agenda number: cg 074/12 agenda item: chief executive assurance report date of meeting ... meeting...

LINK TO VALUES: Accountability

LINK TO STRATEGIC PRIORITIES: 6. Quality & Governance

LINK TO NHS CONSTITUTION: Quality of Care & Environment

LINK TO BOARD RISK REGISTER: 8. Maintain an effective system of internal control

EXECUTIVE SUMMARY

The attached report provides details of the key areas of performance for the Trust as at the

end of April in order that Governors can be assured that the Trust is properly carrying out

its responsibilities to patients and the public in general. This information was presented to

the Trust Board on 7 June 2012.

• Trust Board Integrated Quality & Performance Report – Appendix 1

• Integrated Quality & Performance Framework – Appendix 1a

• Quality Account – Appendix 1b

This report also provides an update from the Director of Nursing in respect of the Trust

Governance report for the period January to March 2012.

1.0 DISCHARGE OF RESPONSIBILITIES

i) Statutory duties

ii) Oversight – Holding the Board of Directors to Account

iii) Directional and Promotional Role

AGENDA NUMBER: CG 074/12

AGENDA ITEM: Chief Executive Assurance Report

DATE OF MEETING: 19 June 2012

PREPARED BY: Heather Tierney-Moore

FOIA STATUS: No exemption Choose an item.

Part exemption applies to page:

REVIEW DATE: 19 June 2012

2.0 COUNCIL OF GOVENORS ACTION

The Council of Governors is asked to:

i) Note the overview of performance provided in this report.

3.0 BACKGROUND

This paper gives the Council of Governors a summary overview of key areas for the

Trust. As representatives of the local community, the Council of Governors plays

an important role in ensuring that the Trust’s assets are safeguarded and applied

for the greater good in pursuit of the organisations vision mission and goals. In

particular, the Council of Governors has an oversight role in holding the Board of

Directors to account and will receive a monthly Integrated Quality and Performance

Report.

4.0 ISSUES

4.1 Integrated Performance & Quality Report

The key issues are contained within section 4.0 of the Integrated Quality and

Performance report (Appendix 1).

4.2 Governance Report

Violence and aggression Violence and aggression is a well-documented issue in mental health services particularly in inpatient units. Reports have revealed an increase in the number of incidents and as a result the Director of Nursing commissioned a more detailed analysis of the current situation. A number of factors have been identified as important in the analysis and a programme of work has been approved to consider how these challenges can be dealt with more effectively.

Energising for Excellence Nationally and locally there are a number of initiatives focused on quality with a particular focus on Nursing. These initiatives are coordinated under the umbrella of the “Energising for Excellence” programme. These initiatives were introduced in the acute hospital sector and are now being rolled out to other areas of health care delivery. An update regarding the approach in Lancashire Care was presented by the Director of Nursing. This work fits logically with the Trust’s overall approach to quality improvement.

Clinical Audit Annual Report The clinical audit progress report was presented to the group which included 5 completed audit summaries:

• Carers strategy and assessment - re-audit

• Physical healthcare and nutrition audit

• Falls re-audit

• Restraint and seclusion

• Supervision

Quality Account All NHS provider organisations produce a Quality Account on an annual basis. These accounts are a key mechanism through which health care organisations can demonstrate their focus on improving the quality of their service. Assurances were provided that a clear plan is in place to ensure the account is produced on time and in accordance with the guidance provided by the Department of Health and Monitor. The Account forms part of the Annual Report and Accounts and was formally signed off by the full Trust Board on 31st May 2012.

Monitor Compliance Framework The framework for 2012/13 was published in March and includes a revised set of Governance indicators based on the relevant priorities for the Operating Framework for the NHS during 2012/13. Progress against these indicators will be reviewed by the Executive Management Team on a weekly basis and reported to the board on a monthly basis. The revisions applicable to the Trust were reviewed. Monitor Compliance Rating quarter 4 2011-12 The trust was subject to an Amber Red rating for Monitor Compliance following a Care Quality Commission review of Balmoral Ward in Parkwood in December 2011. As a result of this visit a detailed action plan was developed and implemented to address the concerns. The Care Quality Commission confirmed, after a further assessment of the ward, that these concerns had been addressed by the Trust and as a result the Trust has now received a Green compliance rating from Monitor.

NICE Compliance The Annual report was received and an update was also provide against the progress made against the dementia guidance which had been an issue raised in previous reports. Progress has been made and this issue is now resolved. The report provided an update against the main strands of work that form part of this project.

Incidents, Complaints and Claims This quarter the reports have been broken down into the new networks. Within the Children and Families network there were 443 incidents reported during this three-month period with patient safety, violence and interface/communications being the most reported types of incidents. This is a 20% reduction compared with the same period last year. The network received a total of 6 complaints in quarter 4 and 15 concerns.

In the Adult Mental Health Network there were 2,303 incidents reported during this three-month period with patient safety and violence, being the most reported types of incidents. This is a 35% increase compared with the same period last year. The majority of incidents (85%) occur in Step 5. There have been 42 complaints received and 54 concerns in Q4 relating to the Adult Mental Health Network.

Within Adult Community there were 578 incidents reported during this three-month period with patient safety, being the most reported type of incident. There has been approximately the same number of incidents reported this quarter when compared to the same quarter in 2011, however when viewed over a full year there has been a steady decrease.

Specialised Services recorded 684 incidents for inpatient services and 13 for offender health services reported during this three-month period with patient safety,

violence, and security being the three most reported type of incident. There has been a gradual increase in the number of incidents reported this quarter when compared to the same quarter in 2011, which is reflected in the overall trend line for the last five quarters. The top two types of reported incident are patient safety and violence and aggression. There were 47 complaints and 52 concerns reported during the quarter.

The Accountable Officer’s Report The Accountable Officer’s report was received. The purpose of this report is to provide assurance to the Executive Management Team and the Trust Board that Lancashire Care Foundation NHS Trust is compliant with the requirements of the Misuse of Drugs Act. Two issues relating to the management of controlled drugs across adult and older adult mental health wards and a complex controlled drugs issue identified in the Trusts community services were considered by the committee.

CQC Monitoring Report and QRP update Given the learning from the Balmoral situation, the current quality and assurance and CQC compliance systems are subject to review. A more integrated system is being implemented to provide assurance across the organisation and to the Board. The focus is less on central monitoring of evidence and more on assurances from the relevant service areas based on the EAM approach. The networks are providing a quarterly statement outlining whether or not they are satisfied that plans are in place to ensure on-going compliance with the CQC registration requirements.

Infection Control Quarterly Report This report outlines activity undertaken by the Infection Prevention and Control team during the period 1st January 2012 and 31st March 2012. The aim of the report is to provide assurances to the Board and the public that everything possible is being done to minimise the incidence of Health Care Associated Infection and, that when infection does occur, this is effectively controlled and treated as a priority within the Trust. The Council of Governors can be assured there is nothing to indicate that the Trust is not fully compliant with the standards and compliant with the Hygiene Code.

Safeguarding Quarterly Report The Annual Report was presented. This report provides assurances regarding safeguarding children and adults. The report described progress against delivery of the agreed Trust’s Safeguarding and Protecting Children Action Plan and highlighted continuing priorities for the coming year. The Council of Governors can be assured there is nothing to indicate that the Trust is not fully compliant with the Care Quality Commission’s Essential Standards for Quality and Safety.

5.0 SUMMARY AND CONCLUSIONS

This report gives an overview of performance with regard to the key areas for the

Council of Governors to discharge their duties: Compliance with Statutory Duties;

Oversight – Holding the Board of Directors to Account; and Direction and

Participation.

6.0 RECOMMENDATION

The Council of Governors is asked to:

i) Note the overview of performance provided in this report.

Appendix 1

LINK TO VALUES: Accountability

LINK TO PRIORITIES: 1. To improve compliance, performance and quality by strengthening our organisational delivery and assurance systems.

LINK TO NHS CONSTITUTION: Quality of Care & Environment

LINK TO BOARD RISK REGISTER:

8. Maintain an effective system of internal control

IMPACT ON THE RISK SCORE OR ASSURANCES IN PLACE:

The report provides new/on-going assurance around an existing risk; no change to risk scoring

EXECUTIVE SUMMARY

The Trust Board receives a monthly integrated report on Quality and Performance. The

report for April 2012 is attached.

• Integrated Quality & Performance Framework – Appendix 1a

• Quality Account – Appendix 1b

1.0 BOARD ACTION

The Board is asked to:

i) Note the overview of performance provided in the report.

2.0 INTRODUCTION

The attached report details the performance of the Trust for April 2012. 3.0 BACKGROUND

The Integrated Quality and Performance Report provides the Board with a monthly overview of performance and aims to give the Board assurance that the level of reporting across the organisation is sufficient to ensure that the Trust is operating effectively, efficiently and economically.

AGENDA NUMBER: TB/100/12

AGENDA ITEM: Integrated Quality and Performance Report

DATE OF MEETING: 07/06/2012

PREPARED BY: Susan Rigg

FOIA STATUS: No exemption Choose an item.

Part exemption applies to page:

REVIEW DATE: 07/06/2012

The framework promotes accountability for performance at a number of levels across the organisation and has been structured to provide assurance in relation to the following areas:

• Monitor – Terms of authorisation and Compliance Framework

• Assurance and Accreditation

• Delivery of NHS Mental Health, Community and Specialised services Contracts

• Delivery of the Quality Strategy – Patient Safety, Patient Experience and Clinical Effectiveness

• Information Governance

• Membership

• Workforce

The frequency of reporting to the Board for each indicator has been developed to reflect the timescale by which progress can be meaningfully demonstrated. A number of indicators will only report on a quarterly or annual basis and where this is the case and a performance indicator is not due to be reported, the indicator is shaded grey in the framework. The report is supplemented with exception reports in respect of those areas that are rated as red or amber and also to highlight other key issues to the Board. The red, amber and green (RAG) metrics have been informed by either nationally prescribed targets where they exist, or by locally developed targets. The locally developed targets will be reviewed on a regular basis to ensure that the thresholds that have been developed reflect the right level of assurance to the Board.

4.0 ISSUES

Quality and Performance

The Board’s attention is drawn specifically to the following: 4.1 Monitor Compliance Framework 2012/13

The Compliance framework for 2012/13 was published on 30th March. A review of the applicability of the recently published indicators to the Trust’s services has been undertaken by the Data Quality Group and approved by the Governance Committee. The performance framework has now been updated to reflect the revised indicators. The key changes are:

• Data completeness levels for trusts commissioned to provide community services, using Community Information Data Set (CIDS) definitions, from April 2012, to consist of

- Referral to treatment times – consultant-led treatment in hospitals and Allied Healthcare Professional-led treatments in the community- 50% threshold

- Community treatment activity – referrals - 50% threshold and

- Community treatment activity – care contact activity – 50% threshold

• Two further CIDS data items will be introduced later in 2012/13, comprising: - Patient identifier information - 50% threshold and - Patients dying at home - 50% threshold

• Admissions to inpatients services had access to crisis resolution home treatment teams – increase in target from 90% to 95%

• Mental health Data completeness: identifiers – reduction in target from 99% to 97%

• New referral to treatment waiting time measures for consultant led services

4.2 In-patient Activity

Following discussion at a previous Board meeting, the performance in relation to

Bed Occupancy and Length of Stay is now included within the Integrated Quality

and Performance Framework. The data currently reflects the monthly performance

and the respective internal targets for each of these indicators will be developed by

the Transformation Director, as part of the In-patient Transition Programme. In view

of this the trend arrows for these indicators reflect the current month’s activity

against the figures reported for March 2012.

4.3 Financial Risk Rating

It is the normal practice that no financial results are produced relating to April (June

meeting). The required focus on producing and auditing the financial results for the

old year adversely impacts on the robustness, reliability and meaningfulness of

figures. The financial reports for May onwards (July meeting) will be available as

normal.

4.4 CQUIN and Quality Schedules NHS Mental Health and Community Contracts

At the formal contract monitoring meeting held on 10th May 2012, commissioners confirmed that the CQUIN and Quality Schedules for the Mental Health and Community Contracts were reconciled and determined to be fully compliant as at the end of March 2012.

4.5 Medicines Management

There has been a slight rise in hypnotic prescribing both PRN and regular. This reflects the position of patients already being prescribed hypnotics on admission to a Trust inpatient facility and it not being clinically appropriate to immediately stop medication.

4.6 Mandatory Training

As expected the percentage of compliance has decreased following the introduction

of the new Mandatory Training Policy and Matrix. This is due to changes in training

requirements for some staff groups and the frequency for maintaining

compliance. All staff have received passwords to the e-learning platform and there

is evidence of update and completion of modules. A new programme of face to

face training is available and additional clinical trainers have been recruited to

provide additional capacity and bespoke targeted training.

4.7 PDR/PDP

High level Trust data is now available via the e-PDR system and this is now being

used to report compliance rather than using data held in ESR/OLM.

Communications continue to raise awareness of the new process and the

completion deadline. Training, advice and support continue to be provided by the

Learning & Organisational Development team and managers are being encouraged

to set team objectives to support implementation of the new process. The Trust has

a target to achieve 100% compliance of completion of PDRs by the end of

June 2012.

4.8 Workforce and Organisational Development Spend on Bank and Agency staff has decreased slightly during April, compared to March’s figure of £1,468,859. The Temporary Staffing and HR Operations teams continue to work closely with managers to reduce this. The top ten users of bank and agency staff are reported to the Executive Management Team on a monthly basis for analysis against other performance indicators and appropriate challenge. The In-month Sickness Absence Rate has decreased slightly since last month. This reduction is attributed to continual monitoring and support from the HR Operations Team. The top ten services with the highest sickness absence rates are also reported to the Executive Management Team on a monthly basis. The 12 month Average Sickness Rate has remained the same this month. However, the Trust has seen a downward trend across the past 12 months. Again, this is attributed to long term support from HR Operations and managers.

5.0 SUMMARY AND CONCLUSIONS

The integrated Quality and Performance report details the performance of the Trust for April 2012.

6.0 RECOMMENDATION

The Board is asked to:

i) Note the overview of performance provided in the report.

No Indicator Title Description of metricOrganisational

Priorities

Care Quality

Commission

requirement

Community or

Mental Health

Contract

requirement

Executive Lead Data Source

Trend from

previous

reporting

period

Frequency of

Report

Red Amber Green

1 Care Programme Approach

Patients receiving follow up contact

within 7 days of discharge from

hospital - target 95%

3 �Director of

Finance

National Care Records

System (NCRS) &

Electronic Care Record

(ECR)

<90% <95% 98.3% Monthly

2 Care Programme Approach Patients having formal review within

12 months- target 95%3

�

Director of

FinanceNCRS & ECR <90% <95% 96.5% Monthly

3Minimising mental health delayed

transfers of care

The percentage of non-acute patients

age 18 & over whose transfer of care

was delayed - target ≤7.5%

3 �Director of

FinanceNCRS & ECR >10% 7.5%-10% 4.05% Monthly

4

Admissions to inpatient services had

access to crisis resolution home

treatment teams

The percentage of gate-kept

admissions to inpatient services

requiring access to crisis resolution

home treatment teams - target 95%

3 �Director of


5Meeting commitment to serve new

psychosis cases by early intervention

Level of performance against

contracted activity - target 95%3 �

Director of

FinanceNCRS & ECR <90% <95% 273% Monthy

6 Mental Health Data Completeness Patient Identifiers - target 97% 1 �Director of


7 Mental Health Data CompletenessOutcomes for patients on CPA - target

50%1 �

Director of


8Access to Healthcare for people with

Learning Disabilities

Certification against compliance with

requirements regarding access to

healthcare for people with Learning

Disabilities

3 �Director of

NursingGreenlight Toolkit

Non Compliant/

Breaches

Moving to

complianceCompliant

Quarterly

(Q4 position)

9 NHS Litigation AuthorityPlan to achieve Level 1 standards in

year1 � �

Director of

NursingDirector of Nursing

Non Compliant/

Breaches

Moving to

complianceCompliant Annual

10Referral to treatment times -

Consultant-led

Maximum time waited for non-

admitted patients (threshold 18 weeks)

completed pathway

-target 95%

1 � �Director of

FinanceNCRS & ECR <95% 99.1% Monthly

11Referral to treatment times -

Consultant-led

Maximum time waited for non-

admitted patients (threshold 18 weeks)

incomplete pathway

- target 92%


FinanceNCRS & ECR <92% 100% Monthly

12Community Information Dataset

(CIDS) Completeness

Referral to treatment times

(50% target for 12/13)1 � �

Director of


13 CIDS CompletenessReferrals

(50% target for 12/13)1 � �

Director of


14 CIDS CompletenessCare Contact Activity

(50% target for 12/13)1 � �

Director of


Performance Framework - position as at April 2012

MONITOR COMPLIANCE FRAMEWORK

Thresholds

Appendix 1a

15 CIDS Completeness

Patient Identifier Information

(this indicator with target of 50% is not

currently within the compliance

framework, but may be introduced

during 12/13)



16 CIDS Completeness

Patient Dying at Home/Care Home

(this indicator with target of 50% is not

currently within the compliance

framework, but may be introduced

during 12/13)


FinanceNCRS & ECR <0% <50% 50% Monthly

Adult - target to be agreed in line with

transition plan

Older Adult - target to be agreed in line

with transition plan

Adult -target to be agreed in line with

transition plan

Older Adult - target to be agreed in line

with transition plan

19 Overall Risk Rating 2Director of

FinanceFinance ledger <3 3 >3 Monthly

20 Achievement of Plan EBITDA Achieved (of plan) 2Director of

FinanceFinance ledger <70% 70%-85% >85% Monthly

21 Underlying Performance EBIDTA Margin 2Director of


22 Financial Efficiency Return on assets 2Director of


23 Financial Efficiency I&E surplus margin 2Director of

FinanceFinance ledger <1% 1%-2% ≥2% Monthly

24 Liquidity Liquidity Ratio (Days) 2Director of

FinanceFinance ledger <15 days 15-25 days >25 days Monthly

25 Care Quality Commission Maintain compliance with standards

1

� �Director of

Nursing

Non Compliant/

Breaches

Moving to

complianceCompliant Monthly

26 Quality Governance Framework Maintain compliance with framework

1

� �Director of

Nursing

Non Compliant/

Breaches

Moving to

complianceCompliant Monthly

27 CQUIN Delivery of CQUIN indicators 3 � �Director of

FinanceNetwork Directors

Non Compliant/

Breaches

Moving to

complianceCompliant

Quarterly

(Q4 position)

28 Schedule 3 / Quality Schedule Delivery of Schedule 3 3 � �Director of

FinanceNetwork Directors

Non Compliant/

Breaches

Moving to

complianceCompliant

Quarterly

(Q4 position)

29 Performance Improvement NoticesPerformance issues identified by

commissioners1 � �

Director of

FinanceLead Commissioner Notice received

No

performance

notices

received

Monthly

FINANCIAL RISK RATING - see report narrative

NHS MENTAL HEALTH & COMMUNITY CONTRACTS

1

1

Director of Service

Delivery &

Transformation

Director of Service

Delivery &

Transformation

100.4%

96%

32.9 days

70. 2 days

ASSURANCE & ACCREDITATION

NCRS

NCRS

IN-PATIENT ACTIVITY

Bed Occupancy

Length of Stay on Discharge17

18 Monthly

Monthly

30 Health Care Acquired InfectionsCumulative number of incidents

reported for C-DIFF 3 �

Director of

Nursing

Infection Prevention &

Control dept.>2011/12 OT On target <2011/12 OT Monthly

31 Health Care Acquired InfectionsCumulative number of incidents

reported for colonised MRSA3 �

Director of

Nursing

Infection Prevention &

Control dept.>2011/12 OT On target <2011/12 OT Monthly

32 Falls resulting in a FractureCumulative number of incidents of falls

resulting in fractrue3 �

Director of

NursingDatix >2011/12 OT On target <2011/12 OT Quarterly

33Pressure Ulcers in the Community -

Central Lancashire locality

Reported number of Category 3 and 4

pressure sores 3 �

Director of

NursingDatix

Increase on

previous

quarter

On target

Decrease on

previous

quarter

Quarterly

(Q4 position)

34Pressure Ulcers in the Community -

Blackburn with Darwen locality

Reported number of Category 3 and 4

pressure sores 3 �

Director of

NursingDatix

Increase on

previous

quarter

On target

Decrease on

previous

quarter

Quarterly

(Q4 position)

35Incidences of Violence on Non Staff

Members by Service Users

Cumulative Incidences of Violence on

Non Staff Members by Service Users5 �

Director of

NursingDatix >2011/12 OT On target <2011/12 OT Monthly

36 Violent Incidents Against StaffCumulative Incidences of Violence on

Staff Members by Service Users5 �

Director of


37 Medicines Management

Reduction in the number of prescribed

hypnotics and anti-psychotics per

network

2 �Director of

NursingChief Pharmacist

Increase on

previous monthOn target

Reduction on

previous monthMonthly

38 Staff Questionnaires: Patient Safety

% Staff witnessing errors, near misses

or incidents in last months that could

hurt service users

5 �Director of

NursingCQC

< below

national

average

Improvement

on previous

year score

> national

average

Annual on

publication of

results

39Staff Questionnaires: Standards of

Care

% of staff that feel satisfied with

quality of work and patient care being

delivered

5 �Director of

NursingCQC

< below

national

average

Improvement

on previous

year score

> national

average

Annual on

publication of

results

40

Staff Questionnaires: Percentage of

Staff with Appraisal completed within

last 12 months

% Staff with a completed appraisal

within last 12 months5 �

Director of

Workforce & ODCQC

< below

national

average

Improvement

on previous

year score

> national

average

Annual on

publication of

results

41 Mandatory trainingPercentage of Staff with Mandatory

Training Completed 75% annual target1 �

�

Director of

Workforce & ODTraining department <70% 70%-75% ≥ 75% Monthly

42 PDP/PDRPercentage of Staff with PDP/PDR

Completed 100% annual target1 �

Director of

Workforce & ODTraining department <80% 80%-99% 100% Monthly

43 Younger People AdmissionsCumulative number of young persons

admissions to adult wards3 �

Director of


44

National Indicators for Quality

Improvement that deals with young

persons admission

CF-01 Number of hospital occupied

bed days on adult psychiatric wards of

patients aged under 16, on admission,

under the care of a psychiatric

specialist

3 �Director of

NursingNCRS

Increase on

previous

quarter

On target

Reduction on

previous

quarter

Quarterly

(Q4 position)

45

National Indicators for Quality

Improvement that deals with young

persons admission

CF-02 Number of hospital occupied

bed days on adult psychiatric wards of

patients aged 16 or 17, on admission,

under the care of a psychiatric

specialist

3 �Director of

NursingNCRS

Increase on

previous

quarter

On target

Reduction on

previous

quarter

Quarterly

(Q4 position)

46 Compliments Number of compliments received per

quarter5 � �

Director of

NursingDatix

Reduction on

previous

quarter

On target

Increase on

previous

quarter

Quarterly

(Q4 position)

PATIENT EXPERIENCE

PATIENT SAFETY

47 ComplaintsNumber of complaints received per

quarter5 � �

Director of

NursingDatix

Increase on

previous

quarter

On target

Reduction on

previous

quarter

Quarterly

(Q4 position)

48 Inpatient SurveysOutcomes of the Internal Inpatient

survey 5 �

Director of

NursingClinical Governance

Reduction on

previous

quarter

On target

Increase on

previous

quarter

Quarterly

(Q4 position)

492011 Mental Health Inpatient Service

Users Survey

Results from the 2011 Mental Health

Inpatient Service Users Survey

undertaken by Quality health

5 �Director of

NursingCQC

< below

national

average

Improvement

of previous

year score

> national

average

Annual on

publication of

results

502011 Community Mental Health

Service Users Survey

Results from the 2011 Community

Mental Health Service Users Survey

undertaken by Quality Health

5 �Director of

NursingCQC

< below

national

average

Improvement

of previous

year score

> national

average

Annual on

publication of

results

51 Carers Assessments Under DevelopmentDirector of

Nursing

52 PEAT Assessment

Patient Environment Action Teams

(PEAT) report published by the

National Patient Safety Agency rates

Trusts on hospitals treat their patients

in cleaner, better maintained

environments.

4 �Director of

FinanceNPSA

Deterioration

last review

Standard

Maintained

Improvement

on last reviewAnnual

53 Advancing Quality- Psychosis

Percentage pass rate on the

achievement of meeting the 3

indicators for Advancing Quality

3 � � Medical Director ECR < 85% Target On target > 85% Target Monthly

54 Advancing Quality- Dementia

Percentage pass rate on the

achievement of meeting the 5

indicators for Advancing Quality

3 � � Medical Director ECR < 75% Target On target > 75% Target Monthly

55 Information Governance ToolkitOverall Attainment Score

National Target 65%1 �

Director of

FinanceIG Toolkit ≤64% ≥65%

Quarterly

(Q4 position)

56 Growing representative membership Target membership - 12827 members 5 �Director of

Workforce & ODCompany Sectretary

>2% Below

target

<2% above

targetAbove target Monthly

ADVANCING QUALITY

INFORMATION GOVERNANCE

MEMBERSHIP

57 Use of Bank & Agency Staff

Total cost of Bank & Agency staff

(includes all Bank payments made

through payroll and all invoiced agency

costs that include agency doctors)

2 �Director of

Workforce & ODGeneral Ledger >£1.5m £1,444,100 ≤£1m Monthly

58Turnover Rate (total new

organisation)

Number of Leavers over a 12 month

period (FTE) / Staff in Post (FTE) *1002 �

Director of

Workforce & ODESR ≥17% >13%-<17% 8% Monthly

59 Sickness absence rate - monthlyFTE Days Lost / FTE Days available *

100 – for current month2 �

Director of

Workforce & ODESR >5.5% >5%-≤5.5% 5% Monthly

60Sickness absence rate - cumulative

position for year to date

FTE Days Lost / FTE Days available *

100 – for year to date2 �

Director of

Workforce & ODESR >5.5% 5% ≤5% Monthly

Trend KeyWhere not due for reporting, the last quarterly/annual position is shown

Above target improving performance

Above target deteriorating performance

Below target improving performance

Below target deteriorating performance

Performance unchanged

Indicator not due for reporting.

WORKFORCE & ORGANISATIONAL DEVELOPMENT

Appendix 1b

April 2012 Trust Board Report

PATIENT SAFETY

Health Care Acquired Infection (HCAI)

Serious Untoward Incidents (SUI)

2116

26 28

1015 18 17

26 22

37 33

3

8

15 12

1010

1 2

2

7

5 13

0

10

20

30

40

50

09/10

Quarter

1

09/10

Quarter

2

09/10

Quarter

3

09/10

Quarter

4

10/11

Quarter

1

10/11

Quarter

2

10/11

Quarter

3

10/11

Quarter

4

11/12

Quarter

1

11/12

Quarter

2

11/12

Quarter

3

11/12

Quarter

4

To

tal

case

s re

po

rte

d

No of incidents reported in each quarter

Not reported in 48 hours Reported in 48 hrs.

2

1520

2418 16 18 18

3023 26

31

5

118

9

76

23

2

45

4

0

10

20

30

40

09/10

Quarter

1

09/10

Quarter

2

09/10

Quarter

3

09/10

Quarter

4

10/11

Quarter

1

10/11

Quarter

2

10/11

Quarter

3

10/11

Quarter

4

11/12

Quarter

1

11/12

Quarter

2

11/12

Quarter

3

11/12

Quarter

4

To

tal

rep

ort

s co

mp

lete

d

No of reports completed in each quarter

Reports not completed within 45 Days Reports completed within 45 Days

0

0

5

10

15

20

25

Ap

r-1

2

Ma

y-1

2

Jun

-12

Jul-

12

Au

g-1

2

Se

p-1

2

Oct

-12

No

v-1

2

De

c-1

2

Jan

-13

Fe

b-1

3

Ma

r-1

3

Cu

mu

lati

ve

MR

SA

re

po

rte

d c

ase

s

Month/Year

Cumulative MRSA Activity against 2012/13 Target

Cumulative YTD Target 12/13 (15 cases)

0

0

1

2

3

4

5

Ap

r-1

2

Ma

y-1

2

Jun

-12

Jul-

12

Au

g-1

2

Se

p-1

2

Oct

-12

No

v-1

2

De

c-1

2

Jan

-13

Fe

b-1

3

Ma

r-1

3

Cu

mu

lati

ve

C-D

Iff

rep

ort

ed

ca

ses

Month/Year

Cumulative C-Diff Activity against 2012/2013 Target


94% 85% 84%

89%80%

0%

20%

40%

60%

80%

100%

11/12 Quarter 1 11/12 Quarter 2 11/12 Quarter 3 11/12 Quarter 4 2011/2012

Yearly position

% Reports completed in 45 days against 2011/12 Targets

% Reports completed in 45 days 90% Target

C-Diff

There has been no reported cases of C-Diff during April 2012.

The second graph shows the cumulative number of reported C-Diff cases against the 2011/12 out turn. LCFT commissioners have not set a target; however it is important not to exceed the 2011/12 out turn of zero.

MRSA (figures are for colonisation on the skin & not causing infection)

There has been no reported cases of MRSA during April 2012.

The second graph shows the cumulative number of Mental health reported MRSA cases against the 2011/12 out turn. LCFT commissioners have not set a target; however it is important not to exceed the 2011/12 out turn of 15 cases.

Data Source: Infection prevention & Control dept.

93% 76% 88% 72% 81%

0%

20%

40%

60%

80%

100%

11/12 Quarter 1 11/12 Quarter 2 11/12 Quarter 3 11/12 Quarter 4 2011/2012Yearly position

% incidents reported in 48 hours against 2011/12 Targets

% incidents reported in 48 hours 90% Target

SUIsThe figures only relate to Mental Health. The Trust is working through integrating the reporting processes . The SUI Quarterly Report provides detailed information on the number and type of SUIs.

Incidents reported in 48 hours (mental health only)Quarter 4 shows that 72% of incidents that were reported in 48 hours which below the 90% target. When looking at the yearly position it can be seen that the Trust reports 81% of incidents within 48 hours. This is below the commissioner's target of 90%.

Reports completed in 45 days (mental health only)Quarter 4 shows that 89% of incidents that were completed within 45 days which is 1% below the 90% target. When looking at the yearly position it can be seen that the Trust has 80% of reports completed within 45 days. This is below the commissioner's target of 90%.

A programme of work is being undertaken to integrate reporting systems, standardise practice and deliver training which will ensure the timescales are met.

0

1

2

3

Jul-

11

Au

g-1

1

Se

p-1

1

Oct

-11

No

v-1

1

De

c-1

1

Jan

-12

Fe

b-1

2

Ma

r-1

2

Ap

r-1

2

No

of

Re

po

rte

d c

ase

s

Month/Year

SPC Chart for MRSA

Average Data UCL LCL

0

1

1

2

2

3

3

4

Jun

-11

Jul-

11

Au

g-1

1

Se

p-1

1

Oct

-11

No

v-1

1

De

c-1

1

Jan

-12

Fe

b-1

2

Ma

r-1

2

Ap

r-1

2

No

of

Re

po

rte

d c

ase

s

Month/Year

SPC Chart for C-Diff

Data Average UCL LCL

No cases of c-Diff have been reported from June 2011

LCFT Quality Account - April 2012 Trust Board Report Page 1

Appendix 1b

Falls Which Result in a Fracture

Pressure Ulcers in the Community

10

2

4

6

8

10

12

14

Ap

r-1

2

Ma

y-1

2

Jun

-12

Jul-

12

Au

g-1

2

Se

p-1

2

Oct

-12

No

v-1

2

De

c-1

2

Jan

-13

Fe

b-1

3

Ma

r-1

3

Cu

mu

lati

ve

re

po

rte

d c

ase

s

Month/Year

Cumulative Falls Activity against 2012/13 Target


Falls which result in a Fracture

There has been no reported incident of a fall resulting in a fracture during April 12. Overall the graph shows that there has been a lot of variance in the number of reported fractures. This is due to the low numbers involved (0-2 cases per month).

The second graph shows the cumulative number of falls resulting in a fracture against the 2011/12 out turn. LCFT commissioners have not set a target; however it is important not to exceed the 2011/12 out turn of 12 cases.

The main area of risk is the older adult network. A six monthly review of the performance takes place and practice issues are managed through the network governance arrangements. The Trust is also participating in Safety Express which is part of the CQUIN and is about reducing harm when such harm is preventable.

Data Source: Datix

Pressure Ulcers in the Community

The first graph shows the number of category 3 and 4 pressure ulcers by provider. The second and third graphs show where the pressure ulcer was acquired by category. Community data only starts from June 11 when organisations merged. There were no reported cases of pressure ulcers for Quarters 1 and 2 for Mental Health. Post TCS there were 2 reported cases in Quarter 3.

Reporting of all Pressure Ulcers (with those graded at 3 or 4 being externally reportable) has been established through the Incident Reporting system. This process in place is working well with action plans being completed for all incidents and within the designated timescales, with close liaison between the Tissue Viability Nurses and the community nurses. There have been some instances where the initial grading has been 3 or 4 and therefore reported on STEIS but have subsequently been found by the specialist Tissue Viability Nurses to be lower (and therefore not STEIS portable) and closed. Categorisation of pressure ulcers is now being addressed in nurse training sessions. Where the pressure ulcer is believed to have been acquired within the acute setting, reports are sent to both East Lancashire Hospitals Trust (ELHT) and Lancashire Teaching Hospitals (LTH) providing them with sufficient detail to allow their own investigation to be completed. Where the pressure ulcer could have been acquired within a nursing/residential home, the reports are sent through to the commissioning organisation for them to follow up with the commissioned service.

The Trust is involved in a collaborative piece of work with East Lancashire and Lancashire Teaching Hospitals regarding the safety express initiative. One area of focus is pressure ulcers and the work is being led by the 3 Directors of Nursing.

Data Source: Datix

28 8 8 8 12

4032

5

1 8 8 7 3

18

8

0

10

20

30

40

50

60

70

Q1 11/12 Q2 11/12 Q3 11/12 Q4 11/12 Q1 11/12 Q2 11/12 Q3 11/12 Q4 11/12

BWD Central

No

of

ca

se

s

Categories of Pressure Ulcers by Provider by Quarter during 2011/12

Category 3 Category 4

23 4 68

3 46

5

3127

23

9

5

0

5

10

15

20

25

30

35

40

45

Q1 11/12 Q2 11/12 Q3 11/12 Q4 11/12 Q1 11/12 Q2 11/12 Q3 11/12 Q4 11/12

BWD Central

No

of

Ca

se

s

Quarter /Year by Area

Setting of Acquired Pressure Ulcer- Category 3

INSIDE- Care home INSIDE- School INSIDE- Pt's Home

INSIDE- Community INSIDE - Hospital

4 46 5

2

1

1

2

1

2

16

6

3

2

2

1

0

2

4

6

8

10

12

14

16

18

20

Q1 11/12 Q2 11/12 Q3 11/12 Q4 11/12 Q1 11/12 Q2 11/12 Q3 11/12 Q4 11/12

BWD Central

No

of

Ca

se

s

Quarter /Year by Area

Setting of Acquired Pressure Ulcer- Category 4

INSIDE- Care home INSIDE- Pt's Home INSIDE- Community

INSIDE - Hospital Not stated

*Definitions for graph are: Inside = Location of where the pressure sore the patient was under the care of community services when a pressure ulcer was acquired Not Stated = Location of

acquired Ulcer not stated.

-

1

2

3

4A

pr-

09

Jun

-09

Au

g-0

9

Oct

-09

De

c-0

9

Fe

b-1

0

Ap

r-1

0

Jun

-10

Au

g-1

0

Oct

-10

De

c-1

0

Fe

b-1

1

Ap

r-1

1

Jun

-11

Au

g-1

1

Oct

-11

De

c-1

1

Fe

b-1

2

Ap

r-1

2

No

of

Re

po

rte

d c

ase

s

Month/YearAverage Data UCL LCL


Appendix 1b

Violent Incidents Against Staff

Number of violent incidents against staff (per 1 000 staff)

(Source: National Violence Data)

579 157541 146394 80887 218

Reported Year

2007/20082008/2009

2009/20102010/2011

Reported

Assaults

Assaults

per 1000

Incidences of Violence on Non Staff Members by Service Users

82

0

100

200

300

400

500

600

700

800

900

1000

Ap

r-1

2

Ma

y-1

2

Jun

-12

Jul-

12

Au

g-1

2

Se

p-1

2

Oct

-12

No

v-1

2

De

c-1

2

Jan

-13

Fe

b-1

3

Ma

r-1

3

Cu

mu

lati

ve

re

po

rte

d c

ase

s

Month/Year

Cumulative incidents of violence against 2012/2013 Target

Target 11/12 (935 Incidents) Cumulative YTD

73

0

200

400

600

800

1000

Ap

r-1

2

Ma

y-1

2

Jun

-12

Jul-

12

Au

g-1

2

Se

p-1

2

Oct

-12

No

v-1

2

De

c-1

2

Jan

-13

Fe

b-1

3

Ma

r-1

3

Cu

mu

lati

ve

Vio

len

t In

cid

en

ts

Ag

ain

st S

taff

(p

er

1,

00

0 S

taff

)

Month/Year

Cumulative incidents of violence against staff against 2012/13 Target

Cumulative YTD Target 12/13 (828 incidents per 1 000 staff)

The data for 2011/12 is currently being collated for submission by the end of June to NHS Protect and will be published in November 2012.

A paper was presented to the Governance Commitee in May on violence and aggression. Further work has been agreed and this will be reported to board when completed.

'Non Staff members' relate to other Service users, Visitors and Carers

This category covers incidents of threats and violence to service users, visitors and carer by service users. There were 82 reported incidents of violence against non-staff members, which in comparison to March, has seen a decrease of 13 reported incidents and is the lowest level reported since November 2011.

Analysis of this data takes place on an on-going basis in order to identify any trends by both network and ward, and identify if an individual service user is responsible for the increases in violence. The security specialist is working with the particularwards where there has been an increase in incidents to review strategies for the management of violence and aggression; this includes environmental, personal and procedural changes. Training related issues are being addressed with the MOVA leads and liaison with the police is continuing.

The second graph shows the cumulative number reported incidents against the 2011/12 out turn. LCFT commissioners have not set a target; however it is important not to exceed the 2011/12 out turn of 935 cases. Source: DATIX

Incidents against Staff

April 12 had 73 reported incidents per 1,000 staff, which is a reduction of 22 incidents per 1,000 staff from March 12. This reduction has occurred in the categories 'Assaults by Patient to Staff' and 'Threat by patient to staff'. The decreases were seen in the Adult Mental Health and Adult Community & Specialised Services networks. A step change has been introduced in June 11 to reflect LCFTs new footprint of services.

These types of incidents will continue to be closely monitored in order to feed into an action plan. Links with the wards regarding major incidents and repeat offenders occur on a daily basis. LCFT is working closely with the CPS and Police in regard to serious cases, for example management of illicit drug use on wards.

The second graph shows the cumulative number reported incidents against the 2011/12 out turn. LCFT commissioners have not set a target; however it is important not to exceed the 2011/12 out turn of 828 incidents per 1,000 staff.

Source: Datix0

20

40

60

80

100

120

Ap

r-0

9

Ma

y-0

9

Jun

-09

Jul-

09

Au

g-0

9

Se

p-0

9

Oct

-09

No

v-0

9

De

c-0

9

Jan

-10

Fe

b-1

0

Ma

r-1

0

Ap

r-1

0

Ma

y-1

0

Jun

-10

Jul-

10

Au

g-1

0

Se

p-1

0

Oct

-10

No

v-1

0

De

c-1

0

Jan

-11

Fe

b-1

1

Ma

r-1

1

Ap

r-1

1

Ma

y-1

1

Jun

-11

Jul-

11

Au

g-1

1

Se

p-1

1

Oct

-11

No

v-1

1

De

c-1

1

Jan

-12

Fe

b-1

2

Ma

r-1

2

Ap

r-1

2

No

of

Re

po

rte

d c

ase

s p

er

1,0

00

sta

ff

Month/YearPer 1,00 staff Average UCL LCL

0

20

40

60

80

100

120

140

Ap

r-0

9

Ma

y-0

9

Jun

-09

Jul-

09

Au

g-0

9

Se

p-0

9

Oct

-09

No

v-0

9

De

c-0

9

Jan

-10

Fe

b-1

0

Ma

r-1

0

Ap

r-1

0

Ma

y-1

0

Jun

-10

Jul-

10

Au

g-1

0

Se

p-1

0

Oct

-10

No

v-1

0

De

c-1

0

Jan

-11

Fe

b-1

1

Ma

r-1

1

Ap

r-1

1

Ma

y-1

1

Jun

-11

Jul-

11

Au

g-1

1

Se

p-1

1

Oct

-11

No

v-1

1

De

c-1

1

Jan

-12

Fe

b-1

2

Ma

r-1

2

Ap

r-1

2

No

of

Re

po

rte

d c

ase

s

Month/YearData Average UCL LCL


Appendix 1b

Medicine Management

Prescribing Observatory for Mental Health (POMH) UK Clinical Audit & Quality Improvement Interventions.

( KF1-% of staff that feel satisfied with quality of work and patient care being delivered)

32%

67% 38.8% 66.6%67% 51.5% 66.7%74% 49.6% 74.3%7% 75.0% 75.0%

PDP/R & Mandatory Training

Mandatory

Training PDP/R

Financial Year 11/12

Q26a (% Staff witnessing errors, near misses or incidents in last months that could hurt service users)

Annual Measures

Patient Safety from Staff Questionnaire

Percentage of Staff with Mandatory Training

Completed

Year End 10/11Year End 09/10

(Workbook and Induction)



Target 11/12


Year end 11/12% Increase

Percentage of Staff with Appraisal completed within last 12 months

Standards of Care

There has been a slight rise in the hypnotic prescribing both PRN and regular which is reflective of patients being admitted on hypnotics that could not be stopped.

Source: Chief Pharmacist

61%

67%

63%

79%

78%

83%

0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100%

Trust Score 2007

Trust Score 2008

Trust Score 2009

Trust Score 2010

Trust Score 2011

National Average for MH Trusts

28%

32%

27%

26%

27%

27%

0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100%

Trust Score 2007

Trust Score 2008

Trust Score 2009

Trust Score 2010

Trust Score 2011

National Average for Mental health Trusts

Source: Staff Survey CQC

59%

78%

77%

73%

74%

0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100%

Trust Score 2008

Trust Score 2009

Trust Score 2010

Trust Score 2011

National Average for Mental health Trusts

Source: Staff Survey CQC

Source: Staff Survey CQC Source: Training Department

Source: Training Department

Audit results for audits that were completed in 2012 to date.

May 2012

The results of the audits for 'Prescribing high dose and combined antipsychotics on adult acute and psychiatric intensive care ward' and 'Prescribing high dose and combined antipsychotics on forensic ward' will be included in the report when published.

Source: Chief Pharmacist


Appendix 1b

National Indicators for Quality Improvement that deals with young persons admission

Year/Quarter

2010/11 Quarter 1

2010/11 Quarter 2

2010/11 Quarter 3

2010/11 Quarter 4

2011/12 Quarter 1

2011/12 Quarter 2

2011/12 Quarter 3

2011/12 Quarter 4

0 0

0 0 2011/12 Quarter 4 3 4

5

0

2010/11 Quarter 2

Younger People Admissions

No of patients

5

PATIENT EXPERIENCE

Occupied Bed Days

0

1

2011/12 Quarter 2 30

1160

1

4

0

0 0

0

0

0

1

2010/11 Quarter 30

Year/Quarter

2010/11 Quarter 1

CF-02 Number of hospital occupied bed days on adult psychiatric wards of patients aged 16 or 17, on

admission, under the care of a psychiatric specialist

0

Occupied Bed Days

95

56

No of patients

CF-01 Number of hospital occupied bed days on adult psychiatric wards of patients aged under

16, on admission, under the care of a psychiatric specialist

2011/12 Quarter 3

2010/11 Quarter 4

2011/12 Quarter 10

00

0 0

0

1

2

3

4

5

6

7

8

Ap

r-0

9

Jun

-09

Au

g-0

9

Oct

-09

De

c-0

9

Fe

b-1

0

Ap

r-1

0

Jun

-10

Au

g-1

0

Oct

-10

De

c-1

0

Fe

b-1

1

Ap

r-1

1

Jun

-11

Au

g-1

1

Oct

-11

De

c-1

1

Fe

b-1

2

Ap

r-1

2

No

of

ad

mit

tan

ces

of

yo

un

g p

oe

ple

Month/YearData Average UCL LCL

1

0

1

2

3

4

5

6

7

8

9

10

Ap

r-1

2

Ma

y-1

2

Jun

-12

Jul-

12

Au

g-1

2

Se

p-1

2

Oct

-12

No

v-1

2

De

c-1

2

Jan

-13

Fe

b-1

3

Ma

r-1

3

Cu

mu

lati

ve

re

po

rte

d c

ase

s

Month/Year

Cumulative incidents of young persons against 2012/13 Target

Cumulative YTD Target 12/13 (9 incidents)Source: DATIX

Young People Admissions

Since April 12 there has been one reported incident of a young person being admitted to an Adult ward. Any admissions are subject to a PIR. The admission to Adult wards was appropriate given the needs of the Young person.

A step change has been introduced to the graph to take into consideration the opening of The Platform in April 2010.

The second graph shows the cumulative incidents of young person admission to an adult ward against the 2011/2012 out turn. LCFT commissioners have not set a target; however it is important not to exceed the 2011-12 out turn of 9 cases. It was agreed at the SUI Advisory Group that this issue would be kept under close review. An investigation into the resulting SUI initiated by a breach now contains a number of key questions. These questions standardise the information being gathered and provide us with a way to identify and action any themes found. In cases where a patient is admitted based on need, the admission will be to an adult ward where work has been undertaken to improve its user friendliness for young people and the specialist services continue to provide input.

Source: Datix

0

0.2

0.4

0.6

0.8

1

Quarter 1 Quarter 2 Quarter 3 Quarter 4 Quarter 1 Quarter 2 Quarter 3 Quarter 4

2010/11 2011/12

Oc

cu

pie

d B

ed

Da

ys

Year/ Quarter

CF-01 Number of hospital occupied bed days on adult psychiatric wards of patients aged under 16, on admission, under the care of a

psychiatric specialist

0

10

20

30

40

50

60

70

80

90

100

Quarter 1 Quarter 2 Quarter 3 Quarter 4 Quarter 1 Quarter 2 Quarter 3 Quarter 4

2010/11 2011/12

Oc

cu

pie

d B

ed

Da

ys

Year/Quarter

CF-02 Number of hospital occupied bed days on adult psychiatric wards of patients aged 16 or 17, on admission, under the care of

a psychiatric specialist

These two graphs display the National Indicators for Quality Improvement that represents young persons admission. It has been added to monitor the number of Occupied Bed Days (OBDs) that an under 16 and 16-17 year old person has spent on Adult wards. They include new admissions and transfers prior to discharge.

The first graph shows there has been no OBDs occuring for a young person under the age of 16 at the Trust.

The second graph shows the number OBD for 16-17 year olds has dramatically decreased since Quarter 1 2010/2011. Since the opening of the Platform in April 2010 there has been a marked decrease in the number of OBD that a young person has on an Adult ward. Any OBD's that occur are due to the Platform reaching its bed capacity and transfers to adult wards prior to discharge.

Personal Development Review

A new Personal Development Review system has been launched based on the principles of Appreciative Leadership. PDR Awareness sessions on using the new paperwork and the on-line system are being delivered across the Trust for managers and staff and details have been advertised through the LCFT Bulletin and in the L&OD Prospectus (available on the Intranet). The on line system will provide robust reporting moving forward. The target is for 100% compliance by the end of Quarter 1.

Mandatory TrainingThe Trust Mandatory Training Lead has reviewed the delivery of mandatory training with stakeholders and subject matter experts and a new policy and mandatory training matrix is being implemented from April 2012. The Mandatory Training Workbook has been updated to reflect changes in legislation and is available for staff to access on the intranet prior to the implementation of the new policy.

ReportingEMT reporting is now in place providing information on staff who either Did Not Attend or Cancelled Mandatory Training so that Network Directors/Managers can follow up to improve levels of attendance. Following the ESR data update additional reports are being developed to implement from April 2012 to support Networks and Managers to monitor compliance with mandatory training requirements.


Appendix 1b

Complaint referred to the Ombudsman Mental Health Only

07/08 08/09 09/10 10/11 11/12

Adult & Older Adult Inpatient Surveys Q2 Q3 Q4 Q1 Q2 Q3 Q4

Was the Ward Clean?* 98% 93% 95% 98% 91% 96% 96%

Could I get a hot drink when I wanted?* 85% 85% 85% 92% 93% 88% 93%

The Ward felt a safe place to be in? + 83% 78% 84% 77% 80% 80% 84%

I knew how to make a complaint if I

needed to +77% 78% 88% 82% 76% 76% 71%

My privacy was respected* 78% 77% 83% 88% 83% 80% 87%

Would you recommend us to a friend? + 7 8 7 7 7 7 8

Sample size 80 60 116 66 71 49 45

Discharges per quarter 904 889 918 977 901 800 840

Response Rate 9% 7% 13% 7% 8% 6% 5%

86% 80%

78% 83%83%81%

2011/12

62%78% 86%

88%

86%

87%

90%84% 80%

76%

86%

86%

92

No of patients who referred their

complaint to the Ombudsman

(Mental Health only)

81%

165

989

5%

81%

77%

69

94%92% 98%

75% 71%

81%

81% 71%

91%

68% 79%

94%

84%

78%

Internal Survey

76%

Inpatient Surveys

Compliments & Complaints

68%

I got as much information as I wanted

about my treatment +

68%

66

79%

88%

939

77%

7% 10%

88%

887

10%

84%

88%

I was satisfied with how I was involved in

planning my hospital care +

879

7%

61% 73%

72% 78%

83%

I was satisfied in how I was involved in

planning my discharge +80%

81% 78%

97 52 85

77%

82% 84%

80%

971

79%

Q1

77% 71%

Q4

2009/2010

Q1 Q2 Q3

2010/2011

86%

13

80%

48 4825

53 45 49 46 49 48 37 47

6437 46

134 155 139

421365

221 238 219 243194

210

289

221

290

-200

-100

0

100

200

300

400

500

600

Quarter 1

09/10

Quarter 2

09/10

Quarter 3

09/10

Quarter 4

09/10

Quarter 1

10/11

Quarter 2

10/11

Quarter 3

10/11

Quarter 1

11/12

Quarter 2

11/12

Quarter 3

11/12

Quarter 4

11/12

No

of

Co

mp

lim

en

ts o

r C

om

pla

ints

re

ceiv

ed

Quarter/ year reported

No of Compliments or Complaints received

Compliments- Community Services Compliments- Mental Health

Complaints- Community Service Complaints- Mental Health

Compliments & ComplaintsQuarter 4 has seen a reduction in Adult Mental Health compliments and a increase in complaints. This is comparable to the previous quarters. Community figures have seen an increase in both compliments and complaints. This is due to an increase of 10 in complaints within Prison Healthcare Depts.

Source: Complaints Dept.

Internal Inpatient Survey

A year on year comparison with Quarter 4 shows an improvement in four areas, maintained position in one and saw a fall in the remaing four areas. The greatest improvements was seen in ‘Could I get a hot drink when I wanted?’ with an increase of 8 percentage points. This is followed by ‘My privacy was respected' with a 4 percentage point increase. The question "would you recommend us to a friend?” saw an improvement by 1 point.

Out of the eight indicators there were four that saw a decrease; ‘Information regarding treatment' saw a 24 percentage point drop followed by 'knowledge of how to make a complaint' that saw a 17 percentage point drop.

N.B. * Aggregated scores for answers 'always' and 'mostly'+ Aggregated scores for answers 'good' and 'satisfactory'

Sample size relates to the number of questionnaires responded to, however, not all questions have been completed within the questionnaire.

Further work is being undertaken in line with the new quality strategy to reviw methods of data collection for patient experience data.

Source: Clinical Governance.

During the year 2011/12 there has been 28 complaints referred to the PHSO. Of them, 16 refer to the MH services and the remaining 12 originated from within community services. Source: Customer

Services Dept.


Appendix 1b

Results from the 2011 Mental Health Inpatient Service Users Survey undertaken by Quality health

How safe did you feel?

The results from the National Inpatient Survey show that LCFT service users felt safe during their stay at our Trust. 2011 results show that we were very close to matching the National Average by 0.6% and we fell short of the 2010 result by 4.3%. When comparing the results obtained from the national survey to our own internal inpatient surveys we can see that the internal surveys fall short of both the National Average by 4.2% and the LCFT survey 11 by 3.6%. The 10/11 internal survey result is 1.5% lower than the 09/10 internal survey.

Changed 2010 result : Previous 2010 figure = 88.1%Revised 2010 figure = 87.9%Variance = -0.2%

Aggregated scores: National Average - 'Yes always' & 'Yes sometimes'09/10 Internal survey- 'Yes'10/11 Internal survey- 'Almost' , 'Mostly' &'Satisfactory'

How clean was your ward?

The results from the National Inpatient Survey show that LCFT service users felt that their ward was clean during their stay at our Trust. 2011 results show that we exceeded the National Average by 6% and matched the 2010 results at 90.2%. When comparing the results obtained from the national survey to our own internal inpatient surveys, we can see that the internal survey exceeds the National average of 10.8% and exceeds the LCFT survey 11 by 4.8%. The 10/11 internal survey result exceeds the 09/10 internal survey by 1%.


Aggregated scores: National Average - Very Clean' & 'Fairly Clean'09/10 Internal survey- 'Almost' & 'Mostly'10/11 Internal survey- 'Almost' & 'Mostly'

Privacy during treatmentThe results from the National Inpatient Survey show that LCFT service users felt that they had privacy during their treatment at our Trust. 2011 results show that we fell short of the National average by 1.3% but exceeded the 2010 results by 2.8%. When comparing the results obtained from the national survey to our own internal inpatient surveys we can see that the internal surveys falls short of both the National average of 7.5% and LCFT survey 11 by 6.2%. The 10/11 internal survey result is identical to the 09/10 internal survey.


Aggregated scores: National Average - 'Yes always' & 'Yes sometimes'09/10 Internal survey- 'Almost' , 'Mostly' & 'Satisfactory'10/11 Internal survey- 'Almost' , 'Mostly' & 'Satisfactory'

Patient involvement in Care and TreatmentThe results from the National Inpatient Survey show that LCFT service users felt that they had some say in the decisions made regarding their care and treatment at our Trust. 2011 results show that we marginally exceeded the National Average by 0.7% and exceeded the 2010 result of 3.5%. When comparing the results obtained from the national survey to our own internal inpatient surveys we exceeded both the National Average by 8.8% and the LCFT survey 11 by 8.1%. The 10/11 internal survey result exceeds the 09/10 internal survey by 2%.


Aggregated scores: National Average - 'Yes definitely & Yes to some extent'09/10 Internal survey- 'Yes'10/11 Internal survey- 'Good' & 'Satisfactory'

Patient awareness of Complaints

The results from the National Inpatient Survey show that LCFT service users felt that were able to make a complaint about any aspects of their care while at our Trust. 2011 results show that we exceeded the National Average by 7% and exceeded the 2010 result of 1%. We are unable to compare the results obtained from the national survey to our own internal inpatient surveys as the question asked in our inpatient survey is too dissimilar for comparison.

Changed 2010 result : No change to figures. Remains at 45%

Aggregated scores: National Average - 'Yes'09/10 Internal survey- 'Yes'10/11 Internal survey- Not comparable

Summary of Survey

A response was received from CQC regarding an issue raised with the 2010 data. The 2010 report which was received from the CQC was an interim report and as such did not show the true 2010 end position for LCFT. This error was noticed when reviewing the 2011 report which contained the 2010 figures. All graphs have been updated to show the change with the variance shown below. The changes do not exceed 1.3% variance. Overall the results in the inpatient survey showed an improvement on last year’s results, with over half the results exceeding the 2010 survey results (23 exceeding and 2 matching the 45 results reviewed). In the cases that exceeded the 2010 results, the average percentage variance was 3.4%. The indicator ‘D32-During your most recent stay, were there enough activities available for you to do during evenings and/or weekends?’ showed the greatest percentage variance at 10% (2011- 48%, 2010- 38% and 2011 National Average- 44%) for criteria ‘Yes all of the time’ and ‘Yes some of the time’. In the cases where we did not exceed 2010 results, the average percentage variance was -4.7%. The indicator ‘B14- Did you receive the help you needed from hospital staff with organising your home situation?’ showed the greatest percentage variance of -14% (2011- 70%, 2010- 84% and 2011 National Average- 73%) for criteria ‘I received all the help I needed’ and ‘I received some of the help I needed’.When comparing 2011 outcomes with the National Average, LCFT exceeded or matched the National Average in over half of the indicators (24 exceeding and 5 matching the 45 results reviewed).In the cases that exceeded the National Average, the average percentage variance was 4.5%. The indicator ‘F34- Do you have the number of someone from your local NHS Mental Health Service that you can phone out of office hours?’ showed the greatest percentage variance at 13% (2011 National Average- 67%, 2011- 80% and 2010- 79%) for criteria ‘Yes’. In the cases where we did not exceed National average, the average percentage variance was -3.3%. The indicator ‘D31- During your most recent stay, were there enough activities available for you to do during the day on weekdays (Monday to Friday)?’ showed the greatest percentage variance of -7% (2011 National Average- 64%, 2011- 57% and 2010- 53%), although there was a 4% improvement year on year, for criteria ‘Yes all of the time’ and ‘Yes some of the time’.The overall score 'how would you rate the care you received on your recent stay', LCFT was 1% lower than 2010 score of 72%, but matched the National Average at 71%, when grouping the responses ‘Excellent’, ‘Very good’, and ‘Good’.

There has been no release on when the 2012 survey results will be published. As soon as the results are now they will included in the report.

No longer comparable


Appendix 1b

Results from the 2011 Community Mental Health Service Users Survey undertaken by Quality health 2012 survey results will be issued Autumn 2012

Carers Assessments

Rating of Care

The results from the National community Survey show that 79.6% of LCFT service users received an excellent, good or better level of care. This outcome is marginally higher than the 2010 result of 79.4% and exceeds the National average of 78.8%.

Aggregated scores: 'excellent', 'very good' & 'good'

Medication Purpose

The results from the National community Survey show that 97.7% of LCFT service users had the purpose of their medication explained to them. This exceeds the 2010 result of 84.4% and the National average of 93.2%

Aggregated scores: Answer 'yes definitely' & 'yes to some extent'

Out of Hours contacts

The results from the National community Survey show that 70% of LCFT service users had the contact number for an out of hour’s service. This percentage exceeds the 2010 result of 63.0% and the National average result of 51.0%Aggregated scores: Answer 'yes'

Review of care plan

The results from the National community Survey show that 77.4% of LCFT service users had a review of their care plan within 12 months. This outcome exceeds the 2010 result of 68.8% and the National average result of 55.6%.

Aggregated scores: ''Yes I have had more than one' & 'Yes I have had one'

91.7%

92.6%

84.4%

97.7%

93.2%

0% 20% 40% 60% 80% 100%

LCFT 2008

LCFT 2009

LCFT 2010

LCFT 2011

2011 National Average

Survey Question 12: Were the purposes of the medication explained to you?

51.0%

70.0%

63.0%

70.0%

51.0%

0% 20% 40% 60% 80% 100%

LCFT 2008

LCFT 2009

LCFT 2010

LCFT 2011


Survey Question 36: Do you have the number of someone from your local NHS mental health service that you can phone out of office hours?

57.1%

71.1%

68.8%

77.4%

55.6%

0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100%

LCFT 2008

LCFT 2009

LCFT 2010

LCFT 2011


Survey Question 30: In the last 12 months have you had a care review meeting to discuss your care?

81.7%

86.2%

79.4%

79.6%

78.8%

0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100%

LCFT 2008

LCFT 2009

LCFT 2010

LCFT 2011


Survey Question 47: Overall, how would you rate the care you have received from NHS mental health services in the last 12 months?

Dignity and Respect

The results from the National community Survey show that 97.5% of LCFT service users believed they were treated with dignity and respect. This exceeds the 2010 result of 97.0% but is 0.3% lower than the National average of 97.8%

Aggregated scores: Answer 'yes definitely' & 'yes to some extent'

Care Plan

The results from the National community Survey show that 51.0% of LCFT service users were offered or given a copy of their care plan. This figure is 1% lower than the 2010 result of 52.0% but still exceeds the National average of 42.0%

Aggregated scores: Answer 'yes in last year'

97.0%

97.5%

97.8%

0% 20% 40% 60% 80% 100%

LCFT 2008

LCFT 2009

LCFT 2010

LCFT 2011

2011 NationalAverage

Survey Question 7: Did this person (Health and Social Care Workers) treat you with respect and dignity

Not comparable to previous surveys

Not comparable to previous surveys

52.0%

51.0%

42.0%

0% 20% 40% 60% 80% 100%

LCFT 2008

LCFT 2009

LCFT 2010

LCFT 2011


Survey Question 29: Have you been given (or offered) a written or printed copy of your NHS care plan?

Not comparable to previous

Not comparable to previous

LCFT is working towards providing Carer's Assessment data from internal information systems. Access to information sources and data quality is being currently reviewed.


Appendix 1b

Section Type 1 Type 2 Type 3

Environment and Facilities 96% 85% 86%

Staffing and Training 94% 82% 63%

Access, Admission and Discharge 100% 94% 100%

Care and Treatment 86% 79% 20%Information, Consent and

Confidentiality95% 85% 100%

Young People’s Rights and

Safeguarding Children97% 100% 100%

Clinical Governance 94% 71% 50%

Privacy and Dignity Single sex accommodation

100%

Care and Treatment

CQC Responsive Review- Balmoral Ward, Parkwood, Blackpool

Access, Admission and Discharge

Environment and Facilities

Young People’s Rights and Safeguarding

Children

Clinical Governance

Information, Consent and Confidentiality

Staffing and Training

Section

93% 83%

80%

100%

100%

100%

Type 1

85%

94%

100%

84%

Peer Review by QNIC The Junction & The Platform External

85%

76%

Type 2 Type 3

91% 100%

91% 50%

83% 50%

79% 60%

The JunctionQNIC Report

The Junction have undertaken an accreditation process in February 2012, which involved a detailed self-review, a detailed peer review and a decision about accreditation category and feedback. This process replaces the Peer Review of previous years. During the self-review phase teams measure their performance against the QNIC service standards:

Type 1 - failure to meet these standards would result in a significant threat to patient safety, rights or dignity and / or breach the law (100% compliance required)

Type 2 – standards that an accredited ward would be expected to meet (80% compliance required)Type 3 – standards that an excellent ward should meet or standards that are not the direct responsibility of the ward

These are initial findings which are subject to external validation in the coming months. Further evidence has been submitted by the service to demonstrate 100% compliance with Type 1 and over 80% compliance with Type 2 standards. If this evidence is validated then The Junction will achieve a QNIC accreditation.

The PlatformQNIC ReportQNIC has also carried out the second peer review at The Platform on 8th March 2012 with the unit taking part in a review covering all sections of the service standards listed in below. This process replaces the Peer Review of previous years which

involved a detailed self-review, a detailed peer review and a decision about accreditation category and feedback. Unlike The Junction, the

Platform did not put itself forward for an accreditation during this years.

Report SummaryThe Platform continues to score well against many areas of the QNIC standards and have this year achieved their highest scores in relation to ‘access, admission and discharge’ and ‘young people’s rights and safeguarding children’. There was goodconsistency across all interviews about the generic strengths and difficulties as well as areas to be developed. Overall, the unit team continue to strive to not only maintain, but further develop an excellent service and staff are creative and forward thinking in their endeavours to achieve this.

The CQC undertook a review of compliance on the Quality & Safety Outcomes on 14th December 2011 at Balmoral Ward, Parkwood. The review carried out was due to concerns in relation to:- Outcome 1 - Respecting and involving people who use services, Outcome 4- Care and welfare of people who use services, Outcome 10- Safety and suitability of premises and Outcome 14- Supporting staff. Standards were reviewed and the outcome was that there were moderate concerns with Outcome 1 and Outcome 14 and Major concerns with Outcome 4 and Outcome 14. The Report was received from the CQC and an action plan developed to address concerns. Implementations of the actions were reviewed on a weekly basis within the Network and at Executive level. The Trust provided an update to the CQC and this was followed by a visit on 26th and 27th April 12-. They have since confirmed that are no longer any major or moderate concerns. There is one major concern for outcome 4 and an action plan is being developed to address the area identified

Lancashire Care NHS Foundation Trust is pleased to confirm that we are compliant with the Government’s requirement to eliminate mixed sex accommodation, except when it is in the patient’s overall best interest, or reflects their personal choice. Our Declaration of compliance is located on LCFT website at the below address http://www.lancashirecare.nhs.uk/Privacy-Dignity.php


Appendix 1b

PEAT Assessment

Annual Measures National Audit

EFFECTIVENESS

Implementation of the Quality Strategy

Quality stratgey 2 has been drafted and was approved by Board in March 2012. A detailed implementation plan is being developed and will be completed in July 2012.

The following National Audits are being carried out during 2012/2013:-

Psychological Therapy Audit - The findings have been received and discussed at the Psychological Therapies Governance Committee. An action plan has been developed and submitted.

POMH-UK Audits- Data collection for audit begins;-February 12- Topic 1f and 3f (Prescribing high dose and combined antipsychotics on adult acute and psychiatric intensive care ward).Data collection hsa been undertaken and submitted in accordance to timescales. Baseline report is due at the end of May 2012The new programme for 12/13 has not been confirmed.

Royal College of Psychiatrist Peer Review:- Evidence was collected and reviewed in December 11 by Royal College of Psychiatrists. Results of the review will be included in the report when published.

2011 Patient Environment Action Teams (PEAT) report published by the National Patient Safety Agency show greater numbers of hospitals are treating their patients in cleaner, better maintained environments.The PEAT programme assesses all hospitals and inpatient units with 10 or more beds.

PEAT teams consist of nurses, matrons, doctors, catering, domestic service managers as well as groups of patients, their representatives and members of the public.They look at levels of cleanliness, some aspects of infection control (such as hand hygiene), the quality of the environment (such as decoration, maintenance and lighting) as well as the standard of food offered to patients.Following the inspection, each hospital is given a score out of excellent, good, acceptable, poor or unacceptable.

NHS trusts are each given scores from 1 (unacceptable) to 5 (excellent) for standards of environment, food and dignity and privacy within buildings).

Overall, the Trust scored well. Comparing the results from the 2010 and 2011 PEAT assessments, overall, eight out of eleven inpatient sites have improved over the previous year.These results highlight an area for improvement which the Trust is already aware of and is acting upon. This is one of the key drivers behind Trust plans to improve inpatient accommodation and provide facilities that are suitable for delivering modern mental health care.

The table now includes results from Longridge Community Hospital

(Source: http://www.ic.nhs.uk/statistics-and-data-collections/facilities/patient-environment-action-team-peat)

Site Name

Weighted

Environment

Score

Food ScorePrivacy &

Dignity Score

QUEENS PARK HOSPITAL 4 Good 4 Good 4 Good

BURNLEY GENERAL MH 3 Acceptable 3 Acceptable 4 Good

CHORLEY GENERAL MH 5 Excellent 5 Excellent 5 Excellent

GUILD PARK LODGE WHITTINGHAM PRESTON 4 Good 5 Excellent 4 Good

RIBBLETON HOSPITAL PRESTON 5 Excellent 5 Excellent 4 Good

ORMSKIRK AND DISTRICT GENERAL HOSPITAL 4 Good 5 Excellent 4 Good

LONGRIDGE COMMUNITY HOSPITAL 4 Good 5 Excellent 5 Excellent

LYTHAM HOSPITAL 4 Good 5 Excellent 4 Good

VICTORIA HOSPITAL, BLACKPOOL 3 Acceptable 3 Acceptable 3 Acceptable

RIDGE LEA HOSPITAL 4 Good 5 Excellent 5 Excellent

ALTHAM MEADOWS 4 Good 5 Excellent 5 Excellent

OAKLANDS 4 Good 5 Excellent 5 Excellent

PEAT Assessment Scores


Appendix 1b

Effectiveness Metrics

Future measures

A number of measures are being identified and developed to enable reporting during 2011/2012. They include the national standard on dementia (NICE), the advancing quality measures on early psychosis and dementia and the PTSD clinic data.

Advancing Quality (AQ)

Data submitted still continues in accordance with the timescales set by Advancing Quality Alliance (AQuA). The baseline data was used to calculate the regions Implementation Stretch Targets that come into effect in October 2011 and last until March 2012. The percentage pass rate against the Implementation Stretch Target and against the Baseline data is shown in the graphs below. Baseline data comprised of January to March 2011 data. From October the Trust entered the monitoring stage by which the performance was judged against the Imposed Stretch Targets created by the AQ Steering Group. Please note that the data below is validated for April to September 12 only. Any data after September 12 is unvalidated.

Psychosis Dementia

Psychosis in Early Intervention Service has an implementation stretch target of 85% which came into force from October 2011 and ends in March 2012. The last four months of submitted data shows that the Trust exceeded the target on all occasions. The cumulative percentage pass rate is 90.85%, which is 5.85% above the CQUIN target of 85%.The Audit Commission has reviewed Quarter 1 and Quarter 2 submissions during March 12. Results of audit show that the Trust have passed the CQUIN data accuracy target of 80%.New indicators are being introduced from May 2012 and will include PANSS assessment, review the Duration of Psychosis and the offering of Psychological therapies. These are being reported in 'shadow format' to AQuA. Work is on-going with the teams to support them in the implementation of the new measures.

Dementia has an implementation stretch target of 75% which came into force from October 2011 and ends in March 2012. The last four months of submitted data shows that the Trust exceeded the target on all occasions. The cumulative percentage pass rate is 85.38%, which is 10.38% above the CQUIN target of 75%.The Audit Commission has reviewed Quarter 1 and Quarter 2 submissions during March12. Results of audit show that theTrust have passed the CQUIN data accuracy target of 80%. New indicators are being introduced from May 2012 and will include assessment for nutritional need and pain. Discharge care plan reviews are also being created to ensure that care plans are still an appropriate package of care. These are being reported in 'shadow format' to AQuA. Work is on-going with the wards to support them in the implementation of the new measures.


agenda number: cg 074/12 agenda item: chief executive assurance report date of meeting ... meeting...

Documents