performance report – october 2012 background document … · performance report – october 2012...

Performance Report – October 2012 Background The Performance Report sets out a summary of DCHS’ performance against the three DCHS Way focus areas of Quality People, Quality Service and Quality Business. Section Index Document Page No’s Summary Document 1 – 5 Overview of Measures 7 DCHS Balanced Scorecard 8 – 9 HCAI Scorecard 11 CQUIN Scorecard 12 Exception Reports 14 –18 Annex 1 19 Glossary 20 – 21 Key for RAG & arrows 22

OVERVIEW Future plans: Ongoing review of indicators within the report to reflect changing and

developing external reporting requirements e.g. the Quality Observatory and Foundation Trust regime

Continuous review of internal indicators to ensure full coverage. One area we are looking to develop is indicators relating to Health Promoting Environments and Services

Incorporation of Performance Reporting into Business Intelligence solution to facilitate consolidation of measures and greater sophistication in rating of the measures

Summary Overview There are 53 green, 32 amber, 8 red and 36 unrated indicators this month.

The Overview of Measures at page 7 gives further details on month on month movement.

Review of Accuracy The DCHS Way has an ‘Achievement of data quality targets for the service

(%)’ indicator. There has been an initial assessment of our major clinical systems, using the data quality ‘kite mark’ and services have been asked for feedback. From this a full project plan will be developed which will include assessment of other non clinical data sources, such as Electronic Staff Record (ESR).

Internal Audit has commenced their baseline assessment of data quality and are due to report to the Audit Committee in January.

Top X This report includes the Quarter 2 review of risks, which has identified the

current Top X. Where previously identified Top X risks that have reduced

below a rating of 12, these will no longer be classified as Top X in line with the policy and will be removed from the balanced scorecard from next month. These risks will continue to be monitored via the risk register processes. Conversely, where new risks have been identified as Top X or risk ratings have increased to a point where they are now classified as Top X, these have been included on the balanced scorecard. Top X risks will be reviewed again in Quarter 3.

QUALITY PEOPLE: (page 8) A new indicator looking at workforce productivity by analysing contract income per full time equivalent has been included in this report. In addition information on total staffing costs has been included. The Good News Essential Learning – In month position 51% against a target of 44%. As a

subset of this, Information Governance training is currently exceeding targeted levels, with 53% completion against a target of 50%.

Challenges Staff Attendance – Attendance has decreased slightly this month to 96.2%

(August was 96.5%). We would typically expect to see attendance decrease as we enter autumn/winter and continued reinforcement of attendance is needed to ensure we reach our 97% target.

Temporary Staffing Costs – The threshold for Temporary Staffing Costs expenditure year to date September is £1,728k, against actual expenditure of £1,850k. Whilst the threshold continues to be breached, in month expenditure was at its lowest level for the last four months. However the decrease in Staff Attendance may impact on this measure next month. Agency spend is being monitored very closely and all agency bookings must now be made by the Flexible Workforce team who will work with managers to identify the most cost effective staffing solution and if an agency worker is required, they will ensure that the best rates are secured.

New Starters Attending Induction – The percentage of new starters attending induction within 3 months has dropped from 94.7% for all June starters, to 87.3% for July starters, reducing the YTD average to 90.3%. There were a high number of new starters in July as result of the award of the Leicester dental contract. The majority were inducted in the first month in an onsite group induction. However there are 10 new starters that have not yet been through induction. Despite missing the three month target, we will continue to work to get these new starters inducted.

Staff with Appraisal Completed – As staff appraisals should be conducted on the anniversary of their last appraisal, there are staff who are not yet due an appraisal and consequently we do not expect to meet the target until year end.

We are monitoring progress in year and the year to date position on ESR shows 19% of staff have had an appraisal. However we believe that the real position is higher and there is a training need for appraisers to ensure that appraisals are recorded on ESR.

QUALITY SERVICE: (page 8)

The Healthcare Acquired Infections (HCAI) scorecard is provided at page 11 and the CQUIN scorecard for DCHS and LCRES is provided at page 12. The Good News Overall – the majority of non Top X related indicators continue to be green

rated. RTT Indicators – Performance to July has continued to remain within national

limits. September data is not yet available. HCAI – All but one indicator is green rated. A&E Patient Impact and Timeliness Indicators – As discussed in the

previous report, DH are publishing A&E statistics for all organisations. We continue to perform well on the A&E measures that the Department of Health (DH) had specifically identified as patient impact and timeliness indicators. However DH appear to have changed their approach on reporting this information and for April data they are showing performance against all indicators and are not giving an overall rating. The comparative information for April for the local organisations is shown at Annex 1 (page 19).

Challenges A&E Total Time in the A&E Department - Longest (mins) – Only one

month out of the six months reported has been green rated, with a year to date total of 7 patients whose waits have exceeded 6 hours. Of these 6 are attributed to delays in inter-hospital transfers. We are having active discussions with East Midlands Ambulance Service (EMAS) on reviewing these breaches and working towards jointly agreeing clinical protocols to assist in delay management. There was one patient wait exceeding 6 hours in September, which was again attributed to delays in inter-hospital transfers. An exception report is provided at page 14.

CQUIN Breastfeeding Sustainment – 83.1% year to date September an increase on the 82.8% year to date August position and a positive move towards achieving the full year target of 84%. The in month achieved 84% for the second month running, supporting the service view that sustainment will increase as the breastfeeding support workers come into post. The challenge is whether the service can generate the in month overperformance required to achieve 84% on the cumulative figure.

QUALITY BUSINESS: (page 9) The activity data is the latest data available, Month 5 (August) of 2011/12 for all commissioners within the multilateral contract. The year to date plan is based on the

activity profile that has been provided by services. In addition services have produced an activity forecast which has been incorporated into this report and the financial position. The Good News Financial Risk Rating – Has remained at 3 and continues to be on target. Speech & Language Therapy – Continues to maintain a green rating for the

YTD position and after unanticipated underperformance in July, has achieved the in month target in August.

Community Podiatry Activity – The in month August position has been green rated and although YTD performance is still red rated, the overall underperformance is the lowest this year, as shown in the exception report at page 17. There is sufficient demand and the service anticipates that the position will be recovered.

Older Peoples Mental Health Inpatients – As anticipated the discharge of some of our longer stay patients has brought our excess bed day performance back on track. Excess bed day performance is quite volatile and the service is continuing to track unfinished patient episodes as a part of the delays process and to understand income flows.

Leicester County & Rutland Elective Services – Having experienced issues with reduced demand, overperformance in July has brought the year to date position to target.

Challenges Risk to contract income due to activity levels on cost per case contracts

– This risk has now been classified as Top X, with a risk rating of 16 as a result of the significant activity underperformance which has been forecast. This underperformance is mainly attributable to Outpatient & Daycase, Health Visiting and Older People’s Mental Health Inpatients. This is being marginally offset by forecast overperformance in therapy services. Where appropriate services are producing detailed action plans on measures to improve performance and/or offset income loss with expenditure reductions. These forecasts will be revisited on a monthly basis.

Asset Transfer uncertainty over timetable from DH – The uncertainty over the timetable and risk of prolonged delays has major consequence to the LTFM and financial planning of DCHS.

Minor Injuries Unit Activity – The year to date position on MIU activity has been red rated and an exception report is provided at page 15. However the in month position has been amber rated and weekly activity monitoring is not showing the downturn usually experienced at this time of year. This is being attributed to warmer than usual weather in August/September. The service are working to maintain the activity levels through the autumn/winter months by marketing the service, which has proven successful in the past. In addition the NHS 111 Derbyshire pilot will be launched in November which means that patients will automatically be directed to their local MIU if appropriate.

Outpatient and Daycase Activity – As shown in the exception report at page 16, underperformance in August has improved slightly on July. Reduced demand and the impact of the Procedures of Limited Clinical Value commissioning policy continue to be an issue. To address this, the service is working on marketing and targeting individual GPs within the area. The service is also mitigating a proportion of the income loss through cost reduction and matching demand with capacity.

Health Visiting – With activity of underperformance of 17% (10% in July), the YTD position continues to be red rated. An element of the underperformance is expected to be recovered as vacancies are filled from the September intake of newly qualified HVs. An exception report is provided at page 18.

DCHS Board Performance Management Reports October 2011

Month

MeasureTotal Number of Measures

Total Number of YTD Measures Rated Green

Total Number of YTD Measures Rated Amber

Total Number of YTD Measures

Rated Red

Total Number of YTD Unrated

Measures

Quality People 18 (16) 3 (3) 5 (5) 0 (0) 10 (8)

Quality Service - Service User Experience 25 12 (11) 0 (0) 1 (1) 12 (13)

Quality Service - Service User Safety 8 2 (1) 5 (6) 0 (0) 1 (1)

Quality Service - Clinical Effectiveness & Planning 4 2 (2) 0 (0) 0 (0) 2 (2)

Quality Business - Finance 4 2 (2) 0 (0) 1 (1) 1 (1)

Quality Business - Business & Marketing 33 (28) 7 (4) 14 (13) 6 (5) 6 (6)

Quality Business - Productivity & Innovation 5 0 (0) 1 (1) 0 (0) 4 (4)

Healthcare Associated Infection 16 15 (15) 1 (1) 0 (0) 0 (0)

CQUIN 16 10 (12) 6 (4) 0 (0) 0 (0)

The number in brackets is the total from the previous Board report.

Derbyshire Community Health Services Board Performance Overview of Measures

October-11

Type Frequency Director2010/11 Outturn

2011/12 Full Year

TargetYTD Target Q1 Jul-11 Aug-11 Sep-11 Trend YTD

Forecast Outturn

Narrative

Staff Attendance (%)DCHS Way/National

Monthly DoHR 95.2% 97% 97% 96.6% 96.5% 96.2% 95.6% 97% 0.5 percentage points from target

Staff with appraisal completed (%) DCHS Way Annually DoHR 50% 100% 50% 95%

Essential Learning completed (% cumulative) DCHS Way Monthly DoHR 79.0% 95% 44% 36% 41% 51% 51% 95%

New starters attending induction (%) DCHS Way Monthly DoHR 60.0% 95% 95% 87.3% 90.3% 95%

Improvement in Staff Survery participation rates (%) DCHS Way Annually DoHR 59% 64% 64%

Improvement in Staff Survery engagement and staff satisfaction scores (No.) DCHS Way Annually DoHR 4 4 3.79

Headcount (No.) Internal Monthly DoHR 4,574 4,712 4,777 4,763 4,767 4,767

Total FTE (No.) National Monthly DoHR 3,336 3,541 3,590 3,579 3,579 3,558

Health Visitor FTE (No.) National Monthly DoHR 117 117 116 125 116 Increase September as a result of trainees filling vacancies

Management FTE (No.) National Monthly DoHR <926 <926 969 968 971 971 Includes Admin & Clerical

Clinical Staff FTE (No.) National Monthly DoHR <2,084 <2,084 2,110 2,101 2,092 2,092

Compulsory Redundancy (No.) National Monthly DoHR 1 1 0 0 2

Workforce Cost - Excl Agency (£000's) Internal Monthly DoHR 113,606 30,108 10,223 10,049 10,205 60,585

Temporary Staffing Costs - Agency (£000's) National Monthly DoHR 1,164

Temporary Staffing Costs - Bank (£000's) National Monthly DoHR 2,377

Temporary Staffing Costs - LCR (£000's) National Monthly DoHR <983 <502 11 6 7 182 <983

Income Per FTE (£'s) Internal Monthly DoHR 3,722 3,921 3,957 3,957 3,941

Staff Turnover (%) Internal Monthly DoHR 7.8% <14% <14% 7.4% 8.0% 7.4% 7.7% <14%

Vacancies (No.) Internal Monthly DoHR 362 95 18 34 11 158 2010/11 average was 30 vacancies per month

Patient and Public Involvement plans completed DCHS Way DoNQ 100% To be developed

A&E Unplanned Re-attendance Rate (%) Patient Impact National Monthly DoSD <5% <5% 2.5% 1.6% 1.8% 2.3% <5%

A&E Left Without Being Seen Rate (%) Patient Impact National Monthly DoSD <5% <5% 2.0% 1.8% 1.9% 2.2% <5%

A&E Total Time in the A&E Department (non admitted) - 95th percentile (mins) Timeliness National Monthly DoSD <240 <240 159 160 158 170 <240

A&E Time to Initial Assessment - 95th percentile (mins) Timeliness National Monthly DoSD <15 <15 n/a n/a n/a n/a n/a <15 For arrivals by emergency ambulance only

A&E Time to Treatment - Median (mins) Timeliness National Monthly DoSD <60 <60 28 25 26 29 <60

A&E Time to Initial Assessment - Longest (mins) National Monthly DoSD <20 <20 5 9 9 9 <20 May breach was an input error and has been corrected

A&E Total Time in the A&E Department (non admitted) - Longest (mins) National Monthly DoSD <360 <360 462 402 553 553 553 There have been 7 breaches YTD. Exception Report at page 14

A&E Time to Treatment - Longest (mins) National Monthly DoSD 291 342 270 263 342 342

A&E Total Time in the A&E Department (non admitted) - Median (mins) National Monthly DoSD 56 50 50 56 54

A&E Time to Initial Assessment - Median (mins) National Monthly DoSD n/a n/a n/a n/a n/a For arrivals by emergency ambulance only

A&E Time to Treatment - 95th percentile (mins) National Monthly DoSD 122 129 122 136

RTT Waits - incomplete pathway (No. patients) National Monthly DoSD 6,875 6,732 6,585 6,585

RTT Waits - incomplete pathway median (weeks) National Monthly DoSD 4 5 5 5

RTT Waits - admitted patients median (weeks) National Monthly DoSD 8 8 9 7

RTT Waits - non admitted patients median (weeks) National Monthly DoSD 5 5 6 5

RTT Waits - incomplete pathway 95th percentile (weeks) National Monthly DoSD <28 <28 14 14 14 <28

RTT Waits - admitted patients 95th percentile (weeks) National Monthly DoSD <23 <23 17 17 17 <23

RTT Waits - non admitted patients 95th percentile (weeks) National Monthly DoSD <18.3 <18.3 14 15 14 <18.3

Mixed Sex Accommodation Breach Rate (%) National Monthly DoSD 0% 0% 0% 0% 0% 0% 0% 0%

Delayed Transfer of Care (%) National Monthly DoSD 18.2% <18.2% <18.2% 15.2% 11.2% 14.4% 14.7% <18.2%

Internal Monthly DoHR 100% 100% 100% 100% 100% 100% 100% 100%

New or revised policies/procedures/strategies supported by EIAs (%) Internal Monthly DoHR 92% 100% 93% 93% 93% 92% 93%

Internal Monthly DoSD 6.0% 4.0% 4.0% 3.8% 2.7% 3.8% 3.9% 4.0%

Internal Monthly DoSD 100% 100% 100% 100% 100% 100% 100% 100%

Identification of Top X risks on an ongoing basis and action plans developed against them DCHS Way Quarterly All To be developed

National Monthly DoNQ 24 3 1 8 Detailed HCAI information provided page 11

Top X Quarterly DoNQ 6 12 12Facilities at four sites pose concern as they are not compliant with essential standards. Funding agreed, work due to commence Autumn 2011.

Top X Quarterly DoNQ 6 4 4 Risk under constant revision as incidents occur. Risk no longer Top X

Top X Quarterly DoSD 12 12 12

Top X Quarterly DoSD 12 8 8Safety express implemented April 2011, all pressure ulcers reported onto DATIX with Root Cause Analysis from September 2011

Top X Quarterly DoSD 9 8 8Safety express implemented April 2011, all falls reported onto DATIX, supoported by safety thermometer data to understand hotspots and multiple fallers

Top X Quarterly DoNQ 6 8 8Risk increased pending implementation of outcomes to safeguarding children serious case reviews

Measure

1,850331 337 289

Risk of harm to individual patients through inadequate clinical record keeping

Risk of harm to patients due to ineffective falls management systems

DCHS PERFORMANCE REPORT BALANCED SCORECARD

QU

ALI

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EOPL

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<3,391

SER

VIC

E U

SER

SA

FETY

<3,391

Focus Area

QU

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ERV

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Annual CIP of £150k , trajectory to be agreed

SER

VIC

E U

SER

EXP

ERIE

NCE

<1,728

Achievement of consultation /involvement/engagement inclusion priorities (%)

Appointment slots available on the Choose and Book System - no of patients unable to book (%)

Patients who have operations cancelled for non clinical reasons receiving treatment within 28 days (%)

Healthcare Care Associated Infections - MRSA bacteraemia & Clostridium difficile (No.)

Potential Non compliance/partial compliance with the Health and Social Care Act 2008 and DH Health & Technical Memorandum 01 series Essential Decontamination StandardsRisk of harm to patients through ineffective action to minimise healthcare acquired infections

Risk of avoidable harm to patients through poor implementation of tissue viability guidance in relation to pressure area care

Risk of harm to children or adults due to failure to implement safeguarding policies and procedures

Type Frequency Director2010/11 Outturn

2011/12 Full Year

TargetYTD Target Q1 Jul-11 Aug-11 Sep-11 Trend YTD

Forecast Outturn

NarrativeMeasure

DCHS PERFORMANCE REPORT BALANCED SCORECARD

Focus Area

Achieve Care Quality Commission compliance DCHS Way Annually DoNQ 100% 100% 100% To be developed

DCHS Way All 100% 100% To be developed

Breastfeeding prevalence 6-8 weeks after birth (%) National Quarterly DoSD 43% 44% >43% 43% 51% 43% 45% 44%

Breastfeeding coverage 6-8 weeks after birth (%) National Quarterly DoSD 100% >95% >95% 100% 100% 100% 100% >95%

Meet planned SLR Gross Contribution (%) DCHS Way Monthly DoSD 100% To be developed

Financial Risk Rating (FRR) Internal Monthly DoFPI 3 3 3 3 3 3 3 3

Better Payment Practice Code - by value (%) National Monthly DoFPI 93.1% 95% 95% 92.6% 96.8% 96.8% 94.9% 95%

Better Payment Practice Code - by volume (%) National Monthly DoFPI 98.1% 95% 95% 98.6% 97.6% 96.2% 97.8% 95%

Delivery of Service Delivery Plans (%) DCHS Way DoSD 100% To be developed

Business Revenue on unit pricing agreements (%) Internal Monthly DoSD 67% 60% 60% 60% 60% 60% 60%

Positive media stories (No.) Internal Monthly DoSD 104 104 54 21 16 20 90

MIU Activity (No.) Internal Monthly DoSD 52,921 52,923 24,506 4,840 4,564 23,264 52,923 Exception Report at page 15

Inpatient Spells Activity (No.) Internal Monthly DoSD 3,770 3,708 1,529 297 281 1,450 3,822 In month position impacted by ward closure

Inpatient Excess Bed Days Activity (No.) Internal Monthly DoSD 12,739 13,733 5,662 926 738 5,648 13,568 In month position impacted by ward closure

OPMH Inpatient Spells Activity (No.) Internal Monthly DoSD 330 291 117 22 26 119 285

OPMH Inpatient Excess Bed Days Activity (No.) Internal Monthly DoSD 2,395 3,533 1,422 132 679 1,683 3,391

Outpatient and Daycase Activity (No.) Internal Monthly DoSD 45,216 43,402 17,924 3,353 3,265 16,321 36,370 Exception Report at page 16

Vasectomy Service Activity (No.) Internal Monthly DoSD 752 468 192 37 32 185 459 7 patients from target

Podiatric Surgery Activity (No.) Internal Monthly DoSD 13,688 13,046 5,177 1,103 1,154 5,680 13,583

Community Podiatry Activity (No.) Internal Monthly DoSD 132,969 133,093 57,405 10,228 10,875 52,685 137,129 Exception report at page 17

Physiotherapy Activity (No.) Internal Monthly DoSD 105,286 105,686 44,595 8,579 8,310 43,025 106,887 In month position improving and continues to be demand

Speech and Language Therapy Activity (No.) Internal Monthly DoSD 15,255 15,165 6,279 1,285 1,131 6,550 15,213

Health Visiting Activity (No.) Internal Monthly DoSD 262,914 260,908 112,806 16,800 18,661 93,753 241,862 Exception Report at page 18

Community Nursing Activity (No.) Internal Monthly DoSD 510,782 519,048 216,877 41,142 42,324 209,214 511,385 Working with the service to understand the issues behind activity performance

Rehabilitation and Intermediate Care Activity (No.) Internal Monthly DoSD 67,914 25,853 10,661 5,447 5,725 26,358

Leicester County & Rutland Elective Servs Activity (No.) Internal Monthly DoSD 127,250 52,706 10,623 10,343 52,861 Marginal underperformance, less than 1% of target

Chlamydia Screening CSO Facilitation (No. of screens) Internal Monthly DoSD 41,440 11,134 8,315 2,937 2,338 13,590

Chlamydia Screening Delivery - coverage (No. screens) Internal Monthly DoSD 12,011 17,745 6,524 3,280 1,996 2,034 7,310

Chlamydia Screening Delivery - positivity (No.) Internal Monthly DoSD 910 342 128 75 78 281

Over focus on Community Foundation Trust application Top X Quarterly All 12 12 12 Comprehensive performance management and reporting systems for early identification of performance. Board development programme focused on managing transition.

Top X Quarterly All 12 12 12 Project structure in place with dedicated project director and office. Transition Board, led by DCHS Chair, overseeing transition project and reporting to full DCHS Board.

Diverse models of care and lack of consistency across geography and services Top X Quarterly DoSD 12 8 8 Risk reduced on register, no longer Top X

Introduction of Any Qualified Provider and changing commissioning landscape Top X Quarterly DoS 12 9 9 Exec Team review on 20th October

Loss of business to competitive Foundation Trusts Top X Quarterly DoS 12 8 8 Risk reduced on register, no longer Top X

Top X Quarterly DoFPI 9 6 6 Risk reduced on register, no longer Top X

Major Performance Failure Top X Quarterly DoFPI 9 6 6 No major breaches to date but still remains a possibility and therefore remains a residual risk.

Asset Transfer and uncertainty over timetable from DH Top X Quarterly 16 16 Being proactive with FTN and SHA around implicationsRisk associated with embedding new more effective governance arrangements in the organisation.

Top X Quarterly 12 12 Launching this early to allow time to embed and improve

Risk of not meeting Monitor community governace indicators resulting in a high risk governance rating

Top X Quarterly 12 12 Action Plan to be developed with countermeasures for November CFT Board

Risk to contract income due to activity levels on cost per case contracts. Top X Quarterly 16 16 Risk rating increased and therefore new Top X

Risk posed by the acquisition of additional services Top X Quarterly DoS 9 2 2 Risk reduced on register, no longer Top X

CIP Achieved (%) DCHS Way Monthly DoS 104% 100% 50.0% 34.1% 36.3% 43.1% 43.1% 100.0% Discussed in detail in the Finance Report

Achievement of data quality targets for the service (%) DCHS Way DoFPI 100%

Workforce Productivity (%) National DoSD

Internal Monthly DoHR 100% 100% 100% 100% 100% 100% 100% 100% 100%

Daycase activity not assigned a HRG (%) Internal Monthly DoSD 8% 1.3% 1.0%

Services with active systems in place to record the equality profile of service users (%)

QU

ALI

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USI

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S

Targets for Derby City PCT have not been agreed and consequently the targets provided are indicative only

Discussed in detail in the Finance Report

PRO

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AN

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INN

OV

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BU

SIN

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& M

AR

KETI

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FIN

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EFFE

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S &

PL

AN

NIN

G

Measurable indicators identified and monitoring mechanisms established and used (%)

Over focus upon operational performance at the detriment of Community Foundation Trust transition

Significant financial challenges, both nationally, regionally and locally pose a risk and potential failure to deliver the Financial Plan as set out in the IBP within the planned timescale

DCHS Healthcare Acquired Infections & CQUIN Scorecards October 2011

Measure Type Frequency Director2010/11 Outturn

2011/12 Full Year

TargetYTD Target Apr-11 May-11 Jun-11 Jul-11 Aug-11 Trend YTD

Forecast Outturn

MRSA Infections - Avoidable (No.) Internal Monthly DoNQ 0 0 0 0 0 0

MRSA Infections - Possible (No.) Internal Monthly DoNQ 0 0 0 0 0 0

MRSA Infections - Unavoidable (No.) Internal Monthly DoNQ 0 0 0 2 0 2

ESBL - Avoidable (No.) Internal Monthly DoNQ 0 0 1 0 0 1

ESBL - Possible (No.) Internal Monthly DoNQ 0 0 0 0 0 0

ESBL - Unavoidable (No.) Internal Monthly DoNQ 0 0 0 0 0 0

Norovirus outbreaks (No.) Internal Monthly DoNQ N/A N/A 0 2 2 0 2 6 N/A

MRSA Bacteriaemia - Avoidable (No.) National Monthly DoNQ 0 0 0 0 0 0

MRSA Bacteriaemia - Possible (No.) National Monthly DoNQ 0 0 0 0 0 0

MRSA Bacteriaemia - Unavoidable (No.) National Monthly DoNQ 0 0 0 0 0 0

MRSA Screenings - Elective Surgery (%) Internal Monthly DoNQ 100% 100% 100% 100% 100% 100% 100% 100% 100%

MRSA Screenings - Non Elective Admissions (%) Internal Monthly DoNQ 100% 100% 96% 100% 100% 98% 100% 99% 99%

MRSA Screenings - Sexual Health (%) Internal Monthly DoNQ 100% 100% 100% 100% 100% 100% 100% 100% 100%

Clostridium Difficile - Avoidable (No.) National Monthly DoNQ 0 0 0 0 0 0 0 0 0

Clostridium Difficile - Possible (No.) National Monthly DoNQ 0 0 0 0 0 0 0 0 0

Clostridium Difficile - Unavoidable (No.) National Monthly DoNQ 0 0 1 2 1 1 1 6 0

N/A N/A N/A

Norovirus OutbreakThe 2 August outbreaks were on the Older Peoples Mental Health wards at Walton Hospital. Following the Root Cause Analysis investigations it was established that there was no link between the 2 outbreaks. There was no obvious source of the infection and both looked to be contract independently. Staff adhered to policy and restricted the socialisation of patients to minimise spread to other patients on Linacre and Melbourne Wards.

Both performance tools have scored amber as the wards have been unable to meet the 24 hour cleaning target. Both completed their clean within 48 hours. It is anticipated that the delay in deep clean will be addressed once Health Promoting Environments and Services can confirm if resources are available for a second Deep Clean Team.

HEALTHCARE ASSOCIATED INFECTION SCORECARD

Focus Area

QU

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SERV

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USE

R SA

FETY

& E

XPER

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N/A N/A N/A

N/A N/A N/A


2011/12 Full Year Target

YTD Target Quarter 1 Jul-11 Aug-11 Sep-11 Trend YTDForecast Outturn

Narrative

Breast Feeding sustainment rate from 10 days to 6-8 weeks (%)

Reg 1 Monthly DoSD

84% 84%

Cumulative Average to M6 = 83.1% Targeted Action Plans in place to addressCommissioners have agreed payment as the last 2 months are above target

Implementation of NICE Stroke Quality Standard Reg 2 Monthly DoSDNew

Data received and accepted by our Commissioners and payment made.

High Impact Actions - FALLS Reg 3a Monthly DoSD Met part one of CQUIN and payment agreed.

High Impact Actions - URINARY CATHETERS Reg 3b Monthly DoSD New Met part one of CQUIN and payment agreed.

High Impact Actions - PRESSURE ULCERS Reg 3c Monthly DoSD

New

↓

The recording of all grades of PUs has commenced on DATIX and monitoring systems are in place.Commissioners have requested a more detailed report to demonstrate compliance to the indicator outcome. Following receipt payment will be agreed.

Content of Care Plans Reg 5 Monthly DoSDNew ↓ Targeted work is being completed by Leads to deliver

this target.Discharge Planning / Communication Reg 6 Monthly DoSD New Action Plans in place - on target to deliver

Improvements in Patient Experience Surveys Local 1 Monthly DoSD

New

↓

Planned Care Division fully completed. Health, Well-being and Inclusion being completed, in line with internally agreed timetable. Commissioners have recognised the work that has been completed to date and are revisiting the details of the CQUIN Indicator

Access to Services by Patients with Learning Dis' Local 2 Monthly DoSDNew

Part one of the target has been met and payment agreed. Illustrative stories to be supplied and wider LD access to services.

In-patient Admissions with a VTE Risk Assessment Local 3 Monthly DoSD New ↓ Monthly audits in place. Additional evidence requested to demonstrate outcome.

Engagement and Communication with Carers Local 4 Monthly DoSDNew ↓ CQUIN Indicator approved. Monthly audit data to be

further analysed to evidence this CQUIN.

Implementation of NICE Dementia Quality Std Local 5 Monthly DoSD New Audit undertaken, baseline set and agreed threshold. Payment agreed.



YTD Target Quarter 1 Jul-11 Aug-11 Sep-11 Trend YTDForecast Outturn

Narrative

Improve the patient experience evidence base and demonstrate positive change

Local 1 Quarterly DoSD New Improve Improve ↔General Manager report to be delivered in 2 weeks, in order to confirm Green and on target to deliver.

Increase the % of Patients (Adults) receiving a VTE Risk Assessments (Daycase)

Local 2 Quarterly DoSD NewIncrease

%Increase

%↔

Audits have been completed. General Manager report to be delivered in 2 weeks, in order to confirm Green and on target to deliver.

Improve timeliness and quality of out-patient letter communications

Local 3 Quarterly DoSD New Improve Improve ↓

General Manager to provide a detailed action plan to L&R PCT in 1 week, in order to confirm Green and on target to deliver. Until this report is received L&R PCT stated that this indicator will be RAG rated as RED.

Increase the % of Smokers accessing specialist 'Stop Smoking' services prior to Elective Treatment

Local 4 Quarterly DoSD NewIncrease

%Increase

%↑

Audits have been completed. General Manager report to be delivered in 2 weeks, in order to confirm Green and on target to deliver.

KEY ISSUES AND ACTIONSThe planned Quality Assurance Group (QAG) meetings with NHS Derbyshire County continue to take place. The 14th October 2011 update meeting received detailed compliance reports , which were accepted by our Commissioners. For the red and amber areas, our Commissioners have requested more detailed reports in order to demonstrate compliance to the indicators outcome. This will be provided and we are confident that these areas will return to green following the receipt of these reports.

CQUIN INDICATORS 2011-12 (DERBYSHIRE)

Focus Area

QU

ALI

TY S

ERV

ICE

EXPE

RIEN

CE, S

AFE

TY &

CLI

NIC

AL

EFFE

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S

Man

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the

CQU

IN ta

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s fo

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1-12

are

Pat

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CQUIN INDICATORS 2011-12 (LEICESTERSHIRE & RUTLAND - PLANNED CARE SERVICES)

Focus Area

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KEY ISSUES AND ACTIONSThe 13th October 2011 meeting between DCHS NHS Trust and NHS Leicestershire & Rutland PCT clarified the evidence submitted to date and the RAG ratings were formally agreed. The new General Manager for L&R Planned Care Services attended the meeting and will be providing detailed reports and action plans on each of the CQUIN Indicators, in order to confirm their Green status.

DCHS Board Exception Reports October 2011

Measure Type Frequency Director


YTD Target Jun-11 Jul-11 Aug-11 Sep-11 YTD

A&E Total Time in the A&E Department (non admitted) - Longest (mins)

National Monthly DoSD <360 <360 460 462 402 553 553

ACTION PLAN:

Exception Report Analysis

- There was one breach in September, which was as a result of delays in the inter-hospital transfer. The patient arrived at 17.27 and was seen at 17.30, having had an accident where there was significant concern over a tender and potentially unstable cervical spine. The patient was immobilised and request for transfer was made at 18.05. The patient was eventually transferred at 02.35. As obs were stable throughout, there was no escalation of the request to 999. Ambulance control were contacted on 6 occasions for updates and reported that they were busy with emergency calls and a vehicle was not available.- A review of the breach concluded that other than informing the on call Director, the correct procedure had been followed by DCHS staff. This has also been followed up with East Midlands Ambulance Service, who reported that there was unpredicted 999 call demand that night.

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Buxton Ilkeston Ripley Whitworth

Num

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f Bre

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s YT

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to A

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Site

Longest Wait - Sept

Number of Breaches YTD

Longest Wait-Target Time

A&E Total Time From Arrival by Site - Longest Wait (mins) September



YTD Target May-11 Jun-11 Jul-11 Aug-11 YTD

MIU Activity (No.) Internal Monthly DoSD 52,923 24,682 4,561 4,657 4,840 4,564 23,264

ACTION PLAN:


- Buxton MIU reverted back to original opening hours from 22nd August and it is envisaged that this will go someway to reducing future underperformance at this site. However, the Buxton Advertiser still has the reduced opening hours and Comms have been contacted to correct this. - A meeting is being arranged between Comms and MIU management in November to take forward an updated marketing strategy designed to increase awareness of MIU over the winter period.- Advertising in the Amber Valley and Erewash locality is being pursued through a local magazine, with an advert to appear during December/January.- The final profile for MIU has been signed off for use in the 111 scheme as of 1st November, once implemented this should increase ambulance service related activity

-2%

-6%-7% -7%

-6%

-25%

-20%

-15%

-10%

-5%

0% 0

5,000

10,000

15,000

20,000

25,000

30,000

% V

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from

Pla

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Act

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Month

Cumulative Planned Activity

Cumulative Actual Activity

% Variance From Plan

MIU Planned & Actual Activity by Month - Cumulative Year To Date August




Outpatient and Daycase Activity (No.) Internal Monthly DoSD 43,402 17,924 3,474 3,609 3,353 3,265 16,321

ACTION PLAN:


• Meeting has taken place with Commissioners to discuss out patients and day case services and planned directions regarding portfolio development. Information on plans to be shared and discussed with Commissioners at further meetings. In addition links with CCGs will be developed• Marketing strategy for out patients and day case services has been produced and work has commenced in collaboration with Communications Team• Discussions held with senior management team at DHFT to move forward progress with transfer of Trauma and Orthopaedic patients from DHFT as well as monthly meeting with DHFT ops team continue to monitor session delivery and service issues• Discussions held with DHFT and commissioners regarding plans for increased use of endoscopy rooms at Ilkeston. Extra activity may be generated linked to future bowel screening programme development• Utilisation figures have shown an increase over the last few months due to focused work on capacity utilisation and the service are continuing to offset a proportion of the income loss through cost reduction

-17%

-10%

-8%

-10%-9%

-18%

-16%

-14%

-12%

-10%

-8%

-6%

-4%

-2%

0% 0

2,000

4,000

6,000

8,000

10,000

12,000

14,000

16,000

18,000

20,000

Apr-11 May-11 Jun-11 Jul-11 Aug-11

Cum

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mac

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)

Act

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Month Cumulative Planned Activity Cumulative Actual Activity % Variance

Outpatients & Daycase Planned & Actual Activity by Month - Cumulative Year To Date August




Community Podiatry Activity (No.) Internal Monthly DoSD 133,093 57,405 10,303 12,000 10,228 10,875 52,685

ACTION PLAN:


There continues to be a high level of demand in this service, as evidenced by high levels of referrals and the service is working to ensure that flexible capacity is available to meet demand and keep waiting times within threshold. To achieve this the service has a plan which addresses the capacity issues that have impacted on year to date activity.

-20%

-14%

-10%

-12%

-8%

-25%

-20%

-15%

-10%

-5%

0% 0

10,000

20,000

30,000

40,000

50,000

60,000

70,000

% V

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Act

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Month

Cumulative Planned Activity

Cumulative Actual Activity

% Variance From Plan

Community Podiatry - Planned & Actual Activity by Month - Cumulative Year To Date August




Health Visiting Activity (No.) Internal Monthly DoSD 260,908 112,806 19,549 19,762 16,800 18,661 93,753

ACTION PLAN:


The current level of underperformance for Health Visiting is due to various factors. These include:• Vacancies, including posts held for students. We plan to relieve this issue in future by engaging with a mid-year cohort so that newly qualified staff are employed twice a year as opposed to just once in September. We continue to have vacancies and actively recruiting to vacancies is a top priority to attract the best staff and reduce impact• Roll out of TPP, where all staff have additional 9hrs training taken out of clinical time. However the service recognises the need for training when implementing IT systems and the benefits will easily outweigh this investment.• Change in HV practice with less focus on high volume low level work towards more early intervention and assessment/multi-agency working. As a part of this we have reviewed child health clinics to ensure that we maximise clinical time utilisation• Analysing activity and working with the staff to ensure accurate recording of activity

4,0006,0008,00010,00012,00014,00016,00018,00020,00022,00024,000

Act

ivit

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Locality

Cumulative YTD PlanCumulative YTD Actual

Health Visiting Planned & Actual Activity by Locality - Cumulative Year To Date August

ANNEX 1

Organisation Code RY8 RTG RFS RK5 ENG

-

Organisation Name

DERBYSHIRE COMMUNITY

HEALTH SERVICES NHS TRUST

DERBY HOSPITALS NHS FOUNDATION

TRUST

CHESTERFIELD ROYAL HOSPITAL NHS

FOUNDATION TRUST

SHERWOOD FOREST HOSPITALS NHS

FOUNDATION TRUST - ENGLAND-

Total number of attendances in A&E HES

(excluding planned follow-up attendances, attendances where the attendance category was unknown, and attendances where the attendance disposal category was unknown) 4,348 10,026 5,807 8,985 1,354,870Number of attendances with an attendance disposal of "Left Department before being treated" 138 90 215 97 45,393 Left department before being seen for treatment 3.2% 0.9% 3.7% 1.1% 3.4%Total number of attendances in A&E HES

(excluding planned follow-up attendances and attendances where the attendance category was unknown)

4,348 10,026 5,807 9,094 1,368,257Number of re-attendances within 7 days of a previous attendance at A&E 199 743 299 653 102,197Re-attendance rate 4.6% 7.4% 5.1% 7.2% 7.5%Median * 6 0 8 6

95th Percentile3 * 1,430 60 50 116

Longest wait4 * 1,430 170 1,439 1,439Median 31 59 84 59 57

95th Percentile3 162 179 183 172 198

Longest wait4 289 1,439 366 504 1,439Median * 207 215 201 214

95th Percentile3 * 332 246 287 397

Longest wait4 * 655 531 462 1,439Median 58 132 123 104 112

95th Percentile3 197 261 230 229 237

Longest wait4 376 1,439 551 496 1,439Median 58 145 144 125 131

95th Percentile3197 277 238 237 258

Longest wait4376 1,439 551 496 1,439

Time to Departure (Performance; minutes)

[All patients]

Department of Health Provisional Accident & Emergency Quality Indicators for England. Experimental Statistics by Provider for April 2011Q

UA

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Left department before being seen for treatment

(Performance)

Re-attendance(Performance)

Time to initial assessment(Performance; minutes)

Time to Treatment(Performance; minutes)

Time to Departure (minutes)

[Admitted patients only]

Time to Departure (minutes)

[Non-admitted patients only]

Measure TypeNew Revised Existing

Description

Staff Attendance (%)DCHS Way/National

Existing

Staff with appraisal completed (%) DCHS Way Existing

Essential Learning completed (% cumulative) DCHS Way Existing

Information Governance Training (% cumulative) National New

New starters attending induction (%) DCHS Way Existing New starters attending induction within 3 months / new starters requiring induction

Improvement in Staff Survery participation rates (%) DCHS Way New Total staff participating / Total staff

Improvement in Staff Survery engagement and staff satisfaction scores (No.)

DCHS Way New

Headcount (No.) Internal Existing All staff who work for DCHS - either full-time, part-time and fixed term contract

Total FTE (No.) National Existing All staff who work for DCHS on any basis

Health Visitor FTE (No.) National New All Health Visiting staff who work for DCHS on any basis

Management FTE (No.) National New Nationally defined as Admin, Estates, Managers & Senior Managers

Clinical Staff FTE (No.) National New Nationally defined as Qualified Nursing, Medical, Dental, ST&Ts and Clinical Support

Compulsory Redundancy (No.) National New

Workforce Cost-Excl Agency ( £000's) National New

Temporary Staffing Costs - Agency (£000's) National New

Temporary Staffing Costs - Bank (£000's) National New

Temporary Staffing Costs - LCR (£000's) National New

Annual Income Per WTE (£000's) Internal New

Staff Turnover (%) Internal Existing

Vacancies (No.) Internal Existing

Patient and Public Involvement plans completed DCHS Way New To be developed

A&E Unplanned Re-attendance Rate (%) National New Unplanned attendances within 7 days of discharge / total attendances

A&E Total Time in the A&E Department (non admitted) - Median (mins) National New The time below which 50% of attendances were transferred or discharged

A&E Total Time in the A&E Department (non admitted) - 95th percentile (mins)

National New The time below which 95% of attendances were transferred or discharged

A&E Total Time in the A&E Department (non admitted) - Longest (mins) National New Single longest time recorded from arrival at A&E to transfer or discharge

A&E Left Without Being Seen Rate (%) National New The percentage of people who leave the A&E without being seen

A&E Time to Initial Assessment - Median (mins) National New The time below which 50% of patients arriving by emergency ambulance are assesed

A&E Time to Initial Assessment - 95th percentile (mins) National New The time below which 95% of patients arriving by emergency ambulance are assesed

A&E Time to Initial Assessment - Longest (mins) National New Single longest time recorded from arrival by emergency ambulance to assessment

A&E Time to Treatment - Median (mins) National New The time below which 50% of attendances were treated

A&E Time to Treatment - 95th percentile (mins) National New The time below which 95% of attendances were treated

A&E Time to Treatment - Longest (mins) National New Single longest time recorded from arrival at A&E to treatment

RTT Waits - incomplete pathway (No. patients) National New The total number of incomplete Referral to Treatment pathways at the end of the period

RTT Waits - incomplete pathway median (weeks) National New Median time waited for patients on incomplete pathways at the end of the period.

RTT Waits - admitted patients median (weeks) National New Median time waited for admitted patients whose clocks stopped during the period

RTT Waits - non admitted patients median (weeks) National New Median time waited for non-admitted patients whose clocks stopped during the period

RTT Waits - incomplete pathway 95th percentile (weeks) National New 95th percentile time waited for patients on incomplete pathways at the end of the period.

RTT Waits - admitted patients 95th percentile (weeks) National New95th percentile time waited for admitted patients whose clocks stopped during the period on an adjusted basis

RTT Waits - non admitted patients 95th percentile (weeks) National New96th percentile time waited for non-admitted patients whose clocks stopped during the period on an adjusted basis

Mixed Sex Accommodation Breach Rate (%) National Revised Number of breaches / number of Finished Consultant Episodes

Delayed Transfer of Care (%) National Revised Number of delayed transfers of care as a proportion of the number of occupied beds

Achievement of consultation /involvement/engagement inclusion priorities (%)

Internal Existing

New or revised policies/procedures/strategies supported by EIAs (%) Internal Existing

Appointment slots available on the Choose and Book System - no of patients unable to book (%)

Internal Existing

Patients who have operations cancelled for non clinical reasons receiving treatment within 28 days (%)

Internal Existing

Identification of Top X risks on an ongoing basis and action plans developed against them

DCHS Way New In development

Healthcare Care Associated Infections - MRSA bacteraemia & Clostridium difficile (No.)

National Existing

Potential Non compliance/partial compliance with the Health and Social Care Act 2008 and DH Health & Technical Memorandum 01 series Essential Decontamination Standards

Top X Revised

Risk of harm to patients through ineffective action to minimise healthcare acquired infections

Top X Revised

Risk of harm to individual patients through inadequate clinical record keeping

Top X Revised

Risk of avoidable harm to patients through poor implementation of tissue viability guidance in relation to pressure area care

Top X Revised

Risk of harm to patients due to ineffective falls management systems Top X Revised

Risk of harm to children or adults due to failure to implement safeguarding policies and procedures

Top X Revised

Achieve Care Quality Commission compliance DCHS Way New In development

Measurable indicators identified and monitoring mechanisms established and used (%)

DCHS Way New In development

Breastfeeding prevalence 6-8 weeks after birth (%) National Existing Number of partially and fully breastfed infants / total infants due a 6-8 week check

Breastfeeding coverage 6-8 weeks after birth (%) National Existing Number of partially, fully and none breastfed infants / total infants due a 6-8 week check

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GLOSSARY

Focus AreaQ

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Measure TypeExisting or New

Narrative

MRSA Infections - Avoidable (No.) Internal Existing Identified non compliance with IP&C standards which may have prevented occurrence

MRSA Infections - Possible (No.) Internal Existing Identified possible risk factors that may have contributed to the infection occurring

MRSA Infections - Unavoidable (No.) Internal Existing Identified that there were pre-disposing risk factors contributing to the infection

ESBL - Avoidable (No.) Internal Existing Extended Spectrum Beta Lactamases

ESBL - Possible (No.) Internal Existing Extended Spectrum Beta Lactamases

ESBL - Unavoidable (No.) Internal Existing Extended Spectrum Beta Lactamases

Norovirus outbreaks (No.) Internal ExistingConsidered unavoidable because DCHS is unable to influence transmission. Number of ‘outbreaks’ and therefore may include more than one patient.

MRSA Bacteriaemia - Avoidable (No.) National Existing Identified non compliance with IP&C standards which may have prevented occurrence

MRSA Bacteriaemia - Possible (No.) National Existing Identified possible risk factors that may have contributed to the infection occurring

MRSA Bacteriaemia - Unavoidable (No.) National Existing Identified that there were pre-disposing risk factors contributing to the infection

MRSA Screenings - Elective Surgery (%) Internal Existing The % of elective surgery patients screened for MRSA

MRSA Screenings - Non Elective Admissions (%) Internal Existing The % of non elective admission patients screened for MRSA

MRSA Screenings - Sexual Health (&) Internal Existing The % of sexual health patients screened for MRSA

Clostridium Difficile - Avoidable (No.) National Existing Identified non compliance with IP&C standards which may have prevented occurrence

Clostridium Difficile - Possible (No.) National Existing Identified possible risk factors that may have contributed to the infection occurring

Clostridium Difficile - Unavoidable (No.) National Existing Identified that there were pre-disposing risk factors contributing to the infection

Meet planned SLR Gross Contribution (%) DCHS Way New Gross contribution delivered / gross contribution planned

Financial Risk Rating (FRR) Internal Existing

The purpose of this measure is to indicate the overall financial performance of the organisation.The measure above are taken directly from the Monitor Foundation Trust Framework, each of the above is then allocated a weighting which when calculated gives the organisation an overall FRR 1 being the lowest and 5 being the highest.

Better Payment Practice Code - by value (%) National Revised Value of invoices paid within 30 days / Total value of invoices paid

Better Payment Practice Code - by volume (%) National Revised No. of invoices paid within 30 days / Total no. invoices paid

Delivery of Service Delivery Plans (%) DCHS Way New In development

Business Revenue on unit pricing agreements (%) Internal Existing Contract value on cost and volume / total contract value

Positive media stories (No.) Internal RevisedThe number of positive media stories reported for DCHS across all media outlets. A positive media story is classed as one that enhances the reputation of DCHS

MIU Activity (No.) Internal Existing Multilateral contract activity, compared against profiled activity plan

Inpatient Spells Activity (No.) Internal Existing Multilateral contract activity, compared against profiled activity plan

Inpatient Excess Bed Days Activity (No.) Internal Existing Multilateral contract activity, compared against profiled activity plan

OPMH Inpatient Spells Activity (No.) Internal Existing Multilateral contract activity, compared against profiled activity plan

OPMH Inpatient Excess Bed Days Activity (No.) Internal Existing Multilateral contract activity, compared against profiled activity plan

Outpatient and Daycase Activity (No.) Internal Existing Multilateral contract activity, compared against profiled activity plan

Vasectomy Service Activity (No.) Internal Existing Multilateral contract activity, compared against profiled activity plan

Podiatric Surgery Activity (No.) Internal Existing Multilateral contract activity, compared against profiled activity plan

Community Podiatry Activity (No.) Internal Existing Multilateral contract activity, compared against profiled activity plan

Physiotherapy Activity (No.) Internal Existing Multilateral contract activity, compared against profiled activity plan

Speech and Language Therapy Activity (No.) Internal Existing Multilateral contract activity, compared against profiled activity plan

Health Visiting Activity (No.) Internal Existing Multilateral contract activity, compared against profiled activity plan

Community Nursing Activity (No.) Internal Existing Multilateral contract activity, compared against profiled activity plan

Rehabilitation and Intermediate Care Activity (No.) Internal Existing Multilateral contract activity, compared against profiled activity plan

Leicester County & Rutland Elective Servs Activity (No.) Internal New LCR Elective Servs activity, compared against profiled activity plan

Very high intensity users contacts (No.) Internal Existing

Chlamydia Screening CSO Facilitation (No. of screens) Internal New

Chlamydia Screening Delivery - coverage (No. screens) Internal Revised Chlamydia Screening Office - total commissioned screens

Chlamydia Screening Delivery - positivity (No.) Internal Revised Chlamydia Screening Office - total commissioned positive screens

Over focus on Community Foundation Trust application Top X Revised

Over focus upon operational performance at the detriment of Community Foundation Trust transition

Top X Revised

Diverse models of care and lack of consistency across geography and services

Top X Revised

Introduction of Any Qualified Provider and changing commissioning landscape

Top X Revised

Loss of business to competitive Foundation Trusts Top X Revised

Significant financial challenges, both nationally, regionally and locally pose a risk and potential failure to deliver the Financial Plan as set out in the IBP within the planned timescale

Top X Revised

Major Performance Failure Top X Revised

Asset Transfer – uncertainty over timetable from DH and risk of prolonged delays may not be transferred until as late as summer 2012 - which has major consequence to the LTFM and financial planning of DCHS.

Top X New

Risk associated with embedding new more effective governance arrangements in the organisation.

Top X New

Risk of not meeting Monitor community governace indicators resulting in a high risk governance rating

Top X New

Risk to contract income due to activity levels on cost per case contracts. Top X New

Risk posed by the acquisition of additional services Top X Revised

CIP Achieved (%) DCHS Way New CIP Achieved / Total CIP required

Achievement of data quality targets for the service (%) DCHS Way New In development

Workforce Productivity (%) National New In development

Services with active systems in place to record the equality profile of service users (%)

Internal Existing

Daycase activity not assigned a HRG (%) Internal Existing

Focus AreaQ

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KEY TO COLOUR CODINGS

Indicator / Measure has met or exceeded targetIndicator / Measure has not met target but is within acceptable tolerances. An action plan is in place and is being monitoredIndicator / Measure has not met target and is beyond accepted tolerances. Immediate action and investigation has been instigated. An action plan is in place and is being monitored. Indicator / Measure is not available or in development

KEY TO SYMBOLS

↑ Performance has improved / is above target

↓ Performance has declined / is below target

↔ Performance is stable and on target to be delivered

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