to Other Current Assets (£1.5m - mainly assets held for sale £0.9m) as offset by increases in Current Liabilities (£-1.7m - mainly Creditors and Deferred Income).

2016/17 revaluation changes c£16.1m , -c£1.8m capex underspend, -£4.3m NBV of disposals (Mainly Ribbleton and Ridge Lea), transfers to assets held for sale-£0.9m and minor unplanned changes re depn and impairments.

2016/17 opening position changes to I&E, including 2016/17 bonus STF monies, and additional PDC for capex (Inpatients, Perinatal and Places of Safety).

Statement of Cash Flow

Year to Date Statement of Cash Flow (Actual v Plan)


Opening cash balance 13.1 13.8 -0.7

Surplus/(deficit) after tax -1.5 1.2 -2.7Non Cash Flows 11.6 11.7 -0.1Operating Cash Flows before WC 10.0 12.9 -2.8

Changes to WC -1.6 -0.7 -1.0Higher than planned accrued income and debtors offset by opening position.

CF from operations 8.4 12.2 -3.8

Capital and Investment Activities -2.8 -7.2 4.4Financing and Other -5.0 -5.1 0.1Capital and Financing -7.9 -12.3 4.5

Net cash inflow/outflow 0.5 -0.1 0.7

Closing cash balance 13.6 13.6 0.0

Forecast Statement of Cash Flow (Forecast v Plan)


Opening cash balance 13.1 13.8 -0.7

Surplus/(deficit) after tax 2.0 2.2 -0.1Non Cash Flows 13.7 15.6 -1.9Operating Cash Flows before WC 15.7 17.7 -2.0

Changes to WC 0.0 -1.7 1.6Movement due primarily to opening position £(2.7m) offset by forecast changes to debtors and creditors

CF from operations 15.7 16.1 -0.4

Capital and Investment Activities -1.8 -9.5 7.7Financing and Other -6.3 -9.4 3.1Capital and Financing -8.1 -18.8 10.8

Net cash inflow/outflow 7.6 -2.8 10.4

Closing cash balance 20.7 11.0 9.7

Forecast capital underspend plus disposal proceeds (Westfields, Ribbleton and Ridge Lea) plus additional external financing re Inpatients and Perinatal.


Annual

I&E position is £2.7m behind plan

Capex is £4.3m behind plan

I&E position currently expected to achieve plan, but through disposals (gains in Capital and Financing)

Cash and Liquidity

Actual Plan Variance Forecast Plan Variance£'m £'m £'m £'m £'m £'m

£13.6m £13.6m -£0.0m £20.7m £11.0m £9.7m

Debt Analysis*

Debt Age 1-30 31-90 90+ Total

Local Authorities £2.2m £0.2m £0.8m £3.1mNon NHS £0.2m £0.2m £0.1m £0.5mNHS £2.8m £3.6m £3.9m £10.3m

Total £5.1m £4.0m £4.8m £13.9m

Local Authorities £1.8m £0.0m £0.9m £2.7mNon NHS £0.3m £0.4m £0.1m £0.8mNHS £2.8m £3.0m £3.9m £9.8m

Total Last Month £4.9m £3.5m £4.8m £13.3m

Year To Date (Current) Annual

0.000

5.000

10.000

15.000

20.000

25.000

30.000

1 2 3 4 5 6 7 8 9 10 11 12

Cash Forecast

Cash Balances Strategic Headroom Operating Headrooom

Minimum Threshold Forecast Plan

Debt Movement

• Debt levels are slightly higher than last month with some increase in NHS debt, mainly OAPs (settled in January) and CQUIN (a national issue, now resolved), and some increases on current council debt.

• Of the NHS 90+ debt c£1.3m relates to recharges (expected to be paid), c£1.6m to current year Block/CQUIN/OAPs/NCAs and c£1m to 2016/17 disputes. All outstanding disputes have now been submitted for mediation.

• Local Authority 90+ debt is mainly staffing recharges (expected to be paid).

*Note that along with phasing adjustments, contract variations and accruals, 2017/18 STF

Cash Variances

• Cash is broadly in line with plan. The capital position continues to offset the I&E position and pressures on working capital.

• High debtors (£2.5m - see below), and accrued contact variations and adjustments (£2.8m -includes STF) are supressing cash.

• Given the external funding anticipated for the inpatients programme and the anticipated disposals the cash forecast is significantly better than plan (£9.7m).

• The forecast assumes that management actions to bring the I&E position back in to line with plan are achieved.

• The key risk to the forecast will be the disposals of Ribbleton, Ridge Lea and Westfields, but even if these don't manifest cash will be above plan assuming other I&E targets are met. A more detailed cash sensitivity analysis will be presented to the next FRG.

Use Of Resource Metric

FINANCE AND USE OF RESOURCES RATING

Plan Actual Plan Forecast 1 2 3 4 Weighting

Capital service cover rating 2 3 2 3 2.5 1.75 1.25 <1.25 20%

Liquidity rating 2 1 2 1 0 -7 -14 <-14 20%

I&E margin rating 2 3 2 2 1.00% 0.00% -1.00% <=-1% 20%

I&E margin: distance from financial plan 1 2 1 1 0.00% -1.00% -2.00% <=-2% 20%

Agency rating 1 2 1 2 0.00% 25.00% 50.00% >=50% 20%

Overall 2 2 2 2 100%

Year to Date Annual

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

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

The improving I&E position yields a rating of 3 and a Capital Service rating of 3 maintaining the overall UoR to a 2 ( 2 at Month 8). Assuming current pressures and risks are addressed through the recovery plan and I&E performance achieves (or exceeds) forecast the Trust will achieve a UoR of 2 in line with the plan. However, though forecast would achieve the overall target rating, Capital Service is based on EBITDA and since part of the Trusts recovery plan is based on disposals (which are excluded from EBITDA) the Trust is not forecast to achieve planned Capital Service. The Trust is also forecast to exceed its liquidity and slip against it's planned Agency target. Should conditions persist and costs not be managed within the control total then the resulting deterioration might trigger a review of our segmentation.

• Capital Service is currently a 3 against a plan of 2, an increase in operating performance of c£1.6m would be required to increase the rating to 2.• Liquidity is currently a 1 against a plan of 2, a deterioration in the liquidity metric of c£4.4m would be required to reduce the rating to 2. • I&E Margin rating is currently 3 against a plan of 2, an increase in operating performance of c£1.3m would be required to increase the rating to 2 - Note that the adjusted deficit of -

£1.3m is £2.5m behind the RCT (£1.1m exc STF)).• I&E Variance from Plan is currently 3, an increase in operating performance of c£2.5m would be required to increase the rating to 2.• Agency is currently 2 based on a metric of 17%, a decrease in agency costs of c£1m would be required to increase rating to 1.

Income and Expenditure - Services

Year to Date Income and Expenditure - Services (Actual v Plan)


Adult Services 101.8 94.6 -7.2 Ward overspends in adult & secure services, CIP slippage, OAPs

Community Services 42.6 42.4 -0.1 Some CIP slippage but underspends compensate

Children And Family Services 32.1 33.0 1.0 Underspends but shortfall on sexual health income

Corporate and Reserves 42.6 47.7 5.1 Some gains on inflation reserves and disposals

Net Network Position 219.1 217.8 -1.3

Forecast Income and Expenditure - Services (Forecast v Plan)


Adult Services 134.8 125.5 -9.3 Ward overspends in adult & secure services, CIP slippage, OAPS

Community Services 56.9 56.6 -0.3 Some CIP slippage but underspends compensate

Children And Family Services 43.1 43.9 0.9 Underspends but slippage on sexual health

Corporate and Reserves 55.0 61.4 6.4 Some gains on inflation, pressures and disposals, VAT

Net Network Position 289.8 287.4 -2.4

Note Service figures do not include Healthcare Income and Capital Charges.


Annual

Staffing

0

200

400

600

800

1,000

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

Agency Spend by Type

Medical and Dental Nursing, midwifery and health visiting staff

Scientific, therapeutic and technical staff Health care assistants and other support staff

Managers and infrastructure support Other

Agency Plan

12,000

14,000

16,000

18,000

20,000

22,000

24,000


Staffing Spend by Category

Substantive Bank Agency Plan Total

Staffing Spend

• Overspends in pay are being driven by occupancy and acuity on wards in both Adult and Secure services.

• Most trust CIPs manifest in pay and the current slippage will manifest as overspends in pay.

• Many community based services are experiencing underspends.

Agency Spend

• Agency expenditure is dominated by medical and dental expenditure, which is broadly constant but significant and increasing.

• Nursing (both qualified and unqualified) is more volatile and reflects the flow of occupancy and acuity on the wards.

• Overall expenditure is exceeding the agency control total, by c£1.3m year to date, 17%.

Month Month Month MonthDec 2017 Oct 2017 Dec 2017 Oct 2017

9 7 Note 9 7 Note

Agency Spend 809 774 Note 1 Bank Spend 1,795 1,388

Network Analysis Network AnalysisMental Health 493 564 - Note 2 Mental Health 1428 1086 - Note 2Children & Young Peoples 143 11 - Note 3 Children & Young Peoples 103 81 - Note 3Community & Wellbeing 233 282 - Note 4 Community & Wellbeing 189 160 - Note 4Corporate Services -60 -83 - Note 5 Corporate Services 75 60 - Note 5

Actual 809 774 Actual 1,795 1,388

1

2

34

5 Corporate Services is net of the charge levied for agency staff. Agency spend is negligible with the exceptions of Health Informatics.The Trust has been given a ceiling by NHS Improvement for agency spend. This target is£7.695m for the year. At the end of period 9, the Trust is -£1,006k, or 18% above it'strajectory. The new Use of Resources rating measures agency against target and containstrigger points. Key trigger points are a requirement for 50% and 25% or better for ratings of3 and 2 respectively. An individual rating of at least 3 is required to obtain an overall ratingof 2 (see also Use of Resources section).

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

A high level of vacancies is supported by bank and agency, though increased levels of recruitment mean overall staffing costs remain high. Agency costs have increased from last month as well as bank costs.Mental Health Networks bank and agency costs are primarily due to the level of acuity on inpatient wards being beyond the level established with aprticualr pressure being experienced in December across both bank and agency.Children and Young Peoples temporary staffing remains relatively minor, but we have seen pressure at The Cove in December.Community and Wellbeing sees an increase in bank but a fall in agency, with the major agency change being the with regard to Learning Disability, and bank recovering in Integrated Teams and Southport.


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

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

2017/18 1312 1268 1625 1365 1481 1813 1388 1322 1795

0200400600800

100012001400160018002000


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

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

2017/18 647 691 711 704 825 863 774 706 809

0

200

400

600

800

1000

1200

1400

Agency Ceiling Apr May Jun Jul Aug Sep Oct Nov Dec Total Projection

Actual 647 691 711 704 825 863 774 706 809 6,730 9,037Plan 639 639 639 636 636 636 633 633 633 5,724 7,695Variance -8 -52 -72 -68 -189 -227 -141 -73 -176 -1,006 -1,342% of Plan -18% -17%

- Forecast Shortfall - Forecast Achievement - YTD Shortfall - YTD Achievement

CIP Achievement (£)

NotesYear to Date PerformanceAt month 9 with CIPs of £10.0m against a plan of £1.1m the Trust is c£1.1m behind plan, an improvement of £0.2m on month 8 (£1.3m behind plan). The adverse variance is mainly due to the continued lack of performance on Run Rate Reduction Programmes on staffing pressures. Compensating schemes have, and continue to be, developed and with c£1.4m of schemes transacted in December confidence in forecasts is increasing. The network management team continue to be support to implement measures aimed at improving the position.

Schemes to be Transacted£0.3m of schemes are yet to be transacted at month 9 leading to year to date slippage of c£0.2m. There is a good degree of confidence in the delivery of these schemes.

Schemes In Process£0.9m of additional schemes identified are not yet sufficiently detailed to transact leading to year to date slippage of c£0.4m. There is some confidence in the delivery of these schemes.

Schemes to be IdentifiedIncluding pipeline schemes planned total remains broadly in line with target, though this is not without risk.

ForecastThe programme is currently expected to achieve the Annual Plan.

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

Plan Actual Variance Plan Forecast Variance

£'m £'m £'m £'m £'m £'m

Cost Improvement Programmes 8.43 9.15 0.71 11.10 13.10 2.00

Run Rate Reduction Programmes 2.67 0.90 -1.77 4.00 2.00 -2.00

Total 11.10 10.05 -1.05 15.10 15.10 0.00


£'m £'m £'m £'m £'m £'m

Monitored Schemes 10.48 10.05 -0.43 14.25 13.87 -0.38

Schemes to be transacted 0.19 -0.19 0.33 0.33 0.00

Schemes in Process 0.43 -0.43 0.52 0.85 0.33

Slippage/Schemes to be identified 0.00 0.05 0.05

Total 11.10 10.05 -1.05 15.10 15.10 0.00

Year to Date Annual

Year to Date Annual

OUT OF AREA ACTIVITY

NetworkActual/ Forecast Apr May Jun Jul Aug Sep Oct Nov Dec Jan Feb Mar TotalAcute OAPs (places) 15 11 14 13 10 11 13 16 11 9 9 9 138PICU OAPs (places) 9 13 9 12 12 11 9 8 11 8 8 8 116Total Beds 24 24 23 25 22 22 22 24 22 17 17 17 259Acute OAPs (£'000) 244 185 228 218 168 179 218 260 201 167 153 167 2274PICU OAPs (£'000) 206 308 206 284 284 252 213 183 261 189 171 189 2697Total £'000 450 493 434 502 452 431 431 443 462 356 324 356 5134

1

23

4

567

ForecastActuals

The Trust has written to commissioners about the pressure caused by patients awaiting alternative placements.The Trust has opened negotiations with commissioners about the financial impact of patients inappropriately occupying our beds in excess of 180 days.

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

The Trust is mobilising Acute Therapy Services in Pennine and Chorley, Crisis Support Units in Preston and Blackpool, and a Crisis House in Coppull. These services have an impact on the bed trajectory and variations in timing will alter the OAPs usage accordingly.If the current trajectory persists this would present pressure a further pressure in the order of £0.25m (net).

There is a fund of c£3m for OAPs, financed 50:50 by the Trust and Lancashire CCGs. After this fund is exhausted, any additional OAPs are accounted for on the basis of 50:50 split between the Trust and CCGs.

Current projection suggest there will be expenditure of £5.1m for OAPs in 2017/18., though slippage on developments takes the net impact to £5.0m as reported elsewhere.

YTD Plan YTD Act Annual ForecastDec 2017 Dec 2017 Variance Plan Out-turn Variance

£000 £000 £000 £000 £000 £000

IT Schemes 1.365 0.825 -0.540 1.900 1.900 0.000 - Note 1

Estate and infrastructure SchemesPrecommittments 0.130 0.046 -0.084 0.130 0.046 -0.084Large Schemes

MH Inpatient Schemes 3.442 0.561 -2.881 4.580 2.200 -2.380 - Note 2

Perinatal 0.000 0.283 0.283 0.000 1.000 1.000 - Note 3

Places of Safety 0.000 0.138 0.138 0.000 0.150 0.150 - Note 4

Other 0.070 0.091 0.021 0.070 0.091 0.021High Priority Schemes 0.818 0.162 -0.656 1.095 0.193 -0.902Spend to Save (inc. Trinity) 0.050 0.196 0.146 0.050 0.496 0.446Maintenance and Replacement 0.524 0.586 0.063 0.698 0.646 -0.052Assurance and Compliance 0.031 0.036 0.005 0.031 0.036 0.005Other (inc. contingency) 0.868 0.083 -0.785 1.007 0.983 -0.024

Total 7.297 3.007 -4.290 9.561 7.741 -1.820 - Note 5

12

3

45

£3.5m of external cash funding was allocated for the Perinatal project, £2.5m in 2017/18. Again issues with third parties have caused some delays and whilst it was hoped this can be managed, discussions with contractors indicate slippage of c1-3 weeks is now likely. NHSI regulatory and capital teams have been notified of the potential impact on 2017/18 expenditure and the associated PDC drawdowns.

£0.5m of external cash funding was allocated for Places of Safety. Funding currently exceeds planned work and the excess will be retained by DoH for reallocation.

Capital Expenditure

Progress against the capital programme has begun to accelerate with expenditure at £3.0m against the original profile of £7.3m. Despite the resolution of a number of issues a reduced level of spend on the 17/18 programme would now appear inevitable, particularly on the Inpatient and Perinatal schemes. Forecasts are in line with reported delays and NHSI have been notified with regard to potential underspends and PDC implications. The Trust continues to work with contractors to ensure trhe planned endpoint remains on track.

IT programme is expected to be delivered on forecast.External cash funding was provisionally allocated to the Inpatient project through the STP and was approved by NHSI in October. Additional information and governance requirements were subsequently added by and provided to DH, and final approval remains to be confirmed. Work has commenced though delays in relation to the Chorley site, primarily caused by third parties, have meant that works have started later than originally intended and whilst it was anticipated the go live date can be managed, significant slippage on 2017/18 expenditure is now expected. NHSI regulatory and capital teams have been notified of the potential impact on 2017/18 expenditure and the associated PDC drawdowns.

The programme is behind and though expenditure is expected to accelerate some slippage is now considered likely. Work is ongoing to manage plans and the year end position.

MATTERS

ID Meeting DatePaper Status

2017/01 Jul-17 VerbalPartial




2017/05 Jul-17 Verbal

Partial

2017/06 Jul-17 VerbalExcluded

2017/07 Jul-17 Verbal Excluded

2017/08 Jul-17 VerbalExcluded

NHSI is currently clarifying the position around elements of the national contingency reserve, £0.5m of which is now outstanding.

SubjectA number of disputes require resolution and have been submitted for mediation, these include NHSE, West Lancs, and Pennine CCGs.

The forecast trajectory with regard to Out of Area Placements (OAPs) is currently projected to net £2.0m, with the assumption that the50% risk share applies.

Provision for charges incurred as a result of the organisational reset have been made, the process is largely complete, but somechallenges remain and these may have financial consequences.

The Trust is actively exploring the potential for land sales. A number of gains are expected to crystallise in 17/18 and are factored in tothe recovery plan and forecasts.

On-going Claims: The process of reclaiming VAT in relation to older developments continues. HRMC have confirmed theappropriateness of the claims and approved claims are being pursued via the contractors (as required by HRMC). The value may be upto £2m, though less than half this amount has been approved and included in plans and forecasts. Our advisors are actively engaged inbringing this to a final resolution but timing and amounts remain uncertain. Treatment is being discussed with external audit but initialindications are positive. STF monies have been included in forecasts on the assumption that the Trust will achieve its revenue control total. Should this not bethe case £2.3m of funding would be lost.The Trust is assessing the impact of recent court decisions around pay for sleepover in Learning Disabilities care placements.

--Board of Directors Agenda Item TB 030/18 Date: 01/02/2018

Report Title Performance Report


Prepared by Louise Corlett, Head of Business Intelligence

Presented by Sue Moore, Chief Operating Officer


Supporting Executive Director Chief Operating Officer PURPOSE OF THE REPORT: Report purpose To appraise the Board of Directors of key elements and

themes from the Month 9 QPR



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

CQC domain Well-led PAPER DEVELOPMENT PROCESS:

Meeting Presented Action Date The Board is asked to note the QPR for month 9 with following comments below:

• All NHSI metrics are compliant with the exception of the Early Intervention in Psychosis Referral to Treatment within 2 weeks.

• The measures within the Board Balanced Scorecard illustrate the challenges faced by the organisation in relation to our financial position and attracting the best people. The Service Delivery domain of the Board Balanced Scorecard now contains a summary of relevant 5YFV performance metrics.

• A new 5YFV dashboard is included in the main body of the QPR. The trajectory of improvement to 2020/21 is provided. Some measures are subject to development and validation and will be available by the new financial year.

• Work has been conducted on the new NHSI measure for Inappropriate Out of Area Placements. A trajectory has been submitted by the STP. Current performance and the trajectory is included in the QPR this month. Discussions have taken place with NHSI and NHSE regarding the application of the definition to ensure appropriate interpretation and reporting.

• Performance measures are aligned to the most appropriate CQC domain according to the detail of the narrative, although it is recognised that not all metrics are exclusively linked to one domain.

Are we SAFE?

The current CQC rating is ‘requires improvement’

Our performance in completing appraisals and mandatory training was a contributory factor in the CQC rating for this domain.

Overall the Trust is compliant against the 85% target for Mandatory Training, achieving 92% for month 9. For some training courses performance is below 85% (page 116), the 3 hotspots in month 9 are basic life support, immediate life support and manual handling. Safeguarding children level 3 is now above 85% having been non-compliant last month. The areas under 85% are being targeted and monitored closely.

Appraisal continues to be a challenge with the month 9 position showing no change from that reported in month 8 (page 116). Networks are producing plans to achieve compliance by the end of the year and will present these to Business Development and Delivery sub-committee on the 21st February.

The use of temporary staffing (and bank and agency spend) continues to be an area of concern. Weekly task and finish meetings continue, chaired by the Executive Director of Nursing and are focussed on interventions to deliver improvements. In addition, meetings have been held with wards where the use of temporary staffing is greatest. These meetings, also chaired by the Executive Director of Nursing, facilitated a discussion to understand the detail of the issues impacting upon staffing for safety and quality. A report of the findings and recommendations was submitted to Finance Recovery Group. Recommendations are now being implemented.

In Southport and Formby Community services, there is high use of agency staffing. This did not triangulate with low rates of sickness absence reporting in previous months. Further investigation has highlighted that sickness absence has not been recorded correctly by the staff and rates in December are 8% compared to 4.9% reported in November (page 133 and 134). A corrective action plan is being developed by the Network.

Are we CARING?

The current CQC rating is ‘Good’.

Attendance at CPA reviews continues to be an issue in secure services (internal target is 80% attendance). For inpatients, 71% of reviews were attended by the care coordinator in month 9 (page 33). For community reviews, attendance was 66.7% in month 9 (page 37), an improvement on 45% in month 8. The Chief Operating Officer has written to each individual care coordinator who failed to attend a CPA review in November and December to set out expectations. A failure to improve will be treated as a performance issue.

The number of service users who have not had a care coordinator allocated –‘unallocated cases’ has increased in Mental Health and Community Well Being Networks this month. This is an important data quality indicator that is receiving renewed focus (Page 71).

Are we EFFECTIVE?


Average Length of stay (ALOS) (on discharge) in adult mental health has reduced to 41.8 days, a decrease of 2 days from last month (page 66) but still higher than the 31 day standard. PICU length of stay has increased to 46 days in month 9, from 34 days in month 8 (page 66). It is inevitable that the LOS will be variable as patients are discharged, therefore the QPR also contains the LOS profile of current inpatients (page 67). Currently, there are 20 adult and 10 PICU patients with LOS greater than 180 days, a slight improvement from 21 and 11, respectively, last month.

Improvements in readmission rates for both 30 and 90 days have been sustained in month 9, with both measures meeting the required standard (page 68&69). This is evidence of the impact of the clinical focus on addressing reasons for patient readmission.

The high demand for inpatient beds continues with occupancy levels exceeding 100%. Consequently, the number of out of area placements (OAPs) continues to exceed plan. In month 9 there was a slight reduction in OAPs at 27.52, compared to 29.93 in month 8 (page 60). Work on reducing the number of patients with length of stay greater than 180 days continues as a means of resolving bed capacity issues (and OAPS). The integrated discharge team was established in December to focus on expediting discharge for these patients.

Demand for the Mental Health Liaison Teams continues to be challenging. Despite this, Mental Health Liaison Team performance against the 4 hour standard achieved 89.4%. This is the highest percentage achievement since April 2017 (page 27 and 28). Mental Health Liaison Teams are reporting 10 individual 12 hour breaches for month 9. This is a small increase compared to the last 3 months (page 27 and 28) and reflects earlier assessment and timely decision to admit (which starts the 12 hour clock) but lack of available capacity to enable admission within 12 hours. This was one of the issues flagged to commissioners as an unintended consequence of investment in Core 24.

In order to understand the dynamics of patient flow in more detail, a deep dive has been commissioned by the COO. This will look specifically at the impact of the Integrated Discharge Team alongside our ability to admit patients from A&E and Police Custody in a timely manner. This will be reported back at the next Business Development and Delivery sub-committee.

In month 9 we are reporting zero breaches of the PACE clock (page 38). This is the first time that we have achieved the target this year. Gold command was in operation during December and was successful in managing patients in a timely manner. Ongoing work to improve relationships with constabulary colleagues aims to maintain this improvement during January.

Occupancy at the Cove continues to be variable and in December was less than the 85% target (Page 26). A deep dive into patient flow and access into the Cove has been commissioned by the COO and will be presented back to Business Development and Delivery sub-committee in February.

Are we RESPONSIVE?


As reported previously, the Early Intervention in Psychosis service is failing to meet the 50% target for referral to treatment within 2 weeks. Performance in month 9 is 33% (Page 48), an improvement on month 7 and 8. The cumulative Q3 position is 24.3% (Page 12), which as expected did not reach 50%.

The remedial action plan is on track and continues to be monitored through a fortnightly task group. Daily teleconferences are in place to provide operational support to the team leaders. All ‘legacy’ patients have now been treated, however, this has impacted upon reported performance throughout the quarter. Late receipt of referrals and patient choice also affected Q3 performance. The implementation of a direct referral pathway is underway to address the issue of late referrals.

Responsiveness is also demonstrated through our achievement of the 18 week referral to treatment (RTT) standard for AHPs and for dental waiting times. In the Community Wellbeing Network, all services monitored are compliant against the contractual RTT measures (page 24).

In the Children and Young People’s Wellbeing Network, 2 out of 5 services are compliant in month 9 against the 18 week AHP RTT, a deterioration on previous months. Occupational therapy services performed below the 92% target this month and will be subject to additional scrutiny to recover the position.

The 2 areas of sustained under-performance are Child Psychology and CAMHs Tier 3 and a detailed report on these services was presented at Trust Board in month 8.

Child Psychology: Performance for month 9 has achieved 84% against the 92% target for incomplete RTT pathways (page 50 and 51). Whilst this is a further deterioration from the position in month 7 and 8, it is a consequence of a reduction in the overall waiting list size (denominator). The number of children waiting longer than 18 weeks has also reduced from 37 to 32. Based on current waiting list size of 206 patients, the service needs to achieve less than 16 children waiting over 18 weeks to achieve the target.

As reported last month, the focus is on resolving capacity issues in the Preston Hospital and Lancaster team (who have 31 of the 32 long waiters) to provide treatment to the children waiting over 18 weeks.

CAMHS Tier 3: The performance in the CAMHS Tier 3 service continues to perform significantly below the standard for incomplete pathways. In month 9, performance is 72% against the 92% standard, compared to 61% in month 8 (page 52 and 53).

The number of children waiting longer than 18 weeks for treatment has reduced again this month to 152, from 228 in month 8. The Chorley and South Ribble team continue to be the main contributor to the under-performance, however, this team is reporting the most positive position for 6 months. Gaps in capacity are being progressed through recruitment and further improvement is expected from month 10.

Also in the Children and Young Peoples Network, ADHD services have been challenged for some time. Over the last year, the service has failed to achieve the 18 week RTT for new patients. This reflects a historical issue of demand outstripping the original service model/specification, compounded with staff capacity issues. Performance in month 9 was 30%, with 230 people waiting in excess of 18 weeks (page 54-56). The Network are seeking a collaborative approach with commissioners to establish a new service model. This will involve the establishment of a virtual neuro-developmental assessment team and also a revised triage/gatekeeping model and referral process. This will be progressed during Quarter 4.

In Mindsmatter (IAPT), a number of measures are monitored that indicate our overall responsiveness. The service continues to perform well against the NHSI metrics for referral to treatment in 6 and 18 weeks and also the percentage of patients entering recovery (page 24).

Achievement of prevalence targets is an area of focus. Cumulative prevalence is being measured against the current 15% target and also the trajectory required to meet 16.8% in Q4 (for relevant CCGs). In month 9, all teams failed to meet the monthly prevalence targets with the exception of the Fylde & Wyre team. However, higher activity in October and November enabled all areas to meet the required cumulative target for Q3.

In depth monitoring is being maintained alongside interventions to increase prevalence (page 42-43). However, a result of the increased prevalence is the increased demand for onward treatment (particularly CBT) which had not been factored into the demand and capacity planning of the service. Issues with vacancies and sickness further compound the capacity gap. Consequently, a significant increase in the number of patients waiting longer than 26 weeks for treatment is seen this month; 154 compared to 59 last month (page 46 and 47). Patients who have waited over 26 weeks are being offered alternative interventions where appropriate. The COO has requested a formal deep dive into IAPT, which triangulates low appraisal rates and areas of high sickness with performance. The report will be presented at Business Development and Delivery sub-committee in February.

In relation to delivery of the contract activity plan, both the mental health (page 95) and community (page 83) contracts are performing ahead of plan. The detail within the QPR shows the status of each service line. Work is being undertaken with BwD CCG to understand areas where the activity plan is not being met and where possible, the number of contacts will be complemented with waiting times information. Treatment rooms is a particular area of focus and from M10, waiting times for treatment rooms will be reported.

Are we WELL-LED?


The staff engagement score for Q3 shows a largely static position with only a decimal point increase on the Q2 position at 3.75% (page 5).

Sickness rates for the organisation as a whole deteriorated to 7.32%, off track in relation to achieving the 4.5% target (page 115). This follows the seasonal sickness trend seen last year. The increase is seen in all Networks however, a 1% decrease in sickness was seen in Support Services. Work continues on absence management across all areas in accordance with policy. In addition, in the mental health network, a specific set of actions are being implemented to support return to work (as appropriate) for staff injured whilst at work.

In response to the information reporting issues identified in EIS, a series of ‘snapshot’ audits for NHSI metrics are being undertaken by the Performance team. The format of each audit is to review and compare a sample of records submitted for each metric against the information within the clinical records system. The first metric to be reviewed was the 6 and the 18 week RTT standard for IAPT. The audit corroborated the compliant position reported to NHSI. Some incidental data quality/ system configuration issues were identified. These did not affect our RTT compliance but are important for onward management of patient pathways. The Performance team are working closely with the Network to implement a series of actions to address the issues identified.

The Business Development and Delivery Sub-committee meeting received each of the 3 Network Reports for month 9; the links for which are provided below

https://www.lancashirecare.nhs.uk/media/Trust%20Board/Trust%20Board%20Documents/January%202018/CWB-NETW.pdf

https://www.lancashirecare.nhs.uk/media/Trust%20Board/Trust%20Board%20Documents/January%202018/CYP%20Network%20Report%20January%202018%20FINAL.pdf

https://www.lancashirecare.nhs.uk/media/Trust%20Board/Trust%20Board%20Documents/January%202018/MH%20Network%20Report%20M9%20Final%20lm.pdf

At the December meeting of Business Development and Delivery sub-committee, the COO, as Chair for the group received a report on the services that have been under-performing for more than 6 months. The purpose of this was to re-set the expectation that recovery of performance needs to be effective within a 6 month window. There was an expectation that Networks would report back on actions to address this, however, this was not received at the January meeting of the sub-committee. This is being addressed individually with Heads of Operations.

Summary and Recommendations

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







Quality & Performance

Report

Month 9 – December 2017

Performance Management

Quality and Performance Report:-

Section 2:- Performance and Data Quality

Section 2.1:- Performance Activity

• NHS Improvement Indicators Dashboard • 5 Year Forward View Dashboard • NHS Improvement Indicators Kitemarking • Key Exceptions • CCG Level Data • Network Level Summary • Key Network Exceptions

Section 2.2:- Patient Flow • Patient Flow Summary • Key Patient Flow Exceptions

Section 2.3:- Data Quality • Data Quality Summary • Key Data Quality Exceptions

Section 3:- Finance and Contracting

Section 3.1:- Financial Activity

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

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

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

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

2

Section 6:- Risk

• Board Assurance Framework

Section 4:- Quality

• Quality and Safety Tile • Quality Surveillance – Safe • Quality Surveillance – Effective • Quality Surveillance – Caring • Quality Surveillance – Responsive • Quality Surveillance – Well Led • Audits • Delivering the Strategy

Section 5:- Workforce

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

Section 1:- Board Balanced Score Care

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

Appendix 1:- Southport & Formby

• Performance Activity • Finance & Contracting • Quality • Workforce


Board Balanced Score Card

Section 1

3


1. Board Balanced Score Card Trust Strategic Priorities

Strategic Priority Strategic Blueprint

Co

mp

as

sio

n

To provide high quality

services

We will ensure that people who use our services are at the heart of everything we do, and the people who deliver and support

delivery of services are motivated, engaged and proud to provide high quality, compassionate, continually improving care. We

will empower people to share their stories so that we know how we are doing and we will listen to learn and to improve quality

together. We will continue to strive to be the best that we can be by upholding our 8 quality commitments and the ‘I’ statements,

empowering everyone to embrace these personal pledges.

Inte

gri

ty

To deliver sustainable services

that meet the needs of local

people

We will collaborate with partners to deliver system wide transformation and we will be an active partner in delivering a bespoke

offer to a number of Accountable Care Systems by

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

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

realising the benefits of our geographical footprint to deliver system wide sustainable infrastructure solutions and

organisational vehicles for new models of care.

Whilst our principal footprint for delivery of services is Lancashire and South Cumbria, we will continue to seek opportunities

across North West STP footprints.

Te

am

wo

rk

To become recognised

for excellence

Our service users and carers will tell us that our services are of high quality. Our people will recommend us to family and

friends. We will be respected by our commissioners and other providers as a co-producing partner in shaping new service

models that deliver our aligned strategies with an emphasis on place based care.

Res

pe

ct

To employ the best

people

We will develop an organisational culture and leadership team equipped to meet its strategic intent and the needs of both its

workforce and the population it serves; in short, a culture of high performing, continually improving and compassionate care.

Staff will be motivated, engaged, high performing and proud of the service they provide. We will proactively support staff to look

after their own health and wellbeing, and to reach their full potential. We will identify and grow our future leaders. People will

want to work here.

Ac

co

un

tab

ilit

y

To provide financially

sustainable services

We will restore and maintain financial balance, and provide services that offer excellent value for money without compromising

financial sustainability. We will work with local partners to deliver system wide efficiency measures. We will actively seek

business opportunities that add value for local people.

Ex

ce

lle

nc

e

To innovate and exploit

technology to transform

care

We will develop and promote digital enabled care, and lead research and innovation to enhance patient experience, reduce

costs and/or improve quality. We will have a culture where staff are given the time, training and resources to research and

innovate. Research will validate innovations and innovations will direct research. Partnerships with third party organisations will

enable rapid execution and exploitation of innovation projects. 4


Research Studies

Oct Nov Dec

52 161 48

Average OAPS

Oct Nov Dec

24.58 29.93 27.52

NHSI Compliance

Oct Nov Dec

92.9% 92.9% 92.9%

Sickness Absence

Oct Nov Dec

6.88% 6.84% 7.32%

Agency Ceiling

Oct Nov Dec

-132,475 -64,550 -167,555

UoR

Oct Nov Dec

3 2 2

Revenue Control Total

Oct Nov Dec

-1.2% -0.8% -0.5%

CIP

Oct Nov Dec

88% 87% 91%

Liquidity

Oct Nov Dec

1 1 1

1. Board Balanced Score Card Summary

Capital Expenditure

Sep Oct Nov

31% 32% 41%

Contract Performance (MH)

Oct Nov Dec

-0.84% -0.75% 11.40%

Contract Performance (Comm)

Oct Nov Dec

-0.6% 2.1% 1.0%

Engagement Score

Q1 17-18 Q2 17-18 Q3 17-18

3.73 3.74 3.75

National COPD Audit

Programme

Report due Feb

2018

Use of depot/LA

antipsychotics for relapse

prevention – baseline audit

Report due date TBC

Prescribing for bipolar

disorder (use of sodium

valproate) re-audit

Report due Feb 2018

Quality Plan

17/18 objectives 16

On track Off track

10 6

Service Delivery Quality & Safety

People & Leadership Finance

5

Prescribing of high dose

antipsychotics

Acute wards & PICU rank 14/57

Secure Services 20/46

5YFV Indicator 17/18

Target

Monthly

Performance

Inappropriate OAPs (total bed days in year) - 972

IAPT Prevalence 16.80% 11.72%

Early Intervention in Psychosis - 2 week RTT 50% 33.3%

Eating Disorders – Urgent (1 week) TBC 37.5% (Quarter 3)

Eating Disorders – Routine (4 week) TBC 93.8% (Quarter 3)


1. Board Balanced Score Card Quality & Safety

Quality Plan The following priorities are off track: staffing for quality and safety, violence reduction, appraisals, core skills, supervision and

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

Exception reporting for each priority is included in the Quality and Safety Report to the Trust Board. The Executive Director or

Nursing and Associate Director of Safety and Quality Governance are holding confirm and challenge meetings with each lead in

January 2018.

Target: 16 objectives

On track 10 Off track 6

Research Studies

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

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

national figures. Local data shows that activity has already reached this year’s annual target. Target: 100 participants monthly

48

6

National Audit –

National COPD Audit

Programme

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

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

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

National Audit –

Prescribing for bipolar disorder

(use of sodium valproate) re-

audit

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

The report will be published Feb 2018.

Target: Upper quartile nationally

National Audit –

Use of depot/LA antipsychotics

for relapse prevention –

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


National Audit –

Prescribing of High dose

antipsychotics

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

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

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

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

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

developed.


Achieved


1. Board Balanced Score Card Service Delivery

Average Out of Area

Placements (OAPS) The average number of OAPs decreased in December by 2.41, alongside a decrease in the OAP OBDs in December with a position of 853, a

decrease of 45 from November.

The overall number of OAPs fell towards the end of December to below 20, remaining below 20 into the first two weeks of January at time of

reporting and this reflecting a sustained improvement in the position.

Target: 15 contracted beds

27.52

Contract Activity - Community

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

1.0%

Contract Activity – Mental

Health With the exception of the Eating Disorders service (still under review) we now have 2017-18 MH Baselines signed off by Commissioners and

therefore we are starting to report variances from M9. The actual M9 YTD variance based on 2017-18 figures and baseline including Eating

Disorders is 11.40%, however variance excluding Eating Disorders is 8.97%. Target: 100% (+/-10%)

11.40%

NHSI Compliance

All NHSI measures are compliant for M9 except for EIP (MR13) which following validation of data has been underperforming under the 50%

standard. Work within the Network is currently ongoing and it is anticipated that performance will improve in Quarter 4. Target: 100% in each quarter

92.9%

7

5 Year Forward View (5YFV)

Inappropriate OAPs trajectory in place for beginning of 18/19 and baseline for Quarter 3 under validation.

IAPT Prevalence on track to achieve 16.8% by end of 17/18.

For EIP, see NHSI compliance below.

Eating Disorders target is to achieve 95% by 2020. Current performance is 37.5% for 1 week target and 93.8% for 4 week target

in Quarter 3. Trajectory to be confirmed.

Targets: see page 5

Off track


Agency Ceiling

Agency usage in Community has increased slightly due to winter

pressures but costs have increased due to the number of Bank Holidays

worked (at an accordingly higher rate of pay). Medical Agency usage

has been reasonably steady however the same cost increases due

to Bank Holidays applies. Inpatients have seen an increased agency

usage due to a rise in sickness absence in the month of December

but overall usage in inpatient services is less in December 2017 than

the corresponding month the previous year.

Target: 641,250

Not achieved

1. Board Balanced Score Card People & Leadership

Oct Nov Dec

YTD Target 641,250 641,250 641,250

YTD Actuals 773,725 705,800 808,805

Under/Over

Agency

Usage

-132,475 -64,550 -167,555

Engagement Score Q3 2017/18 period results :

• Recommend LCFT as a place to receive treatment (Workforce Advocacy): Yes – 71.46%, No – 9.13%, Don’t Know – 19.41%

• Recommend LCFT as a good place to work: (Workforce Involvement and Motivation): Yes – 52.74%, No – 27.51%, Don’t Know – 19.75%

Improvement Initiatives:

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

Motivation and Involvement. The first Staff FFT report to include this new dimension will be available in the Q3 Staff FFT Report.

Target: Top 25% of other Trusts

3.75 for Quarter 3

Sickness Absence

The sickness absence rate for December has increased, reporting at 7.32%. Please refer to the relevant M9 QPR detailed slides for information

about Improvement plans and initiatives. Target: 4.5%

7.32%

8


1. Board Balanced Score Card Finance

Use of Resources (UoR) Risk

Rating* The improvements to the I&E position yield a rating of 3 and a Capital Service rating of 3, improving the overall UoR to a 2.

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

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

2

Capital Expenditure Progress against the capital programme has begun to accelerate with expenditure at £3.0m against the original profile of

£7.3m. Despite the resolution of a number of issues delays on the 17/18 programme would now appear inevitable, particularly

on the Inpatient and Perinatal schemes. The Trust is working with contractors to minimise the impact of delays with a key

focus on maintaining completion dates.

Target: 85-100%

41%

Revenue Control Total Progress with the recovery plan continues and improvements in performance are evident, but with continued pressures delivery will only be

achieved with a considerable coordinated and sustained effort across the organisation.

As a consequence, the Trust continues to forecast achievement of the control total for 2017/18 but this is not without significant risk. Target: ≥0%

-0.5%

Cost Improvement

Programmes (CIPs) At £10.0m in month 9 the Trust is c£1.0m behind the plan of £11.1m and at 91% showing improvement on previous month. The adverse variance

is attributable to a lack of performance on Run Rate Reduction Programmes on staffing pressures. The Trust continues to invest significant time

and effort in managing and developing compensating CIPs and network management are being supported to implement measures aimed at

improving the position. Target: ≥100%

91%

Liquidity

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

1

9

*Under the Single Oversight Framework, the Trust is now managed against the Use of Resource Metrics (UoR). Under the Single Oversight Framework, a score of 1 is now the

best rating and 4 the worst. A rating of 4 on any metric or an average rating of 3 triggers a concern and a potential support need.


2. Performance and Data Quality

10

Section 2:- Performance and Data Quality

Section 2.1:- Performance Activity

• NHS Improvement Indicators Dashboard

• 5 Year Forward View Dashboard

• NHS Improvement Indicators Kitemarking

• Key Exceptions

• CCG Level Data

• Network Level Summary

• Key Network Exceptions

Section 2.2:- Patient Flow

• Patient Flow Summary

• Key Patient Flow Exceptions

Section 2.3:- Data Quality

• Data Quality Summary

• Key Data Quality Exceptions


Performance Activity

Section 2.1

11


2.1 Performance Activity NHS Improvement Indicators Dashboard

12

.

Indicator Target Jan-17 Feb-17 Mar-17 Apr-17 May-17 Jun-17 Jul-17 Aug-17 Sep-17 Oct-17 Nov-17 Dec-17 Q1 17-18 Q2 17-18 Q3 17-18 YTDRolling 12

Month Sparkline

MR01 - 7 Day Follow Up 95.00% 98.8% 96.1% 97.6% 98.6% 96.8% 95.9% 94.1% 96.8% 99.5% 98.0% 96.9% 97.5% 97.1% 96.7% 97.5% 97.08%

MR02 - CPA Review within 12 Months 95.00% 96.9% 97.1% 97.5% 97.0% 97.1% 96.1% 95.9% 97.0% 96.4% 96.5% 96.5% 97.6% 96.7% 96.4% 96.9% 96.67%

MR03 - Mental Health Delayed Transfers of Care ≤ 7.5% 3.81% 2.84% 2.59% 3.01% 3.21% 3.36% 2.80% 2.52% 2.77% 2.65% 2.18% 1.77% 3.2% 2.7% 2.2% 2.70%

MR05 - RTT - Consultant Led (Completed Pathway) 95.00% 96.7% 97.6% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 99.4% 100.0% 100.0% 99.8% 99.92%

MR06 - RTT - Consultant Led (Incomplete Pathway) 92.00% 97.3% 100.0% 99.2% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 99.7% 99.3% 99.6% 100.0% 100.0% 99.5% 99.82%

MR07 - IP Access to Crisis Res. Home Treatment 95.00% 98.6% 99.4% 97.7% 100.0% 100.0% 99.5% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 99.8% 100.0% 100.0% 99.94%

MR08 - MH Data Completeness - Identifiers 97.00% 99.6% 99.6% 99.6% 99.6% 99.6% 99.7% 99.4% 99.4% 99.4% 99.4% 99.4% 99.4% 99.6% 99.4% 99.4% 99.49%

MR09 - MH Data Completeness - Outcomes 50.00% 83.4% 83.2% 83.4% 83.7% 82.2% 81.8% 81.8% 81.7% 80.8% 81.2% 82.5% 83.1% 82.5% 81.4% 82.3% 82.06%

MR13 - 2 week wait for Treatment for EIP Programme 50.00% 82.0% 81.4% 74.4% 11.1% 7.1% 0.0% 9.5% 11.8% 15.6% 9.5% 23.9% 33.3% 6.0% 12.6% 24.3% 15.02%

MR14 - RTT - IAPT 6 Weeks 75.00% 95.1% 95.7% 93.4% 96.4% 94.7% 95.1% 94.5% 94.4% 94.5% 94.6% 94.8% 94.3% 95.4% 94.4% 94.5% 94.79%

MR15 - RTT - IAPT 18 Weeks 95.00% 99.4% 99.8% 98.8% 99.4% 99.2% 99.7% 99.3% 99.4% 99.5% 99.7% 99.8% 99.1% 99.5% 99.4% 99.6% 99.47%


2.1 Performance Activity 5 Year Forward View Dashboard

13

.

Note: Remaining measures are in development. From April 2018, Inappropriate OAPs and Data Quality Maturity Index will move to NHSI

dashboard.

*if threshold already met, a 7% improvement on baseline required.

Indicator17/18

TargetQ1 17-18 Q2 17-18 Q3 17-18 YTD

Quarterly

Sparkline

Inappropriate OAPs (total bed days in the year) N/A 2289 2270 2632 7191

IAPT Prevalence 16.8% 3.79% 7.69% 11.72% 11.72%

Early Intervention in Psychosis (EIP) 2 week RTT 50% 6.02% 12.64% 24.27% 15.02%

CYP Improving Access to CAMHS 30% - - - -

Eating Disorders - Urgent (seen in 1 week) TBC 41.7% 57.1% 37.5% 49.40%

Eating Disorders - Routine (seen in 4 weeks) TBC 57.1% 89.7% 93.8% 73.44%

Data Quality Maturity Index - MHSDS dataset score TBC - - - -

5 Year Forward View for Mental Health

Indicator 2017/18 2018/19 2019/20 2020/21 Measure description

Inappropriate OAPs (total bed days in the year) - 4830 2830 800 Reduction in inappropriate bed days to zero by end 20/21 in accordance with STP trajectory

IAPT Prevalence 16.8% 19% - 25% Increase in number of people accessing IAPT to 25% of the expected prevalence by end 20/21

Early Intervention in Psychosis (EIP) 2 week RTT 50% 53% 56% 60% Increase in the number of people being treated within 2 weeks of referral for First Episode Psychosis to 60% of total by end 20/21

CYP Improving Access to CAMHS* 30% 32% 34% 35% Increase in the number of young people accessing childrens mental health services by 35% compared to 16/17 baseline

Eating Disorders - Urgent (seen in 1 week) TBC TBC 95% 95% Achievement of RTT of 1 week for 95% of people referred urgently by end 2020

Eating Disorders - Routine (seen in 4 weeks) TBC TBC 95% 95% Achievement of RTT of 4 week for 95% of people referred routinely by end 2020

Data Quality Maturity Index - MHSDS dataset score TBC TBC TBC TBC This is a score collated from overall compliance against completeness of data items within the mental health dataset

5YFV Performance Trajectories


2.1 Performance Activity NHS Improvement Indicators Kitemarking

Kitemarking key:

• SOP – Does the indicator have an associated SOP that is within date?

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

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

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

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

negatives?

14


2.1 Performance Activity NHS Improvement Indicators Kitemarking

15


Trust position for Lancashire CCGs:

- In Month 9, the Trust has achieved a performance of 97.4%

against a target of 95% across 8 CCGs.

CCG position:

- In Month 9, the Trust has underperformed in 1 CCG: West

Lancs, with 1 patient not being followed up within 7 days.

Unassigned CCG:

- In Month 9, there were 5 records unassigned a CCG, of which

100% (5) were completed.

16




CCG position:

- In Month 9, the Trust has achieved compliance for all CCGs.

Unassigned CCG:


86.2% (50) were completed.

CPA 12 Month Review 7 Day Follow Up

2.1 Performance Activity NHS Improvement Indicators reported by CCG

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

representative of only 8 contracted CCGs.

Aug-17 Sep-17 Oct-17 Nov-17 Dec-17

94.7% 100.0% 100.0% 94.1% 96.7%

92.9% 96.2% 100.0% 93.9% 96.7%

100.0% 100.0% 100.0% 95.2% 100.0%

100.0% 100.0% 98.0% 100.0% 97.6%

100.0% 100.0% 100.0% 95.8% 100.0%

100.0% 100.0% 93.8% 96.9% 96.6%

86.7% 100.0% 95.0% 100.0% 100.0%

100.0% 100.0% 100.0% 88.9% 88.9%

97.2% 99.5% 97.9% 96.3% 97.4%Total Figure - 8 CCGs

7 DFU CCG

NHS Blackburn with Darwen CCG

NHS Blackpool CCG

NHS Chorley & South Ribble CCG

NHS East Lancashire CCG

NHS Fylde & Wyre CCG

NHS Greater Preston CCG

NHS Morecambe Bay CCG

NHS West Lancashire CCG


98.8% 96.7% 95.6% 97.1% 97.7%

96.2% 96.8% 95.5% 95.3% 96.7%

96.6% 94.0% 95.3% 97.2% 98.2%

96.0% 96.0% 96.5% 95.6% 96.6%

98.0% 98.0% 99.6% 100.0% 100.0%

98.4% 98.2% 98.0% 96.1% 99.6%

95.5% 96.8% 96.1% 96.3% 96.9%

96.9% 95.2% 97.8% 99.1% 99.5%

97.1% 96.5% 96.6% 96.7% 97.8%

12 month CPA


NHS Blackpool CCG


Total Figure - 8 CCGs










Delayed Transfers of Care (DToC)

17

IP Access to Crisis Resolution Home Treatment



against a target of ≤7.5% across 8 CCGs.

CCG position:



- In Month 9, the Trust has achieved a performance of 100%


CCG position:



1.56% 1.55% 1.63% 1.60% 1.58%

0.09% 2.32% 2.00% 0.91% 0.00%

3.82% 2.64% 4.05% 2.28% 0.82%

2.53% 2.92% 3.91% 4.26% 4.46%

2.80% 2.21% 2.11% 0.48% 0.00%

4.63% 3.56% 2.64% 2.99% 2.38%

0.13% 2.09% 0.00% 0.00% 0.00%

3.67% 4.28% 4.98% 0.00% 0.00%

2.47% 2.72% 2.61% 2.11% 1.68%

DToC


NHS Blackpool CCG





NHS Lancashire North CCG




100.0% 100.0% 100.0% 100.0% 100.0%

100.0% 100.0% 100.0% 100.0% 100.0%

100.0% 100.0% 100.0% 100.0% 100.0%

100.0% 100.0% 100.0% 100.0% 100.0%

100.0% 100.0% 100.0% 100.0% 100.0%

100.0% 100.0% 100.0% 100.0% 100.0%

100.0% 100.0% 100.0% 100.0% 100.0%

100.0% 100.0% 100.0% - 100.0%

100.0% 100.0% 100.0% 100.0% 100.0%







% IP Access to CRHTT


NHS Blackpool CCG






RTT – Consultant Led (Completed Pathway)

18

RTT – Consultant Led (Incomplete Pathway)




CCG position:





CCG position:


Note: NHS England guidance published in October 2015 confirmed that the incomplete pathway operational standard should became the sole

measure of patients’ constitutional right to start treatment within 18 weeks. And whilst we are required to maintain reporting on the completed

admitted pathway, the removal of the completed admitted pathway as an operational standard means that there is no longer any provision to report

pauses or suspensions in RTT waiting time clocks in monthly RTT returns to NHS England. This means that patients choosing to cancel

appointments can impact negatively on this measure.


- 100.0% - - -

- - 100.0% - -

100.0% 100.0% 100.0% 100.0% 100.0%

- - - - -

- 100.0% - 100.0% -

100.0% 100.0% 100.0% 100.0% 98.9%

- - - 100.0% -

- - - - -

100.0% 100.0% 100.0% 100.0% 99.4%

RTT Complete


NHS Blackpool CCG









- - - - -

100.0% 100.0% - - -

100.0% 100.0% 100.0% 100.0% 100.0%

100.0% - - - -

100.0% - - - -

100.0% 100.0% 99.4% 98.9% 99.3%

100.0% 100.0% 100.0% - 100.0%

- - - - -

100.0% 100.0% 99.7% 99.3% 99.6%

RTT Incomplete


NHS Blackpool CCG












MH Identifiers

19

MH Outcomes




CCG position:


Unassigned CCG:

- In Month 9, there were 3114 records unassigned a CCG, of

which 93.6% (2914) were complete.




CCG position:


Unassigned CCG:


85.1% (137) were complete.


99.8% 99.8% 99.8% 99.7% 99.8%

99.7% 99.8% 99.8% 99.8% 99.8%

98.8% 98.8% 98.9% 98.9% 98.8%

99.8% 99.8% 99.8% 99.7% 99.7%

99.7% 99.7% 99.7% 99.7% 99.6%

99.6% 99.6% 99.6% 99.6% 99.6%

99.7% 99.7% 99.6% 99.6% 99.7%

99.7% 99.7% 99.6% 99.6% 99.6%

99.6% 99.6% 99.6% 99.6% 99.6%

MH Identifiers


NHS Blackpool CCG









74.7% 72.9% 73.8% 74.6% 74.3%

78.6% 78.1% 79.3% 82.8% 83.2%

86.0% 85.0% 84.2% 85.0% 86.1%

83.4% 82.8% 82.5% 83.0% 83.6%

84.9% 86.0% 85.8% 89.4% 89.7%

80.9% 80.4% 80.5% 80.9% 81.0%

89.4% 89.0% 89.9% 91.0% 90.9%

78.2% 75.6% 75.2% 77.4% 81.5%

81.7% 80.9% 81.3% 82.7% 83.2%

MH Outcomes


NHS Blackpool CCG












2ww EIS

20


- In Month 9, the Trust has achieved a performance of 33.3% against

a target of 50% across 8 CCGs.

CCG position:

- In Month 9, the Trust has underperformed in 6 CCGs: Blackburn

with Darwen, Blackpool, Chorley & South Ribble, Greater Preston,

Morecambe Bay and West Lancs.

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


16.7% 9.1% 12.5%

0.0% 0.0% 0.0%

0.0% 50.0% 20.0%

0.0% 27.8% 80.0%

0.0% - 50.0%

0.0% 0.0% 25.0%

50.0% 50.0% 33.3%

0.0% 100.0% 33.3%

9.5% 23.9% 33.3%

2ww EIS


NHS Blackpool CCG












IAPT – 6 Weeks

21

IAPT – 18 Weeks




CCG position:





CCG position:



82.0% 83.8% 79.6% 85.7% 84.7%

95.1% 99.1% 92.4% 93.6% 94.2%

97.5% 97.4% 97.4% 96.9% 96.7%

96.7% 94.4% 97.8% 96.3% 96.0%

91.9% 94.8% 99.2% 94.4% 94.9%

92.4% 90.4% 88.7% 93.3% 89.2%

98.2% 98.8% 97.3% 99.1% 98.8%

98.6% 92.7% 98.5% 93.9% 97.8%

94.3% 94.5% 94.5% 94.7% 94.3%

RTT IAPT 6 Wks


NHS Blackpool CCG


Not Commissioned







NHS St Helens CCG


100.0% 100.0% 100.0% 100.0% 98.8%

99.2% 100.0% 100.0% 100.0% 98.1%

100.0% 100.0% 100.0% 100.0% 99.5%

98.9% 98.9% 100.0% 98.8% 98.7%

98.1% 98.7% 100.0% 99.1% 100.0%

100.0% 97.9% 98.1% 100.0% 98.8%

99.1% 100.0% 99.1% 100.0% 100.0%

100.0% 100.0% 100.0% 100.0% 97.8%

99.4% 99.5% 99.7% 99.8% 99.1%

NHS St Helens CCG



Not Commissioned





RTT IAPT 18 Wks


NHS Blackpool CCG



2.1 Performance Activity Summary – Mental Health

22

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

Sparkline

NHS Improvement

CPA 7 Day Follow Up (Total Network Performance) NHSI 95% 98.7% 96.7% 97.8% 98.5% 96.8% 95.7% 94.3% 96.6% 99.4% 97.8% 97.1% 97.3%

CPA 7 Day Follow Up (AMH) NHSI 95% 98.5% 96.9% 98.4% 98.9% 96.9% 96.2% 94.4% 96.0% 99.4% 97.5% 97.3% 96.8%

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

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

CPA 12 Month Review (Total Network Performance) NHSI 95% 96.7% 97.0% 97.5% 97.0% 97.2% 95.9% 95.7% 96.8% 96.3% 96.4% 96.5% 97.6%

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

CPA 12 Month Review (OA) NHSI 95% 100.0% 100.0% 100.0% 99.7% 100.0% 99.1% 98.4% 99.7% 99.7% 99.4% 98.5% 98.8%

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

Delayed Transfers of Care (Total Network Performance) NHSI ≤7.5% 3.76% 2.60% 2.39% 3.10% 3.33% 3.48% 2.89% 2.39% 2.55% 2.49% 2.04% 1.74%

Delayed Transfers of Care (AMH) NHSI ≤7.5% 3.66% 2.19% 2.27% 3.26% 3.42% 2.94% 2.31% 1.06% 0.49% 0.66% 1.10% 0.97%

Delayed Transfers of Care (OA) NHSI ≤7.5% 4.11% 3.92% 2.70% 3.27% 2.06% 3.08% 2.72% 4.03% 6.29% 6.01% 2.72% 2.29%

Delayed Transfers of Care (SS) NHSI ≤7.5% 3.91% 3.80% 3.08% 2.74% 3.85% 4.61% 4.00% 3.82% 4.03% 3.68% 3.34% 2.84%

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

MH Data Completeness - Identifiers NHSI 97% - - - 99.6% 99.6% 99.7% 99.5% 99.5% 99.6% 99.5% 99.5% 99.4%

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

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

MH Data Completeness - Outcomes NHSI 50% - - - 85.8% 84.8% 84.5% 84.6% 84.5% 83.6% 83.7% 85.0% 85.6%

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

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

Other Indicators

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

Memory Assessment Service (MAS) seen within 6 weeks (OA) NHSE 70% 25.7% 40.3% 48.4% 47.0% 52.1% 70.4% 79.8% 80.4% 79.6% 78.1% 74.6% 81.1%

PBR Clustering NHSE 95% 96.8% 96.4% 96.5% 96.5% 96.6% 96.7% 96.4% 95.7% 95.9% 95.1% 95.4% 95.0%

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

Network Performance)NHSE 0

313 255 260 267 255 211 233 210 - - 566 672

No of Patients without a Care Co-ordinator Allocated > 2 Weeks (AMH) NHSE 0 262 222 253 245 243 187 203 183 - - 566 672

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

MHLT

MHLT 1hr compliance Commissioners 95% 46.9% 38.7% 51.8% 51.6% 45.9% 47.5% 40.8% 39.5% 42.5% 45.5% 49.3% 52.7%

No of 4hr breaches (Percentage of total) 5% 11.2% 15.4% 9.7% 9.5% 11.4% 14.8% 16.1% 15.1% 16.4% 14.5% 12.4% 10.6%

No of 4hr breaches (Number of breaches) 29 75 102 71 67 79 110 116 102 108 104 80 61

No of 12hr breaches (Percentage of total) 0% 1.5% 1.2% 3.3% 0.9% 1.4% 4.0% 1.8% 2.5% 1.2% 0.8% 1.2% 1.7%

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

Stretch

Stretch


2.1 Performance Activity Summary – Mental Health (Secure)

23

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

*


Sparkline

Secure Mental Health Business Unit

Overall Gross Occupancy NHSE 93% 91.8% 93.3% 93.7% 97.2% 95.9% 96.0% 94.2% 91.3% 91.0% 92.4% 91.3% 90.1%

Violent Incidents resulting in Restraint Stretch ≤ 20.00% 20.8% 17.5% 20.5% 18.4% 15.6% 22.2% 27.1% 17.2% 29.1% 19.3% 16.4% 25.4%

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

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

% of CPA reviews attended by Local Care Coordinators Stretch 80% 25.0% 42.9% 39.3% 65.2% 33.3% 51.7% 42.9% 44.0% 48.1% 43.5% 72.0% 71.4%

% of service users who have Cardiometabolic risk factors assessed within

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

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

25hrs Meaningful Activity - Uptake NHSE 100% 85.0% 80.4% 79.9% 75.6% 82.3% 81.3% 86.8% 74.1% 78.2% 85.2% 86.4% 89.0%

Community Business Unit

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

% of caseload carried longer than 12 months post SMHBU discharge Stretch ≤ 20.00% 72.0% 66.7% 74.0% 60.9% 60.6% 59.7% 63.5% 58.2% 60.9% 66.0% 70.6% 70.0%

% of CPA Reviews Attended by Local Care Coordinators / Local Teams Stretch 80% 62.5% 75.0% 30.0% 33.3% 40.0% 54.5% 33.3% 50.0% 63.6% 25.0% 45.5% 66.7%

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

Health & Justice Business Unit - HMP Liverpool

GP Waits over 2 Weeks NHSE 0% 55.0% 59.5% 64.2% 49.4% 22.8% 0.0% 18.8% 43.6% 43.1% 44.9% 23.5% 34.4%

NHS Health Checks NHSE 40% 26.1% 13.2% 8.9% 1.9% 57.1% 28.6% 14.3% 22.6% 0.0% 33.3% 33.3% 100.0%

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

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

Chlamydia Screening U25's Uptake NHSE 50% 14.3% 33.3% 5.3% 13.0% 27.3% 63.6% 100.0% 21.4% 13.3% 17.7% 11.1% 9.1%

Men C Vaccinations Uptake NHSE 95% 12.2% 4.9% 2.6% 2.4% 21.1% 44.7% 5.3% 7.7% 7.1% 19.4% 4.2% 0.0%

MMR Vaccinations Uptake NHSE 95% 11.1% 0.0% 14.3% 23.8% 3.6% 2.3% 2.3% 1.0% 1.7% 4.1% 3.0% 0.5%

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

QOF NHSE 238 323 314 319 316 323 334 354 385 381 410 457 449


2.1 Performance Activity Summary – Community & Wellbeing

24

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


Sparkline

NHS Improvement

RTT - Consultant Led (Completed Pathway) NHSI 95% 96.7% 97.6% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 99.4%

RTT - Consultant Led (Incomplete Pathway) NHSI 92% 97.3% 100.0% 99.2% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 99.7% 99.3% 99.6%

RTT - IAPT 6 Weeks NHSI 75% 95.1% 95.7% 93.4% 96.4% 94.7% 95.1% 94.5% 94.4% 94.5% 94.6% 94.8% 94.3%

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

Waiting Times - AHP RTT

Adult Learning Disability Service NHSE 92% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0%

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

Intermediate Care NHSE 95% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 99.4% 100.0%

Podiatry NHSE 95% 100.0% 99.8% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0%

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

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

Adult Speech and Language Therapy NHSE 95% 100.0% 100.0% 99.0% 100.0% 100.0% 100.0% 98.6% 100.0% 98.6% 100.0% 98.6% 100.0%

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

Community Respiratory Service NHSE 95% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 98.7% 98.0% 100.0%

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

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

Falls Team NHSE 95% 100.0% 100.0% 100.0% 100.0% 100.0% 99.5% 100.0% 100.0% 99.0% 100.0% 100.0% 100.0%

Nutrition & Dietetics NHSE 95% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 99.5% 99.5%

Other Indicators

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

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

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

Unallocated Cases NHSE 0 12 12 7 15 13 2 7 19 - - 43 70


2.1 Performance Activity Summary – Community & Wellbeing

25


Sparkline

IAPT

IAPT in Month Prevalence

Blackburn with Darwen CCGCommissioner 1.18% 1.32% 1.26% 0.89% 0.74% 1.85% 1.13% 1.27% 1.38% 1.20% 1.09% 1.60% 1.00%

IAPT Cumulative Prevalence

Blackburn with Darwen CCGCommissioner 10.65% - - - 0.74% 2.59% 3.72% 4.99% 6.37% 7.57% 8.66% 10.26% 11.26%


East Lancashire CCGCommissioner 1.25% 1.56% 1.11% 1.77% 1.00% 1.13% 1.64% 1.42% 1.22% 1.30% 1.38% 1.36% 1.10%


East Lancashire CCGCommissioner 11.25% - - - 1.00% 2.13% 3.76% 5.19% 6.41% 7.72% 9.09% 10.45% 11.55%


Chorley & South Ribble CCGCommissioner 1.25% 1.59% 1.08% 1.44% 1.29% 1.53% 1.47% 1.31% 1.45% 1.38% 1.40% 2.10% 0.97%


Chorley & South Ribble CCGCommissioner 11.25% - - - 1.29% 2.81% 4.29% 5.60% 7.05% 8.43% 9.83% 11.93% 12.90%


Greater Preston CCGCommissioner 1.25% 1.24% 1.18% 1.20% 0.92% 1.38% 1.46% 1.41% 1.07% 1.24% 1.67% 1.24% 1.23%


Greater Preston CCGCommissioner 11.25% - - - 0.92% 2.30% 3.76% 5.17% 6.23% 7.48% 9.15% 10.39% 11.62%


West Lancashire CCGCommissioner 1.25% 1.71% 0.83% 1.53% 1.13% 1.51% 1.34% 1.08% 1.48% 1.21% 1.33% 1.67% 1.11%


West Lancashire CCGCommissioner 11.25% - - - 1.13% 2.64% 3.98% 5.06% 6.54% 7.75% 9.08% 10.75% 11.86%


Fylde and Wyre CCGCommissioner 1.25% 1.33% 0.96% 1.40% 1.23% 1.33% 1.36% 1.44% 1.35% 1.37% 1.33% 1.88% 1.31%


Fylde and Wyre CCGCommissioner 11.25% - - - 1.23% 2.55% 3.91% 5.35% 6.70% 8.07% 9.39% 11.27% 12.58%


Morecambe Bay CCGCommissioner 1.25% 1.31% 1.22% 1.41% 1.34% 1.07% 1.40% 1.46% 1.32% 1.27% 1.03% 1.75% 1.16%


Morecambe Bay CCGCommissioner 11.25% - - - 1.34% 2.41% 3.81% 5.27% 6.59% 7.86% 8.88% 10.64% 11.80%


St Helens CCGCommissioner 1.25% 1.31% 1.02% 1.67% 0.88% 1.13% 1.31% 1.07% 1.09% 1.43% 1.56% 1.20% 1.10%


St. Helens CCGCommissioner 11.25% - - - 0.88% 2.01% 3.32% 4.39% 5.48% 6.91% 8.47% 9.67% 10.77%

IAPT Waiting Times (Internal Target) Stretch 0 pts >26 wks - - - 22 23 23 25 14 26 14 59 154

IAPT Recovery NHSE 50% 53.8% 57.0% 53.4% 54.5% 52.6% 57.0% 50.0% 55.1% 57.3% 53.6% 53.4% 53.2%


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

26

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

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

Sparkline

NHS Improvement

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

CPA 12 Month Review NHSI 95% 98.3% 99.5% 98.5% 97.9% 97.5% 95.6% 99.0% 99.5% 100.0% 98.7% 98.7% 98.0% 98.4%

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

MH Data Completeness - Outcomes NHSI 50% 66.3% 64.8% 81.3% 64.9% 63.5% 60.7% 59.3% 58.1% 57.9% 56.7% 58.8% 59.3% 59.1%

2 Week wait for Treatment for EIP Programme NHSI 50% 76.7% 82.0% 81.4% 74.4% 11.1% 7.1% 0.0% 9.5% 11.8% 15.6% 9.5% 23.9% 33.3%

Waiting Lists - RTT 18 Weeks (Completed Outcomes)

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

Child Psychology - Total Network Performance NHSE 92% 70.9% 71.0% 60.3% 64.8% 66.6% 62.4% 66.9% 74.1% 77.7% 84.4% 89.0% 86.3% 84.5%

CAMHS Tier 3 - Total Network Performance NHSE 92% 97.5% 100.0% 98.1% 88.8% 79.4% 78.0% 78.4% 68.1% 64.5% 59.1% 56.9% 60.8% 72.1%

Waiting Lists - RTT 18 Weeks (Incompleted Outcomes)

CITNS - Occ Therapy - Total Network Performance NHSE 92% 81.8% 88.2% 91.2% 95.1% 94.9% 94.0% 96.4% 99.1% 96.3% 98.2% 97.9% 96.2% 90.9%

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

CITNS - SLT- Total Network Performance NHSE 92% 86.9% 86.6% 83.6% 82.7% 84.2% 86.7% 87.0% 88.4% 96.2% 96.3% 98.0% 99.6% 99.9%

CAMHS Tier 4

Bed Occupancy - The Cove NHSE 85% 55.0% 65.5% 80.5% 90.5% 92.8% 86.5% 96.7% 94.6% 68.8% 68.2% 78.9% 90.6% 76.5%

Average Length of Stay (days) - The Cove Bench 83 57.00 44.00 41.00 39.00 67.00 57.00 33.30 60.70 27.70 48.10 26.60 38.80 58.60

National Child Measurement Programme

NCMP - Central NHSE 90% 26.8% 39.5% 52.6% 64.5% 73.8% 88.7% 94.4% - - - 5.1% 20.0% 24.9%

NCMP - BwD (Cumulative) NHSE 95% 24.9% 37.1% 46.3% 60.2% 67.6% 82.2% 95.7% - - - 22.4% 28.1% 36.8%

NCMP - East (Cumulative) NHSE 90% 30.3% 44.3% 56.0% 67.9% 79.5% 93.0% 98.5% - - - 6.4% 21.4% 30.2%

Other Indicators

ADHD - New < 18 Weeks NHSE 92% 40.1% 36.1% 31.6% 37.7% 46.4% 39.0% 35.7% 22.7% 20.9% 34.7% 36.7% 35.1% 30.3%

PBR Clustering NHSE 95% 93.6% 96.2% 96.3% 95.4% 96.0% 97.2% 96.4% 96.5% 95.1% 95.3% 95.1% 93.9% 92.8%

Number of Patients without a Care Co-ordinator Allocated > 2 Weeks NHSE 0 14 8 18 29 23 5 4 2 2 - - 99 82

Currently being validated


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

27

MHLT:

1 Hour Compliance:

The Network is reporting low compliance in the target for patients to be seen within 1 hour of referral, with 52.71% compliance in M9. This

is an improvement on compliance in November and the first time since April 17 that the compliance has been above 50%.

4 Hours Breaches:

The Network is reporting 61 actual 4 hour breaches in A&E for which LCFT were responsible in month 9, reporting 89.4% compliance.

12 Hours Breaches:

The Network is reporting 10 actual 12 hour breaches in A&E from the decision to admit time in month 9, which equates to 1.75% of all

A&E referrals to MHLT. For future reporting, the breach analysis will be complemented with the operational status at time of breach in

order to enhance our ability to triangulate information once collated into a monthly position.

Actions: Due: Owner: Outcome:

1. CORE 24 workshops in progress for development

of the working models. Apr-18

Deputy Head of

Operations

Workshop with Acute Trusts completed 18th

September to agree key points of clinical SOP with

LCFT. This work is to be linked in with the MHDU

SOP development.

2. Development of App and introduction of

electronic devices to provide more accurate data

and improve management oversight

Apr-18

Network Knowledge

Manager/Head of

Performance and HI

Further workshops with key members of staff

arranged for end of January, proposal to be

developed following these workshops.


75.2% 74.5% 76.8% 88.2% 89.9%

75.7% 72.5% 80.4% 89.1% 80.6%

84.2% 73.6% 75.8% 75.3% 78.3%

81.8% 73.2% 77.3% 81.3% 78.9%

87.7% 90.3% 91.2% 88.0% 92.7%

95.1% 91.1% 94.2% 92.3% 93.0%

Central (Total) MHLT

Morecambe Bay MHLT

MHLT 4 hour compliance

Blackpool MHLT

Central Lancs (Chorley) MHLT

Central Lancs (Preston) MHLT

East Lancs MHLT

Team performance:


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

28


29

Occupancy:

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

to 90.11%. The following rationale illustrates the reasons for the monthly bed occupancy:

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

• Whinfell Ward Male Low ABI had 3 vacancies - 1 SU currently on the waiting list due to be admitted 11th January 2018

• Forest Beck Ward Female Step down service had 1 vacancy - Female community bed

• Hermitage ABI/MI Step down Community House had 2 vacancies - Male Community Bed

• Fellside West Ward Male Step Down had 1 vacancy - 1 SU from Marshaw being considered

• Fairsnape Ward MSU had 2 vacancies - 1 SU on Waiting list awaiting medical recommendations to be completed to apply for transfer

warrant

• Elmridge Ward Male Female MSU had 2 vacancies - 2 OAPs on the waiting list, awaiting NHSE confirmation of dates for admission

There are no actions for this measure.

2.1 Performance Activity Mental Health (Secure Services) – Occupancy

OBDAvailable

beds

%

Occ

2016 2325 86.71%

1701 1736 97.98%

864 1023 84.46%

4581 5084 90.11%

Low Secure Wards

Step down Wards

Total

Dec-17

Medium Secure Wards


30

Violent Incidents resulting in Restraint:

Throughout December, there were 126 reportable incidents of verbal and physical violence at Guild Lodge. This sees a 15% increase

when compared to the 110 incidents reported throughout November. The overall use of restraint as a response to violent incidents has

been seen to increase. 25.4% of violent incidents ending in restraint which is significantly higher when compared to 16.3% in November.

Elmridge, Dutton and Bleasdale wards have all seen significant increase in violence and restraint in December due to patient acuity and

staff feeling unsafe. Work is underway to provide support and leadership to these environments.

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

resulting in Restraint


1. Reducing restrictive practice lead working with wards to reduce episodes

of seclusion. End of Q4

Service

Manager

The findings will be reported through

Locality Governance with tracked

actions.

2. Safety and security clinical lead to do focused work with Elmirdge and

Dutton wards. End of Q4

Service

Manager

The findings will be reported through

Locality Governance with tracked

actions.


31

CPA Reviews within 6 Months:

During December, 139 service users were eligible to have a CPA Review within the last 6 months. One service user did not receive their

review in December due to a change in consultant; the CPA has been booked for the next available date and will take place on 9th

January 2018.


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

Within 6 Months


32

Local Care Coordinator:

In December, all admissions were allocated a Care Co-ordinator within 2 weeks.


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

allocated within 2 weeks


33

Attendance of CPA reviews:

The attendance of Local Care Co-ordinators at secure inpatient CPA Reviews has fallen back slightly at 71.4% for December.

There were a total of 21 CPA Reviews planned, of which 15 were attended by Local Care Co-ordinators. It is noted that 3 Local Care

Coordinator sent apologies and that 3 did not attend. The DNAs have been followed up Line Manager to Line Manager.

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

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

CPA reviews


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

all planned CPA. End of Q4

Care Group

Manager Ongoing monthly.

2. Outlook invites to be included within the invite process and the

secretaries will be following up all invites where apologies or the

name of the attendee have not been received.

End of Q4 Admin

Manager Ongoing monthly.

Attended Apologies DNA

15 12 2 1

6 3 1 2

Breakdown of LCCNo of CPA

reviews

Lancashire

Non-Lancashire

Dec-17


34

25hr Meaningful Activity:

In December, 6 of the 15 wards failed to meet the 100% set target relating to the uptake of meaningful activity. The service notes that there

has been an overall improvement with a site wide increase from 86.4% in November, to 89.0% in December.

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

work being undertaken to improve engagement for opportunities of activity both on and off the wards. It is noted that the accuracy of

recording has improved.

Furthermore, it is noted that the service has provided additional matron cover across the wards and there will be a focus on checking

leaves and activities and ensuring these are happening and being recorded.

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


35

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


1. Ward Managers and Team Leaders on Fairoak Ward and

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

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

promotion for service user wellbeing.

End of Q3 Ward

Manager Ongoing. A new matron is in place to cover

these wards and will continue this work.

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

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

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

Ward

Manager This has increased activity uptake on the

ward.

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

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

Ward

Manager Ongoing. A new matron is in place to cover

these wards and will continue this work.

4. Ward activity is not consistently being recorded, discussions to be

had in supervision with Ward Manager on Dutton. Matron to check the

documents being completed daily and address with staff during

matron rounds . Reminder email to also go out to ensure that staff are

completing the 25 hour document. 25 hour activity to be added to

agendas in supervision.

End of Q4

Ward

Matron/Ward

Manager


36

% of FCMHT Caseload >12 months:

There are currently 50 service users on the FCMHT case load; 35 of these service users have been on the FCMHT caseload for over 12

months.

A meeting is arranged with the Commissioner for 12th January 2018 where a discussion will take place regarding the current pathway

and the feasibility and clinical appropriateness of the target being set at 20%. The YTD performance for 17/18 is 62.92%.

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

Caseload >12 months


A meeting is taking place with the commissioner and the

percentage of caseload being carried over 12 months will be

discussed with a suggestion for a more clinically appropriate target.

Oct-17

revised to

Jan-18

FMCHT

Care Group

Manager

This discussion was rescheduled for the

meeting on 12th January 2018 however

unfortunately the meeting did not go ahead

due to sickness and is to be re-arranged.


37

Attendance of CPA Reviews within Community Services:

The attendance of Local Care Co-ordinators at Forensic Community CPA Reviews has continued to increase from 45.5% in November to

66.7% in December.

There were a total of 6 CPA Reviews planned, of which, 4 were attended by Local Care co-ordinators. It is noted that 1 Local Care Co-

ordinator sent apologies and that 1 did not attend. The DNAs have been followed up Line Manager to Line Manager.

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

Reviews.

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

CPA Reviews within Community Services


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

increase levels of attendance at CPA reviews and identify an alternative

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

End of Q3 Service

Manager

Attendance has continued to

increase and this remains

ongoing.


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

Incidents exceeding PACE Clock

38

Number of Incidents exceeding PACE Clock:

There were no PACE breaches throughout December. This is a significant improvement from November when there were 9 breaches.

There was an overall reduction in the number of people referred through to the Hub from police custody, 7 in December from 21 in

November. The work done across Gold Command was successful in managing those referred within the required timeframe. Work

continues into January to ensure this improvement is maintained and the Network are having regular meetings with the local

constabulary to develop relationships and share learning.



HMP Liverpool – HJIP Indicators:

GP Waiting Times:

There are currently 106 patients on the GP waiting list and the longest wait is 15 working days, an increase of 5 working days compared to

November. The contributing factors to this are a DNA rate of 37% and the cancellation of 5 clinics. Cancellation reasons are as follows: 1

GP not provided; 2 GP sick and 2 Bank Holidays. Despite the cancellations, 266 patients were seen, only 16 fewer patients compared to

November. This is due to the increased numbers of patients listed for each clinic to compensate for DNAs. The Nurse Practitioner clinics

have been reduced due to one NP being off sick and the other having to cover other duties due to staffing shortages.

Enablement issues are highlighted below.

NHS Health Checks:

100% completed for December.

Wellman Screening:

The Wellman screenings target has continued to decrease due to staffing shortages and the need to cover essential areas.

Immunisations and Vaccinations:

Due to staffing shortages, only 4 clinics were facilitated during December. 75 appointments were offered with a DNA rate of 62%. A large

percentage of the appointments offered were for Seasonal Flu so they needed to be re-called. Currently there are 35 patients eligible for

Flu vaccination, 19 of these were offered an appointment on 8th January, of which 10 of them Did Not Attend.

DNA - Enablement Issues:

The prison has informed Healthcare that as of 8th January 18, there is to be a new "Core Day" and this should have a positive effect on

enablement. Healthcare should start to see patients arrive for clinics at 9am instead of around 9.45am, with the same improvement for the

afternoon clinics. This will be closely monitored by both Healthcare and Prison staff and feedback given at the Operational Meetings.

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

HJIP Indicators

39



HJIP Indicators

40


1. Enablement issues:

Monitor the effect of the new "Core Day" which

commences w/c 08/01/18 and report to the

Operational Meetings.

31-Jan-18 Care Group

Manager

New escalation structure in place. The PHOG forum to

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

Healthcare issues.

2. Wellman Screening:

Due to staffing shortages a request has been made

to cover the Wellman post with overtime. 30-Dec-17

Care Group

Manager Awaiting confirmation.



HJIP Indicators

41

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

260 296 261 336 358 422 359 307 274 285 283

12 3 27 35 35 99 55 24 43 29 26

3 0 1 0 3 0 0 1 0 0 0

13 7 31 61 72 53 54 24 60 26 7

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

Hep B Vaccinations

No. of new receptions

No. of patients accepting Hep B

Patients vaccinated >4wks

Total vaccinations in month

% patients accepting within 4 wks


307 375 261 336 358 422 359 307 274 285 283

292 335 196 211 117 406 432 301 341 237 213

95.11% 89.33% 75.10% 62.80% 32.68% 96.21% 120.33% 98.05% 124.45% 83.16% 75.27%% completed

Wellman Checks

No. of new receptions

No. of Wellman checks completed


5 6 7 8 9 10 11 44 16 28 12

49 41 19 18 39 54 28 35 37 25 37

59 35 52 31 45 47 69 57 33 48 54

169 165 80 23 0 27 96 103 70 31 54

GP Waits

0-2 days

3-7 days

8-14 days

14+ days


258 247 103 14 14 21 31 22 6 6 5

13.18% 8.91% 1.94% 57.14% 28.57% 14.29% 22.58% 0.00% 33.33% 33.33% 100.00%

18 19 23 11 11 6 14 51 17 9 11

33.33% 5.26% 13.04% 27.27% 63.64% 100.00% 21.43% 13.33% 17.65% 11.11% 81.82%

41 38 41 38 38 19 26 28 31 24 22

4.88% 2.63% 2.44% 21.05% 44.74% 5.26% 7.69% 7.14% 19.35% 4.17% 0.00%

25 21 21 225 132 129 203 241 222 198 198

0.00% 14.29% 23.81% 3.56% 2.27% 2.33% 0.99% 1.66% 4.05% 3.03% 0.51%

5 2 6 2 2 4 1 2 3 1 4

100.00% 100.00% 100.00% 100.00% 100.00% 100.00% 100.00% 100.00% 0.00% 100.00% 100.00%

Patients received NHS

HC Screen

Patients accepting

Men C Vacc

Patients accepting

MMR Vacc

SU received CPA

review <6 months

Total Eligible

% Screened

Total Eligible

% Recieved

Total Eligible

% Recieved

Total Eligible

% Recieved

Patients Screened for

Chlamydia

Total Eligible

% Screened


2.1 Performance Activity Community & Wellbeing – Improving Access to

Psychological Therapies (IAPT) Prevalence

42

IAPT - Prevalence:

A cumulative prevalence model has been developed to support teams to achieve the 16.8% prevalence target set by NHS England at 31

March 2018. The quarter 3 contractual target remains at 15% (BWD is 14.2%); however teams have been working towards an internal

cumulative target of 16.2% in preparation for the 16.8%. St Helens CCG has agreed that prevalence will stay at 15% as they have not

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

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

All teams apart from Fylde and Wyre did not achieve the 15% contractual prevalence target in December.

• Fylde and Wyre did achieve 15% contractual target

It was predicted that the teams would struggle to achieve the prevalence target in December as historically December is a quieter month

for referrals, prevalence and first assessment appointments. In preparation for the anticipated lower numbers in December, the teams

worked hard to increase referrals, prevalence and taster sessions in October and November of quarter 3.

Overall prevalence for quarter 3 is:

• All teams achieved the 15% contractual prevalence target of 15% for quarter 3 (BwD 14.2%)

• Chorley and South Ribble also achieved the 16.2% quarter 3 internal cumulative target

• Greater Preston also achieved the 16.2% quarter 3 internal cumulative targets

• West Lancs also achieved the 16.2% quarter 3 internal cumulative targets

• Fylde and Wyre also achieved the 16.2% quarter 3 internal cumulative target

The impact of increasing prevalence from 15% to 16.8% is that there are additional referrals into the service per month, the with an attrition

rate of approx. 15% this has resulted in an increased treatment demand. This is seen in the number of people waiting greater than 26

weeks on the internal waiting list for onward treatment interventions. See IAPT Waits slide.

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

all teams. Performance data is examined daily to enable teams to respond quickly to areas of deficit in prevalence and direct resources

within each specific locality. Deficits and risk areas to achieve prevalence are highlighted at team and management level and are

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


2.1 Performance Activity Community & Wellbeing – IAPT Prevalence

43


1. West Lancs additional taster sessions planned for

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

Taster sessions continue alongside exploring

direct referral options

2. Action plan developed with Preston and St Helens to

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


1.38% 1.20% 1.09% 1.60% 1.00%

1.45% 1.38% 1.40% 2.10% 0.97%

1.22% 1.30% 1.38% 1.36% 1.10%

1.35% 1.37% 1.33% 1.88% 1.31%

1.07% 1.24% 1.67% 1.24% 1.23%

1.32% 1.27% 1.03% 1.75% 1.16%

1.09% 1.43% 1.56% 1.20% 1.10%

1.48% 1.21% 1.33% 1.67% 1.11%

1.22% 1.26% 1.30% 1.45% 1.06%Total Figure - 8 CCGs




NHS St Helens CCG

CWB IAPT Prev CCG (Monthly)







44



45


2.1 Performance Activity Community & Wellbeing – IAPT Waits

46

IAPT - Waits:

Waiting times have increased across the service in December with 154 people waiting over 26 weeks for treatment:

• 23 people have been waiting over 26 weeks for CBT in East Lancs; this is an increase of 12 since November

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

• 1 person has been waiting over 26 weeks in West Lancs for Counselling, this is an increase of 1 since November

• 16 people have been waiting over 26 weeks in Fylde and Wyre for CBT; this is an increase of 6 since November

• 70 people have been waiting over 26 weeks in Morecambe Bay for Counselling, this is an increase in 52 since November, 1 person has also

been waiting over 26 weeks for CBT

• 11 people have been waiting over 26 weeks in St Helens for CBT; this is a reduction in 3 people since November

There are a number of reasons that when combined have contributed to the increase in waiting times:

• An increase in the national prevalence target from 15% to 16.8 (as described earlier)

• Staff capacity issues due to sickness and turnover in quarter 3 with a difficulty in recruiting to some posts. This has been a national concern

raised with NHS England due to the wave 2 Long Term Conditions programme, where high numbers of staff have moved to new training

posts.

• A reduction in the activity delivered by a sub contract partner Lancashire Women’s Centre.

An action plan is in place across the service to manage and improve the waiting times:

• A recruitment plan, both internally and sub-contracting. All Mindsmatter vacancies have been advertised and some staff will start in post from

January 2018.

• A service transformation plan is in development to change and improve how Mindsmatter deliver the service to accommodate the increasing

prevalence figures

• Staff sickness management plan and measures to mitigate against loss of capacity are in place across teams, including HR support and staff

working more flexibly across the service

• Monthly formal contract and performance meeting with Lancashire Women's Centre

• All service users on the waiting list are being contacted with an offer of an alternative intervention to one-to-one therapy and local actions

plans with individual CCGs are in development

• All staff have been offered bank or overtime to increase activity whilst recruitment takes place

• A further expression of interest to be sent to external providers to increase our 3rd sector offer across the service

• Plan to work with ‘My Space’ colleagues to identify if we have any clients waiting who would benefit from input

In addition, we have also identified some data quality issues which are impacting on the reporting of the length of internal waits. A waiting list

meeting takes place weekly to address allocation places, review trajectories and data quality, with a fortnightly steering group in place chaired by

the Head of Operations.


2.1 Performance Activity Community & Wellbeing – IAPT Waits

47


Internal performance reporting increased and reviewed to

closely monitor waiting times across the teams.

30-Sep-17

revised to

31-Dec-17

continued to

31-Mar-18.

Service

Manager

This will remain in place as there is a large

amount of staff movement in Quarter 3 which

will have an impact on waiting times, and

continue into Quarter 4.


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

48

Early Intervention in Psychosis (EIP):

The position at the end of M9 is that 33.3% of service users received treatment within 2 weeks, this represents 12 people out of 36 within

the cohort. This is a continued improvement of almost 10% from M8, where only 11 out of 46 people received treatment within 2 weeks.

The number of service users waiting at the end of M9 has remained static at 49, with 51 in M8.

The Trust continues to take the issue of EIS RTT performance and reporting with the utmost seriousness. Daily SITREPs and

teleconferences chaired by senior management, involving front line staff and managers plus performance colleagues, are now very well

embedded to ensure that all new referrals are allotted appointments within the 14 day window. There is an extensive action plan in place,

of which key actions are provided below. Further recovery against the RTT is expected in Quarter 4.

The Trust is currently undertaking a self-assessment audit programme which will be completed by February 2018 and submitted to the

RCPsych for national benchmarking.


- - 16.7% 9.1% 12.5%

- - 0.0% 0.0% 0.0%

- - 0.0% 50.0% 20.0%

- - 0.0% 27.8% 80.0%

- - 0.0% - 50.0%

- - 0.0% 0.0% 25.0%

- - 50.0% 50.0% 33.3%

- - 0.0% 100.0% 33.3%

- - 9.5% 23.9% 33.3%

CYP 2ww EIP CCG




NHS Blackpool CCG







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

49


1. Review and amend SOP to ensure clarity and triangulation

with most recent national Guidance Jan-18 Deputy Director Underway.

2. Review of referral processes to ensure timely receipt by

service, including a review of impact of Bluelight 71 Dec-17

Deputy Head of

Operations

New wording completed awaiting

confirmation to launch.

3. Review of allocation processes for telephone and first face

to face with case manager to plan for sufficient timely first face

to face treatment appointments.

Dec-17

Deputy Head of

Operations and

Lead Psychologist

Complete: Formalisation of face to

face appointment 7 days after

telephone to be reviewed at 6 months

once performance stabilised.

4. Training update for staff and team leaders on NCRS, EDMS

and records management Jan-18

Deputy Head of

Operations Workshop arranged January 2018.

5. Undertake a productivity and caseload review of all EIS

teams to ensure capacity is maximised Mar-18

Care Group

Manager

6. A review of referral processes is currently being undertaken.

with a view of streamlining the process Mar-18 Service Manager

Removing delays in the RTT due to

the current referral processes.


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

50

Child Psychology (Total Network Performance):

In M9, overall service performance decreased to 84.5%, from 86.4% in M8. The total number of SUs on the waiting list in M8 reduced to

206 from 270 in M8, of which 32 are waiting over 18 weeks; a decrease of 5 from M8. Four out of the six team’s performance are now

above the target of 92% (BwD/EL; Preston Community; Blackpool; Fylde and Wyre) and two teams under the target (Preston Hospital and

Lancaster).

Preston Hospital

11 out of 17 service users are waiting over 18 weeks (64.7%). This is a 2.8% increase from M8 (61.9%). The longest waiter is 37 weeks.

The Preston Hospital service is provided in line with a historic SLA with Lancashire Teaching Hospitals (LTH). This includes a contractual

requirement for inpatients to be seen at very short notice and this impacts on their capacity for out-patient/community work. A meeting has

been requested with LTH to review the SLA.

Waiting list validation is underway which includes advice on interim support, should families feel that the emotional health and wellbeing of

their child has changed significantly.

Lancaster

Performance in Lancaster increased in M9 to 62.3%, from 59.6% in M8. This equates to 33 out of 53 service users. 5 SUs waiting over 18

weeks have TCIs in January, and 2 in February. The current longest waiter is at 31 weeks.

The new Principal Clinical Psychologist, who took up post on 20th November, is now having a positive impact on service delivery. There

are two Clinical Psychologists off long term sick that are being appropriately managed.


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

51


1. Continue to manage sickness

appropriately. 31-Dec-17 Service Manager Sickness is being managed.

2. To define the waiting list trajectories

with the Network Analyst. 31-Jan-18

Service

Managers and

Lead

Psychologist

Lead Psychologist & Deputy Head of Ops have analysed current and

potential capacity within CPS with a view to introducing new job plans

which would increase CPS activity. New job plans will be used to define

trajectories. Other solutions to address the backlog are being explored

with each team including: additional hours; additional temporary posts;

and the potential use of private sector.

3. Meeting with LTH to review SLA

linked to Preston Hospital waits 31-Jan-18

Deputy Head of

Ops and

Consultant

To review the SLA and refresh in line with current expectation and offer.


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

52

CAMHS Tier 3

In M9, overall service performance has increased by 11.3% from 60.8% to 72.1% (392 SUs). This equates to 152 out of 544 waiting over

18 weeks for treatment, which represents a 33% decrease from M8. The total number of SUs on the waiting list also decreased in M9 from

581 to 544 in M8.

Two out of the five team’s performance remains above the target of 95% (West Lancs and Fylde & Wyre) and three teams under the target

however 90% (137) of SUs waiting over 18 weeks relate to Chorley and South Ribble (C&SR) Team.

Service level performance:

C&SR performance increased slightly for the third consecutive month in M9 to 54.6% from 43.2% in M8. There are currently 137 out of

302 SUs waiting over 18 weeks. 21 SUs have TCI dates in January, of which 20 are waiting over 18 weeks.

The team continues to send validation letters to the longest waiters in order of referral date, and are currently at 34 weeks. From month 10,

validation letters will change and these are being sent out to 18 weeks and above. There are still a number of substantive vacancies which

are having an impact on the teams’ capacity; interviews for vacancies have been organised for January 2018.

Preston performance increased to 89.6% in M9 from 80% in M8. There are currently 11 out of 106 SUs waiting over 18 weeks. 11 SUs

have TCI dates and the longest waiter is 25 weeks. The team are increasing capacity of initial assessments to improve throughput. As a

result, the performance is expected to be below 18 weeks again by the end of January.

Lancaster performance increased in M9 to 83.3% from 57.9% in M8. There are currently 4 out of 24 SUs waiting over 18 weeks. 3 SUs

have TCI dates and the longest waiter is 25 weeks. The teams’ capacity is affected by sickness and vacancies. Sickness is being

managed appropriately and posts are being recruited to. All families next in line for an appointment are being contacted by phone to

confirm their need for an appointment remains and to offer a choice of appointment to encourage attendance.

Overall recovery:

The impact of the validation process in C&SR is having a positive effect on the waiting list size, with an overall reduction from 581 to 544.

Twelve validation responses are still required by the end of M9 and completion of the validation will be achieved by M11. The revised

appointment booking procedure is now in place in C&SR team and further improvements should be realised by the end of M10. These

improvements will give the Network the knowledge to be able to provide accurate CSR and Service level trajectories by M11. Lancaster

and Preston are expected to be meeting the access target at the end of M10.


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

53


Vacancies to be recruited to. 31-Jan-18 Service

Manager Increase team capacity.


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

54

ADHD:

The proportion of new referrals to the ADHD service waiting under 18 weeks for treatment was 30.3%, down marginally from 35.1% as at

the end of M8. This equates to 100 out of 330 new referrals waiting under 18 weeks. In December there were 62 referrals (new and

transition) as opposed to 84 in November; a decrease of 26%.

Issues affecting performance:

• The service still has a vacant NMP post. However, discussions are in place to create 3 NMP posts, each with a specific locality

caseload: North, Central and East. This will be as part of the new service model and will provide further efficiencies. NMP post is being

interviewed on 17th January 2018 and if the post is recruited to which will enable us to take on New Assessment work from the summer.

• The NMP recently joining the service has now begun independently prescribing under close supervision of the team leader, again

creating capacity. However due to the large established case load, this role has been continuing prescribing with patients already in the

service, along with new transitions.

• It was proposed that commissioners and LCFT work together to develop the future model for ADHD. The meeting planned for 22/12/17

was cancelled and a new date has been requested.

• New Assessment waiting list continues to grow as there is no capacity to take on new assessments due to number of reviews.

Transition assessments were agreed to be priority due to ongoing clinical issues with this group not being reviewed once discharged

from CAMHS.

It is of note that the estimated demand in the specification is that 170 adults aged 16 years+ across Lancashire (excluding Blackpool) will

require assessment for continuing need of medication and appropriate transitioning from their existing service each year. There is

expected to be new referral demand in addition, in line with reasonable growth assumptions. The service has in fact received 263 referrals

for ‘transition’ and 357 for ‘new’ since the 1 April this year, which significantly exceeds the contracted demand.



55


1. A new service model to be developed, focusing on effective gatekeeping

and triage alongside robust efficiency of treatment.

30-Nov-17

revised to

01-Jan-18

Service

Manager

Awaiting rescheduling of

Commissioners meeting.

2. Change the referral route process. 30-Nov-17

revised to

01-Jan-18

Service

Manager



3. Set up a virtual neuro-development assessment team. 31-Jan-18 Service

Manager



4. Review all service users who are stable and also open to Adult Mental

Health (AMH) with aim to transfer to AMH. 31-Mar-18

Service

Manager

Meeting to be arranged

with Adult Mental Health to

begin this process.

5. Consider the opportunities to review approach across neuro-

developmental assessment to improve the offer. 31-Jan-18

Deputy Head

of Operations

More effective service

provision.



56


Patient Flow

Section 2.2

57


2.2 Patient Flow Summary – Patient Flow

58


Sparkline

Patient Flow

Average Number of Patients (OAPS) Commissioner 15 22.48 23.29 23.42 24.27 25.52 25.67 24.23 23.68 26.17 24.58 29.93 27.52

OAPS Occupied Bed Days Commissioner 465 697 652 726 728 791 770 751 734 785 762 898 853

LCFT and OAPS Occupancy % (Total Network Performance) Commissioner 85% 101.1% 98.2% 96.8% 105.7% 106.1% 106.4% 105.4% 107.4% 107.6% 107.9% 109.6% 106.7%

Number of LCFT and OAPS Occupied Bed Days (Total Network

Performance)Commissioner 9836 10667 10009 10927 10593 10988 10665 10917 11120 10777 11171 10982 11047

LCFT and OAPS Occupancy % (AMH) 102.9% 102.8% 101.2% 108.6% 107.9% 108.0% 107.7% 107.6% 108.9% 108.3% 109.4% 107.5%

Number of LCFT and OAPS Occupied Bed Days (AMH) 7799 7630 8317 8148 8364 8097 8349 8340 8167 8394 8206 8335

LCFT and OAPS Occupancy % (OA) 96.5% 85.8% 85.0% 97.0% 100.8% 101.9% 98.6% 106.8% 103.6% 106.6% 110.2% 104.1%

Number of LCFT and OAPS Occupied Bed Days (OA) 2868 2379 2610 2445 2624 2568 2568 2780 2610 2777 2776 2712

LCFT only Occupancy % (Total Network Performance) NHSE 85% 98.7% 100.1% 98.5% 98.5% 98.5% 98.8% 98.7% 100.3% 101.9% 100.5% 100.6% 98.5%

Number of LCFT only Occupied Bed Days (Total Network Performance) Stretch 9836 9970 9357 10201 9865 10197 9895 10216 10386 10212 10409 10084 10194

LCFT only Occupancy % (AMH) 99.6% 99.9% 99.1% 99.2% 98.3% 99.0% 98.7% 98.9% 99.9% 99.5% 99.2% 98.4%

Number of LCFT only Occupied Bed Days (AMH) 7102 6990 7679 7437 7622 7426 7648 7665 7492 7715 7441 7626

LCFT only Occupancy % (OA) 96.5% 100.6% 96.9% 96.3% 98.9% 98.0% 98.6% 104.5% 107.9% 103.5% 104.9% 98.6%

Number of LCFT only Occupied Bed Days (OA) 2868 2367 2522 2428 2575 2469 2568 2721 2720 2694 2643 2568

Secure Overall Gross Occupancy NHSE 93% 91.8% 93.3% 93.7% 97.2% 95.9% 96.0% 94.2% 91.3% 91.0% 92.4% 91.3% 90.1%

Average Episode Length of Stay (LOS) (AMH) Bench 31 29.72 40.23 33.00 34.70 36.10 46.40 47.60 29.60 33.30 38.80 43.90 41.80

Average Ward Length of Stay (LOS) (PICU) 58.50 55.20 37.80 39.90 35.10 38.80 30.10 27.60 38.10 34.00 34.00 46.30

Average Episode Length of Stay (LOS) (OA) 123.56 95.35 115.60 122.30 135.50 97.90 104.50 86.90 95.00 129.80 119.00 94.10

Re-Admission Rates - 30 Days (AMH) % NHSE <8.7% 7.8% 12.6% 9.5% 15.3% 13.8% 14.8% 11.5% 6.9% 6.7% 8.6% 7.5% 7.5%

Re-Admission Rates - 30 Days (AMH) Number of patients NHSE 16 18 24 22 31 30 30 24 14 13 16 13 14

Re-Admission Rates - 30 Days (OA) % NHSE <8.7% 0.0% 0.0% 3.4% 8.0% 0.0% 4.0% 0.0% 3.7% 0.0% 0.0% 0.0% 0.0%

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

Re-Admission Rates - 90 Days (AMH) % NHSE 15% 16.5% 23.0% 19.0% 20.7% 22.6% 22.2% 18.7% 17.3% 12.9% 15.1% 17.9% 14.4%

Re-Admission Rates - 90 Days (AMH) Number of patients NHSE 28 38 44 44 42 49 45 39 35 25 28 31 27

Re-Admission Rates - 90 Days (OA) % NHSE 15.0% 0.0% 0.0% 13.8% 0.0% 10.3% 4.0% 5.3% 7.4% 0.0% 0.0% 4.0% 5.6%

Re-Admission Rates - 90 Days (OA) Number of patients NHSE 3 0 0 4 - 3 1 1 2 0 0 1 1


2.2 Patient Flow Out of Area Placements (OAPS)

59

OAPS:

The average number of OAPs decreased in December by 2.41, alongside a decrease in the OAP OBDs in December with a position of

853, a decrease of 45 from November.

The overall number of OAPs fell towards the end of December to below 20, remaining below 20 into the first two weeks of January at

time of reporting and this reflecting a sustained improvement in the position. The Integrated Discharge Team, formed in December 2017,

will be a key driver in addressing the 180+ day Length of Stay cases.

There is system-wide acknowledgement that this cohort of patients are the key factor on flow and reducing the number of out of area

placements. The patient cohort have chronic mental health presentations with slow responses to treatment. As reported previously, from

the current inpatient cohort, zero 180+ day cases would result in zero OAPs and LCFT occupancy on acute wards below 100%. The

Network will use LCFT beds made available through the Integrated Discharge Team to repatriate current OAPs, improving care through

bringing these patients closer to families and community care teams.

No actions provided.


2.2 Patient Flow OAPS Trajectory

60


2.2 Patient Flow Occupancy – Mental Health

61

Occupancy:

Combined LCFT and Adult OAPs occupancy decreased in December by 1.86 percentage points to 107.55%, and Older Adult

occupancy by 6.01 percentage points to 104.15%. Both trends are towards the anticipated trajectory.

The over-occupancy is the direct cause of the reliance on OAPs in month. The Integrated Discharge Team formed in December 2017,

and impact on OAPs will be more evident in January as case work comes to fruition, with 32 long-stay cases identified by the IDT for

action. The focus has now shifted to 150+ days Length of Stay (rather than 180+) in order to drive earlier action for discharge or

transition, and the resulting capacity is the key next step in managing bed stock without OAPs.


1. MCAP standardisation workshop for defining non-qualified bed days

consistently across Trust Wards Dec-17

Deputy Head

of Operations

Postponed due to Gold

Command.

2. Integrated Discharge Team to become operational Dec-17 Head of

Operations Completed.

3. MCAP standardisation workshop for defining non-qualified bed days

consistently across Trust Wards Feb-18

Deputy Head

of Operations


2.2 Patient Flow Occupancy – Mental Health Total

62


2.2 Patient Flow Occupancy – Adult Mental Health

63


2.2 Patient Flow Occupancy – Older Adults

64


2.2 Patient Flow Occupancy

65


2.2 Patient Flow Mental Health – Average LOS

66

Average Ward Length of Stay - Adult:

Adult: The Network is reporting an average LOS of 41.8 days for December, a decrease from November's position. PICU LOS is

included within the Average Network LOS.

PICU: The Network is reporting an average length of stay of 46.3 days. This is above the Trust set target of 30 days and is an increase

of 12.3 days from November’s position.

Older Adult: December has seen a further decrease in the average length of stay, reporting an average of 94.1 days.

Implementation of the Integrated Discharge Team has had positive impact on the LOS and flow of patients.

No actions provided.


2.2 Patient Flow Mental Health – Inpatient LOS

67


2.2 Patient Flow Mental Health – Readmission Rate (90 days)

68

Re-Admission Rate (90 Days):

The Network achieved compliance with the 90 day re-admission rate this month with 13.66% for M9. This includes Older Adult ward data.

The underlying position with Adult Wards has improved from M8 with a position of 14.44%. Older Adults had one re-admission in M9.

28 cases were re-admitted within 90 days. These include the 14 cases re-admitted within 30 days. 14 cases were re-admitted 31-90 days

after discharge.


1. Team Leaders to ensure to review in CMHT/CRHTT

Clinical Discussion Meetings.

Nov-17 revised

to Jan-18

Team

Leaders

Target date revised, this process will be

designed within sectorisation process, and

delayed timescale to ensure appropriate process

has been decided on given that the target is

being met currently and so there is no urgent

pressure on this indicator.

2. Re-admission data to be routinely reviewed in Locality

Governance groups.

Nov-17 revised

to Jan-18

Team

Leaders

Target date revised, this process will be

designed within sectorisation process, and

delayed timescale to ensure appropriate process

has been decided on given that the target is

being met currently and so there is no urgent

pressure on this indicator.


2.2 Patient Flow Mental Health – Readmission Rate (90 days)

69


Data Quality

Section 2.3

70


2.3 Data Quality Summary – Data Quality

71

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

unallocated cases.

Indicators achieved Target Jan-17 Feb-17 Mar-17 Apr-17 May-17 Jun-17 Jul-17 Aug-17 Sep-17 Oct-17 Nov-17 Dec-17 Sparkline

PBR Clustering

Trust PBR Clustering 95% 96.75% 96.37% 96.43% 96.45% 96.66% 96.64% 96.44% 95.70% 95.90% 95.00% 95.30% 95.00%

Mental Health PBR Clustering 95% 96.78% 96.37% 96.48% 96.47% 96.63% 96.65% 96.44% 95.70% 95.90% 95.10% 95.40% 95.00%

Children & Young People's Wellbeing PBR Clustering 95% 96.16% 96.31% 95.35% 95.99% 97.17% 96.35% 96.51% 95.10% 95.30% 95.10% 93.90% 92.80%

Allocated Patients (>2 weeks)

Trust Allocated Patients 0 461 413 443 430 300 228 242 223 0 0 708 824

Mental Health Allocated Patients 0 313 255 260 267 255 211 233 203 0 0 566 672

Community Wellbeing Allocated Patients 0 12 12 7 15 13 2 7 19 0 0 43 70

Children & Young People's Allocated Patients 0 8 18 29 23 5 4 2 2 0 0 99 82

Manual Overrides

Trust NHSI Manual Overrides 0 - - - 3 6 16 21 11 13 2 2 21

MR01 NHSI Manual Overrides 0 - - - 3 5 4 6 8 1 0 2 1

MR02 NHSI Manual Overrides 0 - - - - - - - - - - - 0




MR07 NHSI Manual Overrides 0 - - - 0 1 11 6 3 8 0 0 0






Other NHSI Manual Overrides 0 - - - 0 0 1 9 0 4 2 0 -


2.3 Data Quality Data Quality – Manual Overrides

72

Manual Overrides:

There was one manual override for 7DFU (MR01) in December.

Due to ongoing data validation processes in EIP (MR13), 20 of 36 records have been manually adjusted for reporting purposes (in

accordance with daily SITREP and National Guidance).


2.3 Data Quality Data Quality – PbR

73

PbR:

CYPW performance is below the required 95%. This has been brought to the attention of the interim performance manager who is

actioning.


2.3 Data Quality Data Quality – IAPT

74

IAPT:

The Trust has started in August 2017 a schedule of snapshot audits on its NHSI measures, the purpose of this was to validate what the

Trust reported against each NHSI measure. In October 2017 a snapshot audit was performed on MR14 (IAPT 6 week RTT – 75%) and

MR15 (IAPT 18 week RTT – 95%) in relation to September 2017 data and reported position. Previous notes and clinical admissions

were reviewed manually on the clinical system IAPTUS to determine each patient’s referral date and their first treatment date against

what was reported.

The audit was positive and corroborated the compliant position reported in relation to the Trust’s reported RTT figures for both MR14

and MR15. The audit did uncover some issues around system categorisation whereby appointments in some cases had been

incorrectly categorised by the IAPTUS system. The reason was down to the initial system configuration by the Mindsmatter team and

the IAPTUS system supplier Mayden.

The Performance team in collaboration with Mindsmatter service and Mayden are currently working on correcting and updating this and

other minor issues.

In addition to this, data quality issues were identified around internal subsequent waits i.e.. once service users complete first treatment

and the number of patients who remain on the internal waiting list without further activity. The performance team are working through

this with the service.


75

Section 3:- Finance and Contracting

Section 3.1:- Financial Activity

• UoR Risk Rating

• Summary I&E Position

• Summary of Clinical Services

• CIPS

• Capital Expenditure

Section 3.2:- Contract Activity

• Community & Wellbeing – Network Line Totals

• Community & Wellbeing – Service Line Totals

• Community & Wellbeing – Total Activity Split by CCG

• Community & Wellbeing – Activity Exception Reports by CCG

• Children & Young People’s Wellbeing – Service Line Totals

• Children & Young People’s Wellbeing – Exception Reports by Service

• Children & Young People’s Wellbeing – Total Activity Split by CCG

• Mental Health – Total Activity Split by CCG

• Mental Health – Activity Totals

Section 3.3:- Commissioning for Quality & Innovation

• CQUIN Executive Summary

3. Finance and Contracting


Financial Activity

Section 3.1

76


Use of Resources rating (UoR)

The improvements to the I&E position yield a rating of 3 and a Capital Service rating of 3 improving the overall UoR to a 2.

Assuming current pressures and risks are addressed through the recovery plan and I&E performance achieves (or

exceeds) forecast the Trust will achieve a UoR of 2 in line with the plan. However, though current forecasts anticipate the

achievement of the the overall target rating, Capital Service is based on EBITDA and since part of the Trusts recovery plan

is based on disposals (which are excluded from EBITDA) the Trust is not forecast to achieve planned Capital Service. The

Trust is also forecast to exceed its liquidity and slip against it's planned Agency target.

3.1 Financial Activity Use of Resources (UoR) Risk Rating

77

FINANCE AND USE OF RESOURCES RATING

Plan Actual Plan Forecast

Capital service cover rating 2 3 2 3

Liquidity rating 2 1 2 1

I&E margin rating 2 3 2 2

I&E margin: distance from financial plan 1 3 1 1

Agency rating 1 2 1 2

Overall 2 2 2 2

Year to Date Annual


Sustainability

At month 9, the Trust year to date position is £1.3m deficit (excluding impairments of £0.2m), against a plan to this point of

£1.2m surplus, a gap of £2.5m. Of this £1.4m relates to STF funding leaving an underlying gap of £1.1m. This shows an

improvement of c£0.5m on month 8 but still represents a significant gap and the majority of the improvements relate to

transacting amounts in the recovery plan, staffing pressures in ward and prison areas, OAPs and slippage against CIPs

continue. Unmitigated projections indicate a gap of c£4.2m (£6.3m including STF) and although this shows an improvement

over the month 8 position of c£0.4m, the recovery agenda will require sustained and coordinated responses with robust

management and oversight if the Trust is to achieve its control total.

3.1 Financial Activity Summary I&E Position

78

FUNDED WTE BUDGET DETAIL BUDGET ACTUAL £ ANNUAL PROJECTED £

EST. ACTUAL TO DATE TO DATE VARIANCE BUDGET ACTUAL VARIANCE

£'000 £'000 £'000 £'000 £'000 £'000

Healthcare Income 230,527 229,425 -1,102 305,092.1 305,610 518

5,749.7 5,798.7 Clinical Services -172,460 -178,624 -6,165 -229,216 -237,685 -8,469

772.0 724.4 Corporate Services -39,885 -39,606 279 -53,543 -52,875 668

Reserves and Capital Charges -16,995 -12,486 4,509 -20,163 -12,859 7,304

6,521.7 6,523.2 1,187 -1,291 -2,478 2,170 2,191 21


3.1 Financial Activity Summary of Clinical Services

79

FUNDED WTE BUDGET DETAIL BUDGET ACTUAL £ % ANNUAL PROJECTED £

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

£'000 £'000 £'000 £'000 £'000 £'000

PAY

2,972.5 3,198.7 ADULT PAY 88,113.9 94,626.9 -6,513.0 -7.4 117,744.9 125,171.2 -7,426.3

NON PAY 8,570.2 9,934.6 -1,364.4 -15.9 10,413.2 13,290.1 -2,876.9

PATIENT RELATED INCOME -530.0 -1,063.6 533.6 -100.7 -626.7 -1,460.1 833.4

NON PATIENT RELATED INCOME -1,550.0 -1,665.2 115.3 7.4 -2,066.6 -2,220.3 153.7

2,972.5 3,198.7 TOTAL 94,604.1 101,832.7 -7,228.6 -7.6 125,464.8 134,780.9 -9,316.1

1,627.1 1,526.1 ADULT COMMUNITY PAY 41,901.4 42,573.5 -672.1 -1.6 56,026.7 56,458.3 -431.6

NON PAY 9,302.1 8,960.9 341.3 3.7 12,419.0 12,536.8 -117.8

PATIENT RELATED INCOME -6,783.0 -6,991.5 208.6 -3.1 -9,255.9 -9,532.2 276.3

NON PATIENT RELATED INCOME -1,984.6 -1,966.0 -18.6 -0.9 -2,582.8 -2,561.1 -21.7

1,627.1 1,526.1 TOTAL 42,436.1 42,576.9 -140.8 -0.3 56,607.0 56,901.8 -294.8

1,094.9 1,022.4 CHILDREN AND FAMILY PAY 31,838.2 30,793.0 1,045.2 3.3 42,247.6 41,389.0 858.6

NON PAY 3,617.5 3,261.7 355.9 9.8 4,661.8 4,167.9 493.9

PATIENT RELATED INCOME -1,524.0 -970.9 -553.2 36.3 -1,843.4 -1,218.9 -624.5

NON PATIENT RELATED INCOME -909.0 -1,016.1 107.1 11.8 -1,117.8 -1,251.4 133.6

1,094.9 1,022.4 TOTAL 33,022.6 32,067.7 955.0 2.9 43,948.1 43,086.6 861.6

55.2 51.5 PHARMACY PAY 2,014.0 1,830.5 183.5 9.1 2,685.3 2,441.9 243.4

NON PAY 383.1 321.0 62.1 16.2 510.8 479.2 31.6

NON PATIENT RELATED INCOME 0.0 -4.2 4.2 No Budget 0.0 -5.4 5.4

55.2 51.5 TOTAL 2,397.1 2,147.3 249.8 10.4 3,196.1 2,915.6 280.5

5,749.7 5,798.7 TOTAL 172,459.9 178,624.5 -6,164.6 -3.6 229,216.0 237,684.9 -8,468.9


Cost Improvement Programmes

At £10.0m in month 9 the Trust is c£1.0m behind the plan of £11.1m and at 91% showing improvement on previous

month. The adverse variance is attributable to a lack of performance on Run Rate Reduction Programmes on staffing

pressures. The Trust continues to invest significant time and effort in managing and developing compensating CIPs and

network management are being supported to implement measures aimed at improving the position.

Currently the Trust anticipates it will achieve its annual target of £15.1m.

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

being finalised.

3.1 Financial Activity CIPs

80


£'m £'m £'m £'m £'m £'m

Cost Improvement Programmes 8.43 9.15 0.71 11.10 13.10 2.00

Run Rate Reduction Programmes 2.67 0.90 -1.77 4.00 2.00 -2.00

Total 11.10 10.05 -1.05 15.10 15.10 0.00

Year to Date Annual


Capital Expenditure

Progress against the capital programme has begun to accelerate with expenditure at £3.0m against the original profile of

£7.3m. Despite the resolution of a number of issues delays on the 17/18 programme would now appear inevitable,

particularly on the Inpatient and Perinatal schemes. The Trust is working with contractors to minimise the impact of delays

with a key focus on maintaining completion dates.

3.1 Financial Activity Capital Expenditure

81

YTD Plan YTD Act Annual Forecast

Dec 2017 Dec 2017 Variance Plan Out-turn Variance

£000 £000 £000 £000 £000 £000

IT Schemes 1.365 0.825 -0.540 1.900 1.900 0.000

Estate and infrastructure Schemes

Large Schemes

MH Inpatient Schemes 3.442 0.561 -2.881 4.580 2.200 -2.380

Perinatal 0.000 0.283 0.283 0.000 1.000 1.000

Places of Safety 0.000 0.138 0.138 0.000 0.150 0.150

High Priority Schemes 0.818 0.162 -0.656 1.095 0.193 -0.902

Spend to Save 0.050 0.196 0.146 0.050 0.496 0.446

Maintenance and Replacement 0.524 0.586 0.062 0.698 0.646 -0.052

Other (inc. contingency) 1.098 0.256 -0.842 1.238 1.156 -0.082

Total 7.297 3.007 -4.290 9.561 7.741 -1.820


Contract Activity

Section 3.2

82


2017-18 M9 Activity

LCFT have 11 services overperforming by +10% and 13 underperforming by -10%. However, this over and underperformance means that the overall

variance for the Community contract is -0.8% as shown above.

LCFT continue to provide exception reports for all Services at CCG level that have underperformed for 3 months or more, however following last

month’s Contract meetings, Midlands and Lancashire CSU are to provide a list of Central Services that they require LCFT to investigate further.

The detailed exception reports have been removed from the QPR this month and will be replaced over the coming months with more informative

balancing measures that highlight the impact of the under/over performance. The first service that will be reported in this way is Treatment Rooms

where the C&W Network is working with BwD CCG to evaluate the consequence of underperformance and provide assurance around service

functionality. As part of this full service review, patient waits are being monitored and will be reported from M10 in this section of the QPR.

For those service lines that will not be in a position to make up their negative variance by year end, discussions will need to take place with the

Commissioners.

Work is ongoing to resolve the issues highlighted last month regarding the Central Lancashire Paediatric Liaison Services not having sight of all the

children that are triaged by the ‘Go to Doctor’ service and subsequently deflected away from A&E. This is due to an outstanding information sharing

agreement which LCFT are working to put in place with both the GTD Service and the CSU.

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

83

Network17-18 Monthly

PlanApr-17 May-17 Jun-17 Jul-17 Aug-17 Sep-17 Oct-17 Nov-17 Dec-17 YTD 17-18

YTD 17-18

Variance

YTD 17-18

Variance (%)

Planned YTD

17-18

Community & Wellbeing Total 88,258 90,069 94,927 98,778 90,684 91,640 90,102 95,739 97,260 80,406 829,605 8,190 1.0% 821,415

Children and Young People's

Wellbeing Total 8,208 6,830 9,676 8,101 7,920 7,188 8,855 9,549 9,820 7,286 75,225 -15,886 -17.4% 91,111

Trust Total Against Plan 96,466 96,899 104,603 106,879 98,604 98,828 98,957 105,288 107,080 87,692 904,830 -7,696 -0.8% 912,526


84

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

Please note that the 2016-17 Community Baselines have been produced incorporating seasonal variations for each individual Service where appropriate and so unlike last year the

monthly plans are not determined by dividing the Annual plan by 12.

Service17-18 Monthly


YTD 17-18

Variance

YTD 17-18

Variance (%)

Planned YTD

17-18

Adult Learning Disability Service Total 2,404 1,646 2,345 2,312 2,017 2,080 1,985 2,028 2,549 2,100 19,062 -1,945 -9.3% 21,007

Adult Speech and Language Therapy Total 219 349 298 375 415 368 311 352 390 355 3,213 945 41.7% 2,268

CHESS Total 381 307 427 300 96 213 133 246 153 206 2,081 -1,050 -33.5% 3,131

Children's Learning Disability Service Total 959 1,235 1,660 1,655 1,363 1,214 1,585 1,594 1,681 1,142 13,129 2,561 24.2% 10,568

Community IV Service BwD Total 248 84 97 66 118 92 62 145 177 109 950 -1,270 -57.2% 2,220

Community Matrons Total 1,402 1,264 1,199 1,293 1,236 1,093 879 868 555 494 8,881 -4,385 -33.1% 13,266

Community Neuro Team Total 995 1,067 1,245 1,254 1,246 1,260 1,123 1,081 1,408 996 10,680 1,164 12.2% 9,516

Community Respiratory Service Total 1,987 1,968 2,074 1,933 1,918 2,110 1,798 2,267 2,280 2,414 18,762 3,261 21.0% 15,501

Community Stroke Service Total 431 339 359 382 431 467 399 558 511 473 3,919 -489 -11.1% 4,408

Complex Case Management Total 294 413 395 385 321 294 543 641 588 381 3,961 184 4.9% 3,777

Continence Service Total 252 227 304 223 234 287 290 272 300 252 2,389 -252 -9.5% 2,641

Dermatology Service Total 468 455 489 400 333 433 276 423 388 364 3,561 -465 -11.5% 4,026

DESMOND Total 41 65 78 64 75 68 94 124 73 26 667 10 1.5% 657

Diabetes Specialist Nursing Total 1,045 847 956 974 1,038 1,152 1,081 1,200 1,142 1,081 9,471 -775 -7.6% 10,246

District Nursing Total 37,626 40,895 40,999 39,943 37,898 38,888 37,705 39,928 39,290 35,685 351,231 9,252 2.7% 341,979

Domiciliary Physiotherapy Total 530 701 610 708 704 784 800 920 1,096 661 6,984 2,915 71.6% 4,069

Falls Team Total 331 425 658 656 685 667 727 810 585 534 5,747 2,422 72.8% 3,325

Heart Failure Service Total 430 147 249 261 213 220 251 276 275 207 2,099 -2,209 -51.3% 4,308

Intermediate Care Total 3,517 2,804 3,168 3,223 2,779 2,747 2,900 2,822 2,549 2,196 25,188 -8,264 -24.7% 33,452

Nutrition & Dietetics Total 240 269 262 251 289 211 265 353 380 272 2,552 392 18.1% 2,160

Oxygen Service Total 275 237 269 313 445 371 333 291 300 239 2,798 -39 -1.4% 2,837

Phlebotomy Total 16,146 16,855 16,160 22,004 17,610 16,671 17,630 18,013 20,823 13,996 159,762 14,405 9.9% 145,357

Podiatry Total 4,617 4,396 5,455 5,071 5,009 5,083 4,848 5,059 5,088 4,126 44,135 -1,453 -3.2% 45,588

Pulmonary Rehabilitation Total 436 441 598 680 618 790 597 631 585 391 5,331 892 20.1% 4,439

Rapid Assessment Team Total 1,464 1,527 1,735 1,659 1,730 1,700 1,479 1,504 1,366 1,233 13,933 281 2.1% 13,652

Rheumatology Total 1,424 1,306 1,587 1,729 1,440 1,684 1,641 1,757 1,855 1,394 14,393 1,438 11.1% 12,955

Specialist Nurse TB Total 317 618 381 525 471 481 533 428 451 340 4,228 854 25.3% 3,374

Tissue Viability Service Total 233 228 247 267 296 297 247 282 215 147 2,226 -386 -14.8% 2,612

Treatment Room Total 9,500 8,862 10,500 9,768 9,574 9,895 9,446 10,789 10,196 8,577 87,607 -9,961 -10.2% 97,568

Viral Hepatitis Service Total 46 92 123 104 82 20 141 77 11 15 665 157 30.9% 508

Community & Wellbeing Total 88,258 90,069 94,927 98,778 90,684 91,640 90,102 95,739 97,260 80,406 829,605 8,190 1.0% 821,415


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

85

Community & Wellbeing - Total Activity split by CCG17-18 Monthly


YTD 17-18

Variance

YTD 17-18

Variance

(%)

Planned YTD

17-18

Central Lancs Locality Total 16,146 16,855 16,160 22,004 17,610 16,671 17,630 18,013 20,823 13,996 159,762 14,405 9.9% 145,357

NHS Blackburn with Darwen CCG Total 22,179 21,957 24,654 23,309 23,422 23,699 22,170 24,453 23,582 20,593 207,839 -5,436 -2.5% 213,275

NHS Blackpool CCG Total 58 150 120 142 97 108 139 72 89 55 972 351 56.5% 621

NHS Chorley and South Ribble CCG Total 22,326 26,116 26,299 26,278 24,088 25,577 24,647 25,514 25,741 22,039 226,299 19,438 9.4% 206,861

NHS East Lancashire CCG Total 750 649 948 772 668 647 887 815 1,032 721 7,139 142 2.0% 6,997

NHS Fylde & Wyre CCG Total 437 322 330 478 391 430 464 588 526 334 3,863 -229 -5.6% 4,092

NHS Greater Preston CCG Total 25,629 23,281 25,375 24,630 23,500 23,637 23,388 25,429 24,692 22,051 215,983 -21,288 -9.0% 237,271

NHS Morecambe Bay CCG Total 400 341 486 584 456 396 373 432 434 377 3,879 255 7.0% 3,624

NHS West Lancashire CCG Total 333 398 555 581 452 475 404 423 341 240 3,869 552 16.6% 3,317

Community & Wellbeing Totals 88,258 90,069 94,927 98,778 90,684 91,640 90,102 95,739 97,260 80,406 829,605 8,190 1.0% 821,415


3.2 Contract Activity – Variance to Plan Community & Wellbeing – Activity Exception Reports by CCG

Commissioner: NHS Blackburn with Darwen CCG

86

Service17-18

Monthly PlanApr-17 May-17 Jun-17 Jul-17 Aug-17 Sep-17 Oct-17 Nov-17 Dec-17 YTD 17-18

YTD 17-18

Variance

YTD 17-18

Variance (%)

Planned YTD

17-18

Adult Learning Disability Service 473 135 189 178 160 143 178 240 349 451 2,023 -1,868 -48% 3,891

Children's Learning Disability Service 95 106 121 179 109 140 144 124 144 108 1,175 412 54% 763

Community IV Service BwD Total 201 84 97 66 118 92 62 145 177 109 950 -1,270 -57% 2,220

Community Respiratory Service 498 644 596 578 570 621 566 670 662 742 5,649 821 17% 4,828

Community Stroke Service 469 339 359 382 431 467 399 558 511 473 3,919 -489 -11% 4,408

Dermatology Service 468 455 489 400 333 433 276 423 388 364 3,561 -465 -12% 4,026

DESMOND (Completed Courses) 32 28 25 6 19 11 35 42 30 10 206 -48 -19% 254

Diabetes Specialist Nursing 492 274 387 265 305 429 414 362 380 395 3,211 -1,052 -25% 4,263

Intermediate Care ACS 1,120 866 1,066 1,068 970 1,002 946 957 777 687 8,339 -1,286 -13% 9,625

Pulmonary Rehabilitation 547 441 598 680 618 790 597 631 585 391 5,331 892 20% 4,439

Tissue Viability Service 79 105 119 111 121 97 92 126 95 59 925 114 14% 811

Treatment Room - Non-Serious Injury 98 141 195 189 184 144 166 169 134 127 1,449 308 27% 1,141

Treatment Room Total 6,419 5,590 6,359 5,721 5,659 6,008 5,686 6,405 6,157 5,008 52,593 -9,747 -16% 62,340

Treatment Room - Ulcer & Vascular 168 164 260 330 270 272 195 200 192 166 2,049 581 40% 1,468

Commissioner: NHS Blackpool CCG

Service17-18


YTD 17-18

Variance

YTD 17-18

Variance (%)

Planned YTD

17-18Specialist Nurse TB 58 150 120 142 97 108 139 72 89 55 972 351 57% 621



Commissioner: Central Lancs Locality

87

Service17-18


YTD 17-18

Variance

YTD 17-18

Variance (%)

Planned YTD

17-18

Adult Speech and Language Therapy Total 219 349 298 375 415 368 311 352 390 355 3,213 945 42% 2,268

Community Matrons Total 1,402 1,264 1,199 1,293 1,236 1,093 879 868 555 494 8,881 -4,385 -33% 13,266

Community Neuro Team Total 995 1,067 1,245 1,254 1,246 1,260 1,123 1,081 1,408 996 10,680 1,164 12% 9,516

Community Respiratory Service Total 1,374 1,324 1,478 1,355 1,348 1,489 1,232 1,597 1,618 1,672 13,113 2,440 23% 10,673

DESMOND (Completed Courses) Total 25 37 53 58 56 57 59 82 43 16 461 58 14% 403

Domicillary Physiotherapy Total 530 701 610 708 704 784 800 920 1,096 661 6,984 2,915 72% 4,069

Falls Team Total 331 425 658 656 685 667 727 810 585 534 5,747 2,422 73% 3,325

Intermediate Care ACS Total 2,505 1,938 2,102 2,155 1,809 1,745 1,954 1,865 1,772 1,509 16,849 -6,978 -29% 23,827

Nutrition & Dietetics Total 240 269 262 251 289 211 265 353 380 272 2,552 392 18% 2,160

Tissue Viability Service Total 86 49 50 48 53 57 53 50 27 41 428 -488 -53% 916

Commissioner: NHS Chorley & South Ribble CCG

Service17-18


YTD 17-18

Variance

YTD 17-18

Variance (%)

Planned YTD

17-18

CHESS 141 156 205 107 33 143 77 96 69 128 1,014 -146 -13% 1,160

Children's Learning Disability Service 217 351 504 462 408 273 421 391 496 323 3,629 1,223 51% 2,406

Rheumatology 582 579 677 745 631 695 703 719 770 581 6,100 804 15% 5,296

Specialist Nurse TB 22 35 6 0 39 5 93 62 76 20 336 106 46% 230



Commissioner: NHS East Lancashire CCG

88

Service17-18


YTD 17-18

Variance

YTD 17-18

Variance (%)

Planned YTD

17-18

Children's Learning Disability Service 195 200 281 280 179 208 349 362 361 211 2,431 106 46% 2,146

Commissioner: NHS Fylde and Wyre CCG

Service17-18


YTD 17-18

Variance

YTD 17-18

Variance (%)

Planned YTD

17-18

Adult Learning Disability Service 318 168 184 268 210 284 268 417 321 233 2,353 -438 -16% 2,791


Commissioner: NHS Greater Preston CCG

Service17-18


YTD 17-18

Variance

YTD 17-18

Variance (%)

Planned YTD

17-18

Adult Learning Disability Service 248 185 298 351 381 430 292 206 281 234 2,658 499 23% 2,159

CHESS 240 151 222 193 63 70 56 150 84 78 1,067 -904 -46% 1,971

Children's Learning Disability Service 194 232 271 275 242 246 327 317 316 213 2,439 306 14% 2,133

Heart Failure Service 215 133 228 233 192 201 226 235 241 178 1,867 -287 -13% 2,154

Viral Hepatitis Service 27 70 96 91 62 14 34 37 11 13 428 124 41% 304



Commissioner: NHS Morecambe Bay CCG

89

Service17-18


YTD 17-18

Variance

YTD 17-18

Variance (%)

Planned YTD

17-18

Adult's Learning Disability Service 339 184 321 384 300 248 271 255 255 216 2,434 -532 -18% 2,966

Children's Learning Disability Service 25 91 128 99 80 74 69 114 135 80 870 599 221% 271


Commissioner: NHS West Lancashire CCG

Service17-18


YTD 17-18

Variance

YTD 17-18

Variance (%)

Planned YTD

17-18

Adult Learning Disability Service 146 230 292 324 187 273 184 199 191 97 1,977 710 56% 1,267

Children's Learning Disability Service 173 160 238 233 233 182 180 184 137 140 1,687 -215 -11% 1,902


Viral Hepatitis Service 4 2 14 13 5 6 18 25 0 0 83 37 80% 46


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

and Service Line Totals

90

Children & Young People's Wellbeing -

Total Activity split by CCG

17-18


YTD 17-18

Variance

YTD 17-18

Variance (%)

Planned YTD

17-18

NHS Blackburn with Darwen CCG Total 478 561 753 718 591 535 766 787 819 442 5,972 -307 -5% 6,279

NHS Chorley and South Ribble CCG Total 1,493 1,011 1,339 1,310 1,178 830 1,198 1,229 1,387 904 10,386 -6,160 -37% 16,546

NHS East Lancashire CCG Total 3,583 3,448 5,028 4,026 3,971 3,779 4,438 4,979 4,990 3,839 38,498 -432 -1% 38,930

NHS Greater Preston CCG Total 2,194 1,399 1,994 1,524 1,751 1,575 1,876 2,021 2,036 1,765 15,941 -7,593 -32% 23,534

NHS West Lancashire CCG Total 460 411 562 523 429 469 577 533 588 336 4,428 -1,394 -24% 5,822

Children & Young People's Wellbeing

Total 8,208 6,830 9,676 8,101 7,920 7,188 8,855 9,549 9,820 7,286 75,225 -15,886 -17% 91,111



YTD 17-18

Variance

YTD 17-18

Variance (%)

Planned YTD

17-18

Children's Occupational Therapy Total 698 618 835 851 610 550 799 836 813 512 6,424 -3,041 -32% 9,465

Children's Physiotherapy Total 622 574 645 632 580 518 648 694 740 485 5,516 -1,605 -23% 7,121

Children's Speech & Language Therapy Total 2,090 1,960 2,859 2,573 2,361 1,938 2,772 3,102 3,012 1,513 22,090 -5,207 -19% 27,297

Paediatric Liaison Total 4,798 3,678 5,337 4,045 4,369 4,182 4,636 4,917 5,255 4,776 41,195 -6,033 -13% 47,228

Children and Young People's Wellbeing

Total Against Plan8,208 6,830 9,676 8,101 7,920 7,188 8,855 9,549 9,820 7,286 75,225 -15,886 -17% 91,111


3.2 Contract Activity – Variance to Plan Children & Young People’s Wellbeing – Exception Reports by Service

Commissioner: NHS Blackburn with Darwen CCG

91



YTD 17-18

Variance

YTD 17-18

Variance (%)

Planned YTD

17-18

Children's Occupational Therapy 88 126 126 137 87 74 118 95 94 73 930 -253 -21% 1,183

Commissioner: NHS Chorley & South Ribble CCG



YTD 17-18

Variance

YTD 17-18

Variance (%)

Planned YTD

17-18

Children's Occupational Therapy 143 115 155 172 142 92 154 151 160 93 1,234 -716 -37% 1,950

Children's Physiotherapy 229 257 266 271 213 190 204 226 249 164 2,040 -593 -23% 2,633

Paediatric Liaison 802 261 434 311 366 291 366 277 366 332 3,004 -4,792 -61% 7,796

Commissioner: NHS East Lancashire CCG



YTD 17-18

Variance

YTD 17-18

Variance (%)

Planned YTD

17-18


Children's Speech & Language Therapy 784 634 1,012 887 792 665 916 1,101 969 452 7,428 -2,820 -28% 10,248

Paediatric Liaison 2,572 2,586 3,684 2,818 2,967 2,928 3,233 3,564 3,732 3,206 28,718 3,124 12% 25,594


Commissioner: NHS Greater Preston CCG

3.2 Contract Activity – Variance to Plan Children & Young People’s Wellbeing – Exception Reports by Service

92



YTD 17-18

Variance

YTD 17-18

Variance (%)

Planned YTD

17-18



Children's Speech & Language Therapy 375 270 401 272 361 305 411 451 443 231 3,145 -1,739 -36% 4,884

Paediatric Liaison 1,424 831 1,219 916 1,036 963 1,037 1,076 1,157 1,238 9,473 -4,365 -32% 13,838

Commissioner: NHS West Lancashire CCG



YTD 17-18

Variance

YTD 17-18

Variance (%)

Planned YTD

17-18

Children's Occupational Therapy 101 72 101 107 64 98 92 92 107 58 791 -564 -42% 1,355


Children's Speech & Language Therapy 222 243 335 277 247 250 323 283 263 146 2,367 -535 -18% 2,902


3.2 Contract Activity – Variance to Plan Mental Health – Total Activity split by CCG

93

Demand Metrics17-18 Monthly


Adult/PICU Ward Admissions Total 137 169 195 180 187 175 171 167 153 161 1,558

Adult/PICU Ward Discharges Total 133 167 187 177 165 168 163 160 147 154 1,488

CMHT - Adult Referrals Total 149 153 171 167 153 212 189 187 195 163 1,590

CMHT - Older Adult Total 117 90 139 131 120 142 134 129 144 101 1,130

Community Restart Teams - Accepted Referrals Total 119 130 176 178 165 163 123 158 128 90 1,311

CRHT Teams - Referrals Total 621 720 793 870 806 769 843 806 748 753 7,108

Eating Disorder Service - Referrals Total 56 73 86 93 79 69 69 94 96 66 725

Hospital Liaison Referrals Total 200 149 171 155 158 175 152 154 156 134 1,404

MAS Teams - Referrals Total 544 492 565 627 607 617 575 605 635 548 5,271

Older Adult (Dementia) Inpatient Ward Admissions Total 5 7 12 6 7 7 9 5 6 6 65

Older Adult (Dementia) Inpatient Ward Discharges Total 7 10 6 8 8 5 6 8 6 6 63

Older Adult (Functional) Inpatient Ward Admissions Total 13 11 9 11 12 9 11 4 8 8 83

Older Adult (Functional) Inpatient Ward Discharges Total 13 12 10 9 14 9 11 7 8 9 89

PICU Wards - Transfers In Total 21 16 27 24 26 21 17 24 22 22 199

RITT Referrals Total 164 169 154 168 151 204 159 144 164 139 1,452

Quality Metrics17-18 Monthly


Adult Ward Occupied Bed Days Total 4,978 5,744 5,835 5,676 5,885 5,904 5,784 5,935 5,741 5,856 52,360

Eating Disorder Service DNA's - Follow Up Contacts N/A 94 98 76 123 129 98 95 121 91 925

Eating Disorder Service DNA's - New Contacts N/A 7 8 14 14 19 3 6 12 15 98

PICU Ward Occupied Bed Days Total 723 817 849 846 893 952 897 878 836 851 7,819

Older Adult (Dementia) Ward Occupied Bed Days Total 768 812 850 854 909 945 924 938 895 903 8,030

Older Adult (Functional) Ward Occupied Bed Days Total 943 1,034 1,104 1,081 1,102 1,154 1,101 1,119 1,090 1,109 9,894

Older Adult (Functional) Inpatient 30 Day ReAdmissions TotalReport by

Exception1 0 0 0 0 0 0 0 0 1

Older Adult (Functional) Inpatient 90 Day ReAdmissions TotalReport by

Exception1 1 0 1 0 0 0 0 0 3

Adult Inpatient 30 Day ReAdmissions Rate (8% Target) 8% of Discharges 9.58% 7.49% 9.04% 9.09% 6.55% 7.36% 9.38% 6.12% 7.14% 8.08%Adult Inpatient 90 Day ReAdmissions Rate (15% Target) 15% of Discharges 14.97% 13.90% 16.38% 12.12% 7.74% 7.36% 9.38% 6.12% 5.19% 11.00%


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

Please note that the 2016-17 Mental Health Baselines have been produced incorporating the number of working days per month, and so unlike last year ,the monthly plans are not

determined by dividing the Annual plan by 12.

94

Productivity Metrics17-18 Monthly


YTD 17-18

Variance

YTD 17-18 Variance

(%)

Planned YTD

17-18

ADHD Contacts Total 250 370 253 393 455 316 271 378 468 366 3,270 504 18% 2,766

CMHT AD - Contacts Total 8,060 8,189 9,706 9,627 9,171 9,015 8,881 9,178 8,911 7,090 79,768 -1,265 -2% 81,033

CMHT OA Contacts Total 2,688 2,584 2,846 2,815 2,754 2,862 2,766 3,049 3,003 2,424 25,103 -1,914 -7% 27,017

CRHT Face to Face Contacts - Below 18 Total 100 123 242 153 171 130 137 145 158 127 1,386 367 36% 1,019

CRHT Face to Face Contacts - 18 to 65 Total 3,355 3,667 4,042 3,766 3,921 3,874 3,657 3,716 3,684 3,295 33,622 -108 0% 33,730

CRHT Face to Face Contacts - Over 65 Total 37 65 74 43 73 39 9 19 33 14 369 -11 -3% 380

CRHT Telephone Contacts - Below 18 Total 18 66 128 96 69 80 96 101 98 92 826 646 359% 180

CRHT Telephone Contacts - 18 to 65 Total 969 2,130 2,487 2,148 2,404 2,508 2,518 2,560 2,417 2,284 21,456 11,710 120% 9,746

CRHT Telephone Contacts - Over 65 Total 22 37 106 47 40 41 40 35 20 31 397 180 83% 217

Criminal Justice Liaison - Contacts Total 278 571 665 585 580 649 576 631 482 481 5,220 2,423 87% 2,797

Eating Disorder Service - Contacts Total 623 1,049 1,286 1,328 1,578 1,492 1,422 1,659 1,667 1,114 12,595 6,334 101% 6,261

Hospital Liaison Contacts Total 508 618 745 658 565 708 645 693 531 479 5,642 536 10% 5,106

MAS Teams - Contacts Total 5,359 5,925 6,590 6,165 5,502 5,828 5,873 6,323 6,358 5,015 53,579 2,837 6% 50,742

RITT Contacts Total 3,049 1,921 2,265 2,270 2,571 2,742 2,640 2,530 2,472 2,257 21,668 4,867 29% 16,801

Mental Health Productivity Total 25,316 27,315 31,435 30,094 29,854 30,284 29,531 31,017 30,302 25,069 264,901 27,106 11% 237,795


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

95

Mental Health - Total Contacts Activity split by Locality17-18 Monthly


YTD 17-18

Variance

YTD 17-18

Variance (%)

Planned YTD

17-18

Pennine Locality 7,710 8,938 10,300 9,842 9,799 9,600 9,199 10,005 9,750 7,916 85,349 8,407 10.9% 76,942

North Lancs Locality 8,882 9,722 10,723 10,605 10,473 10,730 10,505 10,778 10,337 8,608 92,481 4,606 5.2% 87,875

Central Locality 7,347 8,655 10,412 9,647 9,582 9,954 9,827 10,234 10,215 8,545 87,071 14,093 19.3% 72,978

Grand Total 23,939 27,315 31,435 30,094 29,854 30,284 29,531 31,017 30,302 25,069 264,901 27,106 11.4% 237,795

Mental Health - Total Contacts Activity split by CCG17-18 Monthly


YTD 17-18

Variance

YTD 17-18

Variance (%)

Planned YTD

17-18

NHS BLACKBURN WITH DARWEN CCG 2,451 3,010 3,370 3,176 3,061 3,036 2,962 3,262 3,059 2,499 27,435 2,955 12.1% 24,480

NHS BLACKPOOL CCG 3,368 3,268 3,761 3,421 3,532 3,647 3,689 3,935 3,591 3,012 31,856 -1,463 -4.4% 33,319

NHS CHORLEY AND SOUTH RIBBLE CCG 2,488 3,115 3,489 3,177 2,974 3,132 3,196 3,344 3,241 2,624 28,292 3,596 14.6% 24,696

NHS EAST LANCASHIRE CCG 5,259 5,928 6,930 6,666 6,738 6,564 6,237 6,743 6,691 5,417 57,914 5,452 10.4% 52,462

NHS FYLDE & WYRE CCG 2,867 3,182 3,428 3,553 3,223 3,392 3,122 3,102 3,050 2,507 28,559 366 1.3% 28,193

NHS GREATER PRESTON CCG 3,074 3,741 4,689 4,512 4,192 4,193 4,315 4,671 4,553 3,949 38,815 8,236 26.9% 30,579

NHS MORECAMBE BAY CCG 2,647 3,272 3,534 3,631 3,718 3,691 3,694 3,741 3,696 3,089 32,066 5,703 21.6% 26,363

NHS WEST LANCASHIRE CCG 1,785 1,799 2,234 1,958 2,416 2,629 2,316 2,219 2,421 1,972 19,964 2,261 12.8% 17,703

Grand Total 23,939 27,315 31,435 30,094 29,854 30,284 29,531 31,017 30,302 25,069 264,901 27,106 11.4% 237,795

2017-18 Baseline Proposal

LCFT are now providing variances against monthly plans at CCG level and where services are reporting under-performance of -10% or more LCFT will

produce exception narrative. Narrative will also be produced for the top 4 over-performing services based on activity numbers.

LCFT have 21 service lines at CCG level that are currently under-performing by -10% or more.

As mentioned in last month’s summary, the Audit of Patient ‘Notes’ identified in some instances the Patient Note does constitute a relevant contact, but in

most cases it does not. The 4 services involved are MAS, Eating Disorders, Hospital Liaison and ADHD, and in all there have been 23,025 over reported

Non-Patient contacts for the period of Apr-17 to Oct-17.

LCFT have also identified that for the above 4 Services and the RITT Service, 4,606 Non-Patient contacts have been reported in error as Face to Face

Contacts, making a total of 27,631 over reported Patient Contacts.

In both cases above, this is a historic issue going back to 2012 and Non-Patient contacts have been a component of baselines for some time. Therefore,

changes of activity over recent years are unrelated to this issue. Commissioners have agreed with LCFT that due to numbers being inflated historically

as a result of the above, the baselines remain accurate and therefore have been agreed. At year end necessary adjustments will be made to remove

‘patient notes from both the Baselines and the reported activity.


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

as at w/c 25th December 2017

96

• Revised planned attendances full year are 27,344. Actual attendances during December 2017 was 1209 – 1039 below

the planned total of 2248

• Initial income for the 17/18 monitoring year shows a provisional increase in M8 and 9, with the total income as at end of

December 2017 at £1,141,642.

(* estimates)


97

3.3 CQUIN Executive Summary

CQUIN Executive Summary: Quarter 2 submissions for 2017/18 schemes have taken place for the Mental Health & Community contracts. The staff flu scheme is currently

behind plan but it expected to meet the 70% target by the end of February 18. Discussions are ongoing with acute trusts regarding the A&E

scheme, however we are working towards the targets for the scheme with Commissioner support. Some further work needs to be done regarding

the Physical Health schemes to achieve the required increase in targets for future quarters. The audit has been completed for Collaboration with

Primary care and initial results are currently being analysed.

The Trust has not been successful in achieving the required targets for the Preventing Illness through Risky Behaviours scheme. The total loss

across the schemes for Q2 was £56k relating to Mental Health and £10k for Longridge. Work has focused on referrals to the Stop Smoking

services and training of staff, however it is anticipated that there will be a loss of £18k in Q3 despite the improvements, so further work is required in

Q4 to achieve full payment. There is concern over the full achievement of the Physical Health for people with severe Mental Illness, collaborating

with Primary Care clinicians scheme that could lead to a potential loss of £13k in Q4. Discussions are ongoing with Community Commissioners

regarding the baseline data to be used for the discharge planning scheme. There is a potential to lose 50% funding in Q4 relating to this scheme.

Q2 schemes for Southport & Formby contract have been submitted in line with the agreed milestones. Further discussions to take place with

Commissioners around future quarter submissions.

£1,033k CQUIN funding across CCG contracts is agreed, based on the Trust meeting its control total in 2016/17. NHSE have now instructed CCGs

to make payment to LCFT for this funding. A further £1,033k CQUIN funding across CCG contracts is agreed based on the Trust's engagement and

commitment to the STP process. Confirmation has been received via BWD CCG that this element of funding has been agreed by the STP.

The Trust is awaiting feedback from NHS England regarding the Cumbria Liaison & Diversion scheme submission but are not expecting any issues.

There are not expected to be any issues with the submission for the Specialist Services schemes for Q3.

Measures are expected to be put into place to ensure that the Trust achieves the remaining CQUIN

funding available and no further losses are seen than those identified in Q2.

Executive Summary

Contract Actual

Loss/

concern Expected

Loss/

concern Expected

Loss/

concern Expected

Loss/

concern % Met Expected

Loss/

concern

Mental Health 100% £652,503 £0 90% £502,074 £56,210 100% £496,721 £18,737 99% £1,829,815 £12,848 98% £3,481,113 £87,795

Southport 100% £45,584 £0 100% £48,657 £0 100% £33,294 £0 100% £128,513 £0 100% £256,048 £0

Community 100% £238,378 £0 96% £244,404 £10,042 100% £174,107 £0 86% £575,640 £96,406 92% £1,232,529 £106,449

NHS England - Spec Comm MH 100% £193,941 £0 100% £193,941 £0 100% £193,941 £0 100% £193,941 £0 100% £775,762 £0

NHS England - Liaison & Diversion 100% £5,201 £0 100% £5,201 £0 100% £5,201 £0 100% £5,201 £0 100% £20,803 £0

NHS England - Imm & Vacc 100% £3,675 £0 100% £3,675 £0 100% £7,350 £0

Dec 2017 CQUIN Position

Expected

PositionTotal

Expected

Position100%

Qtr. 2Qtr. 1

£1,139,282 94% £997,951 £66,253

Qtr. 3

£0

Expecte

d

Position

£903,263 £18,737100%

Qtr. 4

100%

Expecte

d

Position

Full Year

97%£2,733,109 £109,254 £5,773,604 £194,244


Quality

Section 4

98


99

Section 4:- Quality

• Quality and Safety Tile

• Quality Surveillance – Safe

• Quality Surveillance – Effective

• Quality Surveillance – Caring

• Quality Surveillance – Responsive

• Quality Surveillance – Well Led

• Audits

• Delivering the Strategy

4. Quality


4. Quality Quality & Safety Tile

100

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

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

19780 96.08%

90 9016

39

1

5 1585

4101 309

15 53%

2403

2281

90.74%

95% 42.14%

83% 13

QUALITY AND SAFETY TILE

CARING

Compliments

F&F Test

RIDDOR incidents

Incidents

STEIS-reportable serious

incidents

EFFECTIVE

Never Events

Number of red flag incidents

(inpatients only)

Core Skills (%)

SAFE

Physical violence to staff from

patients

Serious HCAI incidents

Use of restraint

Potentially avoidable grade 3 and

4 pressure ulcers

Physical Health HFC Rate (%) Appraisals (%)

Mental Health HFC Rate (%) Concerns raised

Good

Completed within agreed

timeframe (%)

RESPONSIVE

Complaints

Upheld/partially upheld

complaints

WELL LED

Trust CQC rating


4. Quality Safe

101


total

12 months


Incidents n/a 1867 2095 2342 2362 2175 2097 2357 2285 2200 19780 2197.8

Incidents with harm n/a 404 436 486 549 439 474 542 470 450 4250 472.2


incidentsn/a 7 9 4 9 8 10 4 13 8 9 7 2 90 7.5

RIDDOR incidents n/a 2 0 3 4 5 2 6 1 6 5 2 3 39 3.3

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

Medication incidents n/a 127 149 176 151 148 183 186 159 157 1436 159.6

Infection control Serious HCAI incidents 0 1 0 1 1 0 1 0 0 1 0 0 0 5 0.4

Use of restraint n/a 189 263 308 329 301 400 462 335 344 401 361 408 4101 341.8

Use of seclusion n/a 85 65 73 68 66 64 67 93 67 648 72.0

Safeguarding alerts n/a 100 158 138 129 131 96 156 117 96 1121 124.6

Potentially avoidable grade 3

and 4 pressure ulcersn/a 0 2 0 2 0 5 1 2 0 1 2 0 15 1.3

Number of instances of 1 or less

qualified on duty (inpatients)0 192 170 145 139 197 140 132 177 132 84 74 1582 143.8

Number of red flag incidents

(inpatients only)n/a 260 268 221 195 270 227 228 258 228 137 111 2403 218.5

Staff safetyPhysical violence to staff from

patients n/a 140 129 151 155 150 218 268 220 221 218 226 185 2281 190.1

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

QUALITY AND SAFETY SURVEILLANCE - Safe

Incidents

Patient safety

Staffing


4. Quality Effective

102

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

Pressure ulcers (%) - 2.72% 2.91% 5.27% 3.45% 3.45% 4.04% 3.05% 3.12% 2.55% 2.72% 2.57% 3.22%

Falls with harm (%) - 1.28% 1.64% 1.55% 1.55% 0.60% 0.75% 1.21% 0.64% 0.93% 0.53% 0.53% 1.00%

Catheter and UTI (%) - 0.64% 0.27% 0.26% 0.43% 0.45% 0.27% 0.21% 0.07% 0.23% 0.15% 0.08% 0.57%

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

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

Self harm (%) - 4.04% 3.55% 3.43% 3.56% 3.76% 3.75% 4.37% 4.63% 3.71% 3.59% 4.22% 4.48%

Victim of violence (%) - 1.62% 2.71% 1.07% 2.30% 1.46% 2.50% 1.66% 1.89% 1.75% 3.17% 2.53% 3.20%

Feel unsafe (%) - 6.26% 8.35% 9.01% 9.62% 10.65% 7.08% 7.90% 10.53% 8.08% 11.21% 7.81% 8.96%

Omission of medication (%) - 13.74% 16.08% 17.17% 17.99% 18.37% 23.54% 20.37% 19.79% 20.09% 24.10% 19.62% 21.54%

Restraint (%) - 4.65% 4.80% 3.65% 5.23% 5.43% 7.08% 6.86% 7.16% 5.68% 4.86% 5.91% 5.33%

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

QUALITY AND SAFETY SURVEILLANCE - Effective12 months

average

3.3%

1.0%

0.3%

82.9%

Physical Health

Harm Free Care

Mental Health

Harm Free Care

0.4%

19.4%

5.6%

95.2%

3.9%

2.2%

8.8%


4. Quality Effective

103

* N/L/R - National Audit, Local Audit, Re-Audit (if re-audit, the previous compliance figure will be included).

N/L/R*

L

L

R

R

R

L

L

L

L

R

L

L

L

L

R

R

R

L

R

L

R

R

Safeguarding Supervision 87%

90%

Rehabilitation Accomodation 84%

Pressure Ulcers Southport & Formby 54%

Clinical Audits Date

Prevention of Dehydration 54% Sep-17

Compliance (%)

Nursing Management of Clozaril 60% Oct-17

Absent Without Leave 55% Oct-17

Carers 54% Oct-17

Diabetes 65% Sep-17

Risk Assessments

Cerebral Palsy in under 25's (NICE) 82%

83%

Nutrition 77%

Consent to Treatment 94%

Completion of Waterlow risk assessments

Wound assessment documentation

Care of Dying

Clozapine

Antibiotics in dentistry

80%

94%

85%

70%

Education, Health and Care Plans 89% Nov-17

Use of restrictive practices within LD 93%

Acupuncture - Rheumatology & Physiotherapy 97%

79%

85%Learning Disability

Section 132

Compliance Date

TBC - Baeline

assessment

NetworkNICE Baseline Assessments

NG76 Child Abuse & Neglect Safeguarding


4. Quality Caring & Responsive

104


total

12 months


F&F Test 95% 96% 96% 96% 96% 97% 95% 97% 97% 97% 95% 96% 96.08%

F&F Test - Response Rate n/a 1659 2042 1562 1263 1815 1218 1241 1652 923 1669 2736 1616.4

Compliments Compliments n/a 678 1031 788 593 988 697 777 851 606 614 921 472 9016 751.3

QUALITY AND SAFETY SURVEILLANCE - Caring

Friends & Family -

Patients

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


total

12 months


Complaints n/a 114 111 167 95 109 152 133 172 147 147 136 102 1585 132.1


complaintsn/a 22 21 31 26 23 19 24 22 21 51 28 21 309 25.8


timeframe (%)n/a 54.0% 50.0% 54.0% 158.0% 52.7%

Reopened complaints n/a 3 4 2 4 4 7 5 1 2 3 4 1 40 3.3

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

MP enquiries n/a 13 9 15 7 8 5 9 11 5 12 8 13 115 9.6

Environment Mixed Sex Breaches 0 0 0 0 0 0 0 0 1 0 0 0 0 1 0.1

QUALITY AND SAFETY SURVEILLANCE - Responsive

Complaints


4. Quality Well Led

105


total

12 months


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

Regulatory inspections/visits n/a 4 5 4 3 4 3 2 1 2 1 4 0 33 2.75

CQC notifications n/a 2 2 2

Core Skills (%) 85% 89.07% 89.41% 90.68% 90.33% 89.26% 91.06% 91.55% 90.81% 90.87% 91.64% 92.12% 92.07% - 90.74%

Supervision (%) n/a

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



Overdue incident actions 0 94 150 142 - 128.67

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

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

Concerns raised n/a 9 17 13 39 13

Quality Plan priorities off track 0 0 0 0 0 5 6 - 2

Quality assurance visits n/a 1 0 0 0 2 1 4 8 1.14

Assurance

QUALITY AND SAFETY SURVEILLANCE - Well Led

Regulatory

People

Good

Learning and

candour


106

4. Quality Audits 2017/18

National Audit Data collection period Report due Compliance

National Audit of Intermediate Care

(NAIC)

May 2017 to August 2017

Participants will be asked for outturn data

April 2018

National chronic Obstructive

Pulmonary Disease (COPD) audit

programme

April 2017 to July 2017 February 2018

National Diabetes Audit – Adults April 2017 to July 2017 February 2018

Sentinel Stroke National Audit

programme (SSNAP)

April 2017 to March 2018

Collection: April to July, August to November, December to

March, April to March (annual)

January 2018

UK Parkinson’s Audit: (incorporating

Occupational Therapy

Speech and Language Therapy,

Physiotherapy

Elderly care and neurology)

1 May 2017 to 30 September 2017

May 2018

National Audit of Psychosis Autumn/Winter 2017 TBC

National Audit of Anxiety & Depression TBC TBC

Topic 17: Use of depot/LA

antipsychotics for relapse prevention

– baseline audit

May 2017 to June 2017

Sampling & Data Collection: May 2017

Online Data Submission: June 2017

Nov 2017

Topic 15: Prescribing for bipolar

disorder (use of sodium valproate) –

re-audit

September 2017 to October 2017

Sampling & Data Collection: Sept 2017

Online Data Submission: October 2017

Feb 2017

Topic 6: Assessment of side effects of

depot antipsychotic medication – 2nd

supplementary

February 2018 to March 2018

Sampling & Data Collection: February 2018

Online Data Submission: March 2018

July 2018


107

4. Quality Delivering the Strategy

Exec SRO Sue Moore

Programme SRO Joanne Moore

Programme Manager Carly SteerReporting Period November 2017 (Month 8)

Report date 13-Nov-17

The purpose of Delivering the Strategy (DTS) is to deliver the Trust's transformation programme and the operational annual plan. The focus is on

tranformational schemes that are aligned to the STP and LDPs and on continuous improvement of quality within our services. There are 6 DTS

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

Programme Description

DTS Programme Report

Overview

Across each network portfolio, for all schemes that have been initiated, work is ongoing to develop detailed delivery plans where this is not already in

place status summarised for each scheme in Programme assurance heat maps.

Further work required to establish benefit trackers for each programme, to enable leads to measure performance and provide robust assurance on

delivery. Work is now underway in preparation for 18/19 Programmes, with plans in place to ensure all dcumentation is inplace for current and new

projects to ensure we can provide robust assurance on delivery from the 1st April.

CYE FYE

£000's £000's

CIP Target 15,100 15,100

Actual to be delivered 13,871 12,653

Variance: -1,229 -2,447

Schemes at Feasibility/Pipeline:

Red 431 -

Amber 369 -

Green 378 -

Total pipeline 1,178 -

Net Delivery risk total value: -50

NB: Non Recurrent Schemes 1,374

CIP - Peformance YTD & Forecast 2017/18


108


Programme SRO Target (£000)Plan (£000)

YTD

Actual

(£000) YTD

Varianc

e YTD

Pipeline/

Feasibility

(£000) Total

Pipeline/

Feasibility

(£000)

Pipeline/

Feasibility

(£000) Total

Pipeline/

Feasibility

(£000) Total

Overall

CIP

Variance

Narrative

Community Wellbeing Tanya Hibbert 2,265,460 1,175,875 1,090,230 85,645 1,032,237 329,954 270,889 431,394 142,993

£1.75m of schemes is registered as approved with a YTD slippage of £85k

against continence and dental schemes, with current YTD performance at

£1.09m . Value of schemes at feasibility/pipeline are £1.03m, leaving an

overall gap of £143k. However, of the pipeline schemes £702k worth of

schemes are rated amber or red so there is significant risk to delivery.

Mental Health Lisa Moorhouse 7,895,770 5,842,431 5,892,431 -50,000 48,000 48,000 0 0 #######

£5.8m of schemes are registered as approved with an overacheivement

against approved schemes of £50k , with current YTD performance at

£5.89m. Of the schemes at approved further work is ongoing to finalise

recurrent savings as part of the admin review . Value of schemes at

feasibility/pipeline are £48k, leaving an overall gap of £1.9m.

Children & Young People Steve Tingle 2,142,770 2,071,859 2,071,859 0 71,250 0 71,250 0 -339

£2.07m of schemes are registered on the system as approved, which is

currently on track to deliver with no slippage in year.Value of schemes at

feasibility/pipeline are £71,250k, which if achieved would exceed target in

year by £339k . Further work ongoing to finalise schemes at but are

considered low risk of failure.

Organisational reset Joanne Moore 0 0 0 0 0 0 0 0 0Savings delivered through this programme will be reported through the

relevant Network or Corporate services. Phase 2 is in development.

Mobilisation & Demobilisation Louise Giles 0 0 0 0 0 0 0 0 0Savings delivered through this programme will be reported through the

relevant Network or Corporate services.

Support ServicesDominic

McKenna2,801,600 5,163,597 4,816,597 347,000 27,000 0 27,000 0 #######

Schemes to the value of £5.16m are registered at approved with a YTD

slippage of £347k. There remains a risk to achievement of the full Trinity

programme for 17/18 with slippage in this area at £347,000 and in total with

current YTD performance at £4.8m Value of schemes at feasibility/pipeline

are £27k, which if delivered, would give an over-acheivement of £2m which

is offsetting gaps elsewhere.

Total 15,105,600 14,253,761 13,871,116 382,645 1,178,487 377,954 369,139 431,394 55,997

Pipeline/Feasibility Risk RAG RatingForecast



109

Not currently assessed

Project Element not in place

Project Element in place but requires update or further

work

Project Element in place and fit for purpose

Project Element not required

Project Element not in place

Key

PROGRAMME RESOURCE

PMO Lead assigned Dawn Killey Dawn Killey Dawn Killey Dawn Killey Dawn Killey Dawn Killey Dawn Killey Dawn Killey

Transformation Lead

assignedSarah Neve Helena Owen Sarah Neve Sarah Neve

Natalie Hilton/Fran

RileySarah Neve Sarah Neve Sarah Neve

Clinical Lead assigned Lorraine Chadwick Lorraine ChadwickLorraine Chadwick/Claire

BensonGuz Singh Jeremy Tudway TBC

Lorraine

Chadwick

Lorraine

Chadwick

Full resource plan agreed n/a currently

PROGRAMME

DOCUMENTATION

Programme initiation

documentIn Progress

n/a

Currently

Programme Governance

Regular meetings n/a Currently

Benefit tracker Started to map benefits In development

On cost

Project Lead assignedLorraine McDonald-

JohnsonBev Liddle Joe Crocock Phil Horner Pauline Cullen

Crisis House eastASSURANCE CRITERIONMental Health

Access Line

Inpatient Reconfiguration

programme

Mental Health DTS Portfolio

MHDUCore Home

Treatment 24/7 Core 24

Phil Horner Bev Liddle

Richard Morgan

Update In

progress

Programme Plan

Quality Impact Assessment

S136 Primary Care

Model

Dawn Killey

Sarah Neve

Phil Horner

Transforming Secure

Services

In Progress

Joe Crocock

On time

TOR

Risks and Issues log



110

ASSURANCE CRITERION LD IAPT CPSR South Ribble Central BwD Dental CPOC

ASSURANCE CRITERION LD IAPT CPSR South Ribble Central BwD Dental CPOC

PROGRAMME RESOURCE

Programme Lead assigned Stuart Sheridan Deborah Bretherton Julie Nowell Julie Nowell Tanya Hibbert Tanya Hibbert Andy Jones

Transformation Lead

assignedDeborah Howe

Clinical Lead assigned Mahesh Odiyoor Janine Williams Tracy Cook- Scowen Tracy Cook- Scowen Sarah Procter

Full resource plan agree

PROGRAMME

DOCUMENTATIONProgramme initiation

document

Quality Impact Assessment

Programme PlanTo be updated in line

with new governance

structure

High-level – plan in

place further detail

required.

Risks and Issues log

Programme Governance

TOR

Regular meetings Fortnightly

Benefits Tracker

PROJECT PERFORMANCE

On time

On cost

MCP

Community and Wellbeing DTS Portfolio

Mark Wardman

MCP Prime Provider



111

ASSURANCE CRITERIONComplex Packages of Care

(CPOC)

CAMHS Tier 4

Transformation

0-25 Clinical Pathway

including integration of

Child psychology and

PROGRAMME RESOURCE

Project Manager assigned Janet Thorpe Janet Thorpe Janet Thorpe

Transformation Lead

assignedTBC Nicola Adams Nicola Adams

Project Lead assigned Laura Gee Paul AndertonSarah Wright/Anita

Demaria

Clinical Lead assigned Lorna Taylor Debbie Yoxall Julie Ross

Full resource plan agreed

PROGRAMME

DOCUMENTATION

Programme initiation

document

Updated December

17

Agreed on 12th

December

QNIC Review

undertaken

Programme Plan Inplace for phase 1

Risks and Issues log In place

Programme Governance In place In place

TOR In place In place

Regular meetings

PROJECT PERFORMANCE

On time

On cost

Benefits tracker in place

Quality Impact AssessmentReviewed on 29th

December

Children & Young People's Wellbeing DTS Portfolio


Workforce

Section 5

112


5. Workforce

113

Section 5:-

• Actual Workforce Costs Compared to Budget

• Sickness Absence Rates

• Appraisals and Mandatory Training Compliance

• Vacancy Management and Active Recruitment

• Core Workforce Headcount

• Workforce Turnover


114

Actual Workforce Costs Compared to Budget - Quarterly Trend

Peripheral Workforce Spend and Usage

5. Workforce Actual Workforce Costs Compared to Budget

Spend £ % Spend £ % Spend £ %

T rust 18,947,950 1,794,994 8.3% 425,287 2.0% 383,517 1.8% 2,603,799 21,551,749 12.08%

M ental Health 8,579,817 1,428,084 13.6% 264,288 2.5% 229,068 2.2% 1,921,439 10,501,256 18.30%

Community &

Wellbeing4,310,327 189,450 4.0% 160,988 3.4% 71,514 1.5% 421,952 4,732,279 8.92%

Children & Young

People3,217,931 102,522 3.0% 21,961 0.6% 120,962 3.5% 245,445 3,463,376 7.09%

Corporate 2,839,875 74,939 2.6% -21,949 -0.8% -38,026 -1.3% 14,963 2,854,839 0.52%

Flexible

Labour

Reliance %Business Area

Core

Workforce

Spend £

Bank Agency M edical AgencyTotal Spend

£

2017 12

Total

Peripheral

Workforce

Spend £


5. Workforce Sickness Absence Rates

115

Trust 12 Month, Year on Year Trend

Sickness Absence Breakdown

Rate Rate Rate Trend

2017 10 2017 11 2017 12

% Long

Term

Absence

% Short

Term

Absence

12mths

Trust 6.88% 6.84% 7.32% 49.32% 50.68%

Mental Health 8.52% 8.22% 8.75% 52.08% 47.92%

Community & Wellbeing 6.25% 6.58% 7.72% 42.54% 57.46%

Children & Young People 5.53% 5.48% 5.86% 53.14% 46.86%

Support Services 3.75% 3.94% 2.89% 44.75% 55.25%

2017 12


5. Workforce Appraisals and Mandatory Training Compliance

116

E&D

3yr

Fire

Saf

ety

1yr

Hea

lth &

Saf

ety

3yr

Info

rmat

ion

Gov

erna

nce

1yr

Infe

ctio

n Co

ntro

l

Clin

ical

1yr

Basi

c Li

fe S

uppo

rt

1yr

Imm

edia

te L

ife

Supp

ort 1

yr

Conf

lict R

esol

utio

n

3yr

Safe

guar

ding

Child

ren

L2 3

yr

Safe

guar

ding

Child

ren

L3 3

yr

Men

tal C

apac

ity

Act

L1

3yr

Man

ual H

andl

ing

L2 3

yr

Man

ual H

andl

ing

L3 2

yr

Infe

ctio

n Co

ntro

l

L1 2

yr

Safe

guar

ding

Child

ren

L1 3

yr

Safe

guar

ding

Adu

lts L

1

(+PR

EVEN

T) 3

yr

Men

tal C

apac

ity

Act

L1

(One

Tim

e

Com

plet

ion)

Man

ual H

andl

ing

L1 3

yr Appraisal

Compliance

Trust 98% 92% 97% 94% 90% 81% 77% 89% 93% 86% 90% 86% 85% 95% 96% 96% 90% 96% 92% 49%

MHN 99% 93% 98% 93% 91% 77% 76% 89% 93% 80% 91% 80% 81% 97% 99% 96% 94% 98% 91% 32%

C&W 98% 90% 96% 94% 90% 79% 88% 89% 94% 79% 89% 92% 86% 94% 95% 96% 89% 95% 92% 65%

C&YP 97% 91% 96% 94% 88% 91% 85% 89% 0% 94% 90% 90% 89% 95% 93% 94% 90% 94% 93% 62%

SS 98% 93% 97% 95% 97% 86% 67% 93% 97% 100% 93% 89% 0% 95% 95% 95% 89% 97% 95% 57%

All Staff Medical, Clinical & Clinical Support Staff Admin, Clerical & Estates

Total

Vacancy Management and Active Recruitment

Budgeted

Establ ishment (BE)

(FTE)

Actual

Establ ishment (FTE)

Budgeted

Establ ishment

Vacancies

(FTE)

BE Vacancy

Rate

Active Vacancy

Rate

Active Vacancy

FTENo. Pos i tions

Avg. No Days

to Recruit

Trust 6522.00 5675.89 846.11 12.97% 62.65% 530.05 772 38.86

Mental Health 2972.52 2596.85 375.67 12.64% 57.99% 217.86 346 52.30

Community & Wel lbeing 1627.13 1449.51 177.62 10.92% 91.84% 163.12 232 34.75

Chi ldren & Young People 1094.92 980.29 114.63 10.47% 63.45% 72.73 94 32.85

Support Services 827.43 649.24 178.19 21.54% 42.84% 76.34 100 35.55

2017 12

Establ ishment Vacancies Vacancies in Active Recruitment


5. Workforce Core Workforce Headcount

117

Core Workforce

Network Headcount FTE Headcount FTE

Trust 6348 5621.29 6304 5585.95

Mental Health 2777 2567.93 2768 2558.78

Community & Wellbeing 1734 1435.76 1712 1418.15

Children & Young People 1143 979.28 1125 966.09

Support Services 694 638.33 699 642.93

2017 11 2017 12


5. Workforce Workforce Turnover

118


119

6. Risks Board Assurance Framework 17/18 Quarter 2

BOARD ASSURANCE FRAMEWORK DASHBOARD 2017/18 – Q2

Strategic

Priority BAF Risk Sub-committee Director Lead

Risk

Score

01.04.17

Risk

Score

Q1

Risk

Score

Q2

Risk

Score

Q3

Risk

Score

Q4

2017/18

Risk

Target

2017/18

Risk

Target Gap

Final

Risk

Target

Final Risk

Target

Gap

SP

1

Qu

ality

1.1 If we do not meet regulatory

standards for quality and safety we will

not be fit for purpose as care provider.

Quality & Safety DoNQ 12

High

12

High

16

Significant

8

High

8

Close Monitoring

4

Moderate

12

Significant

1.2 If we do not create a culture of

learning then we will be unable to

provide high quality care.


Significant

16

Significant 16 Significant

12

High

4

Tolerable

4

Moderate

12

Significant

1.3 If we do not provide integrated

physical and mental health services we

will lose opportunities to improve patient

outcomes.

Quality & Safety MD 16

Significant

16

Significant

16

Significant

12

High

4

Tolerable

4

Moderate

12

Significant

SP

2

Su

sta

inab

le

Serv

ices

2.1 If we do not work collaboratively with

partners we will not be able to influence

system wide transformation.

Business Dev &

Delivery COO

12

High

12

High

12

High

8

High

4

Tolerable

4

Moderate

8

Close Monitoring

2.2 If we do not deliver new models of

care we will cease to be a creditable

lead provider.

Business Dev &

Delivery COO

12

High

12

High

12

High

8

High

4

Tolerable

4

Moderate

8

Close Monitoring

SP

3 E

xcell

en

ce

3.1 If we do not engage with our

patients and service users we cannot

achieve excellence and quality.


High

12

High

12

High

8

High

4

Tolerable

4

Moderate

8

Close Monitoring

3.2 If we fail to project our achievements

then our reputation will not improve.

Business Dev &

Delivery COO

16

Significant

16

Significant

16

Significant

12

High

4

Tolerable

4

Moderate

12

Significant

SP

4

Peo

ple

4.1. If we do not support the health and

wellbeing of staff we will struggle to

attract, recruit and retain our workforce.

People HRD 20

Significant

20

Significant

20

Significant

10

High

10

Concern

5

Moderate

15

Significant

4.2 If staff are not provided with

extensive education, training and

leadership development we will not

have an organisational culture that

supports high performance.

People HRD 9

High

9

High

12

High

6

Moderate

6

Close Monitoring

3

Low

9

Close Monitoring

SP

5

Mo

ney

5.1 If we do not meet financial

objectives we will not be able to provide

sustainable services.

Finance CFO 15

Significant

20

Significant

20

Significant

10

High

10

Concern

10

High

10

Concern

5.2 If we do not work with partners to

deliver system wide efficiencies this will

undermine our own financial position

and that of the STP.

Finance CFO 15

Significant

15


10

High

5

Tolerable

5

Moderate

10

Concern

SP

6

Inn

ovati

on

6.1 If we do not develop and maintain

infrastructure, we will not be able to

deliver safe, responsive and efficient

care.

Infrastructure CFO 16

Significant

12

High

12

High

8

High

4

Tolerable

4

Moderate

8

Close Monitoring

6.2 If we do not exploit the full

capabilities of the new EPR system and

wider technology to redesign services

we will miss important opportunities to

improve care.

Infrastructure CFO 16

Significant

16


8

High

8

Close Monitoring

4

Moderate

12

Significant


Southport & Formby

Appendix 1

120


1. Performance Activity Southport & Formby – Summary

121

Southport & Formby - Summary:

All of the teams have had their initial visit from Performance completed, except for the Stoma team whom has only one WTE in the team

out of a total of only 2 WTE staff members; therefore they cannot commit any further resource to the deep dive.

Due to unforeseen circumstances, refresh training which was supporting the deep dive has not taken place which has had an impact on

the audits for Continence and Treatment Rooms. We are hopeful that ongoing validation will continue in late January.

The Performance team has been actively engaging with specific teams to help them to undertake a full review of their caseloads. The aim

of which is to remove patients who are not actively engaging with the service and to give a better reflection of caseload sizes and therefore

understand their capacity within the team and demand on the service. The Performance team are currently looking into Podiatry but due

to the high volume of referrals received in this service, this is an extensive piece of work so may take a few months to complete.

Analysis of all team’s activity, waiting times and any ongoing data quality issues continues to be carried out by the Performance team.

Activity data for all service lines is now produced and submitted to the CCG, however validation of this data continues as there are

continuing data quality issues within certain service lines but with the continued support from Performance and the EMIS team, the data is

improving in accuracy. We have seen a dip in activity in M9, although this is in line with seasonal variation which is expected at this time of

year with less working days, more annual leave and sickness, and fewer referrals overall in clinic based services.

RTT validation has commenced with specific service lines including Falls service, so we should start to see some RTT figures being

reported in the next couple of months.

Patient level data is still to be received from St Helens and Knowsley FTs Pathology Department to enable Performance to validate the

Phlebotomy activity.


1. Performance Activity Southport & Formby – Summary

122


Service CCG May-17 Jun-17 Jul-17 Aug-17 Sep-17 Oct-17 Nov-17 Dec-17 Total

Adult Therapies - MS NHS Southport and Formby CCG 1 1 1 2 1 0 0 0 6

Adult Therapies - Neurology NHS Southport and Formby CCG 51 40 39 48 62 45 48 45 378

Adult Therapies - Non Neuro NHS Southport and Formby CCG 154 162 140 163 169 148 142 102 1180

Adult Therapies - SALT NHS Southport and Formby CCG 3 5 3 9 7 9 11 10 57

Adult Therapies - Vestibular NHS Southport and Formby CCG 11 10 6 12 4 12 13 9 77

CERT NHS Southport and Formby CCG 103 119 85 105 98 137 139 141 927

Chronic Care Coordinators NHS Southport and Formby CCG 155 117 141 134 127 119 122 105 1020

Community Matrons NHS Southport and Formby CCG 35 47 49 35 40 52 48 30 336

NHS South Sefton CCG 62 84 77 92 98 118 86 82 699

NHS Southport and Formby CCG 68 93 90 150 104 99 110 76 790

Diabetes NHS Southport and Formby CCG 81 97 97 73 90 97 113 70 718

Dietetics NHS Southport and Formby CCG 251 215 208 208 194 207 216 152 1651

District Nurses NHS Southport and Formby CCG 543 683 632 669 770 775 691 590 5353

District Nurses OOH NHS Southport and Formby CCG 183 170 207 182 195 231 211 187 1566

Falls Service NHS Southport and Formby CCG 81 88 60 72 65 60 61 52 539

Leg Ulcer NHS Southport and Formby CCG 6 13 3 6 10 8 2 6 54

Pain Management NHS Southport and Formby CCG 29 71 46 33 70 23 67 69 408

Phlebotomy NHS Southport and Formby CCG 1738 2216 2234 2261 2091 2315 2301 1430 16586

Podiatry NHS Southport and Formby CCG 368 391 316 366 291 353 315 250 2650

Psychology NHS Southport and Formby CCG 18 14 20 26 20 21 26 13 158

Stoma NHS Southport and Formby CCG 19 24 70 28 13 25 25 18 222

Treatment Rooms NHS Southport and Formby CCG 843 1036 1020 1006 937 1100 973 732 7647

Grand Total 3960 4660 4524 4674 4519 4854 4747 3437 35375

Continence

1. Performance Activity Southport & Formby – Referrals Summary

123

Unvalidated Figures

Validated Figures


Service CCG May-17 Jun-17 Jul-17 Aug-17 Sep-17 Oct-17 Nov-17 Dec-17 Total

Adult Therapies - MS NHS Southport and Formby CCG 6 5 4 5 8 6 5 2 41

Adult Therapies - Neurology NHS Southport and Formby CCG 309 248 280 293 324 301 350 240 2345

Adult Therapies - Non Neuro NHS Southport and Formby CCG 384 424 397 421 480 573 622 402 3703

Adult Therapies - SALT NHS Southport and Formby CCG 13 9 7 12 24 22 27 25 139

Adult Therapies - Vestibular NHS Southport and Formby CCG 29 40 39 40 33 50 43 21 295

CERT NHS Southport and Formby CCG 2146 2528 2567 2495 2393 3154 2914 3112 21309

Chronic Care Coordinators NHS Southport and Formby CCG 478 445 409 320 389 356 376 249 3022

Community Matrons NHS Southport and Formby CCG 256 387 370 361 279 405 367 283 2708

NHS South Sefton CCG 87 92 120 240 235 173 164 113 1224

NHS Southport and Formby CCG 66 156 254 296 224 206 206 93 1501

Diabetes NHS Southport and Formby CCG 452 447 378 484 469 481 513 328 3552

Dietetics NHS Southport and Formby CCG 405 442 440 452 455 438 330 316 3278

District Nurses NHS Southport and Formby CCG 6272 8227 7702 8139 7695 8351 7529 6745 60660

District Nurses OOH NHS Southport and Formby CCG 553 481 603 494 546 683 796 647 4803

Falls Service NHS Southport and Formby CCG 109 91 95 172 160 152 215 211 1205

Leg Ulcer NHS Southport and Formby CCG 51 84 97 80 94 101 93 82 682

Pain Management NHS Southport and Formby CCG 245 289 279 206 353 318 323 308 2321

Phlebotomy NHS Southport and Formby CCG 1337 2215 2063 2128 2004 2128 1929 1632 15436

Podiatry NHS Southport and Formby CCG 1891 2208 2126 2270 2008 2279 2258 1549 16589

Psychology NHS Southport and Formby CCG 250 290 292 376 262 332 302 162 2266

Stoma NHS Southport and Formby CCG 95 99 118 107 69 87 95 62 732

Tissue Viability NHS Southport and Formby CCG 6 9 11 6 6 8 7 8 61

Treatment Rooms NHS Southport and Formby CCG 2090 2618 2454 2569 2119 2371 2424 2240 18885

Grand Total 17530 21834 21105 21966 20629 22975 21888 18830 166757

Continence

1. Performance Activity Southport & Formby – Contacts Summary

124

Unvalidated Figures

Validated Figures


1. Performance Activity Southport & Formby – Continence

125

Southport & Formby - Continence:

Improvements in data recording and waiting list management continue to improve the waiting list profile for the Continence Service.

The team continue to reduce patients waiting over 18 weeks with all higher waiting list bands reducing and moving through into the lower

waiting bands.

Due to unforeseen circumstances, the Continence service audit which was scheduled for M8 will not take place until at least M11.

However, teams continue to validate their own data including any general data quality issues, caseload validation and waiting list reviews.


1. Performance Activity Southport & Formby – Treatment Rooms

126

Southport & Formby – Treatment Rooms:

The Performance team have reviewed the service and identified a training need, therefore EMIS re-training will be taking place in M10

onwards to ensure all clinical staff record their contact activity accurately so that it can be counted in the monthly activity and referral

reports.

Due to unforeseen circumstances, the Continence Service audit which was scheduled for M8 will not take place until at least M11.


2.1 Finance Activity Southport & Formby

Detail for Southport and Formby can be found in the Trust's main QPR Finance and Contracting Section.


128

2.2 Contract Activity Queens Court – Palliative Care subcontract

CNS MAY JUNE Q1 JULY AUG SEP Q2 OCT NOV DEC Q3 Total

Number of referrals received 88 84 172 83 93 76 252 69 81 78 228 317

% appropriate referrals (SEEN BY SERVICE) 80% 79% 79% 78% 78% 74% 77% 91% 84% 86% 87% 81%

Primary health care team (GP) 20 15 35 16 19 22 57 23 20 15 58 150

Specialist nurse / team (internal) 9 13 22 9 4 10 23 7 8 5 20 65

Other hospital staff (internal) 47 46 93 36 50 30 116 31 39 40 110 319

Internal Referral (QCH & SPCS) 11 10 21 21 20 14 55 8 13 15 36 112

Other(other) 1 0 1 1 0 0 1 0 1 3 4 6

Not recorded 0 0 0 0 0 0 0 0 0 0 0 0

Pain/Symptom Control 83 76 159 81 86 66 233 68 74 75 217 609

Psychological Support 44 48 92 39 60 40 139 13 37 41 91 322

Social/Financial 0 0 0 2 0 0 2 0 0 0 0 2

Family Support 0 1 1 1 0 1 2 0 0 0 0 3

Other 0 1 1 0 0 0 0 0 0 0 0 1

Number of patients 'active' 364 363 727 383 390 390 1163 390 320 291 1001 2891

82 41 123 37 43 46 126 45 70 90 205 454

19 18 37 18 20 20 58 6 11 11 28 123

Inappropriate 1 0 1 1 1 2 4 1 3 1 5 10

Died within 24hrs of referral 2 2 4 2 4 1 7 1 2 0 3 14

Declined 0 1 1 1 1 1 3 0 0 0 0 4

Unable to contact (includes admissions) 1 0 1 0 0 4 4 0 2 3 5 10

Contact made, appointment arranged 12 11 23 11 10 8 29 3 4 5 12 64

Other 3 3 6 5 3 4 12 1 0 2 3 21

Unknown 0 1 1 0 1 0 1 0 0 0 0 2

Number 70 66 136 65 73 56 194 63 68 67 198 528

New and re-referred as % of all patients

seen in month41% 39% 40% 36% 39% 33% 36% 35% 55% 44% 44% 40%

Cancer 42 44 86 42 49 34 125 32 43 38 113 324

Non-malignant 28 22 50 23 24 22 69 31 25 29 85 204

Not recorded 0 0 0 0 0 0 0 0 0 0 0 0

% Primary Diagnosis of Cancer 60% 67% 63% 65% 67% 61% 64% 51% 63% 57% 57% 62%

Total (New Non F2F) 82 84 166 83 93 76 252 69 81 78 228 646

Within 48 hours 69 69 138 67 74 54 195 50 68 70 188 521

% target achieved 84% 82% 83% 81% 80% 71% 77% 72% 84% 90% 82% 81%

Referrals not seen (non F:F)

Number of referrals ended (of those seen)

Reason for Referral (maybe more

then 1 per patient)

Referral source

Diagnosis (of those seen)

New and re-referred patients (seen)

Initial Telephone contact

Time from referral to patient contact.

No more than 48hours (75% target)


129



New assessment with patient (New F2F) 54 64 118 59 70 49 178 66 66 78 210 506

OPD 0 20 44 22 34 21 77 30 32 38 100 221

Current place of residence 54 44 74 37 39 28 104 36 34 40 110 288

Review FU with patient (face-to-face) 251 266 578 263 220 252 735 303 186 288 777 2090

OPD 0 78 139 53 63 49 165 44 56 67 167 471

Current place of residence 312 188 439 210 157 203 570 259 130 221 610 1619

Review FU with patient (telephone) 270 270 540 301 203 187 691 305 242 229 776 2007

Advice & Support relative/carer F:F 185 171 356 166 175 190 531 212 126 221 559 1446

Advice/support to a Professional F:F 168 173 341 162 179 145 486 175 125 204 504 1331

Advice & Support relative/carer Tel 222 232 454 217 240 231 688 281 158 198 637 1779

Advice/support to a Professional Tel 147 184 331 158 207 152 517 166 115 183 464 1312

Bereavement visit with relative / carer 0 0 0 1 0 1 2 2 1 1 4 6

Bereavement Telephone with relative / carer 11 16 27 17 24 12 53 16 26 37 79 159

Bereavement Letter to relative / carer 14 17 31 18 15 9 42 16 55 45 116 189

DNA (Total DNA) NR NR NR NR NR NR NR NR NR NR NR NR

0 31 23 54 33 37 22 92 22 29 36 87 233

1 15 14 29 10 7 9 26 16 7 15 38 93

2 5 3 8 0 5 2 7 4 4 3 11 26

3 1 5 6 7 4 5 16 1 2 0 3 25

4 4 6 10 4 5 6 15 3 6 4 13 38

5 1 3 4 2 3 1 6 4 5 2 11 21

6 2 1 3 0 6 0 6 4 4 3 11 20

7 1 4 5 3 1 4 8 0 1 0 1 14

8-14 6 6 12 5 2 6 13 7 8 3 18 43

15-21 3 0 3 0 3 1 4 1 2 1 4 11

22-28 0 0 0 1 0 0 1 1 0 0 1 2

29-41 0 0 0 0 0 0 0 0 0 0 0 0

> 42 0 0 0 0 0 0 0 0 0 0 0 0

Total 69 65 134 65 73 56 194 63 68 67 198 526

Primary healthcare team 24 15 39 22 18 13 53 9 38 29 76 168

Internal referral 1 3 4 2 2 0 4 3 2 7 12 20

Died 57 21 78 12 19 31 62 33 30 54 117 257

Other 0 2 2 1 4 2 7 0 0 0 0 9

Not recorded 0 0 0 0 0 0 0 0 0 0 0 0

Discharged to (of those seen)

Time from Referral to Assessment

in days (seen)

Contacts

(related to caseload)


130



Average time 119 21 32 19 34 45 33 35 53 124 153 33

Shortest time 0 0 0 0 0 0 0 0 0 0 0 0

Longest time 1898 154 1898 279 315 572 572 939 358 959 959 1136

63% 33% 48% 25% 42% 55% 41% 42% 57% 67% 55% 48%

Home 16 3 19 2 5 6 13 8 9 17 34 66

Hospital 21 14 35 9 11 14 34 19 13 18 50 119

Hospice 13 0 13 0 1 1 2 4 2 4 10 25

Care home 7 4 11 1 2 10 13 2 6 15 23 47

Prison 0 0 0 0 0 0 0 0 0 0 0 0

Other 0 0 0 0 0 0 0 0 0 0 0 0

Unknown 0 0 0 0 0 0 0 0 0 0 0 0

PPC achieved 29 9 38 5 7 13 25 19 16 43 78 141

PPC not achieved 14 3 17 0 3 7 10 2 0 0 2 29

PPC unknown 14 9 23 7 9 11 27 12 6 0 18 68

Not recorded 0 0 0 0 0 0 0 0 8 11 19 19

0 - 5 57 54 111 56 61 45 162 50 53 60 163 436

6 - 14 9 11 20 8 9 10 27 11 13 6 30 77

15 - 21 3 0 3 0 3 1 4 1 2 1 4 11

22 - 28 0 0 0 1 0 0 1 1 0 0 1 2

29 - 42 0 0 0 2 0 0 2 2 0 0 2 4

> 42 0 0 0 0 0 0 0 0 0 0 0 0

% Non Hospital Deaths (of those seen)

Time on caseload (of those seen)

Time to receiving care

for referrals in this month

(active data)

Deaths (of those seen)

Place of death (of those seen)


131


Activity perfomance indicator Report frequency May June Q1 July Aug Sept Q2 Oct Nov Dec Q3 Annual total

SERVICE USER EXPERIENCE

1. Complaints received Monthly 0 0 0 0 0 0 0 0 0 1 2 2

2. Compliments Monthly 6 9 15 3 4 1 8 3 4 3 10 33

3. Incidents reported (about the service) Monthly 0 0 0 0 0 0 0 0 0 0 0 0

4. Incidents reported (by the service) Monthly 1 0 1 0 2 0 2 1 0 2 3 6

5. Iwantgreatcare (number of returns) Annually 0 0

STAFF TURNOVER /ATTENDANCE

1. Left employment Quarterly 1 0 0 1

2. Recruited Quarterly 0 0 1 2

3. Sickness % per establishment Quarterly 10.60% 1.59% 3.41% 5.20%

STAFF TRAINING / DEVELOPMENT

1. Annual apprisals completed 100% Annually 0

2. Mandatory training completed 100% Annually 0

3. Clinical supervision (hours) 100% Monthly 0 0 0 1.5 0 1.5 3 1.5 1.5 1.5 4.5 7.5

GSF Attendance Monthly 6 6 12 8 7 11 26 11 12 9 32 70


3. Quality Southport & Formby

132

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

total

12 months


Incidents n/a 20 50 59 56 53 45 84 46 413 52


incidentsn/a 0 1 0 0 0 1 0 0 2 0

RIDDOR incidents n/a 0 0 1 0 0 0 0 0 0 0 0 0 1 0

Fall incidents n/a 0 0 1 0 1 1 0 1 4 1

Pressure ulcer incidents n/a 4 20 21 17 15 13 35 17 142 18

Potentially avoidable grade 3

and 4 pressure ulcersn/a 0 0 0 0 0 0 0 0 0 0 0 0 0 0

Safeguarding alerts n/a 1 3 4 3 1 7 10 6 35 4

Staff safetyViolence or aggression to staff

from patients n/a 0 0 1 0 0 0 2 1 4 1

Pressure ulcers (%) - 1.06% 5.15% 1.09% 1.59% 4.23% 1.95% 3.33% 3.54% - 2.74%

Falls with harm (%) - 0% 0% 0% 0% 0% 0% 0% 0.84% - 0.11%

Catheter and UTI (%) - 0% 0% 0% 0% 0% 0% 0% 0.51% - 0.06%

VTE (%) - 0.53% 1.47% 1.46% 1.27% 0.94% 0.98% 0.74% 0.34% - 0.97%

Physical Health HFC Rate (%) 95% 99% 94% 98% 97% 96% 97% 96% 95% - 96.51%

F&F Test 95% 99.2% 100.0% 100% 100% - 99.73%

F&F Test - Response Rate n/a 126 113 3 366 608 152

Compliments Compliments n/a 0 5 16 45 54 25 53 57 61 316 35

Complaints n/a 0 1 2 12 11 1 7 7 5 46 5


complaintsn/a 0 0 0 6 6 3 2 17 2


timeframe (%)n/a

Reopened complaints n/a

Overdue 3 day reviews 0 2 4 3 9 3

Overdue 7 day reviews 0 12 13 7 32 11

Overdue incident actions 0 0 0 1 1 0

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

Assurance Concerns raised n/a 0 0 0 0 0 0 0 0 0 0

Learning and

candour

Patient safety

Incidents

FOCUSED QUALITY AND SAFETY SURVEILLANCE - Southport & Formby Services

Safe

Effective

Caring

Responsive

Well Led

Physical Health

Harm Free Care

Friends & Family -

Patients

Complaints


133

Actual Workforce Costs Compared to Budget - Quarterly Trend

Peripheral Workforce Spend and Usage

4. Workforce Actual Workforce Costs Compared to Budget


Southport & Formby 658,442 4,309 0.6% 48,918 6.9% 0 0.0% 53,227 711,669 7.48%

Flexible

Labour

Reliance

%Business Area

Core

Workforce

Spend £

Bank Agency Medical Agency

Total Spend

£

2017 12

Total

Peripheral

Workforce

Spend £


4. Workforce Sickness Absence Rates

134

Trust 12 Month, Year on Year Trend

Sickness Absence Breakdown

Rate Rate Rate Trend

2017 10 2017 11 2017 12

% Long

Term

Absence

% Short

Term

Absence

12mths

Southport & Formby 4.77% 4.90% 8.05% 23.87% 76.13%

2017 12


4. Workforce Appraisals and Mandatory Training Compliance

135

Vacancy Management and Active Recruitment

Core Workforce Headcount

E&D

3yr

Fire

Saf

ety

1yr

Hea

lth

& S

afet

y 3

yr

Info

rmat

ion

Go

vern

ance

1yr

Infe

ctio

n C

on

tro

l Clin

ical

1yr

Bas

ic L

ife

Sup

po

rt 1

yr

Imm

edia

te L

ife

Sup

po

rt 1

yr

Co

nfl

ict

Res

olu

tio

n 3

yr

Safe

guar

din

g C

hild

ren

L2

3yr

Safe

guar

din

g C

hild

ren

L3

3yr

Men

tal C

apac

ity

Act

L1

3yr

Man

ual

Han

dlin

g L2

3yr

Man

ual

Han

dlin

g L3

2yr

Infe

ctio

n C

on

tro

l L1

2yr

Safe

guar

din

g C

hild

ren

L1

3yr

Safe

guar

din

g A

du

lts

L1

(+P

REV

ENT)

3yr

Men

tal C

apac

ity

Act

L1

(On

e Ti

me

Co

mp

leti

on

)

Man

ual

Han

dlin

g L1

3yr

Ap

pra

isal

Co

mp

lian

ce

S&F 98% 95% 85% 95% 93% 80% x 77% 91% x 93% 96% 50% 95% 98% 98% 95% 94% 92% 68%


Total

Budgeted

Establ ishment (BE)

(FTE)

Actual

Establ ishment (FTE)

Budgeted

Establ ishment

Vacancies

(FTE)

BE Vacancy

Rate

Active Vacancy

Rate

Active Vacancy

FTENo. Pos i tions

Avg. No Days

to Recruit

Southport & Formby 224.22 206.69 17.53 7.82% 83.13% 14.57 16.00 N/A

2017 12

Establ ishment Vacancies Vacancies in Active Recruitment

Core Workforce

Network Headcount FTE Headcount FTE

Southport & Formby 261 207.42 260 206.69

2017 11 2017 12


136

4. Workforce Workforce Turnover

Board of Directors


Report Title Readiness for General Data Protection Regulation (GDPR) 2018


Prepared by Michelle J Brammah IG, Assurance and Compliance Lead

Presented by Michelle J Brammah


Supporting Executive Director Chief Finance Officer Senior Information Risk Owner (SIRO) PURPOSE OF THE REPORT: Report purpose To provide assurance that the Trust is preparing for the

implementation of GDPR 2018 and that it will be compliant with the changes being introduced



Board Assurance Framework risk 1.1 If we do not meet regulatory standards for quality and safety we will not be fit for purpose as a care provider

CQC domain Well-led 1.0 Background and context

The European Union determined that the divergent implementation of approaches to Data Protection around Europe has led to inconsistent personal data processing, legal uncertainty and compliance issues. This, together with the advances in technology, and changes in the way in which individuals and organisations communicate and share data, led to an EU review.

The General Data Protection Regulation (GDPR) is the regulation by which the European Parliament, the Council of the European Union and the European Commission are strengthening and unifying data protection for all individuals within the European Union (EU).

The GDPR will apply in the UK from 25 May 2018. The government has confirmed that the UK’s decision to leave the EU will not affect the commencement of the GDPR.

2.0 What will be different that is not covered by the current data protection law?

There will be a number of changes to the obligations placed on organisations and on how personal information is processed. The Regulation reinforces the importance of accountability and requires greater demonstration of evidence based compliance, enhanced rights for the data subject and significant increased penalties for breaches of the Regulation. In addition the Regulation requires that all organisations have access to a Data Protection Officer (DPO) and for large public bodies processing large volumes of personal data there is an expectation that the organisation will have their own DPO role.

Refer to Appendix No.1 for a full summary of the differences.

3.0 What will be the Impact on the Trust?

Although there are significant changes, much of the GDPR is familiar territory. The transition from Data Protection Act 1998 to the General Data Protection Regulations will be easier for organisations that have embraced the culture and approach advocated by the Information Commissioners Office.

The Trust has a wide range of good practice which underpins compliance. However as we move forward there will be greater significance placed on the accountability for data protection and how this is embedded in our governance framework. GDPR focuses attention on identifying responsibilities and having strong ability to verify observance of the law.

The IG team will work in partnership with Networks and Support Service areas to deliver the GDPR implementation readiness plan. It is good practice to complete a gap plan as it informs an implementation or readiness action plan. The Information Commissioners (ICO) office produced a Twelve Steps Checklist list to identify the changes coming and to assist organisations to assess their compliance position. The gap document is quite detailed and therefore has not been appended to this document. However the twelve steps checklist is appended. The gap analysis considers what we currently do, what we need to do to be compliant, the method and who to collaborate with so that there is collective ownership.

However the GDPR implementation readiness plan is included at appendices 2 and 3. Completion of tasks will be monitored and reported to the Corporate Governance and Compliance Sub Committee. Employment of the formal Information Asset Owner/Information Asset Administrator (IAO/IAA) structure will be key to assisting completion of preparatory tasks and activities.

4.0 Where would we be if GDPR had come in last year? Would there be any difference in our position?

The last year has seen systematic improvements in our organisational stance towards compliance with the Data Protection Act. We have implemented a formal IAO/IAA structure which is steadily embedding best practice across the Trust.

The following are examples that prove the Trust’s ability to maintain compliance of the current data protection law:

• Information Governance Toolkit (IGT) score – demonstrating above satisfactory assurance

• Internal IGT Audit by MIAA– Significant assurance

• No enforcement action or fines by the Information Commissioners Office (ICO)

• Structured process for Serious Incident assessment and approval

• IGT incidents reported on Datix

• Governance and accountability structure in place from both the networks and support areas and from IG

• Consent for direct care purposes is not required as processing is for medical purpose under current data protection law and the future GDPR. Processing of personal data for healthcare is so that the Trust can perform its official function and this has a clear basis in law. Explicit informed consent should still be sought and obtained for non direct care purpose and must be valid.

5.0 GDPR readiness – Key pieces of work to be completed

• The current Privacy Notice also known as a Fair Processing Notice is inadequate and lacks sufficient detail and explanation to meet the new regulation. Currently the Trust meets the minimum requirement and this is provided in a single Fair Processing notice poster that is accompanied by a service user information booklet called ‘Sharing your information with us’. It only advises the legal basis for data collection and sharing and does not expand on the information rights of individuals or make available contact information. The poster and booklet are currently available across Trust sites including in-patient areas/clinics and out patients areas/receptions and so forth .The booklet provides more explanation but this too can be improved. The Trust needs to look at all possible methods and media open to it to meet the needs of as many patient groups as possible e.g. social media, correspondence, local information notices and so forth.

• All Contracts involving the use of Personal identifiable and confidential data must be reviewed to ensure that there are adequate Information Governance clauses in place and that they are registered on the Trust Contracts register (only for £30K+). IG, Contracts and Procurement will work closely to establish intelligence for this. As data controller the Trust must have assurance in regard to data protection compliance from all data processors that have been engaged to do business with the Trust

• There is a need to review the current Datix reporting and IGT Serious Incident Requiring Investigation (SIRI) assessment and approval process to meet the new 72hrs reporting threshold. Specifically, once the Trust has become ‘aware’ that a serious incident has occurred, i.e. that some facts have been established to confirm the nature and severity of the incident, the Trust has 72 hours to report the incident to the ICO. It is anticipated that the current SIRI system used to report the serious incident to the ICO will be amended before May 2018

• Continue to develop the Information Asset register and Data Flow Mapping register – this is central to identifying the Trust processing activities

• Formal Data Protection Officer (DPO) role to be in place. IG Lead is currently registered as the Trust DPO but this is not formally recognised and the role as it stands is more for contact purposes. The extent of the DPO role will be more significant within the organisation and needs to be formally defined within a job description in line with the requirements of the GDPR. The DPO role will need to be in place by 25th May 2018.

• On-going GDPR communications with the networks and support services

• As part of data collection review clinical systems to ensure that consent obtained for non direct care is properly recorded and does not soley rely on a tick box to validate informed consent being obtained

For an overview of completed and planned activity, along with a report using the ICO website GDPR readiness tool, please see Appendices 2 and 3

6.0 Are there any significant risks?

• Financial – level 1 10,00,00 euros or 2% of Net annual turnover, whichever is the greater or level 2 20,000,000 euros or 4% of net annual turnover, whichever is the greater. Both levels of fines are a significant increase to the previous fine regime which was a maximum of £500K for a serious breach. In context, a company that has an annual turnover of £10 million and receives a level 1 monetary penalty could be looking at a maximum fine of £200K. Using the same example turnover figure, a level two monetary penalty could result in a £400K fine. Whilst these potential monetary fines are cause for concern, the introduction of the new higher fines regime is targeted at the large

private corporations e.g. Talk Talk, Facebook and Google etc and not particularly at the health sector

• Incident reporting timescale will be set at 72 hours. This will create pressures in the system which will have to be addressed.

• Readiness / Implementation timescale to be compliant with new Regulation i.e. by 25th May 2018.

• A lack of continued development of information asset registration and data flow mapping could compromise compliance. The Trust must have an understanding of its data processing activities i.e. the life cycle of data from collection to disposal

• Additional demands on the central Information Governance function will need to be reviewed and addressed to ensure that adequate resource is available

• The National GDPR communications campaign will bring heightened public awareness of information rights. The removal of charges for Subject Access requests (SAR) may have an impact of the Trust and result in an increase of requests to process

7.0 What processes does the Trust already have in place i.e. controls and assurance?

• GDPR gap analysis – This document is based on the ICO twelve steps guidance. It is large volume and therefore has not been appended to this paper. It will be presented to senior management meetings.

• GDPR action plan completed. Refer to appendices for detail.

• GDPR Communications have already commenced – briefing to Board, Corporate Governance and Compliance, Joint SIRO and Caldicott Guardian meeting, Clinical Records and Information Governance meeting, Network Business Delivery group meetings. General briefings will be published to the wider Trust leading up to May 2018. This will be in the form of posters that can be displayed for staff and patients, via Trust Pulse, information awareness within personal ‘My-compliance’ portal, at team meetings and at IG related training.

• IGT Satisfactory rating supported by Internal Audit IGT rating

• New SAR timescale in place – SAR register set up with new timeframe in readiness for implementation, new controls introduced in June 2017 and a new centralised process is proposed to manage and control all SAR’s for the Trust effective from Q1 2018.

• Robust Trust wide governance and assurance framework

• Serious IG Incident assessment using NHS Digital Serious Incident Requiring Investigation (SIRI) criteria and Trust approval protocol for registering the incident

• Introduced a formal Information Asset Management including data flow mapping

• Information sharing agreements (ISA’s) in place with multiple service partners

• Privacy Impact assessments (PIA’s) which are currently ‘best practice’ risk assessments and not a legal requirement until GDPR is in force. The document identifies any risks concerned with pieces

of work/projects/applications/software that process personal data and the controls and assurance in place. This has been standard practice in the Trust for approximately two years

• Currently establishing signed ISA’s with GP’s as part of the Medical Interoperability Gateway (MIG). This is a secure gateway to a set of services for exchanging real time data between trusted and secure third party systems. This will allow LCFT to view GP records and the GP’s will use the gateway to view LCFT records as part of the RiO implementation

8.0 Any there any lessons learned already or to be learned?

• Senior management commitment is required to maintain momentum of compliance activities and practices

• IAO/IAA structure responsibilities are pivotal to ensuring compliance

• Ensure that there is a clear alignment between the strategic Information Governance risk and any required changes in the control and assurance of the organisation

9.0 Conclusion The Trust is making progress in readiness for the new data protection law. It has recognised and identified the work that still needs to take place and fully supported by the organisation will achieve compliance.

10.0 Recommendation

The Trust Board is asked to support all associated requirements and activities in readiness to be compliant with the General Data Protection Regulation 2018 that comes into force in on 25th May 2018.

Appendix No.1 Summary of Differences between the Data Protection Act (DPA) 1998 and the General Data Protection Regulations (GDPR) 2018

DPA GDPR Reach Only applies to the UK

Applies to the whole of the EU and, crucially, also to any

global company which holds data on EU citizens

Enforcement Enforced by the Information Commissioner’s Office (ICO)

Compliance will be monitored by a Supervisory

Authority in the UK with each European country having

its own SA. The ICO is the UK’s SA

Penalties Non-compliance can result in fines of up to £500,000 or 1% of annual turnover

The potential penalties for non-compliance are much more severe with fines of up to a maximum of €20 million or 4% of the businesses annual global turnover

Data Protection Officer Under the current legislation there is no need for any business to have a dedicated DPO

A DPO is mandatory for any business or organisation

with more than 250 employees

Data Breaches

Businesses are under no obligation to report data

breaches though they are encouraged to do so

A serious data breach must be reported to the ICO (Supervisory Authority) within 72 hours of the incident

Data Erasure (removal)

There is no requirement for an organisation to remove

all data they hold on an individual

An individual will have the ‘Right to erasure’ – which

includes all data including web records with all

information being permanently deleted. This is

applicable to Corporate and Private organisations and is

unlikely to apply to health providers as a health history/

record is required to deliver care and treatment.

Privacy by design

Protection Impact Assessments (PIA) are not a legal

requirement under DPA but has always being

‘championed’ by the ICO

Data Privacy Impact Assessments (DPIA) will be

mandatory and must be carried out when there is a high

risk to the freedoms of the individual. A DPIA helps an

organisation to ensure they meet an individual’s

expectation of privacy and should be completed for all

https://ico.org.uk/

projects involving the processing of personal / sensitive

information

Opting in and Privacy Notices Data collection does not necessarily require an opt-in under the current Data Protection Act. Basic Fair processing notices (Privacy Notices) required outlining reasons for processing, who it may be shared with and so forth

The need for consent underpins GDPR. However consent is not required for direct care purposes. Individuals must opt-in whenever data is collected by health providers for non direct care purposes with affirmation recorded. There must be clear privacy notices which provide full explanation of information rights. Those notices must be concise and transparent, available in multiple media and individuals must be made aware that their consent can be withdrawn at any time

Subject Access Individuals may request copies of the personal data held about them by the organisation and be charged up to £50 per request. The organisation must respond within forty calendar days

GDPR has removed the charge for a request (charges may be applied by exception for large volume or complicated requests) and the organisation must respond within one calendar month

Accountability No specific accountability principle and accountability is limited Data protection governance down to best endeavours

Accountability is explicit. Organisations must be able to

demonstrate they comply with the principles of

GDPR. Crucially, it is the organisations responsibility to

ensure compliance.

Data Responsibility Responsibility rest with the Data Controller

Rests with both the controller and processor with the controller being able to seek damages from the processor

Right to Compensation Any person who has material damage is entitled to claim compensation

Any person who has suffered material or non-material damage is entitled to claim compensation

Appendix 2

This graphic shows aspects of the GDPR which are complete or partially completed

This is an output from a status report generated from an ICO readiness assessment

Appendix 3 High level plan on a page


Report Title LCFT Q3 Workforce Board Report 2017/18


Prepared by Michelle Kaye

Presented by Damian Gallagher


Supporting Executive Director Chief Executive PURPOSE OF THE REPORT: Report purpose To support and inform the Board’s delivery of the LCFT

Workforce Strategy


To employ the best people

Board Assurance Framework risk 4.1

CQC domain Well-led Introduction: The LCFT Workforce Board Report has been designed to provide the Board with a quarterly update on the organisations performance against ten agreed workforce Key Performance Indicators (KPI’s). The data presented is supported with narrative that highlights the current workforce management challenges being experienced by the Business. The structure of the narrative is designed to provide high level information about the remedial and supportive activities and actions being taken to manage performance improvement and provide assurance to the Board that the organisation is committed to effectively managing and mitigating the identified workforce management risks. This report provides performance against the workforce indicators for the Quarter 3 period, 01 October 2017 to 31 December 2017. The data presented in this report is sourced from the following LCFT Directorates:

• Human Resources • Human Resources Quality Academy • Finance

Information to support the preparation of narrative is provided by HR Business Partners in conjunction with Network Management. Members of the Board are invited to note the content of the report and are encouraged to ask any questions and make requests for further information with the Director of Human Resources. Workforce KPI Performance Headlines: The workforce indicators set out on page 3 of the Workforce Board Report present LCFT’s overall performance against the ten workforce KPI’s in the Quarter 3 period.

Performance is rated against the Trusts defined targets, using the Red and Green indicators adopted by LCFT. These are supplemented with an indicative performance trend arrow. The trend is set against performance reported in the previous quarter. 1. Peripheral Workforce Reliance LCFT’s use of a Bank and Agency workforce has increased through the Q3 period, closing the

quarter at 12.08%. Although the trend through the period has been upward, overall spend at the close of the quarter shows a slight reduction against the closing position of Q2. The LCFT Bank Workforce continues to be the primary source of flexible labour for the Trust.

2. Operational Gap The Trust operating gap continues to report a stable 2.86% at the close of Q3 and remains below

the Trust target of 5%. The total operating gap (including Sickness Absence and Annual Leave absences) is 13.6% at the

close of Q3. This is a slight increase on the Q2 closing percentage of 11.46%. 3. Sickness Absence

Sickness Absence has increased in the last month of the quarter, closing Q3 at 7.32%. This is an increased position when compared with performance across Q2. All Networks continue to focus on Sickness Absence Management and have undertaken internal reviews on how they are managing and tracking the management of sickness in their networks to ensure that they are adopting the best and most effective approach for their particular services and system needs. This quarter’s dedication to making sustainable improvements in this area has resulted in the following activity in Long Term sickness across the networks: 128 individuals have been facilitated to return to work 4 individuals have been identified for redeployment 4 individuals have been dismissed on the grounds of capability 5 individuals have resigned from their position with the Trust.

Long term and short term sickness absence have changed places in the quarter with Long Term

sickness now accounting for just under half of all absences. The position at the close of the quarter is 49.32% s attributable to Long Term absence and 50.68% attributable to Short Term absence.

4. Vacancy Rate The Board Report provides two rates to support the assessment of vacancies.

Establishment Vacancy Rate: The number of vacancies the business runs with against its Budgeted Establishment

Active Vacancy Rate: The number of vacancies being actively recruited to (this is a count of any vacancy that is within the recruitment process from recruitment authorisation through to starting with the trust).

The budgeted establishment vacancy rate has continued the upward trend seen in Q2, through the Q3 period and reports a closing rate of 12.97%.

The number of these in active recruitment at the close of Q3 is 62.65%. This equates to 772 ‘live’

recruitment events totalling 530.05 FTE across the Trust. 34 of these vacancies are at the internal redeployment recruitment stage (26.78 FTE) and 738 vacancies are in Open Recruitment (503.27 FTE).

5. Safer Employment Compliance

• Core Workforce Compliance in recruiting and employment, across the Core Workforce, continues to perform well

with 100% compliance in Safer Recruitment practice and 98% for Safer Employment practice.

• Bank Workers Compliance within the Bank Only Worker population for Safer Recruitment Practice and Safe Bank

Worker Engagement Practice also continues to perform well with both reporting 99% compliance in Q3.

6. Turnover Rate

Quarter 3 has seen a slight increase in the Trust Turnover rate, reporting 14.69% at the close of the quarter.

7. Appraisal Performance Quarter 3 of the 2017/18 performance year includes PDR quarterly review activity in the compliance measure. The Quarter 3 Appraisal report uses four categories to measure PDR activity and performance against the Trust target:

The proportion of employees who have either: 1. The proportion of employees who have initiated their 2017/18 PDR in the ePDR system have objectives

in place and have review activity recorded. 2. Have completed the Medical Workforce Appraisal process.

1. New Starters, within the 60 day grace period, who have registered with the ePDR system but do not yet

have personal objectives in place. 2. Members of the Medical Workforce who have arrangements in place to complete their Medical Appraisal

and are inside the approved timescales for completion.

The proportion of existing employees who have either: 1. Have not initiated the 2017/18 PDR in the ePDR system. 2. Have not registered with the ePDR system and for whom we have no information. 3. Members of the Medical Workforce who have not completed the Medical Appraisal process and are

outside of their ‘Appraisal birthday’. 4. Have initiated their 2017/18 PDR but who do not have objectives in place 5. Have objectives in place but have not completed a review

The proportion of New Starters, within the 60 day grace period, who have not registered with the ePDR system.

The overall Trust Appraisal compliance rate for Q3 (inclusive of the Medical Workforce) is 49.05%. This is an improved position against the Q2 reported closing rate. Compliance remains below the Trust target of 85%

8. Mandatory & Statutory Training Compliance Overall mandatory and statutory training compliance continues to improve and has achieved the

Trust Target, reporting an overall compliance of 92% at the close of Q3. Significant improvements have been achieved in this area over the last performance year and continue to be sustained.

The People sub-committee continues to monitor this target closely and each Network reports

improvements in compliance and accuracy of centrally held compliance data. 9. Induction The Induction completion rate continues to perform well and reports 97.78% at the close of Q3. Damian Gallagher HR Director

LCFT Workforce Board Report

Quarter 3

October 2017 to December 2017Prepared by Michelle Kaye & Phil Connolly

• Operational Gap• Sickness Absence Rate• Appraisal Rate

• Staff Turnover• Sickness Absence • Peripheral Workforce Spend

to Core Workforce Spend

• Vacancy Rate• Safer Employment Compliance• Sickness Absence • Peripheral Workforce Spend to

Core Workforce Spend• Operational Gap

• Appraisal Rate• Mandatory & Statutory

Training Compliance

• Appraisal Rate• Mandatory & Statutory Training Compliance

KPI PERFORMANCE OVERVIEW

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

Information in this report is accurate as at 31st December 2017.

Key Performance Indicators Trust TargetQuarter 2 Closing

Figures(Q2: 2017/18)

Quarter 3 Closing

Figures(Q3: 2017/18)

Trend (Against Previous

Quarter)

Total Workforce Expenditure (Cumulative Spend in Quarter)

£64,865,459

Budget£64,523,097 £63,773,406 q

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

6.0% 12.33% 12.08% q

Operational Gap 5.0% 2.96% 2.86% q

Sickness Absence 4.5% 6.35% 7.32% p

Vacancy Rate 5.0% 12.07% 12.97% p

Of which in Active Recruitment - 55.63% 62.65% p

Safer Employment Compliance

(Core workforce)85.0% 82.97% 98.79% p

( Bank workers) 85.0% 96.58% 96.58% p

Turnover Rate 10.0% 13.95% 14.69% p

Appraisal Performance 85.0% 37.66% 49.05% p

Mandatory & Statutory Training

Compliance 85.0% 89.25% 90.05% p

Induction (within 28 days of starting) 95.0% 88.24% 98.22% p

WORKFORCE EXPENDITURE

Workforce Expenditure against Established Budget – Quarter 3 Source Data: EFIN Finance Ledger

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

Workforce Expenditure against Established Budget – Quarter 3 Cumulative figures

0

5

10

15

20

25

2017 10 2017 11 2017 12

£ m

illio

ns

Medical Agency

Agency

Bank

Core

Budget

Business Area Established Budget

£'s

Spend on Core

Workforce £'s

Spend on Peripheral

Workforce £'s

Total Spend on

Workforce £'s

Budget &

Expenditure

Variance £'s

Trend (Against

Previous

Quarter)

Trust 64,865,459 56,972,024 6,801,382 63,773,406 -1,092,053 q

Mental Health 14,118,199 13,023,325 1,266,773 14,290,098 171,899 p

Community & Wellbeing 29,785,753 25,996,357 5,091,603 31,087,961 1,302,207 q

Children & Young People 10,590,140 9,662,450 483,240 10,145,690 -444,449 p

Support Services 10,371,366 8,289,892 -40,235 8,249,657 -2,121,710 p

VACANCY RATE

The Vacancy Rate presents the % difference between the Trusts budgetedestablishment and its actual spent establishment. This measurement has been basedon FTE and is one of the measures referenced when assessing core workforce stability.

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

Budgeted Establishment Vacancy Rate – 12 Month Trend

Budgeted Establishment & Active Vacancy Rate Comparison – Position as at 31st December 2017

Source Data: ESR and Finance Ledger

0.0%

2.0%

4.0%

6.0%

8.0%

10.0%

12.0%

14.0%

16.0%

18.0%

20.0%

22.0%

24.0%

2016 12 2017 01 2017 02 2017 03 2017 04 2017 05 2017 06 2017 07 2017 08 2017 09 2017 10 2017 11 2017 12

Trust

Mental Health

Community & Wellbeing

Children & Young People

Support Services

Budgeted Est. FTE

(BE)FTE in Post

Budgeted FTE

Vacant

Budgeted Est.

Vacancy Rate

(BE VR)

Vacant FTE in Active

Recruitment

Active Vacancy Rate

(AVR)

6522.00 5675.89 846.11 12.97% 530.05 62.65%

Vacancy Rate & WTE – Quarter 3 Monthly Actuals, by Business Area Source Data: ESR, Finance Ledger, Recruitment



VACANCY RATE

Hot Spot Analysis:

Mental Health Network: The Establishment Vacancy Rate has slightlyincreased through Quarter 3 closing at 12.64%. The number of thosevacancies being actively recruited to has also slightly increased through thequarter and reports 57.99%.

Board Assurance: The Guild have reviewed and enhanced the preceptorship programme to

attract Band 5 nurses into the Service to promote retention. A series of Exit Interview sessions have been planned in for Nursing

Support and Nursing staff who have notified us that they are leaving tohelp the service better understand the reasons people are leaving and tosee how this information can support a retention plan. Stay Interviewsessions are also being considered.

The Network are managing some small scale transformation programmesand a number of vacancies are being held to support displaced staff andthe redeployment process.

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

Trust 6493.39 5703.43 12.17% 57.49% 6499.97 5701.67 12.28% 63.34% 6522.00 5675.89 12.97% 62.65%

Mental Health 2956.79 2608.89 11.77% 53.82% 2952.68 2599.52 11.96% 59.64% 2972.52 2596.85 12.64% 57.99%

Community &

Wel lbeing1616.39 1462.55 9.52% 94.76% 1618.6 1465.24 9.48% 99.93% 1627.13 1449.51 10.92% 91.84%

Chi ldren & Young

People1103.15 990.14 10.24% 54.46% 1102.47 992.88 9.94% 65.17% 1094.92 980.29 10.47% 63.45%

Support Services 817.06 641.85 21.44% 34.00% 826.22 644.03 22.05% 38.59% 827.43 649.24 21.54% 42.84%

2017 11 2017 122017 10

Community & Wellbeing Network: The Establishment Vacancy Rate hasfluctuated through Q3, closing the quarter at an increased rate of 10.92%.91.84% of the vacancies are being actively recruited to, this is an increasedposition when compared to the close of Q2. The Network continues to facechallenges with recruitment in AHP disciplines and experienced a delay inrecruitment to Dental vacancies due to the redesign.

Board Assurance: The Network continue to drive recruitment programmes designed to

target hard to fill posts. The Network continue to manage transformation programme activity and

consideration is being given to skill mixing and recruiting differently toroles.

Vacancy Rate & WTE Hot Spot Analysis continued Source Data: ESR and Finance Ledger



VACANCY RATE

Children & Young People's Wellbeing Network: The Establishment VacancyRate has increased in Q3 from the Q2 position, closing the period at 10.47%.The Network are actively recruiting to around 63.45% of these vacancies,which is slightly lower than the Networks normal Active Vacancy rateperformance.

Board Assurance: 0-19 Universal Services have completed the Tendering process and we

are now in a period of legal challenge. The Network is currently reviewingwhether the holding of vacancies continues to be an appropriateresponse and whether the associated risks are tolerable from a patientcare and workforce wellbeing perspective.

Operational Gap is the measure of absences that affect operational performance otherthan Sickness and Annual Leave.

This section of the report considers employees who are absent from operational workfor the following reasons: Career Break, Maternity & Adoption, Paternity, Out onExternal Secondment (Paid), Out on External Secondment (Unpaid), Suspend No Pay,Suspend With Pay.

Operational Gap by Business Area – 12 Month Trend Source Data: ESR

OPERATIONAL GAP

Total Operational Gap Analysis, by Reason – Position as at 31st December 2017

0.00

50.00

100.00

150.00

200.00

2017 01 2017 02 2017 03 2017 04 2017 05 2017 06 2017 07 2017 08 2017 09 2017 10 2017 11 2017 12

F

T

E

Mental Health Community & Wellbeing Children & Young People Support Services Specialist Services

Indicator Heads FTE

Total Workforce 6393 5675.89

Mat / Adoption Leave 143 131.13

Career Break 18 12.41

Secondment 6 6.00

Suspension 10 9.96

Sickness Absence 453 399.89

Annual Leave 326 295.92

Total Workforce Gap 956 855.31

Active86.4%

Sickness Absence6.4%

Annual Leave4.8%

Mat / Adoption Leave 2.1%

Career Break0.2%

Suspension0.2%

Other0.4%

Operational Gap by Business Area – Quarter 3 Monthly Actuals, by Business Area Source Data: ESR

OPERATIONAL GAPOperational Gap is the measure of absences that affect operational performance otherthan Sickness and Annual Leave.

This section of the report considers employees who are absent from operational workfor the following reasons: Career Break, Maternity & Adoption, Paternity, Out onExternal Secondment (Paid), Out on External Secondment (Unpaid), Suspend No Pay,Suspend With Pay.

Average

FTE

Average No

Absent

Employees

Gap Average

FTE

Average No

Absent

Employees

Gap Average

FTE

Average No

Absent

Employees

Gap

Trust 5646.96 157.74 2.79% 5621.29 160.75 2.86% 5585.95 159.51 2.86%

Mental Health 2582.51 68.23 2.64% 2567.93 67.73 2.64% 2558.78 67.63 2.64%

Community & Wellbeing 1445.07 43.53 3.01% 1435.76 47.25 3.29% 1418.15 47.21 3.33%

Children & Young People 983.54 33.48 3.40% 979.28 35.45 3.62% 966.09 33.35 3.45%

Support Services 635.85 12.50 1.97% 638.33 10.32 1.62% 642.93 11.32 1.76%

2017 10 2017 11 2017 12

The Sickness Absence rate is calculated as follows:

Total absence (hours) during a month ÷ Total actual headcount contractedtime (hours) during a month x 100

Sickness Absence Rate – Year on Year 12 Month Trend AnalysisSource Data: ESR

SICKNESS ABSENCE

Sickness Absence Rates by Business Area – Quarterly Actuals

0.00%

2.00%

4.00%

6.00%

8.00%

10.00%


Current Yr Prev Yr Target

Rate Rate Rate

2017 10 2017 11 2017 12

% Long

Term

Absence

% Short

Term

Absence

Trust 6.88% 6.84% 7.32% 49.32% 50.68% 523,204 36,705 3,095,258

Mental Health 8.52% 8.22% 8.75% 52.08% 47.92% 239,111 20,323 1,666,510

Community & Wel lbeing 6.25% 6.58% 7.72% 42.54% 57.46% 134,108 9,191 756,664

Chi ldren & Young People 5.53% 5.48% 5.86% 53.14% 46.86% 90,809 5,107 467,276

Support Services 3.75% 3.94% 2.89% 44.75% 55.25% 59,176 2,084 204,809

Total

Available FTE

Days in

Quarter

Total FTE Days

Lost To

Sickness in

Quarter

Estimated

Cost to Trust

in Quarter £

Trend

12mths

2017 12

The Sickness absence rate is calculated as follows:


Sickness Absence Hot Spot Analysis Source Data: ESR

SICKNESS ABSENCE

0.00%

2.00%

4.00%

6.00%

8.00%

10.00%



Mental Health Network: Sickness Absence has undulated through Q3 and closesthe period at an increased rate of 8.75%.

Board Assurance: The management of sickness absence remains a top priority for the Network

and they have clear management plans in place for all short term and long termabsences.

Network focus on long term Sickness Absence continues and has resulted in thefacilitated return of 83 employees, the commencement of the redeploymentprocess for 3 individuals, 5 resignations and 4 dismissals due to capability duringQ3.

Care Group managers continue to be provided with detailed sickness absencedata for their localities, followed by meetings with Service Managers to agreeaction plans for every sickness absence case. These arrangements are workingwell.

0.00%

2.00%

4.00%

6.00%

8.00%

10.00%



Community & Wellbeing Network: Sickness absence has steadily increasedthroughout Q3 and closes the quarter with a rate of 7.72%. This closing ratemeans the Network have not met their sickness absence trajectory target for Q3.Seasonal factors and the continued roll-out of HealthRoster are considered ascontributors.

Board Assurance: Network focus on Sickness Absence continues and remains a top priority of

ExSMT and has resulted in 3 dismissals due to capability (ill health) during Q3. Action plans are in place for significant Long Term Sickness cases. Only 1 case

over 12 months remains active and will proceed to a hearing early Q4. The Network introduced new systems and processes in September to increase

business focus on sickness absence management. The impact of this can beseen in the policy compliance evidence being provided through the network forthe management of short term absence. More focus and scrutiny is planned inthis area through Q4 as compliance, although improved, remains low.

The Sickness absence rate is calculated as follows:


Sickness Absence Hot Spot Analysis Source Data: ESR

SICKNESS ABSENCE

Children & Young Persons Wellbeing Network: The sickness absence rate hasincreased through the Q3 period and closes the Quarter at 5.86%.

Board Assurance: The effective Management of Long Term Sickness has resulted in the facilitated

return of 45 employees, the commencement of redeployment for 1 individualand 1 dismissal due to capability (ill health) during Q3.

Through Q3, HRBP’s have supported the Network on focussing on Short Termrepeated Absence Management. This has been enhanced with theimplementation of a Case Conference approach to short-term absences.

Network report that they have not met their agreed sickness absence trajectoryat the close of Q3 reporting 5.86% against their Network target rate of 4.81%.Although this target has not been met, the absence rate reported for the closeof the quarter is an improved position on the same period last year, whichrecorded a closing position of 6.02%.

0.00%

2.00%

4.00%

6.00%

8.00%

10.00%



AGENCY & BANKSPEND

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

Usually, a link can be seen between the level of expenditure on peripheralworkforce (Bank, Agency and Locum), the Vacancy Rate, Sickness Absence andOperational Gap.

Bank & Agency Pay Spend by Business AreaSource Data: Finance, Healthroster & ESR


Trust 18,980,436 1,385,013 6.6% 450,291 2.1% 325,788 1.5% 2,161,092 21,141,528 10.22%

Mental Health 8,772,131 1,085,908 10.4% 356,069 3.4% 207,649 2.0% 1,649,625 10,421,756 15.83%

Community & Wel lbeing 4,361,753 160,395 3.3% 133,017 2.8% 149,092 3.1% 442,505 4,804,258 9.21%

Chi ldren & Young People 3,222,158 81,341 2.5% 7,382 0.2% 3,709 0.1% 92,432 3,314,590 2.79%

Support Services 2,624,394 57,369 2.2% -46,177 -1.8% -34,662 -1.3% -23,471 2,600,923 -0.90%


Trust 19,043,638 1,332,951 6.3% 319,252 1.5% 384,288 1.8% 2,036,491 21,080,129 9.66%

Mental Health 8,644,409 1,057,354 10.4% 190,804 1.9% 272,381 2.7% 1,520,539 10,164,948 14.96%



Support Services 2,825,622 53,001 1.9% -19,841 -0.7% -64,887 -2.3% -31,727 2,793,895 -1.14%

Flexible

Labour

Reliance %Total Spend

£

Flexible

Labour


£

Business Area

Total Core

Workforce

Spend £

Bank Agency Medical Agency

Business Area

Total Core

Workforce

Spend £

BankTotal

Peripheral

Workforce

Spend £

Total

Peripheral

Workforce

Spend £

2017 10

2017 11

Agency Medical Agency

AGENCY & BANKSPEND

Bank & Agency Pay Spend by Business Area Source Data: Finance, Healthroster & ESR



Mental Health Network: Reliance on peripheral workers has fluctuated throughthe Q3 period and, notable in this quarter, is the reliance fluctuates in line withthe Sickness Absence trend for this period. The Network report acuity ofService Users and Sickness Absence as key contributors to the level of spend onBank and Agency.

Board Assurance: Secure Services and the Harbour continue to hold weekly Bank and Agency

meetings to establish the reasons for high usage. The regular reviews conducted by the Care Teams to appraise the level of

service user acuity and staffing levels has resulted in a reduction in spend onPeripheral workers from an average weekly spend of £99,791 in Q2 to anaverage weekly spend of £87,106 through Q3.


Trust 18,947,950 1,794,994 8.3% 425,287 2.0% 383,517 1.8% 2,603,799 21,551,749 12.08%

Mental Health 8,579,817 1,428,084 13.6% 264,288 2.5% 229,068 2.2% 1,921,439 10,501,256 18.30%



Support Services 2,839,875 74,939 2.6% -21,949 -0.8% -38,026 -1.3% 14,963 2,854,839 0.52%

Flexible

Labour


£Business Area

Total Core

Workforce

Spend £

BankTotal

Peripheral

Workforce

Spend £

2017 12

Agency Medical Agency

Community & Wellbeing Network: Q3 has seen a slight increase in the use ofand spend on peripheral workforce at the end of the quarter and reports a finalposition of 8.92%. The network continues to see high usage in Southport &Formby Community Services, in Dental Services for sessional Dentists and forconsultants in LDS. These areas contribute to the increased spend on Agencyworkers. The Network continue to report vacancies and sickness absence ascontributors to the current level of spend on additional workforce.

Board Assurance: The planned changes in Dental Services have now been implemented and

this has started to realise a reduction on the reliance on Agency and BankWorkers since M7 in Q3.

Services continue to review their need for the use of Bank and Agency andutilise the usage escalation processes.

Bank and Agency usage in Learning Disabilities Supported Living Services hassignificantly increased following the implementation of HealthRoster. SeniorHRBP and Network Management continue to work closely with theHealthRoster Project Manager to understand the reasons why.

Hot Spot Analysis:

AGENCY & BANKSPEND

Bank & Agency Pay Spend by Business Area Source Data: Finance, Healthroster & ESR



Children & Young People’s Wellbeing Network: Reliance on peripheralworkers has been stable for the first 2 months of the quarter and seen asignificant increase in the final month of the period. The Increase is notable inthe Medical Agency Spend, reporting 3.5% for the December Period.

Board Assurance: The increase in spend on Medical Agency is indicative of the recent

engagement of 1 Speciality Doctor and 2 Consultants to fill ongoingvacancies. Discussions are underway with 2 of these individuals to convertthem from Agency to Trust Doctors, which will reduce agency spend in thelonger term.

TURNOVER

The Turnover Rate is one of the indicators used to assess employee satisfaction with theTrust. It is presented as a rolling 12 month figure, calculated at the end of eachreporting period and is calculated as follows:

Total number of leavers ÷ total number of contracted employees.

To provide the Board with a true picture of turnover activity in the Organisation, threemeasures of turnover are reported: Overall Trust Turnover, BAU Turnover and TUPETransfer Turnover.

Turnover Rate – 12 Month Trend Analysis Source Data: ESR

Leaving Reasons for QuarterTurnover by Business Area

0.00%

5.00%

10.00%

15.00%

20.00%

2017 01 2017 02 2017 03 2017 04 2017 05 2017 06 2017 07 2017 08 2017 09 2017 10 2017 11 2017 12

BAU Turnover TUPE Turnover All Turnover

Business AreaHeadcount

2017 122017 10 2017 11 2017 12

Trust 5,586 14.42% 14.56% 14.69%

Mental Health 2,559 7.55% 7.71% 7.62%

Community & Wellbeing 1,418 11.47% 11.65% 12.27%

Children & Young People 966 13.36% 13.56% 14.58%

Support Services 643 19.51% 20.03% 19.60%

Resignation61.5%

Retirement20.5%

Dismissal4.5%

End of FTC4.5%

Redundancy4.5%

Ill Health …

TUPE1.9%

TURNOVER

The Turnover Rate is one of the indicators used to assess employee satisfaction with theTrust. It is presented as a rolling 12 month figure, calculated at the end of eachreporting period and is calculated as follows:

Total number of leavers ÷ total number of contracted employees.

To provide the Board with a true picture of turnover activity in the Organisation, threemeasures of turnover are reported: Overall Trust Turnover, BAU Turnover and TUPETransfer Turnover.

Turnover Rate – Reasons for Leaving by Network Source Data: ESR

Business Area Dismissal End of FTCIll Health

RetirementRedundancy Resignation Retirement TUPE

Trust 7 7 4 7 96 32 3

Mental Health 5 0 1 1 34 10 3

Community & Wellbeing 2 1 0 2 25 16 0

Children & Young People 0 1 1 4 27 4 0

Support Services 0 5 2 0 10 2 0

APPRAISAL RATE

Appraisal Rate – Quarter 3 Performance Source Data: Learning & Development

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

49.05%50.95%

Overall Appraisal Compliance

% Compliant % Non Compliant

Active

HeadcountCompliant

%

Compliant

% Non

Compliant

Trust 6139 3011 49.05% 50.95%

Mental Health 2704 873 32.29% 67.71%

Community & Wellbeing 1655 1077 65.08% 34.92%

Children & Young People 1093 673 61.57% 38.43%

Support Services 687 391 56.91% 43.09% 0

20

40

60

80

100

120

Trust Mental Health Community &Wellbeing

Children &Young People

SupportServices

Act

ive

He

adco

un

t

Doctors Apprasials

Completed Medical Appraisal Process Exempt

0

1000

2000

3000

4000

5000

6000

7000

Trust MentalHealth

Community& Wellbeing

Children &YoungPeople

SupportServices

Act

ive

He

adco

un

t

AfC Appraisals

Signoff With Objectives & Review Taken Place

With Objectives Not Compliant With PDR Process

New Starters Not Registered on PDR New Starters Registered on PDR

APPRAISAL RATE

Appraisal Rate – Quarter 3 Performance Source Data: Learning & Development

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

Hot Spot Analysis:

Mental Health Network: The Network continue to track PDR compliance on amonthly basis at the Locality level. PDR Q3 compliance has increased slightly,but remains lower than the Network would like, reporting 32.29%.

Board Assurance: PDR compliance is monitored on a monthly basis at the Network People

Group Meeting and uses the Tier 2 monthly Network People PerformanceReport. SHRBP working closely with Care Group Managers to focus themon the key hotspot areas for improvement.

Children & Young Persons Wellbeing Network: PDR Compliance has steadilyimproved through the Quarter and reports 61.57% at the close. The Networkcontinue to track PDR compliance and are in the process of agreeing a NetworkPDR Compliance Trajectory.

Board Assurance: The Network discuss PDR compliance, compliance recovery and delivery

expectations at the monthly People and Leadership Sub-Committee Monthly individual level status reports are shared with the Network SMT and

CGM’s for targeted action.

Support Services: PDR compliance for Q3 has risen slightly against the Q2position but remains low, reporting 59.91% at the close of the quarter.

Board Assurance: SHRBP has commenced analysis of the PDR compliance information for

Support Services and is working with individual Directorates to review,understand and address hotspot areas.

Community and Wellbeing Network: The Network continue to track PDRcompliance on a bi-weekly basis. PDR Q3 compliance remains lower thanTrust target, but is a much improved position against Q2 performance.

Board Assurance: PDR compliance has been monitored on a monthly basis at the Network

SMT and People Group Meetings and uses the Tier 2 monthly NetworkPeople Performance Report. Bi-weekly reports are sent via HR to eachlocality to feed into monthly SMT.

The Network introduced new systems and processes in September toincrease business focus in this area. This sees the delivery ofimprovements being lead by service managers. A positive impact from thishas been experienced through Q3 with good progress in service lines inmost localities.

TRAINING & INDUCTION

The Induction rate calculation is as follows:Total Number of New Starters requiring Corporate Induction that haveattended within 28 dayS of starting in their new role.

Induction Completion Rate – Quarter 3 PerformanceSource Data: ESR and Quality Academy

The following New Starters are defined by Quality Academy as not requiringCorporate Induction: PIP Clinical Assessors (Employment is confirmed on successful completion

of PIP Training) Retiree’s returning to work within 6 months of leaving Individuals engaged to work on a short-term Fixed Term Contract (3

months or less)

New

Starters

New

Starters

requiring

Induction

Completed

induction

within 4

weeks

Not

CompletedIC Rate

New

Starters

New

Starters

requiring

Induction

Completed

induction

within 4

weeks

Not

CompletedIC Rate

New

Starters

New

Starters

requiring

Induction

Completed

induction

within 4

weeks

Not

CompletedIC Rate

Trust 59 54 52 2 96.30% 76 70 70 0 100.00% 48 45 44 1 97.78%

Mental Health 32 32 32 0 100.00% 28 26 26 0 100.00% 17 14 14 0 100.00%

Community & Wellbeing 13 10 9 1 90.00% 27 27 27 0 100.00% 16 16 15 1 93.75%

Children & Young People 12 11 11 0 100.00% 11 11 11 0 100.00% 13 13 13 0 100.00%

Support Services 2 1 0 1 0.00% 10 6 6 0 100.00% 2 2 2 0 100.00%

2017 09 2017 10 2017 11

0

10

20

30

40

50

60

70

2017 09 2017 10 2017 11

Not Completed

<28 Days


Mandatory Training covers 18 key indicator courses.

Source Data: Learning & Development

Mandatory & Statutory Training Compliance by Business Area – Position as at 31st December 2017

Hot Spot Analysis:

Mental Health Network: The Network are achieving the overall Trust Targetof 85% for mandatory training compliance and report an overall compliancerate of 91% at the close of Q3. This is an increase of 3% on the Q2 position.The Network continue to work closely with the Quality Academy to ensurethat courses are available for staff to attend to sustain and improvemandatory training compliance levels.

Board Assurance: MHN continue to explore and deliver new initiatives to increase the

accessibility of training and training resources for all staff to support theachievement of compliance rate improvement.

Community & Wellbeing Network: The Network are achieving the overallTrust Target of 85% for mandatory training compliance and report an overallcompliance rate of 92% at the close of Q3. Network continue to work closelywith Quality Academy to improve compliance in the two hot spot areas thatare currently non compliant.

Board Assurance: The Network continue to embed their new systems and processes to

improvement and compliance in this area. Improvement and compliancedelivery is now being lead by service managers.

Dedicated training sessions have been delivered in Southport


Total

E&D

3yr

Fire

Saf

ety

1yr

Hea

lth

& S

afet

y 3

yr

Info

rmat

ion

G

ove

rnan

ce 1

yr

Infe

ctio

n C

on

tro

l C

linic

al 1

yr

Bas

ic L

ife

Sup

po

rt 1

yr

Imm

edia

te L

ife

Sup

po

rt

1yr

Co

nfl

ict

Res

olu

tio

n 3

yr

Safe

guar

din

g C

hild

ren

L2

3yr

Safe

guar

din

g C

hild

ren

L3

3yr

Men

tal C

apac

ity

Act

L1

3

yr

Man

ual

Han

dlin

g L2

3yr

Man

ual

Han

dlin

g L3

2yr

Infe

ctio

n C

on

tro

l L1

2yr

Safe

guar

din

g C

hild

ren

L1

3yr

Safe

guar

din

g A

du

lts

L1

(+P

REV

ENT)

3yr

Men

tal C

apac

ity

Act

L1

(O

ne

Tim

e C

om

ple

tio

n)

Man

ual

Han

dlin

g L1

3yr

Trust 98% 92% 97% 94% 90% 81% 77% 89% 93% 86% 90% 86% 85% 95% 96% 96% 90% 96% 92%

Mental Health 99% 93% 98% 93% 91% 77% 76% 89% 93% 80% 91% 80% 81% 97% 99% 96% 94% 98% 91%

Community & Wellbeing 98% 90% 96% 94% 90% 79% 88% 89% 94% 79% 89% 92% 86% 94% 95% 96% 89% 95% 92%

Children & Young People 97% 91% 96% 94% 88% 91% 85% 89% 0% 94% 90% 90% 89% 95% 93% 94% 90% 94% 93%

Support Services 98% 93% 97% 95% 97% 86% 67% 93% 97% 100% 93% 89% 0% 95% 95% 95% 89% 97% 95%


Mandatory Training covers 18 key indicator courses.

Source Data: Learning & DevelopmentMandatory & Statutory Training Compliance Hot Spot Analysis continued..

Children & Young Persons Wellbeing Network: The Network are achieving theTrust target for overall compliance at the close of Q3, reporting 93%.

Board Assurance: The continued tracking and monitoring of compliance through the

Network People and Leadership sub group, whose role it is to support theachievement of compliance against each individual subject.

SAFER EMPLOYMENT

Core Workforce Quarter 3 Compliance

Safer Recruitment

Bank Workers Quarter 3 Compliance

Safer Recruitment

Safer Employment reports against the Trusts compliance with its legalobligations as an employer, in recruiting and providing a Safe Workforce.

The KPI’s presented measure the Trusts compliance against the SafeRecruitment Standards and Safer Staffing Frameworks in place within theNHS.

Safer Employment Safer Engagement

Business Area % Compliant % Compliant

Right to Work 100%

DBS Cleared pre 1st shift 98%

Visas & Work Permits 100%

Overall Compliance 99%


DBS Renewals 79%

Professional Membership

Registration Renewals80%

Visas & Work Permit Renewals 100%



Right to Work 100%

DBS Cleared pre start date 100%

Visas & Work Permits 100%



DBS Renewals 95%

Professional Membership Registration

Renewals99%




DBS Renewals 98%

Professional Membership

Registration Renewals100%



SAFER EMPLOYMENTCore Workforce

Source Data: ESR & Recruitment Team



Safe Recruitment Standards Compliance, by Business Area – Quarter 3 PerformanceRight to Work, DBS, Visa / Work Permit Checks and Professional Registration Validation

Business AreaTotal New

Starters

Total Right to

Work Entries

%

Compliant

Total New

Starters

Requiring DBS

Total No DBS

Entries

%

Compliant

Total No. New

Starters

requiring Visa /

Work permit

Total No.

Work Permit

/ Visa Entries

on ESR

%

Compliant

Trust 177 177 100% 158 158 100% 8 8 100%

Mental Health 68 68 100% 65 65 100% 8 8 100%

Community & Wel lbeing 54 54 100% 54 54 100% 0 0 100%

Chi ldren & Young People 30 30 100% 30 30 100% 0 0 100%

Support Services 25 25 100% 9 9 100% 0 0 100%

TUPE 0 0 100% 0 0 100% 0 0 100%

Business Area

Total New

Starters Requiring

Clinical

Professional

Registration

Total Clinical

Professional

Regsitration

Entries

%

Compliant

Trust 118 118 100%

Trust 40 40 100%

Mental Health 38 38 100%

Community & Wel lbeing 21 21 100%

Chi ldren & Young People 12 12 100%

Support Services 7 7 100%

Source Data: ESR, Recruitment Team, Medical & DentalTeam, Employee Relations Team




Safer Employment Compliance, by Business Area – Quarter 3 PerformanceDBS Renewals, Professional Membership Registration Revalidation and Visa and Work Permit Renewals

Hot Spot Analysis:

Professional Registration Renewals: 4 Professional Registrations have expiredthis quarter. 1 GMC and 3 NMC registrations.

Board Assurance: 1 GMC renewal has been confirmed by the individual but the GMC system

have not registered the renewal. GMC are looking into the issue. Theindividual is approved for work and ESR will be manually updated once theregistration status has been rectified on the GMC website (MHN)

1 NMC registration has expired – individual absent from work long term sick.NMC Registration will be required prior to their return ( C&YPN)

1 NMC Registration has expired – individual retiring from practice (C&WBN). 1 NMC Registration has expired – escalated to HRBP and Management and

case under investigation. Action has been taken to protect the Business andits (C&WBN)

Business Area

Total DBS

Renewals

Required

Total Number

of Expired

Entries

%

Compliant

Total

Professional

Membership

Renewals

Required

Total Number

of Expired

Entries on ESR

%

Compliant

Total No of Work

Permit & Visa

Renewals

Required

Total

Number of

Expired

Entries on

ESR

%

Compliant

Trust 79 4 95% 332 4 99% 1 0 100%

Mental Health 5 0 100% 151 1 99% 1 0 100%

Community & Wel lbeing 0 0 100% 94 2 98% 0 0 100%

Chi ldren & Young People 74 4 95% 54 1 98% 0 0 100%

Support Services 0 0 100% 33 0 100% 0 0 100%

Source Data: ESR, Recruitment Team, Medical & DentalTeam, Employee Relations Team




Safer Employment Compliance, by Business Area – Quarter 3 PerformanceDBS Renewals, Professional Membership Registration Revalidation and Visa and Work Permit Renewals

Q2 Safer Employment Compliance Hot Spot Update

Business Area

ProfessionalMembership

Renewals Q3 Update

Work Permit /Visa Renewals

Q3 Update

MHN 98% 99.4% 0% 100%

C&WBN 98% 98% - -

SS 88% 100% - -

Professional Membership Renewals: 3 of the 8 non compliant from Q2remain non compliant at the close of Q3.

Board Assurance: 1 outstanding NMC expiry – individual on Career Break, renewal will be

required prior to return (C&WBN). 2 outstanding NMC renewals continue to be investigated by HRBP’s. Steps

have been taken to protect the business and its patients. (C&WBN & MHN)

SAFER EMPLOYMENTBank Workers



Safe Recruitment Standards Compliance, by Business Area – Quarter 3 Performance (Bank Only Post holders) Right to Work, DBS, Visa / Work Permit Checks and Professional Registration Validation

Source Data: ESR & Temporary Staffing Team

Business AreaTotal No. New

Bank Workers

Total Right to

Work Entries% Compliant

Total No. New

Bank Workers

Requiring DBS

Total No. New

Bank Workers

Requiring DBS

Released to

Work

Total No

Blank Entries% Compliant

Total No. New

Bank Workers

requiring Visa /

Work permit

Total No.

Work Permit

/ Visa Entries

on ESR

% Compliant

Total Bank 61 61 100% 61 60 1 98% 4 4 100%

Clinical 47 47 100% 47 46 1 98% 4 4 100%

Non-clinical 14 14 100% 14 14 0 100% 0 0 100%

Medical 0 0 100% 0 0 0 100% 0 0 100%

Hot Spot Analysis:

DBS Checks: 1 Clinical Bank Only Worker is non-compliant against the DBS check requirements of their Bank Assignment this quarter.

Board Assurance: Individual presented for bank registration with a live DBS transferable under the

DBS Update Service. Update Service subscription expired during theengagement process and A new DBS clearance is now being applied for. Thisindividual will not be released for Bank work until DBS Clearance has beenupdated.





Safer Engagement Compliance, by Bank Worker type – Quarter 3 PerformanceDBS Renewals, Professional Membership Registration & Revalidation, Visa and Work Permit Renewals

Hot Spot Analysis:

DBS Renewals: 4 Clinical Bank Only Workers are non-compliant with the DBSrenewal requirements of their Bank Assignment this quarter.

Board Assurance: 3 have been contacted to reapply for their DBS Clearance and that process is

underway. Their Allocate BankStaff Status has been updated to ‘Inactive’ untilclearance has been granted.

1 has not responded to contact re the required renewal of their DBS clearanceand their registration with the Work Bank has ben terminated

Business Area

Total DBS

Renewals

Required

Total No.

Expired Entries% Compliant

Total

Professional

Membership

Renewals

Total No.

Expired Entries

on ESR

% Compliant

Total No.

Work Permit

& Visa

Renewals

Required

Total No. Expired

Entries on ESR% Compliant

Total Bank 186 4 98% 6 0 100% 0 0 100%

Clinical 151 4 97% 6 0 100% 0 0 100%

Non-clinical 35 0 100% 0 0 100% 0 0 100%

Medical 0 0 100% 0 0 100% 0 0 100%





Safer Engagement Compliance, by Bank Worker type – Quarter 3 PerformanceDBS Renewals, Professional Membership Registration & Revalidation, Visa and Work Permit Renewals

Q2 Safer Engagement Compliance Hot Spot Update

Business Area

DBS Renewals

Q3 Update ProfessionalMembership

Renewals Q2 Update

Clinical 86% 100% 94%c 100%

DBS Renewals: The 51 non-compliant Bank Only Workers from Q2 are now all resolved.

Professional Membership Renewals: 5 non compliant from Q2 are now all resolved.

Board of Directors


Report Title Board Assurance Framework (BAF) Quarter 3 Review


Prepared by Andrew Mawdsley, Risk and Assurance Business Partner

Presented by Julie-Ann Bowden, Associate Director of Risk and Assurance

Action required Decision

Supporting Executive Director Chief Executive


Report purpose To provide assurance in relation to the Q3 review of the BAF risks and request Board of Director’s decision on the end of quarter position.

Strategic Priorities this work supports


Board Assurance Framework risk This report contains an update relating to all BAF risks

CQC domain Well-led

PAPER DEVELOPMENT PROCESS:

Meeting Presented Action Date

All sub-committees within the governance framework over the course of Q2 have reviewed BAF risks and 15 and above risks

NA NA NA

Monthly Risk Update - SLT Andrew Mawdsley, Risk & Assurance Business Partner

Discussion 18.12.17

Q3 BAF Review Andrew Mawdsley, Risk & Assurance Business Partner

Discussion 22.01.18

1.0 INTRODUCTION 1.1 The Board of Directors has overall responsibility for ensuring that systems and controls are

in place that are adequate to mitigate any significant strategic risks which threaten the

achievement of the strategic objectives.

1.2 The strengthened management processes around the analysis and evaluation of risk which

compliments the governance arrangements, continues to support more detailed analysis,

which has provided Senior Leadership Team with an opportunity to look at the aggregation

of risk from a management perspective and examine the impact on the strategic priorities of

the organisation.

1.3 As part of the Q3 process the Board Assurance Framework (BAF) has been reviewed in

detail with each risk owner. The review has considered:

The need to consider the re-scoring of the BAF risks taking account of an assessment

of the assurances and controls and any gaps identified during Q3. This takes particular

account of assurances delivered through the governance meetings and information in

the Chairs’ Reports.

Work to strengthen the analysis of mitigating actions required to close the gap between

the current risk score and the target risk score.

Ensuring that systems and controls are in place that are adequate to mitigate any

significant strategic risks which threaten the achievement of the strategic objectives.

1.4 The report provides an opportunity for the Board to review the Q3 BAF risk position along

with the operational plan objectives aligned with the BAF. In addition, themes and gaps

that the Risk and Assurance team have identified as part of the risk profiling and assurance

mapping are included which has also been informed through discussions with Executive

Directors and reporting through to the corporate governance meetings.

2.0 RISK ASSURANCE PROCESS 2.1 Review of the Board Assurance Framework (BAF) is carried out at each committee and

sub-committee for the BAF risks, providing an opportunity to consider the information

relating to the BAF risks, commission additional assurances and identify any associated

risks that need escalating or de-escalating. Operational objectives that are mapped to the

BAF risks are included within the BAF risk reports, providing the position in terms of the

achievement of each objective. This supports the identification of any additional

assurances that may need to be commissioned by the Chair as well as recognising where

the achievement of objectives may support the mitigation and control of the BAF risks.

2.2 The 15 and above risks are scored using the Trust’s standard risk scoring matrix and are

aligned against the relevant BAF risk so that Executive Directors have the opportunity to

review significant operational risks as reported on Datix. These risks may also collectively

impact on the strategic risks contained within the BAF. The review of 15 and above risks

takes place in management meetings across the organisation as well as at sub-committee

level in the organisation.

2.3 To support the Q3 review of the BAF risks, the Risk and Assurance team has collated

assurance information throughout the quarter onto the Assurance Map. The information has

been identified through attendance at sub-committee meetings and review of chairs reports

from all sub-committees. The assurance mapping has been used to support discussions

with Executive Directors and assist with updating of the BAF risks. .

2.4 The Risk Surveillance activity that the Risk and Assurance Team have introduced during

Q2 includes a process of quality review of risks that are added to the Datix system. The

key focus for Q3 has been a review of the risk titles to ensure that they are framed

appropriately and reviewing long standing risks. Through adopting this proactive approach,

the team have also been able to support colleagues from across the organisation in their

understanding of the risk management process

3.0 REVIEW OF THE BAF STRATEGIC RISK REGISTER Q3

3.1 The quarterly review process provides an opportunity for Executive Director leads to meet

with the Risk and Assurance Team to discuss the update of their relevant risks. All these

meetings have taken place and adjustment to the BAF risks has subsequently been

undertaken prior to review by Senior Leadership Team on 22.01.18. The proposed end of

Q3 position for the BAF risks with associated operational plan objectives can be viewed in

Appendix 1.

3.2 The Heat Maps for the year to date can be reviewed in Appendix 3. There has been a

decrease in the scoring of risks during Q3 as follows:-

BAF risk 2.1 – If we do not work collaboratively with partners we will not be able to

influence system wide transformation.

This risk has decreased in score as a result of the collaborative work that has taken place

during Q3. It is acknowledged that the loss of universal services poses risks that will be

managed operationally but in the wider scope of the Trust there has been an increase in

collaboration work. Conversations have taken place to develop robust collaboration across

multi organisation recovery learning disability and the Trust is exploring partnership with

Cumbria Partnership. The joint integrated Discharge team with LCC and the CCGs is now

up and running.

4.0 REVIEW AND THEMING OF RISKS

The following themes have consistently been reported to Trust Board since Q1 2017/18.

These themes are still considered to be appropriate, with the relevant updated wording as

below:

4.1.1 Financial The challenge to close the financial gap and achieving the control total has increased

throughout the quarter. At the end of Q3 there is an improved position reported in that the

gap has reduced by £2m, with a saving of £4m still needing to be identified to achieve the

agreed control total. The position continues to be driven by staffing pressures as a result of

excess activity, sickness absence and high levels of acuity in in-patient services in

particular. The delayed progress in delivering against planned cost improvement

programmes, land sales, VAT and non-payment of additional activity are also key factors.

There is a continued focus on key actions in the Financial Recovery Plan to minimise the

impact of these pressures, with recognition that the impact of a health economy under

significant strain is a crucial element.

4.1.2 Workforce Clinical staffing shortages continue to be a key pressure during Q3 which have an impact

on the health and wellbeing of the people working in the organisation, as well as on the

financial position and ultimately the quality of services provided. This in turn is impacted by

Original Score 01.04.17

Score at Q1

Score at Q2 Score at Q3 2017/18 Risk

Target

12 12 12 8 8

3x4 3x4 4x3 2x4 2x4

a higher There are also continued challenges with recruitment, managing sickness

absence and core skills/ PDR compliance. The overall core skills rate is above the Trust

target of 85% (Q3 achieved 92% in mandatory and statutory overall compliance).

Compliance remains below target for 2 of the 18 key core skill indicators (Basic Life Support

81% and Immediate Life Support 77%) are below the target of 85%. The People Plan

continues to be a fundamental programme of work, although work is still required to ensure

that the People Plan is having the desired impact.

4.1.3 Quality The strong operational risk profile across a number of BAF risks highlights the significant

challenge in providing quality services which links closely to the other themes within this

report, such as finance and workforce in particular. There are continued challenges relating

compliance with regulatory requirements and learning from adverse events. Clinical staff

shortages continue to impact on the challenge to achieve safer staffing across the Trust.

Governance and risk management processes have been strengthened and there is on-

going delivery of our Quality Led Strategy, supported by the Quality Plan priorities. The

focused CQC inspection of the Trust is underway during quarter four.

High levels of acuity are impacting on staffing levels. Where this is related to placing of

patients within an inappropriate therapeutic environment, conversations are taking place

with commissioners to ensure that appropriate placements are found. The higher acuity

can significantly affect the staffing levels which in turn links to a correlation in increased

violence and aggression and instances of restraint. Quality Committee continue to review

assurances relating to the work underway to mitigate this.

4.1.4 Collaboration and Partnerships The Trust continues to be an active partner in system-wide clinical and non-clinical

workstreams, as well as Local Delivery Plans, leading and supporting the development of

new models of care. In Q3, the Board took the opportunity to consider in more detail our

place in the STP and the outputs from this session has sharpened our focus in a number of

key areas.

The collaboration between mental health services and acute services continues to be a

priority in supporting how the system responds to the winter pressures. The joint integrated

Discharge team with LCC and the CCGs is now up and running and the implementation of

Core 24 has taken place. Conversations are taking place to develop the collaboration with

Cumbria Partnership. The impact of the loss of the universal services contract continues to

be a factor in relation to the impact on the BAF risks.

5.0 OPERATIONAL RISK EXPOSURE

5.1 An in-depth review of the operational risks has been undertaken which has resulted in the

updating of the ‘operational risk exposure summary’ section for each BAF risk. These can

be viewed on the BAF document in Appendix 2. The analysis has also resulted in the

production of a thematic summary of the operational risks. This can be viewed along with a

breakdown of new, escalated, reduced and closed operational risks throughout Q2 at

Appendix 3.

6.0 RECOMMENDATION

6.1 The Board of Directors is requested to approve the BAF 2016/17 Risk Register at Q3

Board

Assurance Framework 2017/18

Q3 Position

BAF Risks 2017/18

Data extracted from Datix:

22 January 2018

APPENDIX 1

Board Assurance Framework Legend Strategic Priority: The 2017/22 strategic priority that the BAF risk has been aligned to. BAF Risk: The title of the strategic risk that threatens the achievement of the aligned strategic priority. CQC Domain: Key areas at the heart of the way that CQC regulates organisations.

2017/18 Shared Objectives: Provide a shared understanding of what our must dos are for 2017/18. The Trust has 7 shared objectives that are our focus for the next 12 months and each individual team or service business plan will contribute towards achieving them.

Risk Appetite Rationale: The statement that outlines the Board’s view on the level of risk willing to be taken against the relevant strategic priority that supports the management and actions taken to mitigate the risk.

Rationale for Risk: Further detail of what the BAF risk is taking account of which supports alignment of other elements, such as operational risk and controls/assurances. Key Work Programmes: There are the key programmes that support the delivery of the strategic objectives and support the mitigation of the BAF risks. Rationale for Current Risk Score: This narrative is updated on a quarterly basis and provides a summary of the information that has supported the assessment of the BAF risk. Provider Licence Compliance: NHS Improvement provider licence conditions that align to the BAF risk to provide assurance on compliance. Operational Risk Exposure: The key areas of operational risk scored 15 and above that align with the BAF risk and have the potential to impact on the score. Controls: The measures in place to reduce the risk likelihood or risk consequence and assist secure delivery of the strategic priority. Assurances: The measures in place to provide confirmation that the controls are working effectively in supporting the mitigation of the risk. Gaps in Controls: Areas that require attention to ensure that systems and processes are in place to mitigate the BAF risk. Gaps in Assurance: Areas where there is limited or no assurance that processes and procedures are in place to support the mitigation of the BAF risk.

Mitigating Actions: Operational plan objectives aligned to the BAF risks which on completion will provide additional controls to mitigate the BAF risk. When these actions are outstanding, they are an important consideration in assessing gaps in controls and assurances.

CQC Domains - Five questions asked of all services

Are they safe? Safe: you are protected from abuse and avoidable harm. Are they effective? Effective: your care, treatment and support achieves good outcomes, helps you to maintain quality of life and is based on the best available evidence. Are they caring? Caring: staff involve and treat you with compassion, kindness, dignity and respect. Are they responsive to people’s needs? Responsive: services are organised so that they meet your needs.

Are they well-led? Well-led: the leadership, management and governance of the organisation make sure it’s providing high-quality care that’s based around your individual needs, that it encourages learning and innovation, and that it promotes an open and fair culture.

Risk Rating Matrix (Likelihood x Consequence) Trust Board Risk Target Gap Director Lead:

Likelihood

Consequence Gap Score: 0 or

<0 Risk Target Achieved

CEO COO CFO HRD DoNQ MD

Chief Executive Chief Operating Officer Chief Finance Officer Human Resources Director Director of Nursing & Quality Medical Director

Insignificant 1

Minor 2

Moderate 3

Major 4

Catastrophic 5

5. Almost Certain

5 Moderate

10 High

15 Significant

20 Significant

25 Significant

Gap Score: 1 - 5 Tolerable

4. Likely 4 Moderate

8 High

12 High

16 Significant

20 Significant

Gap Score: 6 - 9 Close

Monitoring

3. Possible 3 Low

6 Moderate

9 High

12 High

15 Significant

Gap Score: 10 Concern

2. Unlikely 2 Low

4 Moderate

6 Moderate

8 High

10 High

Gap Score: 11> Significant

1. Rare 1 Low

2 Low

3 Low

4 Moderate

5 Moderate

BOARD ASSURANCE FRAMEWORK KEY

BOARD ASSURANCE FRAMEWORK DASHBOARD 2017/18

Strategic Priority BAF Risk Sub-

committee Director

Lead

Risk Score

01.04.17

Risk Score

Q1

Risk Score

Q2

Risk Score

Q3

Risk Score

Q4

2017/18 Risk

Target

2017/18 Risk

Target Gap

Final Risk

Target

Final Risk Target Gap

SP

1

Qua

lity

1.1 If we do not meet regulatory standards for quality and safety we will not be fit for purpose as care provider.

Quality & Safety

DoNQ 12 High

12 High

16 Significant

16 Significant 8

High

8 Close

Monitoring

4 Moderate

12 Significant

1.2 If we do not create a culture of learning then we will be unable to provide high quality care.


Significant 16

Significant 16

Significant 16

Significant 12 High

4 Tolerable

4 Moderate

12 Significant

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

Quality & Safety MD 16

Significant 16

Significant 16

Significant 16

Significant 12 High

4 Tolerable

4 Moderate

12 Significant

SP

2 Su

stai

nabl

e Se

rvic

es

2.1 If we do not work collaboratively with partners we will not be able to influence system wide transformation.

Business Dev & Delivery COO 12

High 12

High 12

High 8

High 8 High

2017/18 Risk Target Achieved

4 Moderate

4 Moderate

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


High 12

High 12

High 12

High 8 High

4 Tolerable

4 Moderate

8 Close

Monitoring

SP

3 E

xcel

lenc

e 3.1 If we do not engage with our patients and service users we cannot achieve excellence and quality.

Quality & Safety

DoNQ 12 High

12 High

12 High

12 High 8

High 4

Tolerable 4

Moderate

8 Close

Monitoring

3.2 If we fail to project our achievements then our reputation will not improve.


Significant 16

Significant 16

Significant 16

Significant 12 High

4 Tolerable

4 Moderate

8 Close

Monitoring

SP

4 P

eopl

e

4.1. If we do not support the health and wellbeing of staff we will struggle to attract, recruit and retain our workforce.

People HRD 20 Significant

20 Significant

20 Significant

20 Significant 10

High 10

Concern 5

Moderate 15

Significant

4.2 If staff are not provided with extensive education, training and leadership development we will not have an organisational culture that supports high performance.

People HRD 9 High

9 High

12 High

12 High 6

Moderate

6 Close

Monitoring

3 Low

9 Close

Monitoring

SP

5 M

oney

5.1 If we do not meet financial objectives we will not be able to provide sustainable services.

Finance CFO 15 Significant

20 Significant

20 Significant

20 Significant 10

High 10

Concern 10

High 10

Concern

5.2 If we do not work with partners to deliver system wide efficiencies this will undermine our own financial position and that of the STP.

Finance CFO 15 Significant

15 Significant

15 Significant

15 Significant 10

High 5

Tolerable 5

Moderate 10

Concern

SP

6 In

nova

tion

6.1 If we do not develop and maintain infrastructure, we will not be able to deliver safe, responsive and efficient care.

Infrastructure CFO 16 Significant

12 High

12

High

12 High 8

High 4

Tolerable 4

Moderate

8 Close

Monitoring

6.2 If we do not exploit the full capabilities of the new EPR system and wider technology to redesign services we will miss important opportunities to improve care.

Infrastructure CFO 16 Significant

16 Significant

16 Significant

16 Significant

8 High

8 Close

Monitoring

4 Moderate

12 Significant

Strategic priority Strategic Blueprint

Com

pass

ion

We will ensure that people who use our services are at the heart of everything we do, and the people who deliver and support delivery of services are motivated, engaged and proud to provide high quality, compassionate, continually improving care. We will empower people to share their stories so that we know how we are doing and we will listen to learn and to improve quality together. We will continue to strive to be the best that we can be by upholding our 8 quality commitments and the ‘I’ statements, empowering everyone to embrace these personal pledges, for example ‘I connect to my knowledge, skills and experience to deliver the best quality’ ‘I have the courage and strength to do the right thing’ ‘I go the extra mile, whatever the situation, whomever the person’

Inte

grity

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

• being the prime provider of specialist, acute and community mental health services, and • a lead provider in delivering new models of integrated physical and mental health out of hospital services, and • realising the benefits of our geographical footprint to deliver system-wide sustainable infrastructure solutions and organisational

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

Team

wor

k

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

Res

pect

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

Acc

ount

abili

ty

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

Exce

llenc

e

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


To deliver sustainable services that meet the needs of local people

To become recognised for excellence

To employ the best people

To provide financially sustainable services

To innovate and exploit technology to transform

care

Strategic Priorities 2017-22

BOARD ASSURANCE FRAMEWORK 2017/18

STRATEGIC PRIORITY: To provide high quality services DIRECTOR LEAD: Director of Nursing & Quality DATIX NO: 8500 BAF RISK: 1.1 If we do not meet regulatory standards for quality and safety we will not be fit for purpose as care provider.

DATE OF REVIEW: 31 Dec 2017 DATE OF NEXT REVIEW: 31 Mar 2018

CQC DOMAIN: Safe / Effective/ Caring/ Responsive / Well-led

2017/18 SHARED OBJECTIVE: To deliver Year 2 of our Quality Plan ensuring that quality remains our number one focus so that we keep people safe and give them the best possible experience and outcomes.

ASSURANCE SUB-COMMITTEE TO REVIEW: Quality and Safety ASSURANCE COMMITTEE TO REVIEW: Quality

RISK APPETITE RATIONALE: We are willing to take risk in those activities that have been identified to improve quality and clearly impact on motivating, engaging and empowering people who deliver and support delivery of services. (There is an averse appetite in relation to any impact on non-compliance with regulatory standards.) RATIONALE FOR RISK: This risk reflects the Trust position to not tolerate failure in basic standards of compliance which could compromise care quality, statutory requirements and licence conditions. This risk takes into account all issues that may prevent compliance with regulatory standards and includes issues relating to the delivery of safe services which may affect the quality of services. The key challenges relating to this risk include safer staffing, the reduction of violence and the improvements in harm free care.

KEY WORK PROGRAMMES • Quality Led Strategy and Quality Plan • 0-25 clinical pathway (DTS) • Transforming Care in Learning Disabilities (DTS) • Medicines Optimisation • Improving Access to IAPT (DTS) • Urgent Care Pathway • Inpatient Reconfiguration • Prime Provider/Contractor model (DTS)

QUALITY PRIORITIES

4. Application of Mental Health Law 5. Clinical Risk in Mental Health 7. Standards of Record Keeping 8. Staffing for Quality and Safety 9. Seclusion 10. End of Life Care 13. Pressure Ulcers 14. Medication Safety 15. Physical Healthcare in Mental Health

RISK RATING:


Score at Q1

Score at Q2

Score at Q3

Score at Q4

2017/18 Risk Target

Final Risk Target

12 12 16 16 8 4 3x4 3x4 4x4 4x4 2x4 1x4

RATIONALE FOR CURRENT RISK SCORE: The CQC Re-inspection in September 2016 rated the Trust as Good with an acknowledgement that there are some areas for improvement. Governance and risk management processes have been strengthened and there is on-going delivery of our Quality Led Strategy, supported by the Quality Plan. However, a CQC inspection of offender healthcare services at HMP Liverpool in September 2017 has identified areas for improvement and there are specific areas of concern in relation to quality such as safer staffing and violence. The focused CQC inspection of the Trust is underway during quarter four. As a result of these factors the risk has remained at 16 for Q3.

OPERATIONAL RISK EXPOSURE SUMMARY: PROVIDER LICENCE COMPLIANCE: There are a number of quality and safety themed risks relating to physical violence to staff, restraint and pressure ulcers. There are also operational risks relating to IG, data quality, mental health legislation and services provided at HMP Liverpool. These risks along with the risks resulting from staff shortages have a potential impact on quality and compliance with regulatory standards and Trust procedures.

G7 - Registration with the Care Quality Commission

CONTROLS: 1. Strong support from Quality Improvement function and Quality Governance function to clinical services 2. Strengthened professional leadership within the new Network structures 3. Ongoing delivery of the Quality Plan, People, Health Informatics Plan and Estates Plan 4. Patient safety initiatives - Harm Free Care, Reducing Restrictive Practices, Physical Health in Mental

Health, Sign up to Safety 5. Systems to support and demonstrate compliance with CQC and NHS Improvement quality governance

requirements - Quality Surveillance and Assurance Visits, etc. 6. Staffing for Quality and Safety improvement work 7. Improvement plans following inspections and audits (internal and external) 8. Use and development of quality governance systems (i.e. Datix, Friends and Family) 9. Delivery of the Capital Programme impacting positively on the estate and patient environment 10. Opening of new and expanded services to improve access, capacity and flow. 11. New clinical systems such as Electronic Prescribing and Medicines Administration (EPMA) and RiO 12. Focused sessions held with the highest spending areas in relation to Bank and Agency 13. Confirm and Challenge Meetings with wards to help staff in addressing some barriers that they experience.

ASSURANCES: 1. CQC Re-inspection Report – Rating Good (External) 2. Quality and Performance Reports tracking key indicators on a monthly basis – Significant assurance (Internal) 3. Monthly Safety Thermometer Reporting (Internal) 4. Quality Assurance Visits - LCFT and Commissioner (External) 5. Staffing for Quality and Safety Reports (Internal) 6. Health and Safety Audits, IPC Audits, Ligature Audits, PLACE Audits (Internal) 7. Clinical Audit Programme (Internal), Internal Audit Programme (External) ad-hoc Compliance Audits (Internal) 8. CQC Mental Health Act Monitor Visits (External) 9. Capacity and flow management processes (Internal) 10. Real time quality surveillance systems and dashboards (Internal) 11. e-Rostering usage continues to increase (Internal) 12. Improvement in 4 hour target in relation to patients requiring MH assessment – 89.4% in December 17 (Internal) 13. Continued progress has been made on ensuring compliance with the relevant legislation around safer recruitment (I) 14. High level of compliance against monitor risk assessment framework (2015) for learning disabilities – significant

assurance (external) 15. Notable decrease inred flag staffing incidents – significant assurance (Internal) 16. Robust process to ensure exec level clinical oversight of CIPs supported by assoicted QIAs (internal)

GAPS IN CONTROLS: 1. Despite improvement work, an increasing trend in violence and aggression 2. Challenges with achieving safe staffing levels across professions 3. Suitability of some parts of the estate (including community premises) 4. Increased acuity and demand in Mental Health Network 5. Health economy wide system resilience pressures

GAPS IN ASSURANCES: 1. Differing systems to record and capture data 2. Confidence in improvement plans and learning following adverse events 3. Alignment of financial codes to the team naming convention which has impact on various systems 4. Compliance remains low in relation to Mental Health Law 5. Highest levels of acuity are impacted partly by patients inappropriately placed 6. Responsiveness of estates responsiveness with the new hard FM provider 7. Completion of all 45 ligature audits completed – Limited assurance (3 remain outstanding) 8.

05

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April Q1 Q2 Q3 Q4

RiskScore

MITIGATING ACTIONS (Operational Plan Objectives):

NETWORK/SUPPORT SERVICE OBJECTIVE OUTCOME MEASURE DEADLINE Q3

POSITION

Medical Directorate

4. Align involvement in the benchmarking, national audit and accreditation programmes to achieve consistent completion and demonstrable improvements

Improvement in performance against benchmarking, national audit and accreditation projects Q4

15. Robust management of risk within the Medical Directorate All risks reviewed within appropriate timescales and evidenced by Medical Director’s SMT Q2

Health Informatics

5. Continue to implement Information Governance Improvement Action Plan

Identification of Trained asset owners and administrators across the Trust Visibility of assets and ownership, with visibility of Data Flow Maps for critical assets. Clear flow of assurance to SIRO and CGCSC

Q4

8. Improve Health Records Management Improved capability to store, track, scan and retrieve health records Q4

Pharmacy

1. To prepare a business case for EPMA in the community teams and subject to successful funding roll out in line with the project plan

EPMA will be implemented across all community teams in line with the agreed project plan and the identified benefits will be quantified and achieved

Q4

3. To develop the role of the Community Clinical Pharmacy Technician across all community mental health teams for all ages to support adoption of the Five Year Forward View for mental health in delivering the physical health care agenda and good medicines optimisation.

Our patients will have improved physical health monitoring and prescribing will be rationalised to deliver optimised outcomes Q4

4. To scope and develop outcome measures for effective medicines optimisation in order to support the Five Year Forward View for mental health.

Prescribing for our patients will be optimised and will be able to measure in terms of defined outcomes. Q4

7. To ensure that patients prescribed clozapine are monitored according to the requirements laid down in the SPC and that the prescribing risks are minimised with improved outcomes for patients

Patients prescribed clozapine will be managed within the requirements of the produce specification and licensing requirements for clozapine and the risks will be minimised.

Q4

Nursing & Quality Directorate

1. To provide Safe Services: People who use our services will receive high quality care from the right number of appropriately qualified and trained staff.

Reporting against Quality Plan metrics Q3

4. Demonstrate effective safeguarding practice & evidence that care is better and safer to safeguard people who use our services

Continued improvement in safeguarding standards and practice can be evidenced to show that care is better and safer Q4

10. Continue to deliver a comprehensive risk and assurance programme for the Trust

Fully systemised tool for reporting transparent, evidence based assurance supporting compliance Q4

11. To develop the knowledge and legal advice programme Knowledge and legal advice programme fully embedded across the organisation resulting in improved effectiveness and efficiencies Q4

Property Services 10. Support Secure Services (Guild Lodge) with increased and more effective dietetic support in liaison with catering services.

Service users receiving the correct nutrition for their condition and reduced consumption of takeaway food Q4

Company Secretary Team

1. Continue to embed a culture of good governance throughout LCFT in particular the design and implementation of formal network governance arrangements following the network redesign.

Well-evidenced Annual Governance Statement. Robust flow of assurance through organisation’s governance structure. Q4

2. Continue to embed the corporate policy framework, strengthening key policy and procedures within the Corporate Governance & Compliance remit.

Relevant policies refreshed in line with the Corporate Policy Handbook and evidence available in relation to the Trust’s compliance with the Standards of Business Conduct requirements.

Q4

3. Support the Trust Chair and Governors in the appraisal of Non-Executive Directors and ensure compliance with well-led requirements.

Appraisals undertaken and compliance with well-led framework. Q4

4. Support the Council of Governors to ensure effective discharge of their statutory responsibilities.

Clearly defined information flows and training which support the Governors in discharging their statutory responsibilities Q4

5. Deliver the Trust Annual Report and all governance related year-end reporting requirements.

Compliance with the Annual Reporting Manual and reporting requirements of the Trust’s Provider Licence. Q4

Children & Young People’s Wellbeing Network

1. Quality & Safety: To provide high quality care and experience for Service Users and Carers

To provide evidence against the quality visions outcomes and metrics Q4

4. Performance: To consistently deliver against contractual and regulatory requirements

Contract activity: Community contract ≤ 10% deviation from baseline NHSI compliance: 100% compliance with all targets 100% of CQUIN targets Contract activity: Community contract ≤ 10% deviation from baseline

Q4

Community and Wellbeing Network

1. Quality and Safety - To embed the Trust’s Quality Strategy across C&W ensuring the right care is delivered in the right place at the right time every time To provide evidence against the quality visions outcomes and metrics Q4

6. Service Delivery - To deliver compliance against regulatory, statutory and contractual targets, with particular focus on achievement of RTT 95% and 92%, improvement in activity planning and data quality.

Contracted activity against plan 95% and 92% RTT rheumatology PDS plus dental contract

Q4

Mental Health Network

1. To provide high quality care and experience for Service Users and Carers

10% Improvement in patient reported outcomes and experience from baseline 10% Improvement in results of Inpatient survey from baseline Delivery of CQUIN targets

Q4

4. To consistently deliver against contractual and regulatory requirements Contract activity: mental health contracts ≤ 10% deviation from baseline NHSI compliance: 100% compliance with all targets Q4

6. Transforming secure services Formulation and delivery on a transformation plan that is compliant with our contract, competitive in terms of other providers and reflects high quality, evidence based, safe care for our service users.

Q4

9. To demonstrate compliance in relation to all aspects of Mental Health Law Compliance with s.123 to be included in QPR from April 2017 Q4

BOARD ASSURANCE FRAMEWORK 2017/18 STRATEGIC PRIORITY: To provide high quality services DIRECTOR LEAD: Director of Nursing & Quality DATIX NO: 8501 BAF RISK: 1.2 If we do not create a culture of learning then we will be unable to provide high quality care. DATE OF REVIEW: 31 Dec 2017 DATE OF NEXT REVIEW: 31 Mar 2018 CQC DOMAIN: Safe / Effective/ Caring/ Responsive / Well-led


ASSURANCE COMMITTEE TO REVIEW: Quality ASSURANCE SUB-COMMITTEE TO REVIEW: Quality and Safety

RISK APPETITE RATIONALE: We are willing to take risk in those activities that have been identified to improve quality and clearly impact on motivating, engaging and empowering people who deliver and support delivery of services. (There is an averse appetite in relation to any impact on non-compliance with regulatory standards.)

RATIONALE FOR RISK: This risk reflects the Trust’s refreshed strategy in relation to providing high quality services with people who use our services at the heart of everything we do. A learning culture and environment taking into account complaints, feedback and patient stories is required to improve quality. Leadership and culture is a key element to how we can ensure continuous improvement.

RISK RATING:


Score at Q1

Score at Q2

Score at Q3

Score at Q4

2017/18 Risk Target

Final Risk Target

16 16 16 16 12 4 4x4 4x4 4x4 4x4 3x4 1x4

KEY WORK PROGRAMMES: • Quality Plan • People Plan • Benchmarking

QUALITY PRIORITIES: 1. Core Skills 2. Supervision 3. Appraisals 6. Holistic and Care Planning 12. Reduction in Violence and Aggression

RATIONALE FOR CURRENT RISK SCORE: The Trust has a range of approaches and systems to support the culture of continuous learning and improvement. These have been strengthened over recent years with initiatives such as the Investigations and Learning Team and refreshed Quality Plan. However, cultural change is a gradual process and there are some parts of the organisation where challenges exist to learning and improvement. Equally, service pressures impact upon learning and communication.

OPERATIONAL RISK EXPOSURE SUMMARY: PROVIDER LICENSE COMPLIANCE:

Learning from adverse events is not always embedded within teams and lack of consistent re-assessment process for patient admitted to 136 suites have an impact on on creating a culture of learning at the Trust.

C1 - The right of patients to make choices

CONTROLS: 1. Delivery of the Quality Plan 2. Launch and roll-out of the Life QI system to monitor improvement work 3. Introduction of a mortality review process 4. Involvement of commissioners in the Serious Incident Learning Panel 5. Development of a centralised investigations and learning function 6. Improvement plans following inspections and audits (internal and external) 7. Proactive improvement work through the Quality Improvement Framework 8. Refreshed approach to complaints using a hearing feedback principle 9. Learning programme to support people who investigate complaints and produce response

letters.

ASSURANCES: 1. Hearing Feedback Quarterly Report (Internal) 2. Serious Incidents Quarterly Report - Significant assurance (Internal) 3. Reports to the Quality and Safety Sub-committee from sub-groups and Networks (Internal) 4. Scrutiny of the Serious Incident Learning Panel (Internal) 5. CQC Re-inspection Report (Internal) 6. Clinical Audit Programme, Internal Audit Programme and ad-hoc Compliance Audits (Internal) 7. Internal benchmarking activity in relation to restrictive practices (Internal) 8. The person centred case management approach at Guild has had a positive impact with no complaints

breaching Trust deadlines or NHS regulations (Internal) 9. Zonal observations having positive impact on inpatient environment and supporting the reduction of

V&A (Internal)

GAPS IN CONTROLS: 1. Some areas of the Trust experiencing challenges with sustainable improvement

GAPS IN ASSURANCES: 1. The roll-out of Life QI is in an early stage so improvement work is recorded on local systems 2. Confidence in improvement plans and learning following adverse events 3. Timely completion of 3/7 day incident reviews 4. Some re-audits have not met the required standard – each audit struggled to improve quality

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2. To provide effective professional leadership Reporting against professional leadership assurance metrics Q4

8. To provide safe services Reporting against Quality Plan metrics as detailed in the Quality and Safety Surveillance Report Q4

9. To provide effective quality governance Reporting against Quality Plan metrics as detailed in the Quality and Safety Surveillance Report Q4

Medical Directorate 14. Implementation of a structured process for Maintaining High Professional Standards investigations

Set of structured letter templates for Case Investigators and Case Managers. Clear process setting out each stage of procedure for investigation

Q4





1. Quality and Safety - To embed the Trust’s Quality Strategy across C&W ensuring the right care is delivered in the right place at the right time every time

To provide evidence against the quality visions outcomes and metrics

Q4


1. To provide high quality care and experience for Service Users and Carers


Q4

5. Staffing at all times is at a level that allows safe and effective care Sickness absence ≤ 4.5% Mandatory and essential training completion >85%

Q4

BOARD ASSURANCE FRAMEWORK 2017/18 STRATEGIC PRIORITY: To provide high quality services DIRECTOR LEAD: Medical Director DATIX NO: 8502 BAF RISK: 1.3 If we do not provide integrated physical and mental health services we will lose opportunities to improve patient outcomes.


CQC DOMAIN: Safe / Effective/ Caring/ Responsive / Well-led



RISK APPETITE RATIONALE: We are willing to take risk in those activities that have been identified to improve quality and clearly impact on motivating, engaging and empowering people who deliver and support delivery of services. (There is an averse appetite in relation to any impact on non-compliance with regulatory standards.)

RATIONALE FOR RISK: The challenges relating to the quality of physical healthcare training for mental health staff as well as resource to deliver the training remain in 2017/18 and present a risk to the Trusts ability to provide high quality integrated care which improve patient outcomes. RISK RATING:


Score at Q1

Score at Q2

Score at Q3

Score at Q4

2017/18 Risk Target

Final Risk Target

16 16 16 16 12 4 4x4 4x4 4x4 4x4 3x4 1x4

KEY WORK PROGRAMMES: • Quality Plan • Medicines Optimisation • Prime Provider/Contractor Model

(DTS)

QUALITY PRIORITIES: 4. Application of Mental Health Law 15. Physical Healthcare in Mental Health

RATIONALE FOR CURRENT RISK SCORE: Requirement to improve whole person holistic care and ensure the organisation provides parity of esteem in relation to mental healthcare and physical healthcare. There is significant challenge to ensure that physical and mental health is delivered in a holistic way. Particular challenges in relation to this relate to the capacity to deliver and the quality of physical healthcare training for Trust staff. In addition, local authority public health spending cuts are impacting on commissioned services and population access to key health and wellbeing services. Clarification required of reporting structures for work streams which previously reported to PHPH group.


The key operational risks for this BAF risk relate to medicine management including risks associated with compliance with medicine management procedures, safety & security and storing of medicines and staffing shortages.

IC1 - Provision of integrated care

CONTROLS: 1. The Nerve Centre using the alert system for physical health care 2. MECC embedded into everyday practice for staff (MD Operational Plan obj 10) 3. Chief Clinical Information Officer in post who will lead on implementation of an EPR which supports

whole person health care 4. Weekly mortality reviews collating data related to mentally unwell patients. 5. Physical Health Assessment Management Escalation (PHAME) training has been commissioned

from a university to ensure it remains evidence based and up to date 6. Level 1 and 2 diabetes training has been developed in conjunction with the pharmacy team and

medicines management nurses 7. Hydration Assessment Procedure developed which includes a hydration assessment, revised fluid

balance chart, clinical pathways and training for staff 8. Monitoring of CQUINS and participation in national benchmarked audits

ASSURANCES: 1. MECC programme board is a sub-group of the Promoting Health and Preventing Harm Group and provides

regular update reports. (Internal) 2. Weekly Exec led SI meetings – (Internal) 3. Public Health Plan 2017-2020 – (Internal)

GAPS IN CONTROLS: 1. Areas of non-compliance with NMP 2. Lack of training in physical health competencies 3. Need to improve ability to deliver interventions through MECC 4. No consistent process to liaise with acute Trusts and manage SLAs 5. IT systems do not facilitate monitoring of patients on mental health drugs 6. IT systems do not facilitate monitoring and screening of physical health care.

GAPS IN ASSURANCES: 1. The PHPH group is no longer in place and currently there is no clear reporting mechanism for the

workstreams previously reporting to this group to provide any assurance. A new Quality Governance framework will support assurance around this risk, but will not be in place until April 2018

2. Deficiencies in EPR mean it is difficult to produce reports of effectiveness of physical health monitoring. 3. Mental health patients not participating in health screening programmes, and no mechanism to support this. 4. No reviews of SLAs and liaison pathways with acute Trusts to determine if clinical effectiveness is being

delivered. 5. Complete mortality review process not fully implemented

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Medical Directorate

5. To embed the implementation of the NMP in networks and realign the implementation actions appropriately between the corporate level and network level.

Notes of network meetings demonstrate they are considering the issues and acting on them. Q4

6. Embed MECC level 1 and level 2 in the organisation An increase in the training accessed by staff and development of a viable recording system to determine volume and output of conversations

Q4

7. Continue to develop the public health capacity in LCFT A member of a number of national and regional groups Progress being made towards being a health promoting hospital (if agreed)

Q4

8. To facilitate a co-ordinated and structured approach to the physical health care of service users with a mental health disorder.

Review of completed work plan to determine areas of improvement Q3

Pharmacy 3. To develop the role of the Community Clinical Pharmacy Technician across all community mental health teams for all ages to support adoption of the Five Year Forward View for mental health in delivering the physical health care agenda and good medicines optimisation.

Our patients will have improved physical health monitoring and prescribing will be rationalised to deliver optimised outcomes Q4


STRATEGIC PRIORITY: To deliver sustainable services that meet the needs of local people DIRECTOR LEAD: Chief Operating Officer DATIX NO: 8503 BAF RISK: 2.1 If we do not work collaboratively with partners we will not be able to influence system wide transformation.


CQC DOMAIN: Responsive / Well-led

2017/18 SHARED OBJECTIVE: To transform our services with partners, to meet the health and wellbeing needs of our local communities, as close to their homes as possible so that they get the right support at the right time.

ASSURANCE SUB-COMMITTEE TO REVIEW: Business Development and Delivery ASSURANCE COMMITTEE TO REVIEW: Finance and Performance

RISK APPETITE RATIONALE: We are willing to accept risks that will enable delivering system wide transformation and collaboration with partners. This may include new and novel business both inside and outside the principal footprint of Lancashire and South Cumbria. (There is an averse appetite in relation to any impact on non-compliance with regulatory standards). RATIONALE FOR RISK: This risk takes account of the refreshed blueprint statement which reflects the external environment that the Trust is now operating in particularly in relation to the STP and the introduction of new organisational forms. There has been a change in strategy from being patient focused through a commercial approach to being patient focused through a collaborative approach. This means that the trusts ability to work with partners is key to influencing commissioning decisions and system wide transformation. RISK RATING:


Score at Q1

Score at Q2

Score at Q3

Score at Q4

2017/18 Risk Target

Final Risk Target

12 12 12 8 8 4 3x4 3x4 3x4 2x4 2x4 1x4

KEY WORK PROGRAMMES: • Operational Plan • STP and LDP programme • Boards Strategic Alliance

QUALITY PRIORITIES: -

RATIONALE FOR CURRENT RISK SCORE: The Lancashire and South Cumbria STP Board has now been established, with a non-executive director from the Trust appointed as a member. The Chief Executive is also a Board member and has been appointed as the LDP lead for central Lancashire. Winter resilience has lower A&E admissions to Mental Health by 20% in month. Conversations are being had to develop a more robust collaboration across multi org recovery LD and exploring further conversations with Cumbria Partnership.


The operational risks aligned to this BAF risk are business development and commissioning themed risks which includes the contract requirements at HMP Liverpool , havingSLAs in place and maintaining OAT's costs whilst having a risk share agreement with CCGs

C2 - Competition oversight

CONTROLS: 1. Business Development Framework 2. Transformation Advisory Services (TAS) and SOP in place. 3. DTS Transformation Programme. 4. 2017-22 Strategic Plan 5. Strategic Alliance Policy - monitoring against policy commenced. 6. Trust Operational Plan 2017/18 to 2018/19 submitted to NHSI 7. Lancashire and South Cumbria Change Programme governance arrangements 8. Engagement with commissioners 9. Business Development and Transformation Group of reference agreed 10. Investment in Professional Leadership Model 11. Mapping of key STP meetings to ensure Trust representation is maintained 12. Introduction of the Integrated Discharge Team has supported patient flow including the

discharge of patients to the most appropriate place

ASSURANCES: 1. DTS dashboard reported to BDD sub-committee (Internal) 2. Work with voluntary sector – (Internal) 3. Cheshire Wirral Partnership for Perinatal and Mental Health Services (External) 4. Richmond Fellowship partnership for Crisis House (External) 5. Trust representation for STP - Exec lead for LD, Clinical Lead for MH (Internal) 6. Commercial Pipeline Paper to BDD (Internal) 7. STP refreshed governance arrangements supported by LCFT Board (Internal) 8. Active partner in the development of the Fylde and Wyre MCP model and a member of the MCP Alliance leadership team. (Internal) 9. A Locality based focus as a result of the network restructure at key meetings (Internal) 10. Trust represented on all STP Groups (Internal) 11. Capacity to manage collaboration outside organisation and sustain relationships (Internal) 12. Material benefits of Professional Leadership model to new model of care (Internal) 13. Assurance around the internal audit completed by MIAA - Demobilisation, Mobilisation and Transition of Services (Internal) 14. The Trust has complied across all the NHS Improvement (NHSI) indicators in December 2017 (Internal) 15. Improvement in 4 hour target in relation to patients requiring MH assessment – 89.4% in December 17 (Internal)

GAPS IN CONTROLS: 1. Alignment of plans across local health economy and Lancashire need further development 2. BBSC indicators reflect the refreshed strategy

GAPS IN ASSURANCES: 1. Monitoring of compliance with Strategic Alliance Policy 2. Shared understanding of aspirations in Central LDP 3. Trust representation on all STP groups 4. Implications of TUPE and non-award of HMP Liverpool contract

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Company Secretary Team 6. Develop greater knowledge and insight into the STP/LDP governance arrangements

Clear lines of accountability and reporting in relation to the Lancashire & South Cumbria STP and LDPs Q4

Pharmacy 6. To support the scoping and delivery of STPs, Vanguards, ACOs etc. in order to transform services across Lancashire in respect of good medicines optimisation.

Where identified collaborative working will deliver good medicines optimisation Q4

Communication & Engagement Service

3. To support the Trust’s aspiration to meet both the physical and mental health needs of local people, supporting them within their communities and close to their homes

Our stakeholders will tell us that our services are high quality when surveyed Q3

4. To communicate and engage with partners to support the transformation and delivery of services by building and strengthening relationships across the STP footprint.

Positive letter from the CEO after quarterly review with no concerns raised about sustainability of the service Q4

5. To support specialist services to work with partners across the relevant geographies (Lancashire and South Cumbria/North West) to transform and deliver specialist services for those people with the most complex needs, so they are met now and in the future

Key relationships and partnerships developed to support the Trust’s strategy Q4

Performance & Information & PMO

4. To maintain agility in reporting to ensure that activity and performance reporting continues to reflect new models of care delivery

LDP reporting metrics in place Q4

6. To develop approach and strategy required for outcome reporting Pre-work for 2018/19 Objective achieved Q4

7. Maximise the effectiveness of our Programme Management Strategy and Methodologies

Delivery of 17/18 programmes. Achievement of all critical goals Q4

Strategy and Transformation

1. Produce and publish the Trust’s Annual Planning Framework (APF) A published Annual Planning Framework for 18/19 Q2

2. Complete a review of the Trust’s Strategy, outlining next steps and linking to workstreams in the DTS Programme

A strategic plan for the Trust, that remains consistent with the wider LSC STP, and meets NHS Improvement expectations

Q4

5. Robust BD reporting including tender pipeline and resource planning to shape and lead the Trust’s approach to Business Development (Strategy, Bidding & Mobilisation)

BD report that captures all appropriate opportunities and risks in line with LCFT strategy and the wider LSC STP Q4

6. Deliver Transformational Change and contribute to Trust productivity and efficiency targets

Clearly defined approach to support teams in delivering measureable improvements in productivity and efficiency Q3

7. Business development Forum- Ensure processes in place to ensure that all BD decisions are based on the best available intelligence and made within the context of the developing market and existing potential partnerships

Clearly defined process applied to all business development opportunities Q4

8. The TAS team to take the lead on major transformation for all LCFT major strategic projects

Focused strategy and clearly defined approach to deliver major transformation and service mobilisation Q4

9. To lead and develop robust systems and processes for mobilisation and demobilisation Clearly defined process to lead and support teams Q4


5. Work with commissioners to determine priority areas within ‘RightCare’ and build an associated business case to support hospital avoidance and early discharge

Reduced A & E attendances for under 5 years within defined cohorts e.g. respiratory and IV therapy Q4

6. Transformation: to develop and implement a new safe and effective service model for CAMHS Tier 3 and Children’s Psychology Services in response to commissioning intentions

LCFT achieve prime provider status whilst maintaining safe and effective care , monitored by quality and performance metrics

Q4

8. Transformation: Develop a sustainable 0-19 Universal health visiting service which responds to commissioning intentions, links and supports the Chorley reform and maps against MCP development

Retain contract for 0-19 Universal health visiting service Q4




Q4

4. Transformation - To proactively lead the Network in its contribution to LCFT being a strong provider of community based services in Lancashire Achievement of Network CIP and control targets Q4

5. Business Development - To use clinical and business expertise to recommend and inform potential bids to pursue new business that maximises our potential for growth and stability and mobilise where needed.

Network income growth of 20% against baseline Q4

Mental Health Network 12. To improve quality and performance within Prison Healthcare Services Increase performance of the HJIP Report by March 2018 Q4

Nursing & Quality 11. To develop the knowledge and legal advice programme Knowledge and legal advice programme fully embedded across the organisation resulting in improved effectiveness and efficiencies

Q4


STRATEGIC PRIORITY: To deliver sustainable services that meet the needs of local people DIRECTOR LEAD: Chief Operating Officer DATIX NO: 8504

BAF RISK: 2.2 If we do not deliver new models of care we will cease to be a creditable lead provider. DATE OF REVIEW: 31 Dec 2017 DATE OF NEXT REVIEW: 31 Mar 2018

CQC DOMAIN: Responsive / Well-led

2017/18 SHARED OBJECTIVE: To transform our services with partners, to meet the health and wellbeing needs of our local communities, as close to their homes as possible so that they get the right support at the right time.

ASSURANCE SUB-COMMITTEE TO REVIEW: Business Development and Delivery ASSURANCE COMMITTEE TO REVIEW: Finance and Performance

RISK APPETITE RATIONALE: We are willing to accept risks that will enable delivering system wide transformation and collaboration with partners. This may include new and novel business both inside and outside the principal footprint of Lancashire and South Cumbria. . (There is an averse appetite in relation to any impact on non-compliance with regulatory standards.)

RATIONALE FOR RISK: This new risk reflect the refreshed strategic blueprints around delivering new models of integrated physical and mental health as well as out of hospital services. Failure to deliver new models of care may prevent the Trust from being a lead provider which may prevent sustainable services being delivered to local people. RISK RATING:


Score at Q1

Score at Q2

Score at Q3

Score at Q4

2017/18 Risk Target

Final Risk Target

12 12 12 12 8 4 3x4 3x4 3x4 3x4 2x4 1x4

KEY WORK PROGRAMMES: • Operational Plan • Strategic Alliance • Prime Provider/Contractor

Model

QUALITY PRIORITIES:

RATIONALE FOR CURRENT RISK SCORE: The mitigation of this risk was to invest in a professional leadership model with the expectation that there would be proposals for service re-design in the light of UK and international best practice. This was expected to deliver new models of care and attract workforce. We are now developing a Mental Health Primary Care model with GP input. The joint integrated Discharge team with LCC and the CCGs is now up and running. Developing the Mental Health decision units and all ages places of safety and implementation of Core 24. Due to implementation of early models of care we aim to hit the current scoring at the end of Quarter 4.


The key operational risks associated with this BAF risk relates to mobilisation of perinatal services and the loss of universal services. There are also operational risks associated with the delivering services at HMP Liverpool.

G8 - Patient eligibility and selection criteria

CONTROLS: 1. Strategic Plan 2017-22 sets out intent to be a lead provider across STP footprint 2. Operational plan 2017/18 aligned with refreshed strategy 3. Business Development meeting held fortnightly (to strengthen review process) between CFO

and COO to support commercial review of opportunities identified in pipeline 4. Annual Planning Framework 2017/18 in place 5. Engagement with commissioners 6. Business Development and Transformation Group Terms of reference agreed 7. Mobilisation and De-mobilisation policy 8. Network re-design to align management model to STP

ASSURANCES: 1. Delivering the Strategy sets direction (Internal) 2. BDD oversight (Internal) 3. Southport and Formby contracts went live from 1 May 2017 (External) 4. Mental Health Service Core 24 bid successful –(Internal) 5. Primary Mental Health model via STP – (External) 6. Perinatal and Mental Health Services (Internal) 7. CAHMs Tier 4 transformation (Internal) 8. Mobilization of new Perinatal Services (Internal) 9. Establish baseline metrics that enable new care models to be effectively evaluated 10. Developing a Mental Health Primary Care model with GP input. 11. The joint integrated Discharge team with LCC and the CCGs is now up and running 12. Developing the Mental Health decision units and all ages places of safety and implementation of Core 24 13. Sectorisation for Medical consultants

GAPS IN CONTROLS: 1. Alignment of plans across local health economy and Lancashire need further

development (Developed for MH but further clarity needed on Community)

GAPS IN ASSURANCES: 1. Timely mobilisation of perinatal services in accordance with plan (8853)Establish baseline metrics that enable new care models to be effectively evaluated

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Pharmacy 5. To support the Network redesign and new developments/acquisitions with respect to medicines optimisation

Organisational reset will be supported in terms of the delivery of good medicines optimisation Q4


3. To support the Trust’s aspiration to meet both the physical and mental health needs of local people, supporting them within their communities and close to their homes

Our stakeholders will tell us that our services are high quality when surveyed Q3



Company Secretary Team 6. Develop greater knowledge and insight into the STP/LDP governance arrangements

Clear lines of accountability and reporting in relation to the Lancashire & South Cumbria STP and LDPs Q4

Performance & Information PMO

2. Identify and realise the benefits of EPR in line with the implementation plan and timescales

Benefits identified with a plan for delivery in 18/19 Q4

3. To develop contractual/performance reporting for new business gained and extend methodology to existing business

Deliver regulatory and contracted measures Q2

5. Provide information, resources and tools to allow services to forecast and implement management actions

Performance metrics and trajectories achieved Q4


5. Robust BD reporting including tender pipeline and resource planning to shape and lead the Trust’s approach to Business Development (Strategy, Bidding & Mobilisation)

BD report that captures all appropriate opportunities and risks in line with LCFT strategy and the wider LSC STP Q4

7. Business Development Forum - Processes in place to ensure that all BD decisions are based on the best available intelligence and made within the context of the developing market and existing potential partnerships


9. To lead and develop robust systems and processes for mobilisation and demobilisation Clearly defined process to lead and support teams Q4



LCFT achieve prime provider status whilst maintaining safe and effective care , monitored by quality and performance metrics Q4

7. Transformation: to develop and implement a new safe and effective service model for CAMHS Tier 4 in response to NHSE commissioning intentions

LCFT achieve maintain Tier 4 contract and improve service offer to meet needs of revised service specification including bench-marking against national best practice , monitored by quality and performance metrics

Q4






Q4

4. Transformation - To proactively lead the Network in its contribution to LCFT being a strong provider of community based services in Lancashire Achievement of Network CIP and control targets Q4




2. To provide the right care at the right time and in the right (least restrictive) place through direct and indirect provision

Patient flow – occupancy of inpatient units ≤ 85% Q4

6. Transforming secure services Formulation and delivery on a transformation plan that is compliant with our contract, competitive in terms of other providers and reflects high quality, evidence based, safe care for our service users.

Q4

11. Ensure the Network is match fit in respect of perinatal services, and prepared to bid for the next wave of funding in order to develop these services.

Successfully securing of national monies as part of the next wave of funding to develop perinatal mental health services Q4


STRATEGIC PRIORITY: To become recognised for excellence DIRECTOR LEAD: Director of Nursing & Quality DATIX NO: 8505

BAF RISK: 3.1 If we do not engage with our patients and service users we cannot achieve excellence and quality


CQC DOMAIN: Responsive/Well-Led

2017/18 SHARED OBJECTIVE: To achieve recognition for excellence by seeking opportunities to lead whole patient pathways and contributing to the redesign of the organisation.


RISK APPETITE RATIONALE: We are willing to accept risks or circumstances where difficult decisions are taken for the right reasons where the benefits clearly outweigh the risks. Risks are actively taken where the benefits of ‘social capital’ demonstrates a significant reward. . (There is an averse appetite in relation to any impact on non-compliance with regulatory standards.) RATIONALE FOR RISK: This risk reflects the refreshed strategic blueprint in terms of effective and innovative involvement of people who use our services. It has been highlighted through benchmarking undertaken by our internal auditors that engagement and patient feedback is one of the top 10 most common BAF risks at Trusts. The Trust faces challenges in ensuring that recognition for excellence is achieved at both a local level within the STPs and with commissioners but also at national level. RISK RATING:


Score at Q1

Score at Q2

Score at Q3

Score at Q4

2017/18 Risk Target

Final Risk Target

12 12 12 12 8 4 3x4 3x4 3x4 3x4 2x4 1x4

KEY WORK PROGRAMMES: • People Plan • Quality Plan • Benchmarking

QUALITY PRIORITIES: 6. Holistic and Care Planning 10. End of Life Care 12. Reduction in Violence and Aggression

RATIONALE FOR CURRENT RISK SCORE: The Trust has in place systems and processes to hear feedback from people use service, their families and carers including real time patient feedback systems and a refreshed approach to complaints (using hearing feedback principles). The work around experience and involvement has been brought together aligning Network and Support Service teams. Challenges exist around timely responses to feedback. Overall upward trends in complainst is reported for Q3 which is reflected nationally.


Operational risks associated with this BAF risk relate current capacity of the Hearing Feedback Team so support networks and inability to drive/deliver QI's

G2 - Publication of information

G5 - NHSI guidance

CONTROLS: 1. Hearing Feedback Best Practice Principles policy and procedure 2. Quality Plan 3. People Plan 4. Real time patient feedback systems 5. Quality improvement activity from hearing feedback 6. Training programme for feedback reviewers (complaint investigators) 7. Implementation of Triangle of Care

ASSURANCES: 1. CQC Re-inspection Report (Internal) 2. Clinical Audit Programme and Internal Audit Programme (Internal) 3. Quality and Safety Report (Internal) 4. Hearing Feedback Quarterly Reports (Internal) 5. Reports to the Quality and Safety Sub-committee from sub-groups and Networks (Internal) 6. Real time patient feedback system (Internal) 7. Quality surveillance reports (Internal) 8. CQC patient surveys (Internal) 9. Network Quality and Safety Reports / Clinical Director Reports (Internal) 10. Friends and Family test results have been positive and above target since January 2017 (Internal)

GAPS IN CONTROLS: 1. Challenges in responding to complaints within policy timescales across some areas

GAPS IN ASSURANCES: 1. Embedding learning from feedback within all of the networks

0

5

10

15

20

25

April Q1 Q2 Q3 Q4

Risk Score

2017/18Risk Target

Final RiskTarget


NETWORK/SUPPORT SERVICE OBJECTIVE OUTCOME MEASURE DEADLINE Q3 POSITION







Q4

Mental Health Network 1. To provide high quality care and experience for Service Users and Carers


Q4


STRATEGIC PRIORITY: To become recognised for excellence DIRECTOR LEAD: Chief Operating Officer DATIX NO:8506 BAF RISK: 3.2 If we fail to project our achievements then our reputation will not improve. DATE OF REVIEW: 31 Dec 2017 DATE OF NEXT REVIEW: 31 Mar 2018 CQC DOMAIN: Responsive/Well-Led

2017/18 SHARED OBJECTIVE: To achieve recognition for excellence by seeking opportunities to lead whole patient pathways and contributing to the redesign of the organisation.

ASSURANCE SUB-COMMITTEE TO REVIEW: Business Development & Delivery ASSURANCE COMMITTEE TO REVIEW: Finance & Performance

RISK APPETITE RATIONALE: We are willing to accept risks or circumstances where difficult decisions are taken for the right reasons where the benefits clearly outweigh the risks. Risks are actively taken where the benefits of ‘social capital’ demonstrates a significant reward. (There is an averse appetite in relation to any impact on non-compliance with regulatory standards.) RATIONALE FOR RISK: This risk is aligned to the refreshed blueprint statements around organisational reputation and the Trust's ability to work as a collaborative co-producing partner. The risk reflects the challenges outlined in the strategic blueprint statement relating to being 'recommended by friends and family' and 'respected by commissioners and partners'. Promoting the organisation’s achievements is a key element to this risk. RISK RATING:


Score at Q1

Score at Q2

Score at Q3

Score at Q4

2017/18 Risk Target

Final Risk Target

16 16 16 16 12 4 4x4 4x4 4x4 4x4 3x4 1x4

KEY WORK PROGRAMMES: • Quality Plan • Benchmarking


RATIONALE FOR CURRENT RISK SCORE: This risk links closely the collaboration with partners and delivery of new models of care are factors that will contribute to enhancing the Trust reputation. 12 hour breaches, IAPT prevalence and services provided at the prisons are all key factors that the potential to drive reputational damage along with our relationship with commissioners and LCC assurance. The schedule for pro-active PR and social media Plan is a key factor in supporting the mitigation of this risk. A&E admissions for Mental Health being improved by 20%, prisons are still an issue but time limited.


There are a number of risks which have the potential to damage the Trusts reputation such as negative outcomes from high profile inquests, delivery the EPR system and negative public comments from GPs and/or Commissioners

G2 - Publication of information

G5 - NHSI guidance CONTROLS: 1. Dealing with the media policy 2. Staff Awards Events 3. Pro-active PR and Social Media Plan 4. Highlight of achievements through internal communications channels 5. Review of media coverage 6. The Communications’ Team provides a roundup of media coverage on a weekly basis via the

Board Briefing. 7. Sharing of achievements on social media platforms e.g. Trust Twitter account 8. Management of Trust website 9. Alignment of Communications and engagement team to clinical networks 10. Shout about success project 11. Life QI system 12. Participation in Combined Inpatient and Community MH national benchmarking project, 13. External comms & engagement framework

ASSURANCES: 1. Quarterly engagement score monitoring (Internal) 2. Staff Survey results (Internal) 3. Monthly KPI reports to Clinical Networks (Internal) 4. Quarterly KPI report to BDD sub-committee and Board to highlight media coverage and reputational issues (I) 5. Linking with clinical networks (Internal) 6. LCFT won a HFMA Award for Innovation (External) 7. LCFT was voted the top 50 employers which is an improved position by 25 places (External) 8. Trust has retained its mindful employer status (Internal) 9. AE admissions for Mental Health have improved by 20% prisons are still a problem but time limited (Internal) 10. LCFT won an award at the positive practice awards for the personality disorder network (External) 11. Social Value report (Internal) 12. Regular horizon scanning with networks to establish factors that may impact reputation e.g. 12hour breaches/

IAPT/ Prisons services (Internal) 13. The Trust hosted the Positive Practice in Mental Health Awards and the Psychosis and Bipolar Psychological

Care Network won the Psychological Therapies (Internal) 14. Disability Conflict Employer status (Internal)

GAPS IN CONTROLS: 1. Regularly scheduled reputation management training 2. Internal comms & engagement framework 3. Marketing Plan

GAPS IN ASSURANCES: 1. Receive an increase in the number of compliments 2. State of the nation report 3. Positive Relationship with LCC and Commissioners 4. Improved outcome in National audits

0

5

10

15

20

25

April Q1 Q2 Q3 Q4

Risk Score

2017/18Risk Target

Final RiskTarget



Communication & Engagement Network

1. To deliver a high quality communications and engagement service and constantly look for ways to do things even better

Positive letter from the CEO after quarterly review with no concerns raised about sustainability of the service.

Q4



Strategy and Transformation 9. To lead and develop robust systems and processes for mobilisation and demobilisation Clearly defined process to lead and support teams Q4

Medical Directorate

4. Align involvement in the benchmarking, national audit and accreditation programmes to achieve consistent completion and demonstrable improvements

Improvement in performance against benchmarking, national audit and accreditation projects Q4

7. Continue to develop the public health capacity in LCFT

A member of a number of national and regional groups Progress being made towards being a health promoting hospital (if agreed)

Q4


STRATEGIC PRIORITY: To employ the best people DIRECTOR LEAD: HR Director DATIX NO: 8507 BAF RISK: 4.1. If we do not support the health and wellbeing of staff we will struggle to attract, recruit and retain our workforce


CQC DOMAIN: Well-led 2017/18 SHARED OBJECTIVE: To deliver Year 1 of the People Plan so that we all play a part in making Lancashire Care a great place to work by living our values, supporting each other, being clear about what we need to do and ensuring we have the right skills to do it

ASSURANCE SUB-COMMITTEE TO REVIEW: People ASSURANCE COMMITTEE TO REVIEW: Quality

RISK APPETITE RATIONALE: We are willing to take risks in relation to innovative approaches to development our workforce and are prepared to take risks to ensure that our staff are of the highest quality, supported in their own health and wellbeing and in reaching their full potential. (There is an averse appetite in relation to any impact on non-compliance with regulatory standards.) RATIONALE FOR RISK: This risk reflects the ongoing workforce challenges facing the Trust in both the network and corporate functions. In addition, this risk includes communicating and engaging with staff to ensure that health and wellbeing is supported to prevent sickness and retain staff. This risk also considers the support provided to ensure that LCFT is seen as an employer of choice. RISK RATING:


Score at Q1

Score at Q2

Score at Q3

Score at Q4

2017/18 Risk Target

Final Risk Target

20 20 20 20 10 5 4x5 4x5 4x5 4x5 2x5 1x5

KEY WORK PROGRAMMES: • People Plan • Workforce Planning System • Occupation Health Service

Provision Options Appraisal

QUALITY PRIORITIES: 2. Supervision 8. Staffing for Quality and Safety 11. Supporting Staff 16. New Professional Roles

RATIONALE FOR CURRENT RISK SCORE: The Trust has made considerable progress in addressing the gaps in Assurance and Control, fundamental to the management of this BAF Risk, and in managing and mitigating BAF 4.1 aligned Risk. The People Plan has been a key focus over the last quarter, with a considerable amount of work being put into ensuring that the plan is fit for purpose and engages our workforce in the achievement of these important deliverables. The Q3 BAF Review has agreed that the Risk Score will remain at 20 in acknowledgment of the importance of measuring the impact of the interventions applied to this, and all associated, Risk and ensuring our workforce see, feel and report an improved employment experience.


There is a large operational risk profile associated with this BAF risk which relates to There is a large operational risk profile in this areas that relates to recruitment and retention of clinical staff (consultants, AHP and nurses) and staff shortages in clinical areas due to a lack registered nurses, staff sickness and lack of bank staff.

G4 – Fit and Proper Persons

CONTROLS: 1. People Plan and People Plan Steering Group 2. Workforce Planning Steering Group 3. Health & Wellbeing Charter 4. HR Risk & Compliance Management Group 5. Health Roster (needs to complete full trust rollout) 6. ePDR system, delivery Training, SOP, Guidance and Policy 7. DBS Policy & Procedure 9. WNS Organisational Hierarchy Control System 10. Attendance Management policy 11. Recruitment and retention policy 12. Temporary Staffing Policy and Procedure 13. Redeployment Process 14. Occupational Health Contract 15. Attendance Management Steering Group

ASSURANCES: 1. Employee Relations Activity & Compliance Monitoring Report – Significant assurance (Internal) 2. Recruitment Process Performance Monitoring (Internal) 3. Health Roster Management Performance (Internal) 4. Safe Care Monitoring Performance (Internal) 5. EFIN to ESR monthly reconciliation (Internal) 6. Assurance report to NHS Improvement re Agency Cap (Internal) 7. Equality & Diversity Inclusive Top 50 UK Employers Accreditation (External) 8. Quarterly Staff FFT Survey Reporting and Quarterly Engagement Score Monitoring (Internal) 9. Annual Staff Survey/Annual Staff Engagement Score increasing (Internal) 10. Quarterly Workforce Board Report and Workforce Planning Steering Group (Internal) 11. Medical & Dental Staffing Recruitment & Retention Plan (Internal) 12. Occupational Health Contract Performance Meetings (Internal) 13. Positive performance on employment checks and DBS compliance (Internal)

GAPS IN CONTROLS: 1. Leadership Code of Conduct 2. Workforce Planning Policy and Procedure (currently being internallay agreed) 3. Health Roster (Rollout Completion Planned) 4. Establishment Control SOP (Imminent) 5. New WNS system - Establishment Control (Imminent)

GAPS IN ASSURANCES: 1. Limited information available in relation to Compliance with EWTD regulations (resolution = HealthRoster

Implementation) 2. Working towards implementation of Health & Wellbeing Charter 3. Trust Wide Recruitment and Retention plan 4. No SOP in place for Establishment Control (Imminent) 5. There is limited use of internal service performance KPIs to ensure compliance with HR policy and procedure 6. Return To Work Quality Review Reporting (IAA) 7. Health & Wellbeing CQUIN Target Achievement Tracking (resolution commencing in Q3) 8. Delivery of apprenticeship levy plan 9. Rrealising the impact of delivery of the People Plan within the organisation

0

5

10

15

20

25

April Q1 Q2 Q3 Q4

Risk Score

2017/18Risk Target

Final RiskTarget



POSITION

Medical Directorate 18. Improve recruitment and retention of medical staff Medical recruitment website, improved survey results and induction feedback Q4

Nursing & Quality Directorate 3. To improve staff health and wellbeing across the Trust Progress against the workplace wellbeing charter and CQUIN plans reported Q4

Human Resources

1. Develop a proactive recruitment and retention strategy to attract the right people, recruited in the most efficient way with the values of the Trust at the heart.

Reduction in turnover in relation to specific roles Reduction in bank and agency usage Reduce time to recruit 100% compliance on employment checks.

Q4

2. To develop and enhance the temporary staffing function to contribute to the safety and quality of staffing levels

Reduction in bank and agency usage Reduced time to recruit 100% compliance on employment checks Increase online mandatory training compliance to 95% Increase bank fill rate to 90% Increase DBS compliance to 98% Increase face to face mandatory training compliance to 95%

Q4

3. To implement and maintain an effective E-Roster system across the organisation to support reduction in bank and agency usage by effective rostering

Increase in compliance around working time directive, reduction in bank and agency usage

Q4

4. To develop systems and processes to enable the delivery of supportive, timely and robust ER interventions, Including case investigations.

100% compliance for policies against review date and in line with employment legislation. Reduction in investigation turnaround time to a maximum of three months Reduction in no. of live cases longer than six months and those that are of this duration or more are exceptional/unavoidable in circumstance. Improvement in the overall quality of investigation reports presented to panels.

Q3

5. To further develop the delivery of Operational HR processes and services across the Trust.

Internal mediation programme in operation. Reduction in the number of redundancies. Reduction in number of Employment Tribunal claims. Reduction in sickness absence. Improved staff morale (staff survey feedback).

Q4

6. To ensure the medical staffing function continues to act within the legal framework and develops new ways of working to ensure continuous improvement.

100% completion of job plans. Improved job planning process quality creating greater efficiency and generating improved outcomes for service users. Junior Doctor Contract implemented in line with national timeframes 7-day working implemented leading to greater productivity and efficiency across services. Increased consistency in practice and outcomes for service users. Reduction in sickness absence. Reduction in employment tribunal claims.

Q4

7. Support the reduction in sickness absence across the Trust to achieve Trust target of 4.5%.

Reduction in sickness absence to achieve target of 4.5% across the Trust. Introduction of in-house Occupational Health Service.

Q4

11. To ensure that Organisational Change Policy and Practice facilitate delivery of the Trust’s commitment to its target zero redundancy, whilst supporting the Trust’s vision of delivering high quality care in the right place at the right time every time.

Reduction in the number of Employment Tribunal claims linked to Organisational Change. Improved staff resilience through change (Staff FFT Workforce Module)

Q4

12. Proactively support the Trust in meeting the requirements set out in the Equality and Diversity Statement of Intent 2015-2020

Improved Workforce Race Equality Standard (WRES) scores Equality Delivery System (EDS2) scores of Achieving and Excelling Improved staff survey scores (on E&D relevant questions) Accreditations and Awards Maintained online toolkits Assurance reports Regular communications

Q4

Finance

5. Ensure Compliance with Trust Indicators Compliance with Trust Indicators Q1 - Q4

9. Maintain and Adapt Finance Department Resilience and Sustainability Reduction in number of temporary staff Q4


3. People and Leadership - To ensure our services are appropriately staffed with people who have the right skills and who are supported to be the best they can be.

Network workforce plan developed Improved staff survey results Reduced Medical staffing risk rating from current score 15 to target score 4

Q4



Compliance with all mandatory training metrics. Achieve the Trust sickness absence target. Mandatory and essential training completion >85% achieved Reduction in recruitment time > 85% of staff have an annual PDR Turnover rate improved and maintained at less than 10% 100% of nurses achieve revalidation Improved staff engagement

Q4


5. Staffing at all times is at a level that allows safe and effective care

Sickness absence ≤ 4.5% Mandatory and essential training completion >85% Q4

7. Develop an open and transparent culture in line with the Trust Values

Improved flow of communication from front line staff to senior management team, and improved relationships measured by the results of the engagement survey.

Q4


STRATEGIC PRIORITY: To employ the best people DIRECTOR LEAD: HR Director DATIX NO: 8508 BAF RISK: 4.2 If staff are not provided with extensive education, training and leadership development we will not have an organisational culture that supports high performance.


CQC DOMAIN: Effective/Well-led 17/18 SHARED OBJECTIVE: To deliver Year 1 of the People Plan so that we all play a part in making Lancashire Care a great place to work by living our values, supporting each other, being clear about what we need to do and ensuring we have the right skills to do it

ASSURANCE SUB-COMMITTEE TO REVIEW: People ASSURANCE COMMITTEE TO REVIEW: Quality

RISK APPETITE RATIONALE: We are willing to take risks in relation to innovative approaches to development of our workforce and are prepared to take risks to ensure that our staff are of the highest quality, supported in their own health and wellbeing and in reaching their full potential. (There is an averse appetite in relation to any impact on non-compliance with regulatory standards.) RATIONALE FOR RISK:. The People Plan has been finalised and is being delivered with a full implementation plan in place, however there are a number of 15 and above operational risk relating to compliance with core skills and training which have contributed to this risk transferring into 2017/18. The delivery of the People Plan over the next three years will also support how this risk is managed and controlled. RISK RATING:


Score at Q1

Score at Q2

Score at Q3

Score at Q4

2017/18 Risk Target

Final Risk Target

9 9 12 12 6 3 3x3 3x3 4x3 4x3 2x3 1x3

KEY WORK PROGRAMMES: • People Plan • Workforce Planning System

QUALITY PRIORITIES: 1. Core Skills 2. Supervision 3. Appraisals 11. Supporting Staff 12. Reduction in Violence and Aggression 16. New Professional Roles

RATIONALE FOR CURRENT RISK SCORE: During Quarter 3 the Directorate has focussed on Core Skills Compliance. The Directorate have been concentrating on recovery and the achievement of the Core Skills Compliance Targets and giving attention to improving the clarity of Core Skills requirements by Role, Compliance Reporting arrangements and delivering the Trust compliance targets sustainably. The Q3 BAF Risk Review agreed that the Risk Score would remain at a score of 12 to reflective the overall Core Skills position and that 5 out of 14 important subjects remain below the Trust target of 85%.


The operational risks associated with this BAF risk relating to compliance with training particularly for mental health, mental capacity, deprivation of liberty and violence reduction. There is also a risk highlighting the lack of a training needs analysis for the Trust.

No Provider Licence Conditions mapped to this BAF risk

CONTROLS: 1. Quality Plan 2. People Plan Steering group 3. Workforce Plan 4. Programme of Induction 5. Learning and development policies and procedures 6. ePDR system 7. PDR Delivery Training, SOP, Guidance and Policy 8. Talent Management Pathway 9. Valued based Behavioral Framework 10. Additional training sessions has been provided in more convenient sessions for the areas of

core skills where compliance is still below target. 11. Core and Essential Skills Training Programme

13. Medical appraisal system 14. People Plan

ASSURANCES: 1. Reporting on Core Skills compliance (Internal) 2. Reporting on ePDR compliance (Internal) 3. People Sub-committee scrutiny (Internal) 4. Quality & Safety Sub-committee scrutiny (Internal) 5. Employee Relations Activity & Compliance Monitoring Report (Internal) 6. HR Delivery & Governance Management Group (Internal) 7. Quarterly Staff FFT Survey Reporting (Internal) 8. Quarterly Engagement Score Monitoring (Internal) 9. Monthly Network and Corporate Report – PDR Compliance (Internal) 10. LEP Annual Report provides positive assurance meaning no scheduled visit from HENW required in 2018

(Internal)

GAPS IN CONTROLS: 1. Some areas of non-compliance with Core Skills requirements 2. Leadership code of Conduct 3. Workforce Planning Policy and Procedure 4. PDR Non-compliance sanctions 5. Professional skills training 6. Sign off of the Revised Core Skills map to Roles Framework (TNA) 7. Training Systems and Process quality

GAPS IN ASSURANCES: 1. Timeliness of employee changes in ESR (employee moves, recording of sickness etc..) impacts on the ability

to provide accurate Core Skills Compliance Information 2. There is limited use of internal service performance KPIs to ensure compliance with HR policy and procedure 3. Implementation of workforce planning and ESR/HR payroll internal audit actions 4. Core Skills Compliance Recovery Trajectory for the period June to December 2017 5. Compliance with EPDR target 6. No information is available in the Life QI system for Core Skill and Appraisal

0

5

10

15

20

25

April Q1 Q2 Q3 Q4

Risk Score

2017/18Risk Target

Final RiskTarget


NETWORK/ SUPPORT SERVICE

OBJECTIVE OUTCOME MEASURE DEADLINE Q3 POSITION

Company Secretary Team

3. Support the Trust Chair and Governors in the appraisal of Non-Executive Directors and ensure compliance with well-led requirements.

Appraisals undertaken and compliance with well-led framework. Q4

4. Support the Council of Governors to ensure effective discharge of their statutory responsibilities.

Clearly defined information flows and training which support the Governors in discharging their statutory responsibilities Q4

Medical Directorate

2. Evaluation of the consultant development programme Reportable conclusions on Year 1 to influence the success of Year 2 and future cohorts Q4

3. Embed the use of consultant dashboard A useable dashboard in place for OAMH Q4

12. Development of library services

Improved LQAF accreditation score compared with 16/17. Survey reports and action plans for staff and service users library services. Uptake in library information skills training.

Q4

13. Development of appraisal and revalidation system 95% of doctors completing appraisal and revalidation Q4

16. Promote movement of interested doctors though the Certificate of Eligibility for Specialist Registration (CESR) program to decrease number of Acting Consultants without Certificate of Completion of Training or CESR.

Appointment of SAS Tutor Q4

17. Deliver Annual Educators Conference Conference held and evaluation of feedback Q2

19. Implement required actions following Deanery visit All actions fully implemented Q3

20. Introduce Annual Educational Appraisal and review its progress. All educators to complete Annual Educational Appraisal Q4

Communication & Engagement

2. To ensure the Communication & Engagement team will all play a part in making Lancashire Care a great place to work by living our values, supporting each other, being clear about what we need to do and ensuring we have the right skills to do it

Achievement of all workforce KPIs Q4

Finance 9. Maintain and Adapt Finance Department Resilience and Sustainability Reduction in number of temporary staff Q4


1. To provide Safe Services: People who use our services will receive high quality care from the right number of appropriately qualified and trained staff.

Reporting against Quality Plan metrics Q3

2. To provide effective professional leadership Reporting against professional leadership assurance metrics Q4

6. To drive continual quality improvement The Quality improvement metrics within the Quality Plan are achieved Q4

7. To improve the experience of people who use our services Reporting against Quality Plan metrics Q4

Human Resources

2. To develop and enhance the temporary staffing function to contribute to the safety and quality of staffing levels

Reduction in bank and agency usage Reduced time to recruit 100% compliance on employment checks Increase online mandatory training compliance to 95% Increase bank fill rate to 90% Increase DBS compliance to 98% Increase face to face mandatory training compliance to 95%

Q4

4. To develop systems and processes to enable the delivery of supportive, timely and robust ER interventions, Including case investigations.

100% compliance for policies against review date and in line with employment legislation. Reduction in investigation turnaround time to a maximum of three months Reduction in no. of live cases longer than six months and those that are of this duration or more are exceptional/unavoidable in circumstance. Improvement in the overall quality of investigation reports presented to panels.

Q3

6. To ensure the medical staffing function continues to act within the legal framework and develops new ways of working to ensure continuous improvement.

100% completion of job plans. Improved job planning process quality creating greater efficiency and generating improved outcomes for service users. Junior Doctor Contract implemented in line with national timeframes 7-day working implemented leading to greater productivity and efficiency across services. Increased consistency in practice and outcomes for service users. Reduction in sickness absence. Reduction in employment tribunal claims.

Q4

8. Redesign/Transform the HR services to provide HR excellence

Positive service experience feedback from networks and other support services Positive quarterly review meetings Delivery on all HR service action plans

Q4

9. To work in partnership with Finance, Nursing and Quality, Health Informatics, Business Intelligence and our Payroll provider to maximise the quality, performance and integration of the Electronic Staff Record (ESR)

Person to position alignment between Finance SIP list and ESR Staff List Established Vacancy Rate at the ESR position level. Alignment of all LCFT systems that reference and utilise Team, Cost Centre and the Organisational Structure for operating and reporting purposes

Q4

10. Introduce a live and real time Workforce Planning approach to LCFT and embed workforce planning into operational service planning and delivery.

Consistent Workforce Planning Activity and documentation outputs across the Trust Quarterly WFP data capture and trajectory monitoring

Q4


3. Continuing to support the delivery of an integrated approach to communicating and embedding the Trust’s strategy

Contributes to an increase in staff engagement scores as part of National Staff Survey Q4

4. Develop and deliver a workforce sustainability plan for Strategy and Transformation Improved retention of staff with clear succession plan in place Q4



Network workforce plan developed Improved staff survey results Reduced Medical staffing risk rating from current score 15 to target score 4

Q4


STRATEGIC PRIORITY: To provide financially sustainable services DIRECTOR LEAD: Chief Finance Officer DATIX NO:8509 BAF RISK: 5.1 If we do not meet financial objectives we will not be able to provide sustainable services DATE OF REVIEW: 31 Dec 2017 DATE OF NEXT REVIEW: 31 Mar 2018 CQC DOMAIN: Well-led 2017/18 SHARED OBJECTIVE: To do things better and more efficiently so that we

deliver the savings that the Trust needs to make and contribute to the overall saving needed in Lancashire and South Cumbria.

ASSURANCE SUB-COMMITTEE TO REVIEW: Finance ASSURANCE COMMITTEE TO REVIEW: Finance and Performance

RISK APPETITE RATIONALE: We are willing to take risk that represents a consistent focus on the best possible return for the organisation, local partners and local people. (There is an averse appetite in relation to any impact on non-compliance with regulatory standards.) RATIONALE FOR RISK: The financial challenges faced by the Trust have continued to present a risk to the delivery of the control total during 2016/17. This risk will continue in 2017/18 taking account of the sustained financial challenges that the Trust faces in the coming year. There is also a risk in relation to how a shared control total may be introduced across the STP and the impact this will have on the Trust. RISK RATING:


Score at Q1

Score at Q2

Score at Q3

Score at Q4

2017/18 Risk Target

Final Risk Target

15 20 20 20 10 10 3x5 4x5 4x5 4x5 2x5 2x5

KEY WORK PROGRAMMES: • Financial Plan Benchmarking • Capital Programme • DTS Programme • Capacity and Flow Plan

QUALITY PRIORITIES: 8. Staffing for Quality and Safety

RATIONALE FOR CURRENT RISK SCORE: After adjusting for impairments of £0.2m the adjusted deficit for month 8 is £1.9m which excludes year to date planned Sustainability and Transformation Funding of c£1.1m, against a plan surplus to date of £0.9m. Performance is therefore £2.9m behind the plan and £1.6m behind the control total (excluding STF). The position continues to be driven by staffing pressures in ward and prison areas and the slow start to delivery against planned cost improvement programmes. In addition, expenditure is exceeding funding on OAPs resulting in current and forecast pressures. Performance does however show an improvement on the Month 7 position of £0.5m and an in month surplus over plan of £0.3m. Unmitigated projections indicate a gap of c£4.6m (£6.8m including STF), which highlights the challenge the Trust faces in achieving the control total.

OPERATIONAL RISK EXPOSURE SUMMARY: PROVIDER LICENSE COMPLIANCE: The operational risks associated with this BAF risk related to staffing, use of bank and agency and property services (repayment of debts and vacated leases), non-achievement of the control target, achievement of CIP plans and capital expenditure.

COS1 - Continuing provision of Commissioner Requested Services COS3 - Standards of corporate governance and financial management COS4 - Undertaking from the ultimate controller COS5 - Risk pool levy COS6 - Cooperation in the event of financial stress COS7 - Availability of resources FT2 - Payment to NHSI in respect of registration and related G9 - Application of Section 5 (Continuity of Services)

CONTROLS: 1. Trust is working with a number of partners to understand the relative efficiency of its services 2. Standing Financial Instructions and Decision Rights Framework (update due Jan 18) 3. Financial Recovery Plan in place 4. Monthly Financial Recovery Group meeting 5. Monthly Finance and Performance meetings with Networks 6. CIPs signed and agreed with Networks 7. Establishment of a joint Task and Finish Group to oversee and manage OAPs position, delivery trajectory and minimise any risks 8. Risk sharing agreement in place for OAPs (currently agreeing the share beyond current arrangements) 9. NHSI and STP provided with a monthly briefing in respect of financial risk 10. Monthly reporting to NHSI in respect of agency costs 11. Focused sessions held with the highest spending areas in relation to Bank and Agency 12. Land disposals – complete on sale of Ribbleton

ASSURANCES: 1. Self-assessment and list of financial improvement measures in place reporting to Finance Recovery Group

and Finance Sub-committee (Internal) 2. Budgetary and CIP Reporting System (Internal) 3. OAPs reporting and capacity and flow tracked on a daily basis. (Internal) 4. DTS reporting and monitoring. (Internal) 5. NHSI re-categorised the Trust (Q1) from segment 2 to segment 1 due to improvements in relation to the

Finance/Use of Resources domain (External) 6. Application of NHSI new financial risk ratings (Internal) 7. Continued progress that has been made on ensuring compliance with the relevant legislation around safer

recruitment for the current workforce and all new starters (Internal) 8. Significant assurance provided around procurement process (Internal) 9. Significant assurance provided for breachers and waivers process (Internal) 10. Significant assurance provided for productivity improvement plan - overall above baseline by 0.42% (Internal)

GAPS IN CONTROLS: 1. Some CIP programmes have not gained as much traction as we had anticipated 2. Clarity needed on actions required as part of longer-term STP.

GAPS IN ASSURANCES: 1. Uncertainty over completion of commissioning arrangements of in-patient programme. 2. Lack of certainty on impact of loss of universal services on financial position 3. Lack of certainty that Lack of certainty VAT element of the plan will land this year 4. Lack of improvement in overpayments position

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Final RiskTarget



POSITION Medical Directorate 9. Work towards R&D financial balance Improved financial balance of R&D budget Q4

Pharmacy 2. To deliver on the Lord Carter plans for Pharmacy in Mental Health and Community Trusts (extension of Operational productivity and performance in English Acute Hospitals unwarranted variation)

The Trust will be in a position to submit a Hospital Pharmacy Transformation programme (HPTP) to NHS England by the deadline outlined by the Carter Review for Mental Health and Community Trusts

Q4


7. To find ways to do things better and more efficiently to find the savings that the Trust needs to make

Delivery of CIP Q4

Nursing & Quality Directorate 5. Reduce wastage and inefficiencies and promote standardisation in clinical practice and procurement

Demonstrable reduction in spend of £150,000 against network expenditure; Improvements in quality & safety and value for money Q4

Property Services

1. Ensure delivery of CIP targets All CIP targets met Q4

2. Ensure delivery of Capital Programme All approved schemes delivered on time as detailed in the programme, on budget to the specified quality Q4

4. Dispose / develop non-operational sites Non-operational sites disposed or development agreed Q4

11. Market Testing Hard FM Services New contract in place by November 2017 Q3

12. Soft FM services review Soft FM contractor awarded 2 year allowable extension of contract Q2

Finance Department

1. Establish Robust Financial Systems and Processes to Enable the Trust to Maintain Financial Resilience

Financial outturn in-line with Board working plan Ongoing

2. Establish Robust Financial Systems and Processes to Enable the Trust to Maintain Financial Sustainability

Financial performance and risk rating in-line with Board approved Long Term Financial Model Ongoing

3. Support the Trusts emerging strategy The embedding of processes required to support the strategy Ongoing

4. Establish and Maintain Robust Governance Systems Self-Assessment Report plus Internal/External Audit Opinions Q1-Q4

5. Ensure Compliance with Trust Indicators Compliance with Trust Indicators Q1-Q4

6. Manage Non-Core Activities Financial and Reputational Risk

Non-Core relationships in-line with approved plans Q1-Q4

7. Ensure Finance Department Capacity is Sufficient to Address Business Need

Sufficient capacity throughout 2017-18 to meet demand Q1-Q4

8. Establish and Maintain Systems and Processes to enable the Trust to Achieve Value For Money (VFM)

Unqualified use of resources audit opinion/ VFM demonstrated through Annual VFM Report Q4

9. Maintain and Adapt Finance Department Resilience and Sustainability Reduction in number of temporary staff Q4


2. Financial Sustainability - To deliver value for money and financial sustainability by achieving CIP targets and Network control target

Achieve £3.265m CIP plan Achieve a breakeven control target for the Network Completed QIAs for all CIP schemes

Q4


2. Financial Sustainability - To deliver value for money and financial sustainability by achieving CIP targets and Network control target

Achieve £3.265m CIP plan Achieve a breakeven control target for the Network Completed QIAs for all CIP schemes

Q4


3. To deliver services in budget and to achieve all CIPs Financial Activity: CIP target of £4.497m delivered with budget balanced or in surplus by year end Reduction of over-expenditure of £3.4m

Q4

11. Ensure the Network is match fit in respect of perinatal services, and prepared to bid for the next wave of funding in order to develop these services.

Successfully securing of national monies as part of the next wave of funding to develop perinatal mental health services Q4

BOARD ASSURANCE FRAMEWORK 2017/18 STRATEGIC PRIORITY: To provide financially sustainable services DIRECTOR LEAD: Chief Finance Officer DATIX NO: 8510

BAF RISK: 5.2 If we do not work with partners to deliver system wide efficiencies this will undermine our own financial position and that of the STP.


CQC DOMAIN: Responsive/Well-led

2017/18 SHARED OBJECTIVE: To do things better and more efficiently so that we deliver the savings that the Trust needs to make and contribute to the overall saving needed in Lancashire and South Cumbria

ASSURANCE SUB-COMMITTEE TO REVIEW: Finance ASSURANCE COMMITTEE TO REVIEW: Finance and Performance

RISK APPETITE RATIONALE: We are willing to take risk that represents a consistent focus on the best possible return for the organisation, local partners and local people. (There is an averse appetite in relation to any impact on non-compliance with regulatory standards.) RATIONALE FOR RISK: The refresh of the strategy has provided the opportunity to assess the impact of the STP on the organisation from a strategic perspective. The risk reflects the challenges of working with partners to ensure the Trust has an opportunity to influence key decisions made across the health economy. Failure to participate in STP back office initiatives and influence decisions made by the STP may have an adverse effect on identifying system wide opportunities and efficiencies. RISK RATING:


Score at Q1

Score at Q2

Score at Q3

Score at Q4

2017/18 Risk Target

Final Risk Target

15 15 15 15 10 5 3x5 3x5 3x5 3x5 2x5 1x5

KEY WORK PROGRAMMES: • Financial Plan • Capital Programme • STP and LDP programme Boards • Strategic Alliance


RATIONALE FOR CURRENT RISK SCORE: The Trust continues to be an active partner in system-wide clinical and non-clinical workstreams, as well as Local Delivery Plans, leading and supporting the development of new models of care in addition to efficiencies across a range of back office functions. The Board recently took the opportunity to consider in more detail our place in the STP and the outputs from this session will further sharpen our focus in a number of key areas.


Operational risks associated to this BAF risk relate to the stretch on operational performance due to STP work in place.

G3 - Payment of fees to NHSI P1 - Recording of information P2 - Provision of information P4 - Compliance with the National Tariff P5 - Constructive engagement concerning local tariff modifications

CONTROLS: 1. 2017-22 Trust Strategic Plan 2. Trust NED representation at STP level 3. Representation on STP Finance & Investment Group 4. Outputs from Board development session (Q3) providing increased focus for the Trust's place in

the STP 5. Board committed to future development session regarding partnerships 6. NHSI and STP provided with a monthly briefing in respect of financial risk 7. Risk sharing agreement in place for OAPs (currently agreeing the share beyond current

arrangements) 8. Feedback loop in development to share strategic intelligence with key staff across the Trust

ASSURANCES: 1. Communication and Engagement report provides assurance around external engagement. (Internal) 2. Refreshed STP governance arrangements supported by Board (Internal) 3. Senior Trust representation across key STP workstreams (Internal) 4. Significant assurance in relation to controls as evidenced by the DTS heat map (Internal)

GAPS IN CONTROLS: 1. Ability to influence at the STP and LDP levels 2. Alignment of plans across the local health economy require further development

GAPS IN ASSURANCES: 1. STP Assurance reporting to the Trust 2. Assurances in relation to monitoring of compliance with Strategic Alliance Policy 3. Limited assurance with regards to compliance given the current year and full year gap in CIP delivery

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Final RiskTarget



Finance Department 8. Establish and Maintain Systems and Processes to enable the Trust to Achieve Value For Money (VFM)

Unqualified use of resources audit opinion/ VFM demonstrated through Annual VFM Report Q4

Strategy and Transformation 6. Deliver Transformational Change and contribute to Trust productivity and efficiency targets

Clearly defined approach to support teams in delivering measureable improvements in productivity and efficiency

Q3

Mental Health

2. To provide the right care at the right time and in the right (least restrictive) place through direct and indirect provision

To be in line with the national average on NHS Benchmarking data for team caseloads Q4

6. Transforming Secure Services

Formulation and delivery on a transformation plan that is compliant with our contract, competitive in terms of other providers and reflects high quality, evidence based, safe care for our service users.

Q4


4. Transformation - To proactively lead the Network in its contribution to LCFT being a strong provider of community based services in Lancashire

Achievement of Network CIP and control targets Q4




5. Work with commissioners to determine priority areas within ‘RightCare’ and build an associated business case to support hospital avoidance and early discharge

Reduced A & E attendances for under 5 years within defined cohorts e.g. respiratory and IV therapy Q4


LCFT achieve prime provider status whilst maintaining safe and effective care , monitored by quality and performance metrics Q4

7 Transformation: to develop and implement a new safe and effective service model for CAMHS Tier 4 in response to NHSE commissioning intentions

LCFT achieve maintain Tier 4 contract and improve service offer to meet needs of revised service specification including bench-marking against national best practice , monitored by quality and performance metrics

Q4




STRATEGIC PRIORITY: To innovate and exploit technology to transform care DIRECTOR LEAD: Chief Finance Officer DATIX NO: 8511 BAF RISK: 6.1 If we do not maintain and develop appropriate infrastructure, we will not be able to deliver safe, responsive and efficient care.


CQC DOMAIN: Well-led 2017/18 SHARED OBJECTIVE: To roll out the Electronic Patient Record and other new systems so that we can do our jobs better and think of new ideas to give the people using our services a positive experience

ASSURANCE SUB-COMMITTEE TO REVIEW: Infrastructure ASSURANCE COMMITTEE TO REVIEW: Finance and Performance

RISK APPETITE RATIONALE: We will accept risk where innovations are identified that will enhance patient experience, reduce costs and/or improve quality. We will actively seek higher risk/higher return projects and strive to establish pioneering partnerships that can support execution and exploitation of innovation projects. (There is an averse appetite in relation to any impact on non-compliance with regulatory standards.) RATIONALE FOR RISK: The Trust must be able to deliver and sustain effective infrastructure to ensure the provision of safe, high quality patient care, whilst reducing costs and improving efficiency. These challenges remain in 2017/18 with this risk paying particularly attention to health informatics and estate infrastructure.

RISK RATING:


Score at Q1

Score at Q2

Score at Q3

Score at Q4

2017/18 Risk Target

Final Risk Target

16 12 12 12 8 4 4x4 3x4 3x4 3x4 2x4 1x4

KEY WORK PROGRAMMES: • Estates Plan • Information Management Strategy • IT Plan • Network Redesign (DTS) • Corporate Services Redesign (DTS)

QUALITY PRIORITIES: 9. Seclusion

RATIONALE FOR CURRENT RISK SCORE: Current Health Informatics BAU controls remain in place and are providing a secure and stable infrastructure. Improvements to systems which could further reduce the likelihood of incident are considered by the HI Security Forum where incidents and threats are regularly reported and assessed.

OPERATIONAL RISK EXPOSURE SUMMARY: PROVIDER LICENSE COMPLIANCE: The operational risks associated with this BAF risk mainly relate to property and Health informatics risks which include smoking related issues, safety of building, IT infrastructure risks and data quality risks impacting systems used across the Trust.

COS2 - Restriction on the disposal of assets

CONTROLS: 1. CAS alert remedial actions and checks implemented in line with recommendations 2. Lancashire Care Project Director is the Estates Lead for the STP. This role leads the production of the STP

Estates Strategy and is currently producing the 2017 update for submission to NHSE during Q3. 3. Infrastructure Capital and Estates provides controls for projects within capital programme 4. Long-term Estates Strategy Plan sets the strategic context for the investment and divestment of the estate.

September 2017 Estates plan data updated. Further strategy works to be completed November 2017 in line with STP and Trust priorities.

5. Implementation of IT security management processes 6. Standardised approach to the development of new services and bids which ensures that all aspects of the

required infrastructure are deliverable and costed. 7. Business Development and Transformation meeting enables overarching review of new services and bids 8. Monthly Estates Management and Assurance meetings held, reporting to the Infrastructure Sub-committee

quarterly 9. Annual testing of anti-ligature magnetic tracking through Hard FM contract. This will continue with the new

hard FM provider from November 1st 2017.

ASSURANCES: 1. Infrastructure Capital and Estates reports provided on the projects within the Capital Programme (Internal) 2. External review of the Nurse Call System at The Harbour (External) 3. Reports from yearly penetration tests and action plan development and implementation (Internal) 4. Specification and build of IT devices future proof the Trust at least five years (Internal) 5. A yearly plan of work which identifies the priorities and planned expenditure for health informatics and

Networks/corporate services. This is monitored via network performance meetings (Internal) 6. Assurance reporting from IT and Estates now being received by Infrastructure Sub-committee – significant

assurance (Internal) 7. CAS alert actions completed declarations from Networks and Estates via the Datix system (Internal) 8. IT Asset Management internal audit report provided ‘Significant’ assurance (External) 9. Fire Safety checks carried out post Granville incident (Internal) 10 . e-Rostering usage continues to increase (Internal) 11. EPR assurance report – Significant assurance (Internal)

GAPS IN CONTROLS: 1. Availability of capital within any year to meet the trust's requirements and aspirations. 2. Planning a service change and/or tenders may not, by routine, involve Estates and Health Informatics. 3. Dependency on other Trusts' management of systems and infrastructure. 4. Difficulty in forming multi disciplinary teams to undertake Environmental audits to identify infrastructure

risks 5. Ability to achieve trimely repairs to environment at the Cove impacted by PFI contract

GAPS IN ASSURANCES: 1. Being on a collaborative IT network means another organisation may make changes which impacts others. Their

control gaps cause potential risks 2. Inability to plan and manage existing data and potential expansion (which affects VDC capacity) due to lack of

access to detailed projections. 3. Delay in response from Networks to building infrastructure CAS alert and LCFT internal alerts. RRCS are

continually seeking advice from Trust specialists via the Environmental Safety and Security Group. Network Management are invited to meetings.

4. Achievement of Carbon reduction Target – Limited assurance 5. Roll out of EPMA in alignment of project plan and suitability of community module 6. Development of Sceptre Point 25 7. Responsiveness of estates responsiveness with the new hard FM provider 8. Completion of all 45 ligature audits completed – Limited assurance (3 remain outstanding)

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POSITION

Medical Directorate

1. Development of Infrastructure Sub-Committee

Good progress towards implementation of a clinically acceptable EPR. Feedback from clinicians influencing development of the Trust’s estates plan.

Q4

10. Promote engagement with research development and delivery activities Achievement of Clinical Research Network recruitment targets and Department of Health timeline Q4

11. Develop long-term business plan for shared Clinical Research Facility Forecast long-term viability of CRF Q4

Pharmacy 1. To prepare a business case for EPMA in the community teams and subject to successful funding roll out in line with the project plan

EPMA will be implemented across all community teams in line with the agreed project plan and the identified benefits will be quantified and achieved

Q4

Health Informatics

1. Maintain, optimise & future proof IT Services ensuring Infrastructure Stability & reviewing latest technologies.

IT infrastructure and systems have been reviewed (VFM) and new ways of delivering services tested/implemented where applicable.

Q4

6. Draft & implement data security action plan Data Security Plan drafted, agreed and delivered as per the plan milestones – including ISO 27000:1 accreditation Q4

8. Improve Health Records Management Improved capability to store, track, scan and retrieve health records Q4

Property Services

2. Ensure delivery of Capital Programme All approved schemes delivered on time as detailed in the programme, on budget to the specified quality Q4

3. Continue with the estates rationalisation programme (depends on Trinity & capital funding) and review in line with clinical services business development needs for all Networks. Including option appraisal for ‘Sceptre Point 2’.

29% estate rationalised from 2011 base line Q4

4. Dispose / develop non-operational sites Non-operational sites disposed or development agreed Q4

5. Support the Mental Health Network with increasing clinic based activity Increased clinic based activity / better utilisation of clinical rooms across the estate Q4

6. Support the Mental Health Network with Clinical Support Unit (CSU’s) provision

Increased clinic based activity / better utilisation of clinical rooms across the estate Q4

7. Support the Mental Health Network with the in-patient re-design Increased clinic based activity / better utilisation of clinical rooms across the estate Q2 18/19

8. Support the Community Health & Wellbeing Network with their community improving productivity programme including Southport & Formby mobilisation.


9. Support the Children’s & Young Persons Network with their community improving productivity programme including Sexual Health provision.


11. Market Testing Hard FM Services New contract in place by November 2017 Q3

12. Soft FM services review Soft FM contractor awarded 2 year allowable extension of contract Q2


STRATEGIC PRIORITY: To innovate and exploit technology to transform care DIRECTOR LEAD: Chief Finance Officer DATIX NO: 8512

BAF RISK: 6.2 If we do not exploit the full capabilities of the new EPR system and wider technology to redesign services we will miss important opportunities to improve care.


CQC DOMAIN: Well-led 17/18 SHARED OBJECTIVE: To roll out the Electronic Patient Record and other new systems so that we can do our jobs better and think of new ideas to give the people using our services a positive experience

ASSURANCE SUB-COMMITTEE TO REVIEW: Infrastructure ASSURANCE COMMITTEE TO REVIEW: Finance and Performance

RISK APPETITE RATIONALE: We will accept risk where innovations are identified that will enhance patient experience, reduce costs and/or improve quality. We will actively seek higher risk/higher return projects and strive to establish pioneering partnerships that can support execution and exploitation of innovation projects. (There is an averse appetite in relation to any impact on non-compliance with regulatory standards.) RATIONALE FOR RISK: Revised Phase A and Phase B early adopter approach agreed at 09.01.18 EPR PMG following consideration of readiness checklists. Workstreams are progressing but amber statuses exist across some key workstreams including Business Change, System Design & Configuration. Recovery plans are in place and statuses should improve following the phasing decision as referenced above. Programme Management changes embedded (although under continual improvement review) and recruitment to the resource profile is being progressed. The programme document set is being updated and improved. Monthly programme financial reviews are mainstreamed with the Network Accountant/s - Corporate Services. Formal paper outlining programme sequence and iPM replacement has been reviewed at SLT. Tranche 2 now confirmed as Secure Care & IPM replacement. RISK RATING:


Score at Q1

Score at Q2

Score at Q3

Score at Q4

2017/18 Risk Target

Final Risk Target

16 16 16 16 8 4 4x4 4x4 4x4 4x4 2x4 1x4

KEY WORK PROGRAMMES: • Estates Plan • Health Informatics Plan • IT Plan

QUALITY PRIORITIES: 7. Standards of Record Keeping

RATIONALE FOR CURRENT RISK SCORE During Q3 the Programme has progressed as planned in the majority of areas but there have been a number of issues which have required recovery plans to be implemented, reflected in the revised Phase A & Phase B approach for the early adopter services. The Programme has current resource shortages due to delays in initiating recruitment & also staff sickness. Mitigation plans are in place to accelerate recruitment and cover sickness where possible. Key workstreams within the programme are at an amber status due to the above shortages and some weaknesses within the programme start-up phase. The development of integration with eMIS using the Medical Interoperability Gateway (MIG) and ‘Smart View’ technologies is dependent on a third party named HealthCare Gateway. Delays in initiating this piece of work and lead times at Healthcare Gateway have delayed this work-stream although this does not impact upon the planned Go Live dates. A recovery plan is in place. The issues above and current aggregated profile of the EPR risk register warrant the score remaining at 16


The operational risks associated with this BAF relate to the implementation of EPR and the associated data quality risks.

No Provider License Conditions mapped to this BAF risk.

CONTROLS: 1. Signed contract with Servelec 2. EPR related objectives in clinical network operational plans 3. Established EPR Programme Management Group with senior stakeholder membership 4. Datix reporting for all EPR programme related risks 5. Core Clinical Forum in place 6. Managing Successful Programmes documentation (being produced) 7. Network reporting on compliance with / achievement of EPR related objectives 8. Future sequencing of next stage of EPR 9. Approval of managing successful programmes documentation

ASSURANCES: 1. Regular reports to corporate meetings (Internal) 2. Independent assurance being undertaken by Best Practice Group (External) 3. Chief Clinical Information Officer is part of the EPR Programme Management team (Internal) 4. Documentation resulting from management boards and other governance and control mechanisms (Internal) 5. Networks engaged in framing requirements for tender (Internal) 6. Review of Network risks and recognition that many risks can be directly or indirectly controlled by ePR

(Internal) 7. Further due diligence with colleagues in North Cumbria reported to SLT. (Internal/External) 8. Audit undertaken in learning disabilities provided assurance of high level of comploinace against monitor

frameowkr 2015 – supporting preaoration for go mlive with Rio

GAPS IN CONTROLS: 1. Full engagement with all networks on the implementation of the EPR system is dependent on the

Implementation Plan. 2. Programme assurance role to be appointed to EPR PMG (auditor or third party consultant/advisor)

GAPS IN ASSURANCES: 1. Report from MIAA commissioned to conduct a programme assurance review 2. Visibility of Network reporting on compliance with / achievement of EPR related objectives 3. Approval of Managing Successful Programmes documentation

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NETWORK/SUPPORT SERVICE OBJECTIVE OUTCOME MEASURE DEADLINE

Q3 POSITION

Health Informatics

1. Maintain, optimise & future proof IT Services ensuring Infrastructure stability & reviewing latest technologies

IT infrastructure and systems have been reviewed (VFM) and new ways of delivering services tested/implemented where applicable.

Q4

2. Procure & commence deployment of new EPR to clinical services New EPR being actively used by clinical services as per delivered milestones within programme plan Q4

3. Continue to tactically improve & maintain ECR whilst in EPR transition

Successful delivery of 4 quarterly releases on time & within designated budget Q4

4. Promotion & Delivery of Health Informatics Plan Compliance with outcomes of agreed plan (supporting strategy) Q4

7. Continue to proactively engage with support services & clinical networks to draft & deliver an agreed work pan that supports the Organisation in delivering digital enabled care & the mobilisation/demobilisation of services

Health Informatics 17/18 work plan agreed & prioritised with all work plan projects delivered as per agreed timescales

Q4

Communication & Engagement 6. To help to roll out new systems that enable us to do our jobs better and think of new ideas to give the people using our services the best possible experience

Qualitative feedback/examples at Quarterly Review Q4

Performance & Information &PMO

1. Develop and implement performance and information measures, reports and datasets for the Trust’s new Patient Administration System (PAS)

Services migrated will be reported from the new PAS Q4


Benefits identified with a plan for delivery in 18/19 Q4


7. Business development Forum- Ensure processes in place to ensure that all BD decisions are based on the best available intelligence and made within the context of the developing market and existing potential partnerships




New EPR being actively used by clinical services as per delivered milestones within programme plan Q4


4. Transformation - To proactively lead the Network in its contribution to LCFT being a strong provider of community based services in Lancashire

Achievement of Network CIP and control targets Q4


New EPR being actively used by clinical services as per delivered milestones within programme plan Q4

Mental Health Network 8. Embrace new technology to improve service users experience

Improved service users satisfaction rates Enhanced service user care, reduction in costs, and improved quality to be determined based on the benefits realisation work (as described in input a)

Q4

10. Identify and realise the benefits of EPR in line with the implementation plan and timescales Benefits identified with a plan for delivery for 18/19 Q4

Medical Directorate 6. Embed MECC level 1 and level 2 in the organisation An increase in the training accessed by staff and development of a viable recording system to determine volume and output of conversations

Q4

APPENDIX 2

BAF Heat Maps 2017/18

Risk Key

HIGH

MEDIUM

LOW

Original Risk Score April 2017 Risk Score at Q1 Risk Score at Q2

Risk Score at Q3 Risk Target 17/18 Risk Score at Q4

Operational Risk Exposure Summary Thematic Summary A review of the risks rated 12 and above has been carried out to provide a thematic summary of the operational risk exposure against each BAF risk. The thematic summary has identified risks of a similar nature that are common across several risk themes. These common themes are outlined below:

1. Staffing, Recruitment and Training – There is a large operational risk profile in this areas that

relates to recruitment and retention of clinical staff (consultants, AHP and nurses) and staff shortages in clinical areas due to a lack registered nurses, staff sickness and lack of bank staff. In addition there are a number of operational risks relating to compliance with training particularly for mental health, mental capacity, deprivation of liberty and violence reduction. There is also a risk highlighting the lack of a training needs analysis for the Trust.

To support the mitigation of these risks staffing recruitment drives and actions plans and actions plans have been developed. Training compliance levels are being monitored is monitored and shared at committee level. These risks have aggregated up to support level to ensure consideration of the risks occurs at appropriate governance meetings to identify control measures and assurance. These risks are a key consideration for the review of BAF risk 4.1 and 4.2 as well as 1.1 from a safety perspective.

2. Compliance with Regulatory Standards and Trust Procedures - There are a number of risks relating to compliance with regulatory and statutory requirements which are both clinical and non-clinical in nature. This includes risks relating to NICE quality standards, Information Governance (GDPR, DPA and records management), mental health legislation (Mental Health Act section 136 and section 17) and health and safety legislations. These risks all have an impact on the Trusts ability to maintain a CQC rating of good. There are also several risks relating to compliance with Trust procedures. This includes medicines management procedures, seclusion policy and nicotine management policy as well as compliance with waiting times.

The overall regulatory burden that the Trust experiences remain high with the risk profile providing corporate awareness of associated risks in this area. Data collection and quality surveillance supports the management of these risks. Risks in this area aligned to BAF risk 1.1 although they may be aligned to other BAF risks depending on the nature of the regulations.

3. Finance - Finance risks run across the majority of themes to include risks relating to staffing, use of bank and agency and property services (repayment of debts and vacated leases). There are also risks that’s have been escalated which are managed at support service/Executive Director Level for mitigation. These risks relate to the non-achievement of the control target, achievement of CIP plans and capital expenditure and property. The Finance Recovery group is in place to provide mitigation of these risks. All finance related risks are considered through the review of BAF risks 5.1 and 5.2.

4. Contracts and Commissioning – Operational risks in this area relates to contracts and commissioning of services including the development of new models of care. Risks in Datix specifically relate to the mobilisation of perinatal services, the loss of universal services, contract requirements at HMP Liverpool and SLAs in place. These risks are considered through the review of BAF risks 2.1 and 2.2.

5. Data Quality – Data quality risks run across a variety of risk themes including EPR, Health Informatics and quality systems. This includes risks to EPR information and system requirements, data/activity reporting in Datix and other systems and the alignment of financial codes to the team

APPENDIX 3

names which impacts several systems across the Trust. The data quality plan supports the mitigation of these risks and assurance reports are regularly reported to sub-committee level. These risks are considered through the review BAF risks 6.1 and 6.2 as well as 1.1 from a quality and safety perspective.

The Risk and Assurance team has responsibility for providing risk management support and the operational risk management systems. This process has been further enhanced during Q3 with the delivery of the Governance and Risk Health Checks for the Medical Directorate and Community and Wellbeing Network. Following the risk health checks we have worked closely with Networks and support services to work on the areas for development identified.

Risk and Assurance training has been launched during Q3. This has consisted sessions provided by the Risk and Assurance team upon request. All Networks have been involved in the training provided and more sessions are scheduled for Q4.

As part of the risk surveillance work carried out by the Risk and Assurance engagement has taken place with teams and risk owners to review risk registers and re-articulate risks. There has also been targeted work carried out to review of long standing risks and risks beyond due date.