report to the trust board - 26 september 2013 · report to the trust board - 26 september 2013 ......

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REPORT TO THE TRUST BOARD - 26 SEPTEMBER 2013

Title Integrated Quality and Performance Report (IQPR) Executive summary

The aim of this report is to provide the Trust Board with an integrated quality and performance dashboard showing levels of compliance with the Monitor Compliance Framework and CQC (Care Quality Commission) registration. The report also provides a series of exception reports on areas which require escalation, and dashboard analyses on specific areas of Quality and Performance, including financial and workforce information. The report format has received further refinement to align the Key Performance Indicators (KPIs) against the Trust governance groups with greater clarity.

Recommendation

The Trust Board is recommended to:

• Receive the report and review achievements to date • Receive assurance on the areas of quality and performance which are

receiving performance improvement action

Related Trust objectives

The related strategic objective is: 1. We will continuously improve quality, with services

shaped from user experience, audit and research.

Risk and assurance Poor performance increases the risk profile for the Trust in respect of financial viability, quality, clinical safety and reputation.

Performance has a key impact on organisational reputation and the impact of achievements and concerns must be highlighted and responded to at the earliest stage.

Legal implications/ regulatory requirements

This report has a connection with Monitor, CQC and CQUIN (Commissioning for Quality and Innovation) requirements and aims to review performance against all regulatory areas.

Evidence for the Quality Governance Framework

4A and 4B Paper evidences board appropriate quality information being analysed and challenged and provides assurance of the robustness of the quality information.

Presenter

Will Legge – Chief Information Officer

Author(s) Will Legge – Chief Information Officer

* Disclaimer: This report is submitted to the Trust Board for amendment or approval as

H

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appropriate. It should not be regarded or published as Trust Policy until it is formally agreed at the Trust Board meeting, which the press and public are entitled to attend.

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TRUST BOARD 26th SEPTEMBER 2013

INTEGRATED QUALITY & PERFORMANCE REPORT

Introduction 1. The Integrated Quality and Performance Report (IQPR) summarises the Trust’s

performance against key Monitor, Commissioner and other targets, and provides analysis and commentary on those areas which require additional actions to ensure that we achieve our targets and objectives.

2. In addition, work is underway to establish a fully automated data collection and

reporting tool to be used for the production of the IQPR and other information reporting requirements.

3. The report format has received further refinement to align the KPIs against the

Trust governance groups with greater clarity.

4. The new Monitor Risk Assessment Framework was released on the 27th August 2013 in final form, with a ‘live’ date of 1st October 2013. The IQPR will continue to provide evidence against the existing Compliance Framework and in shadow form for the Risk Assessment Framework up to and including the October IQPR, covering September data. The November IQPR (covering October data) will reflect the changes of the new documents fully.

5. It should be noted that the following Monitor compliance is demonstrated in the

report:

Governance Risk Rating 6.0 – Red

Financial Risk Rating 4 – Green

Shadow Governance Concerns Material governance issue – Amber/Red

Shadow Continuity of Services Risk Rating 4 - Green

Aim

6. The aim of this report is to provide the Trust with an integrated quality and

performance report showing levels of compliance with the Monitor Compliance Framework and CQC registration, together with detailed analyses for those areas requiring additional action to ensure achievement of targets.

Recommendations

7. The Trust Board is asked to :

i) Receive the report and review achievements to date

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ii) Receive assurance on the areas of quality and performance which are receiving performance improvement action

iii) Review the Monitor ‘FRR and GRR section’ on page 10 for areas relating to the Trust’s Governance Risk Rating (GRR)

8. Finance and Performance Committee – Points for Discussion Key Performance Indicator Overview

Finance

• The Trust is reporting a net income and expenditure surplus of £1,126k at

the end of Month 05. This is in line with plan.

• The EBITDA margin as at Month 05 is 5.1%. The forecast EBITDA margin for the year is 5.2%.

• Current CIP delivery is 90% of the year to date target. Divisions are working to ensure that their CIP targets are delivered by the end of the financial year, and as such this is expected to improve the percentage CIP delivery.

• The cash balance at the end of Month 05 is £16.4m. This is on par with the year to date plan cash figure. Debtors > 90 days have slightly increased to 6.0% in M5 compared to 5.9% in M4.

• The report includes the Shadow Monitor Continuity of Services Risk Rating, to replace the Financial Risk Rating following closure of the consultation and shadow running (expected October 2013).

0

1

2

3EBITDA Margin

I&E Surplus (Excl.impairments)

Income (against budget)

Expenditure (againstbudget)

CIP achievement

Cash balance (YTDtarget = FIMS Plan)

Capital Expenditure(target spend =…

Debtors > 90 days

Creditors > 90 days

Better Payment PracticeCode

FRR

Finance Performance

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Performance

• % Delayed Patients (Community) – Performance has decreased compared

to July and reads as 2.55% for August 2013 against the target of 2.12% for the month.

• % Delayed Patients (MH) – Performance against this indicator has increased for the Month of August to 6.3% and is within target.

• Occupancy Rate – Mental Health – The trust target for this indicator is

<=85% and the current month actual is at 92.5% compared to 92.4% during July and remains over the required target.

• Total number of Home Treatment episodes carried out by Crisis Resolution team (year to date) – Current position as at August are 743 episodes for the year, which if continued at the same growth rate will be under-performing at the end of the financial year.

• 18 week maximum wait from referral to treatment (non-admitted, complete pathways) – The 95% target has been achieved during August with performance at 99.0%. The failure to meet the 95% target in July has resulted in the continued addition of 1.0 to the Trust Governance Risk Rating for the remaining quarter as specified in the Monitor Compliance Framework. FYPC is continuing to execute a multi-point action plan to address waiting times for the community paediatric service that comprises LPT’s non-admitted, consultant-led pathways.

• Waiting Times – Waiting times performance against commissioner targets

will continue to be reported along with the month the target will take effect as agreed with commissioners. Waiting time performance is based on the number of patients that received treatment in the month and the percentage of

0

1

2

3Occupancy Rate - MH

OccRate - Community

% Delayed Patients(DToC) - Community

% of Admissions GateKept

MHMDS DataCompleteness:

Records


Outcomes

Efficient Services

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those ‘waits’ that were within the target waiting time. A 5% tolerance giving a 95% target has been agreed with commissioners.

• Data Quality – The overall position since measurement began has consistently improved and has increased for the month of August when compared to July.

RAG Sep-12 Oct-12 Nov-12 Dec-12 Jan-13 Feb-13 Mar-13 Apr-13 May-13 Jun-13 Jul-13 Aug-13 Var

Red 2.10% 3.50% 1.50% 1.00% 1.00% 1.00% 1.00% 1.00% 1.00% 1.00% 1.10% 0.60% -0.50%

Amber 14.90% 7.40% 8.10% 8.60% 8.60% 8.60% 9.50% 8.60% 8.60% 8.60% 5.90% 3.40% -2.50%

Green 83.10% 89.10% 90.40% 90.40% 90.40% 90.40% 89.50% 90.40% 90.40% 90.40% 93.00%

96.00% 3.00%

Feedback from Finance and Performance Committee – 17th September 2013

• The Committee received the IQPR and noted the levels of performance demonstrated.

• The Committee noted the performance against the Governance Risk Rating and Risk Assessment Framework.

• The continuingly high rate of MH Bed Occupancy was noted

• The Committee noted the Early Intervention in Psychosis indicator performing above the required level, exceeding the year to date target.

• The Committee requested further information to be provided in relation to the CQUIN targets that were not being met.

0.00%20.00%40.00%60.00%80.00%

100.00%

Data Quality Progress

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9. Quality Assurance Committee – Points for Discussion Key Performance Indicator Overview

• Non-Compliance with CQC Essential Standards (Enforcement Actions) - The Committees attention is drawn to the formal issuing of two warning notices from the CQC following an inspection undertaken on the Bradgate Unit in July 2013. The issued report contains enforcement actions, continuing to result in the addition of ‘4’ to the Governance Risk Rating score being reported in August Governance and Trust Board.

• CPA: % patients having Formal Review within 12 months – Performance for this indicator has slightly decreased for the reporting month ending August 2013, where the performance is 96.4%, but remains above threshold.

• CPA: 7 Day Follow Up – The 95% target has been missed in this reporting period with performance at 91.8% for July compared with 98.1% for the previous month. Attempts were made to follow-up with 5 out of the 6 breaching patients without success. The year to date position is 95.0% and is narrowly meeting the

0

1

2

3

Mixed sexaccommodation

breaches

Complaintsacknowledged

within 3 workingdays

% Complaintsclosed within

timescales

Quality -Personal Services

0

1

2

3

Early Interventionin Psychosis

% patients on CPAfollowed up within7 days of discharge

% patients on CPAhaving Formal

Review within 12months

Breast Feeding-Status

Breast Feeding-Prevalence

SmokingCessation:Numberof 4 week quitters

GU Medicine- %Offered

appointment within48 hours

Quality-Effective Services

0

1

2

3Never Events

STEIS - SI actionplans implementedwithin timescales

Compliance withhygiene code

MRSA Bacteraemiacases - Community

Clostridium Difficile(C Diff) Cases

Quality -Safe Care

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threshold. The failure to meet the 95% target has resulted in the addition of 1.0 to the Trust Governance Risk Rating for the month

• Early Intervention in Psychosis - % newly diagnosed cases against commissioner contract – The 95% target has been met in this reporting period with the August 2013 performance at 136.4% compared to 45.5% for the previous month. Small numbers involved in the denominator for calculation of this indicator equates to significant swings in performance month on month and figures are refreshed each month to ensure accurate position. The year to date position is 109.1% and is above target.

• National Chlamydia Screening Programme- Number of screens for 15-24 year olds – During the month of August, the City service failed to achieve the monthly target achieving 510 screenings against the target of 834. The County service failed to achieve the monthly target achieving 691 screenings against a target of 1000. These figures are as expected due to seasonal variations which see highest activity levels in line with start and end of the academic year.

• There have been no mixed sex accommodation breaches in 2013/14 to date.

• Breastfeeding prevalence at 6 – 8 weeks – Prevalence in the County for the

first quarter is 44.5% against the commissioner target of 46.3%. The service has advised that its action plan for addressing this includes daily monitoring of breastfeeding prevalence and objective-setting to raise awareness with health visitors.

• Infection Control: C Diff (MH & Community) – The annual target reflects the

Monitor Compliance Framework 2013/14 de minimus limit set at 12 cases. There was 1 case of Clostridium Difficile (C Diff) in the month of August, which takes the year to date position to 3.

There is an internal root cause analysis currently being carried out by the infection prevention and control team in conjunction with the ward area to identify any issues or causes, currently the investigation has not identified any issue in particular but work is on-going.

Feedback from Quality Assurance Committee – 17th September 2013

• The Committee received the IQPR and noted the levels of performance demonstrated.

• The Committee acknowledged the performance of the 18 week wait target for Community Paediatrics, now being above the required target level.

• The Committee sought assurance in relation to the underperformance of the CPA 7 day follow up target. Assurances were given that all efforts had been made to contact the 6 patients who were not followed up within 7 days, and that the initial indications of the performance in August are showing that it is above target

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• The continuingly high rate of MH Bed Occupancy was noted

• The Committee noted the Early Intervention in Psychosis indicator performing above the required level, exceeding the year to date target.

• The Committee held a discussion in relation to the future monitoring and focus around the targets that demonstrate that the Trust is doing all it can to ensure the management of access to inpatient beds. The Committee noted the performance of the Home Treatments carried out by the Crisis Resolution Team in this regard.

• The Committee requested further information to be provided at the meeting in October in relation to Community Health Service waiting times, specifically those with very low current performance.

10. Workforce and Organisational Development Committee - Discussion

Key Performance Indicator Overview

• % Staff with a valid Appraisal & PDP: Performance in this metric is currently above the 80% trust target at 82.4% for the whole trust.

• % Sickness Absence: Performance against this indicator is reported a month in

arrears and for the month of July is 4.3% (a slight decrease of 0.1% on the previous month) and remains underperforming against the 4% and below organisational target.

• Ratio of Bank Usage to Agency Usage: Performance against this indicator

demonstrates an increase in agency usage when compared to bank usage over the previous month, resulting in a ratio of 1:0.97 across the organisation and over target.

0

1

2

3

Core MandatoryTraining

Appraisal

Sickness AbsenceRatio of Bank Usageto Agency Usage

Vacancy Rate

Workforce Metrics

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Feedback from Workforce and OD Committee – 18th September 2013

• Sickness Absence - The committee acknowledged there were on-going actions across divisions to reduce sickness levels and noted the most days lost to sickness could be attributed to stress and MSK related issues

• Bank & Agency Usage - The committee discussed the high usage of bank and

agency was in part due to the length of time it takes to recruit into vacant posts

• Time to Recruit - The committee noted the continued red rated performance

against the ‘days taken to recruit’ SLA although an improvement over last 4 weeks was recognised. A paper provided a summary to identify that the recruitment team were improving by reducing time taken to complete tasks, however managers were taking longer to complete theirs. An additional 2 recruitment administrators have been funded and 1 vacancy has been filled with all 3 new recruits to start this week in training.

The committee noted that plans were underway to automate booking ID checks to reduce the days needed to recruit.

The committee noted that Recruitment is an LIA project so focus group will be set up soon starting with listening event

• Learning and Development

Core Mandatory Training - The committee noted significant improvements April to date.

• (not discussed) AMH Complex care – work to be completed to review TNA for prisons and put together a training plan

• PDR – The committee were provided assurance that HIS CMT and PDRs are

reviewed at its internal management board every month and an action plan is in place to ensure all PDRs are booked and CMT courses are attended. It is anticipated that HIS will reach compliance by 30th October. Within Procurement, assurance was given that PDRs had been completed for 10 of the 11 staff and IG and Fire Safety training would be completed by 20th September

11. Summary of Monitor FRR and GRR

• The Boards attention is drawn to the significant potential impact to the Trust of Governance Risk Rating score and Shadow Governance Concern shown in this report.

• Discussions with Divisions will continue to be undertaken during the Executive Performance Review meetings in month to raise awareness of impact to the GRR and the importance of the continued performance of all other Monitor indicators.

• GRR (Governance Risk Rating) – Performance against the Monitor Compliance Framework standard for GRR in August 2013 is 6.0 (Red). This indication must be taken as a ‘point in time’ score (end August 2013) for the month only.

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• FRR (Financial Risk Rating) – Performance against the Monitor Compliance Framework standard for FRR in August 2013 was at Level 4 (Green).

12. Conclusion This report demonstrates that whilst there are a significant number of targets being achieved, along with some notable areas of improvement, there remain a number of targets which are not currently being achieved and where attention is now being directed to ensure continued improvement in the coming months.

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Appendix A – Monitor Risk Assessment Framework Summary of Monitor triggers of governance concern

Monitor Risk Assessment Framework – Final Metrics

Integrated Quality and Performance Report

Integrated Quality and Performance

Report

Advancing health and well-being

End August 2013 PositionData to 31st August 2013 unless otherwise stated

Previous months data refreshed where available

Date of report: 19/09/2013 Page 1 of 34


Page

Performance against Monitor Targets 3

4

5

LPT Benchmarking Information 7

Key Performance Indicators (KPIs): Overview 8

9

10

11

12

QUALITY AND ASSURANCE

13

14

Quality: Safe Care Breakdown 15

16

17

FINANCE AND PERFORMANCE

18

19

20

Performance: Finance 21

WORKFORCE AND ORGANISATIONAL DEVELOPMENT

22

HR Workforce (Extended Metrics Data) 23

Waiting Times Compliance - Community Health Services 24-25

Waiting Times Compliance - Adult Mental Health Services and Learning Disabilities 26

Waiting Times Compliance - Families, Young People and Children 27

Appendices

Appendix 1

Appendix 2

Contents

Governance Concern Score

Detailed Exception Report - Maximum time of 18 weeks from point of RTT

Quality: Personal Services

Quality: Safe Care

Performance: Efficient Services

Performance Summary Dashboard

Detailed Exception Report - National Chlamydia Screening Programme

Detailed Exception Report - % Staff with a valid Appraisal & PDP

Detailed Exception Report - % CPA 7 Day Follow-up

Appendix 2 - CQUIN Achievement Targets 2013-14

Analysis of CQUINS (2013-14)

Quality: Effective Services

Appendix 1 - Change Log

Performance: Efficiency

Performance: Bed Occupancy

HR: Workforce



Indicator TargetReporting

Frequency

Data

As At

Current

Month

Previous

monthTravel Sparkline

Quarter

to Date

Quarter

End

Forecast

YTD

Total

Performance

against

National

Standards

Third Parties -

CQC

Third Parties -

CNST

Mandatory

Services

Other cert

failuresOther factors Comments

Accountable

Director

Infection Control: MRSA

Meeting the MRSA Objective

0 (Year

end)Monthly AUG 0 0 0 0 0 0.0 0 0 0 0 0 Adrian Childs

Infection Control: C Diff (MH & Community)

Meeting the Clostridium Difficle Objective

12 (Year

end)Monthly AUG 1 0 1 2 3 0.0 0 0 0 0 0

Annual target reflects the Monitor Compliance Framework 2013/14 de

minimus limit set at 12 cases. There is an internal root cause analysis

currently being carried out by the infection prevention and control team in

conjunction with the ward area to identify any issues or causes, currently

the investigation has not identified any issue in particular but work is on-

going.

Adrian Childs

Maximum time of 18 weeks from point of referral to treatment in aggregate (non-

admitted, complete pathways)95% Monthly AUG 99.0% 89.8% 93.8% 93.8% 91.2% 1.0 0 0 0 0 0

The Chief Operating Officer has agreed a remedial action plan with the

Families, Young People and Childrens’ division which will bring monthly

performance back to a ‘green’ status by the end of Quarter 2

Paul Miller

Maximum time of 18 weeks from point of referral to treatment in aggregate (non-

admitted, incomplete pathways)92% Monthly AUG 99.1% 95.3% 97.0% 97.0% 97.2% 0.0 0 0 0 0 0 Paul Miller

Data Completeness: Community Services (Referral to Treatment Information) 50% Monthly AUG 99.9% 100.0% 99.9% 99.9% 99.9% 0.0 0 0 0 0 0Full assessment of Tiara and Systmone relying on data warehousing of

information rather than systems extraction or reportingPaul Miller

Data Completeness: Community Services (Referral Information) 50% Monthly AUG 81.1% 85.0% 83.1% 83.1% 84.4% 0.0 0 0 0 0 0Full assessment of Tiara and Systmone relying on data warehousing of


Data Completeness: Community Services (Treatment Activity Information) 50% Monthly AUG 99.9% 99.9% 99.9% 99.9% 99.9% 0.0 0 0 0 0 0Full assessment of Tiara and Systmone relying on data warehousing of


Data Completeness: Community Services (Patient Identifier Information) - may be

included later in 2013/14 by Monitor50% Monthly - - - - - - - - - - - - Paul Miller

Data Completeness: Community Services (Patients Dying at Home/Care Home

Information) - may be included later in 2013/14 by Monitor50% Monthly - - - - - - - - - - - - Paul Miller

Care Programme Approach:

% patients followed up within 7 days of discharge95%

Monthly

(in arrears)JUL 91.8% 98.1% 91.2% 91.2% 95.0% 1.0 0 0 0 0 0

Data runs one month behind to allow for target to be monitored. Out of 73

patients discharged in July, 6 patients were not followed up. See detailed

exception report on page 9.

Paul Miller

Care Programme Approach:

% patients having Formal Review within 12 months95% Monthly AUG 96.4% 96.9% 96.6% 96.6% 96.3% 0.0 0 0 0 0 0 Paul Miller

Minimising Mental Health Delayed Transfers of Care

(% Patients Delayed)<=7.5% Monthly AUG 6.3% 6.6% 6.4% 6.4% 5.8% 0.0 0 0 0 0 0 Paul Miller

% of Admissions Gate Kept by the Crisis Resolution & Home Treatment Team 95% Monthly AUG 97.5% 100.0% 99.0% 99.0% 99.3% 0.0 0 0 0 0 0 Paul Miller

Early Intervention in Psychosis:

% newly diagnosed cases against commissioner contract95% Monthly AUG 136.4% 45.5% 90.9% 96.0% 116.4% 0.0 0 0 0 0 0

The relatively small numbers involved in the denominator of this indicator

results in significant percentage shifts month on month. The trust is on

target to meet the annual commissioner contract target and year to date

position is 116.4%

Paul Miller

Mental Health Minimum Dataset (MHMDS) Data Completeness: Identifiers 97% Quarterly Q1 98.4% 97.6% 98.4% 98.4% 98.4% 0.0 0 0 0 0 0 Paul Miller

Mental Health Minimum Dataset (MHMDS) Data Completeness: Outcomes for

patients on CPA50% Quarterly Q1 55.3% 61.5% 55.3% 55.3% 55.3% 0.0 0 0 0 0 0 Paul Miller

Access to Healthcare for All: Self Certification against compliance 4 Quarterly Q1 4 4 4 4 4 0.0 0 0 0 0 0 Paul Miller

Non-Compliance with CQC Essential Standards resulting in Enforcement Action No Monthly AUG Yes Yes Yes Yes Yes 0.0 4 0 0 0 0

The Care Quality Commission’s has issued the Trust with two warning

notices (outcomes 6 and 4) after its visits in July to the Bradgate Mental

Health Unit. Trust’s Board of Directors has met and has put in place a

firm action plan for improvements.

Adrian Childs

2.0 4.0 0.0 0.0 0.0 0.0

0.9 or below = Green, 1 - 1.9 = Amber-Green, 2 - 3.9 = Amber-Red and 4 or above = Red

NB: Monitor indicators are either RED or GREEN, the trust has set no tolerances.

RAG status for Total GRR Score reflects Monitor guide to applicants requirement for GRR of 1.9 or less to be authorised.

1.9 or below = Green, 2.0 or above - Red

Summary of Performance against Monitor Targets

Total GRR Score(based on current months performance)

6.0



The Governance Concern Score (GCS) is proposed to replace the Governance Risk Rating (GRR)

LPT will operate in shadow form a Governance Concern Score alongside the Governance Risk Rating

* This category referrs to triangulation from external agency reports about the Trust.

Due to the lack of any additional concerns (outside of the CQC) an asssessment of 'Unlikely' has been made against this becoming a trigger.

** It is understood this indicator referrs to staff metrics and quality governance performance for the Trust. Due to areas under development,

this category has been currently self-assesed to be 'Possibly' causing a trigger.

Governance Concern Score

LPT PositionCategory Self Assessed Trigger

Material governance issue -

potential use of formal powers

CQC Concerns

Access Metrics

Outcomes Metrics

3rd Party Reports

Quality Governance

Financial Risk

Yes, CQC warning notices (CQC outcomes 6 and 4)

Green

Green

Understood to be 'none reported'

Patient & Staff satisfaction survey results - requires further analysis. Number of Board level changes in period

Continuity of Services Risk Rating (CSSR) = 4

Yes

No

No

Unlikely*

Possibly**

No

Amber Red



MON/COM Monthly MSP.01 Infection Control: MRSA Meeting the MRSA Objective AUG 0 0 0 0

MON Monthly MSP.02 Infection Control: C Diff (MH & Community) Meeting the Clostridium Difficle Objective AUG 1 0 3 12

MON Monthly MSP.03 Maximum time of 18 weeks from point of referral to treatment in aggregate (non-admitted, complete pathways) 95.0% AUG 99.0% 89.8% 91.2% 95.0%

MON Monthly MSP.13 Maximum time of 18 weeks from point of referral to treatment in aggregate (non-admitted, incomplete pathways) 92.0% AUG 99.1% 95.3% 97.2% 92.0%

MON Monthly MSP.14 Data Completeness: Community Services (Referral to Treatment Information) 50.0% AUG 99.9% 100.0% 99.9% 50.0%

MON Monthly MSP.15 Data Completeness: Community Services (Referral Information) 50.0% AUG 81.1% 85.0% 84.4% 50.0%

MON Monthly MSP.16 Data Completeness: Community Services (Treatment Activity Information) 50.0% AUG 99.9% 99.9% 99.9% 50.0%

MON Monthly MSP.17 Data Completeness: Community Services (Patient Identifier Information) - may be included later in 2013/14 by Monitor 50.0% - - - - - - 50.0%

MON Monthly MSP.18Data Completeness: Community Services (Patients Dying at Home/Care Home Information) - may be included later in 2013/14 by

Monitor50.0% - - - - - - 50.0%

MONMonthly (In

Arrears)MSP.05 Care Programme Approach:% patients followed up within 7 days of discharge 95% JUL 91.8% 98.1% 95.0% 95%

MON Monthly MSP.06 Care Programme Approach:% patients having Formal Review within 12 months 95% AUG 96.4% 96.9% 96.3% 95%

MON Monthly MSP.07 Minimising Mental Health Delayed Transfers of Care (% Patients Delayed) <=7.5% AUG 6.3% 6.6% 5.8% <=7.5%

MON Monthly MSP.08 % of Admissions Gate Kept by the Crisis Resolution & Home Treatment Team 95% AUG 97.5% 100.0% 99.3% 95%

MON Monthly MSP.09 Early Intervention in Psychosis:% newly diagnosed cases against commissioner contract 95% AUG 136.4% 45.5% 116.4% 95%

MON Quarterly MSP.10 Mental Health Minimum Dataset (MHMDS) Data Completeness: Identifiers 97% Q1 98.4% 97.6% 98.4% 97%

MON Quarterly MSP.11 Mental Health Minimum Dataset (MHMDS) Data Completeness: Outcomes for patients on CPA 50% Q1 55.3% 61.5% 55.3% 50%

MON Quarterly MSP.12 Access to Healthcare for All: Self Certification against compliance 4 Q1 4 4 4 4

TRUST Monthly QPS.01 % people reporting being treated with dignity and respect 0 0 0 0

COM/DOH Monthly QPS.02 Mixed sex sleeping accommodation breaches 0 AUG 0 0 0 0

TRUST Monthly QPS.03 % adult service users reporting having out of hours (OOH) contact details 95%

TRUST Monthly QPS.04 Compliments received 0 AUG 707 644 3245 0

TRUST Monthly QPS.05 Total complaints received 0 AUG 20 32 136 0

TRUST Monthly QPS.06 Complaints acknowledged within 3 working days 100% AUG 100.0% 100.0% 100.0% 100%

MON/CQC Monthly QPS.07 % Complaints closed within timescales 100% AUG 100.0% 100.0% 100.0% 100%

CQUINMonthly (In

Arrears)QPS.09 Net Promoter Score: Total Discharges JUN 434 340 1351

CQUINMonthly (In

Arrears)QPS.10 Net Promoter Score: Cards Returned JUN 131 139 463

CQUINMonthly (In

Arrears)QPS.11 Net Promoter Score: Return Rate JUN 30.2% 40.9% 34.3%

CQUINMonthly (In

Arrears)QPS.08 Net Promoter Score: Overall Score JUN 64.58 76.25 0

TRUST Monthly QSC.03 Never Events 0 AUG 0 0 0 0

COM Monthly QSC.04 Total Serious Incidents (SIs) 0 AUG 22 23 87 0

COM Monthly QSC.05 STEIS - SI action plans implemented within timescales 100% AUG 100.0% 100.0% 98.7% 100.0%

TRUST Monthly QSC.15 % No Harm (Patient Safety Incidents) 69% AUG 61.1% 58.8% 59.1% 69%

TRUST Monthly QSC.14 Incident Rate (Patient Safety Incidents) 0% AUG 38.7 42.4 32.3 0

TRUST Monthly QSC.16 PST: Pressure Ulcer Harms 0% AUG 4.8% 6.8% 6.0%

TRUST Monthly QSC.17 PST: Falls Harms 0% AUG 0.2% 0.1% 0.5%

TRUST Monthly QSC.18 PST: Catheter UTI Harms 0% AUG 0.5% 0.3% 0.4%

TRUST Monthly QSC.19 PST: VTE Harms 0% AUG 0.7% 0.5% 0.4%

COM/DOH Monthly QSC.10 Compliance with hygiene code 0 AUG

MON/COM Monthly QSC.11 MRSA Bacteraemia cases - Community AUG 0 0 0 0

MON/COM Monthly QSC.13 Clostridium Difficile (C Diff) Cases AUG 1 0 3 12

TRUST Monthly QSC.23 Total incidents reported (including near misses) AUG 1091 1267 5627

TRUST Monthly QSC.20 Total incidents reported (Pressure Sore) AUG 224 224 1326

TRUST Monthly QSC.21 Total incidents reported (Other) AUG 867 967 4301

DoH/SHA Monthly QSC.22a Non-Compliance with Essential Standards resulting in a Major Impact on Patients No AUG No No No No

DoH/SHA Monthly QSC.22b Non-Compliance with CQC Essential Standards Resulting in Enforcement Action No AUG Yes Yes Yes No

TRUST Monthly QES.01 % Signed Care Pathways in place for Service Users 0 0 0 0

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g

Fre

qu

en

cy

Quality - Safe Care

Quality - Effective

services

Quality - Personal

Services



TRUST Monthly QES.02 % Carer Input into Care Plans on PAS - where input is requested by the Service User 0% 0.0% 0.0% 0.0%

MON Monthly QES.03 Early Intervention in Psychosis - % newly diagnosed cases against commissioner contract 95% AUG 136.4% 45.5% 116.4% 95%

MONMonthly (In

Arrears)QES.04 % patients on CPA followed up within 7 days of discharge 95% JUL 91.8% 98.1% 95.0% 95%

MON Monthly QES.05 % patients on CPA having Formal Review within 12 months 95% AUG 96.4% 96.9% 96.3% 95%

MON Monthly QES.07 Access to Healthcare for All 4 Q1 4 4 4 4

QES.08a County: 95% 99.3% 96.7% 99.3% 95%

QES.08b City: 95% 99.2% 96.0% 99.2% 95%

QES.09aCounty- 46.3%

Q144.5% 45.3% 44.5% 46.7%

QES.09b City- 53.5% Q1 57.8% 52.5% 57.8% 54.0%

QES.10aCounty - 5240

Q45249 3684 5249 5240

QES.10b City- 2644 Q4 2743 2042 2743 2644

COM/DoH Monthly QES.11 Genito Urinary Medicine- % Offered appointment within 48 hours 98% AUG 99.6% 100.0% 99.8% 98%

COM Monthly QES.12aCity: 834

(monthly)AUG 510 650 3002 7500

COM Monthly QES.12bCounty: 1000

(monthly)AUG 691 541 3932 9000

COM Monthly QES.13aCity: 46

(monthly)AUG 18 26 129 410

COM Monthly QEFS.01 Average Length of Stay (ALoS) - Mental Health TBC AUG 48.2 65.9 0 TBC

TRUST Monthly QEFS.02 Median Length of Stay (ALoS) - Mental Health 0 AUG 18.0 21.0 18.0 0

TRUST Monthly QEFS.13 Average Length of Stay (ALoS) - Community hospital rehab wards AUG 25.4 22.6 25.2

TRUST Monthly QEFS.14 Average Length of Stay (ALoS) - Stroke wards (ward 1 st lukes, ward 1 Coalville) AUG 27.3 27.5 30.4

TRUST Monthly QEFS.15 Average Length of Stay (ALoS) - Mental health (ward 4 Coalville) AUG 50.8 402.0 119.9

TRUST Monthly QEFS.16 Average Length of Stay (ALoS) - City rehab beds (CICB/CRB) AUG 19.8 18.0 19.4

TRUST Monthly QEFS.04 Occupancy Rate - Mental Health <=85% AUG 92.5% 92.4% 92.2% 85.0%

TRUST Monthly QEFS.05 Occupancy Rate - Community >=93% AUG 92.3% 93.6% 92.6% 93.0%

MON Monthly QEFS.06 % Delayed Patients (DToC) - Mental Health <=7.5% AUG 6.3% 6.6% 5.8% <=7.5%

COM Monthly QEFS.07 % Delayed Patients (DToC) - Community <=2.12% AUG 2.55% 0.71% 1.81% <=2.12%

MON Monthly QEFS.08 % of Admissions Gate Kept by the Crisis Resolution & Home Treatment Team 95% AUG 97.5% 100.0% 99.3% 95.0%

COM Monthly QEFS.09 Total number of Home Treatment episodes carried out by Crisis Resolution team year to date.1895 (Year

end Target)AUG 743 643 743 1895

TRUST Monthly QEFS.10 % Discharge Summaries issued within 24 hours 0 0 0 0 0 0 0

MON Quarterly QEFS.11 MHMDS Data Completeness: Records 97% Q1 98.4% 97.6% 98.4% 97.0%

MON Quarterly QEFS.12 MHMDS Data Completeness: Outcomes 50% Q1 55.3% 61.5% 55.3% 50.0%

Monthly PF.01 EBITDA Margin JUL 5.1% 5.1% 5.1% 5.2%

Monthly PF.02 I&E Surplus £000 (Excl. impairments) JUL 1,126 898 1,126 2,903

Monthly PF.03 Income (against budget) £000 JUL 107,198 85,754 - 107,198 262,520

Monthly PF.04 Expenditure (against budget) £000 JUL 106,073 84,856 - 106,073 259,617

Monthly PF.05 CIP achievement £000 JUL 3,738 2,929 - 3,738 11,831

Monthly PF.06 Cash balance £000 (as per original FIMS Plan) JUL 16,364 15,026 16,364 11,089

Monthly PF.7 Capital Expenditure (target spend = available funds) £000 JUL 1,427 1,074 1,427 15,085

Monthly PF.8 Debtors > 90 days JUL 6.0% 5.9% 6.0% 5.0%

Monthly PF.9 Creditors > 90 days JUL 2.3% 1.2% 2.3% 5.0%

Monthly PF.10 Better Payment Practice Code JUL 96.4% 96.1% 96.4% 95.0%

TRUST Monthly PW.25 Number of WTE Employed 0 AUG 4551.3 4554.5

TRUSTMonthly (In

Arrears)PW.26 % of Sickness Absence (1 month in arrears) <=4% JUL 4.3% 4.2% 4.4% <=4%

TRUST Monthly PW.27 % of total workforce turnover including training grade medics (Projected to Mar-14) 8-12% AUG 11.6% 9.3% 8-12%

TRUSTMonthly (In

Arrears)PW.34 % Vacancy Rate (1 Month in Arrears) 6-12% JUL 8.8% 9.6% 6-12%

TRUST Monthly PW.32 Ratio of Bank Usage to Agency Usage <1:0.75 AUG 1: 0.97 1:0.89 1: 0.9 <1:0.75

TRUST Monthly PW.29 Number of staff at risk of redundancy AUG 13 27

TRUST Monthly PW.30 Number of open formal grievances AUG 7 8 8

TRUST Monthly PW.31 Number of open formal disciplinaries AUG 28 27 18

TRUST Monthly PW.14 % of staff with an appraisal/ PDR within the last 12 months >=80% AUG 82.4% 84.2% >=80%

TRUST Monthly PW.19 % of staff trained in Core Mandatory Training >=85% AUG 93.7% 93.6% >=85%

TRUST Monthly PW.33 % of Mandatory Training DNAs <=15% AUG 14.4% 12.7% <=15%

Q1

COM/DoH Smoking Cessation:Number of 4 week quitters attending NHS stop smoking services - YTD Cumulative Q4

Quarterly

Performance -

Finance

Chlamydia Screening service - Number of screens for 15-24 year olds

Q1

Quality - Efficient

Services

Chlamydia Positive Screens- Number of positive screens for 15-24 year olds

Quarterly

Quarterly

HR Workforce

Quality - Effective

services

Breast Feeding- Prevalence at 6 - 8 weeks

COM/DoH Breast Feeding- Status recorded at 6 - 8 weeks

COM/DoH



Data Source

Data

Reporting

Period

CPA 12m Review

(95%)

CPA 7 day follow

up (95%)

DToC (Monitor)

(<=7.5%)

Crisis Resolution

Gatekeeping

(95%)

Early

Intervention in

Psychosis (95%)

MHMDS

Completeness -

Identifiers (97%)

MHMDS

Completeness -

Outcomes (50%)

18 week wait

time non

admitted

complete

pathway (95%)

18 week wait

time non

admitted

incomplete

pathway (92%) Comment

Leicestershire Partnership NHS Trust Trust Board Papers Jul-13 96.90% 98.10% 6.50% 100.00% 45.50% 98.40% 55.10% 89.80% 95.30%

Nottinghamshire Healthcare NHS Trust Trust Board Papers Jul-13 96.30% 98.80% 6.20% 99.20% 96.10% 99.70% 96.10% n/a n/a

Northamptonshire Healthcare FT Trust Board Papers Jul-13 not published not published not published not published not published not published not published not published not published Papers not published at time of writing

Coventry and Warwickshire Partnership Trust Trust Board Papers Jul-13 not published not published not published not published not published not published not published not published not published Papers not published at time of writing

Lincolnshire Partnership NHS FT Trust Board Papers Jul-13 98.20% not published 3.20% 96.70% 100.00% 99.50% not published 99.30% 96.60%

Derbyshire Healthcare NHS FT Trust Board Papers Jul-13 98.20% 97.50% 0.81% 96.05% 126.10% 99.95% 97.74% 98.33% 96.73%

Cambridge & Peterborough NHS FT Trust Board Papers Jul-13 95.31% 98.17% 4.67% 95.20% 100.00% 99.00% 90.15% n/a n/a

South Staffs and Shropshire Healthcare NHS FT Trust Board Papers Jul-13 not published not published not published not published not published not published not published not published not published July performance papers not published

LPT Benchmarking Information - July 2013 Report

0%

20%

40%

60%

80%

100%

120%

CPA Performance

CPA 12m Review (95%)

CPA 7 day follow up (95%)0%

20%

40%

60%

80%

100%

120%

140%

Crisis & Early Intervention Performance

Crisis Resolution Gatekeeping (95%)

Early Intervention in Psychosis (95%)

0%

20%

40%

60%

80%

100%

120%

MHMDS Performance

MHMDS Completeness -Identifiers (97%)

MHMDS Completeness -Outcomes (50%)

0%

20%

40%

60%

80%

100%

120%

18 Week Wait Performance

18 week wait time non admittedcomplete pathway (95%)

18 week wait time non admittedincomplete pathway (92%)

0%

1%

2%

3%

4%

5%

6%

7%

DToC Performance

DToC (Monitor) (<=7.5%)

Notes: Analysis of the July 2013 benchmarking data indicates the trust failed to achieve the 95% target against the Early Intervention In Psychosis and continues to underperform against the 18 Week Referral to treatment Completed Pathways target. The trust figures for the month of August indicates an improvement against both key performance indicators indicating action plans implemented have achieved the desired outcomes.



Key:- 3 = Green achieved target, 2= Amber Within 95% of Target, 1= Red Failing Target

Key Performance Indicators (KPIs): Overview

0

1

2

3Occupancy Rate - MH

OccRate - Community

% Delayed Patients(DToC) - Community

% of Admissions GateKept

MHMDS DataCompleteness: Records


Outcomes

Efficient Services

0

1

2

3

Mixed sexaccommodation

breaches

Complaintsacknowledged within

3 working days

% Complaints closedwithin timescales

Quality -Personal Services

0

1

2

3Never Events

STEIS - SI action plansimplemented within

timescales

Compliance withhygiene code

MRSA Bacteraemiacases - Community

Clostridium Difficile (CDiff) Cases

Quality -Safe Care

0

1

2

3

Early Intervention inPsychosis

% patients on CPAfollowed up within 7 days

of discharge

% patients on CPA havingFormal Review within 12

months

Breast Feeding- StatusBreast Feeding-

Prevalence

SmokingCessation:Number of 4

week quitters

GU Medicine- % Offeredappointment within 48

hours

Quality-Effective Services

0

1

2

3

Core MandatoryTraining

Appraisal

Sickness AbsenceRatio of Bank Usage to

Agency Usage

Vacancy Rate

Workforce Metrics



Performance (%) Apr-12 May-12 Jun-12 Jul-12 Aug-12 Sep-12 Oct-12 Nov-12 Dec-12 Jan-13 Feb-13 Mar-13 Apr-13 May-13 Jun-13 Jul-13

% CPA 7 Day Follow-up 98.5% 98.5% 100.0% 97.3% 98.8% 98.1% 100.0% 94.1% 92.6% 100.0% 96.2% 95.9% 98.4% 100.0% 98.1% 91.8%

Target 95% 95% 95% 95% 95% 95% 95% 95% 95% 95% 95% 95% 95% 95% 95% 95%

DETAILED EXCEPTION REPORT - % CPA 7 Day Follow-up Follow

Responsible Lead: Paul Miller Indicator Source: MON

Comments and Actions: Follow ups on the SAME day as discharge are not registered as a follow up. The follow-up must occur after the day of discharge. Patients re-admitted within 7 days are not included in the calculation. 73 patients were discharged on CPA during July 2013, 6 were not followed up within 7 days -4 patients were not contactable after several attempts -1 patient went missing after discharge and attempts are on-going to locate the patient. -1 patient was seen on the day of discharge but was not subsequently followed up. NB: This data is always a month behind due to the timescale available to deliver the IQPR. With the 7 day lead time plus 5 days to enter data into the system, current month’s data would not be available until at least the 15th of the month.

80%

85%

90%

95%

100%

Apr-12 May-12 Jun-12 Jul-12 Aug-12 Sep-12 Oct-12 Nov-12 Dec-12 Jan-13 Feb-13 Mar-13 Apr-13 May-13 Jun-13 Jul-13

Monthly - % CPA 7 Day Follow-up

% CPA 7 Day Follow-up Target



RTT Performance

(%)Aug-12 Sep-12 Oct-12 Nov-12 Dec-12 Jan-13 Feb-13 Mar-13 Apr-13 May-13 Jun-13 Jul-13 Aug-13

Completed

Pathways Actual 99.0% 96.2% 96.6% 96.6% 95.5% 98.7% 95.1% 95.1% 92.9% 86.5% 88.6% 89.8% 99.0%

Completed

Pathways Target 95% 95% 95% 95% 95% 95% 95% 95% 95% 95% 95% 95% 95%

Incomplete

Pathways Actual 98.5% 97.7% 98.4% 95.5% 98.9% 97.7% 97.9% 97.2% 97.0% 98.7% 96.3% 95.3% 99.1%

Incomplete

Pathways Target 92% 92% 92% 92% 92% 92% 92% 92% 92% 92% 92% 92% 92%

Responsible Lead: Paul Miller Indicator Source: MON Comments and Actions: Performance for Completed Pathways in August-13 is at 99.0% :- - 1 patient breaching Department of Health guidance states that providers must continue to monitor the length of the patients waiting time until treatment starts for all the above reasons. The trust notes the following actions have addressed the decline in performance:- - Implementation of new clinic booking rules to increase the number of new (first) appointment slots - Review of the SPA process (single point of access for the service), ensuring appropriate signposting of new referrals - Locum consultants to start during July to assist with short-term capacity issues - Recruitment exercise for 2 vacant positions to address long-term capacity issues The remedial action plan has returned monthly performance back to a ‘green’ status .

DETAILED EXCEPTION REPORT - Maximum time of 18 weeks from point of referral to treatment

99.0%

96.2% 96.6% 96.6%

95.5%

98.7%

95.1% 95.1%

92.9%

86.5%

88.6%

89.8%

99.0% 98.5%

97.7% 98.4%

95.5%

98.9%

97.7% 97.9% 97.2% 97.0%

98.7%

96.3%

95.3%

99.1%

85%

87%

89%

91%

93%

95%

97%

99%

Aug-12 Sep-12 Oct-12 Nov-12 Dec-12 Jan-13 Feb-13 Mar-13 Apr-13 May-13 Jun-13 Jul-13 Aug-13

Maximum time of 18 weeks from point of referral to treatment

Completed Pathways Actual Incomplete Pathways Actual

Completed Pathways Target Incomplete Pathways Target



No. of Screens Aug-12 Sep-12 Oct-12 Nov-12 Dec-12 Jan-13 Feb-13 Mar-13 Apr-13 May-13 Jun-13 Jul-13 Aug-13

City Actuals673 869 985 940 569 777 998 853 563 639 640 650 510

City Target669 669 669 669 669 669 669 669 834 834 834 834 834

County

Actuals 731 2204 1303 2311 1055 1154 1457 1508 692 956 1052 541 691

County Target1500 1500 1500 1500 1500 1500 1500 1500 1000 1000 1000 1000 1000

Responsible Lead: Paul Miller Indicator Source: COM Comments and Actions: Trajectory work has been undertaken by the City and County Chlamydia Services against the screening targets set. The service expects the first two quarters to have a below average number of screens and expects an increase in the third quarter in line with the start of the new academic year. April to December 2013 City and County target figures have been revised City 7500 & County 9000.

DETAILED EXCEPTION REPORT - National Chlamydia Screening Programme- Number of screens for 15-24 year olds

0

500

1000

1500

2000

2500

Number of screens for 15-24 year olds

City Actuals

County Actuals

City Target

County Target



Current Month Previous Month

Adult Learning Disabilities 86.4% 89.0%

Adult Mental Health 79.9% 84.0%

Community Health Services 85.9% 88.5%

Enabling Services 82.0% 82.2%

Families, Young People and

Children Services80.8% 81.5%

Hosted Services 64.1% 55.6%

Split by Division

* Current Month Position is also YTD position

DETAILED EXCEPTION REPORT - % Staff with a valid Appraisal & PDP (renewed every 12 months) and Taken from ESR

Responsible Lead: Alan Duffell Indicator Source: TRUST Comments and Actions: Target updated to reflect 13/14 indicator Hosted services have overall increased their PDR compliance by approximately 10% since last month. The biggest improvement was in HIS where compliance increased from 64.8% to 74.8%. HIS will need to complete a further 6 PDRs plus the 12 due to expire in September to meet the target. Finance procurement have 11 PDRs which have not been completed with no improvement from last month There were 16 new starters in July in EMIAS which has decreased the compliance rate. If we omit the new starters who are due a PDR in the next 3 months the compliance rate is 81%. Adult Mental Health have dipped to just below the target at 79.9% PDR compliance. It should be noted that complex care has retained 100% compliance; and 3 other areas have shown an improvement

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

% Staff with a valid Appraisal & PDP (renewed every 12 months) - Taken from ESR

% Available staff with a valid Appraisal & PDP (renewed every 12 months) - Taken from ESR Target



Tim

elin

ess

Cen

tral

Syste

m

Exec

Dire

cto

r

Sig

n o

ff

% people reporting being treated with

dignity and respectTRUST - AC

Mixed sex sleeping accommodation

breachesCOM/DOH Monthly 0 AUG 0 0 0 0 PM 0 0 0 0

% adult service users reporting having out

of hours (OOH) contact detailsTRUST Monthly 95% PM

Compliments received TRUST Monthly AUG 707 644 3245 AC 48 2 641 14

Total complaints received TRUST Monthly AUG 20 32 136 AC 10 0 7 3

Complaints acknowledged within 3 working

daysTRUST Monthly 100% AUG 100.0% 100.0% 100.0% 100% AC 100.0% - 100.0% 100.0%

% Complaints closed within timescales MON/CQC Monthly 100% AUG 100.0% 100.0% 100.0% 100% AC 100.0% - 100.0% 100.0%

Net Promoter Score: Total Discharges CQUINMonthly (In

Arrears)JUN 434 340 1351 AC

Net Promoter Score: Cards Returned CQUINMonthly (In

Arrears)JUN 131 139 463 AC

Net Promoter Score: Return Rate CQUINMonthly (In

Arrears)JUN 30.2% 40.9% 34.3% AC

Net Promoter Score: Overall Score CQUINMonthly (In

Arrears)JUN 64.58 76.25 AC 70.96 - 64.58 0.00

Trust Performance Divisional Performance - Latest Month

Quality - Personal Services

Adu

lt L

ea

rnin

g

Dis

abili

ties

Exec D

ire

cto

r

Le

ad

Adu

lt M

en

tal

Hea

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Com

mun

ity

Hea

lth

Data

As A

t

Spa

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Curr

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on

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Actu

al

** Data Quality is measured against the items below:

1) TIMELINESS:

GREEN: Data is submitted in time to the central system for accurate reporting (in line with trust policies) AND data is verified and any data quality issues are resolved in time for reporting deadlines AND data is extremely unlikely to change in subsequent months.

AMBER: Action Plans are in place to ensure business processes are adapted to meet the GREEN requirements.

RED: Data is not available in a timely fashion (according to trust policies) OR Data has not been verified and data quality issues haven't been resolved OR Data is likely to change in subsequent months

2) EXTRACTED FROM A CENTRAL SYSTEM:

GREEN: ALL reported data is extracted from the SAME central system (such as Safeguard, Maracis, ESR, Finance etc)

AMBER: Action plans are in place to submit data to central systems rather than using manual processes OR action plans are available for merging multiple systems into one central system.

RED: Data is extracted from a manual system (even if only in one particular area) OR data is extracted from multiple central systems.

3) SIGNED OFF BY AN EXECUTIVE DIRECTOR

GREEN: The position of data quality items 1) and 2) have been agreed and signed off by an Executive Director

RED: The data quality position has not been agreed and signed off by an Executive Director

Sou

rce

Mon

thly

ta

rge

t

Tra

ve

l on

pre

vio

us

mon

th

YT

D P

ositio

n

Pre

vio

us

mon

th

Rep

ort

ing

Fre

que

ncy

Fam

ilies,

You

ng

Peo

ple

& C

hild

ren

Data Quality

Yea

r E

nd

Targ

et

Comments and Actions:

Compliments:

All figures are received for August but are subject to continual validation, any changes that may occur will be updated in next months IQPR.

Net Promoter Score:

Trust overall score is based on CHS performance only.



Tim

elin

ess

Ce

ntr

al

Syste

m

Exe

c

Dire

cto

r S

ign

off

Never Events TRUST Monthly 0 AUG 0 0 0 0 AC 0 0 0 0

Total Serious Incidents (SIs) COM Monthly AUG 22 23 87 AC 10 0 10 2

STEIS - SI action plans implemented within

timescalesCOM Monthly 100% AUG 100.0% 100.0% 98.7% 100.0% AC 100.0% 100.0% 100.0% 100.0%

Total incidents reported (including near misses) TRUST Monthly AUG 1091 1267 5627 AC 244 98 536 58 16 139

Total incidents reported (Pressure Sore) TRUST Monthly AUG 224 224 1326 AC 3 0 154 0 0 67

Total incidents reported (Other) TRUST Monthly AUG 867 967 4301 AC 241 98 382 58 16 72

Total patient safety incidents reported

(including near misses)TRUST Monthly AUG 756 845 3392 AC 154 71 401 45 11 74

% No Harm (Patient Safety Incidents) TRUST Monthly 69% AUG 61.1% 58.8% 59.1% 69% AC 68.8% 46.5% 51.4% 75.6%

Incident Rate (Patient Safety Incidents) TRUST Monthly AUG 38.7 42.4 32.3 AC 21.5 204.0 36.1 48.3

PST: Pressure Ulcer Harms TRUST Monthly AUG 4.8% 6.8% 6.0% AC 4.8%

PST: Falls Harms TRUST Monthly AUG 0.2% 0.1% 0.5% AC 0.2%

PST: Catheter UTI Harms TRUST Monthly AUG 0.5% 0.3% 0.4% AC 0.5%

PST: VTE Harms TRUST Monthly AUG 0.7% 0.5% 0.4% AC 0.7%

Compliance with hygiene code COM/DOH Monthly AUG AC

MRSA Bacteraemia cases - Community MON/COM Monthly AUG 0 0 0 0 AC 0

Clostridium Difficile (C Diff) Cases MON/COM Monthly AUG 1 0 3 12 AC 0 0 1 0

Non-Compliance with Essential Standards

resulting in a Major Impact on PatientsDoH/SHA Monthly No AUG No No No No AC No No No No

Non-Compliance with CQC Essential Standards

Resulting in Enforcement ActionDoH/SHA Monthly No AUG Yes Yes Yes No AC Yes No No No

Quality - Safe Care


1) TIMELINESS:





GREEN: ALL reported data is extracted from the SAME central system (such as Safeguard, Maracis, ESR, Finance etc.)






Ad

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Dis

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Co

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es

Mo

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Fa

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Yo

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Pe

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Ch

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n


Non-Compliance with CQC Essential Standards Resulting in Enforcement Action: Following the Care Quality Commission’s decision to issue the Trust with two warning notices (for CQC outcomes 6 and 4) after its visits in July to the Bradgate Mental Health Unit, the Trust’s

Board of Directors has met and – as well as putting in place a firm action plan for improvements to care – is making sure further professional and emotional support is in place for staff both on the Unit itself and across the Trust.

Level 2 SI Action Plans implemented within timescales: This indicator considers only those SI action plans that should have been completed by the latest month. SI's investigations must be closed within 60 working days. Only then are any action plans implemented, each SI

action plan will have its own deadline. Previous months performance has been updated to reflect performance during the reporting period and shows an indication of a monthly performance.

Incident Rate: This indicator is derived from the total number of patient safety incidents per month per thousand occupied bed days (excluding leave). This indicator is not appropriate to break down to sub-Trust level (divisional break-down is for information only).

Total patient safety incidents reported (including near misses): Previous months figures have been updated to reflect accurate position.

MRSA Bacteraemia: Community - cases are not validated until 15th of each month following lock down on the national system MESS. Therefore, current month figures might change in future months which is why the current data quality rating for timeliness is red. Year end target

of 0 (Zero) is based on the Commissioner target, Monitor’s annual de minimis limit for cases of MRSA reflecting a governance concern is set at 6.

Clostridium Difficile (C Diff) Cases: Annual target reflects the Monitor Compliance Framework 2013/14 de minimus limit set at 12 cases. There is an internal root cause analysis currently being carried out by the infection prevention and control team in conjunction with the ward

area to identify any issues or causes, currently the investigation has not identified any issue in particular but work is on-going.

Incident Reporting Direction of Travel Indicators: The approach taken by LPT in monitoring incident related KPIs is to encourage a reporting culture in line with the NPSA and the NRLS reports into incident reporting rates. This results in a 'green, up arrow' being applied when

incident reporting has increased (for all incident related KPIs above except Pressure Sores), and a 'red, down arrow' being applied where incident reporting has decreased. In the case of Pressure Sores, a 'green, up arrow' depicts fewer reported Pressure Sores and a 'red, down

arrow' showing an increase in pressure sores. For the % No Harm KPI, the Trust is aiming to achieve the highest percentage possible, so a 'green, up arrow' depicts improving performance (higher percentage) on the previous month whereas a 'red, down arrow' depicts poorer

performance.

Re

po

rtin

g

Fre

qu

en

cy

Sp

ark

line

Division Performance - Latest MonthTrust Performance

3rd

part

y/E

xte

rnal

Exe

c D

ire

cto

r

Lead

Pre

vio

us m

onth Data Quality

Da

ta A

s A

t

Incidents

Patient Safety Thermometer



Division Apr-13 May-13 Jun-13 Jul-13 Aug-13 Sep-13 Oct-13 Nov-13 Dec-13 Jan-14 Feb-14 Mar-14 SparklineAMHS 9 34 13 14 48LD 1 0 2 1 2CHS 377 689 742 625 641FYPC 5 13 4 3 14

Total 392 736 761 643 705


Total 30 23 31 32 20


Total 932 987 910 1077 936

Division Apr-13 May-13 Jun-13 Jul-13 Aug-13 Sep-13 Oct-13 Nov-13 Dec-13 Jan-14 Feb-14 Mar-14 SparklineAMHS 70.3% 60.5% 83.5% 72.7% 68.8%LD 68.2% 78.0% 80.0% 65.6% 46.5%CHS 47.0% 48.4% 44.4% 49.9% 51.4%FYPC 75.0% 79.2% 77.8% 74.6% 75.6%

Total 55.7% 55.5% 58.3% 58.8% 61.1%

Division Apr-13 May-13 Jun-13 Jul-13 Aug-13 Sep-13 Oct-13 Nov-13 Dec-13 Jan-14 Feb-14 Mar-14 Sparkline

AMHS 4 7 3 8 10

LD 0 0 0 0 0

CHS 10 10 5 14 10

FYPC 1 2 0 1 2

Total 15 19 8 23 22

Incidents Reported and Serious Incidents Logged YTD 2013/14

Comments & Actions:

Methodology for calculating total percentage for Degree of No Harm of Patient Incidents updated revised to exclude non-divisional incidents

Compliments, Complaints and Incidents Divisional Detail

Patient Related Incident Themes YTD 2013/14 (Top 10)

Complaint Themes YTD 2013/14 (Top 10)

Degree of No Harm of Patient Incidents

Total Serious Incidents Logged

Compliments

Complaints

Total Incidents Reported

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Total Incidents Reported

Total Serious Incidents Logged



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% Signed Care Pathways in place for Service Users TRUST - PM

% Carer Input into Care Plans on PAS - where input is

requested by the Service UserTRUST - PM

Early Intervention in Psychosis - % newly diagnosed

cases against commissioner contractMON Monthly 95% AUG 136.4% 45.5% 116.4% 95.0% 116.4% PM 136.4%

% patients on CPA followed up within 7 days of

dischargeMON

Monthly (In

Arrears)95% JUL 91.8% 98.1% 95.0% 95% 95.0% PM 91.7% 100.0% 100.0% 100.0%

% patients on CPA having Formal Review within 12

monthsMON Monthly 95% AUG 96.4% 96.9% 96.3% 95% 96.3% PM 96.1% 96.7% 98.1% 98.2%

Access to Healthcare for All MON Quarterly 4 Q1 4 4 4 4 4 PM

County: 95% 99.3% 96.7% 99.3% 95.0% 99.3% PM 99.3%

City: 95% 99.2% 96.0% 99.2% 95.0% 99.2% PM 99.2%

County- 46.3% Q1 44.5% 45.3% 44.5% 46.7% 44.5% PM 44.5%

City- 53.5% Q1 57.8% 52.5% 57.8% 54.0% 57.8% PM 57.8%

County - 5240 Q4 5249 3684 5249 5240 NA PM 5249

City- 2644 Q4 2743 2042 2743 2644 NA PM 2743

Genito Urinary Medicine- % Offered appointment within

48 hoursCOM/DoH Monthly 98% AUG 99.6% 100.0% 99.8% 98.0% 99.8% PM 99.6%

COM Monthly City: 834 (monthly) AUG 510 650 3002 7500 5404 PM 510

COM MonthlyCounty: 1000

(monthly)AUG 691 541 3932 9000 7078 PM 691

Chlamydia Positive Screens- Number of positive

screens for 15-24 year olds COM Monthly City: 46 (monthly) AUG 18 26 129 410 232 PM 18


1) TIMELINESS:





GREEN: ALL reported data is extracted from the SAME central system (such as Safeguard, Maracis, ESR, Finance etc.)






Breast Feeding- Prevalence at 6 - 8 weeks COM/DoH Q1

Smoking Cessation:Number of 4 week quitters

attending NHS stop smoking services - YTD

Cumulative

COM/DoH

Chlamydia Screening service - Number of screens for

15-24 year olds

Q4

Quarterly

Quarterly


% patients on CPA followed up within 7 days of discharge: Data runs a month behind to enable tracking of target. Please note that this indicator represents patients 18 years and over. Out of 73 patients discharged in July, 6 patients were not followed up. Please see the detailed

exception report on page 9.

Early Intervention: Small numbers involved in the denominator for calculation of this indicator can equate to significant swings in performance month on month; Figures refreshed each month to ensure accurate position is monitored accounting for data entry after IQPR production cut

off. The service enters data by the 15th of the month therefore performance maybe underinflated due to the early deadline set for the IQPR.

Genito Urinary Medicine- % Offered appointment within 48 hours: Target has been revised from 100% to 98% as per Schedule 4 - Quality Requirements 2013-14.

Breast Feeding: Q1 figures have been updated to reflect an accurate position.

Smoking Cessation: Quarter 1 figures expected 9th September 2013.

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Divisional Performance - Latest MonthTrust Performance



CQUIN No Domain IncomeTarget to Achieve 100%

PaymentQ1 Q2 Q3 Q4

Forecast to

31.3.2014Comment on Red & Amber Ratings

National 1Patient

Experience£502,400

Plan signed off by Board with

milestones and achieve all actionsG G

Regional 1 Safety £502,400Achievement between 100% and

96%R G

Work with commissioners is progressing to renegotiate

this CQUIN to focus on avoidable pressure ulcers

which are within the Trusts control and where we are

currently making a significant impact. Therefore early

indications are that this CQUIN should be achievable in

Quarter 2.

Regional 5 Effectiveness £502,400 Achieve all actions G G

CQUIN No Domain IncomeTarget to Achieve 100%

PaymentQ1 Q2 Q3 Q4

Forecast to

31.3.2014Comment on Red & Amber Ratings

MH Local 6 Safety £237,200 Achieve 70% or above G G

CHS Local 6 Safety £208,100 Achieve 90% or above G G

MH & LD Local

7Safety £474,400

Tool kit pilot in June achieved -

further details TBCG G

MH & LD Local

8

Patient

Experience£355,800 Achieve 90% or above G G

MH & LD Local

9Effectiveness £237,200 Achieve 90% or above A A

Early indications are that we are performing close to the

target for this CQUIN in Quarter 2.

This is based on early figures which indicates

performance on the 4 blood tests has improved over

Quarter 1, resulting in an indicative Amber rating at this

stage.

MH & LD Local

10

Patient

Experience£355,800 Achieve 90% or above G G

CHS Local 11 Effectiveness £416,200Roll out completed in all Q1, Q2 and

Q3 areas and 95% complianceG G

CHS Local 12 Effectiveness £208,100 Report produced meeting set criteria G G

CHS Local 13 Effectiveness £312,150 Achieve 80% and above G G

CHS Local 14 Effectiveness £312,150 Achieve all actions G G

PH Local 15Patient

Experience£156,100

Receive full report with

recommendationsG G

LAT Local 16Patient

Experience£243,600

Evidence via report on promotion of

guidelinesG G

School Nurse Communications “App”

Improving formulary adherence of emollient

prescribing amongst health visitors

Commentary:

Formal Quarter 1 CQUIN outcomes are expected during September 2013 and for Quarter 2 they are expected during December 2013.

However, outcome predictions have been provided in this IQPR and coloured blue to indicate they are provisional and data requires verification or is incomplete. Provisional performance has been

indicated with (R)ed, (A)mber or (G)reen.

See Appendix 2 for detailed CQUIN target information.

Communication physical wellbeing to primary

care from AMH & LD inpatient services:

Discharge summary to include QRISK and

blood test scores

The inpatient ward as a therapeutic space –

AMH (adult mental health)

Reviewing patient care in all CHS inpatient

settings (exc MHSOP): implementing the

Advanced Nurse Practitioner model

MSK (musculo-skeletal) physiotherapy patient

reported outcome measures

Personalised care plans for patients with long

term conditions (LTC)

Dementia Care: developing staff knowledge

and skills

The inpatient ward as a therapeutic space –

Learning Disabilities

National & Regional CQUINS 2013-14

Description

Friends and Family Test

NHS Safety Thermometer: reduction in

pressure ulcer prevalence

Making Every Contact Count

Commentary:

Formal Quarter 1 CQUIN outcomes are expected during September 2013 and for Quarter 2 they are expected during December 2013.

However, outcome predictions have been provided in this IQPR and coloured blue to indicate they are provisional and data requires verification or is incomplete. Provisional performance has been

indicated with (R)ed, (A)mber or (G)reen.

See Appendix 2 for detailed CQUIN target information.

Local CQUINS 2013-14

Description

Venous Thromboembolism (VTE) in Mental

Health Services for Older People (MHSOP)

VTE in Community Hospitals

Suicide Prevention on AMH inpatient wards at

the Bradgate Unit



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Average Length of Stay (ALoS) - Mental Health COM Monthly TBC AUG 48.2 65.9 TBC PM 62.4 9.2 77.4 21.3

Median Length of Stay (ALoS) - Mental Health TRUST Monthly AUG 18.0 21.0 18.0 PM 26 7 51 7

Average Length of Stay (ALoS) - Community hospital rehab wards TRUST Monthly AUG 25.4 22.6 25.2 PM 25.4

Average Length of Stay (ALoS) - Stroke wards (ward 1 st lukes, ward 1

Coalville)TRUST Monthly AUG 27.3 27.5 30.4 PM 27.3

Average Length of Stay (ALoS) - Mental health (ward 4 Coalville) TRUST Monthly AUG 50.8 402.0 119.9 PM 50.8

Average Length of Stay (ALoS) - City rehab beds (CICB/CRB) TRUST Monthly AUG 19.8 18.0 19.4 PM 19.8

Occupancy Rate - Mental Health TRUST Monthly <=85% AUG 92.5% 92.4% 92.2% 85.0% PM 93.5% 70.2% 92.6% 96.9%

Occupancy Rate - Community TRUST Monthly >=93% AUG 92.3% 93.6% 92.6% 93.0% PM 92.3%

% Delayed Patients (DToC) - Mental Health MON Monthly <=7.5% AUG 6.3% 6.6% 5.8% <=7.5% PM 7.7% 11.4% 4.2% 0.0%

% Delayed Patients (DToC) - Community COM Monthly <=2.12% AUG 2.55% 0.71% 1.81% <=2.12% PM 2.55%

% of Admissions Gate Kept by the Crisis Resolution & Home Treatment

TeamMON Monthly 95% AUG 97.5% 100.0% 99.3% 95% PM 97.5%

Total number of Home Treatment episodes carried out by Crisis

Resolution team year to date.COM Monthly

1895 (Year

end Target)AUG 743 643 743 1895 PM 743

% Discharge Summaries issued within 24 hours TRUST - PM

MHMDS Data Completeness: Records MON Quarterly 97% Q1 98.4% 97.6% 98.4% 97.0% PM

MHMDS Data Completeness: Outcomes MON Quarterly 50% Q1 55.3% 61.5% 55.3% 50.0% PM


1) TIMELINESS:

Comments & Actions:

Mental Health Average Length of Stay: The average length of stay displayed for Mental Health & LD is the national operating framework definition, which takes data from HES and includes ALL divisions and lengths. All previous month’s figures are updated each month to allow for late entry of data.

Mental Health Bed Occupancy Rate: The trust figure does not consider that certain areas of the trust have different targets, e.g, MHSOP has a 90% target; Specialist Services represents Eating Disorders with a 80% target and INCLUDES patients on leave; CAMHS INCLUDES patients on leave; Adult

represents Adult Acute only and LD represents the Agnes Unit with a target of 95% for the 4 new Intensive Support beds but 85% otherwise. There are no Divisional targets yet set and thus cannot be RAG rated. The RAG ratings are:

Green: Actual > Target AND Actual < Target + 5%; Amber: Actual >= Target + 5% AND Actual <= Target + 10% OR Actual <= Target AND Actual >= Target - 5%; Red: Actual > Target + 10% OR Actual < Target - 5%

Occupancy Rate - Community: The occupancy rate includes the mental health ward 4 (this ward has a contracted 60% target, all other wards are 93%). Figures have been updated for the previous month to reflect true position and Intensive Community Support Beds.

% Delayed Patients (DToC) - MH: DToC information now comes directly from Maracis and manual data is no longer used.

% Delayed Patients (DToC) - Community: Community DToC figures have been revised to reflect Monitor indicator based on the Monitor rules & guidance.

Numerator: the number of non-acute patients (aged 18 and over on admission) per day under consultant and non-consultant-led care whose transfer of care was delayed during the reporting period. For example, one patient delayed for five days counts as five.

Denominator: the total number of occupied bed days (consultant-led and non-consultant-led) during the reporting period.

Delayed transfers of care attributable to social care services are included.

% of Admissions Gate Kept by the Crisis Resolution & Home Treatment Team: Calculation method amended for current and back months, all figures validated.

MHMDS Data Completeness: Records and Outcomes: From 2013/14. MHMDS submissions have move from quarterly to monthly submissions. The Overall figure is based on the monthly MHMDS extract and is always several months behind, whereas the divisional figures depict those currently held in

Maracis. The RED "Records" areas are due to issues with Marital Status data completeness, whereas the "Outcomes" is down to "Settled Accommodation" & "Paid Employment". Business Units should be made aware that even if a patient is over 69 or under 18 years old, a valid code for Settled

Accommodation and Paid Employment must be entered, even if this is "Not Stated" or "Not Known". MHMDS is assessed at patient level and should not be split by divisions.

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Performance - Efficiency

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Average Length of Stay (days) - Trust

Adult-MH CHS-MH FYPC-MH LD-MH CHS-COM

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Occupancy Rates

Adult-MH CHS-MH CHS-COM FYPC-MH LD-MH



93.1%

97.5%

93.1% 95.6%

91.3% 91.1% 92.1% 96.3%

93.4% 94.5% 91.5%

88.9% 89.8%

92.5%

94.2% 92.4% 92.5%

75%

80%

85%

90%

95%

100%

105%

110%

Apr-12 May-12 Jun-12 Jul-12 Aug-12 Sep-12 Oct-12 Nov-12 Dec-12 Jan-13 Feb-13 Mar-13

Trust Bed Occupancy - 2010-2012

Occupancy 12/13 Occupancy 2010/11 Target 12/13

Responsible Lead: Paul Farrimond Indicator Source: COM/DOH Operating Framework Comments and Actions: Targets: Eating Disorders Target for 2010/11 was 85%, Reduced to 80% from July 2010. MHSOP Target 2010/11 was 95%, Reduced to 90% from September 2010. CAMHS - 2011 On leave beds counted as admitted LD - 2011 On leave beds counted as admitted Eating Disorders 2010 On leave beds counted as admitted This may result in occupancy rates above 100%

Bed Occupancy Rate (%)

90%

93%

94%

92% 93% 93%

97%

93%

96%

91% 91% 92%

96%

93% 95%

91%

89%

75%

80%

85%

90%

95%

100%

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

Trust Bed Occupancy - 2012-2014

Occupancy 13/14 Occupancy 12/13 Target 13/14

Responsible Lead: Paul Miller Indicator Source: COM/DOH Operating Framework Comments and Actions: Targets: to be confirmed for the current finacial year. CAMHS (FYPC) - On leave beds counted as admitted LD - On leave beds counted as admitted This may result in occupancy rates above 100%

Bed Occupancy Rate (%)

81% 83%

92%

101% 97%

91% 92% 96% 93%

81% 84%

90%

99%

85% 83% 75%

69%

30%

50%

70%

90%

110%


FYPC - Occupancy 2012-2014

Occupancy 13/14 Occupancy 12/13

79% 73% 74% 77%

70%

64%

81% 71% 66% 71% 71%

69% 76% 72% 69% 67% 70%

30%

50%

70%

90%

110%


Adult Learning Disabilities - Occupancy 2012-2014


98% 104%

94% 92% 94% 94% 96% 97% 96% 92% 93% 92%

96% 96% 97% 93% 94%

30%

50%

70%

90%

110%


Adult Mental Health - Occupancy 2012-2014


85% 91%

95% 93% 93% 96% 92% 95% 94% 95% 92% 88%

99% 93%

97% 96%

87%

30%

50%

70%

90%

110%


Community Health Services - Occupancy 2012-2014




(M11 figures/example figures)

FINANCE KPIs

YTD Target

(Budget)YTD Actual

Year end

target

Year end

forecastYTD Target YTD Actual YTD Target YTD Actual YTD Target YTD Actual YTD Target YTD Actual YTD Target YTD Actual YTD Target YTD Actual YTD Target YTD Actual

EBITDA Margin 5.1% 5.1% 5.2% 5.2%

I&E Surplus £000 (Excl. impairments) 1,126 1,126 2,903 2,903

Income (against budget) £000 107,148 107,198 262,520 262,520

Expenditure (against budget) £000 106,023 106,073 259,617 259,617

CIP achievement £000 4,165 3,738 11,831 11,087 422 367 161 90 1,332 1,332 833 782 605 529 440 265 372 373

Cash balance £000 (YTD target

= FIMS Plan)16,379 16,364 11,089 11,089

Capital Expenditure (target spend =

available funds) £0001,427 1,427 15,085 15,085

Debtors > 90 days 5.0% 6.0% 5.0% 5.0%

Creditors > 90 days 5.0% 2.3% 5.0% 5.0%

Better Payment Practice Code 95.0% 96.4% 95.0% 95.0% 95.0% 93.8% 95.0% 95.2% 95.0% 97.3% 95.0% 96.7% 95.0% 99.7% 0.0% 0.0% 95.0% 95.2%

ANNUAL MONITOR FINANCIAL RISK RATING

FRR MetricMonitor

weighting

Annual

target

Updated

annual

forecast

Annual

target

Updated

annual

forecast

EBITDA Margin (%) 25% 5.2% 5.2% 3 3

EBITDA Achieved (%) 10% 100% 100.0% 5 5

Net Return after Financing (%) 20% 2.4% 2.4% 4 4

I&E Surplus Margin (%) 20% 1.1% 1.1% 4 4

Liquidity ratio (days) 25% 26 26 4 4

Overall FRR 100% 4 4

New proposed Risk

Assessment Framework

Monitor

weightingAnnual

target

Updated

annual

forecast

Annual

target

Updated

annual

forecast

Liquidity days (%) 50% 5.7% 5.7% 4 4

Capital Service Capacity (%) 50% 3.1 x 3.1 x 4 4

RAG rules

Green: On target/exceeding target

Amber: Adverse variance - within 5% target

Red: Adverse variance - distance from target greater than 5%

METRIC TARGET FRR TARGET

Continuity of Services Risk Rating (CSSR)

Monitor proposes to use a risk rating to identify the risk of providers of Commissioner Requested Services not being a going

concern. The proposed ratings comprise two financial metrics:

Liquidity: this ratio indicates whether the provider can meet its operational cash obligations

Capital Servicing Capacity: this ratio indicates whether the provider can meet its financing obligations

CSRR SCOREMETRIC TARGETSHADOW CONTINUITY OF SERVICE RISK RATING

Performance - Finance August 2013 (MONTH 05)

TOTAL TRUST BUSINESS UNIT

HOSTEDADULT MH COMM SERVICES FYPC ENABLING RESERVESLD

0

1

2

3EBITDA Margin

I&E Surplus (Excl.impairments)

Income (against budget)

Expenditure (againstbudget)

CIP achievement

Cash balance (YTD target =FIMS Plan)

Capital Expenditure(target spend = available…

Debtors > 90 days

Creditors > 90 days

Better Payment PracticeCode

FRR

Finance Performance The Trust is reporting a net income and expenditure surplus of £1,126k at the end of Month 05. This is in line with plan. The EBITDA margin as at Month 05 is 5.1%. The forecast EBITDA margin for the year is 5.2%. Current CIP delivery is 90% of the year to date target. Divisions are working to ensure that their CIP targets are delivered by the end of the financial year, and as such this is expected to improve the percentage CIP delivery. The cash balance at the end of Month 05 is £16.4m. This is on par with the year to date plan cash figure. Debtors > 90 days have slightly increased to 6.0% in M5 compared to 5.9% in M4.



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Number of WTE Employed TRUST AUG 4551.3 4554.5 AD 251.9 940.3 1648.1 450.8 1074.2 186.1

% of Sickness Absence (1 month in arrears) TRUST <=4% JUL 4.3% 4.2% 4.4% <=4% AD 4.0% 5.2% 5.3% 2.6% 3.4% 1.9%

% Total Workforce Turnover including training

grade medics (Projected to Mar-14)TRUST 8-12% AUG 11.6% 9.3% 8-12% AD 6.8% 8.6% 9.7% 37.8% 9.3% 3.8%

% Vacancy Rate (1 Month in Arrears) TRUST 6-12% JUL 8.8% 9.6% 7.1 6-13% AD 5.9% 8.5% 9.1% 14.2% 8.9% 3.1%

Ratio of Bank Usage to Agency Usage TRUST <1:0.75 AUG 1: 0.97 1:0.89 1: 0.9 <1:0.75 AD 1: 0.06 1: 0.81 1: 1.31 1: 0.6 1: 2.26 1: 5.01

Number of staff at risk of redundancy TRUST AUG 13 27 AD 1 2 4 3 3 0

Number of open formal grievances TRUST AUG 7 8 8 AD 0 4 2 0 1 0

Number of open formal disciplinaries TRUST AUG 28 27 18 AD 5 9 7 7 0 0

% of staff with an appraisal/ PDR within the last 12

monthsTRUST >=80% AUG 82.4% 84.2% >=80% AD 86.4% 79.9% 85.9% 82.0% 80.8% 64.1%

% of staff trained in Core Mandatory Training TRUST >=85% AUG 93.7% 93.6% >=85% AD 92.0% 93.6% 95.3% 94.2% 93.7% 80.5%

% of Mandatory Training DNAs TRUST <=15% AUG 14.4% 12.7% <=15% AD


1) TIMELINESS:











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Comments & Actions:

% of Sickness Absence (1 month in arrears):

Divisional performance RAG ratings based on division specific targets

% Total Workforce Turnover including training grade medics (Projected to Mar-14):

37.8% for Enabling Services is a result of Junior Doctors rotation and a number of fixed term contract ending.

Turnover is calculated by projecting to the end of the financial year based on the figures YTD. It is expected therefore that as we move through the year the percentage will reduce.

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Human Resources - WorkforceTrust Performance Divisional Performance - Latest Month

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Number of WTE Employed 4575.2 4556.8 4546.6 4555.8 4554.5 4551.3 -5.5

Number of Headcount Employed 5286 5278 5270 5268 5298 5298 +20.0

Vacancy Rate (1 month in arrears) 6-12% 9.5% 7.1% 8.1% 9.6% 8.8% not due Estimates from Finance are available one month in arrears

% Staff From a BME Background >=18% 18.5% 17.5% 17.5% 17.5% 17.6% 17.3% -0.3%


% Sickness Absence <=4% 4.7% 4.5% 4.3% 4.2% 4.3% not due 4.4% Recalculated each month

WTE Days Lost to Sickness 83747 6172 6065 5680 6158 not due 24075 Recalculated each month

% Short Term Sickness 38.5% 48.3% 34.3% 30.4% not due

% Long Term Sickness 61.5% 51.7% 65.7% 69.6% not due

Cost of Sickness (£) £480,203 £534,814 £517,024 £488,710 £547,208 not due £2,087,756 Recalculated each month


% Normalised Workforce Turnover

(Rolling previous 12 months)8-12% 11.6% 11.7% 12.0% 11.9% 11.1% 11.9% All Staff rolling previous 12 months with TUPE omitted

% Total Workforce Turnover

(Rolling previous 12 months)8-12% 20.1% 20.3% 20.3% 20.2% 19.3% 20.1% All Staff rolling previous 12 months

% Total Workforce Turnover including training grade medics

(Projected to Mar-14)8-12% 20.1% 12.7% 10.5% 9.3% 9.3% 11.6% All Staff

% Turnover for Clinical Registered Staff *

(Projected to Mar-14)8-12% 12% 14.4% 10.9% 9.8% 9.8% 13.7% Nursing, S&ST, M&D, AHP, Students

% Turnover for Clinical Non Registered Staff

(Projected to Mar-14)8-12% 9.4% 10.3% 9.3% 8.9% 8.8% 8.7% Add Clinical Services

% Turnover for Non-Clinical Staff

(Projected to Mar-14)8-12% 45.7% 11.0% 10.5% 8.3% 8.7% 10.3% Admin & Estates

Stability Index 33 6 5 4 31 Leavers within 12 months


Average Cost Per Head £3,067 £2,910 £3,080 £3,168 £2,966 £3,007 Total pay divided by heacount

Bank Costs £8,513,390 £675,000 £524,970 £663,390 £720,980 £768,840 £3,353,180

Bank Spend as a % of Total Employee Benefit Expenditure 4.2% 4.4% 3.2% 4.0% 4.6% 4.8% 4.2%

Agency Costs £8,711,231 £432,590 £363,660 £840,600 £642,660 £746,800 £3,026,310

Agency Spend as a % of Total Employee Benefit Expenditure 4.3% 2.8% 2.2% 5.0% 4.1% 4.7% 3.8%

Ratio of Bank Spend to Agency Spend <1:0.75 1:1.02 1:0.64 1:0.69 1:1.27 1:0.89 1: 0.97 1: 0.9

0.64 0.69 0.89 0.97 #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0!

Apr May Jun Jul Aug Sep Oct Nov Dec Jan Feb MarNumber of Staff Affected by Change 950 571 356 332 161 117 307 YTD and 2012-13 position is average

Number of Staff at Risk of Redundancy 52 26 70 31 27 13 33 YTD and 2012-13 position is average

Number of Staff on Notice of Redundancy 26 3 52 27 25 4 22 YTD and 2012-13 position is average

Number of Staff Redeployed 438 1 37 23 2 6 69

Number of Staff Made Redundant 2 1 0 1 15 19

Number of Staff on Pay Protection 228 266 231 211 189 197 219 YTD and 2012-13 position is average

Cost of Pay Protection (£) £57,532 £47,286 £45,170 £42,568 £43,525 £236,079

Apr May Jun Jul Aug Sep Oct Nov Dec Jan Feb MarNumber of Open Formal Grievances 49 9 7 4 8 7 8

Number of Open Bullying and Harrassment Cases 22 9 9 7 8 6 2

Number of Open Formal Disciplinaries 113 33 25 27 27 28 18

Number of Open Capability Cases 37 7 8 10 9 9 4

Number of Ill Health Terminations 1 3 3 3 0 0

Number of Open Employment Tribunals 12 9 6 7 8 7 2

Number of Open Suspension Cases 25 11 6 9 11 11 11

Average Working Days Lost to Suspension 40 23 30 36 37 40 Changed from 'calendar days lost to suspension'

No. of Issues Raised through Whistleblowing 1 0 0 0 1 2


% Staff Recommend LPT as a Place to Work 54% 48% 47% not due 47%

% Staff happy with Standard of Care Provided 59% 57% 61% not due 61% ie recommend as a place to receive treatment

Response Rate 26% 16% not due 16%

Apr May Jun Jul Aug Sep Oct Nov Dec Jan Feb MarAverage Time to Recruit (Weeks) <=12 16.2 15.6 18.5 16.6 18.0 17

Average Number of Applicants Per Advertised Post 23 25 23 26 17 22 22

% BME Applicants >=35% 45% 39.0% 39.1% 45.0% 52.0% 47.0% 44% BME excludes White, White Irish, White Other

BME Ratio of Appointees to Shortlisted Candidates <=1:3 1: 5.9 1: 1.28 1: 1.80 1: 3.5 1:1.3


% of Consultants with an Appraisal/ PDR >=90% 94.0% 90.8% 90.8% 94.2% 92.0% 92.0%Excludes those on maternity leave, long term sickness or a new starter within the last 12

months

% of Staff with an Appraisal/ PDR >=80% 77.3% 80.1% 83.9% 85.9% 84.2% 82.4% 83.3%

% of Staff In Date with Core Mandatory Training >=85% 93.8% 93.6% 92.5% 93.3% 93.6% 93.7% 93.3% Trust policy to attend every 3 years

% of Staff In Date with Fire Safety >=85% 76.7% 79.1% 81.6% 86.8% 88.3% 88.3% 84.8%

% of Staff In Date with Information Governance >=95% 84.4% 84.8% 85.5% 88.8% 86.5% 84.5% 86.0%

% of Staff In Date with All Other Mandatory Training >=85% 61.6% 65.0% 78.6% 81.8% 80.4% 73.5%

% of Spaces on Mandatory Training that were Booked >=85% 77.5% 59.0% 82.2% 54.5% 68.2% 68.3%

% of Mandatory Training DNAs <=15% 15.9% 14.0% 13.2% 13.0% 12.7% 14.4% 13.5%

% of New Starters in who Attended Trust Induction Day Within their

First 4 Weeks>=95% 96.7% 90.2% 100.0% 100.0% 64.5% 90.3%

YTD

PositionComments

* includes trainee clinical psychologists on rotation. These staff changed division mid year resulting in fluctuating turnover rates.

YTD

AverageLearning and Development Target

2012-13

Position

2013-14Sparkline

Bank/ Agency and Pay Target2012-13

Position

2013-14Sparkline

CommentsSickness Absence (1 month in arrears) Target2012-13

Position

2013-14Sparkline

YTD

Position

HR Workforce Extended Metrics Data

Workforce Profile Target2012-13

Position

2013-14Sparkline

YTD

ChangeComments

Organisational Change Target2012-13

Position

2013-14Sparkline

Employee Relations Target2012-13

Position

2013-14Sparkline

2013-14Sparkline

YTD

PositionComments

Distinct

no. of Comments

Comments

Comments & Actions:

2012-13 Position - Where available this is the 2012-13 YTD actual/ average position, otherwise it is the 2012-13 out-turn figure

YTD

AverageComments

Recruitment Target2012-13

Position

2013-14Sparkline

YTD

AverageComments

Employee Engagement Target2012-13

Position

YTD

PositionCommentsStaff Turnover Target

2012-13

Position

2013-14Sparkline



Tim

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Younger Persons Memory Clinic COM Monthly (In arrears) Maracis JUL 11 weeks TBC 12 8 60.0% 40.0% PM

Older Persons - Day Care COM Monthly (In arrears) Maracis JUL 4 Weeks TBC 14 1 93.3% 93.3% PM

Older Persons - Community

Teams COM Monthly (In arrears) Maracis JUL

High Priority 4

weeksTBC 15 0 100.0% 87.5% PM

Older Persons - Community

Teams COM Monthly (In arrears) Maracis JUL Routine 6 weeks TBC 112 38 74.7% 80.9% PM

Older Persons - Outpatients COM Monthly (In arrears) Maracis JULHigh Priority 4

weeksTBC 16 3 84.2% 100.0% PM

Older Persons - Outpatients COM Monthly (In arrears) Maracis JUL Routine 6 weeks TBC 52 21 71.2% 70.6% PM

Older Persons - Memory Clinic COM Monthly (In arrears) Maracis JULHigh Priority 4

weeksTBC 2 3 40.0% 83.3% PM

Older Persons - Memory Clinic COM Monthly (In arrears) Maracis JUL Routine 6 weeks TBC 54 75 41.9% 40.1% PM

MSK Physiotherapy: Routine COM Monthly (In arrears) Tiara JUL 4 Weeks TBC 116 1209 8.8% 12.2% PM

MSK Physiotherapy: Urgent COM Monthly (In arrears) Tiara JUL 5 Days TBC 319 305 51.1% 46.0% PM

Podiatry - Routine COM Monthly (In arrears) Tiara JUL 4 Weeks Mar-14 377 907 29.4% 27.8% PM

Podiatry - Urgent COM Monthly (In arrears) Tiara JUL 5 Days Mar-14 19 9 67.9% 58.6% PM

Speech Therapy: Routine COM Monthly (In arrears) Tiara JUL 4 Weeks Apr-13 50 31 61.7% 62.9% PM

Speech Therapy: Urgent COM Monthly (In arrears) Tiara JUL 2 Weeks Apr-13 30 29 50.8% 53.9% PM

Intermediate Care & Domicilary

TherapyCOM Monthly (In arrears) SystmOne JUL TBC TBC PM

Long Term Conditions:

Acute 24 hour COM Monthly (In arrears) SystmOne JUL 24 Hours TBC 5 5 50.0% 75.0% PM

End of life 2 weeks COM Monthly (In arrears) SystmOne JUL 2 Weeks TBC 2 100.0% N/A PM

Patient's co-operation COM Monthly (In arrears) SystmOne JULPatient's

InitiatedTBC 14 0.0% 0.0% PM

Post discharge 5 working

daysCOM Monthly (In arrears) SystmOne JUL 5 Days TBC 1 0.0% 94.4% PM

Routine 4 weeks COM Monthly (In arrears) SystmOne JUL 4 Weeks TBC 157 47 77.0% 59.4% PM

Urgent opinion 2 weeks COM Monthly (In arrears) SystmOne JUL 2 Weeks TBC 2 6 25.0% 47.3% PM

Waiting Times Compliance - Community Health ServicesTrust Performance

So

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req

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ime

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Sp

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Data Quality

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Falls - therapy services COM Monthly (In arrears) SystmOne JUL TBC TBC PM

Rapid Intervention Team: COM Monthly (In arrears) SystmOne JUL TBC TBC PM

County Continence: COM Monthly (In arrears) SystmOne JUL TBC TBC PM

City Specialist Continence:

Routine COM Monthly (In arrears) SystmOne JUL 10 Days Oct-14 0 23 0.0% 0.0% PM

Comments & Actions:

Waiting time performance reporting for all services is based on the number of patients that received treatment in the month and the percentage of those completed waits that were within the target waiting time. The

agreement with commissioners requires revised waiting time targets to be met from a certain month in the 2013/14 year and these ‘target achievement months’ are listed next to the target waiting time. Some target

months haven't yet been agreed with commissioners and are marked as ‘to be confirmed’ (TBC).

Figures are subject to change due to validation.


1) TIMELINESS:

GREEN: Data is submitted in time to the central system for accurate reporting (in line with trust policies) AND data is verified and any data quality issues are resolved in time for reporting deadlines AND data is extremely unlikely to change

in subsequent months.












Tim

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LD - Community Teams COMMonthly (In

arrears)Marcis JUL 8 weeks Mar-14 64 21 75.3% 85.3% PM

Assertive Outreach COMMonthly (In

arrears)Maracis JUL 6 weeks Jul-13 1 0 100.0% 100.0% PM

Personality Disorders COMMonthly (In

arrears)Maracis JUL

13 weeks to

assessmentJul-13 21 0 100.0% 100.0% PM

Dynamic Psychotherapy COMMonthly (In

arrears)Maracis JUL

13 weeks to


Liaison - Perinatal Outpatient & Community COMMonthly (In

arrears)Maracis JUL

4 weeks to

treatmentSep-13 19 2 90.5% 92.9% PM

Liaison - Psycho Oncology COMMonthly (In

arrears)Maracis JUL

4 weeks to

treatmentJun-13 23 0 100.0% 96.3% PM

Liaison - Psychiatry COMMonthly (In

arrears)Maracis JUL

13 weeks to

treatmentJul-13 29 2 93.5% 100.0% PM

Cognitive Behavioural Therapy COMMonthly (In

arrears)Maracis JUL

13 weeks to

assessmentApr-13 26 0 100.0% 100.0% PM

Forensic - Community and Out Patients COMMonthly (In

arrears)Maracis JUL

8 weeks to

assessmentSep-13 13 1 92.9% 100.0% PM

Adult General Psychiatry - Community Mental Health

Teams and Outpatients - TreatmentCOM

Monthly (In

arrears)Maracis JUL

6 weeks to

treatmentMar-14 212 103 67.3% 70.8% PM

Mett Day Centre and Linnaeus Nursery COMMonthly (In

arrears)Maracis JUL 4 weeks Mar-14 33 3 91.7% 85.7% PM

Homeless Service COMMonthly (In

arrears)Maracis JUL

1 week to


Adult ADHD Service COMMonthly (In

arrears)Maracis JUL

18 weeks to

treatmentDec-13 8 4 66.7% 64.3% PM

Huntington's Disease COMMonthly (In

arrears)Maracis JUL

4 weeks to

assessmentApr-13 1 0 100.0% 100.0% PM

Aspergers Assessment COMMonthly (In

arrears)Maracis JUL 13 weeks Dec-13 16 0 100.0% N/A PM

Acute Assessment Service:

2 Hours Emergency COMMonthly (In

arrears)Maracis JUL 2 Hours TBC 104 10 91.2% 86.5% PM

4 Hours Crisis COMMonthly (In


72 Hours Urgent COMMonthly (In


Deliberate Self Harm Team COMMonthly (In


Waiting Times Compliance - Adult Mental Health Services and Learning DisabilitiesTrust Performance

So

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1) TIMELINESS:











Sp

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Data Quality

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Comments & Actions:

Waiting time performance reporting for all services is based on the number of patients that received treatment in the month and the percentage of those completed waits that were within the target waiting time. The agreement with

commissioners requires revised waiting time targets to be met from a certain month in the 2013/14 year and these ‘target achievement months’ are listed next to the target waiting time. Some target months haven't yet been agreed with

commissioners and are marked as ‘to be confirmed’ (TBC).




Tim

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Eating Disorders Out Patients COMMonthly (In

arrears)Maracis JUL 13 Weeks Apr-13 16 0 100.0% 100.0% PM

CAMHS- Outpatient & Community

(Routine)COM

Monthly (In

arrears)Maracis JUL 13 Weeks TBC 192 43 81.7% 83.3% PM

CAMHS- Outpatient & Community

(Urgent)COM

Monthly (In

arrears)Maracis JUL 4 Weeks TBC 8 0 100.0% 100.0% PM

CAMHS - Young People Team COMMonthly (In


CAMHS - Learning Disability Service COMMonthly (In

arrears)Maracis JUL 18 weeks Apr-13 9 0 100.0% 95.8% PM

CAMHS - Paediatric Psychology COMMonthly (In

arrears)Maracis JUL 18 weeks TBC 11 8 57.9% 70.0% PM

Childrens Dietetics COMMonthly (In

arrears)Tiara JUL

18 weeks to

treatmentJul-13 61 3 95.3% 98.6% PM

Childrens OT COMMonthly (In

arrears)SystmOne JUL

18 weeks to

treatmentApr-13 58 0 100.0% 100.0% PM

Childrens Physio COMMonthly (In


18 weeks to

treatmentApr-13 47 1 97.9% 100.0% PM

Childrens SALT COMMonthly (In


18 weeks to

treatmentApr-13 284 5 98.3% 98.0% PM

GUM COMMonthly (In

arrears)Lille JUL 48 Hours TBC 231 0 100.0% 100.0% PM

PIER COMMonthly (In


Paediatrics COMMonthly (In

arrears)SystmOne JUL RTT 18 weeks Jul-13 115 13 89.8% 88.6% PM

Audiology COMMonthly (In


Routine

Assessment -

6 Weeks

Apr-13 N/A 0.0% PM

Stop Smoking Service COMMonthly (In

arrears)TBC JUL TBC TBC N/A 0.0% PM

Domiciliary Visits (Urgent) COMMonthly (In

arrears)TBC JUL 1 Week TBC N/A 0.0% PM

Domiciliary Visits (Routine) COMMonthly (In

arrears)TBC JUL 4 Weeks TBC N/A 0.0% PM

Weight Management Groups COMMonthly (In

arrears)TBC JUL 18 Weeks TBC N/A 0.0% PM

Waiting Times Compliance - Families, Young People and Children servicesTrust Performance

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Sp

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Data Quality

Exe

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Le

ad

TBC

TBC

Comments & Actions:

Waiting time performance reporting for all services is based on the number of patients that received treatment in the month and the percentage of those completed waits that were within the target waiting time. The agreement

with commissioners requires revised waiting time targets to be met from a certain month in the 2013/14 year and these ‘target achievement months’ are listed next to the target waiting time. Some target months haven't yet been

agreed with commissioners and are marked as ‘to be confirmed’ (TBC).



1) TIMELINESS:

GREEN: Data is submitted in time to the central system for accurate reporting (in line with trust policies) AND data is verified and any data quality issues are resolved in time for reporting deadlines AND data is extremely unlikely to change in

subsequent months.










TBC

TBC

TBC



Appendix 1: IQPR Change Log

DateIndicator

Code

Indicator Description Requested by Change

QSC.02 Total Harm Events reported Quality Indicator removed and replaced with QSC.14 Incident Rate indicator

QSC.02 % Harm caused from patient accidents Quality Indicator removed and replaced with QSC.14 Incident Rate indicator

QSC.02 % Harm caused from clinical incidents Quality Indicator removed and replaced with QSC.14 Incident Rate indicator

QSC.02 % Harm caused from violent incidents Quality Indicator removed and replaced with QSC.14 Incident Rate indicator

MSP.13 Maximum time of 18 weeks from point of referral to treatment in aggregate (non-admitted, incomplete pathways) Monitor Indicator added

MSP.04 Stroke indicator (Community) Monitor Indicator not in 12/13 schedule

MSP.14 Data Completeness: Community Services (Referral to Treatment Information) Monitor Indicator added

MSP.15 Data Completeness: Community Services (Referral Information) Monitor Indicator added

MSP.16 Data Completeness: Community Services (Treatment Activity Information) Monitor Indicator added

MSP.17 Data Completeness: Community Services (Patient Identifier Information) - may be included later in 2012/13 Monitor Indicator added

MSP.18 Data Completeness: Community Services (Patients Dying at Home/Care Home Information) - may be included later in

2012/13

Monitor Indicator added

QSC.16 PST: Pressure Ulcer Harms FPC Indicator added

QSC.17 PST: Falls Harms FPC Indicator added

QSC.18 PST: Catheter UTI Harms FPC Indicator added

QSC.19 PST: VTE Harms FPC Indicator added

QPS.09 Net Promoter Score: Total Discharges Quality Indicator added

QPS.10 Net Promoter Score: Cards Returned Quality Indicator added

QPS.11 Net Promoter Score: Return Rate Quality Indicator added

QPS.08 Net Promoter Score: Overall Score Quality Indicator renamed to bring it into line with new requirements

PW.14 % of staff with an appraisal within the last 12 months WOD New workforce indicator added

PW.15 Trust training expenditure (as a % of Trust income) WOD New workforce indicator added

PW.16 Number of internal training days made available WOD New workforce indicator added

PW.17 Number of internal training days attended WOD New workforce indicator added

PW.18 % of new starters in last 12 months who have attended Trust Induction Day within their first 6 weeks WOD New workforce indicator added

PW.19 % of staff trained in Core Mandatory Workshop WOD New workforce indicator added

PW.20 % of staff trained in Information Governance Training WOD New workforce indicator added

PW.21 % of staff trained in Fire Safety WOD New workforce indicator added

PW.22 Average number of training days attended per employee WOD New workforce indicator added

PW.23 % of staff with a qualification at a minimum of level 2 (Skills Pledge) WOD New workforce indicator added

PW.24 % Internal training attendance rate WOD New workforce indicator added

PW.15 Trust training expenditure (as a % of Trust income) WOD Indicator retired from Summary Dashboard to allow focus on April 2012 new

Workforce metrics

PW.16 Number of internal training days made available WOD Indicator retired from Summary Dashboard to allow focus on April 2012 new

Workforce metrics

PW.17 Number of internal training days attended WOD Indicator retired from Summary Dashboard to allow focus on April 2012 new

Workforce metrics

PW.18 % of new starters in last 12 months who have attended Trust Induction Day within their first 6 weeks WOD Indicator retired from Summary Dashboard to allow focus on April 2012 new

Workforce metrics

PW.20 % of staff trained in Information Governance Training WOD Indicator retired from Summary Dashboard to allow focus on April 2012 new

Workforce metrics

PW.21 % of staff trained in Fire Safety WOD Indicator retired from Summary Dashboard to allow focus on April 2012 new

Workforce metrics

PW.22 Average number of training days attended per employee WOD Indicator retired from Summary Dashboard to allow focus on April 2012 new

Workforce metrics

PW.23 % of staff with a qualification at a minimum of level 2 (Skills Pledge) WOD Indicator retired from Summary Dashboard to allow focus on April 2012 new

Workforce metrics

April 2012

May 2012

Date of report: 19/09/2013 Appendix 1


PW.25 Number of WTE Employed WOD Indicator added to Summary Dashboard to bring focus on April 2012 new Workforce

metric

PW.26 % of Sickness Absence WOD Indicator added to Summary Dashboard to bring focus on April 2012 new Workforce

metric

PW.27 % of total workforce turnover (including training grade medics) WOD Indicator added to Summary Dashboard to bring focus on April 2012 new Workforce

metric

PW.28 Bank & Agency Spend as a % of pay bill WOD Indicator added to Summary Dashboard to bring focus on April 2012 new Workforce

metric

PW.29 Number of staff at risk of redundancy WOD Indicator added to Summary Dashboard to bring focus on April 2012 new Workforce

metric

PW.30 Number of open formal grievances WOD Indicator added to Summary Dashboard to bring focus on April 2012 new Workforce

metric

PW.31 Number of open formal disciplinaries WOD Indicator added to Summary Dashboard to bring focus on April 2012 new Workforce

metric

QSC.14 Total incidents reported (Presure Sore) EPR Added New Indicator

QSC.15 Total incidents reported (Other) EPR Added New Indicator

- CPA Benchmarking FPC New tab added

PW.27 % of total workforce turnover (including training grade medics) WOD Indicator target revised

PW.28 Bank & Agency Spend as a % of pay bill WOD Indicator target revised

QSC.22a Non-Compliance with Essential Standards resulting in a Major Impact on Patients QAC Indicator added to support SOM submission

QSC.22b Non-Compliance with CQC Essential Standards resulting in Enforcement Action QAC Indicator added to support SOM submission

- Trend Sparklines implemented for financial year to date Monitor Trend Sparklines implemented for financial year to date against KPI's

- Quarterly GRR and Forecast GRR Monitor Quarterly GRR and Forecast GRR added to Monitor Service Performance tab

QES.12a Chlamydia Screening service - Number of screens for 15-24 year olds FPC The indicator target for City has been revised to 8028 screens for the year 12/13.

QES.13a Chlamydia Positive Screens- Number of positive screens for 15-24 year olds - CITY FPC This indicator has been included into the report as indicated in the August IQPR - City

target confirmed

QES.13b Chlamydia Positive Screens- Number of positive screens for 15-24 year olds - COUNTY FPC This indicator has been included into the report as indicated in the August IQPR -

County target yet to confirmed

QEFS_13 Added Average Length of Stay (ALoS) - Community hospital rehab wards WL

QEFS_14 Added Average Length of Stay (ALoS) - Stroke wards (ward 1 st lukes, ward 1 Coalville) WL

QEFS_15 Added Average Length of Stay (ALoS) - Mental health (ward 4 Coalville) WL

QEFS_16 Added Average Length of Stay (ALoS) - City rehab beds (CICB/CRB) WL

QSC.22b Non-Compliance with CQC Essential Standards requiring improvements WL This indicator has been included on the Summary of Performance against Monitor

Targets page

- Appendix 2: CQUIN Achievement Targets FPC New tab added

PW.32 Ratio of Bank Usage to Agency Usage WOD New indicator

PW.33 % of total workforce turnover including training grade medics (Cumulative annualised) WOD New indicator

PW.34 % Vacancy Rate WOD Target revised from 6-13% to 6-12%

PW.28 Bank & Agency Spend as a % of pay bill WOD This indicator has been superseeded by indicator PW.32

PW.24 % Internal Training Attendance Rate WOD This indicator has been superseeded by indicator PW.33

- Governance Concern Score FPC New page added to shadow the Monitor Governance Concern Score

- Appendix 3: CQUIN Achievement Targets 2013-2014 FPC New sheet added

- Waiting Times Compliance-CHS Trust Board New tab added

- Waiting Times Compliance-AMHS Trust Board New tab added

- Waiting Times Compliance-FYPC Trust Board New tab added

QPS_2 Mixed sex sleeping accommodation breaches QAC Indicator description updated to include 'sleeping accommodation breaches'

PW.27 % Total Workforce Turnover including training grade medics (Projected 12 months) WOD Indicator description updated

- Staff Turnover WOD Revision of Staff Turnover indicators on the HR Workforce Extended Metrics Data

page

October 2012

September 2012

May 2012

June 2012

July 2012

August 2012

July 2013

May 2013

December 2012

April 2013



% Normalised Workforce Turnover (Rolling previous 12 months) WOD New indicator added in the 'HR Workforce (Extended Metrics) tab

% of Consultants with an Appraisal/ PDR WOD Addition of target and RAG for this indicatorAugust 2013



Appendix 2: CQUIN Achievement Targets 2013-2014

CQUIN No CQUIN Detail QuarterQuarterly

PaymentsReporting Date 100% 50% 0%

National 1 Family and Friends Test

Evidence sign off by Board & Implementation plan with Q2, Q3

and Q4 milestones Q1 £23,720 September

Plan signed off by Board with

milestones for Q2, Q3 and Q4.

Milestones to be RAG rated

N/A No plan

Q2 milestones achieved Q2 £71,160 DecemberAchieve all actions

Achieve all high and medium Q2

actions

High and medium actions not

achieved

Q2 & Q3 milestones achieved Q3 £71,160 March

Q2 & Q3 actions achievedQ2 all actions achieved & Q3 high and

medium actions achieved

Not achieved Q2 actions and Q3 high

and medium actions not achieved

All milestones achieved Q4 £71,160 May

All actions achievedQ2 & Q3 all actions achieved & Q3

high and medium actions achieved

Not achieved Q2 & Q3 actions and

Q4 high and medium actions not

achieved

National 2 NHS Safety Thermometer- MHSOP & CHS services only

Pump priming funding Q1 £61,377 SeptemberAutomatic achievement at month 1 N/A N/A

15% reduction on baseline set Q1 £43,955 September

15% reduction on baseline set Q2 £43,955 December

30% reduction on baseline set Q3 £43,955 March

30% reduction on baseline set Q4 £43,955 May

Regional 5 Making Every Contact Counts

Agreed implementation plan with targets and deliverables for

Q2 to Q4 Q1 £94,880 September

Implementation plan developed and

agreedN/A No implementation plan

Achieve targets and deliverables Q2 Q2 £47,440 DecemberAchieve all Q2 actions


actionsActions not achieved for Q2

Achieve targets and deliverables Q3 Q3 £47,440 MarchAchieve all actions Achieve all high and medium actions Actions not achieved

Achieve targets and deliverables Q4 Q4 £47,440 MayAchieve all actions Achieve all high and medium actions Actions not achieved

MH Local 6 VTE - MHSOP

20% for VTE assessment and prophylaxis Q1 £59,300 September Achieve 20% or above Achieve between 15% and 19% Below 15%

40% for VTE assessment and prophylaxis Q2 £59,300 December Achieve 40% or above Achieve between 35% and 39% Below 35%

60% for VTE assessment and prophylaxis Q3 £59,300 March Achieve 60% or above Achieve between 55% and 59% Below 55%

70% for VTE assessment and prophylaxis Q4 £59,300 May Achieve 70% or above Achieve between 65% and 69% Below 65%

CHS Local 6 VTE - Community Hospitals

60% for VTE assessment and prophylaxis Q1 £52,025 September Achieve 60% or above Achieve between 55% and 59% Below 55%

70% for VTE assessment and prophylaxis Q2 £52,025 December Achieve 70% or above Achieve between 65% and 69% Below 65%

80% for VTE assessment and prophylaxis Q3 £52,025 March Achieve 80% or above Achieve between 75% and 79% Below 75%

90% for VTE assessment and prophylaxis Q4 £52,025 May Achieve 90% or above Achieve between 85% and 89% Below 85%

Achievement Target % of Payment



MH & LD Local 7

Suicide Prevention on AMH inpatient wards at the Bradgate

Unit

Pilot tool kit June 2013 Q1 £47,440 September Tool kit pilot in June achieved Develop tool kit Tool kit not developed

Baseline data with action plan and targets for Q3 and Q4.

Targets to be agreed with Commissioners Q2 £47,440 December

Action plan with suggested targets

producedN/A No action plan with targets produced

Q3 target to be set once Q2 baseline data received Q3 £189,760 MarchTo be confirmed after targets Q2 set To be confirmed after targets Q2 set To be confirmed after targets Q2 set

Q4 target to be set once Q2 baseline data received Q4 £189,760 MayTo be confirmed after targets Q2 set To be confirmed after targets Q2 set To be confirmed after targets Q2 set

MH & LD Local 8

The inpatient ward as a therapeutic space – Learning

Disabilities

To set up activities and develop the database to record activity

and record baselines Q1 £35,580 SeptemberAchieve recording baselines

Set up activities and establish

databaseNot achieved 50% payment

50 % of patients offered an activity session 5 times a week Q2 £106,740 DecemberAchieve 50% or above Achieve between 40% and 49% Below 40%

75 % of patients offered an activity session 5 times a week Q3 £106,740 MarchAchieve 75% or above Achieve between 65% and 74% Below 65%

90 % of patients will have been offered an activity session 5

times a week Q4 £106,740 MayAchieve 90% or above Achieve between 80% and 89% Below 80%

MH & LD Local 9

Communicating physical wellbeing to primary care from AMH

& LD Inpatient services

Percentage of eligible patients who have QRISK and metabolic

screening communicated to GP each quarter

· Q1 – 70% Q1 £59,300 September Achieve 70% or above Achieve between 60% and 69% Below 60%

· Q2 – 75% Q2 £59,300 December Achieve 75% or above Achieve between 70% and 74% Below 70%

· Q3 – 85% Q3 £59,300 March Achieve 85% or above Achieve between 76% and 84% Below 75%

· Q4 – 90% Q4 £59,300 May Achieve 90% or above Achieve between 85% and 89% Below 85%

MH & LD Local 10

The inpatient ward as a therapeutic space - AMH Bradgate

Mental Health Unit inpatient wards, The Willows and Stewart

House

To set up activities and develop a database to record activity

and record baselines (3 requirements) Q1 £35,580 SeptemberAchieve all 3 requirements Achieve 2 requirements Achieve 1 requirements

50 % of patients offered an activity session 5 times a week Q2 £106,740 DecemberAchieve 50% or above Achieve between 40% and 49% Below 40%

75 % of patients offered an activity session 5 times a week Q3 £106,740 MarchAchieve 75% or above Achieve between 65% and 74% Below 65%

90 % of patients will have been offered an activity session 5

times a week Q4 £106,740 MayAchieve 90% or above Achieve between 80% and 89% Below 80%



CHS Local 11

Reviewing patient care in all CHS inpatient settings (excluding

MHSOP)

Roll out Rutland, Ashby and City Q1 £83,240 September

Roll out to 3 identified inpatient

settings


settings


settings

Roll out to Loughborough and Melton Q2 £83,240 December

Roll out achieved at 3 Q1 areas and 2

Q2 inpatient settings





Roll out to Hinckley and Bosworth, Coalville, Feilding Palmer,

Market Harborough and City Ward 2 (new Ward) Q3 £83,240 March

Roll out achieved at 5 Q1 & Q2 areas

and 5 Q3 inpatient settings


and 4 or 3 Q3 inpatient settings


and below 3 Q3 inpatient settings

95% compliance Q4 £166,480 May

Roll out completed in all Q1, Q2 and

Q3 areas and 95% compliance


Q3 areas and between 85 % and 94%

compliance


Q3 areas and below 85 % compliance

CHS Local 12 MSK

3 Outcomes to be introduced and establish baseline for 3

PROMs Q1 £20,810 September

Report produced meeting set criteria

Evidence on introduction of PROMs

and continued collection of 2012/13

PROMS data but no report

No evidence produced to support

introduction of PROMs and/or proof

of continued data collection of

PROMs data

Introduce outcome 4 and report on PROMs Q2 £62,430 December








PROMs data

Introduce outcome 5 and report on PROMs Q3 £62,430 March








PROMs data

Introduce outcome 6 and report on PROMs Q4 £62,430 May








PROMs data

CHS Local 13 Personalised Care Plans for LTC

75% of patients offered a PCP Q1 £37,458 September Achieve 75% or above Achieve between 65% and 74% Below 65%

Of the completed PCP 60% having all quality indicators

completed Q1 £40,580 SeptemberAchieve 60% and above Achieve between 50% and 59% Below 50%

78% of patients offered a PCP Q2 £37,458 December Achieve 78% or above Achieve between 77% and 75% Below 75%


completed Q2 £40,580 DecemberAchieve 65% and above Achieve between 60% and 64% Below 60%

82% of patients offered a PCP Q3 £37,458 March Achieve 82% or above Achieve between 81% and 78% Below 78%


completed Q3 £40,580 MarchAchieve 70% and above Achieve between 65% and 69% Below 65%

85% of patients offered a PCP Q4 £37,458 May Achieve 85% or above Achieve between 82% and 84% Below 82%


completed Q4 £40,580 MayAchieve 80% and above Achieve between 70% and 79% Below 70%

CHS Local 14 Dementia Care

Roll out of dementia Cat B awareness training for Community

Nurses

Identify training needs analysis Q1 £0 September N/A N/A N/A

30% of staff identified will have completed training Q2 £46,822 December Achieve 40% or over Achieve between 30% and 39% Below 30%

50% of staff identified will have completed training Q3 £46,822 March Achieve 60% or over Achieve between 50% and 59% Below 50%



65% of staff identified will have completed training Q4 £62,430 May Achieve 90% or over Achieve between 80% and 89% Below 80%

Impact on practice and patient care

Q1 devise audit tool and methodology to assess impact on

practice and patient care for staff trained in dementia Cat B

awareness training during 2012/13 (sample to achieve 95%

statistical significance n=179 staff to be included Q1 £0 September

N/A N/A N/A

Commence data collection, data analysis and develop action

plan (actions to be RAG rated) Q2 £46,822 DecemberAction plan developed Data analysis completed Data collection completed

Implement action plan Q3 £46,822 MarchAchieve all Q3 actions


actionsActions not achieved for Q3

Achieve action plan deliverables Q4 £62,430 MayAchieve all actions Achieve all high and medium actions Actions not achieved

PH Local 15 School Nurse Communications “App”

Report and action plan for pilot 1 Q1 £39,025 September

Report & Action plan developed and

agreedN/A No report with action plan

Report on pilot 1 showing achievement of agreed percentage

delivery Q2 £18,732 December

Report on pilot 1 showing

achievement of agreed %

Report on pilot 1 but agreed % not

achieved

No report received and % not

achieved

Action plan for pilot 2. Q2 £20,293 December Action plan for pilot 2 N/A No action plan

Report on pilot 2 showing achievement of agreed percentage

delivery. Q3 £39,025 March

Report on pilot 2 showing

achievement of agreed %

Report on pilot 2 but agreed % not

achieved

No report received pilot 2and % not

achieved

Full report including recommendations for next steps Q4 £39,025 May

Full report received with

recommended next stepsN/A No report received

LAT Local 16

Improving formula adherence of emollient prescribing

amoungst health visitors

Establish baseline Q1 £0 September

Produce and approve simple guidelines Q2 £30,450 December

Report recived providing evidence of

guidelinesN/A No report

Promote guidelines and new formula guidelines Q2 £30,450 December

Evidence via report on promotion of

guidelinesN/A No report

Increase in formula adherence (to be agreed) Q3 £91,350 MarchIncrease in formula adherence (to be agreed) Q4 £91,350 May


report to the trust board - 26 september 2013 · report to the trust board - 26 september 2013 ......

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