AGENDA ITEM: Chief Executive Assurance Report DATE OF ... Meeting... · systems to support the systematic populating of balanced scorecards with real time data and the assurance that

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LINK TO VALUES: Accountability

LINK TO STRATEGIC PRIORITIES: 6. Quality & Governance

LINK TO NHS CONSTITUTION: Quality of Care & Environment

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

EXECUTIVE SUMMARY The attached reports provide details of the key areas of performance for the Trust. In order that Governors can be assured that the Trust is properly carrying out its responsibilities to patients and the public in general, the Integrated Quality and Performance reports are attached as appendices. As there was no meeting of the Council of Governors in December the reports for October and November 2011 are attached in order to provide continuity of information.

• Appendix 1 – Future Performance Report Requirements and Integrated Performance and Quality Report. This report was presented to the Trust Board on 6 December 2011.

• Appendix 2 – Integrated Performance and Quality Report. This report was presented to the Trust Board on 5 January 2012.

• Appendix 3 – Update on Volunteering Services Programme

• Appendix 4 – Update on Charity Programme

Following discussion at the last meeting in relation to the Volunteering Services Programme and Charity Programme, updates on current activity are attached for the information of the Council of Governors.

The report also provides a briefing on the recent Care Quality Commission’s inspection of Balmoral Ward in the Parkwood Unit, Blackpool.

AGENDA NUMBER: CG 011/12

AGENDA ITEM: Chief Executive Assurance Report

DATE OF MEETING: 24 January 2012

PREPARED BY: Heather Tierney-Moore

FOIA STATUS: No exemption Choose an item.

Part exemption applies to page:

REVIEW DATE: 24 January 2012

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1.0 DISCHARGE OF RESPONSIBILITIES

i) Statutory duties ii) Oversight – Holding the Board of Directors to Account iii) Directional and Promotional Role

2.0 COUNCIL OF GOVENORS ACTION The Council of Governors is asked to: i) Note the overview of performance provided in this report. ii) Note the update in relation to the Volunteering Services Programme and the

Charity Programme. iii) Note the briefing in respect of the Care Quality Commission’s inspection of

Balmoral Ward in the Parkwood Unit, Blackpool.

3.0 BACKGROUND This paper gives the Council of Governors a summary overview of key areas for the Trust. As representatives of the local community, the Council of Governors plays an important role in ensuring that the Trust’s assets are safeguarded and applied for the greater good in pursuit of the organisations vision mission and goals. In particular, the Council of Governors has an oversight role in holding the Board of Directors to account and will receive a monthly Integrated Performance and Quality Report. At the meeting of the Trust Board held on 6 December 2011, the Board supported a proposal to revise the format for future integrated Performance and Quality reports to reflect the development of the Trust’s integrated business plan and associated performance management framework. It was agreed that reporting in the revised format will commence from 1 April 2012.

4.0 ISSUES 4.1 Integrated Performance & Quality Reports

The key issues are contained within section 3.0 and 4.0 of the respective reports (Appendices 1 and 2).

4.2 Update on the Volunteering Services and Charity Programmes

As requested at the last meeting, attached for the information of the Governors is an update in respect of the Volunteering Services Programmes during 2011 (Appendix 3). This paper also sets out the future priorities which the Trust is proposing to introduce to enhance the Volunteering Services offered during 2012. Attached at Appendix 4 is an update in relation to the progress of the Trust’s Charity Programme during 2011. This paper also sets out the future priorities for the Charity Programme during 2012.

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4.3 Care Quality Commission’s Visit to the Balmoral Ward, Parkwood Unit,

Blackpool During December the Care Quality Commission undertook a visit of Balmoral Ward at Parkwood in Blackpool. Some areas for improvement have been highlighted in relation to; the care planning approach, standards of privacy and dignity, the ward environment and staffing. These matters are being addressed as a matter of urgency. I would like to give you my assurance that the Trust is taking the feedback from the Care Quality Commissioner very seriously and acting on the recommendations made with immediate effect to ensure that the service being provided is of the high quality that is expected.

5.0 SUMMARY AND CONCLUSIONS

This report gives an overview of performance with regard to the key areas for the Council of Governors to discharge their duties: Compliance with Statutory Duties; Oversight – Holding the Board of Directors to Account; and Direction and Participation.

6.0 RECOMMENDATION

The Council of Governors is asked to: i) Note the overview of performance provided in this report. ii) Note the update in relation to the Volunteering Services Programme and the

Charity Programme. iii) Note the briefing in respect of the Care Quality Commission’s inspection of

Balmoral Ward in the Parkwood Unit, Blackpool. �

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


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

EXECUTIVE SUMMARY The Trust Board receives a monthly integrated report on Performance and Quality and the report for October 2011 is attached for the information of the Board. (Appendices 1a-1c).

This report also outlines a proposed performance management framework (Appendix 1d) to ensure the delivery of the integrated business plan, and proposes a revised format (Appendix 1e) for the integrated performance and quality report, which will be reviewed on an incremental basis as the framework becomes embedded across the organisation.

BOARD ACTION

The Board is asked to: i) Note the overview of performance provided in the report; ii) Discuss the proposed performance management framework; and iii) Approve the revised format of the integrated Performance and Quality report

for introduction from 1 April 2012.

AGENDA NUMBER: TB196/11

AGENDA ITEM: Future Performance Report Requirements and Integrated Performance and Quality Report

DATE OF MEETING: 06 December 2011

PREPARED BY: Susan Rigg



REVIEW DATE: 06 December 2011

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1.0 INTRODUCTION The Integrated Performance and Quality Report provides the Board with a monthly overview of performance against key indicators relating to:

• the Monitor Compliance Framework (including financial Performance Indicators), and

• performance against quality, operations, staffing and reputation indicators. The attached report for October 2011 has been developed to reflect the acquisition of Community Services, however, this report now proposes a revised format for future integrated Performance and Quality reports to reflect the development of the Trust’s integrated business plan and associated performance management framework.

2.0 BACKGROUND The current board report was developed in 2009 and took account of a number of principles concerning the importance of providing information at a high level to assure the Board of performance with regard to indicators which:

• inform the Board and the wider public of the Trust’s performance against indicators of quality in the three areas of patient safety, patient experience and clinical effectiveness.

• are part of the quarterly declaration of compliance to Monitor • are part of what has become the CQC Registration framework • are important to the Trust’s reputation with commissioners and the wider public

The Board also emphasised the importance of ensuring that the report performance focused on patient care as well as on financial and governance issues.

3.0 ISSUE October Performance report The Board’s attention is draw to the following:

• Commissioning intentions have been received for the Community and Mental Health contracts. A formal response has been prepared.

• The formal Community and Mental Health Contract Monitoring meeting was held with commissioners on 9 November 2011.

• Further discussion is taking place with commissioners regarding the repatriation of out of area treatments and the performance against the contract requirements will be reviewed the end of quarter 3.

• CQUIN quarter 2 reconciliation has been confirmed Proposed Performance and Quality report In developing a Performance management framework, the Board needs to be assured that the level of reporting across the organisation is sufficient to ensure that the Trust is operating effectively, efficiently and economically.

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A proposed Performance management framework is attached to this report for discussion. The framework promotes accountability for performance at a number of levels across the organisation and proposes that the Trust Board continues to receive an integrated performance and quality report on a monthly basis. However, it is proposed that the granularity of the information within the report will reflect the assurance that the Board has, in the performance management framework that is established throughout the organisation and hence the report would predominantly be focused on exception reports. The performance management framework relies on the further development of information systems to support the systematic populating of balanced scorecards with real time data and the assurance that the performance monitoring systems are in place at each level within the organisation. This will be an incremental process, but as part of this process the opportunity has been taken to review the current integrated Performance and Quality report. The report has been structured to provide assurance in relation to the following areas;

• Monitor – Terms of authorisation and Compliance framework • Delivery of the Quality Strategy – patient safety, patient experience and clinical

effectiveness. • Delivery of Commissioned activity and targets • Workforce • Membership • Information governance

The report will be supplemented on a monthly basis with exception reports in respect of those areas that are rated as red and amber.

The frequency of reporting to the Board for each indicator has been developed to reflect the timescale by which progress can be meaningfully demonstrated.

The red, amber and green (RAG) metrics have been informed by either nationally prescribed targets where they exist or by locally developed targets. The locally developed targets will need to be reviewed on a regular basis to ensure that the thresholds that have been developed reflect the right level of assurance to the Board. The report will be colour coded to reflect the level of performance achieved for each month and to give an indication of the trend from the previous report. It is proposed, that if the revised format is approved, that it would be introduced from April 2012 in line with commencement of the business plan.

A draft copy of the proposed report format is attached for discussion. 4.0 SUMMARY AND CONCLUSIONS The monthly integrated report on Performance and Quality for October 2011 is attached for the information of the Board.

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As part of the development of a Performance management framework, a revised format for future integrated Performance and Quality Reports is proposed.

5.0 RECOMMENDATION

The Board is asked to: i) Note the overview of performance for October 2011, provided in the report. ii) Discuss the proposed performance management framework and iii) Approve the revised format of the integrated Performance and Quality report

for introduction from 1 April 2012.

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October 2011

Director of Finance: Dave Tomlinson Company Secretary Di HalseyFinancial Risk Rating �

Achievement of Plan EBITDA Achieved (cf plan) ��

Underlying Performance EBIDTA Margin ��

Financial Efficiency Return on assets ��

I&E surplus margin ��

Liquidity Liquidity Ratio (Days) ��

Current MonthNew Members 49

Members Leaving 19

Public Members 8321Staff Members 6658

Director of Finance/Director of Nursing: Dave Tomlinson/Patrick Sullivan Total Members 14979CPA Patients receiving follow-up contact with 7 days of discharge from hospital �� Target March 2010 12827CPA Patients having formal review within 12 months (Adult network) ��

Minimising delayed transfers of care + ��

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Comment:

Director of Workforce & Organisational Development: Joanne Marshall

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Comment:

Dave TomlinsonDirector of Finance:

Information Governance Management 80%Confidentiality and Data Protection Assurance 75%Information Security Assurance 68%Clinical Information Assurance 73%Secondary Use Assurance 66%Corporate Information Assurance 66%Overall Attainment Score 71%

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INTEGRATED PERFORMANCE AND QUALITY REPORT

Data Completeness: outcomes

HUMAN RESOURCES


MONITOR COMPLIANCE FRAMEWORKFINANCIAL RISK CONSTITUTION AND AUTHORISATION

Comment

Admissions to inpatient services had access to crisis resolution home treatment teams*

Governor Elections will take place in November for the following vacancies: Public, Central Lancs - 3, North Lancs - 2, East Lancs - 2, Out of area -1; Staff, Nursing and nurse professionals =-1, Other Clinical and Social Care Professionals and Clinical Support Staff 1. Ballot papers will be issued during week commencing 21st November.

Comment:All measures have improved over the last month, with the overall risk rating rising to 4 as a consequence, better than plan. The overall forecast outturn remains at 3 in line with plan, though all individual measures are expected to be better than plan.

Growing a Representative Membership

£1,222,041

MONITOR COMPLIANCE FRAMEWORK INDICATORS

Use of Bank & Agency Staff

Data Completeness: Identifiers

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Media Coverage

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No drug misusers currently in treatment & no successfully discharged in period - compared to plan

Bed Occupancy - CAMHS Tier 4 (The Junction)

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Median Length of Stay

Maintain level of crisis resolution teams set in 03/06 planning round (or subsequently contracted with PCT)

Bed Occupancy - Secure Services

Key Targets

Early Intervention: No. people receiving EIS (No. of PCTs in 10% of target current caseload)

Activity/Demand

Assertive Outreach: Number of people on caseload No. of (PCTs in 10% of target)

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Number of Crisis episodes (No of PCT's in 10% of target)

The chart below shows the Trust's assessment of its media coverage. The chart uses a scale whereby the most favourable of articles is scored at +4 and the least favourable of articles is scored as -4. The aggregate score for each month is plotted below

TRUST REPUTATIONWORKING WITH COMMISSIONERS

Director of Finance:Commissioning for Quality & Innovation (CQUIN) Payment

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Health Care Acquired Infection (HCAI)

Serious Untoward Incidents (SUI)

QUALITY ACCOUNT

October 2011-12 Board Report

PATIENT SAFETY

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Cumulative YTD Target 11/12 (17 cases)

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% Reports completed in 45 days 90% Target

C-Diff

The first graph shows since April 11 there has been no reported cases of C-Diff at the Trust. There have not been any cases of C-Diff reported in the community services since 1st June 2011.

The second graph shows the cumulative number of reported C-Diff cases against the 2011/12 target agreed with LCFT commissioners. The target has been agreed not to exceed the 2010-11 out turn of 4 cases.

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

Since April 11 there has been an increase in the number of reported MRSA cases which peaked at 4 cases being reported by the Trust for June 11. August 11 has shown a decrease back to one incident (from community setting) which has continued into September. October has seen two reported cases.

The second graph shows the cumulative number of reported MRSA cases against the 2011/12 target agreed with LCFT commissioners. The target has been agreed not to exceed the 2010-11 out turn of 17 case. The graph shows that since April 11 a total of 11 cases have been reported by the Trust.

Data Source: Infection prevention & Control dept.

93%76%

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% incidents reported in 48 hours against 2011/12 Targets

% incidents reported in 48 hours 90% Target

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

Incidents reported in 48 hours The percentage of the incidents reported within 48 hours shows that Quarter 1 met the commissioner target of 90% by 3%, however, in Quarter 2 only 76% of incidents were reported within 48 hours which was below the 90% target.

Reports completed in 45 daysThe percentage of the reports completed within 45 days shows that Quarter 1 met the commissioner target of 90% by 4%, however, in Quarter 2 only 85% reports were completed within 45 days which was below the 90% target.

The short fall in obtaining the 90% targets for SUI reporting and investigations have been discussed at the SUI group and network risk meetings. A review of the process has been undertaken and discussed with key people. The issue of extensions and delays has been discussed and an escalation process put in place. Further guidance will also be sent out to staff reminding them of the timescales.It has been agreed with the Lead PCT that in exceptional circumstances (i.e. where the SUI is complex) there may be an extension to the 45 working day deadline. The figure above excludes the PIRs which had an extension.

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SPC Chart for MRSA


LCFT Quality Account - October Board Report 2011 Page 1

Falls Which Result in a Fracture

Pressure Ulcers in the Community

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Cumulative Falls Activity against 2011/2012 Target


Falls which result in a Fracture

There have been 3 incidents of falls resulting in a fracture since April 11, one occurring in April , one in July and one in October. The graph shows that overall there has been a lot of variance in the number of reported fractures. This is due to the low numbers involved (0-2 cases per month).

The second graph shows the cumulative number of falls resulting in a fracture against the 2011/12 target agreed with LCFT commissioners. The agreed target is not to exceed the 2010-11 out turn of 13 cases.

The main area of risk is the older adult network. A six monthly review of the performance takes place and practice issues are managed through the network governance arrangements.

Data Source: Datix


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

Reporting of all Pressure Ulcer (with those graded at 3 or 4 being externally reportable) regardless of where on the patient, has been established through the Incident Reporting system.This process in place is working well with Action plans being completed for all incidents and within the designated timescales, with close liaison between the Tissue Viability Nurses and the Community nurses. There have been some instances where the initial grading has been 3 or 4 and therefore reported on STEIS but have subsequently been found by the specialist Tissue Viability Nurses to be lower (and therefore not STEIS portable) and closed . Categorisation of sores is now being

addressed in nurse training sessions. Where the sore is believed to have been acquired within the acute setting, reports are sent to both East Lancashire Hospitals Trust (ELHT) and Lancashire Teaching Hospitals (LTH) providing them with sufficient detail to allow their own investigation to be completed. Where the sore could have been acquired within a nursing/residential home, the reports are sent through to the Commissioning organisation for them to follow up with the commissioned service.

There has been an increase in the category 3 pressure ulcers for both Central and Blackburn with Darwen (BWD) for Quarter 2, with a reduction of category 4 Ulcers in the same period. BWD saw their Category 3 increase from 2 to 8 with their acquisition moving from care home setting to Community setting. The category 4 has been reduced from 5 to 1 with the acquisition remaining the same for Patient home and no new acquisitions from the Care home setting. Central saw their Category 3 increase from 8 to 12 with new acquisitions coming from Care home and Patient home setting. The category 4 has been reduced from 7 to 3 with the acquisition reducing in care home setting and a new case from patients home.The Director of Nursing, Director of Operations and the Medical Director review on a weekly basis and LCFT is commissioning a piece of work to review the data in more detail and look at the implications for Clinical practice.

Data Source: Datix

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Categories of Pressure Ulcers by Provider during Quarter 1 and 2 11-12

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Setting of Acquired Pressure Ulcer- Category 3

ENTRY-Hospital INSIDE- Care homeINSIDE- Pt's Home INSIDE- Community

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*Definitions for graph are: Entry = on entry into community services i.e. From hospital the patient already had a pressure ulcer

Inside = the patient was under the care of community services when a pressure ulcer was acquired Not Stated = Location of acquired Ulcer not stated.

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Month/YearData Average UCL LCL


Violent Incidents Against Staff

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

579 157541 146 27%

394 80 -42%

887 218 128% (Source: National Violence Data)

-15%2011/2012 450

Reported

Assaults

Assaults

per 1000

Year on Year Reported

Incidents (April to Oct)

Incidences of Violence on Non Staff Members by Service Users

2007/20082008/2009

2009/2010

315

232

400

2010/2011 529

% VarianceReported Year

452

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s

Month/Year

Cumulative incidents of violence against 2011/2012 Target

Target 11/12 (871 Incidents) Cumulative YTD

452

0

100

200

300

400

500

600

700

800

Ap

r-1

1

Ma

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Jun

-11

Jul-

11

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-11

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-12

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b-1

2

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2

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mu

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Vio

len

t In

cid

en

ts

Ag

ain

st S

taff

(p

er

1,

00

0 S

taff

)

Month/Year

Cumulative incidents of violence against staff against 2011/12 Target

Cumulative YTD Target 11/12 (744 incidents per 1 000 staff)

The National Figures released in November 11 shows an increase in the reported incidents by 493 with a 264 or 6.5% decrease in staffing levels. Year on year analysis shows that the we have fewer cases of reported incidents than this time last year with the severity of the incidents predominantly falling in the "None - No injury or adverse/outcome" category. LCFT have analysed the figures and although there is a decline in performance the figure matches the mean when benchmarked against similar organisation, however we are taking this matter seriously with discussions within each network being used to investigate reported incidents. There is currently an analysis of the trend of violent and aggressive incidents across the Trust. Certain key areas have already been identified which should be undertaken to improve staff and patient safety. Staff training is to be reviewed to ensure that staff fully understand recognising aggression triggers, appropriate engagement and a physical skill that used as a last option. De-escalation competence will also be reviewed. Full engagement is needed within networks to address the violence and aggression issues especially where there are repeat offenders. The environment and activities are also key factors for violence and aggression incidents. Work is currently on-going to assess the level and quality of therapeutic activity being undertaken on our wards.

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

Since April 11, with the exception of June 11, the Trust has seen a dramatic decline in the number of violent incidents against non-staff members. October's figures, however, have seen a dramatic increase from September 11 to record the highest number of reported incidents since September 2010. In comparison with September 11, October has seen a 51% increase (29 more incidents) in the number of reported incidents against non- staff. The 2 main categories that has seen an increase are 'Assault by patient to patient' with a 100% increase (21 more incidents reported) and 'Violent behaviour' with a 86% increase (6 more incidents reported). Out of the 17 categories reviewed there has been 7 other categories have seen an increase of one or two incidents more than September, with the remaining categories showing either no increase or a slight decrease in reported incidents. When reviewing the increase by network there has been an 200% increase (34 more incidents) of incidents in the Adult MH network and a a 47% increase (9 more incidents) in the Older Adult Network.

Further investigations will examine if an individual service user is responsible for the increases in violence or if it is a group of other factors. Analysis of this data takes place on an on-going basis in order to identify any trends by both network and ward. The Director of Nursing submitted a detailed report on violence to the October Trust Board

The second graph shows the cumulative number of reported incidents against the 2011/12 target agreed with LCFT commissioners. The target have not been set by our commissioners, however it is important not to exceed the 2010-11 out turn of 871 incidents. The current trend shows that the target will not be exceeded. Source: Datix

Incidents against Staff

Since April 11 there has been an overall increase in the number of violent incidents against staff culminating in July's figure being the highest incident rate since October 2010. Analysis shows that violent, threatening and abusive behaviour towards staff continues to cause concern. Physical assaults remain at a constant while verbal assaults and threats appear to be the root of the overall increase in incidents. These types of incidents will continue to be closely monitored in order to feed into an action plan. September has maintained the downward trend from July's high incident rate to bring the rate below the average. October's figures show that this month is the lowest incident rate per thousand staff since April 11.

The second graph shows the cumulative number of reported incidents to staff against the 2011/12 target agreed with LCFT commissioners. If we were to continue with the current trend we would breach the target in Febrruary 2012. The Director of Nursing submitted a detailed report on violence to the October Trust Board Data Source: Datix

0

20

40

60

80

100

120

Ap

r-0

9

Ma

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9

Jun

-09

Jul-

09

Au

g-0

9

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p-0

9

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-09

No

v-0

9

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c-0

9

Jan

-10

Fe

b-1

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Ma

r-1

0

Ap

r-1

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-10

Jul-

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70

80

90

100

Ap

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9

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-09

Jul-

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g-0

9

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p-0

9

Oct

-09

No

v-0

9

De

c-0

9

Jan

-10

Fe

b-1

0

Ma

r-1

0

Ap

r-1

0

Ma

y-1

0

Jun

-10

Jul-

10

Au

g-1

0

Se

p-1

0

Oct

-10

No

v-1

0

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c-1

0

Jan

-11

Fe

b-1

1

Ma

r-1

1

Ap

r-1

1

Ma

y-1

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Jun

-11

Jul-

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Au

g-1

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p-1

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Oct

-11

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of

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d c

ase

s p

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1,0

00

sta

ff

Month/YearPer 1,00 staff Average UCL LCL


Medicine Management

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

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

32%

67% 38.8% 66.6%67% 51.5% 66.7%0% 53.4% 71.7%

36.5% 57.8%

75.0% 75.0%

Patient Safety from Staff Questionnaire

Standards of Care

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

Annual Measures

Percentage of Staff with Mandatory Training

Completed PDP/R & Mandatory Training

% Increase

Financial Year 10/11

Target 11/12

Mandatory

Training Financial Year 08/09

Quarter 1 11/12Quarter 2 11/12

PDP/R

Year End 10/11Year End 09/10

Percentage of Staff with Appraisal completed within last 12 months

(Workbook and Induction)


The prescribing of hypnotics has been discussed at the Adult Network Governance group for Step 5. A memo has been circulated to all the wards in Central Lancs requesting that Junior Doctors prescribe stat dose for hypnotics and anxiolytics and they must not prescribe either regular or PRN dose without contacting the second on call or the Consultant on call. Where PRN prescribing is considered necessary out of hours the prescription will be reviewed by the Medical team the following day.

Source: Chief Pharmacist

61%

67%

63%

79%

82%

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

Trust Score 2007

Trust Score 2008

Trust Score 2009

Trust Score 2010

National Average for MH Trusts

28%

32%

27%

26%

28%

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

Trust Score 2007

Trust Score 2008

Trust Score 2009

Trust Score 2010

National Average for Mental health…

Source: Staff Survey CQC

59%

78%

79%

75%

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

Trust Score 2008

Trust Score 2009

Trust Score 2010




Source: Training Department


Audit results for audits that were completed in 2011 to date.

Use of antipsychotic medicine with learning difficultiesThere are eight standards in this section. The baseline data was undertaken in-house in August 2009 due to the service not being part of LCFT when the POMH-UK baseline audit was done. The re-audit was undertaken in January 2011 from 40 Trusts. The data shows that LCFT came within the top 18 of the ranking for 6 of the 8 standards. The best position was joint 1st for two standards and the worst position were two standards in 31st place for the monitoring of weight and blood pressure.

Prescribing antipsychotics for people with DementiaThere are nine standards in this section. This is a baseline audit that was undertaken in March 2011. Out of the 53 Trusts that took part, our lowest position was 8th with four standards achieving joint 1st ranking. The remaining three standards were not ranked, however when comparing the results the % of patients with a diagnosis of dementia in LCFT who are prescribed an antipsychotic is 14% compared to 15% for the National average.


PATIENT EXPERIENCE

Younger People Admissions

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25

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Month/Year

Cumulative incidents of young persons against 2011/12 Target

Cumulative YTD Target 11/12 (0 incidents)Source: DATIX

Young People Admissions

Since April 11 there have been five reported incidents of a young person being admitted to an Adult ward; one in May 11, three in August 11 and one for September 11. No admissions were reported for October. These admissions are subject to a PIR. The number of the admissions to adult wards have been appropriate given the needs of the Young person. An example is the requirement for a PICU bed

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

The second graph shows the cumulative incidents of young person admission to an adult ward against the 2010/2011 out turn. LCFT commissioners have not set a target; however it is important not to exceed the 2010-11 out turn of 21 cases

It was agreed at the SUI Advisory Group that this issue would be kept under close review. A more detailed review of all such incidents has been undertaken. Investigations into the resulting SUI initiated by a breach will now contain a number of key questions. These questions will standardise the information being gathered and provide us with a way to identify and action up on any themes found.

PDR – the data provided reflects the information held centrally by the Learning & OD Team, we continue to request Networks return notifications to the L&OD team for tracking purposes. The new PDR process is being launched in January 2012 and will be supported by an electronic monitoring system which is currently being piloted and is scheduled to be cascaded to all staff prior to the launch of the new process. Once the new process is fully implemented, it is anticipated that PDR data will be updated automatically which will provide more timely and robust reporting in future.Mandatory Training Workbook Compliance – a Mandatory Training Lead has recently been appointed to and is currently reviewing the current frequency and methods of delivery of mandatory training. A blended approach to the delivery of mandatory training is being considered for the future, including making greater use of E-learning as a more efficient and cost effective method of delivering training. However, this may take some time to implement. A new Mandatory Training Policy has been developed and is being consulted upon. All subject matter experts have agreed to delivery targets which have been included in the Mandatory Training Matrix which will support the new Policy. Once approved, the new policy will be implemented from 1 April 2012. Therefore, as an interim solution the content of the Mandatory Training Workbook (MTW) has been updated on the intranet and consideration is being given to providing access to all staff, including those that joined LCFT as part of TCS, to allow staff to fill any gaps in their mandatory training requirements pending implementation of the new policy and matrix from 1 April 2012.

A new report has been developed for the Executive Management Team which provides information on staff who either Did Not Attend or Cancelled Mandatory Training so that Network Directors/Managers can follow up to improve levels of attendance.Further reports are being developed to monitor compliance against Mandatory Training and the L&OD team are currently identifying how to develop these through the use of Data Cube with the IT Team ready for implementation in 2012.


National Indicators for Quality Improvement that deals with young persons admission

Year/Quarter

2010/11 Quarter 1

2010/11 Quarter 2

2010/11 Quarter 3

2010/11 Quarter 4

2011/12 Quarter 1

2011/12 Quarter 2

Complaint referred to the Ombudsman

07/08 08/09 09/10 10/11 Quarter 1

11/12

Quarter 2

11/12

Source: Customer Services Dept.

0

5

2010/11 Quarter 4

1

4

2011/12 Quarter 1

913

0

0

0 10

0 2011/12 Quarter 2 30

2

1

No of patients who referred their

complaint to the Ombudsman

Compliments & Complaints

0

1

Occupied Bed Days

0

0

2010/11 Quarter 3

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

admission, under the care of a psychiatric specialist

No of patients

5

5

0

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

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

Occupied Bed Days

95

56

No of patients

6

11

0

60

0

0

Year/Quarter

2010/11 Quarter 1

2010/11 Quarter 2

48 4825

53 45 49 46 49 69 48

64

134 155 139

421365

221 238193 219 243

289

-200

-100

0

100

200

300

400

500

600

Quarter 1

09/10

Quarter 2

09/10

Quarter 3

09/10

Quarter 4

09/10

Quarter 1

10/11

Quarter 2

10/11

Quarter 3

10/11

Quarter 4

10/11

Quarter 1

11/12

Quarter 2

11/12

No

of

Co

mp

lim

en

ts o

r C

om

pla

ints

re

ceiv

ed

Quarter/ year reported

No of Compliments or Complaints received

Compliments- Community Services Compliments- Mental Health

Complaints- Community Service Complaints- Mental Health


Quarter 2 is the first full quarter where we have managed the community providers and this will provide the base line for future quarterly reports. This quarter shows that the number of Mental Health complaints is consistent with previous quarters. The exception to this is quarter 1 where the number of complaints for mental health services was higher than previous quarters . Quarter 2 shows that the number of complaints for mental health services have reduced to previous reported levels.

Source: Complaints Dept.

0

0.2

0.4

0.6

0.8

1

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

2010/11 2011/12

Oc

cu

pie

d B

ed

Da

ys

Year/ Quarter

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

psychiatric specialist

0

10

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100


2010/11 2011/12

Oc

cu

pie

d B

ed

Da

ys

Year/Quarter

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


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

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

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


Adult & Older Adult Inpatient Surveys Q2 Q3 Q4 Q1 Q2

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

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

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

I knew how to make a complaint if I

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

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

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

Sample size 80 60 116 66 71

Discharges per quarter 904 889 918 977 901

Response Rate 9% 7% 13% 7% 8%

77% 71%

91%

2011/12

68%

83%83% 87%

85

78%

78% 86%

88%

81%

86%86%

7%

61% 73%

7% 10%

88% 77%

Q4

88%

I was satisfied with how I was involved in

planning my hospital care +83%

I was satisfied in how I was involved in

planning my discharge +80%

5%

68%

I got as much information as I wanted

about my treatment +

68%

66

989

81%

84%

98% 94%

Internal SurveyInpatient Surveys

2009/2010

Q1 Q2 Q3

2010/2011

Q1

77% 81% 79%

94%92%

879

79% 81% 78%

79%

90%84% 80%

77% 82% 84%

80%

6997 52

887

10%

Source: Clinical Governance.

86%

86%

971939

80%

78% 81% 81% 71%

75% 71% 86%

72% 78%

Internal Inpatient Survey

The trend for the last 10 quarters has shown an improvement in the majority of areas.The largest improvements was seen in ‘Could I get a hot drink when I wanted?’ with an increase of 25%. This is followed by ‘I knew how to make a complaint if I needed to' with an 8% increase, although the highest figure was 88% in Q4 2010/11. ‘How to make a complaint’ has an 8% increase although the highest figure was in Q4 2010/11 with 88%.

‘How clean in the ward’ has seen a drop by 1% although the highest figure was 98% Q1 2011/12. The only areas to see a decrease was 'The Ward felt a safe place to be in?’ which saw an 8% drop. LCFT Work is on-going to improve patient safety on the wards.

The question "would you recommend us to a friend?” LCFT scored 7 out of the possible 10. LCFT therefore received an average score of 7.2 out of 10 for the 5 quarters.

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

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


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

How safe did you feel?

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

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

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

How clean was your ward?

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


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

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


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

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


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

Patient awareness of Complaints

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

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

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

Summary of Survey

A response was received from CQC regarding an issue raised with the 2010 data. The 2010 report which was received from the CQC was an interim report and as such did not show the true 2010 end position for LCFT. This error was noticed when reviewing the 2011 report which contained the 2010 figures. All graphs have been updated to show the change with the variance shown below. The changes do not exceed 1.3% variance.

Overall the results in the inpatient survey showed an improvement on last year’s results, with over half the results exceeding the 2010 survey results (23 exceeding and 2 matching the 45 results reviewed). In the cases that exceeded the 2010 results, the average percentage variance was 3.4%. The indicator ‘D32- During your most recent stay, were there enough activities available for you to do during evenings and/or weekends?’ showed the greatest percentage variance at 10% (2011- 48%, 2010- 38% and 2011 National Average- 44%) for criteria ‘Yes all of the time’ and ‘Yes some of the time’. In the cases where we did not exceed 2010 results, the average percentage variance was -4.7%. The indicator ‘B14- Did you receive the help you needed from hospital staff with organising your home situation?’ showed the greatest percentage variance of -14% (2011- 70%, 2010- 84% and 2011 National Average- 73%) for criteria ‘I received all the help I needed’ and ‘I received some of the help I needed’.

When comparing 2011 outcomes with the National Average, LCFT exceeded or matched the National Average in over half of the indicators (24 exceeding and 5 matching the 45 results reviewed).In the cases that exceeded the National Average, the average percentage variance was 4.5%. The indicator ‘F34- Do you have the number of someone from your local NHS Mental Health Service that you can phone out of office hours?’ showed the greatest percentage variance at 13% (2011 National Average-67%, 2011- 80% and 2010- 79%) for criteria ‘Yes’. In the cases where we did not exceed National average, the average percentage variance was -3.3%. The indicator ‘D31- During your most recent stay, were there enough activities available for you to do during the day on weekdays (Monday to Friday)?’ showed the greatest percentage variance of -7% (2011 National Average- 64%, 2011- 57% and 2010- 53%), although there was a 4% improvement year on year, for criteria ‘Yes all of the time’ and ‘Yes some of the time’.

The overall score 'how would you rate the care you received on your recent stay', LCFT was 1% lower than 2010 score of 72%, but matched the National Average at 71%, when grouping the responses ‘Excellent’, ‘Very good’, and ‘Good’.

No longer comparable


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

Carers Assessments

Rating of Care

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

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

Medication Purpose

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

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

Out of Hours contacts

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

Aggregated scores: Answer 'yes'

Review of care plan

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

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

91.7%

92.6%

84.4%

97.7%

93.2%

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

LCFT 2008

LCFT 2009

LCFT 2010

LCFT 2011

2011 National Average

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

51.0%

70.0%

63.0%

70.0%

51.0%

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

LCFT 2008

LCFT 2009

LCFT 2010

LCFT 2011


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

57.1%

71.1%

68.8%

77.4%

55.6%

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

LCFT 2008

LCFT 2009

LCFT 2010

LCFT 2011


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

81.7%

86.2%

79.4%

79.6%

78.8%

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

LCFT 2008

LCFT 2009

LCFT 2010

LCFT 2011


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

Dignity and Respect

The results from the National community Survey show that 51.0% of LCFT service users believed they were treated with dignity and respect. This figure is 1% lower than the 2010 result of 52.0% but still exceeds the National averageof 42.0%

Aggregated scores: Answer 'yes in last year'

Care Plan

The results from the National community Survey show that 97.5% of LCFT service users were offered or given a copy of their care plan. This exceeds the 2010 result of 97.0% but is 0.3% lower than the National average of 97.8%


97.0%

97.5%

97.8%

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

LCFT 2008

LCFT 2009

LCFT 2010

LCFT 2011

2011 NationalAverage

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

Not comparable to previous surveys


52.0%

51.0%

42.0%

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

LCFT 2008

LCFT 2009

LCFT 2010

LCFT 2011


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

Not comparable to previous


LCFT Is working towards providing Carer's Assessment data from internal information systems. This will be included in next quarters report.


Environment & Facilities 96%

Staffing & Training 89%

Access, Admission & Discharge 94%

Care & Treatment 78%

Information, Consent & Confidentiality 97%

Young People’s Rights & Safeguarding

Children98%

Clinical Governance 92%

Location Within a Public Health Context

and Commissioning71%

Privacy and Dignity Single sex accommodation

100% 2%

Peer Review by QNIC The Junction & The Platform External

Access, Admission & Discharge

Overall

score for

2011

% Variance

Information, Consent & Confidentiality

99% 100% 1%

Care & Treatment

98% 6%

8%

100% 100%

92%

90% 2%

90% 98%

98%

88% 96% 8%

Young People’s Rights & Safeguarding Children

Clinical Governance

Location Within a Public Health Context and

Commissioning

0%

97% 94% -3%

88%

Lancashire Care NHS Foundation Trust is pleased to confirm that we are compliant with the Government’s requirement to eliminate mixed sex accommodation, except when it is in the patient’s overall best

interest, or reflects their personal choice. Our Declaration of compliance is located on LCFT website at the below address http://www.lancashirecare.nhs.uk/Privacy-Dignity.php

Initial

Review

2011

SectionSectionOverall

score 2010

Environment & Facilities

Staffing & Training

The JunctionQNIC ReportA review was undertaken on 11th February 2011 by QNIC, Royal College of Psychiatrists’ Centre for Quality Improvement. A visiting team spent one day at the unit speaking to staff, young people and parents about the service focusing on:- Care & Treatment- Information, Consent and Confidentiality

SummaryThe Junction is performing well across all sections of the service standards, and is continuing to improve their compliance with the standards year on year. The team have undertaken many changes since their last QNIC review. In particular, the unit has introduced progress meetings which are working well and the team are looking to continue to build on this. The team have also started to allocate multi-disciplinary mini teams to each young person to get them more involved in their care and planning their treatment.

Clinical Governance is the area that has seen a reduction since the last review in October 2009. The reasons for the reduction have been identified and are now being resolved.

The PlatformQNIC ReportQNIC has also carried out the first peer review at The Platform on 15th March 2011 with the unit taking part in a review covering all sections of the service standards listed in below.

SummaryThe Platform is a new service that opened in April 2010 in response to the amendments to the Mental Health Act and provides a specific service for 16 – 17 year olds. The Platform are performing well against the QNIC standards, and there is a lot of excellent work undertaken to ensure comprehensive user participation.


PEAT Assessment

Annual Measures National Audit

Implementation of the Quality Strategy

(Source: http://www.ic.nhs.uk/statistics-and-data-collections/facilities/patient-

environment-action-team-peat)

EFFECTIVENESS

All in-patient units have been reviewed and the action plans are being developed. The review of community services has been completed and the reports are being drafted. An update on the Quality Strategy has been provided to the Board in December 11

The following National Audits are being carried out during 2011/2012:-

Patient Involvement Project: Older Peoples Experiences of Falls and Bone Health- the Trust has registered for this national audit which is applicable to a number of community services. The PPI audit packs are currently being sent out to registered trusts by the project officers from RCP. Staff and patients questionnaires have been sent out as per requirements.Psychological Therapy Audit - Nationally the release of the report has been put back till early December 2011. National Audit of Schizophrenia – Online data collection has commenced and will be completed by November 2011

POMH-UK Audits- Data collection for audit begins;-September 11 - Topic 7c (Monitoring of patients prescribed lithium)- The audit began in September with data inputting being completed.November 11 - Topic 10b (Use of antipsychotic medicine in CAMHS)- The audit began in November as per requirementsFebruary 12- Topic 1f and 3f (Prescribing high dose and combined antipsychotics on adult acute and psychiatric intensive care ward.

Royal College of Psychiatrist Peer Review:- Evidence is currently being gathered for review in December by Royal College of Psychiatrists and the results will be included when published.

PEAT SCORES 2011

Site Name Site CodeWeighted Environment

ScoreFood Score

Privacy & Dignity

Score

ALTHAM MEADOWS RW5LX 4 Good 5 Excellent 5 Excellent

BURNLEY GENERAL MH RW5CA 3 Acceptable 3 Acceptable 4 Good

CHORLEY GENERAL MH RW5DA 5 Excellent 5 Excellent 5 Excellent

GUILD PARK LODGE WHITTINGHAM PRESTON RW5ED 4 Good 5 Excellent 4 Good

LYTHAM HOSPITAL RW5GD 4 Good 5 Excellent 4 Good

OAKLANDS RW5MA 4 Good 5 Excellent 5 Excellent

ORMSKIRK AND DISTRICT GENERAL HOSPITAL RW5FA 4 Good 5 Excellent 4 Good

QUEENS PARK HOSPITAL RW5AA 4 Good 4 Good 4 Good

RIBBLETON HOSPITAL PRESTON RW5EF 5 Excellent 5 Excellent 4 Good

RIDGE LEA HOSPITAL RW5LA 4 Good 5 Excellent 5 Excellent

VICTORIA HOSPITAL, BLACKPOOL RW5GJ 3 Acceptable 3 Acceptable 3 Acceptable

3.86 Above Acceptable 4.3 Very Good 4 GoodOverall Score

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

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

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

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


Effectiveness Metrics

Future measures

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

Advancing Quality (AQ)

Baseline data was submitted in accordance with the timescales set by Advancing Quality Alliance (AQuA). The baseline data was used to calculate the regions Implementation Stretch Targets that come into effect in October 2011 and last until March 2012. May 11’s data has recently been submitted for both Psychosis and Dementia. The percentage pass rate against the Implementation Stretch Target and against the Baseline data is shown in the graphs below. Baseline data comprised of January to March 2011 data. From October the Trust as entered the monitoring stage by which the LCFTwill be against the Imposed Stretch Targets created by the AQ Steering Group.

Psychosis Dementia

Psychosis has an implementation stretch target of 85%. Even though this target does not commence till October 11 it is vital we monitor current practice to identify area where we may fall short. The baseline data submission of 88% exceeds the target by 3% however April’s submission fell short of the target by 6%. May’s and June’s figure’s also exceeded the target by 8% and 7% respectively. July is the latest submission with a submission of 74%. This fell short of the target by 11%. The fall is due to service users transfering into our service from other regional EIS teams. Clarification from AQuA is being sort as to whether these should be included in the sample group. Due to this calculated percentages are more easily influence by the small number of fails in the data. Since all the indicators are time limited the missed opportunities to passes are often a result of the criteria being outside the time scale rather than it not taking place at all. Reports have been issued to all senior managers in regard to the figures and recommendation have been made being actioned.

Dementia has an implementation stretch target of 75%. Even though this target does not commence till October 11 it is vital we monitor current practice to identify area where we may fall short. The baseline data submission of 56% fell short of the target by 19%; with April’s submission again falling short by 23%. May’s and June’s figures again fell short of the target by 15% and 19% respectively. July is the latest submission with a submission of 58%. This again fell short of the target by 17% but was a 2% improvement on the previous month. Due to this calculated percentages are more easily influence by the small number of fails in the data. Some of the indicators are time limited with the missed opportunities to passes often a result of the criteria being completed outside the time scale rather than it not taking place at all. The Indicators that need the most attention are in regard to assessment of Depression and Anxiety and tailored care plans for difficult behaviour. Work is on-going with lead clinicians and ward staff in making people aware that assessments must be completed within the set time frames and that appropriate recording of care plans is made. This is being done through posters and instruction manuals which are being issued to all clinical staff and in-depth discussions with Consultant to understand what support they require to ensure the improvement of the indicators and ultimately patient care.All Older Adult wards are continuing to implement the use of eCPA to record the activities required for the submission of the AQ indicators

56% 52% 60%56% 58%

75%

0%

20%

40%

60%

80%

100%

Baseline data Apr-11 May-11 Jun-11 Jul-11

Pe

rce

nta

ge

Pa

ss

Ra

te

Month- Year

AQ Dementia Percentage Pass Rate against Implementation Stretch Targets

LCFT Baseline Pass Rate LCFT Percentage Pass RateImplementation Target

Sample = 98

Sample= 34

Sample = 21

Sample = 27

Sample = 29

88% 79% 93% 92%74%

85%

0%

20%

40%

60%

80%

100%


Pe

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Pa

ss

Ra

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Month- Year

AQ EIS Psychosis Percentage Pass Rate against Implementation Stretch Targets


Sample= 47

Sample= 15

Sample= 23

Sample= 16

Sample= 17


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Appendix 1d

Performance Management Framework

1. Introduction

This paper sets out the proposals for the development of a performance management framework to provide assurance that the Trust is delivering the Integrated Business Plan. 2. Background In developing a performance management framework, the Board needs to be assured that the level of reporting across the organisation is sufficient to ensure that the Trust is operating effectively, efficiently and economically. The Board currently receives a monthly integrated performance and quality report that was developed in 2009 and took account of a number of principles concerning the importance of providing information at a high level to assure the Board of performance with regard to indicators which:

• inform the Board and the wider public of the Trust’s performance against indicators of quality in the three areas of patient safety, patient experience and clinical effectiveness;

• were part of the quarterly declaration of compliance to Monitor; • were part of what has become the CQC Registration framework; • were important to the Trust’s reputation with commissioners and the wider public.

The Board also emphasised at that time the importance of ensuring that the report performance focused on patient care as well as on financial and governance issues. The opportunity is now being taken following the transfer of community services and the restructuring of corporate and network teams to review the performance management and reporting arrangements across the organisation.

3. Development of a Performance management culture In developing a performance management culture the following areas remain as key drivers:

• Monitor – Terms of authorisation and Compliance Framework; • Delivery of Commissioned activity and targets; • Delivery of the Trust integrated business plan; • Delivery of the Quality Strategy.

The key performance indicators in respect of Monitor Compliance are well documented within the Compliance Framework. The NHS Mental Health Contract and the NHS Community Services Contract also include an agreed set of performance indicators that are contained within Schedule 5 of the contract documentation.

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The Trust’s Integrated Business Plan for 2012-15 is currently being developed through a set of network business plans and corporate enabler plans, with detailed objectives and key performance indicators. The Quality Strategy is also being refreshed and will detail a range of performance measures to evidence implementation. Having established a full set of key performance indicators, a Performance Management Framework needs to be established across the organisation to:

• monitor and report performance on a regular basis; and, • ensure that appropriate action is taken to address areas of underperformance as they arise.

In order for a performance management culture to be embedded within the organisation there needs to be a clear line of sight between individual members of staff’s objectives and the Trust’s strategic aims and priorities and their contribution to the delivery of key performance indicators. 4. Performance management framework This report focuses on the development of a hierarchy of systems that will enable performance to be owned and reviewed on a regular basis at the appropriate level within the organisation. Enterprise assurance management is integral to performance management in that it requires the management of risks at every level of the organisation and is an on-going, flowing process of continuous improvement aligned to monitoring performance. The following diagram summaries the relationship between the integrated business plan and the performance management framework:

4.1 Individual performance Individual objectives will be set in accordance with the Trust’s annual personal development review process. These will define the individual’s contribution to the Trust’s strategic aims and priorities and will link to the team and network objectives.

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4.2 Team Information Centres Information Centres are the hub of developing a Lean organisation and achieving continuous improvement. They provide the vehicle for improving communications across teams and facilitate more visible performance management and understanding of the drivers of performance. �

The Service Transformation team are leading the development of information centres. They initially engage with teams to gain an understanding of their key performance indicators and to design the information centres hierarchy. A further session is then held to train the Information Centre owners in the theory and practical application of Information Centres by providing materials and guidance to construct their boards and to support the go live of the board and the meetings.

There is a standard around content (People, Performance and continuous improvement) and a draft standard operating procedure has been developed. Discussions are taking place with Learning and Development about building this approach into the Management Skills Programme.

The benefits of information centres include:

• Get teams to focus on what they are there to deliver- clear link to corporate priorities brought to life for individuals and teams

• Improve quality of data • Develop a performance culture • Provide assurance for our key measures • Begin to develop a better understanding of the drivers of performance particularly around

capacity and demand management and seek to address DNA and cancellations which directly impact our waiting lists.

• Increase skills in forecasting and planning use of capacity and demand. • View performance data, issues and ideas at a glance • Structured communications across teams to get everyone owning and focussed on

improvement, performance and opportunities. • Increase the understanding of the inputs that effect outcomes • Support Appreciative Leadership as the conversation can be based on appreciative inquiry.

The Information Centres will over time develop a corporate standard and interface with electronic systems. However, it is the frontline teams that generate our data and the information centres develop from the principle that if they capture this data manually and interact with it, they own it and begin to question it.

This information then rolls up into business unit set of data and upwards to an organisational picture. The performance section will be developed to reflect the same measures as the network balance scorecards.

As information systems and data collection are refined manual data collection will be replaced by electronic data capture.

The visibility of the data is the key to the success of information centres and the regular meetings of a team to engage with it.

This approach brings to life the concept of the NHS as a business to business arrangement linked to contracts.

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4.3 Balanced scorecards Network and corporate team balanced scorecards will provide a concise summary of the key performance indicators across each of the following areas:

• Monitor – Terms of authorisation and Compliance Framework; • Delivery of Commissioned activity and targets; • Delivery of the Trust’s Integrated Business Plan, including financial and workforce

performance; • Delivery of the Quality Strategy.

The scorecards will be informed through information from the corporate information systems and information gathered at team information centres. Performance will be monitored through the network and corporate team governance structures and performance improvement plans established where performance is below plan/ trajectory. The development of the balanced scorecards is being led by a project team across the networks as part of the business planning process. 4.4 Executive Team information centre The Executive Management team information centre meeting is held on a weekly basis to review performance against a range of indicators including;

• Monitor Compliance • Trust key operational targets • Governance indicators • Human Resource indicators • Reputation management

Exception reports from the balance scorecards will inform the weekly EMT information centre, together with details of performance improvement plans. The establishment of an electronic ‘drill down’ solution is currently being developed but the weekly meeting to collectively review performance will continue. 4.5 Business Change Forum The Business Change Forum has been established to provide scrutiny and approval to ensure corporate and strategic fit for programmes and projects, to ensure delivery of the Trust’s business plan.

The forum will undertake the following roles • Undertake Gateway Reviews of all service development and Cost Improvement proposals • Encourage Innovation • Support Change Management • Promote Knowledge Management

The Forum will provide the Executive Management Team with assurance that the programme will deliver the Trust’s aims and priorities and raise early awareness of risk and its impact on project viability.

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�

The membership of the Business Change forum includes;

• Transformation Director (Chair) • Network Directors • Assistant Director Finance • Associate Director of HR • Assistant Director of IMT • Associate Director of Performance Management and Planning • Capital Project Director • Associate Director of Estates & Facilities • Lean Development Lead

The forum meets on a monthly basis and reports to the Executive Management team. �

4.6 Chief Executive Performance reviews The Chief Executive Performance review process has been established as part of the Trust’s governance arrangements. Each network and corporate team’s performance will be systematically reviewed against the balanced scorecard that has been established, to provide assurance to the Executive management team, which has responsibility for the operational management of the Trust. 4.7 Governance Committee

The Governance Committee is chaired by the Chief Executive and meets on a quarterly basis to receive assurance in relation to the following areas;

• Serious untoward incidents • Safeguarding • Incidents claims and customer care • Medicines management • CQC compliance • Risk management • Clinical audit • NICE compliance

4.8 Trust Board The Trust Board receives an integrated performance and quality balanced scorecard on a monthly basis. The granularity of the information has been reviewed to reflect the assurance that the Board has, in the performance management framework that is established throughout the organisation, and will predominantly be focused on exception reports, with the ability to request more in depth reports to provide further assurance. 4.9 Council of Governors The Council of Governors will receive a copy of the integrated performance and quality balanced scorecard on a monthly basis and will have the opportunity to focus on exception reports and request further details through thematic reviews.

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5. Performance management information systems

The ability for individuals, teams, EMT and the Board to access detailed information will be developed through the Informatics portal and through the business intelligence Sharepoint site. This is a key priority as all the above processes rely on robust real time data being available to support individuals, teams and networks in owning and managing their own performance. The ability to ‘drill ‘ down and to model and benchmark activity and data, will support the organisation in applying service transformation tools, for example Lean and Care Aims, to increase productivity and efficiency whilst improving the quality of care provided.

5.1 Clinical systems

The Trust currently has a number of administrative and clinical information systems to support the delivery of clinical care across the organisation.

The Trust’s strategy is to deploy the National Care Records Systems and Electronic Care Records across the majority of clinical services. A clinical systems deployment plan is in place in order to deliver the Mental Health and Community minimum data sets in line with national timescales.

5.2 Finance and ESR systems

Current finance and ESR systems are in place and provide performance management information. The relational alignment of systems is currently being progressed to support the population of the balanced scorecards.

5.3 Informatics portal

The Informatics portal currently has a number of established reports that are accessible to the organisation to monitor performance. These are predominantly activity based reports which are supplemented further by a number of bespoke and ad hoc reports that have either been requested through the Information team or the Performance team.

As scorecards develop the ‘menu’ of reports will be reviewed and streamlined and a process agreed for the production of ad hoc reports.

5.4 Balanced Scorecard development

The alignment of clinical, financial and workforce systems is a key priority to enable the population of scorecards.

The core data requirements of the network scorecards are currently under development and will be incrementally populated as the information systems become aligned.

5.5 Sharepoint development

The availability of business intelligence will be progressed through the development of Sharepoint which will become the repository of information and intelligence to support the development and review of the integrated business plan.

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6. Summary

The paper proposes a performance management framework supported by the development of information systems.

A detailed action plan will be established to deliver each aspect of the framework and this would be monitored through the business change forum.

Susan Rigg

Associate Director of Performance management and planning

November 2011

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


LINK TO BOARD RISK REGISTER:

8. Maintain an effective system of internal control

IMPACT ON THE RISK SCORE OR ASSURANCES IN PLACE:

Not relevant to the risk register

EXECUTIVE SUMMARY The Trust Board receives a monthly integrated report on Performance and Quality. The report for November 2011 is attached.

• Integrated Performance & Quality Report – Appendix 2a • Quality Account – Appendix 2b • Community Service Performance Management Framework – Appendix 2c

At the meeting held on 6 December 2011, the Board supported a proposal to revise the format for future integrated Performance and Quality reports to reflect the development of the Trust’s integrated business plan and associated performance management framework. It was agreed that reporting in the revised format will commence from 1 April 2012.

1.0 BOARD ACTION

The Board is asked to: i) Note the overview of performance provided in the report.

AGENDA NUMBER: TB016/12

AGENDA ITEM: Integrated Quality and Performance Report

DATE OF MEETING: 05/01/2012

PREPARED BY: Susan Rigg



REVIEW DATE: 05/01/2012

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2.0 INTRODUCTION

The Integrated Performance and Quality Report provides the Board with a monthly overview of performance against key indicators relating to: the Monitor Compliance Framework (including financial PI’s), and performance against quality, operations, staffing and reputation indicators.

3.0 BACKGROUND At the meeting held on 6 December 2011, the Board supported the introduction of a revised Performance Management Framework which will promote accountability for performance at a number of levels across the organisation. The report has been structured to provide assurance in relation to the following areas:

• Monitor – Terms of authorisation and Compliance framework • Delivery of the Quality Strategy – patient safety, patient experience and clinical

effectiveness • Delivery of Commissioned activity and targets • Workforce • Membership • Information governance The report will be colour coded to reflect the level of performance achieved for each month and to give an indication of the trend from the previous report and will be supplemented with exception reports in respect of those areas that are rated as red and amber. The red, amber and green (RAG) metrics have been informed by either nationally prescribed targets where they exist or by locally developed targets. It has been agreed that the reporting in the revised format will commence from April 2012. During the intervening period it is planned to share the revised framework with Networks to ensure that reporting arrangements are clearly defined and embedded across the organisation.

4.0 ISSUE

Performance and Quality: The attached report includes commentary on performance. The Board’s attention is drawn specifically to the following:

• Discussions for preparation of the 2012/13 Mental Health and Community

contracts have commenced. Publication of the Department of Health standard contract documentation is expected in January and this will inform the discussions on the future commissioning arrangements in relation to Local Authority commissioners and Specialist commissioning. It will also identify any deed of variations that will be required in respect of the Mental Health and Community contracts which have one year and two years respectively, remaining within the current contract cycle. Regular internal meetings have been established with Network Directors to inform the contracting process.

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• The quarter 3 CQUIN submission is due on 20 January 2012. Full compliance

and reconciliation is expected based on quarter 2 feedback. Regular monthly meetings with the PCT Quality lead have been established to inform the requirements of the 2012/13 CQUIN and Quality schedules. Commissioners are liaising with CCG leads regarding the content. A first draft is expected in mid-January.

• Bed Occupancy Rates – The Junction. The report indicates a month end position of 62%. However, recent activity indicates that the number of referrals to the Junction is increasing. The level of beds occupied has risen since the end of November to 75%.

• Bed Occupancy Rates – Secure Services. Step down accommodation at

Fellside and Forest Beck opened at the end of November. Patients are being moved into new accommodation on a phased basis which has resulted in a reduction in the overall bed occupancy rates for Secure Services (96% October; 85% November). It is anticipated that the wards will be fully utilised by the New Year.

• At the end of November, bed occupancy rates across the Adult Network

reached 100%. This takes into account the closure of Stirling Ward at Blackpool. The networks continue to actively manage the bed capacity.

• Quality Account Inpatient Surveys – It is acknowledged that survey findings

have been based on low response rates. A number of alternative methods for seeking patient feedback are being pursued as part of the updated Quality Strategy, for example, mystery shopper.

5.0 SUMMARY AND CONCLUSIONS

The Integrated Performance and Quality Report provides the Board with a monthly overview of performance against key indicators relating to: the Monitor Compliance Framework (including financial PI’s), and performance against quality, operations, staffing and reputation indicators.

6.0 RECOMMENDATION

The Board is asked to: i) Note the overview of performance provided in the report.

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November 2011

Director of Finance: Dave Tomlinson Company Secretary Di HalseyFinancial Risk Rating �

Achievement of Plan EBITDA Achieved (cf plan) ��

Underlying Performance EBIDTA Margin ��

Financial Efficiency Return on assets ��

I&E surplus margin ��

Liquidity Liquidity Ratio (Days) ��

Current MonthNew Members 22

Members Leaving 260

Public Members 8079Staff Members 6658

Director of Finance/Director of Nursing: Dave Tomlinson/Patrick Sullivan Total Members 14737CPA Patients receiving follow-up contact with 7 days of discharge from hospital �� Target March 2010 12827CPA Patients having formal review within 12 months (Adult network) ��

Minimising delayed transfers of care + ��

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Comment:


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Comment:

Dave TomlinsonDirector of Finance:

Information Governance Management 80%Confidentiality and Data Protection Assurance 75%Information Security Assurance 68%Clinical Information Assurance 73%Secondary Use Assurance 66%Corporate Information Assurance 66%Overall Attainment Score 71%

Meeting Commitment to serve new psychosis cases by early intervention teams

38.25%

Turnover Rate (Total new organisation)

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INFORMATION GOVERNANCE

12.94%

% Staff with Return to Work interview-Target 90% (LCFT only)

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INTEGRATED PERFORMANCE AND QUALITY REPORT

Data Completeness: outcomes

HUMAN RESOURCES


MONITOR COMPLIANCE FRAMEWORKFINANCIAL RISK CONSTITUTION AND AUTHORISATION

Comment

Admissions to inpatient services had access to crisis resolution home treatment teams*

Comment:

Overall rating has fallen back to 3 in line with plan. All metrics are better than plan with a weighted average of 3.6, but overall rating has been constrained at 3 by Underlying Performance scoring a 2.

Growing a Representative Membership

£1,276,983

MONITOR COMPLIANCE FRAMEWORK INDICATORS

Use of Bank & Agency Staff

Data Completeness: Identifiers

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Governor election results were published on 16 December. The successful candidates are as follows: Public: East Lancs - Catherine Dobson & Hilary Whitworth; Central Lancs - Sean Barnes, Jane Kay & Dr Selvizhi Subramanian; North Lancs - Jack Owen & Tony WadeOut of Area - Tahir Khan. Staff: Other Clinical and Social Care Professionals & Support Staff - Barbara Hummer. Nursing Professions & Support Staff - Andrew Kirkby

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D J F M A M J J A S O N D J F M A M J J A S O N D J F M A M J J A S O N

Membership Numbers

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Target March2010

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Media Coverage

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Bed Occupancy

Average Length of Stay

(Untrimmed)Adult �� Adult ��

Older Adult �� Older Adult ��

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Director of Finance:Commissioning for Quality & Innovation (CQUIN) Payment

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Maintain level of crisis resolution teams set in 03/06 planning round (or subsequently contracted with PCT)

Bed Occupancy - Secure Services

Key Targets

Early Intervention: No. people receiving EIS (No. of PCTs in 10% of target current caseload)

Activity/Demand

Assertive Outreach: Number of people on caseload No. of (PCTs in 10% of target)

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Number of Crisis episodes (No of PCT's in 10% of target)

The chart below shows the Trust's assessment of its media coverage. The chart uses a scale whereby the most favourable of articles is scored at +4 and the least favourable of articles is scored as -4. The aggregate score for each month is plotted below

TRUST REPUTATIONWORKING WITH COMMISSIONERS

No drug misusers currently in treatment & no successfully discharged in period - compared to plan

Bed Occupancy - CAMHS Tier 4 (The Junction)

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40

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A M J J A S O N D J F M A M J J A S O N D J F M A M J J A S O N D J F M A M J J A S O N

Length of Stay: Adults

Series1 Series20

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40

60

80

100

120

A M J J A S O N D J F M A M J J A S O N D J F M A M J J A S O N D J F M A M J J A S O N

Length of Stay: Older Adult

Series1

Series2

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A M J J A S O N D J F M A M J J A S O N D J F M A M J J A S O N

CMHT Referrals

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Appendix 2

Health Care Acquired Infection (HCAI)

Serious Untoward Incidents (SUI)

QUALITY ACCOUNT

November 2011-12 Board Report

PATIENT SAFETY

2116

26 28

10 15 18 1726 22

3

8

15 12

1010

1 2

2

7

0

10

20

30

40

50

09/10

Quarter 1

09/10

Quarter 2

09/10

Quarter 3

09/10

Quarter 4

10/11

Quarter 1

10/11

Quarter 2

10/11

Quarter 3

10/11

Quarter 4

11/12

Quarter 1

11/12

Quarter 2

To

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No of incidents reported in each quarter

Not reported in 48 hours Reported in 48 hrs.

2

1520

2418 16 18 18

3023

5

118

9

76

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2

4

0

10

20

30

40

09/10

Quarter 1

09/10

Quarter 2

09/10

Quarter 3

09/10

Quarter 4

10/11

Quarter 1

10/11

Quarter 2

10/11

Quarter 3

10/11

Quarter 4

11/12

Quarter 1

11/12

Quarter 2

To

tal

rep

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s co

mp

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d

No of reports completed in each quarter

Reports not completed within 45 Days Reports completed within 45 Days

13

0

5

10

15

20

25

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Cumulative MRSA Activity against 2011/2012 Target


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Cumulative C-Diff Activity against 2011/2012 Target


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0%

20%

40%

60%

80%

100%


% Reports completed in 45 days against 2011/12 Targets

% Reports completed in 45 days 90% Target

C-Diff

The first graph shows since April 11 there has been no reported cases of C-Diff at the Trust. There have not been any cases of C-Diff reported in the community services since 1st June 2011.

The second graph shows the cumulative number of reported C-Diff cases against the 2011/12 target agreed with LCFT commissioners. The target has been agreed not to exceed the 2010-11 out turn of 4 cases.

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

Since April 11 there has been an increase in the number of reported MRSA cases which peaked at 4 cases being reported by the Trust for June 11.The following two months saw a fall in incidents until September when one incident was reported.October and November have both reported two cases of MRSA. Analysis of the data shows there were no trends found in the reported cases and no evidence to support cross contamination within wards/areas as the incident locations occurred.Community figures have been removed from the graph. The combination of Mental Health and Community reported incidents wrongly represents this years activity and does not allow for comparison to previous years activity displayed in the graph. The number of reported incidents of MRSA from a community setting is one in July and 1 in August.

The second graph shows the cumulative number of reported MRSA cases from a Mental Health setting against the 2011/12 target agreed with LCFT commissioners.The target has been agreed not to exceed the 2010-11 out turn of 17 case. The graph shows that since April 11 a total of 13 cases have been reported by the Trust. Data Source: Infection prevention & Control dept.

93%76%

0%

20%

40%

60%

80%

100%


% incidents reported in 48 hours against 2011/12 Targets

% incidents reported in 48 hours 90% Target

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

Incidents reported in 48 hours The percentage of the incidents reported within 48 hours shows that Quarter 1 met the commissioner target of 90% by 3%, however, in Quarter 2 only 76% of incidents were reported within 48 hours which was below the 90% target.

Reports completed in 45 daysThe percentage of the reports completed within 45 days shows that Quarter 1 met the commissioner target of 90% by 4%, however, in Quarter 2 only 85% reports were completed within 45 days which was below the 90% target.

The short fall in obtaining the 90% targets for SUI reporting and investigations have been discussed at the SUI group and network risk meetings. A review of the process has been undertaken and discussed with key people. The issue of extensions and delays has been discussed and an escalation process put in place. Further guidance will also be sent out to staff reminding them of the timescales.It has been agreed with the Lead PCT that in exceptional circumstances (i.e. where the SUI is complex) there may be an extension to the 45 working day deadline. The figure above excludes the PIRs which had an extension.

0

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1

1.5

2

2.5

3

3.5

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Oct

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Jun

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No

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SPC Chart for C-Diff


0

1

2

3

4

5

6

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9

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Jun

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Jul-

09

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0

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r-1

1

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Jul-

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Oct

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No

v-1

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No

of

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Month/Year

SPC Chart- Number of reported cases of MRSA in a Mental Health

Setting


LCFT Quality Account - November Board Report 2011 Page 1

Appendix 2

Falls Which Result in a Fracture


5

0

2

4

6

8

10

12

14

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r-1

1

Ma

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1

Jun

-11

Jul-

11

Au

g-1

1

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p-1

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Oct

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No

v-1

1

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-12

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2

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2

Cu

mu

lati

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re

po

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Month/Year

Cumulative Falls Activity against 2011/2012 Target


Falls which result in a Fracture

There have been 5 incidents of falls resulting in a fracture since April 11, one occurring in April , one in July, one in October and two in November. The graph shows that overall there has been a lot of variance in the number of reported fractures. This is due to the low numbers involved (0-2 cases per month).

The second graph shows the cumulative number of falls resulting in a fracture against the 2011/12 target agreed with LCFT commissioners. The agreed target is not to exceed the 2010-11 out turn of 13 cases.

The main area of risk is the older adult network. A six monthly review of the performance takes place and practice issues are managed through the network governance arrangements.

Data Source: Datix


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

Reporting of all Pressure Ulcer (with those graded at 3 or 4 being externally reportable) regardless of where on the patient, has been established through the Incident Reporting system.This process in place is working well with Action plans being completed for all incidents and within the designated timescales, with close liaison between the Tissue Viability Nurses and the Community nurses. There have been some instances where the initial grading has been 3 or 4 and therefore reported on STEIS but have subsequently been found by the specialist Tissue Viability Nurses to be lower (and therefore not STEIS portable) and closed . Categorisation of sores is now being addressed

in nurse training sessions. Where the sore is believed to have been acquired within the acute setting, reports are sent to both East Lancashire Hospitals Trust (ELHT) and Lancashire Teaching Hospitals (LTH) providing them with sufficient detail to allow their own investigation to be completed. Where the sore could have been acquired within a nursing/residential home, the reports are sent through to the Commissioning organisation for them to follow up with the commissioned service.

There has been an increase in the category 3 pressure ulcers for both Central and Blackburn with Darwen (BWD) for Quarter 2, with a reduction of category 4 Ulcers in the same period. BWD saw their Category 3 increase from 2 to 8 with their acquisition moving from care home setting to Community setting. The category 4 has been reduced from 5 to 1 with the acquisition remaining the same for Patient home and no new acquisitions from the Care home setting. Central saw their Category 3 increase from 8 to 12 with new acquisitions coming from Care home and Patient home setting. The category 4 has been reduced from 7 to 3 with the acquisition reducing in care home setting and a new case from patients home.The Director of Nursing, Director of Operations and the Medical Director review on a weekly basis and LCFT is commissioning a piece of work to review the data in more detail and look at the implications for Clinical practice.

Data Source: Datix

2

88

12

5

1

7

3

0

2

4

6

8

10

12

14

16

Q1 11/12 Q2 11/12 Q1 11/12 Q2 11/12

BWD Central

No

of

ca

se

s

Categories of Pressure Ulcers by Provider during Quarter 1 and 2 11-12

Category 3 Category 4

32

68

6

5

0

2

4

6

8

10

12

14

Q1 11/12 Q2 11/12 Q1 11/12 Q2 11/12

BWD Central

No

of

Ca

se

s




0

45

2

1

1

1

2

0

1

2

3

4

5

6

7

8

Q1 11/12 Q2 11/12 Q1 11/12 Q2 11/12

BWD Central

No

of

Ca

se

s




*Definitions for graph are: Entry = on entry into community services i.e. From hospital the patient already had a pressure ulcer

Inside = the patient was under the care of community services when a pressure ulcer was acquired Not Stated = Location of acquired Ulcer not stated.

0

0.5

1

1.5

2

2.5

3

3.5

4

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r-0

9

Ma

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Jun

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Appendix 2

Violent Incidents Against Staff

Number of violent incidents against staff (per 1 000 staff) (Source: National Violence Data)

579 157541 146394 80887 218

Reported

Assaults

Assaults

per 1000

Incidences of Violence on Non Staff Members by Service Users

2007/20082008/2009

2009/20102010/2011

Reported Year

537

0

100

200

300

400

500

600

700

800

900

1000

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Month/Year

Cumulative incidents of violence against 2011/2012 Target

Target 11/12 (871 Incidents) Cumulative YTD

515

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600

800

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g-1

1

Se

p-1

1

Oct

-11

No

v-1

1

De

c-1

1

Jan

-12

Fe

b-1

2

Ma

r-1

2

Cu

mu

lati

ve

Vio

len

t In

cid

en

ts

Ag

ain

st S

taff

(p

er

1,

00

0 S

taff

)

Month/Year

Cumulative incidents of violence against staff against 2011/12 Target

Cumulative YTD Target 11/12 (744 incidents per 1 000 staff)

The National Figures released in November 11 shows an increase in the reported incidents by 493 with a 264 or 6.5% decrease in staffing levels. Year on year analysis shows that the we have fewer cases of reported incidents than this time last year with the severity of the incidents predominantly falling in the "None -No injury or adverse/outcome" category. LCFT have analysed the figures and although there is a decline in performance the figure matches the mean when benchmarked against similar organisation, however we are taking this matter seriously with discussions within each network being used to investigate reported incidents. There is currently an analysis of the trend of violent and aggressive incidents across the Trust. Certain key areas have already been identified which should be undertaken to improve staff and patient safety. Staff training is to be reviewed to ensure that staff fully understand recognising aggression triggers, appropriate engagement and a physical skill that used as a last option. De-escalation competence will also be reviewed. Full engagement is needed within networks to address the violence and aggression issues especially where there are repeat offenders. The environment and activities are also key factors for violence and aggression incidents. Work is currently on-going to assess the level and quality of therapeutic activity being undertaken on our wards. When comparing the unvalidated year on year data for Quarter 1 and Quarter 2, it is suggestive that the rate of incidents this year are lower than the previous year.

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

Since April 11, with the exception of June 11, the Trust has seen a dramatic decline in the number of violent incidents against non-staff members. October's figures, however, have seen a dramatic increase from September 11 to record the highest number of reported incidents since September 2010. October's figures are lower than SeptemberIn comparison with October 11, November has seen a 8% decrease (6 fewer incidents) in the number of reported incidents against non-staff. The main categories that has seen an decrease was 'Violent behaviour' with a 46% decrease (6 fewer incidents reported). Out of the 17 categories reviewed there has been 6 other categories have seen an decrease of one or two incidents than October, with the remaining categories showing either no increase or a slight decrease in reported incidents. When reviewing the increase by network there has been an 57% increase (4 more incidents) in incidents in the Secure Services however there has been a decrease of 18% (9 fewer incidents) in the Older Adult Network and 4% decrease (4 fewer incidents) in the Older Adult Network.Further investigations will examine if an individual service user is responsible for the increases in violence or if it is a group of other factors. Analysis of this data takes place on an on-going basis in order to identify any trends by both network and ward. The Director of Nursing submitted a detailed report on violence to the October Trust Board

The second graph shows the cumulative number of reported incidents against the 2011/12 target agreed with LCFT commissioners. The target have not been set by our commissioners, however it is important not to exceed the 2010-11 out turn of 871 incidents. The current trend shows that the target will not be exceeded. Source: Datix

Incidents against Staff

Since April 11 there has been an overall increase in the number of violent incidents against staff culminating in July's figure being the highest incident rate since October 2010. November has seen an increase of three incidents per thousand staff from October’s figures. The types of incidents that have seen an increase are 'Assaults by Patient to Staff' and 'Threats by Patient to Staff'. These types of incidents will continue to be closely monitored in order to feed into an action plan. November’s increase has seen the activity return to a rate matching the Trust average. Links with the wards regarding major incidents and repeat offenders occur on a daily basis. LCFT is working closely with the CPS and Police in regard to serious cases, for example management of illicit drug use on wards.

The second graph shows the cumulative number of reported incidents to staff against the 2011/12 target agreed with LCFT commissioners. If we were to continue with the current trend we would breach the target in Febrruary 2012. The Director of Nursing submitted a detailed report on violence to the October Trust Board. Data Source: Datix

0

10

20

30

40

50

60

70

80

90

100

Ap

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-09

Jul-

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-11

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-11

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v-1

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s p

er

1,0

00

sta

ff

Month/YearPer 1,00 staff Average UCL LCL

0

20

40

60

80

100

120

Ap

r-0

9

Ma

y-0

9

Jun

-09

Jul-

09

Au

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9

Se

p-0

9

Oct

-09

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v-0

9

De

c-0

9

Jan

-10

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Ma

r-1

0

Ap

r-1

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Ma

y-1

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-10

Jul-

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-10

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De

c-1

0

Jan

-11

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b-1

1

Ma

r-1

1

Ap

r-1

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Ma

y-1

1

Jun

-11

Jul-

11

Au

g-1

1

Se

p-1

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Oct

-11

No

v-1

1

No

of

Re

po

rte

d c

ase

s



Appendix 2

Medicine Management

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

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

32%

67% 38.8% 66.6%67% 51.5% 66.7%0% 53.4% 71.7%

36.5% 57.8%

75.0% 75.0%

Patient Safety from Staff Questionnaire

Standards of Care

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

Annual Measures

Percentage of Staff with Mandatory Training

Completed PDP/R & Mandatory Training

% Increase


Target 11/12

Mandatory

Training Financial Year 08/09

Quarter 1 11/12Quarter 2 11/12

PDP/R

Year End 10/11Year End 09/10

Percentage of Staff with Appraisal completed within last 12 months

(Workbook and Induction)


The prescribing of hypnotics has been discussed at the Adult Network Governance group for Step 5. A memo has been circulated to all the wards in Central Lancs requesting that Junior Doctors prescribe stat dose for hypnotics and anxiolytics and they must not prescribe either regular or PRN dose without contacting the second on call or the Consultant on call. Where PRN prescribing is considered necessary out of hours the prescription will be reviewed by the Medical team the following day. The decrease in hypnotic prescribing is evident of the work that has been done in Blackpool and Central Lancs to reduce the amount of hypnotics being prescribed.

Source: Chief Pharmacist

61%

67%

63%

79%

82%

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

Trust Score 2007

Trust Score 2008

Trust Score 2009

Trust Score 2010

National Average for MH Trusts

28%

32%

27%

26%

28%

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

Trust Score 2007

Trust Score 2008

Trust Score 2009

Trust Score 2010



59%

78%

79%

75%

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

Trust Score 2008

Trust Score 2009

Trust Score 2010






Audit results for audits that were completed in 2011 to date.

Use of antipsychotic medicine with learning difficultiesThere are eight standards in this section. The baseline data was undertaken in-house in August 2009 due to the service not being part of LCFT when the POMH-UK baseline audit was done. The re-audit was undertaken in January 2011 from 40 Trusts. The data shows that LCFT came within the top 18 of the ranking for 6 of the 8 standards. The best position was joint 1st for two standards and the worst position were two standards in 31st place for the monitoring of weight and blood pressure.

Prescribing antipsychotics for people with DementiaThere are nine standards in this section. This is a baseline audit that was undertaken in March 2011. Out of the 53 Trusts that took part, our lowest position was 8th with four standards achieving joint 1st ranking. The remaining three standards were not ranked, however when comparing the results the % of patients with a diagnosis of dementia in LCFT who are prescribed an antipsychotic is 14% compared to 15% for the National average.


Appendix 2

PATIENT EXPERIENCE

Younger People Admissions

0

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3

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6

7

8

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Jan

-11

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y-1

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of

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ces

of

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un

g p

oe

ple


5

0

5

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15

20

25

Ap

r-1

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-11

Jul-

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Au

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Se

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-11

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Jan

-12

Fe

b-1

2

Ma

r-1

2

Cu

mu

lati

ve

re

po

rte

d c

ase

s

Month/Year

Cumulative incidents of young persons against 2011/12 Target

Cumulative YTD Target 11/12 (0 incidents)Source: DATIX

Young People Admissions

Since April 11 there have been five reported incidents of a young person being admitted to an Adult ward; one in May 11, three in August 11 and one for September 11. No admissions were reported for October and November. These admissions are subject to a PIR. The number of the admissions to adult wards have been appropriate given the needs of the Young person. An example is the requirement for a PICU bed

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

The second graph shows the cumulative incidents of young person admission to an adult ward against the 2010/2011 out turn. LCFT commissioners have not set a target; however it is important not to exceed the 2010-11 out turn of 21 cases

It was agreed at the SUI Advisory Group that this issue would be kept under close review. A more detailed review of all such incidents has been undertaken. Investigations into the resulting SUI initiated by a breach will now contain a number of key questions. These questions will standardise the information being gathered and provide us with a way to identify and action up on any themes found.

PDR – the data provided reflects the information held centrally by the Learning & OD Team, we continue to request Networks return notifications to the L&OD team for tracking purposes. The new PDR process is being launched in January 2012 and will be supported by an electronic monitoring system which is currently being piloted and is scheduled to be cascaded to all staff prior to the launch of the new process. Once the new process is fully implemented, it is anticipated that PDR data will be updated automatically which will provide more timely and robust reporting in future.Mandatory Training Workbook Compliance – a Mandatory Training Lead has recently been appointed to and is currently reviewing the current frequency and methods of delivery of mandatory training. A blended approach to the delivery of mandatory training is being considered for the future, including making greater use of E-learning as a more efficient and cost effective method of delivering training. However, this may take some time to implement. A new Mandatory Training Policy has been developed and is being consulted upon. All subject matter experts have agreed to delivery targets which have been included in the Mandatory Training Matrix which will support the new Policy. Once approved, the new policy will be implemented from 1 April 2012. Therefore, as an interim solution the content of the Mandatory Training Workbook (MTW) has been updated on the intranet and consideration is being given to providing access to all staff, including those that joined LCFT as part of TCS, to allow staff to fill any gaps in their mandatory training requirements pending implementation of the new policy and matrix from 1 April 2012.

A new report has been developed for the Executive Management Team which provides information on staff who either Did Not Attend or Cancelled Mandatory Training so that Network Directors/Managers can follow up to improve levels of attendance.Further reports are being developed to monitor compliance against Mandatory Training and the L&OD team are currently identifying how to develop these through the use of Data Cube with the IT Team ready for implementation in 2012.


Appendix 2

National Indicators for Quality Improvement that deals with young persons admission

Year/Quarter

2010/11 Quarter 1

2010/11 Quarter 2

2010/11 Quarter 3

2010/11 Quarter 4

2011/12 Quarter 1

2011/12 Quarter 2

Complaint referred to the Ombudsman

07/08 08/09 09/10 10/11 Quarter 1

11/12

Quarter 2

11/12

Source: Customer Services Dept.

0

0

0

5

2010/11 Quarter 4

1

4

2011/12 Quarter 1

913

0

0

0 1

2011/12 Quarter 2 30

2

1

No of patients who referred their

complaint to the Ombudsman


0

1

Occupied Bed Days

0

0

2010/11 Quarter 3

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

admission, under the care of a psychiatric specialist

No of patients

5

5

0

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

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

Occupied Bed Days

95

56

No of patients

6

11

0

60

0

0

Year/Quarter

2010/11 Quarter 1

2010/11 Quarter 2

48 4825

53 45 49 46 49 69 48

64

134 155 139

421365

221 238193 219 243

289

-200

-100

0

100

200

300

400

500

600

Quarter 1

09/10

Quarter 2

09/10

Quarter 3

09/10

Quarter 4

09/10

Quarter 1

10/11

Quarter 2

10/11

Quarter 3

10/11

Quarter 4

10/11

Quarter 1

11/12

Quarter 2

11/12

No

of

Co

mp

lim

en

ts o

r C

om

pla

ints

re

ceiv

ed

Quarter/ year reported

No of Compliments or Complaints received

Compliments- Community Services Compliments- Mental Health

Complaints- Community Service Complaints- Mental Health


Quarter 2 is the first full quarter where we have managed the community providers and this will provide the base line for future quarterly reports. This quarter shows that the number of Mental Health complaints is consistent with previous quarters. The exception to this is quarter 1 where the number of complaints for mental health services was higher than previous quarters . Quarter 2 shows that the number of complaints for mental health services have reduced to previous reported levels.

Source: Complaints Dept.

0

0.2

0.4

0.6

0.8

1


2010/11 2011/12

Oc

cu

pie

d B

ed

Da

ys

Year/ Quarter

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


0

10

20

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40

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100


2010/11 2011/12

Oc

cu

pie

d B

ed

Da

ys

Year/Quarter

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


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

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

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


Appendix 2

Adult & Older Adult Inpatient Surveys Q2 Q3 Q4 Q1 Q2

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

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

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

I knew how to make a complaint if I

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

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

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

Sample size 80 60 116 66 71

Discharges per quarter 904 889 918 977 901

Response Rate 9% 7% 13% 7% 8%

77% 71%

91%

2011/12

68%

83%83% 87%

85

78%

78% 86%

88%

81%

86%86%

7%

61% 73%

7% 10%

88% 77%

Q4

88%

I was satisfied with how I was involved in

planning my hospital care +83%

I was satisfied in how I was involved in

planning my discharge +80%

5%

68%

I got as much information as I wanted

about my treatment +

68%

66

989

81%

84%

98% 94%

Internal SurveyInpatient Surveys

2009/2010

Q1 Q2 Q3

2010/2011

Q1

77% 81% 79%

94%92%

879

79% 81% 78%

79%

90%84% 80%

77% 82% 84%

80%

6997 52

887

10%

Source: Clinical Governance.

86%

86%

971939

80%

78% 81% 81% 71%

75% 71% 86%

72% 78%

Internal Inpatient Survey

The trend for the last 10 quarters has shown an improvement in the majority of areas.The largest improvements was seen in ‘Could I get a hot drink when I wanted?’ with an increase of 25%. This is followed by ‘I knew how to make a complaint if I needed to' with an 8% increase, although the highest figure was 88% in Q4 2010/11. ‘How to make a complaint’ has an 8% increase although the highest figure was in Q4 2010/11 with 88%.

‘How clean in the ward’ has seen a drop by 1% although the highest figure was 98% Q1 2011/12. The only areas to see a decrease was 'The Ward felt a safe place to be in?’ which saw an 8% drop. LCFT Work is on-going to improve patient safety on the wards.

The question "would you recommend us to a friend?” LCFT scored 7 out of the possible 10. LCFT therefore received an average score of 7.2 out of 10 for the 5 quarters.

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

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


Appendix 2

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

How safe did you feel?

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


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

How clean was your ward?

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


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

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


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

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


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

Patient awareness of Complaints

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

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

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

Summary of Survey

A response was received from CQC regarding an issue raised with the 2010 data. The 2010 report which was received from the CQC was an interim report and as such did not show the true 2010 end position for LCFT. This error was noticed when reviewing the 2011 report which contained the 2010 figures. All graphs have been updated to show the change with the variance shown below. The changes do not exceed 1.3% variance.

Overall the results in the inpatient survey showed an improvement on last year’s results, with over half the results exceeding the 2010 survey results (23 exceeding and 2 matching the 45 results reviewed). In the cases that exceeded the 2010 results, the average percentage variance was 3.4%. The indicator ‘D32- During your most recent stay, were there enough activities available for you to do during evenings and/or weekends?’ showed the greatest percentage variance at 10% (2011- 48%, 2010- 38% and 2011 National Average- 44%) for criteria ‘Yes all of the time’ and ‘Yes some of the time’. In the cases where we did not exceed 2010 results, the average percentage variance was -4.7%. The indicator ‘B14- Did you receive the help you needed from hospital staff with organising your home situation?’ showed the greatest percentage variance of -14% (2011- 70%, 2010- 84% and 2011 National Average- 73%) for criteria ‘I received all the help I needed’ and ‘I received some of the help I needed’.

When comparing 2011 outcomes with the National Average, LCFT exceeded or matched the National Average in over half of the indicators (24 exceeding and 5 matching the 45 results reviewed).In the cases that exceeded the National Average, the average percentage variance was 4.5%. The indicator ‘F34- Do you have the number of someone from your local NHS Mental Health Service that you can phone out of office hours?’ showed the greatest percentage variance at 13% (2011 National Average-67%, 2011- 80% and 2010- 79%) for criteria ‘Yes’. In the cases where we did not exceed National average, the average percentage variance was -3.3%. The indicator ‘D31- During your most recent stay, were there enough activities available for you to do during the day on weekdays (Monday to Friday)?’ showed the greatest percentage variance of -7% (2011 National Average- 64%, 2011- 57% and 2010- 53%), although there was a 4% improvement year on year, for criteria ‘Yes all of the time’ and ‘Yes some of the time’.

The overall score 'how would you rate the care you received on your recent stay', LCFT was 1% lower than 2010 score of 72%, but matched the National Average at 71%, when grouping the responses ‘Excellent’, ‘Very good’, and ‘Good’.

No longer comparable


Appendix 2

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

Carers Assessments

Rating of Care

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

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

Medication Purpose

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


Out of Hours contacts

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

Aggregated scores: Answer 'yes'

Review of care plan

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

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

91.7%

92.6%

84.4%

97.7%

93.2%

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

LCFT 2008

LCFT 2009

LCFT 2010

LCFT 2011


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

51.0%

70.0%

63.0%

70.0%

51.0%

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

LCFT 2008

LCFT 2009

LCFT 2010

LCFT 2011


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

57.1%

71.1%

68.8%

77.4%

55.6%

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

LCFT 2008

LCFT 2009

LCFT 2010

LCFT 2011


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

81.7%

86.2%

79.4%

79.6%

78.8%

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

LCFT 2008

LCFT 2009

LCFT 2010

LCFT 2011


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

Dignity and Respect

The results from the National community Survey show that 51.0% of LCFT service users believed they were treated with dignity and respect. This figure is 1% lower than the 2010 result of 52.0% but still exceeds the National averageof 42.0%

Aggregated scores: Answer 'yes in last year'

Care Plan

The results from the National community Survey show that 97.5% of LCFT service users were offered or given a copy of their care plan. This exceeds the 2010 result of 97.0% but is 0.3% lower than the National average of 97.8%


97.0%

97.5%

97.8%

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

LCFT 2008

LCFT 2009

LCFT 2010

LCFT 2011

2011 NationalAverage

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



52.0%

51.0%

42.0%

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

LCFT 2008

LCFT 2009

LCFT 2010

LCFT 2011


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

Not comparable to previous


LCFT Is working towards providing Carer's Assessment data from internal information systems. This will be included in next quarters report.


Appendix 2

Environment & Facilities 96%

Staffing & Training 89%

Access, Admission & Discharge 94%

Care & Treatment 78%

Information, Consent & Confidentiality 97%

Young People’s Rights & Safeguarding

Children98%

Clinical Governance 92%

Location Within a Public Health Context

and Commissioning71%

Privacy and Dignity Single sex accommodation

100% 2%

Peer Review by QNIC The Junction & The Platform External

Access, Admission & Discharge

Overall

score for

2011

% Variance

Information, Consent & Confidentiality

99% 100% 1%

Care & Treatment

98% 6%

8%

100% 100%

92%

90% 2%

90% 98%

98%

88% 96% 8%

Young People’s Rights & Safeguarding Children

Clinical Governance

Location Within a Public Health Context and

Commissioning

0%

97% 94% -3%

88%

Lancashire Care NHS Foundation Trust is pleased to confirm that we are compliant with the Government’s requirement to eliminate mixed sex accommodation, except when it is in the patient’s overall best

interest, or reflects their personal choice. Our Declaration of compliance is located on LCFT website at the below address http://www.lancashirecare.nhs.uk/Privacy-Dignity.php

Initial

Review

2011

SectionSectionOverall

score 2010

Environment & Facilities

Staffing & Training

The JunctionQNIC ReportA review was undertaken on 11th February 2011 by QNIC, Royal College of Psychiatrists’ Centre for Quality Improvement. A visiting team spent one day at the unit speaking to staff, young people and parents about the service focusing on:- Care & Treatment- Information, Consent and Confidentiality

SummaryThe Junction is performing well across all sections of the service standards, and is continuing to improve their compliance with the standards year on year. The team have undertaken many changes since their last QNIC review. In particular, the unit has introduced progress meetings which are working well and the team are looking to continue to build on this. The team have also started to allocate multi-disciplinary mini teams to each young person to get them more involved in their care and planning their treatment.

Clinical Governance is the area that has seen a reduction since the last review in October 2009. The reasons for the reduction have been identified and are now being resolved.

The PlatformQNIC ReportQNIC has also carried out the first peer review at The Platform on 15th March 2011 with the unit taking part in a review covering all sections of the service standards listed in below.

SummaryThe Platform is a new service that opened in April 2010 in response to the amendments to the Mental Health Act and provides a specific service for 16 – 17 year olds. The Platform are performing well against the QNIC standards, and there is a lot of excellent work undertaken to ensure comprehensive user participation.


Appendix 2

PEAT Assessment

Annual Measures National Audit

Implementation of the Quality Strategy

(Source: http://www.ic.nhs.uk/statistics-and-data-collections/facilities/patient-

environment-action-team-peat)

EFFECTIVENESS

All in-patient units have been reviewed and the action plans are being developed. The review of community services has been completed and the reports are being drafted. An update on the Quality Strategy has been provided to the Board in December 11

The following National Audits are being carried out during 2011/2012:-

Patient Involvement Project: Older Peoples Experiences of Falls and Bone Health- the Trust has registered for this national audit which is applicable to a number of community services. The PPI audit packs are currently being sent out to registered trusts by the project officers from RCP. Staff and patients questionnaires have been sent out as per requirements.Psychological Therapy Audit - Nationally the release of the report has been put back till early December 2011. Currently we are still waiting for the

report to be issued.National Audit of Schizophrenia – The audit data has been collected and submitted within National timescles.

POMH-UK Audits- Data collection for audit begins;-September 11 - Topic 7c (Monitoring of patients prescribed lithium)- The audit began in September with data inputting being completed.November 11 - Topic 10b (Use of antipsychotic medicine in CAMHS)- The audit began in November as per requirementsFebruary 12- Topic 1f and 3f (Prescribing high dose and combined antipsychotics on adult acute and psychiatric intensive care ward.

Royal College of Psychiatrist Peer Review:- Evidence is currently being gathered for review in December by Royal College of Psychiatrists and the results will be included when published.

PEAT SCORES 2011

Site Name Site CodeWeighted Environment

ScoreFood Score

Privacy & Dignity

Score

ALTHAM MEADOWS RW5LX 4 Good 5 Excellent 5 Excellent

BURNLEY GENERAL MH RW5CA 3 Acceptable 3 Acceptable 4 Good

CHORLEY GENERAL MH RW5DA 5 Excellent 5 Excellent 5 Excellent

GUILD PARK LODGE WHITTINGHAM PRESTON RW5ED 4 Good 5 Excellent 4 Good

LYTHAM HOSPITAL RW5GD 4 Good 5 Excellent 4 Good

OAKLANDS RW5MA 4 Good 5 Excellent 5 Excellent

ORMSKIRK AND DISTRICT GENERAL HOSPITAL RW5FA 4 Good 5 Excellent 4 Good

QUEENS PARK HOSPITAL RW5AA 4 Good 4 Good 4 Good

RIBBLETON HOSPITAL PRESTON RW5EF 5 Excellent 5 Excellent 4 Good

RIDGE LEA HOSPITAL RW5LA 4 Good 5 Excellent 5 Excellent

VICTORIA HOSPITAL, BLACKPOOL RW5GJ 3 Acceptable 3 Acceptable 3 Acceptable

3.86 Above Acceptable 4.3 Very Good 4 GoodOverall Score

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

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

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

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


Appendix 2

Effectiveness Metrics

Future measures

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

Advancing Quality (AQ)

Baseline data was submitted in accordance with the timescales set by Advancing Quality Alliance (AQuA). The baseline data was used to calculate the regions Implementation Stretch Targets that come into effect in October 2011 and last until March 2012. July11’s data has recently been submitted for both Psychosis and Dementia. The percentage pass rate against the Implementation Stretch Target and against the Baseline data is shown in the graphs below. Baseline data comprised of January to March 2011 data. From October the Trust as entered the monitoring stage by which the LCFTwill be against the Imposed Stretch Targets created by the AQ Steering Group. The data below is unvalidated. Discussions with the Audit Commission is being undertaken to established dates when external audits can take place.

Psychosis Dementia

Psychosis has an implementation stretch target of 85%. Even though this target does not commence till October 11 it is vital we monitor current practice to identify area where we may fall short. The baseline data submission of 88% exceeds the target by 3% however April’s submission fell short of the target by 6%. May’s and June’s figure’s also exceeded the target by 8% and 7% respectively. July is the latest submission with a percentage pass rate of 83%. This fell short of the target by 2%. This figure has changed since last reported on in October 11. There was an issue with patients that had been transferred from other out of area EIS teams. It was agreed with AQuA that these can be excluded from the population and as such their removal has increased the pass rate. Due to this calculated percentages are more easily influence by the small number of fails in the data. Since all the indicators are time limited the missed opportunities to passes are often a result of the criteria being outside the time scale rather than it not taking place at all. Reports have been issued to all senior managers in regard to the figures and recommendation have been made being actioned.

Dementia has an implementation stretch target of 75%. Even though this target does not commence till October 11 it is vital we monitor current practice to identify area where we may fall short. The baseline data submission of 56% fell short of the target by 19%; with April’s submission again falling short by 23%. May’s and June’s figures again fell short of the target by 15% and 19% respectively. July is the latest submission with a submission of 58%. This again fell short of the target by 17% but was a 2% improvement on the previous month. Due to this calculated percentages are more easily influence by the small number of fails in the data. Some of the indicators are time limited with the missed opportunities to passes often a result of the criteria being completed outside the time scale rather than it not taking place at all. The Indicators that need the most attention are in regard to assessment of Depression and Anxiety and tailored care plans for difficult behaviour. Work is on-going with lead clinicians and ward staff in making people aware that assessments must be completed within the set time frames and that appropriate recording of care plans is made. This is being done through posters and instruction manuals which are being issued to all clinical staff and in-depth discussions with Consultant to understand what support they require to ensure the improvement of the indicators and ultimately patient care.All Older Adult wards are continuing to implement the use of eCPA to record the activities required for the submission of the AQ indicators

56% 52% 60%56% 58%

75%

0%

20%

40%

60%

80%

100%


Pe

rce

nta

ge

Pa

ss

Ra

te

Month- Year

AQ Dementia Percentage Pass Rate against Implementation Stretch Targets


Sample = 98

Sample= 34

Sample = 21

Sample = 27

Sample = 29

88% 79% 93% 92%83%

85%

0%

20%

40%

60%

80%

100%


Pe

rce

nta

ge

Pa

ss

Ra

te

Month- Year

AQ EIS Psychosis Percentage Pass Rate against Implementation Stretch Targets


Sample= 47

Sample = 15

Sample = 23

Sample = 14

Sample = 17


��LCFT Community Performance Management Framework position as at end of November 2011

No Indicator Title Description of metric Thresholds Red Amber Green Comments 1 Central Lancashire - Four Week

Smoking Quitters- 2011/12 target 2505

Cumulative percentage of smokers successfully quit at 4 wk follow up against plan

Not on target to achieve plan

Recoverable slippage against plan

On target to achieve plan

Performance for October is slightly lower than the trajectory, however, an additional 86 quitters are still to be confirmed.

2 East Lancashire - Four Week Smoking Quitters- 2011/12 target - 3200

Cumulative percentage of smokers successfully quit at 4 wk follow up against plan




October position reported. Performance continues to be significantly above trajectory.

3 Central Lancashire Chlamydia Screening Target (2011/12) Group 1 – 18.5%; Group 2 – 11.5%

Cumulative percentage of target population screened against plan

Not on target to achieve plan(July position)



An action plan has been developed to increase the volume of screens. Other teams (Contraceptive services & Children’s teams) also have action plans in place to increase screens.

4 Central Lancashire - Access to Genitourinary Medicine - 100% of patients offered an appt to be seen within 48 hrs

Cumulative percentage of patients seen within 48 hours

below target

on target

5 Central Lancashire - Community Equipment (Health)

100% of routine deliveries within 7 days >20% below target

>10% below target

<10% below target

Achieved delivery at 100% for November.

6 Blackburn with Darwen - Community Equipment (Health)

100% of routine deliveries within 7 days >20% below target

>10% below target

<10% below target

Achieved delivery at 100% for November.

7 Central Lancashire - Human Papillomavirus - 90% uptake of target population [Academic year 11/12]

Percentage uptake against plan Not on target to achieve plan



94% of dose 1 immunisations during the first 3 months of the 2011-12 programme. Dose 2 immunisations commenced in October.

8 East Lancashire - Human Papillomavirus - 90% uptake of target population [Academic year 11/12]




90.8% of dose 1 immunisations during the first month of the 2011-12 programme. Dose 2 immunisations commenced in October.

9 Blackburn with Darwen - Human Papillomavirus - 90% uptake of target population [Academic year 11/12]




90.8% of dose 1 immunisations during the 3 months of the 2011-12 programme. Dose 2 immunisations commenced in October.

10 Central Lancashire - National

Child Measurement Programme [Academic year 11/12] Local Target 90%

Delivery of Height and Weight recorded in Reception and Year 6 Children – Target 90%




Delivery of the programme has commenced in line with plan.

11 East Lancashire - National Child Measurement Programme [Academic year 11/12] Target 85%





Delivery of the programme has commenced in line with plan.

12 Blackburn with Darwen - National Child Measurement Programme [Academic year 11/12] Target – Reception 95%; Year 6 90%





The service has achieved the target for Year 6 children (95.4% achieved) Delivery of the programme measuring Reception age children is scheduled to commence.

13 Central Lancashire - School Health Immunisation [Financial Year 2011/12] delivered from September 2011

Cumulative percentage of school leavers boosters delivered – target 90%




Delivery of the vaccination programme has commenced and is on target to achieve plan.

14 East Lancashire - School Health Immunisation [Financial Year 2011/12] delivered from September 2011





Delivery of the vaccination programme has commenced and is on target to achieve plan.

15 Blackburn with Darwen - School Health Immunisation [Financial Year 2011/12] delivered from September 2011





Delivery of the programme in commenced in November.

16 Access to consultant led services within 18 weeks (Central Lancashire)

Number of Patients waiting 18 weeks or more from referral to treatment

�95% <95%

17 Access to Central Lancashire Community Services (18 week PTL including consultant led services)

100% of patients had no 18 week wait at end of November.

>10% below target

<10% below target

<2% below target

Services with an increased wait of over 18 weeks include: • Chronic Fatigue Service – subject

to commissioner review • MSK Physiotherapy – action plan

in place to address service capacity issues

• Primary Care Mental Health Workers – waiting list initiative has commenced to address capacity issues. The service expects to see a reduction in waiting times by the end of February to a maximum of 3 weeks.

Volunteering Services�

�

�

�

��

Update on Volunteering Services Programme Introduction This document provides a comprehensive update on the Volunteering Services Programme and intends to review the current position and provide information about future priorities. We now currently have within our system a total of 518 volunteers, 309 of which are in post. A further breakdown of figures is included in this report. Lancashire Care NHS needed to demonstrate how they would involve the general public and local communities into the Trust. Key to this aim would be volunteering and volunteers. Also, patient experience lay at the heart of the white paper, and so this gave Volunteering Services the opportunity to demonstrate how volunteers made a vital contribution to, not only the personal experience of patients, but also in the methods by which patient experience was measured. We have demonstrated the contribution to the aspirations and goals contained within the plans for the Trust. Progress During 2011

� Streamlining and Improvement of recruitment process � Development of branding and materials � Refined volunteering documentation � Development of website / intranet / SharePoint � Development of policies and guidelines(ready for ratification) � Monthly recruitment awareness sessions � Volunteer corporate and local inductions � Attended external volunteering events � Promoted volunteering services internally � Developed and provided managers workshop � Presented to Senior Management to encourage the involvement of volunteers within

their networks (SMT meetings) � Led on the development of a new database provided by IM&T (90% complete) � Built relationships with third parties (including; CVS, Job Centre and MIND) � Gained membership with NAVSM (National Association of Volunteering Service

Managers – The Trust’s Volunteering Services Manager now represents the North West region at a national level) and Volunteering England

� In process of identifying potential volunteer coordinators already in substantive posts � Recruited a full time, paid administrator – also to become a member of NAVSM � Introduced a structure for the management of volunteers (three month reviews, long

service awards and closer support via Volunteer Services)


�

�

Current Position

1. Volunteer Status Analysis

In Post Pending TCS Volunteer Not Yet In System On Hold

309 121 43 35 10 Comments: The above chart signifies the percentage of applicants within each stage of the recruitment process. These roles are defined as follows:

� In Post – currently volunteering or applicant set to be volunteering within 1 month. � Pending – Currently within the application process. � TCS volunteer – Volunteers we have taken on through TCS. � Not yet in system – Applicant details not yet on the database. � On Hold – Volunteers are defined as ‘on hold’ if, for example they are unwell.

Manageable Targets: Currently we have 309 volunteers in placement and we are looking to keep this figure around the 300 mark in the next year to focus on quality volunteers rather than quantity. .

2. Locality Breakdown

East Central Blackpool,

Fylde & Wyre

North West Other / Across Border

131 20 102 16 0 40

Comments: This demonstrates volunteer involvement across each region. We have incorporated involving West Lancashire into our 2012 targets.


�

�

Future Priorities We are proposing to introduce the following to enhance the Volunteering Services offering in 2012:

� DVD for corporate inductions � Implementation of volunteer policies � Improved co-ordination of staff in networks that volunteer � Volunteer recruitment awareness sessions � Volunteering strategy for The Harbour � Volunteers events � Volunteer mentor training (3 monthly) � Improve links with voluntary organisations (CVS, MIND and Job Centre) � Increase the spread of volunteer usage across the Trust � Launch of volunteer awards

3. Projects and placements launched in 2011

Location December 2011 Location December 2011

ADEPT, Blackburn 33 It's A Goal, Rossendale 5 Balladen House, Rossendale 48 Lymphoedema Team 1

Breast Feeding Support 0 Memory Assessment, Ribbleton 6

Bridge House, Blackburn 1 Older Adult Psychology, Burnley 2

Clitheroe Hospital Rehab Day Unit 1 Open Door Anxiety Peer

Support Group, Colne 1

Colne Children’s Centre, Colne 2 Parkwood, Blackpool 11

Communities Against Cancer 15 Pendle Community Hospital 1

Daisyfield Mill 2 Ribbleton Hospital / Masonic Hall Fundraiser 2

Disability Cycling Programme 1 Ridge Lea, Lancaster 15 Early Intervention Services, Blackburn 3 Ross Centre, Morecambe 1

Fishing Group, Chorley 1 Sceptre Point, Preston 4

Guild Lodge 2 Speech and Language Therapy 1

Healthy Lifestyles, Burnley 3 Springbank Court 1 Healthy Lifestyles, Hyndburn 5 The Bridge, Preston 3 Healthy Lifestyles, Pendle 6 The Chai Centre, Burnley 5

Helpline, Blackpool 85 Volunteer Assistant Psychologist 3

Hyndburn Stepping Out Project 28 Volunteers Counselling,

Chorley 4

Interpreters 1 Wyre Club House 6

�

�

��

Update on Charity Programme Introduction Lancashire Care’s newly developed charity, BetterFutures aims to enhance and compliment the services within the Trust. The aim of the charity is to enhance the service the Trust already provides by being instrumental in developing care and facilities for service users and their families within the local communities. The charity aims to raise independent funds through the kindness of the community and other donations from Trusts, grants and companies. A Fundraising Committee will be established to co-ordinate fundraising initiative and oversee projects and appeals. Funds raised will be used to enhance the services that the Trust provides by providing extra resources, research and equipment. The Trust is corporate trustee for charitable trust funds, but its powers and responsibilities are vested in the Board of Directors (“the Board”). The Board has established a Trustee Committee (“the Committee”) to support it in this regard. The Committee will ensure that charitable funds held in trust are appropriately managed and monitored. Progress During 2011

� Soft launch of the charity at Trust Members Event 12 December 2011

� Pennies from Heaven - The Trust has signed up to the Pennies from Heaven scheme, which enables employees to donate the spare pennies from their income to charity.

� Established Trust Charity Committee

� Fundraising opportunities identified and 8 grant applications submitted to:

o BT - for a free BT internet service (Info Café) o The Dowager Countess Eleanor Peel Trust o Comic Relief Grant o Santander Trust o Tesco o Henry Smith Charity o The Allen Lane Foundation o Lancashire Link (Local Involvement Network)

� Development of Charity Policies & Documents

o Fundraising Strategy (ready for ratification) o Terms of Reference for the Trust Charity Committee (agreed) o Terms of Reference for the Fundraising Committee (to be agreed)

� Development of Communications Plan

o Includes proposals for the development of a website to support the charity and merchandise

�

Future Priorities for 2012

� Business Case – To be finalised and signed off. This will address the governance and operating arrangements that need to be established in order for the charity to run effectively. It will propose an organisational structure and related committees such as the fundraising committee and charity steering group.

� Fundraising Opportunities via o Trust Ball - LCFT are hoping to get involved in the celebrations for Preston

Guild in 2012 and also raise money for BetterFutures. o Global Challenge to India o The Big Lottery Fund o The Gannett Foundation o Small Sparks o Yapp Charitable Trust o West Lancashire Prevention and Early Intervention Small Projects Fund