Board of Directors Thursday 02 April 2020

09:30am

Via Skype Due to the ongoing Covid-19 (coronavirus) outbreak, the Trust is following Government guidance to avoid, wherever possible, large gatherings of all but essential staff. Therefore we will hold this Trust Board meeting in a closed session, all papers and subsequent minutes will be made available on the website as usual.

Nomination Remuneration

Committee Quality

Committee Audit

Committee

Board of Directors

Finance & Performance Committee

Board of Directors Meeting Board of Directors Meeting

Location Virtual Meeting (via Skype/Tele conference)

Date Thursday 02 April 2020

Time 09:30am

Due to the ongoing Covid-19 (coronavirus) outbreak, the Trust is following Government guidance to avoid, wherever possible, large gatherings of all but essential staff. Therefore we will hold this Trust Board meeting in a closed session, all papers and subsequent minutes will be made available on the website as usual.

PART ONE – MEETING IN PUBLIC

Reference Item Lead Action Enc.

TB 098/20 Welcome and opening comments Chair Verbal

TB 099/20 Apologies for absence and confirmation of quoracy Chair Verbal

TB 100/20 Declarations of Interest Chair Verbal

TB 101/20 Minutes of the previous meeting Chair Decision Paper

TB 102/20 Action Tracker Chair Decision Paper

ITEMS FOR ASSURANCE/STANDARD BUSINESS

TB 103/20 Trust Chair’s Report Chair Noting Paper

TB 104/20 Chief Executive’s Report Chief Executive Noting Paper

TB 105/20 Coronavirus Report Director of Nursing and Quality Noting To Follow

TB 106/20 Monthly Safer Nurse Staffing Report

Director of Nursing and Quality Assurance Paper

TB 107/20 Infection, Prevention and Control Quarter 3 Report

Director of Nursing and Quality Assurance Paper

TB 108/20 CQC Update Director of Improvement and Compliance Assurance Paper

TB 109/20 Board Assurance Framework Q4 Report

Director of Improvement and Compliance Assurance Paper

ITEMS FOR DISCUSSION OR DECISION

TB 110/20 Contingency Arrangement for Associate Hospital Manager Reviews During Covid-19

Director of Improvement and Compliance Decision Paper

ITEMS TO NOTE

TB 111/20 Quality Committee Chair’s Report Committee Chair Noting Paper

TB 112/20 Mental Health Improvement Plan Director of Operations Noting Paper

TB 113/20 Quality and Performance Report (QPR)

Interim Director of Partnerships & Strategy Noting Paper

TB 114/20 Finance Report Director of Finance Noting Paper

TB 115/20 Any Other Business Chair Verbal

Declarations of Interest – Board of Directors

Name Role Description Date Inputted Comments

David Eva Chairman

1. Employed by Union Learn as National Manager 2. Trustee of national Association of Racing Staff 3. Non-Executive Director Liverpool Media Academy 4. Independent Chair of the Wirral Integrated Care Partner

20/02/2019

Louise Dickinson Non-Executive Director

1. Director at Talegar Limited 2. Consultancy Services at Talegar Limited 3. Foundation Governor and Finance Chair at St. Vincent’s primary School

20/02/2019

Isla Wilson

Non-Executive Director

1. NED - Progress Housing Group 2. Shareholder - FSquared Ltd 3. Shareholder - Ruby Star Associates Ltd 4. Consultancy/Advisory Work Ruby Star Associates 5. NED - Healthier Lancashire & South Cumbria ICP 6. Chair - Borough Care 7. Director - Life In Colour Ltd 8. Innovation Agency

24/09/2019

Debbie Francis Non-Executive Director Managing Director at Direct Rail Services 01/09/2019

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Name Role Description Date Inputted Comments

Shazad Sarwar Non-Executive Director

1. Director Msingi Research Ltd 2. Lay Member Lord Chancellors Advisory Committee for Cumbria & Lancashire 3. Independent Member Joseph Rowntree Foundation Audit & Risk Management Committee 4. Community Representative Pendle Community Safety Partnership

30/08/2019

Paul Farrimond Non-Executive Director

1. Managing Director of P.F. Consultancy Ltd 2. Facilitate meetings and conferences for the CEOs of the nine mental health Trusts in North East and Yorkshire and Humber 3. Specialist mental health advisor to NHS Providers

24/12/2019 No conflict with LSCFT

Peter Williams Non-Executive Director 1. Secondary Care Doctor Manchester Health and Care Board 2. Non Executive Director NHS transformation unit.

01/01/2020

Bill Gregory Chief Finance Officer

1. Trustee of Healthcare Financial Management Association 2. Co-opted member of Lancaster University Financial and General Purpose Committee 3. Director of HSIS 4. Director and shareholder of Healthcare Business Partnerships Limited (HBP). 5. Strasys Associate Liaison Group NED Advisor

15/01/2020

HBP will not be providing any services to the Trust

Richard Morgan Acting Medical Director Nil Declaration 02/04/2019

Caroline Donovan Chief Executive Nil Declaration 29/04/2019

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Name Role Description Date Inputted Comments

Russell Patton Director of Operations Nil Declaration 28/06/2019

Maria Nelligan Director of Nursing and Quality

1. CQC Executive Reviewer 2. Honorary Senior Lecturer – Chester University 3. Company Secretary at National Mental Health & Learning Disability Director of Nursing Forum

10/10/2019

Nicky Ingham Interim Director of HR 1. Chief Executive – Nicky Ingham and Associates Ltd 2. Executive Director – Healthcare People Management Association (HPMA)

25/09/2019

Ursula Martin Director of Compliance and Improvement Nil Declaration 01/10/2019

Phil Evans Interim Director of Partnerships & Strategy Nil Declaration 31/01/2020

Shelley Wright Director of Communications Nil Declaration 01/02/2020

Declaration of Interest Presented to the Board of Directors on 02 April 2020

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BOARD OF DIRECTORS

Minutes of the Part One Board of Directors meeting held on 05 March 2020 Boardroom, Sceptre Point

PRESENT: David Eva, Trust Chair (Chair)

Caroline Donovan, Chief Executive Louise Dickinson, Non-Executive Director Debbie Francis, Non-Executive Director David Curtis, Non-Executive Director Paul Farrimond, Non-Executive Director Peter Williams, Non-Executive Director Shazad Sarwar, Non-Executive Director Isla Wilson, Non-Executive Director Ursula Martin, Executive Director of Improvement and Compliance Russell Patton, Interim Executive Director of Operations Phil Evans, Interim Executive Director of Partnerships and Strategy Maria Nelligan, Executive Director of Nursing and Quality Bill Gregory, Chief Finance Officer Richard Morgan, Acting Medical Director Nicky Ingham, Interim Executive Director of Workforce & OD Shelley Wright, Executive Director of Communications

IN ATTENDANCE: Chris McAteer, Peer Support Worker (TB 068/20) Kelly Simpson, Patient Experience Administrator (TB 068/20) Louise Guss, Interim Company Secretary

Viv Prentice, Deputy Company Secretary (minutes) OBSERVERS: Sam Proffitt, Newly Appointed Director of Finance, LSCft Justine Westwell, Business Manager to the Chief Executive, LSCft

Chris Watson, Inspection Manager, Care Quality Commission Lesley Davison, Public Governor, LSCft Shamine Hall, Nurse Staffing Manager, LSCft

TB 065/20 WELCOME AND OPENING COMMENTS The Chair welcomed everyone to the meeting and introductions were made.

TB 066/20 APOLOGIES FOR ABSENCE AND CONFIRMATION OF QUORACY There were no apologies for absence and confirmation of quoracy was provided.

TB 067/20 DECLARATIONS OF INTEREST

There were no declarations of interest.

TB 068/20 PATIENT STORY The Director of Nursing and Quality introduced Peer Support Worker, Chris McAteer who was in attendance to present his story through a podcast created by himself. Having used the Trust’s services over many years, the Board heard how he had become involved with the Trust’s Patient Experience Team, firstly becoming involved in projects, then becoming an activity worker at The Guild followed by a Psychological Wellbeing Practitioner (PWP) in the Improving Access

UNCONFIRMED

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to Psychological Therapies (IAPT) service. Now a Peer Support Worker in Blackpool working in the Trust through Calico, a third sector partner of the Trust, the Board heard how experts by experience supported the recovery of others and the powerful impact this had. The Chief Executive thanked Chris for his podcast and confirmed that the Executive Director of Nursing and Quality was currently undertaking a comprehensive review of staffing and was keen to escalate the use of Peer Support Workers. A Non-Executive Director highlighted that this was a real opportunity to innovate how the Trust worked with its service users. The Executive Director of Nursing and Quality confirmed that discussions were already taking place with service users in respect of how they would like to engage with the Trust and an Open Space event had been scheduled for the 06 March 2020 providing service users with the opportunity to ask open questions. It was, however, recognised that further work was required to ensure true collaboration and engagement. A Non-Executive Director highlighted the importance of engaging with self-help groups, whilst the Executive Director of Operations referred to the recent Pennine Community Transformation update to Board which had involved carers and highlighted true co-production. A Public Governor took the opportunity to highlight a particular study at Kirkham Prison where prisoners, families and staff were taught how to identify things in the community that would be beneficial in helping prisoners move on with their lives. Board members were encouraged to refer to the study in terms of enabling people to become involved in their own care.

The Chair thanked Chris McAteer for attending Board and presenting his podcast, which was a great illustration of the power of the support worker.

TB 069/20 MINUTES OF THE PREVIOUS MEETINGS

The minutes of the previous meeting held on the 06 February 2020 were agreed as a true and accurate record.

TB 070/20 ACTION TRACKER The Board reviewed the action tracker and received an update in respect of the one open action. There were no matters arising.

TB 071/20 TRUST CHAIRS REPORT

The Chair presented his monthly report which included an overview of the activity of Non-Executive Directors and Governors. The Board’s attention was drawn to the outcome of the 2019 governor elections which had resulted in the appointment of four newly appointed Public Governors, two re-elected Public Governors and one re-elected Staff Governor.

The Board noted the content of the report.

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TB 072/20 CHIEF EXECUTIVE’S REPORT The Chief Executive presented her report which provided an overall summary of the Trust’s position and highlighted areas for further discussion and celebration. The Chief Executive confirmed that the Trust continued to prioritise improvements in line with the actions identified by the CQC in July 2019 and confirmed that a more detailed update would be provided by the Executive Director of Improvement and Compliance at today’s meeting. The Trust had continued to make significant progress with its Mental Health Improvement Plan. There had been reductions in both the number of people waiting longer in places of safety and the number of people waiting more than 12 hours in A&E. Out of Area Placements (OAPs) did, however, remain a challenge. In relation to South Cumbria, the Trust was working with Cumbria, Northumberland, Tyne and Wear NHS Foundation Trust (CNTW) to review clinical pathways. A full update with options and recommendations would be presented to Board in due course. The national 2019 Staff Survey Results had been published on the 18 February 2020. A more detailed update would be provided by the Interim Executive Director of Workforce & OD; however, it was pleasing to note that staff would recommend the organisation as a place to work, which was a key improvement since 2018. The Chief Executive referred to previous discussions at Board in respect of the closure of the Adult ADHD Service and confirmed that from the 01 July 2020 the Trust would no longer provide this service. The Board were reminded of the ‘Pass It On’ event that was scheduled for the 23 March 2020 following completion of the 20-week Listening into Action (LiA) programme. An update was provided in relation to the ICS and Trust Strategy. From 2020/21 onwards, planning was moving away from requesting operational plan narratives from every organisation, but instead requesting system-led narrative submissions, requiring the ICS to prepare and submit an operational plan narrative on behalf of, and in liaison with commissioners and trusts within the system. The Chief Executive also confirmed that negotiations were still underway in respect of the Mental Health Investment Standard (MHIS). The Chief Executive was pleased to confirm that the target set by CQUIN and agreed with commissioners of 80% of frontline staff being vaccinated had been achieved. The Chief Executive referred to the preferred option for locality working which had been agreed by the Board in February. Engagement with staff had continued, which had included further workshops. A paper to include costings was scheduled to be presented to the April Board.

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Smoke Free continued to be a real challenge for the Trust. Engagement had continued with staff, service users and carers but there was still significant work to do. The Chief Executive referred to a recent incident that highlighted the learning and the need to work more closely with the Police. The Trust’s mental health and wellbeing helpline extended its offer by launching a texting service in September 2019. Feedback collected since then had demonstrated that 100% of people who had used the service said they would do so again. The Board received an update regarding the coronavirus. Posters and information to use around the Trust’s facilities to alert patients and keep them informed had been provided. The Executive Director of Nursing and Quality confirmed that a weekly meeting had been introduced and teams were reviewing their continuity plans. The Executive Director of Operations highlighted that the Trust would have to consolidate its focus on hard core services which would have implications on some of the Trust’s mental health provision. It was therefore important to ensure that community staff had the skills to work on the wards. The Executive Director of Nursing confirmed that teams were looking at infection control processes and workshops would be held to test the plans in place. Following a question from a Non-Executive Director regarding the impact of possible school closures, the Executive Director of Operations confirmed that staff skills and competencies would be reviewed which would include consideration of office staff taking on different roles. Following further discussion, the Chief Executive requested a comprehensive update be presented to the Board in April. ACTION A Non-Executive highlighted the current speed of change and queried how the updates would be communicated. The Chief Executive confirmed that in addition to next month’s comprehensive update, should the Board need to make any decisions beforehand this could be done virtually or by convening an extra-ordinary meeting.

TB 073/20 QUALITY COMMITTEE CHAIR’S REPORT The Committee Chair presented the Chair’s Report following the meeting held on the 10 January 2020 and confirmed that concerns had been highlighted in respect of RiO and the pace of roll out given that there were currently three systems within the Trust. An accelerated programme was in place and an update would be presented at the March meeting. The Chief Executive highlighted that this would be an early priority for the newly appointed Executive Director of Digital who was due to commence in post on the 01 May 2020. Emerging issues highlighted to the Committee included the rapid tranquilisation Q4 re-audit which had indicated a slippage but was yet to be validated. In addition, a review was being undertaken of infection, prevention and control and the results

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of the PLACE visits were due. The Committee would receive updates on these three emerging issues at its March meeting which would focus on progress made. An update on safer staffing had been received. The Committee were happy with the work that was taking place and had been pleased to note that the occurrence of one registered nurse on duty had decreased during the month.

The Pressure Ulcer Improvement Plan had been received by the Committee which highlighted that the level of harm had not been recorded in the correct way. Realignment of policies and guidance around the categories of harm was underway and Datix would also be updated. Concerns had also been raised in respect of how the Trust accessed equipment. Discussions were taking place with the CCG and an update would be presented to the next meeting. The Committee Chair was pleased to note that Sarah Green, Chief Pharmacy Technician had been awarded ‘Pharmacy Technician of the Year’ by the Associate of Pharmacy Technicians UK. The Chair took the opportunity to highlight that this was the Committee Chair’s last Chair’s Report prior to leaving the Trust at the end of March and thanked him for his contributions. The Board noted the content of the Chair’s Report.

TB 074/40 SOUTH CUMBRIA COMMITTEE CHAIR’S REPORT The Committee Chair presented the Chair’s Report following the meeting held on 20 February 2020 and confirmed that an initial paper in respect of the quality of services pertaining to the services in South Cumbria had been received. It had been agreed that the Executive Director of Improvement and Compliance would provide guidance on this assurance framework for the Committee.

In respect of the Post Transfer Assurance Report, the estates plan was currently under review and the phasing of work had been prioritised on the level of ligature risk areas. The Committee Chair confirmed that the Committee was reviewing the quality of assurance and triangulation between the Safety Team and the HSIS team to ensure that the programme of works would address the gaps. Quality and safety issues on Ramsey ward were currently being investigated following a second referral to the CQC. The Committee would therefore receive a report on the underlying quality and safety themes and would monitor the proposed response. With regards to integration into the Bay locality model, the Committee Chair confirmed that a report would be presented to the next meeting.

The Board noted the contents of the Chair’s Report.

TB 075/40 PEOPLE AND CULTURE COMMITTEE CHAIR’S REPORT The Committee Chair presented the Chair’s Report following the meeting held on 24 February 2020 and confirmed that this was a newly established committee of

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the Board and that given the scale of challenge the first meeting had been held ahead of April 2020. The draft Terms of Reference (ToR) were discussed and proposed changes suggested.

The Committee received a presentation outlining the People Strategy and the underpinning six work streams. A discussion also took place in respect of the Board Assurance Framework and if people risks were fully articulated.

The Board noted the content of the Chair’s Report.

TB 076/20 MONTHLY SAFER STAFFING REPORT AND ANNUAL SAFER STAFFING REPORT The Executive Director of Nursing and Quality presented her report, which provided an update on the Trust’s nurse staffing and assurance of actions being taken to improve safety and quality in the delivery of care to people who use the Trust’s services. During January, across 43 inpatient settings, the Trust achieved an average day fill rate for registered nurses (RNs) of 77.8% and 127% for health care support workers (HCAs). For night shifts, the average fill rate had increased to 98.9% for RNs and 162% for HCAs. Taking skill mix adjustments into account, an overall fill rate of 91.8% on days and 149% on nights was achieved. This demonstrated a decrease in fill rates on days and an increase on nights in month.

The Executive Director of Nursing and Quality confirmed that the Trust monitored incidents in relation to staff through Datix, the Trust’s incident reporting system. A total of 10 Datix incidents were recorded in January 2020 for inpatient wards in relation to staffing, all of which resulted in ‘no harm’.

In order to maintain safe staffing levels, a total of 838 staff breaks were cancelled on inpatient wards in December. Any time accrued due to missed breaks was taken back as time off in lieu (TOIL) with agreement of the Ward Manager. This would be continually reviewed to ensure that staff wellbeing was supported.

An update was provided on recruitment and retention, which continued to be a priority for the Trust. A number of recruitment events had been held and the Trust was working with Cumbria, Northumberland, Tyne and Wear NHS Trust (CNTW) to explore overseas recruitment.

The newly registered practitioners (RNs, AHPs and Nursing Associates) who commenced with the Trust continued to be supported by the Preceptorship Academy Pathway. Currently, 85 preceptor RNs and 11 Nursing Associates were being supported.

The Executive Director of Nursing and Quality drew attention to Appendix 1 within the report and confirmed that the total column headed ‘RN vacancies’ should read 270.67 and not 29.96.

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The Executive Director of Nursing and Quality presented the Annual Safer Staffing Report (2019) which detailed the findings of the 2019 annual review of ward nursing staffing establishments completed in December 2019. This review followed on from the previous 2018 review undertaken using the Hurst model, which was presented to Board in February 2019. In addition to implementing the 2018 Annual Safer Staffing Review, during 2019 the Trust implemented a revised shift pattern. This resulted in a standardised hybrid shift model being introduced, which included a mixture of both long and short shifts. The impact the shift pattern consultation has had on the current staffing review was in relation to the funding required for the shift pattern. The hybrid pattern costs more to implement on wards established for long days only and less for wards established for a short shift pattern. The Executive Director of Nursing and Quality confirmed that a number of recommendations were made within the report to ensure that safe staffing was maintained within a sustainable model, which supports high quality care. This included ensuring inpatients had access to a range of psychological interventions, improvements in the environment on inpatient wards and the development of a clear nursing career pathway from Band 2 entry level through to Consultant Nurse. The development and expansion of new roles would also include Peer Support Workers, Registered Nursing Associates, Advanced Nurse Practitioners and Consultant Nurses. In addition, there would be a robust clinical and leadership continuing professional development (CPD) offer to support continual improvement in delivery of high quality care and a rolling recruitment programme for RNs. A summary of the financial case for safer staffing was provided. The Executive Director of Nursing and Quality confirmed that the impact of the skill-mix changes would be a reduction in budgeted establishment of £768,479. In addition, the review had identified that the Harbour required Practice Development support and that all wards should have 0.5 WTE Peer Support Workers, which would total £289,911. This would result in an overall reduction in budgeted establishments of £478,568. The financial impact of the hybrid shift pattern was highlighted as £246,571. As a result, the recommendation of the Safer Staffing review would result in an overall reduction in budget of £231,997.

In respect of reporting, the Director of Nursing and Quality confirmed that to strengthen assurance to the Board, safer staffing fill rates would be reported using clinically required staff as the planned staffing levels from April 2020.

A Non-Executive Director highlighted the physical and psychological impact of shift work and the importance of ensuring staff were fully supported.

The Acting Medical Director referred to recommendation one within the report and confirmed that any future alterations to shift patterns for medical staff would be overseen by himself and not the Executive Director of Nursing and Quality.

Following a question from a Non-Executive Director regarding oversight, the Executive Director of Nursing and Quality confirmed that following approval of the

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recommendations, the action plan would feed up to both the Quality Committee and People and Culture Committee. In addition, the action plan would be periodically presented to Board and an Annual Report would be presented every six months.

Following a comment from a Non-Executive Director regarding longer hours, travel time and possible fatigue, the Chief Executive requested that the Interim Director of Workforce & OD considered fatigue indicators and how it would fit into the overall approach to the Trust’s People Strategy. ACTION

The Executive Director of Nursing and Quality took the opportunity to formally acknowledge and thank the teams that participated in the review and confirmed that it was her view that overall, with the mitigations in place, nurse staffing levels were safe.

The Board noted the content of the report.

Lesley Davison left the meeting

TB 077/20 PROGRAMME OF INTERNAL VISITS The Executive Director of Nursing presented an update on the programme of internal visits, which included the key functions of each visit programme and how they were designed to provide assurance and support improvements within clinical teams. An overview of the current visits that take place was provided. It was proposed that the Good Practice Visits and CCG Quality Visits were merged to ensure that there was robust governance around such visits. The Safer Staffing review visits and PLACE inspections would continue as per the current programmes. The overall assurance framework would be strengthened by the addition of Trust Unannounced Assurance visits which were designed to provide the Trust Board with the opportunity to view practice and performance and seek assurance that individual team’s on-going quality improvements were robust and sustained. It was also proposed that Director Engagement visits be introduced, facilitated by an Executive Director, who would visit Trust teams on a rotational monthly basis. Later in the year, Observe and Act visits would be introduced that would be service user led and were designed to review the clinical environment from a service user’s perspective. The Quality and Assurance visits would be reported to the Quality Committee through the quarterly Quality Visits Report with proposed implementation at the end of Quarter 3.

Following a question from a Non-Executive Director regarding unannounced visits and whether staff-side would view them negatively, the Executive Director of Nursing and Quality confirmed that they would be conducted in a balanced, supportive, professional manner.

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The Chair confirmed his support of the visits, which helped staff prepare for actual inspections from regulatory bodies. Following a further comment from a Non-Executive Director in respect of ensuring the visits were perceived as positive, the Acting Medical Director confirmed that the message to staff was really important, as was ensuring visits were undertaken in a supportive way and not performance managed. The Executive Director of Improvement and Compliance welcomed the paper and was particularly pleased to note that the Trust would be working with the CCG to undertake joint visits. The Board approved the following recommendations

Merge Good Practice and CCG Quality Visits Introduction of Trust Unannounced Assurance Visits from April 2020 Introduction of Director Engagement Visits from April 2020 Introduction of Observe and Act Visits from Quarter 3 Introduction of a Quarterly Quality Visits report to Quality Committee from

01 April 2020. Shamine Hall left the meeting

TB 078/20 MENTAL HEALTH IMPROVEMENT PLAN The Interim Executive Director of Operations presented his report, which provided an update on the mental health pathway developments and detailed the work being undertaken on the Pennine Lancs Transformation programme, rehabilitation developments and the latest iteration of the Mental Health Improvement Plan.

The Interim Executive Director of Operations confirmed that there continued to be high numbers of individuals receiving care by the Home Treatment Team with caseloads equating to circa 24 wards of patients being home treated. There was a variance in the ratio of patients to staff in teams, ranging from 2.4 patients per WTE in Pennine to 5.5 patients per WTE in Lancaster. The Interim Director of Operations recalled previous concerns regarding how well the Trust was recording face-to-face activity and confirmed that advice and guidance had been provided to teams to ensure more accurate recording. January performance data had provided an early indication of success with a 12.6% increase in face-to-face activity in January compared to December 2019, which was very positive. In respect of the increase in mental health liaison activity, this was in line with expectations of increased investment.

In terms of A&E one and four hour compliance, there had been a marked improvement, which had been recognised by acute colleagues at the recent Regional Review meetings.

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Twelve-hour breaches remained an area of concern for the Trust and its acute colleagues. The total number of breaches linked to the Trust increased in January to 28, compared to 21 in December 2019. An emerging issue was the number of patients attending East Lancs Emergency Department that had been referred by NHS111 which would need to be addressed.

Both the average and longest post-Decision to Admit (DTA) times were showing downward trends. It was also highlighted that January breaches occurred across a range of weekdays, with spikes on Thursdays and Sundays.

The Board’s attention was drawn to the bed utilisation graph in the report and the black horizontal line that reflected the total bed capacity that the Trust (excluding South Cumbria) would have if inpatient capacity was commissioned at the population-weighted national average, which highlighted that there would be little or no pressures in acute wards. In respect of monthly averages, the Interim Director of Operations confirmed that it was important to recognise that the increase from September 2019 to November 2019 corresponded with the closure of the Mental Health Decision Units (MHDUs).

January saw a slight decrease in police calls to the Mental Health Access Line compared to the previous month, with 138 calls having been recorded. A meeting had therefore been held with the police to encourage constables on the beat to utilise the access line. The Interim Director of Operations confirmed that it was important to recognise that the number of s136 detentions had decreased slightly in January from 119 to 116.

The Interim Director of Operations referred to the deep dive into activity, which highlighted that the bulk of referrals in the liaison service were between 8am and 12noon and 12noon and 4pm. In respect of 136 activity, there was significant use between 8pm and 4am, which demonstrated a lack of suitable alternatives. Within crisis/HBT, the bulk of activity was between 8am and 8pm.

Following a question from a Non-Executive Director regarding 12-hour breaches and the use of AMPs, the Acting Medical Director confirmed that the Trust was working with Lancashire County Council with regards to stepping down patients.

An update was provided regarding the Pennine Lancs Transformation Programme, which had commenced in September 2019. A number of design workshops had been held during late 2019 and early 2020 involving service users, carers, partners, key clinical staff and support staff. A number of standard processes and pathways were considered for review, which included a simple referral process to access mental health services that was accessible to all. In addition, the concept of a ‘trusted assessment’ would be adopted throughout the prescribed pathways.

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The clinical pathways were discussed at length during the workshop. If deemed appropriate for mental health intervention, service users would access one of three clinical pathways: psychosis, non-psychosis or cognitive. Since completion of the clinical pathway re-design workshops, it had been recognised that there would be value in designing a discreet pathway to meet the needs of patients who present with EUPD. This design workshop, facilitated in conjunction with CNTW was planned for the 16/17 April 2020.

Following the design workshops, a two-day planning event was held to review the pathway design work and staff feedback sessions held to ensure high levels of ownership and buy-in.

The next steps were outlined which included the development of a high-level Transformation and Delivery Plan. An update was provided regarding rehabilitation provision. At the August Board the benefits of developing a ‘moving on’ rehabilitation ward at the Avondale site in Chorley was discussed. Unfortunately, the Trust had been advised that there would be a delay in the construction and fitting out of this facility with handover to services anticipated as being mid-May 2020. The Board noted the contents of the report.

TB 079/20 QUALITY AND PERFORMANCE REPORT (QPR) The interim Director of Partnerships and Strategy presented the report for month ten and confirmed that that the Trust was compliant with eight of the 11 current NHSI metrics. The Trust failed the 95% target of following up discharges from Mental Health inpatients within 7 days of the discharge date, achieving 93.4%. Inappropriate Out of Area Placements (OAPs) continued to exceed the current trajectory (as agreed at the start of 18/19), as it did not account for the absence of rehabilitation beds and the National Team’s hypothesis regarding the factors causing OAPs in Lancashire. Actions to improve the OAPs position were being progressed as part of the system-wide action plan developed to respond to the NTW review. The latest position available (October 2019) of the Data Quality Maturity Index (DQMI), reported by NHS Digital, showed the Trust was non-compliant against the 95% standard (and the 90% - 95% for the CQUIN achievement) at 89.2% but was continuing a month on month improvement.

The Interim Director of Partnerships and Strategy referred to the South Cumbria monthly metrics dashboard and highlighted the improvements in performance data for 7-day follow-ups and the two-week wait for treatment for EIP programme. There still remained a challenge for OAP usage. In respect of Children and Young People’s Wellbeing, the referral to assessment performance for CAMHS/CPS teams did not achieve the 92% target. Of the seven

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teams within the Emotional Wellbeing service, five were currently achieving the 92% 18 weeks RTT standard. The teams not achieving 92% were noted as Chorley, South Ribble (CSR) at 66.8% and Lancaster and Morecambe at 91.1%.

The ADHD service continued to underperform against the 92% target. There had been 115 referrals in month 10, which was a total of 981 so far in 2019/20 compared to the contracted number of 556 per annum.

In respect of IAPT prevalence, the year to date target was 28,171. To date the service had undertaken 25,317 new assessments, a shortfall of 2,854. An action plan was therefore in place to address this.

The Executive Director of Nursing and Quality provided an update on the quality section of the report and confirmed that it had been recognised that a significant amount of work needed to be undertaken with regard to incident reporting and management. Two external reviews had been concluded, the results of which would be presented to the Quality Committee. In the meantime, incidents were being reviewed on a daily basis in terms of severe harm incidents.

Following a question from a Non-Executive Director regarding the CQUIN summary for 2019/20 and the loss against the Data Quality Maturity Index, the Director of Improvement and Compliance confirmed that this would be reported to the Executive Directors on a regular basis through the Finance Committee. Following a further question regarding whether there was sufficient resource, the Director of Improvement and Compliance confirmed that the Trust had recently appointed an Executive Director of Digital to bring together the data. The Chief Executive also highlighted that data quality would be a high priority for the newly appointed Executive Director of Digital. The Board noted the content of the report.

TB 080/21 OPERATIONAL PLAN 2020/21

The Interim Director of Partnerships and Strategy presented the Board with the Trust’s draft Forward Plan for 2020/21 in response to national and ICS guidance.

The Chief Executive highlighted that the Trust had been clear that there was significant investment in year in adult crisis services and that making that recurrent was a priority

The Board noted the draft Trust 2020/21 Forward Plan.

TB 081/20 FINANCE REPORT The Chief Finance Officer presented the finance report and confirmed that the year to date position was in line with plan at £1.6m deficit. Cash continued significantly ahead of plan, with further increases from last month mainly as a result of the sale of the Sharoe Green site.

Following a question from a Non-Executive Director regarding the control total, the Chief Finance Officer confirmed that this would be signed off by the 27 April 2020.

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The Board noted the contents of the report. TB 082/20 CQC UPDATE

The Executive Director of Improvement and Compliance presented the report which provided Board with an update in relation to the outcome of the internally led CQC preparation visits to the Acute Wards and PICU week commencing 10 February 2020 and exception reporting against the CQC action plan. The Board’s attention was drawn to the exception report at Appendix 1. Good progress was being made with progress reviewed through the CQC Steering Group. In order to gain further assurance that actions had been completed, a series of visits were undertaken in February 2020 across the Trust’s Acute Wards and PICUs. The aim of the visits was to specifically review the key elements of the Warning Notice issued to the Trust on 24 July 2019. An update on the findings was provided which included significant improvement in medicines management and consent to treatment. There was also evidence of significant improvement in supervision with a focus on sustaining compliance. In respect of environmental issues, work to remove dormitory accommodation was underway and in respect of learning disability and autism, training was now in place and compliance monitored and reported. The quality of care plans remained under scrutiny to ensure consistency, with a number of actions underway to address this. In respect of the Trust not implementing the no smoking policy, some elements of positive practice were evident during the visit that was largely aligned to good leadership and really good supervision and training. With regards to staffing, on the whole, across the wards that were visited, there was sufficient nursing and care staff on shift.

An update was provided in respect of the dormitory risk assessments. At the Scarisbrick Inpatient Unit at Ormskirk work was currently underway and scheduled to be completed on the 08 May 2020. At Hurstwood at Hillview Blackburn, a plan was being scoped and at Kentmere in Kendal a piece of work was underway to review bed provision within The Bay locality. In the meantime, the risk assessments conducted across the three wards were being reviewed on a regular basis. A Non-Executive Director requested that attention be paid to the wording when articulating the risk around dormitories as mixed sex was a dignity risk.

The Executing Director of Nursing and Quality referred to the smoking issue and confirmed that whilst work was on-going the message would need to be reinforced whilst ensuring there was leadership at ward and team level. The Chief Executive requested an update on the implementation of smoke free to be included as an appendix to the CQC update paper. ACTION

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The Chief Executive thanked the Director of Improvement and Compliance for a comprehensive report and the change in culture from reassurance to assurance.

The Board noted the progress and update provided together with the associated governance arrangements.

TB 083/20 STAFF SURVEY RESULTS The Interim Director of Workforce & OD presented her report to inform Board members of the nationally benchmarked results from the 2019 Annual Staff Survey. The results were based on staff in post and organisational structures as at 01 September 2019 and therefore did not include South Cumbria staff. A summary of the results was provided which highlighted that the Trust’s score for overall staff engagement had improved slightly. Eleven summary indicators referred to as ‘themes’ had been created from responses to certain individual questions. The Trust’s scores had improved slightly since 2018 for six of the 11 key themes. The Interim Director of Workforce & OD confirmed that the three priority areas for improvement identified by staff included equality, diversity and inclusion; safety culture and health and wellbeing. The Trust had commenced work on these three themes building on work already underway across the Trust. The Network and Directorate Leadership Teams were currently in the process of analysing the results specific to their areas and action plans would be developed to address improvement and build on strengths. These would be presented to the March 2020 Business Performance meeting. The People & Culture Committee would also apply scrutiny and oversight to the Trust-wide action plan which would be presented to the Board in April. ACTION A further discussion ensued regarding the three priority areas for improvement following which it was agreed that appraisals would also be added as a priority area for improvement. ACTION

The Board noted the outline summary of the staff survey report, the four priority areas for Trust-wide action and noted the role of the People and Culture Committee in overseeing the staff survey improvement plan.

TB 084/20 FREEDOM TO SPEAK UP BI-ANNUAL ASSURANCE REPORT

The Executive Director of Improvement and Compliance presented the bi-annual update on the raising concerns system and process which was an independent, impartial and objective report from the Freedom to Speak Up Guardian. In respect of reporting, the Executive Director of Improvement and Compliance confirmed that the quarterly Freedom to Speak Up report that was previously presented to the Quality Committee would, in future, be presented to the People & Culture Committee.

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In addition to providing assurance reports, regular meetings were held with the Freedom to Speak Up Guardian and the Non-Executive lead for Freedom to Speak Up. As highlighted in December 2019, the Trust’s full-time Freedom to Speak Up Guardian was now in place and proactive work was being undertaken within the Trust in respect of encouraging staff to feel confident in raising any concerns with their managers. Recruitment for Freedom to Speak Up Ambassadors had been advertised across the organisation and there were currently 21 Ambassadors on the Ambassador register. In order to grow the register, the Freedom to Speak Up Guardian and the Equality and Diversity Lead were planning to join Ambassador roles across both provisions in May/June 2020. Following a question from a Non-Executive regarding people raising concerns that wished to remain anonymous, the Executive Director of Improvement and Compliance confirmed that this was included in the quarterly report and their anonymity protected.

The Board noted the report and the assurance provided.

TB 085/20 PROPOSED TRUST CORPORATE GOVERNANCE STRUCTURES

The Executive Director of Improvement and Compliance presented both her report and presentation, which provided Board with proposals in relation to new corporate governance structures. A summary of the feedback themes following the recent development session was provided. This included importance of clarity of Terms of Reference, the importance of discussions between Executive leads and Chairs of Committees before and between meetings and clarity upon approval route for business cases.

A piece of work that had been undertaken in parallel was looking at a meeting structure from ward level right up through the organisation and ensuring there was a golden thread. The Executive Director of Improvement and Compliance drew the Board’s attention to the Board and Committee meetings structure, highlighting in particular what was new. This included decommissioning of the Finance Recovery Group (FRG). The Chief Executive commented that service users were not a consultative body and needed to be at the same level as the Council of Governors and that it was important that they were seen as a partner.

The Board confirmed they were happy in principle with the structure. The Executive Director of Improvement and Compliance confirmed that further work would be undertaken which included determining the positioning of digital in the reporting structures, splitting out infrastructure so that digital and capital were separate entities and the introduction of a Research and Complaints Quality Assurance meeting.

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The Board were presented with the three options for meeting frequency. The pros and cons of each option was subsequently outlined to the Board.

A discussion ensued in respect of the three options. The Chief Executive confirmed that she was supportive of the views of the Committee Chairs on the frequency of meetings but stressed that there needed to be a clear link between the committees and the Board and was therefore hesitant about moving to bi-monthly Board meetings.

Following further discussion, it was agreed that Board meetings would be held monthly with the exception of August and December. Committee meetings would be held bi-monthly with the exception of the Audit Committee, which would continue to meeting quarterly, and the Finance and Resource Committee that would meet on a monthly basis.

The next steps were outlined which included the production of standard business templates for use.

TB 086/20 ANY OTHER BUSINESS There was no further business to discuss.

The Chair noted that this was the last meeting for both Non-Executive Director, David Curtis and the Deputy Company Secretary as they were both due to leave the Trust at the end of March. The Chair thanked them both for their contribution to the Trust and wished them well for the future.

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BOARD OF DIRECTORS – ACTION TRACKER – PART ONE

DATE ACTION REF NO

ACTION OWNER ACTION

KEY DATES/FORECAST

COMPLETION STATUS IMPLEMENTATION STATUS/CLOSE

OUT ACTION

February 2020

TB 036/20

SW Timings of Future Board Meetings Consider future arrangements, for example venues and timings of Board meetings.

April 2020 Open On the Board agenda for April 2020 with implementation from May 2020 Due to the ongoing developments with the coronavirus, this has been removed from the April agenda and added to the forward plan for discussion at a later date.

March 2020 TB 072/20 MN

Coronavirus An update of the Trust’s preparedness and plans to be presented to the Board in April.

April 2020 Closed Included on the April agenda.

March 2020 TB 076/20 NI

Safer Nurse Staffing Consideration to be given to fatigue indicators that will fit into the overall approach to the Trust’s People Strategy.

June 2020 Open

March 2020 TB 078/20

MN

CQC Update An update on the implementation of smoke-free to be included as an appendix to the CQC update paper presented to Board.

April 2020 Closed An update has been included within the CQC update

March 2020 TB 083/20

NI Staff Survey Results Appraisals to be added as a priority area for improvement.

April 2020 Closed Appraisals have been added as a priority area for improvement.

March 2020 TB 083/20

NI Staff Survey Staff survey action plan to be brought to the April Board.

April 2020 Open It has been agreed that this will now be presented to the May Board.

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Board of Directors Agenda Item TB 0103/20 Date: 02/04/2020

Report Title Trust Chair’s Report

Prepared By Umme Batan, Corporate Governance Support and PA to Chair & Non-Executive Directors

Presented By David Eva, Trust Chair

Action Required Noting

Supporting Executive Director Chief Executive

PURPOSE OF THE REPORT: Report Purpose The purpose of the report is to provide the Board with an

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

Strategic Objective(s) this work supports

To become recognised for excellence

Board Assurance Framework Risk 1.0 The Trust does not protect the people who use its services from avoidable harm and fails to comply with the CQCs standards for the quality and safety of services

CQC Domain Well-led 1.0 NON-EXECUTIVE DIRECTOR ACTIVITY

The Non-Executive Directors have been attending the Board Committee meetings of which they are a member and apologies have been given where they were unable to attend. In addition to the usual Board business, Non-Executive Directors (NEDs) have been involved in their areas of special interest during the period 02 March 2020 – 27 March 2020:

David Curtis

Attended the Clinical Excellence Awards Training Attended the Nomination Remuneration Committee Attended the NEDs quarterly meeting Attended the Quality Committee Attended the Council of Governors meeting Had the bi-monthly Chair and Senior Independent Director meeting Chaired the Quality Committee meeting

Louise Dickinson

Attended the Nomination Remuneration Committee Attended the NEDs quarterly meeting

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Chaired the South Cumbria Assurance Committee meeting Had a discussion around the Digital Strategy with the Director of Improvement and

Compliance and the Deputy Medical Director/Chief Clinical Information Officer and Non-Executive Director Paul Farrimond

Isla Wilson Had a discussion around the ICS Board with Amanda Doyle Attended the ICS Board Meeting Attended the Nomination Remuneration Committee Attended the NEDs quarterly meeting Had a handover for the Finance and Performance Committee with NED Shazad Sarwar Took part in the formal panel for the ICS Independent Chair Interviews Attended the LiA Pass it On Event Had the Chair and Deputy Chair catch up Attended the ICS Governance task and Finish Group Attended the North West Provider/CCG Chairs Event Attended the Quality Committee meeting

Shazad Sarwar

Attended the Nomination Remuneration Committee Attended the NEDs quarterly meeting Attended a Hospital Managers Hearing in Pendleview Had a handover for the Finance and Performance Committee with NED Shazad Sarwar Attended the Quality Committee meeting Had a conversation with the Chief Finance Officer around the Finance Committee Attended the South Cumbria Assurance Committee Attended the LiA Pass it On Event

Debbie Francis

Had a conference call regarding Digital Strategy Attended the Nomination Remuneration Committee Attended the NEDs quarterly meeting Had a discussion around the Digital Strategy with the Director of Improvement and

Compliance and the Deputy Medical Director/Chief Clinical Information Officer and Non-Executive Director Louise Dickinson

Attended the HSIS Board Meeting

Paul Farrimond Had a discussion around Mental Health Act with the Director of Improvement and

Compliance, the Associate Director of Effectiveness and the Mental Health Act Law Manager

Had a discussion around the Digital Strategy with the Interim Director of Workforce and OD and the Deputy Director of Health Informatics

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Attended the Nomination Remuneration Committee Attended the Open Space Event

Peter Williams

Attended the Nomination Remuneration Committee Attended the NEDs quarterly meeting Attended a two day Non-Executive Director Induction delivered by NHS Providers Met with the Interim Director of Strategy and Partnerships to discuss the Strategy and

Partnership Committee meeting Attended the LiA Pass it On Event

2.0 CHAIR’S ACTIVITY

Had the weekly catch ups with the Chief Executive Had the monthly 1:1 with the Deputy Chair Had the bi-monthly Chair and Senior Independent Director Meeting Attended the Nomination Remuneration Committee Attended the NEDs quarterly meeting Met with Nominated Governor from Lancashire County Council The Chair and Chief Executive met with the MP for West Lancashire Had the monthly catch up with the Interim Company Secretary The Chair and Chief Executive met with Ribble Valley to discuss Dementia Care in

Lancashire Had a discussion around the Digital Strategy with the Chief Nursing Officer Chaired the Council of Governors meeting

3.0 COUNCIL OF GOVERNORS UPDATE

Due to the ongoing developments with the Coronavirus pandemic, the decision was taken not to hold the Council of Governors meeting scheduled for the 19 March 2020.

4.0 USE OF THE COMMON SEAL To inform the Board that the Common Seal has not been applied.

5.0 BOARD ACTION

The Board of Directors is asked to: Note the content of the Trust Chair’s Report

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cBoard of Directors Agenda Item TB 104/20 Date: 02/04/2020

Report Title Chief Executive’s Report

Prepared By Caroline Donovan, Chief Executive

Presented By Caroline Donovan, Chief Executive

Action Required Noting

Supporting Executive Director Chief Executive

PURPOSE OF THE REPORT: Report Purpose The purpose of this report is to provide Board members with

an overall summary of the Trust position and highlight areas for further discussion and celebration.

Strategic Objective(s) this work supports

To provide high quality services

Board Assurance Framework Risk 2.0 The Trust does not deliver safe, appropriate and therapeutic environments to deliver high quality services

CQC Domain Well-led INTRODUCTION

This report updates the Board on activities undertaken since the last meeting and draws the Board’s attention to any other issues of significance or interest.

Local Updates BOARD ACTION: Noting

1. CORONAVIRUS/COVID-19 UPDATE Following a Board briefing circulated to colleagues on March 17, 2020, and to prevent out of date circulating, a report will be tabled at the meeting.

2. CQC UPDATE The Care Quality Commission (CQC) completed a series of unannounced visits to our adult inpatient wards between March 10 and 15, 2020 related to the warning notices. We received some positive initial and informal feedback from the team, with a formal report setting out the findings expected and will be shared in due course. Thank you to everyone involved in supporting the significant improvements evidenced to the CQC from within the Trust and for the professional approach in supporting these visits.

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The Trust has also received formal confirmation following on from the Health Based Places of Safety inspection, undertaken in January 2020, that the warning notices relating to the Health Based Place of Safety has been lifted due to the significant improvements the Trust has made, specifically in relation to the significant improvement in Section 136 breaches and monitoring and follow up of these, mandatory training, supervision and the governance arrangements in place from the Trust and from a multi-agency perspective. In addition, the CQC has written to us to say that due to the fast-moving response to the Coronavirus pandemic it will be refocusing activity where it is needed most and concentrating on those areas where the risk to the quality of care is the highest and it can make the biggest difference. The CQC has confirmed that it will be supporting providers by looking at reducing preparation for inspection and limiting the need to be on site.

3. MENTAL HEALTH IMPROVEMENT PLAN

The Trust and the local system’s approach to the delivery of an effective urgent care mental health pathway continues to be the subject of national scrutiny, in particular in terms of its impact on the number of our inpatients who are treated out of our geographical area. As Board members will be aware, we have utilised locally commissioned and nationally secured funding to invest in a broad range of key clinical areas. This investment has enabled us to recruit more people to a number of key services which, in turn, has increased clinical performance as well as service user experience. One of the most prominent examples of this can be found within the Mental Health Liaison Service where the number of clinical contacts, compliance and the amount of time people in spend in health based places of safety and A&E before being treated, have all seen a significant improvement in year, despite a marked increase in people accessing our services through emergency departments (EDs). For many of our service users in crisis, the EDs continue to be the ‘front door’ to mental health services therefore it is imperative that we continue to give ongoing focus to this discreet service offer. A full summary of the key urgent care mental health pathway metrics is included as part of the agenda and will be summarised further by the Executive Director of Operations in presenting the report to the Board. We are currently working to strengthen even further our urgent mental health response in light of the COVID-19 pandemic.

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4. VACANCIES The Trust continues to proactively recruit to the high number of vacancies we currently have within the organisation. The Recruitment and Retention group has now been established. This includes a number of options for consideration including a broader reach relocation policy, refer a friend, Recruitment and Retention premium, amongst other ideas. We have launched a campaign to encourage applications to the Trust and are working on a far reaching campaign with nursing and quality with communications and workforce colleagues. We are exploring other opportunities in relation to international recruitment with colleagues at CNTW. The need to recruit registered nurses continues to be a priority for the Trust and in line with the safer staffing review, the changes to skill mix will support the Trust in being proactive in career development and educational opportunities for our staff. Recruiting to the high number vacancies we have across our wards will escalate further under the pressure of responding to the COVID-19 pandemic. We do have and are implementing detailed plans to recruit registered nurses. An update will be provided to the board in due course.

5. LEARNING DISABILITY AND/OR AUTISM The Trust continues to focus on one of our key priorities to improve the Learning, Disability and Autism pathways for Lancashire and South Cumbria service users. As part of a number of significant developments, the Lancashire and South Cumbria Integrated Care System has now established an improvement board which is chaired by its Chief Executive Amanda Doyle. The board has further established a number of work streams, which are now underway. These include:

Development of an Intensive Support Team initially working on transferring this function from our colleagues at Mersey Care NHS Foundation Trust to Lancashire and South Cumbria NHS Foundation Trust

A steering group which will oversee all plans through the creation of an overarching business case which seeks to establish and increase in provision at the Whalley site

A further business case has been developed to provide a service specifically for people with autism. This is now progressing through the governance process for the improvement board

The Executive Director of Nursing and Quality is the Executive lead for Learning Disability transformation plans, working with other Execs from the Trust and partners from within the system including the Clinical Commissioning Groups.

6. ICS & TRUST STRATEGY UPDATE As part of the national response to the COVID-19 pandemic, the operational planning process for 2020/21 has been suspended. All analyses of draft submissions made to the Integrated Care

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System (ICS) and Regional Team on March 5 will be stopped and weekly system planning calls and system planning workshops have been cancelled. Guidance has been published by NHSE/I setting out the revised financial arrangements for April 1 to July 31, 2020, which includes directives for additional costs incurred in responding to the outbreak. With regards to our existing contracts with CCGs, all NHS providers will have a guaranteed minimum level of income reflecting current cost bases and commissioners have been instructed to agree block contracts with all NHS providers with whom they have a contract for the period April 1 to July 31, 2020. For mental health trusts, this will include an uplift to deliver the mental health investment standard. Despite the suspension of the planning process, we will continue to work with commissioners and other partners in the development of our mental health services, including rehabilitation facilities, and in providing appropriate services for people with learning disabilities and autism.

7. PARTNERSHIP PROJECT RECOGNISED FOR MENTAL HEALTH BENEFITS The Trust’s partnership with the Wildlife Trust was recently recognised at the North West Coast Research and Innovation Awards 2020. The Myplace project won the ‘Partnership in Innovation’ award for work to connect people with nature to support with mental health problems such as anxiety and depression. The partnership project has helped more than 1,200 people between the ages of 13 and 50 over the last three years. Feedback from participants has been really positive and the model is set to be replicated across the North West and the rest of the country.

National Updates BOARD ACTION: Noting

8. COVID-19 PANDEMIC

National focus from all NHS organisations remains firmly on the response to the COVID-19 global pandemic. A number of nationally organised events have been cancelled including the NHS ConfedExpo, scheduled to take place at Manchester Central on June 10 and 11.

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Board of Directors Agenda Item TB 106/20 Date: 02/04/2020

Report Title Monthly Safer Staffing March 2020 Report (February data)

Prepared By Shamine Hall, Nurse Staffing Manager

Presented By Maria Nelligan, Executive Director of Nursing and Quality

Action Required Assurance

Supporting Executive Director Director of Nursing and Quality

PURPOSE OF THE REPORT: Report Purpose To provide Board with:

An update on LSCFT nurse staffing Assurance of actions being taken to improve safety

and quality in the delivery of care to people who use our services

The report provides assurance that all efforts are being made to ensure detailed internal oversight and scrutiny is in place to ensure safer staffing levels are maintained

Proposed next steps.

Strategic Objective(s) this work supports

To provide high quality services

Board Assurance Framework Risk 1.0 The Trust does not protect the people who use its services from avoidable harm and fails to comply with the CQCs standards for the quality and safety of services 2.0 The Trust does not deliver safe, appropriate and therapeutic environments to deliver high quality services 6.0 The Trust does not have sufficient leadership to deliver the transformational change required to address the cultural changes, improve wellbeing and to empower staff and widen the diversity of our workforce

CQC Domain Safe

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1. Introduction

The National Quality Board (NQB) has described the importance of organisations supporting their staff to provide high quality compassionate care. Lancashire and South Cumbria NHS Foundation Trust (LSCFT) is committed to developing a nursing workforce, which is highly skilled and resilient to deliver safe and effective care.

This report details the in-patient daily nurse staffing levels during the month of February 2020 following the reporting of the planned and actual hours of Registered Nurses, Registered Nursing Associates (RNAs) and Health Care Support Workers (HCA) to NHS Digital. Additionally, as required, the Trust has also reported Care Hours per Patient Day (CHPPD) to NHS Digital. The CHPPD calculation is based on the cumulative total number of patients daily over the month divided by the total number of care hours.

2. Background

The monthly reporting of safer staffing levels is a requirement of NHS England and the National Quality Board (NQB) in order to inform the Trust Board and the public of staffing levels within in-patient units.

In addition to the monthly reporting requirements the Executive Director of Nursing and Quality is required to review ward staffing on a 6 monthly basis (comprising of a comprehensive annual review and 6 month follow-up) and report the outcome of the review to the Trust Board of Directors. The comprehensive annual safer staffing review report for 2019 was presented to March 2020 Board by the Executive Director of Nursing. This review, prioritised the adult acute mental health wards and utilised the Telford model which takes into account professional judgement and includes nursing practice, leadership, finance and estate. The recommendations from this report were approved by Board in March 2020 and will be progressed and monitored through the Staffing for Safety and Quality Group. The group has representatives from Nursing and Quality, Networks, Workforce Information and the Quality Academy who are responsible for progressing the Safer Staffing recommendations agreed by Board. The group reports to the Quality and Safety Sub-Committee directly and People and Quality Committee in the form of a Chairs report.

3. Trust Performance

During February, across 43 in-patient settings, the Trust achieved an average day fill rate for registered nurses (RNs) of 72.3% and 125% for health care support workers (HCA’s). For night shifts the average fill rate was 95.7% for registered nurses and 159.3% for HCA. Taking skill mix adjustments into account an overall fill rate of 87.4% on days and 147.2% on nights therefore overall a 117% fill-rate was achieved This demonstrates a decrease in fill rates on days and an increase on nights in month. Where 100% fill rate was not achieved for RN’s, safety was maintained by the deployment of nurses working additional hours, RNA’s and HCA’s covering shifts and cross cover by ward and senior nurses. Wards were also supported by ward managers, matrons and MDT colleagues. The current staffing review has identified that throughout days there are additional clinical staff that are supernumerary and these provide additional support for the wards. Night duties are supported by a duty matron who is based centrally at the Harbour. A breakdown of ward fill rates can be found in appendix 1.

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4. Care Hours per Patient Day (CHPPD)

The Trust is required to report CHPPD to NHS Digital on a monthly basis. The CHPPD calculation is based on the cumulative total number of patients daily over the month divided by the total number of care hours. The CHPPD metric has been developed by NHSI to provide a consistent way of recording and reporting deployment of staff providing care in inpatient units. The aim being to eliminate unwarranted variation in nursing and care staff distribution across and within the NHS provider sector by providing a single means of consistently recording, reporting and monitoring staff deployment.

As reported via NHS Digital overall the Trust averaged 14.3 hours in February 2020 per patient day per day on the wards. For the Trust CHPPD (appendix 1) continues to be highest within specialist services that have a greater staff to patient ratio, for example perinatal and PICUs. Two of the Trust PICUs have a low number of beds (Lathom 4 and Calder 6 beds) which also increases CHPPD. Additionally the high percentage of in-patients with a diagnosis of Emotionally Unstable Personality Disorder (EUPD) and other complex presentations have required high levels of observations on wards, often these patients, have been unable to be discharged due to lack of community provision. All of these factors contribute to this higher level of CHPPD.

5. Impact of Safe Staffing Levels

Ward managers’ report the impact of unfilled shifts on a shift by shift basis. Staffing issues contributing to fill rates are summarised in appendix 2.

5.1 Impact on Patient Safety

The Trust utilises HealthRoster to monitor and report on staffing, within HealthRoster the SafeCare module includes a census 3 times a day to enhance the ‘real time’ oversight and response to staffing. The SafeCare module now includes a red flag summary. Red flag events are locally and nationally determined early indicators that safer staffing levels on a ward may be of concern and therefore have a potential impact on the safety of patients. These are identified via the SafeCare module on HealthRoster and enable an early response to issues as they arise; they are utilised in daily staffing huddles by matrons and by site managers for this purpose.

During February the majority of red flags related to reported incidences of there being 1 RN on duty of which there were 151 occurrences (an increase from 126 in January 2020). In terms of themes the one area where there was a significant number of occurrences (64) was within Guild Secure Services, all of which were on days; this was however a reduction of 16 in month. Of these day shifts 51 were on weekdays when ward managers, modern matrons and lead nurses are on duty. Therefore increased senior nurse visibility on wards to maintain safe staffing and further support was provided by MDT colleagues. Additionally, Guild Lodge have a supernumerary senior nurse on site to co-ordinate staffing, provide clinical leadership and maintain safety. The Orchard has had 5 red flags in month of instances of one RN on duty. This has been due to sickness on nights.

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In addition to the red flag summary in SafeCare the Trust also monitors incidents in relation to staffing through Datix, the Trust incident reporting system. A total of 9 Datix incidents were recorded in February 2020 for inpatient wards in relation to staffing, all of which resulted in ‘no harm’. These incidents were:

Site/Ward Staffing Incident Mitigation Guild Bank staff did not attend for duty leaving the

ward short Patients leave was rearranged and breaks were cancelled. Temporary staffing team informed for follow up.

Guild Only 13 RNs on site (for 15 wards) for the night shift

One RN was transferred from the Harbour, two RNs from days remained on duty until 10pm, and the senior nurse was ward based ensuring that all wards had RN duties.

Guild Only 16 RNs on site (for 15 wards) for the night shift

Breaks for RNs reduced or cancelled.

Longridge Staff (HCA) unable to attend for duty due to weather conditions

Local staff contacted following this shift sent to agency but unable to cover

Orchard One RN from 1am and bank HCA had to leave the night shift early (0630)

On-call informed

Harbour Preceptorship nurse only RN on duty Supported by RN on adjoining ward (including cover for break) and the MHUNIC

Shift numbers shorts resulting in patients leave being cancelled and breaks reduced

Leave rearranged for patients

Shift numbers shorts due to high levels of acuity Staff breaks cancelled or reduced Ramsey Shift number short on the night shift due to

sickness Escalated to manager, attempted to cover but not successful.

5.2 Impact on Patient Experience

Staff prioritise patient experience and direct patient care. During February 2020 there were 10 occasions when therapeutic leave had to be cancelled as a result of shortfall in nursing staff. All leave was rearranged at the earliest opportunity.

5.3 Impact on Staff Experience

In order to maintain safe staffing levels a total of 815 staff breaks were cancelled on inpatient wards in February; this is approximately 4.2% of breaks and this is a slight decrease of 23 in month. Any time accrued due to missed breaks is taken back as time-off in lieu (TOIL) with agreement of the ward manager.

Breaks should only be missed breaks in order to maintain patient and staff safety and must be approved on HealthRoster by the level 1 approver (band 7 or above). Missed breaks are monitored via HealthRoster and staff are allocated time owed in lieu. This is being monitored at a local level by the Heads of Nursing.

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5.4 Mitigating Actions

Ward managers and members of the multi-disciplinary team have clinically supported day shifts to ensure safe patient care. Additionally, skill mix may be altered to maintain safe staffing, in February a total of 99 RN shifts were covered by HCA where RN temporary staffing was unavailable and there were 28 instances of RNs covering HCA shifts. Additionally, as outlined in section 5.3 staff breaks have been shortened or cancelled and wards have crossed covered to support safer staffing levels. Both the Harbour and Guild Lodge have daily safety huddles with senior nursing staff. Further oversight is provided by a daily safety teleconference between services. Additionally, Temporary Staffing was utilised to backfill vacant shifts with a total of 489.16 (an increase of 40.59 WTE in month) supplied on average each week during February, with the breakdown as follows:

Role Bank WTE average per week Agency WTE average per week

Registered 88.56 19.16

Support Workers 341.76 39.68

Total 430.32 58.84

6. RN Staff Vacancies and Recruitment

In comparison to December, vacancies for RN within inpatients rose by 8.5 WTE during February 2020 however at a Trust wide level the RN vacancy rate remained reasonably static in February at 15.56% from 15.32% in January 2020. This corroborates reports that a number of RNs transferred to community teams within the mental health network and therefore they did not leave the Trust however highlights the need to have attractive career opportunities within the in-patient wards; this is being addressed through the Annual Safer Staffing Review currently being undertaken by the Director of Nursing and Quality. Additionally it should be noted that the annual safer staffing review recommendations increased Band 4 and Band 6 nursing roles and decreased band 5 roles; as a result there will be a reduction in RN vacancies of 58 WTE once the recommendations have been transacted. This is being planned for April 2020.

RN Nursing Vacancies (Inpatients)

Apr 2019

May 2019

Jun 2019

Jul 2019

Aug 2019

Sep 2019

Oct 2019

Nov 2019

Dec 2019

Jan 2020

Feb 2020

All inpatient wards excluding South Cumbria

167.12 257.91

(Hurst included)

262.2 270

275

272.75

227.8 227.2 253.48 256.7 265.18

South Cumbria – Kentmere, Dova and Ramsey

14.1 14.1 13.9 13.9 19.74

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Recruitment of registered practitioners continues to be a priority for LSCFT. Innovative approaches includes the employment of Learning Disability nurses and Global Learners within mental health settings. Two global learners have passed their OSCE enabling them to register with NMC. Three are due to arrive in late March. The Trust is also working with Cumbria, Northumberland, Tyne and Wear NHS Trust (CNTW) to explore overseas recruitment.

The newly registered practitioners (RNs, AHPs and Nursing Associates) who commenced within the Trust continue to be supported by the Preceptorship Academy Pathway. South Cumbria held a second recruitment event on the 7th March 2020 and 3 third year student nurses (2 MH and 1 LD) were offered posts.

The second phase of the safer staffing review has commenced in February 2020 prioritising the Guild and South Cumbria Wards.

7. Summary

This report provides an update on LSCFT nurse staffing for February 2020. During the reporting period staffing challenges remain evident, which also reflects the current national picture. Despite these challenges, ward managers and clinical teams have maintained safer staffing levels. The Director of Nursing and Quality is currently overseeing the annual staffing review and will lead the safer staffing action plan to ensure recruitment, retention and skill mix of staffing on wards is maximised.

8. Recommendations

The Board is asked to:

Receive the report; Note the challenges in delivery safer staffing; Note the mitigations and action plans in place; Be assured that safe staffing levels have been maintained during February with the support of

rostered and non-rostered nursing and MDT staff.

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2020 February

Ward

Day

Establishment Day Actual

Night

Establishment Night Actual

Day

Establishment Day Actual

Night

Establishment Night Actual Day Fill Rate % Night fill rate Day Fill Rate

Night Fill

Rates Overall RN%

Overall Care

Staff %

Overall

Staffing

Longridge Ward (C) 840 1004.75 560 580 1050 756.75 560 510 119.6% 103.6% 72.1% 91.1% 111.6% 81.6% 96.6%

The Orchard 900.48 802.14 616 557.12 1500.8 1777.32 1232 1411.82 89.1% 90.4% 118.4% 114.6% 89.8% 116.5% 103.1%

Fairsnape Ward (S) 924 571.09 301 364.58 616 996.48 602 1149.25 61.8% 121.1% 161.8% 190.9% 91.5% 176.3% 133.9%

Greenside Ward (S) 924 469.92 301 360.5 1232 1091.27 602 935.42 50.9% 119.8% 88.6% 155.4% 85.3% 122.0% 103.6%

L2063 Calder Ward (S) 924 626.68 301 352.5 1232 1767.49 602 1952.8 67.8% 117.1% 143.5% 324.4% 92.5% 233.9% 163.2%

Fairoak Ward (S) 924 449.75 301 377.34 924 838.75 602 664.42 48.7% 125.4% 90.8% 110.4% 87.0% 100.6% 93.8%

Forest Beck Ward (S) 616 435.93 301 404.5 616 588.42 602 596.42 70.8% 134.4% 95.5% 99.1% 102.6% 97.3% 99.9%

Whinfell Ward (S) 924 668.91 301 380.5 924 1141.25 602 956.75 72.4% 126.4% 123.5% 158.9% 99.4% 141.2% 120.3%

Marshaw Ward (S) 924 585.59 301 451 1232 1137.51 602 1045.99 63.4% 149.8% 92.3% 173.8% 106.6% 133.0% 119.8%

Elmridge Ward (S) 1232 585.92 301 295.5 924 2418.46 903 3406.92 47.6% 98.2% 261.7% 377.3% 72.9% 319.5% 196.2%

Bleasdale Ward (S) 924 637.26 301 326.75 924 1408.14 602 1726.68 69.0% 108.6% 152.4% 286.8% 88.8% 219.6% 154.2%

Mallowdale Ward (S) 616 427.01 301 336.17 308 655.98 602 637.92 69.3% 111.7% 213.0% 106.0% 90.5% 159.5% 125.0%

Dutton Ward (S) 1232 491.35 301 361.75 924 1519.11 1204 1561.98 39.9% 120.2% 164.4% 129.7% 80.0% 147.1% 113.6%

Langden Ward (S) 1232 659.18 301 326.75 924 1485.68 903 1112.48 53.5% 108.6% 160.8% 123.2% 81.0% 142.0% 111.5%

Fellside East Ward (S) 924 467.02 301 347.33 616 1812.18 602 2307.49 50.5% 115.4% 294.2% 383.3% 83.0% 338.7% 210.9%

Fellside West Ward (S) 616 545.34 301 307.42 616 770.02 602 442.5 88.5% 102.1% 125.0% 73.5% 95.3% 99.3% 97.3%

Hermitage Ward (S) 616 479.11 301 337.92 308 658.56 301 340.33 77.8% 112.3% 213.8% 113.1% 95.0% 163.4% 129.2%

Ribble Assessment 1500.8 1386.33 924 610.32 1200.64 1114.83 616 1006.68 92.4% 66.1% 92.9% 163.4% 79.2% 128.1% 103.7%

Worden Ward 1200.64 991.6 616 606.6 1200.64 1369.19 1232 1186.98 82.6% 98.5% 114.0% 96.3% 90.5% 105.2% 97.9%

Hyndburn Ward 1200.64 777.65 616 580.18 1200.64 1521.29 1232 1447.2 64.8% 94.2% 126.7% 117.5% 79.5% 122.1% 100.8%

Darwen Ward 1200.64 1137.86 616 578.88 1200.64 1344.13 1232 1243.52 94.8% 94.0% 112.0% 100.9% 94.4% 106.4% 100.4%

PICU Calder 900.48 888.19 616 569.16 1200.64 1339.68 924 1554.4 98.6% 92.4% 111.6% 168.2% 95.5% 139.9% 117.7%

PICU Avenham 900.48 733.2 616 537.8 1200.64 2018.92 924 2940.74 81.4% 87.3% 168.2% 318.3% 84.4% 243.2% 163.8%

Edisford Assessment 1500.8 1468.22 924 428.39 1200.64 1436.47 616 1065.78 97.8% 46.4% 119.6% 173.0% 72.1% 146.3% 109.2%

Hurstwood 900.48 818.58 616 589.6 1500.8 2625.37 1232 2263.67 90.9% 95.7% 174.9% 183.7% 93.3% 179.3% 136.3%

Duxbury Ward 1200.64 794.18 616 581.16 1200.64 1487.06 1232 1309.6 66.1% 94.3% 123.9% 106.3% 80.2% 115.1% 97.7%

Shakespeare 1260 719.54 600.32 590.38 1862 2114.11 900.48 1821.63 57.1% 98.3% 113.5% 202.3% 77.7% 157.9% 117.8%

Stevenson Ward 1260 722.22 600.32 514.49 1862 1872.4 1082.48 1590.66 57.3% 85.7% 100.6% 146.9% 71.5% 123.8% 97.6%

Churchill Ward 1260 757 600.32 589.6 1260 1321.23 900.48 1068.9 60.1% 98.2% 104.9% 118.7% 79.1% 111.8% 95.5%

Orwell Ward 1260 615.99 600.32 450.52 1260 1687.74 900.48 1181.29 48.9% 75.0% 133.9% 131.2% 62.0% 132.6% 97.3%

PICU Byron Ward 1260 619.53 600.32 531.28 1862 2105.83 1082.48 1675.16 49.2% 88.5% 113.1% 154.8% 68.8% 133.9% 101.4%

PICU Keats Ward 1260 687.57 600.32 591.55 1260 1755.37 900.48 1419.54 54.6% 98.5% 139.3% 157.6% 76.6% 148.5% 112.5%

Austen Ward 1260 724.91 600.32 557.4 1680 1647.36 900.48 1429.38 57.5% 92.9% 98.1% 158.7% 75.2% 128.4% 101.8%

Dickens Ward 1260 738.4 600.32 557.44 1680 1530.56 900.48 1372.16 58.6% 92.9% 91.1% 152.4% 75.7% 121.7% 98.7%

Bronte Ward 840 633.72 600.32 556.32 1680 2250.81 900.48 2115.56 75.4% 92.7% 134.0% 234.9% 84.1% 184.5% 134.3%

Wordsworth Ward 840 628.98 600.32 538.72 1680 2946.75 900.48 2529.92 74.9% 89.7% 175.4% 281.0% 82.3% 228.2% 155.2%

Scarisbrick 1200.64 944.33 616 612.82 1200.64 1425.44 1232 1425.57 78.7% 99.5% 118.7% 115.7% 89.1% 117.2% 103.1%

PICU Lathom 600.32 711.96 616 526.56 900.48 1099.34 924 1114.88 118.6% 85.5% 122.1% 120.7% 102.0% 121.4% 111.7%

CAMHS The Cove 900.48 788.5 616 655.47 1200.64 1186.45 1232 1515.53 87.6% 106.4% 98.8% 123.0% 97.0% 110.9% 104.0%

Perinatal 900.48 844.5 660.00 659.79 900.48 864 332.22 399.7666667 93.8% 100.0% 95.9% 120.3% 96.9% 108.1% 102.5%

Kentmere Ward 690 467.5 290.88 274.77 883 643 804.88 957.47 67.8% 94.5% 72.8% 119.0% 81.1% 95.9% 88.5%

Dova Ward 921 820 325.5 236 1043 1472.5 907.5 828 89.0% 72.5% 141.2% 91.2% 80.8% 116.2% 98.5%

Ramsey ward 806.5 1200 281 346.69 1691.5 1528 814.9 1058.43 148.8% 123.4% 90.3% 129.9% 136.1% 110.1% 123.1%

Totals 43577.5 31527.41 21259.58 20339.52 49882.46 62531.2 36581.30 58281.587 72.3% 95.7% 125.0% 159.3% 87.40% 147.20% 117.00%

Appendix 1 Safer Staffing Febraury 2020

Register Nurse Care StaffRegistered Nurses Care Staff Total Nursing Staff

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Feb-20Bed Occupancy

Cumulative count of patients CHPPD

Safe Staffing was maintained by RN Vacancies HCA Vacancies

Longridge Ward (C)88.66% 386 9.39

Low bed Occupancy0.37 3.18

The Orchard 93.83% 529 8.70

Nurses working additional unplanned hours and altering skill mix10.22 -0.43

Fairsnape Ward (S)90.95% 203 15.96

WM and Matrons working clinically and altering skill mix8.41 -2.04

Greenside Ward (S)100.00% 336 9.50

WM and Matrons working clinically and altering skill mix6.71 6.11

Calder Ward (S)100.00% 260 26.75

WM and Matrons working clinically and altering skill mix6.43 3.42

Fairoak Ward (S)100.00% 522 5.42

WM and Matrons working clinically and altering skill mix7.9 1.53

Forest Beck Ward (S)75.00% 174 12.43

WM and Matrons working clinically and altering skill mix4.75 0.4

Whinfell Ward (S)77.78% 167 16.75

WM and Matrons working clinically and altering skill mix6.56 -4.04

Marshaw Ward (S)100.00% 270 10.76

WM and Matrons working clinically and altering skill mix7.49 4.3

Elmridge Ward (S)72.41% 192 32.54

WM and Matrons working clinically and altering skill mix9.53 -3.18

Bleasdale Ward (S)66.67% 152 32.53

Bed numbers reduced due to a patient with extra package of care4.76 -9.46

Mallowdale Ward (S)99.14% 214 9.45

WM and Matrons working clinically and altering skill mix5.36 -3.24

Dutton Ward (S)98.39% 403 10.71

WM and Matrons working clinically and altering skill mix10.26 -3.75

Langden Ward (S)80.00% 288 10.66

WM and Matrons working clinically and altering skill mix9.91 -9.12

Fellside East Ward (S)83.14% 218 17.24

WM and Matrons working clinically and altering skill mix7.59 -9.18

Fellside West Ward (S)97.93% 433 4.95

WM and Matrons working clinically and altering skill mix5.15 -2.22

Hermitage Ward (S)80.00% 232 6.88

WM and Matrons working clinically and altering skill mix4.84 -2.61

Appendix 1 Safer Staffing

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Ribble Assessment94.09% 335 12.70

Nurses working additional unplanned hours and altering skill mix7.07 2.14

Worden Ward101.38% 434 10.17

Nurses working additional unplanned hours and altering skill mix4.14 0.3

Hyndburn Ward99.48% 467 8.40

Nurses working additional unplanned hours and altering skill mix3.72 2.72

Darwen Ward 99.64% 530 8.42

Nurses working additional unplanned hours and altering skill mix4.73 8.37

PICU Calder 97.70% 171 30.81

Nurses working additional unplanned hours and altering skill mix1.49 7.37

PICU Avenham 82.76% 154 34.09

Nurses working additional unplanned hours and altering skill mix4.38 1.5

Edisford Assessment 85.96% 352 12.35

Nurses working additional unplanned hours and altering skill mix10.33 0.86

Hurstwood 99.62% 504 11.28

Nurses working additional unplanned hours and altering skill mix2.63 0.17

Duxbury Ward100.46% 417 9.81

Nurses working additional unplanned hours and altering skill mix6.38 -0.01

Shakespeare 102.11% 581 7.71

Nurses working additional unplanned hours and altering skill mix including TNAs 12.02 0.74

Stevenson Ward107.56% 508 8.98

Nurses working additional unplanned hours and altering skill mix including TNAs 13.4 -0.66

Churchill Ward 100.19% 532 6.45

Nurses working additional unplanned hours and altering skill mix including TNAs 15.74 -0.41

Orwell Ward 88.12% 454 8.60

Nurses working additional unplanned hours and altering skill mix including TNAs 12.78 -1.38

PICU Byron Ward 96.55% 226 31.77

Nurses working additional unplanned hours and altering skill mix including TNAs 8.05 3.15

PICU Keats Ward 99.57% 230 15.87

Nurses working additional unplanned hours and altering skill mix including TNAs 9.35 2.48

Austen Ward 104.46% 558 10.15

Nurses working additional unplanned hours and altering skill mix including TNAs 6.59 -1.69

Dickens Ward 98.76% 485 7.94

Nurses working additional unplanned hours and altering skill mix including TNAs 4.78 0.42

Bronte Ward93.10% 403 11.94

Nurses working additional unplanned hours and altering skill mix including TNAs 3.84 0.41

Wordsworth Ward 98.85% 430 18.59

Nurses working additional unplanned hours and altering skill mix including TNAs 3.26 -2.49

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Scarisbrick 72.41% 443 8.24

Nurses working additional unplanned hours and altering skill mix4.86 1.28

PICU Lathom 100.00% 120 36.92

Nurses working additional unplanned hours and altering skill mix4.03 -1.46

CAMHS The Cove 54.19% 219 15.46

Low bed Occupancy3.74 3.99

Perinatal 98.28% 149 20.28

Nurses working additional unplanned hours and altering skill mix1.63 0.77

Kentmere Ward89.66% 396 8.66

Nurses working additional unplanned hours and altering skill mix4.26 3.72

Dova Ward98.79% 573 5.69

Nurses working additional unplanned hours and altering skill mix8.48 1.93

Ramsey ward98.97% 287 15.34

Bed numbers reduced to 10Agency RNs blocked booked 7 1.45

Totals92.25% 14.30 284.92 5.34

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Appendix 2 Staffing Issues

From the introduction of the new hybrid shift model, wards have experienced difficulty in the number of late shifts being filled. Ward Managers are addressing this by reducing the number of early shifts available to temporary staff. This will continue to be monitored.

The number of RN vacancies have increased in month on inpatient areas however a number of RNs have transferred to community teams within the mental health network.

Three areas within secure services had RN fill rates of less than 50%. Staffing deficits for Fairoak, Elmridge and Dutton (Guild) were addressed by adjusting

skill-mix and utilising temporary staffing with further support from ward managers and MDT colleagues. Overall fill rates for days were Dutton 113%, Elmridge 196.2% and Fairoak 93%. It should be noted that these wards are established for 4 RNs per day-shift therefore 50% would be equivalent to 2 RNs on duty. Elmridge has a RNA.

Orwell and Byron wards at the Harbour had a RN fill rate of below 50% for days, however Orwell ward is supported by 3 RNAs which has a positive impact on the skill mix and experience of the ward team. Byron ward have 3 TNAs in post. Orwell ward is currently established for 4 RNs and Byron Ward 3 RNS. Overall fill rates were 97.3% and 101% respectively.

Edisford Ward have had a RN fill rate of below 50% for nights (the ward is established for 3 RNs on nights). Three RNs have left in month however the ward does have a RNA and 3 RNs are due to start in April and May 2020. The Blackburn site is covered by a MHUNIC who is a RN and provided support to the ward. Overall fill rates were 109%.

Due to RN vacancies within secure services and staffing projections, this area has been prioritised for the safer staffing review in February 2020. Safer staffing is maintained by a daily safety huddle reviewing the patient activities prioritising urgent matters such as hospital appointments, courts appearance and meaningful activities. The ward managers and matrons are also working clinically to support the wards with the shortfalls. Additionally the plan to introduce the new shift pattern has been delayed due to the potential impact on fill-rates.

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Board of Directors

PURPOSE OF THE REPORT: Report purpose To provide assurance around IPC activity

Strategic Objective(s) this work supports

To provide high quality services

Board Assurance Framework risk

1.0 The Trust does not protect the people who use its services from avoidable harm and fails to comply with the CQCs standards for the quality and safety of services

CQC domain Safe PAPER DEVELOPMENT PROCESS:

Meeting Presented Action Date Executive Team Maria Nelligan Discussion 25/02/20

Quality Committee Julie Seed Assurance 12/03/20

Board Maria Nelligan Assurance 02/04/20

Agenda Item TB 107/20 Date: 02/04/2020

Report Title Director of Infection Prevention and Control Quarter 3 Report

Prepared by Julie Dziobon, Head of IPC, Physical Health and Communicable Diseases

Presented by Maria Nelligan, Executive Director of Nursing and Quality

Action required Assurance

Supporting Executive Director Director of Nursing and Quality

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Quarter 3 Director of Infection Prevention & Control (DIPC) Report

1. Purpose of the Report

The purpose of this report is in line with the requirements set out in the Health and Social Care

Act 2008 and Care Quality Commission standards (Outcome 8, Regulation 12). This report

informs the Board on behalf of the Director of Infection Prevention and Control (DIPC) to appraise

the Board on a quarterly basis on the arrangements and activity within infection, prevention and

control (IPC). The report will update and provide assurances to the Board for Quarter 3.

2. HealthCare Associated Infections (HAI’s)

During Quarter 3 there were no cases of MRSA bacteraemia in Lancashire and South Cumbria

Foundation Trust (LSCFT). MRSA admission screening continues as per procedure.

In October 2019, there was one case of Clostrium Difficle at Longridge Community Hospital, a

full Post Infection Review (PIR) has been completed by the clinical staff with the support of the

Infection Prevention and Control Team (IPCT), pharmacist and a microbiologist. There were no

lapses in care noted. This will be reviewed in the Infection Prevention Control Steering Group.

3. Outbreaks

Over Quarter 3 we have seen a number of outbreaks across LSCFT attributable to Influenza and

norovirus.

FLU In November 2019, three wards were closed to admissions within the Harbour at Blackpool and

Pendleview at Blackburn due to being unable to isolate patients. Orwell ward at the Harbour had

four confirmed cases, Ribble ward at Pendleview had one confirmed case and one symptomatic

patient. Edisford ward at Pendleview had one confirmed case and two symptomatic patients.

The IPCT visited the wards on a daily basis to provide support in relation to IPC precautions to

the ward staff and offer staff flu vaccines. Patients were risk assessed for antivirals in line with

PHE guidance. All patients resolved from symptoms and did not require transfer to the acute trust

for treatment despite compliance with prescribed antivirals being poor.

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In December 2019, a patient on Dova ward in South Cumbria was identified as having Influenza

A, the ward was closed to admissions as further spread due was anticipated as the patient had

been in communal areas with symptoms. PHE guidance was followed with respect to IPC

precautions and treatment with anti-virals.

NoroVirus In December 2019, two wards were closed at Chorley in-patients with confirmed norovirus. Five

out of six patients on Avenham Psychiatric Intensive Care Unit became symptomatic within 24

hours. One positive specimen was obtained, no other specimens were able to be collected

however all symptoms presented were consistent with Norovirus. Duxbury ward at Chorley in-

patients also had patients experiencing symptoms, this was reported on January 3rd 2020, the

ward is adjacent to Duxbury and norovirus was suspected. Following samples being taken there

was one confirmed positive sample from a patient. All wards implemented outbreak pack and all

patients self-resolved from symptoms.

Prior to re-opening all wards had a full clean and curtain change which is in line with policy. 4. Annual Staff Flu Campaign

The immunisation programme during Quarter 3 is the time to capture most staff nearly 2,500 staff

had a flu vaccine administered in this quarter across LSCFT. For staff there have been numerous

opportunities to be vaccinated these included drop-in clinics which have been held by the

Occupational Health provider across Lancashire and South Cumbria, peer vaccinators who have

worked closely with the IPCT to support staff vaccination and attendance by the IPCT at

educational events and meetings which have supported the uptake of the vaccine. The IPCT have

visited most clinical areas which has supported staff to easily obtain the vaccine without having

to leave their workplace.

Nationally flu cases have been identified earlier in the season and locally there has been a

significant number of flu cases reported which have resulted in most health care providers having

to close wards to admissions, including LSCFT. This has had a positive impact on the staff flu

campaign and has resulted in an increased number of staff seeking out the vaccine in the month

of December, where we would normally see a steady decline leading up to the festive period. At

the end of December 2019 the Trust was in a position of having vaccinated 60% of all staff and

72% of frontline staff. The CQUIN trajectory of 80% was achieved on 10 February 2020.

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A full evaluation report of the staff flu campaign will be completed and will be part of a further

DIPC report.

5. Coronavirus (COVID-19) The Trusts response to the global outbreak of Coronavirus is being led by the Trust’s Emergency

Planning Officer and the IPC Lead. The situation is evolving on a daily basis and staff within the

organisation are being directed to 111 should they feel that they are at risk. Public Health England

have produced national guidance on all aspects of the outbreak which LSCFT are incorporating

into the Action Plan that has been developed. Progress against the action plan to mobilise staff

to swab patients in the community is being monitored on a daily basis via a teleconference,

resilience planning is to commence to mitigate the risks of staff being off unwell and frontline staff

are being supported by the IPCT who are reinforcing the Public Health messages and providing

specialist advice.

6. Incidents

There was 1 needlestick injury in Quarter 3 in the mental health network, the member of staff was

advised on actions to take by Occupational Health.

7. Infection Prevention and Control Steering Group

The group met in November 2019 and the chairs report has been presented at the Quality and

Safety Sub-Committee. Main points to note;

Aseptic Non-Touch Technique – task and finish group to meet to identify methods of

improving compliance

Terms of reference to be reviewed

Assurance around actions for staff flu campaign

IPC audit programme presented and reviewed by the steering group.

8. CQC Cleanliness Audits

In Quarter 3 the IPCT audited all acute wards and PICU’s to ensure that policies and procedures

relating to IPC were being adhered to and that the cleanliness on the wards was maintained. The

National Infection Prevention Society audit tool was used.

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Action plans from the audits were sent to the ward managers and the audits were sent to property

services to form part of the CQC action plan. The main themes from the audits were lack of

adherence to uniform policy and isolated issues with cleanliness in patient’s bedrooms, these

were addressed at the time of the audit.

9. Plan for Next Quarter

Development of a work plan, which will form part of this report

Continuing staff flu vaccination campaign

Work with all clinical teams to improve adherence to the essential steps audit and Aseptic

Non-Touch Technique (ANTT)

Review HAI assurance framework.

10. Recommendations

The Board is asked to provide assurance for the DIPC Quarter 3 Report for 2019/20.

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Board of Directors Agenda Item TB 108/20 Date: 02/04/2020

Report Title CQC Update

Prepared By Julie-Ann Bowden, Associate Director of Effectiveness Shannon Higginbotham, Governance Manager

Presented By Ursula Martin, Director of Improvement and Compliance

Action Required Assurance

Supporting Executive Director Director of Improvement and Compliance

PURPOSE OF THE REPORT: Report Purpose To provide the Board with an update in relation to:-

An update on the unannounced CQC visits to the Trust’s Acute and PICU wards w/c 09.03.20

An update on the Trust’s response to becoming Smoke Free

Exception reporting against the CQC Action Plan.

Strategic Objective(s) this work supports

To provide high quality services

Board Assurance Framework Risk 1.0 The Trust does not protect the people who use its services from avoidable harm and fails to comply with the CQCs standards for the quality and safety of services

CQC Domain Well-led 1.0 INTRODUCTION 1.1 This paper provides the Board of Directors with the monthly update in relation to the

organisational response to the 2019 CQC inspection. 1.2 The single CQC action plan has continued to be monitored and reviewed within the CQC

Steering Group which has been meeting on a monthly basis. The meeting for March 2020 has currently been ‘stood down’ as a result of the Covid-19 organisational response. The work supporting the monitoring and validation of actions continues to be undertaken as a priority currently. Where action leads have requested a target date extension, this is discussed and agreed at the CQC Steering Group as part of a robust governance process.

1.3 The quality assurance process is now embedded, with action forms completed by the action

lead and signed off by the lead Director. The forms and associated evidence are reviewed by the CQC Governance Team for approval.

1.4 The exception report (Appendix 1) provides the current position in relation to the CQC action

plan. Where actions have reached their due date, the action forms and evidence are being collated and reviewed as a matter of urgency. The exception report is issued to the Director of Improvement and Compliance on a weekly basis and is reported across the governance structure as necessary to escalate actions and provide assurance on progression with the plan.

2.0 UNANNOUNCED CQC VISITS TO THE ACUTE AND PICU WARDS – MARCH 2020 2.1 During the week of the 09 March 2020, the CQC undertook unannounced visits to several of the

Trust’s Acute and PICU Wards to assess the improvements made since the Section 29A Warning Notices were issued in July 2019.

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2.2 The CQC visited the Wards at the Harbour, Blackpool, the Orchard, Lancaster and Pendleview and Hillview, Blackburn.

2.3 All requests for information from the CQC during the visits were made via the CQC Enquiries team, as per the Trust’s CQC visit procedure.

2.4 A de-brief with the CQC Inspectors, the Ward team and a senior manager of the Trust’s

Governance department was held on-site, at the end of each visit to receive initial feedback. This feedback was then shared with the Trust’s Executive Team and senior management teams at the end of each day.

2.5 CQC will write to us officially and provide a brief summary quality report in relation to this specific core service. The initial feedback which was further supplemented on the monthly CQC relationship call with the Trust on Friday 13 March 2020 has been encouraging, with the inspection team identifying positive improvements. In particular, CQC commented positively in relation to supervision, ILS/BLS compliance, medicines management, staffing and privacy and dignity. CQC have acknowledge that there were varying degrees of implementation of stop smoking across the units visited but recognised the work undertaken so far to improve the culture of becoming smoke-free (see section 5 of this report).

3.0 S29A WARNING NOTICE – CRISIS SERVICES AND HEALTH BASED PLACES OF SAFETY 3.1 The Trust has now received the CQC quality report for this core service which was visited by

CQC on 10 January 2020. This was a follow-up visit to review the progress that the Trust has made in relation to the warning notice for this particular core service.

3.2 The Trust has 10 working days to respond to the CQC in terms of factual accuracy, following

which the report will be formally issued to the Trust and made public on the CQC website.

4.0 OVERVIEW OF THE CQC ACTION PLAN PROGRESS 4.1 There are 208 actions within the CQC action plan as at 19 March 2020, 98 are completed, with

47 not yet due. There are no overdue actions. This can be further broken down by core service to evident the spread of the actions required and the current performance at the time of writing this paper.

Action Validated

(Complete)

Additional Evidence

Requested

Awaiting Director Sign Off

Awaiting QA

Overdue Action not yet

due

Target Date

Extension Agreed

Target Date Extension Requested

Total

Must Do 64 20 6 7 0 32 10 1 140

Should Do 34 9 4 2 0 15 4 0 68

Total 98 29 10 9 0 47 14 1 208

A further detailed exception report can be reviewed in Appendix 1. 5.0 TOWARDS SMOKE FREE 5.1 Since the CQC inspection in 2019, the Trust has undertaken substantial work to enable the Trust

to abstain from smoking and to shift the smoking culture across the inpatient services.

5.2 The Trust has developed a robust Nicotine Management Improvement Plan which is monitored by the Nicotine Management Group and CQC Steering Group. In addition, the Nicotine Management Policy has been refreshed with an emphasis on abstaining from smoking for those patients who are admitted to an inpatient setting. The Policy has been shared across all networks and services and includes supportive guidance for clinical staff to apply on admission.

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5.3 A Nicotine Management Working Group is now well established in each of the Trust’s localities and there are a number of Nicotine Management Champions across the localities to support staff and patients.

5.4 The Trust has ensured increased accessibility to Nicotine Management products for staff to

provide to patients on and during admission. In addition, a number of pilots are underway to promote and increase the use of nicotine replacement products.

5.5 Essential training and ‘masterclasses’ in relation to abstaining from smoking is currently under

development and will be provided to Ward Managers, Matrons, staff and medics.

5.6 Whilst significant improvement work has been undertaken across the organisation to comply with the policy and to abstain inpatients from smoking, the Trust is aware of the substantial challenges that remain on some of the inpatient units. This continues to be a focus for the Trust’s senior clinical and operational leads within the Mental Health Network and the Executive Director of Nursing and Quality.

6.0 BOARD ACTION

The Board are requested to note the progress and update provided in relation to the CQC processes in place and associated governance arrangements.

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Appendix 1: CQC Exception Report LCFT CQC Exception Report (as at 19.03.20)

Core Service Action Validated

(Complete)

Additional Evidence

Requested

Awaiting Director Sign

Off

Awaiting QA Overdue Action not yet due

Target Date Extension

Agreed

Target Date Extension Requested

Total

LCFT Trust-wide 11 (must do)

1 (must do) 0 1

(must do) 0 6 (must do)

2 (must do) 0 21

LCFT Adult Acute wards and PICU

23 (17 must do, 6 should o)

10 (7 must do,

3 should do)

6 (4 must do,

2 should do)

5 (4 must do,

1 should do)

0 8

(5 must do, 3 should do)

2 (must do)

1 (must do) 55

LCFT MH Crisis services and

HBPoS

23 (20 must do, 3 should do)

5 (must do) 0 1

(must do) 0 9

(6 must do, 3 should do)

1 (should do) 0 39

LCFT Adult Community based

MH services

4 (must do)

2 (must do)

1 (must do) 0 0

6 (5 must do, 1

should do)

6 (4 must do, 2

should do) 0 19

LCFT Child and adolescent MH

wards

8 (should do) 0 0 0 0 1

(should do) 0 0 9

*Target date extension requests are to be approved at the CQC Steering Group

6 CPFT CQC Exception Report (as at 19.03.2020)

Core Service Action

Validated (Complete)

Additional Evidence

Requested

Awaiting Director Sign

Off Awaiting QA Overdue

Action not yet due

Target Date Extension

Agreed

Target Date Extension Requested

Total

South Cumbria Trust-wide 9

(3must do, 6 should do)

0 1 (must do) 0 0 2

(must do) 0 0 12

South Cumbria Adult Acute Wards and PICU

10 (3 must do, 7 should do)

6 (3 must do,

3 should do)

1 (should do)

2 (must do) 0

9 (5 must do,

4 should do)

2 (1 must do, 1

should do) 0 30

South Cumbria MH Crisis Services and HBPoS

9 (5 must do, 4

should do)

5 (2 must do,

3 should do)

0 0 0 5

(2 must do, 3 should

do)

1 (must do) 0 20

South Cumbria MH Wards for older people

1 (must do) 0 1

(should do) 0 0

1 (must do) 0 0 3

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Board of Directors Agenda Item TB 109/20 Date: 02/04/2020

Report Title Board Assurance Framework Q4 Position

Prepared By Shannon Higginbotham, Governance Manager Louise Guss, Interim Company Secretary

Presented By Ursula Martin, Director of Improvement and Compliance

Action Required Assurance

Supporting Executive Director Director of Improvement and Compliance

PURPOSE OF THE REPORT: Report Purpose To provide the Trust Board with the Q4 Board Assurance

Framework position

Strategic Objective(s) this work supports

To provide high quality services

Board Assurance Framework Risk 6.0 The Trust does not have sufficient leadership to deliver the transformational change required to address the cultural changes, improve wellbeing and to empower staff and widen the diversity of our workforce

CQC Domain Well-led 1.0 INTRODUCTION The Board Assurance Framework (BAF) is an essential tool for Boards in gaining a clear understanding of the strategic risks faced by the organisation in the pursuit of its strategic objectives. It provides the Board with an overview of the assurances currently in place, consideration to the assurances’ effectiveness and the identification of gaps. Whilst the Board delegates authority to its Committees to monitor assurance against its strategic risks, it is ultimately responsible for the oversight of the BAF and the Committees are expected to escalate any significant assurance issues as they arise. The Board must therefore be satisfied that the BAF is robust and is an accurate reflection of the organisation’s current challenges. The BAF will ultimately determine the Board and Board Committees agendas. 2.0 REVIEW OF THE BAF To strengthen the Board’s ability in overseeing and managing risks to the delivery of its objectives, the Board re-visited the key strategic risks which were then approved by the Board on the 01 August 2019.

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On a quarterly basis, individual discussions take place with each responsible Director to review the content of the risk/s upon which they lead and to consider the assurances, controls, gaps and progress with required mitigating actions. This is reflected in the updated BAF presented within this report. In readiness for this paper to the Board, the final quarterly positions were presented to the Quality Committee and People and Culture Committee during quarter four. Due to timings of Committees during 2019/20, no Finance and Performance Committee was held before the Board meeting, therefore the risks that were aligned to this Committee were shared with the Chair for consideration. The Q4 BAF position can be seen at Appendix One. Please note, text in red in the appendix reflects changes since the last quarter update. The current strategic risk register is as follows. Strategic Risk Risk

Score The Trust does not protect the people who use its services from avoidable harm and fails to comply with the CQCs standards for the quality and safety of services

16

The Trust does not ensure safe and effective transfer of South Cumbria mental health, CAMHS and learning disability services into the Trust

16

The Trust does not have sufficient leadership to deliver the transformational change required to address the cultural changes, improve wellbeing and to empower staff and widen the diversity of our workforce

16

The Trust does not identify and maximise new innovations to transform services and improve care

16

The Trust does not achieve the required efficiency savings whilst delivering and improving quality

15

The Trust does not achieve financial performance sufficient to maintain resilience and sustainability

15

The Trust does not have the ability to address and meet service demands which is affected by uncertain and limited commissioning arrangements.

12

The Trust does not build its reputation with all stakeholders through appropriate engagement and partnership working

12

The Trust does not exploit the full capabilities of technology and fails to achieve the desired benefits to improve quality of care and data

12

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

10

2.1 Amendments to risk scoring on the BAF There has been no risk that has been rescored since the last review of the BAF at the Board of Directors.

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2.2 Exception report on actions being taken to address gaps in controls and assurance

Strategic Risk Actions to be completed Q4

Exceptions

1.0 The Trust does not protect the people who use its services from avoidable harm and fails to comply with the CQCs standards for the quality and safety of services

2 actions due to be

completed

1 action completed 1 action

extended

Action: To identify the key actions following serious incident reviews and themes from patient experience outcomes and develop action plans for implementation Completed: This action was due in Q3 and was rated as partially completed. This action has been completed during Q4 following the external reviews for complaints and serious incidents. This was reported at Board in February 2020. Action: The Trust will ensure that all recommendations within the Developing Workforce Safeguards guidance are implemented and maintained Extended: This action has been extended into Q1 2020/21 as the work continues.

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

2 actions due to be

completed

1 action completed 1 action

extended

Action: To implement a process that ensures that themes arising from complaints support the development of action plans to make improvements Completed: This action was due in Q3 and rated as amber, the action has now been completed during Q4 following the external reviews for complaints, serious incidents and reporting of deaths. This was reported at Board in February 2020. Action: The Board must approve the final Estates Strategy, following completion of the overall Trust Strategy Extended: This action has been extended to the Q1 2020/21 BAF in line with the strategy reporting requirements to the Board in April 2020

3.0 The Trust does not have the ability to address and meet service demands which is affected by uncertain and limited commissioning arrangements.

4 actions due to be

completed

2 actions completed 1 action

extended 1 action partially

completed

Action: Continue to deliver the work within the mental health improvement plan to reduce OAPS Completed: This action has been completed through the work within the MHIP. The OAPs challenge still remains and an additional action has been taken over to 2020/21 in BAF risk 7.0 Action: Engagement with the Commissioners to improve the current commissioning arrangements Completed: The Trust continues to work with Commissioners and the ICS to improve investment shortfalls and reduce OAPs Action: Work with NHS England to confirm and establish the most appropriate governance arrangements prior to full implementation of the new care models initiative

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Strategic Risk Actions to be completed Q4

Exceptions

Extended: This action has been extended to Q1 2020/21 as the development of the governance arrangements continues in line with the LPC business case Action: Develop three business cases for the provision of LD inpatient beds, an autism only service and an intensive support service Partially completed: Draft business cases presented to the Senior Leadership Team at the end of March 2020.

4.0 The Trust does not ensure safe and effective transfer of South Cumbria mental health, CAMHS and learning disability services into the Trust

9 actions due to be

completed

4 actions completed 5 actions extended

Action: implement the post-transaction integration plan including the capital investment Completed: This is monitored through the SCAC, it is a live document which includes actions from the CQC action plan and service developments. Action: The Trust must ensure the data discrepancies are addressed and a baseline position for mandatory training data to be concluded Completed: The Executive Group agreed to use the ESR data as a baseline. Work is now underway to address compliance and a trajectory is in place. Action: Commence a Trust-Wide dormitory risk assessment review to include Kentmere Completed: This was completed and reported to the Board in March. Action: Agree and commence the recruitment within CAMHs Completed: This has been completed and rolling recruitment in place. Note: Recruitment remains a significant challenge. Action: The Trust must develop and implement a clear management transition plan from the 01 April 2020 Extended: This action has been extended to Q2 2020/21 as the work continues Action: The Trust must implement clear governance arrangements both internally and externally Extended: This action has been extended to Q1 2020/21. It is in place but requires amendments to support the move to the Bay. Revised deadline for final implementation Action: The Trust must continue to monitor and review investment into the Kentmere unit Extended: This action has been extended to Q4 2020/21. This will be part of capital works in 2020/21.

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Strategic Risk Actions to be completed Q4

Exceptions

Action: Work with the management team in South Cumbria to address concerns in particular around the environment and staffing Extended: This action has been extended to Q2 2020/21. This will be part of capital works in 2020/21 and is progressing. Action: Through reporting within the governance structure, the Trust must provide assurance on the improvement in the quality of services following transfer Extended: this action has been extended to Q1 2020/21. Work has commenced and is reported to the Executive Group and South Cumbria Committee.

5.0: The Trust does not build its reputation with all stakeholders through appropriate engagement and partnership working

3 actions to be completed

1 action

completed 2 actions extended

Action: The Trust will develop and implement a clear strategic partnership and aligned plan with the third sector Completed: The Trust has developed a 0-6 months and 6 – 12 months plan with the third sector Action: The Trust will undertake a management restructure that is locality facing to support this challenge Extended: This action has been extended to Q2 2020/21 in line with the implementation dates for the new structure in September. Action: The Trust will regularly share emerging thinking and updates in relation to upcoming strategies with the Trust’s stakeholder and partners Extended: This action has been extended to Q2 2020/21 however the work with stakeholders, the public and partners has been ongoing in line with the refresh of the strategies. The strategies will be fully completed during 2020/21.

6.0 The Trust does not have sufficient leadership to deliver the transformational change required to address the cultural changes, improve wellbeing and to empower staff and widen the diversity of our workforce

5 actions to be completed

5 actions extended

Action: The Trust will complete the development of the diversity and inclusion strategy (as part of the People and Culture Strategy) for 2020 – 25 Extended: This action has been extended to Q1 2020/21 in line with current timescales for completion Action: The Trust will embed the principles within the NHSI interim People Plan and report this to the Board Extended: This action has been extended to Q1 2020/21 as the work is linked to the development of the People and Culture strategy Action: The Trust will develop a Trust wide People and Culture strategy and report this to the Board

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Strategic Risk Actions to be completed Q4

Exceptions

Extended: This action has been extended to Q1 2020/21 in line with current timescales for completion of the enabler strategies Action: The Trust will ensure that all recommendations within the guidance are implemented and maintained Extended: This action has been extended to Q1 2020/21 as the work progresses further during April and May. Action: The Trust will embed and sustain the Just culture principles Extended: This action has been extended to Q1 2020/21. This has been achieved partially in regards to the LiA work undertaken and full implementation is due in Q1.

7.0 The Trust does not achieve financial performance sufficient to maintain resilience and sustainability

5 actions to be completed

1 action

completed 1 action no

longer applicable 2 actions extended

1 action partially completed

Action: The Trust must continue to drive the CQUINs delivery and escalate any concerns through the governance structure Completed: The governance around CQUIN has been reviewed and refreshed. The Trust is predicting a loss of £262K which is sighted by the Board. Action: Work closely with the networks and support services to improve the CIP position through adopting a transformational approach to the delivery of CIPS No longer applicable: This action has been reframed and now sits within BAF risk 7.0 for Q1 2020/21 as ‘The Trust will agree and implement the methodology for the identification and reporting of CIPs’ Action: The Trust will continue to work with the Commissioners and the ICS to address investment shortfalls to strengthen the mental health pathway Extended: This action has been extended to Q1 2020/21 in light of the collaborative work with the ICS and commissioners to address investment shortfalls. Weekly ‘Gateway’ meetings are taking place to establish baseline funding. Action: The Trust will work in collaboration with the Commissioners and the ICS as part of the risk share agreement to improve the OAPs position through the development of a range of rehabilitation services Extended: This action has been extended to Q1 2020/21 as the Trust works with the ICS and Commissioners to develop a broad range of rehabilitation services to address OAP demands.

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Strategic Risk Actions to be completed Q4

Exceptions

Action: The Trust will continue to work to achieve the potential upsides during 2019/20 to achieve the Trust’s control total Partially Completed: To be confirmed at year-end

8.0 The Trust does not achieve the required efficiency savings whilst delivering and improving quality

6 actions to be completed

3 actions

completed 2 actions extended

1 action partially completed

Action: Work will be undertaken to consider all CIPs within the scheme and the action being taken to increase CIPs in the Pipeline Completed: This action was completed and a follow up action has been added for Q1 2020/21 to agree and implement the refreshed methodology Action: Senior leaders will take opportunities within the management re-structure to look at more effective leadership around CIPs to support the networks Completed: This action was completed and a follow up action has been added for Q1 2020/21 to agree and implement the refreshed methodology Action: A full quality impact assessment will be undertaken against all CIPs Completed: This was undertaken prior to all schemes being agreed at the beginning of 2019/20. Action: The Trust will adopt a transformational approach to the delivery of CIPS and report this through the governance structure Extended: This action has been extended to Q1 2020/21 as the work on CIP’s develops. Action: The Trust will agree and implement the methodology for the identification and reporting of CIPs Extended: This action has been re-framed and extended to Q1 2020/21 in light of the work being undertaken around CIPs for 2020/21 Action: The Trust must continue to work closely with the network to support delivery of the additional c£654K in year Partially Completed: To be confirmed at year-end

9.0 The Trust does not exploit the full capabilities of technology and fails to achieve the desired benefits to

2 actions to be completed

2 actions

completed

Action: The Trust will continue to monitor the deployment to South Cumbria services for any additional issues that may impact deployment of EPR Completed: The deployment of systems to South Cumbria was completed successfully in December 2019. A RiO Clone instance was provided to enable a smooth transition and work is now being undertaken to integrate the South Cumbria

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Strategic Risk Actions to be completed Q4

Exceptions

improve quality of care and data

instance into the core LSCFT Instance of RiO. This will be completed by the end of 2020. Action: The Trust will continue to monitor delivery of EPR against its objectives Completed: Resourcing requirements of the EPR/GDE programme is continuously monitored and the Trust is utilised both internal and external employees to achieve the deployment plan. Escalations are made to the GDE Programme Board.

10.0 The Trust does not identify and maximise new innovations to transform services and improve care

5 actions to be completed

1 action

completed 3 actions extended

1 no longer applicable

Action: Commission a review of the HSIS SLA and KPIs undertaken by the Board to ensure there is a clear understanding of roles and responsibilities Completed: This was undertaken by the Board in January 2020 Action: The Trust will develop an improvement strategy Extended: This action has been extended to Q1 2020/21 in line with the timescales for the enabler strategies Action: The Trust will develop its Digital strategy Extended: This action has been extended to Q2 2020/21 in line with the timescales for the enabler strategies and commencement of the Director of Digital. Action: The Trust will develop improvement and innovation hubs as part of the developing improvement strategy Extended: This action has been extended to Q1 2020/21 in line with the timescales for the development of the improvement strategy Action: Transformation activity will form part of the Finance and Performance Committee cycle of business following the development of the digital strategy No longer applicable: in light of the refreshed governance structure that is coming into place in April 2020. The reporting arrangements have been refreshed and aligned as appropriate.

3.0 PROPOSED NEW BAF RISK The impact of the Covid-19 virus has become increasingly significant for the Trust, the public and staff in recent weeks. The Trust is working together with NHS England, Public Health England

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(PHE), commissioners and partner organisations to ensure that we are well prepared to provide the care and medical assistance needed, keep as many services as possible available, whilst ensuring the safety of service users and all our staff. It is clear however that the impact of Coronavirus and arrangements to cope with its effects pose a risk to the Trust’s strategic objectives. In order to explicitly detail the risks to the organisation, and set out organisational efforts to mitigate those risks, it is proposed that the following risk be added to the BAF; ‘’Inability to respond to Corona Virus pandemic, caused by internal and external factors, resulting in risk to service users and staff’ The Board will receive an update paper on the Trust’s response to Covid-19 at its meeting on the 2nd April. The information contained therein, and frequent updates in this fast-moving area will enable a fully described work-up of gaps in controls, mitigations, actions and risk scoring to be presented to the Board moving forward. 4.0 REFRESH OF THE BOARD ASSURANCE FRAMEWORK FOR 2020/21 The Well-Led Review undertaken by AQuA was presented to the Board of Directors at the Board development session on 17 December 2019. This includes a number of recommendations to take forwards to strengthen the risk processes in the organisation including:

Development of a Risk Management Strategy, refreshing the risk management framework within the Trust;

Review the risk reporting processes to ensure consistency in risk scoring and invest in risk management training;

Ensure that risk management is integrated with other governance and performance reporting, so that the BAF accurately reflects the risks in the organisation.

Ensure that the Trust Datix system supports dynamic risk management processes. In addition, the Trust is currently developing a refreshed vision and strategic objectives which will support the development of the BAF for 2020/21. The Board was planning to hold a dedicated session in May 2020 to consider the proposed BAF risks for 2020/21. This will be deferred until business as usual is reinstated. The refreshed BAF will then be agreed by the Board and presented to the Board in June 2020. 5.0 RECOMMENDATION

1. The Board is asked to note the content of the Q4 BAF position 2. The Board is asked to approve the inclusion of a new BAF risk relating to the impact of

the Covid-19 virus upon business continuity and patient care

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Appendix 1 - BAF 2019/20 Quarter 4

Board Assurance Framework 2019/20 BAF RISK 1.0: The Trust does not protect the people who use its services from avoidable harm and fails to comply with the CQCs standards for the quality and safety of services

LEAD DIRECTOR: DoN/MD/DoI&C

Reporting to: People and Quality Committee STRATEGIC PRIORITY: To deliver sustainable services that meet the needs of local people RISK SCORE:

16 RISK TARGET SCORE: 12

4x4 3x4

Risk Score By Quarter Q1 Q2 Q3 Q4 16 16 16 16 4x4 4x4 4x4 4x4

Mitigating Controls Controls Assurances The Trust has commissioned an external company to review the Trust’s death data The Trust has received the final report and an action plan reflecting the findings are due to be

presented to the Board in March 2020 The Trust has a robust annual clinical audit programme to identify gaps and areas for improvement Quarterly reporting to the Audit Committee and Quality Committee

The Trust effectively uses the Datix system to input risks and serious incidents

The Trust has a central serious incidents team leading on the management of investigations

There is a non-executive director led meeting that considers themes for serious incidents There is a review of the Datix system underway – with the new Datix IQ system to be implemented October 2020

An action plan has been developed and is being monitored at various forums to address issues in the CQC notices received in July 2019

Between December 2019 and January 2020, the Trust has responded in full to several requests for information from the CQC The Mental Health Network hold a weekly meeting to discuss quality and safety issues and the CQC action plan is a standing agenda item for review and discussion The Trust has re-established the CQC Steering Group which meets on a monthly basis and is chaired by the Director of Improvement and Compliance to support the delivery of the CQC actions

The Trust has received feedback from the CQC mental health act inspections The findings are collated on an overall action plan with a robust quality assurance process for validation that has been implemented in parallel with the overall CQC action process

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Appendix 1 - BAF 2019/20 Quarter 4

The Trust has established monthly relationship meetings with the CQC This is attended by the Director of Nursing and Quality and Director of Improvement and Compliance and fedback to the Board as necessary

The Service User and Carer Strategy is under development This will be led by the new Director of Nursing and Quality and reported to the Board The Trust has embedded a robust quality assurance process to monitor, deliver and validate the CQC actions on the overall CQC action plan

There is a weekly exception report that is produced and reported across the Governance structure and to the Director of Improvement & Compliance for oversight and escalation

Gaps in Controls/Assurance Required Action Lead Deadline Monitored at

The Trust has insufficient numbers of suitably trained mortality reviewers

To implement a training programme for staff undertaking mortality reviews Medical Director Q3 People and Quality

Committee To increase recruitment of mortality reviewers

The Trust has not developed a full action plan to address issues raised in the final CQC inspection 2019

Once the final report is received, develop a CQC action plan that can be implemented and evidenced

Director of Improvement and

Compliance Q3 Trust Board

Actions from the serious incident and patient experience reviews are not pro-actively concluded and then implemented

To identify the key actions following serious incident reviews and themes from patient experience outcomes and develop action plans for implementation

Director of Improvement and

Compliance

Q3 Completed during Q4

People and Quality Committee

The Trust has been issued with a Warning Notice in respect of the required improvements in relation to PDR and supervision on the Acute wards

The Trust must comply with the conditions outlined within the warning notice by the required deadline

Director of Improvement and

Compliance

20 December 2019 Trust Board

In-complete data transfer of patient information to an external organisation, as per the data transfer agreement

Use the outcome of the clinical audit to review the cases to understand the challenges and mitigate future risk Medical Director Q3 Trust Board

The Trust needs to ensure continued work to remain compliant with the NHSI Developing Workforce Safeguards guidance to ensure maintained achievement over the next 12 months

The Trust will ensure that all recommendations within the guidance are implemented and maintained

Director of Nursing and

Quality

Q1 2020/21 (Originally Q4) Trust Board

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Appendix 1 - BAF 2019/20 Quarter 4

Board Assurance Framework 2019/20 BAF RISK 2.0: The Trust does not deliver safe, appropriate and therapeutic environments to deliver high quality services LEAD DIRECTOR: DON&Q Reporting to: People and Quality Committee STRATEGIC PRIORITY: To deliver sustainable services that meet the needs of local people RISK SCORE:

10 RISK TARGET SCORE: 8

5x2 2x4

Risk Score By Quarter Q1 Q2 Q3 Q4 10 10 10 10 5x2 5x2 5x2 5x2

Mitigating Controls Controls Assurances The Trust completes annual health and safety assessments (including PLACE and anti-ligature assessments)

Reported to the Quality Committee and assurance received that the estates are appropriately assessed to reduce ligature risks

The Trust has identified baseline positions to eliminate dormitory accommodation in line with standards set by the CQC (Same sex accommodation standard)

This is reported through to the Directors Group and Board Committees to ensure the work is progressed.

An Operational Management group has been established to oversee operational and management priorities across all three networks

This takes place on a weekly basis and is led by the Director of Operations, with any major concerns escalated to the Board as necessary

The development of the long-term Estates Strategy is underway which sets the strategic context for the investment and development of the estate, which will feed into the overall Trust Strategy The Estates Strategy is due for approval by the Board in Q1 2020/21 (Originally Q4 2019/20)

As part of the response to the CPFT CQC report, the Estates team have developed a safety prioritisation action plan to address estates and safety concerns at South Cumbria sites

This was developed against the risk assessment work carried out by the Trust’s safety department and is overseen by the Director of Nursing and Quality and Director of Improvement and Compliance

Gaps in Controls/Assurance Required Action Lead Deadline Monitored at There is a lack of an appropriate process to respond to themes arising from complaints from service users to conclude actions

To implement a process that ensures that themes arising from complaints support the development of action plans to make improvements

Director of Improvement and

Compliance

Q3 Completed during Q4

People and Quality Committee

It has not been concluded how the dormitory accommodation issue will be addressed and by when

Through reporting, a decision must be made to implement dormitory accommodation standards

Director of Nursing and

Quality Q3

Finance and Performance Committee

The Estates Strategy has not been finalised and approved by the Board

The Board must approve the final Estates Strategy, following completion of the overall Trust Strategy

Chief Finance Officer

Q1 2020/21 (originally Q4) Trust Board

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Appendix 1 - BAF 2019/20 Quarter 4

There is a lack of visibility and oversight of waiting times across the Trust’s services which is impacting on positive patient experience

Ensure that the Trust’s Senior Leadership Team has regular reporting of waiting times to ensure that there is appropriate escalation and oversight

Director of Nursing and

Quality Q1 2020/21 Quality Committee

There is a lack of compliance with the Mental Health Act, in particular due to breaches on Section 136 due to limited resources

Continue to monitor compliance with the MHA Code of Practice on a weekly basis at the Senior Leadership Team within the Mental Health Network and escalate to the Board Committee

Director of Nursing and

Quality Q1 2020/21 Quality Committee

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Appendix 1 - BAF 2019/20 Quarter 4

Board Assurance Framework 2019/20 BAF RISK 3.0: The Trust does not have the ability to address and meet service demands which is affected by uncertain and limited commissioning arrangements.

LEAD DIRECTOR: DoO

Reporting to: Finance and Performance Committee STRATEGIC PRIORITY: To deliver sustainable services that meet the needs of local people RISK SCORE:

12 RISK TARGET SCORE: 9

4x3 3x3

Risk Score By Quarter Q1 Q2 Q3 Q4 12 12 12 12 4x3 4x3 4x3 4x3

Mitigating Controls Controls Assurances The Trust has formed an agreement for the risk share basis of OAPS with Commissioners. (Acute care and PICU patients is a 50/50 risk share and Commissioners hold 100% responsibility for rehabilitation and learning disability beds)

The Trust is monitoring OAPs placements on a daily basis and this reported monthly to the Trust Board

The Trust has successfully obtained dedicated funding for Crisis Services and Liaison Services via the Community Crisis Care funding applications and has received two tranches of money since August 2019

This provides the Trust with access to a greater level of dedicated resource to recruit more appropriately skilled staff into Crisis Service and Home Treatment Teams and these services now operate on a 24/7 service provision Local commissioners increased funding for dedicated urgent care mental health services during

Q2 which will support improvements across the year The Trust will be the lead provider of Secure services by April 2021 and CAMHs services by October 2020, as agreed by NHS England

The Trust continues to work closely with NHS England to prepare to become the provider of the specialist care models initiative

The Trust is working in partnership with the ICS to develop a rehabilitation model There is currently no formal rehabilitation model and the development of this will support the provision of rehabilitation services to reduce inappropriate placements

Gaps in Controls/Assurance Required Action Lead Deadline Monitored at The Trust is not the chosen provider for some areas of its care as we are not meeting the needs of the local population

Work with NHS England to confirm and establish the most appropriate governance arrangements prior to full implementation of the new care models initiative

Director of Partnerships and

Strategy

Q1 2020/21 (originally Q4) Trust Board

The Trust still reports a considerable number of Out of Area Placements

Continue to deliver the work within the mental health improvement plan to reduce OAPS

Director of Operations Q4

Finance and Performance Committee

Trust Board

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Appendix 1 - BAF 2019/20 Quarter 4

There remains a lack of commissioning arrangements to support the Trust in providing its core services

Engagement with the Commissioners to improve the current commissioning arrangements

Chief Finance Officer

Director of Operations

Q4 Trust Board

The Trust has no dedicated learning disability commissioned beds which results in a number of inappropriate placements

Develop three business cases for the provision of LD inpatient beds, an autism only service and an intensive support service

Director of Operations Q4 Trust Board

The Trust does not have a formal personality disorder model which results in patients not always receiving appropriate care

Appoint the Clinical Lead for personality disorder to support the Personality Disorder Pathway redesign with CNTW

Director of Operations Q1 2020/21 Trust Board

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Appendix 1 - BAF 2019/20 Quarter 4

Board Assurance Framework 2019/20 BAF RISK 4.0: The Trust does not ensure safe and effective transfer of South Cumbria mental health, CAMHS and learning disability services into the Trust

LEAD DIRECTOR: DoMH&LD

Reporting to: South Cumbria Assurance Committee STRATEGIC PRIORITY: To provide high quality services

RISK SCORE: 16 RISK TARGET SCORE: 12

4x4 4x3

Risk Score By Quarter Q1 Q2 Q3 Q4 16 16 16 16 4x4 4x4 4x4 4x4

Mitigating Controls Controls Assurances The South Cumbria Assurance Committee has met monthly during Q2 and Q3 and provides additional scrutiny on all South Cumbria post-transfer matters on behalf of the Board

The Committee is chaired by a Non-Executive Director and provides assurance to the Board on the process to deliver a successful pre and post transition and works to mitigate risks and gaps

The Trust has confirmed an interim clinical and operational management structure between 01 October 2019 and 01 April 2020

This supports the delivery of the mobilisation and PTIP including the delivery of the relevant CQC actions

An external assurance group has been set up to and is Chaired by NHSE, to oversee the mobilisation delivery

This is attended by the Director of Improvement and Compliance and escalations of risks and assurances are fed back to the South Cumbria Assurance Committee on a monthly basis

The Trust is delivering the Post Transfer Implementation Plan which was developed as part of the full business case and continues to be a live document as matters arise

Assurance around the delivery of the PTIP is reported to the South Cumbria Assurance Committee monthly

The South Cumbria Assurance Committee is providing additional scrutiny on improvement in services in South Cumbria

Assurance will be provided to the Committee in February 2020 and supports the focus and delivery of required improvements

An integration board was due to be established to support the establishment of the locality model This will be attended by the Director of Mental Health and LD (South Cumbria) and escalations to the South Cumbria Assurance Committee

Gaps in Controls/Assurance Required Action Lead Deadline Monitored at The Trust has not yet fully implemented the post-transaction implementation plan

The Trust must implement the post-transaction integration plan including the capital investment

Director of Mental Health and LD

Q4 South Cumbria Assurance Committee

The Trust has not yet fully embedded the clinical and operational management structure post-transaction

The Trust must implement the interim management structure until April 2020

Director of Mental Health and LD

Q3 South Cumbria Assurance Committee

The Trust has not yet developed a clear plan to support the transition from the interim management structure to the permanent structure from the 01 April 2020

The Trust must develop and implement a clear management transition plan from the 01 April 2020

Director of Operations

Q2 2020/21 (originally Q4) South Cumbria

Assurance Committee

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Appendix 1 - BAF 2019/20 Quarter 4

The Trust has not yet developed of a clear post-transaction governance structure

The Trust must implement clear governance arrangements both internally and externally

Director of Mental Health and LD

Q1 2020/21

(originally Q4)

South Cumbria Assurance Committee

The Trust has not yet resolved the Capital gap at Kentmere The Trust must continue to monitor and review investment into the Kentmere unit (To continue to review during 2020/21)

Director of Mental Health and LD

Q4 2020/21

(originally Q4)

South Cumbria Assurance Committee

Capacity issue of the mobilisation team in light of recent leavers Conclude a plan to deliver the mobilisation plan and address capacity issues

Director of Mental Health and LD

Q3 South Cumbria Assurance Committee

The Trust has received several notifications from the CQC in respect of concerns at the Dova and Ramsey units

Work with the management team in South Cumbria to address concerns in particular around the environment and staffing

Director of Improvement and Compliance

Q2 2020/21

(originally Q4)

South Cumbria Assurance Committee

There are challenges with the workforce data, in particular mandatory training

The Trust must ensure the data discrepancies are addressed and a baseline position for mandatory training data to be concluded

Director of Mental Health and LD

Q4 South Cumbria Assurance Committee

The Trust cannot yet explicitly outline the improvement in the quality of services that transition from South Cumbria

Through reporting within the governance structure, the Trust must provide assurance on the improvement in the quality of services following transfer

Director of Mental Health and LD

Q1 2020/21

(Originally Q4)

South Cumbria Assurance Committee

There remains dormitory accommodation on Kentmere unit Commence a Trust-Wide dormitory risk assessment review to include Kentmere

Director of Mental Health and LD

Q4 South Cumbria Assurance Committee

There is staffing challenges in South Cumbria services, in particular Psychiatry within the CAMHs services

Agree and commence the recruitment within CAMHs Director of Mental Health and LD

Q4 South Cumbria Assurance Committee

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Board Assurance Framework 2019/20 BAF RISK 5.0: The Trust does not build its reputation with all stakeholders through appropriate engagement and partnership working LEAD DIRECTOR: DoPS

Reporting to: Trust Board STRATEGIC PRIORITY: To deliver sustainable services that meet the needs of local people RISK SCORE:

12 RISK TARGET SCORE: 8

3x4 2x4

Risk Score By Quarter Q1 Q2 Q3 Q4 12 12 12 12 3x4 3x4 3x4 3x4

Mitigating Controls Controls Assurances The Trust has Executive and Non-Executive Director representation on the ICS Board The Trust representatives receive relevant updates in relation to the ICS and support the building of

relationships with partners in the ICS The Director of Partnerships and Strategy is a Trust representative on the ICP Board The Trust has established a regular partnership update to the Board and Executive Group

Partnership Strategy development is addressed within the overarching Trust Strategy The development of the Partnership Strategy is reported to the Board to oversee the progress with partnership working in regards to the delivery of the Trust Strategy

The Trust shared and agreed a high level emerging clinical strategy with the ICP’s and ICS This continues to support the Trusts shared understanding and agreement with partners and stakeholders in respect of emerging Trust strategies

Gaps in Controls/Assurance Required Action Lead Deadline Monitored at

There is a lack of executive capacity to be able to send senior decision makers to all appropriate ICP forums

The Trust will undertake a management restructure that is locality facing to support this challenge

Director of Operations

Q2 2020/21

(originally Q4)

Trust Board

The Trust does not engage sufficiently with the local authorities

The Trust will continue to engage with the key local authorities and develop enhanced working relationships with the three district CAMHS services and Lancashire County Council

Director of Partnerships and

Strategy Q3

Finance and Performance Committee

The Trust does not have meaningful relationships with partners including the ICP Boards, third sector and the Primary Care networks

The Trust will attend and represent the Trust at the ICP Boards and associate management meetings to therefore develop good relationships with PCNs and the third sector

Director of Partnerships and

Strategy Q3

Finance and Performance Committee

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The Trust has not yet got a clear strategic partnership plan with the third sector

The Trust will develop and implement a clear strategic partnership and aligned plan with the third sector

Director of Partnerships and

Strategy Q4 Trust Board

There is a lack of a shared understanding and agreement with stakeholders and partners in respect of the Trust’s emerging clinical strategy

The Trust will regularly share emerging thinking and updates in relation to upcoming strategies with the Trust’s stakeholder and partners

Director of Partnerships and

Strategy

Q2 2020/21 (originally Q4) Trust Board

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Board Assurance Framework 2019/20 BAF RISK 6.0 The Trust does not have sufficient leadership to deliver the transformational change required to address the cultural changes, improve wellbeing and to empower staff and widen the diversity of our workforce

LEAD DIRECTOR: HRD

Reporting to: People and Culture Committee STRATEGIC PRIORITY: To deliver sustainable services that meet the needs of local people RISK SCORE:

16 RISK TARGET SCORE: 9

4x4 3x3 Risk Score By Quarter

Q1 Q2 Q3 Q4 16 16 16 16 4x4 4x4 4x4 4x4

Mitigating Controls Controls Assurances The Trust is developing a People and Culture Strategy as an enabler to the overall Trust Strategy The People and Culture strategy will be reported to the Board for approval at the end of Q1 20/21 The remaining People Plan priorities will be built into the overall Trust People and Culture strategy The Trust is implementing the principles of the NHSI Interim People Plan The progression of this is reported to the Board on a regular basis. Final NHSI People Plan

guidance anticipated end April 2020. The Trust has undertaken a gap analysis to embed the principles of the Developing Workforce Safeguards guidance and is on trajectory for continued achievement

This was reported to the Board in June 2019 and further work is planned across the next 12 months This will also be monitored as part of the People and Culture Strategy

The Trust has recruitment and retention activity of all staff ongoing across the organisation The scheduled work has been developed in line with NHSI retention programme. A new toolkit has been issued by NHSI, the Trust will use as a core part of the P&C Strategy.

The Trust is optimising the apprenticeship framework to ensure that workforce and skills gaps are effectively addressed

The People and Culture strategy will formalise this apprenticeship optimisation. In the meanwhile, the Trust is fully optimising. The Trust is currently collecting narrative around short-term and long-term issues to support this optimisation.

The Trust is embedding the Hate Crime project at the Guild The Hate Crime work is reported to the People & Quality Committee on a regular basis The Trust has embedded an LiA programme, led by the Chief Executive and a dedicated LiA team

The outcomes of the LiA are communicated across the Trust and are supporting increased engagement and response to staff concerns. Pass it On event to take place in March 2020.

Gaps in Controls/Assurance Required Action Lead Deadline Monitored at

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The Trust has not yet identified clear actions to be more inclusive of BAME and disabled staff

The Trust will complete the development of the diversity and inclusion strategy (as part of the People and Culture Strategy) for 2020 - 25

Director of Human Resources

Q1 2020/21 (originally Q4)

People and Quality Committee

The Trust has not yet fully implemented the NHSI interim People Plan The Trust will embed the principles within the NHSI interim People Plan and report this to the Board This links to the People and Culture Strategy

Director of Human Resources

Q1 2020/21 (originally Q4)

Trust Board People and Quality Committee

The Trust has not yet fully embedded its People and Culture strategy The Trust will develop a Trust wide People and Culture strategy and report this to the Board

Director of Human Resources

Q1 2020/21 (originally Q4)

Trust Board People and Quality Committee

The Trust needs to ensure continued work to remain compliant with the NHSI Developing Workforce Safeguards guidance to ensure maintained achievement over the next 12 months

The Trust will ensure that all recommendations within the guidance are implemented and maintained

Director of Human Resources

Q1 2020/21 (originally Q4) Trust Board

Significant work to be undertaken to deliver the Just Culture programme The Trust will embed and sustain the Just culture principles Director of Nursing

and Quality Q1 2020/21

(originally Q3) People and Quality Committee

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Board Assurance Framework 2019/20 BAF RISK 7.0: The Trust does not achieve financial performance sufficient to maintain resilience and sustainability LEAD DIRECTOR: CFO

Reporting to: Finance and Performance Committee STRATEGIC PRIORITY: To provide financially sustainable services RISK SCORE:

15 RISK TARGET SCORE: 10

3x5 2x5

Risk Score By Quarter Q1 Q2 Q3 Q4 15 15 15 15 3x5 3x5 3x5 3x5

Mitigating Controls Controls Assurances The Trust continues to work align transformation to CIP delivery (Linked to BAF risk 8.0) There is a process in place to track the delivery of the CIP Programme The Trust aims to manage the OAPs position to reach the NHS Improvement trajectory (Through the mental health improvement plan) The delivery of the mental health improvement plan is reported to the Board on a monthly basis

The Trust has implemented a process to oversee the financial aspect of the South Cumbria transition

The South Cumbria full business case includes the financial model and the Trust continues to liaise with the externally commissioned advisors to ensure oversight of any financial changes

The Trust has secured £3.3m funding for 2019/20 as part of the request for investment as part of the Mental Health Investment Standard

The Trust continues to meet with Commissioners to discuss their commitment to a recurring investment

The Trust has initiated re-charge of stranded patients to the Commissioners There has been a slight improvement with the OAPs position during Q2

Gaps in Controls/Assurance Required Action Lead Deadline Monitored at

The Trust is not efficiently delivering the transformation elements of CIPs in the networks

The Director of Operations will work closely with the networks and support services to improve the CIP position through adopting a transformational approach to the delivery of CIPS

Director of Operations

Q3 No longer applicable

Finance and Performance Committee

The Trust does not yet have full commitment from Commissioners in respect of recurrent investment as part of the mental health investment standard to strengthen the mental health pathway

The Trust will continue to work with the Commissioners and the ICS to address investment shortfalls to strengthen the mental health pathway

Director of Operations

Q1 2020/21 (originally Q3)

Finance and Performance Committee

The Trust remains off track with the OAPs position, with a current shortfall of £5.3m primarily driven by OAPs

The Trust will work in collaboration with the Commissioners and the ICS as part of the risk share agreement to improve

Director of Operations

Q1 2020/21 (originally Q4) Trust Board

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Appendix 1 - BAF 2019/20 Quarter 4

the OAPs position through the development of a range of rehabilitation services

There is still some uncertainty around the achievement of the Trust’s shared ICS control total for 2019/20, which would result in the Trust losing PSF monies

The Trust will continue to work to achieve the potential upsides during 2019/20 to achieve the Trust’s control total

Chief Finance Officer Q4 Trust Board

The Trust was at financial risk of c£730K due to risk around non-delivery of the 2019/20 CQUINs, in particular the IAPT and data quality maturity index CQUINs

The Trust must continue to drive the CQUINs delivery and escalate any concerns through the governance structure

Director of Improvement and

Compliance Q4

Finance and Performance Committee

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Board Assurance Framework 2019/20 BAF RISK 8.0: The Trust does not achieve the required efficiency savings whilst delivering and improving quality LEAD DIRECTOR: DoO

Reporting to: Finance and Performance Committee STRATEGIC PRIORITY: To provide financially sustainable services RISK SCORE:

15 RISK TARGET SCORE: 8

5x3 2x4

Risk Score By Quarter Q1 Q2 Q3 Q4 15 15 15 15 5x3 5x3 5x3 5x3

Mitigating Controls Controls Assurances The Trust has a system in place to monitor, deliver and report CIPS across the year There is regular review of CIPs at Finance and Performance Committee and Operational

Management Group

The Trust has delivered 106% of its CIPs for 2019/20 Whilst the target has been achieved, this is heavily caveated on transactional CIPs and there is a gap in the transformational approach to delivering CIPs

The Trust has assigned Meridian to undertake an independent review of the required system changes to support the Community and Wellbeing Network with the achievement of CIP This intends to support the Network with the achievement of CIP targets

Gaps in Controls/Assurance Required Action Lead Deadline Monitored at

There is a lack of transformational activity linked to the CIP programme

The Trust will adopt a transformational approach to the delivery of CIPS and report this through the governance structure

Director of Operational

Finance

Q1 2020/21

(originally Q3)

Finance and Performance Committee

There is a lack of understanding around the work being undertaken to improve the CIP pipeline

Work will be undertaken to consider all CIPs within the scheme and the action being taken to increase CIPs in the Pipeline

Director of Operational

Finance

Q3 Completed during

Q4

Finance and Performance Committee

There is a lack of ownership and engagement by senior management towards setting the network CIP targets which results in unachievable expectations which the networks have not agreed to

Senior leaders will take opportunities within the management re-structure to look at more effective leadership around CIPs to support the networks

Director of Operations

Q3 Completed during

Q4

Finance and Performance Committee

The Trust has not agreed a robust methodology to identify, deliver and report the CIP schemes effectively

The Trust will agree and implement the methodology for the identification and reporting of CIPs

Director of Operations

Q1 2020/21

(originally Q4)

Finance and Performance Committee

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Appendix 1 - BAF 2019/20 Quarter 4

A number of CIP schemes have not undergone the required quality impact assessments

A full quality impact assessment will be undertaken against all CIPs

Director of Operations Q4

Finance and Performance Committee

There was a significant risk in the Community and Wellbeing Network in relation to the delivery of CIPs

The Trust must continue to work closely with the network to support delivery of the additional c£654K in year

Director of Operations Q4

Finance and Performance Committee

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Board Assurance Framework 2019/20 BAF RISK 9.0: The Trust does not exploit the full capabilities of technology and fails to achieve the desired benefits to improve quality of care and data

LEAD DIRECTOR: CFO

Reporting to: Finance and Performance Committee STRATEGIC PRIORITY: To innovate and exploit technology to transform care RISK SCORE:

12 RISK TARGET SCORE: 12

3x4 3x4

Risk Score By Quarter

Q1 Q2 Q3 Q4 12 12 12 12 3x4 3x4 3x4 3x4

Mitigating Controls Controls Assurances The Trust’s EPR Programme Board is live and monitors the delivery of EPR objectives There is appropriate senior management on the EPR board and separate work stream’s which focus

on the additional areas, including the GDE programme The Trust internal auditors continue to include EPR reviews within the Trusts annual internal audit plan The outcome of the EPR internal audit reviews to date have received substantial assurance

The Trust participates in bi-monthly meetings with NHS Digital to monitor the EPR The Trust receives additional assurance from NHS Digital via the GDE/EPR Programme Board that EPR is progressing appropriately and is able to escalate any risks/concerns

Gaps in Controls/Assurance Required Action Lead Deadline Monitored at There is a risk that the South Cumbria transition may affect activity and ultimately delay the clinical benefits from the deployment in the software

The Trust will continue to monitor the deployment to South Cumbria services for any additional issues that may impact deployment of EPR

Chief Finance Officer Q4

Finance and Performance Committee

There is a potential internal resourcing risk which may affect the delivery of EPR

The Trust will continue to monitor delivery of EPR against its objectives

Chief Finance Officer Q4

Finance and Performance Committee

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Appendix 1 - BAF 2019/20 Quarter 4

Board Assurance Framework 2019/20 BAF RISK 10.0: The Trust does not identify and maximise new innovations to transform services and improve care LEAD DIRECTOR: DoI&C

Reporting to: Finance and Performance Committee STRATEGIC PRIORITY: To innovate and exploit technology to transform care RISK SCORE:

16 RISK TARGET SCORE: 9

4x4 3x3

Risk Score By Quarter

Q1 Q2 Q3 Q4 12 12 16 16 4x3 4x3 4x4 4x4

Mitigating Controls Controls Assurances The Trust has a dedicated Transformation team and Head of Transformation to lead on transformation of services

The Transformation work reports to the Trust’s operational services group on a weekly basis for assurance

The Trust has recruited an Innovation Manager to deliver innovation activity The innovation manager will report into the Finance and Performance Committee to provide assurance on innovation activity

Innovation activity is reported to the Infrastructure Sub-Committee, and ultimately to the Finance and Performance Committee

Innovation activity will be reported as a separate agenda item for 2019/20 recognising the need for focus and additional assurance

The Trust is seeking to establish dedicated Innovation hubs to support innovation objectives for 2019/20

The innovation hub would support collaborative working with external organisations to broaden innovation and technologies

Gaps in Controls/Assurance Required Action Lead Deadline Monitored at

The Trust does not have an effective transformation plan The Trust will develop an improvement strategy Director of

Improvement & Compliance

Q1 2020/21

(originally Q4)

Trust Board

The Trust does not yet have a robust digital innovation strategy to deliver better services The Trust will develop its Digital strategy Chief Finance

Officer

Q2 2020/21

(originally Q4)

Trust Board

The Finance and Performance Committee does not have direct oversight of the transformational activity underway

Transformation activity will form part of the Finance and Performance Committee cycle of business following the development of the digital strategy

Chief Finance Officer

Q4 No longer applicable

Finance and Performance Committee

The Trust has not received any direct funding to support the development of the Innovation hubs

The Trust will develop improvement and innovation hubs as part of the developing improvement strategy

Director of Improvement &

Q1 2020/21

Finance and Performance

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Compliance (originally Q3) Committee

The understanding of roles and responsibilities of the Trust’s Estates is unclear due to the current content of the SLA

Commission a review of the HSIS SLA and KPIs undertaken by the Board to ensure there is a clear understanding of roles and responsibilities

Chief Finance Officer Q4 Trust Board

Risk Rating Matrix (Likelihood x Consequence)

Director Lead: Likelihood

Consequence CEO DoPS CFO HRD DoNQ MD DoO DoI&C

Chief Executive Director of Partnerships and Strategy Chief Finance Officer Director of Human Resources Director of Nursing & Quality Medical Director Director of Operations Director of Improvement & Compliance

Insignificant 1

Minor 2

Moderate 3

Major 4

Catastrophic 5

5. Almost Certain

5 Moderate

10 High

15 Significant

20 Significant

25 Significant

4. Likely 4 Moderate

8 High

12 High

16 Significant

20 Significant

3. Possible 3 Low

6 Moderate

9 High

12 High

15 Significant

2. Unlikely 2 Low

4 Moderate

6 Moderate

8 High

10 High

1. Rare 1 Low

2 Low

3 Low

4 Moderate

5 Moderate

Board Assurance Framework Key

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Board of Directors Agenda Item TB 110/20 Date: 02/04/2020

Report Title Contingency arrangements for Associate Hospital Manager Reviews during Covid-19

Prepared By Julie-Ann Bowden, Associate Director of Effectiveness

Presented By Ursula Martin, Director of Improvement and Compliance

Action Required Decision

Supporting Executive Director Director of Improvement and Compliance

PURPOSE OF THE REPORT: Report Purpose To provide assurance that appropriate measures are being

put in place to ensure that the requirements in relation to AHM continue to be delivered with appropriate contingency measures in place.

Strategic Objective(s) this work supports

To meet our statutory/compliance obligations

Board Assurance Framework Risk 1.0 The Trust does not protect the people who use its services from avoidable harm and fails to comply with the CQCs standards for the quality and safety of services

CQC Domain Well-led 1.0 INTRODUCTION 1.1 The role of Hospital Managers as outlined in the Mental Health Act Code of Practice cannot be

undertaken by employees or officers of the Trust. The role is thereby undertaken by the Non-executive Directors of the Board. The legislation allows the Trust to appoint a group of ‘Associate Hospital Managers’ (AHMs) to undertake some of the duties required of ‘Hospital Managers’ within the meaning of the Mental Health Act, particularly the duty to discharge patients where appropriate.

1.2 The Hospital Managers retain the responsibility for the performance and application of their

delegated duties and as such must be kept informed 1.3 The Government recently announced the move from the ‘Contain’ phase of the Coronavirus

response to the second phase, ‘Delay’. The Trust’s overarching response is provided in an update paper in this pack under agenda item TB 105/20.

1.4 The Hospital Managers retain a responsibility for the performance of their delegated duties and as

such must monitor and ensure these duties are carried out in accordance with the Act and good practice standards.

2.0 BACKGROUND 2.1 Following announcement by the Government to move to the ‘Delay’ phase of the Coronavirus

response, the Trust has taken the decision to stand down / postpone most corporate events and

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meetings. Staff are asked to minimise unnecessary travel internally and to external events/meetings; where possible we should use video/telephone conferencing.

2.2 Sections 20 and 20A of the Mental Health Act imply that the hospital managers have a statutory

duty to hold an AHM hearing when an inpatient section is renewed or a Community Treatment Order extended, and a present it is the Trust’s practice to hold a face-to-face review meeting for all AHM hearings, attended by clinical staff and often by the patient, their legal representative and others.

2.3 It is clear that continuing to hold face-to-face AHM hearings under the current circumstances would

present an unacceptable direct risk of Covid-19 transmission and it is likely that continuing to commit clinical resources to facilitate face-to-face AHM hearings may also present disproportionate indirect risks to patient safety in the context of safe staffing for the delivery of care. For these reasons the Mental Health Law Manager has cancelled all scheduled face-to-face AHM hearings from 20 March until further notice.

2.4 The purpose of this document is to propose a temporary framework for conduct of AHM hearings

during this period of elevated risks as a result of coronavirus. 3.0 THE PROPOSAL 3.1 The Director of Compliance and Improvement has agreed the following proposal for the conduct

of AHM hearings during the Covid-19 outbreak, informed by discussions with colleagues internally and externally.

a) Until further notice all hearings will be in the form of “paper reviews” conducted remotely – that is

to say the AHM panel will consider via telephone conference whether to discharge patient. In the case of uncontested renewal hearings, the panel will make a decision based purely on the written reports. In the case of patient appeals or where the patient or their representative has informed us that they wish to contest the renewal, the panel will convene a telephone conference with the professionals involved and the patient and/or their representative. The Trust has chosen to make this distinction to ensure that patients can be involved if they wish to.

b) In cases in which the patient is not contesting being on their current section and the AHM panel are not minded to discharge the patient, the decision will be made at that initial hearing and the chair will forward a decision form to the MHA office. Where patients are legally represented their representative will be contacted by the MHA office prior to the hearing and invited to indicate whether the patient is contesting or not.

c) In cases in which it is believed that the patient is contesting their renewal, and/or cases in which at the initial paper review hearing the panel are potentially minded to discharge the patient, the panel will convene a teleconference with the report authors and the patient (and their representative), and both written and verbal evidence will be considered.

d) In exceptional circumstances the Mental Health Law Manager in consultation with the individual

panel members may follow a different procedure.

e) Although the Code of Practice only requires the Hospital Managers to consider holding a review if a patient requests this, at this stage, there are no plans to routinely not hold appeal hearings. Where a patient appeals or a barring order is made, a teleconference hearing will be arranged by the MHL Team. Although the MHL Team will facilitate a telephone conference in these

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circumstances, it should be noted that the hospital managers panel may choose to use their discretion and not to convene in line with the Code of Practice. It may be that the Trust choses to restrict such appeals in the future, should pressures become overwhelming for our clinical staff. This will remain under review.

4.0 COMPLIANCE WITH THE MHA CODE OF PRACTICE 4.1 It is acknowledged that the proposed system is not fully compliant with chapter 38 of the MHA Code

of Practice, in that:

it doesn’t allow for face-to-face hearings in contested cases (38.45);

it limits the ability of the patient, their relatives or carer to participate fully in the process (38.28-31, 38.34-36);

it limits the ability of the patient, their representative and of the panel members to engage in a dialogue with clinicians with respect to the evidence (38.36-37).

4.2 The Code states:

“Commissioners, providers, professionals and others providing care under the Act should document, and justify, any decision to depart from the Code or a particular guiding principle. The Care Quality Commission will look for evidence of this during their inspections and commissioners can use it as part of their contract monitoring.” (1.24)

“… departures from the Code could give rise to legal challenge, reasons for any departure should be recorded clearly. Courts will scrutinise such reasons to ensure that there is sufficiently convincing justification in the circumstances.” (intro)

4.3 It is the view of the Trust, having received information from other Trusts, that the proposed

framework represents a proportionate, cogent and justifiable departure from the MHA Code of Practice in the context of the Covid-19 pandemic. This process would also seem to be in line with the Tribunal’s service emergency procedures. Although it is by no means essential that the AHM processes mirrors that of the Tribunal service, it does provide some assurances that our procedures would be considered just and lawful at this time.

4.4 Reviews will still take place with as much rigour as can be justified without giving rise to

unacceptable risks, and patients will still have a realistic possibility of being discharged by the hospital managers through this process.

4.5 Given the increased reliance AHMs will have on written reports it will be particularly important that,

when producing their reports, the professionals write concise evidence that addresses the criteria fully and gives accurate information without too much historical/irrelevant data. Inaccurate or contradictory information in report will serve to increase the burden on all parties to ask and answer follow-up questions after the initial paper review. This will be communicated to clinicians via professional groups and networks.

5.0 KEEPING THE REVISED FRAMEWORK UNDER REVIEW 5.1 These arrangements will be kept under review by the Director of Improvement & Compliance and

Mental Health Act Law Manager in light of feedback from stakeholders and guidance issued by the government, Trust, the CQC, and the Tribunal Service.

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6.0 RECOMMENDATION The Board is requested to approve the arrangements put in place to implement contingency

measures in relation to the delivery of the duties delegated to the AHMs.

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Board of Directors Agenda Item TB 111/20 Date: 02/04/2020

Report Title Quality Committee Chair’s Report

Prepared By Marion Fountain, Executive Personal Assistant

Presented By Ursula Martin, Director of Improvement and compliance

Action Required Assurance

Supporting Executive Director Director of Improvement and Compliance

PURPOSE OF THE REPORT: Report Purpose To provide an outline of the activity undertaken by the Quality

Committee on the 12th March 2020, highlight assurance received and risks identified.

Strategic Objective(s) this work supports

To provide high quality services

Board Assurance Framework Risk 1.0 The Trust does not protect the people who use its services from avoidable harm and fails to comply with the CQCs standards for the quality and safety of services 2.0 The Trust does not deliver safe, appropriate and therapeutic environments to deliver high quality services 6.0 The Trust does not have sufficient leadership to deliver the transformational change required to address the cultural changes, improve wellbeing and to empower staff and widen the diversity of our workforce

CQC Domain Well-led 1.0 INTRODUCTION

This Chair’s Report outlines the activity undertaken by the Board level Quality Committee held on the 12th March 2020.

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

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MEETING: Quality Committee DATE: 12th March 2020

RISKS: (including actions to address gaps in controls rated red) 1.0 The Trust does not protect the people who use its services from avoidable harm and fails to comply with the CQCs standards for the

quality and safety of services. 2.0 The Trust does not deliver safe, appropriate and therapeutic environments to deliver high quality services. 6.0 The Trust does not have sufficient leadership to deliver the transformational change required to address the cultural changes, improve

quality, wellbeing and to empower staff and widen the diversity of our workforce. AGENDA ITEM COMMITTEE ACTION Terms of Reference The Terms of Reference for the newly formed Quality Committee were discussed for approval. The inclusion of the sub-committees reporting into this Committee are to be detailed within this document.

The Committee will receive the final Terms of Reference for approval at the April meeting ahead of ratification at Board of Directors.

Chair’s Reports Health and Safety Forum – Bring Your Dogs to Work Day was raised. No pets are permitted in the workplace that are not assistance animals or for Pets as Therapy. CQC Steering Group – it was noted that the CQC are currently in the organisation, following up on the warning notices with The Orchard, Scarisbrick and Harbour already been visited. They were still to visit Blackburn and Chorley. They have noted the improvements undertaken since their last visit, as part of informal feedback to date. Infection, Prevention and Control – good work undertaken to achieve the CQUIN - special mention for achieving the flu vaccination target and compliance in mandatory training.

Safeguarding Quarter 3 Report The Committee received this very comprehensive report highlighting current case reviews, themes and trends. Targets have been achieved for basic Prevent and WRAP and there has

The Committee received assurance that the Trust is meeting its statutory safeguarding responsibilities.

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AGENDA ITEM COMMITTEE ACTION been a significant improvement in mandatory training compliance. In relation to harm in adults, it was noted that physical, emotional and domestic are prevalent (at one time it was only physical abuse) – there has been an increase in sexual abuse cases as well as in trafficking. Safeguarding processes within the Trust are effective to ensure that children and adults who use the services are safeguarded and processes are in place to protect from harm. In relation to domestic abuse, 3 positively received training sessions were undertaken in January. An event had been held for people to share their stories, speak to health staff and feel supported. In the future, a film to support this group of people will be developed with their help and the Communications Team.

Learning from Deaths Quarter 3 Report The Committee received a quarterly Learning from Deaths report. South Cumbria is now included within this report - the number of deaths reported has increased as have the number of deaths actioned for Mortality Review. The number of reviewers has risen from 17 to 33. A new SI learning group is to be established to incorporate the mortality review, the SI reviews, suicide rates and safety summit to share learning beyond the Trust – this will be established in the next 2-3 weeks. There is a backlog of LeDeR reviews due to a shortage of reviewers. The Trust’s learning from deaths team will undertake a review within the Trust’s service and collate information available.

External Safety and Learning from Death Reviews and Action Plan The integrated action plan from the external reviews on Safety and Learning from Deaths were reviewed and confirmation received that some of the actions have already been implemented. It was noted and discussed some of the fundamental governance systems and processes that need to be addressed. The action plan was approved by the Committee head of being presented to the Board of Directors.

The Committee will monitor the action plan at every meeting.

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AGENDA ITEM COMMITTEE ACTION Rapid Tranquilisation Audit The Committee discussed the rapid tranquilisation audit and it was noted to show poor compliance in some areas and not provide assurance. It was noted that in 2017, the data for the baseline audit was submitted from one PICU only but, in 2018, the re-audit included 9 wards. The compliance was 32% against a national average of 18%. Mental Health Network requested a re-audit as part of their priority programme to include all wards in Lancashire (43% compliance) and South Cumbria (11% compliance) – initial reports suggest that there has been an increase in all but one parameter and an action plan is in development. Pharmacy Liaising with the Communications Team to develop branding for the podcasts and e-learning packages to be established. A patient safety matrix for inpatient wards will be developed including rapid tranquilisation audits has been implemented with monthly performance reporting.

The Committee will receive quarterly updates on progress.

DIPC Quarter 3 Report The committee received the quarterly report. There was one case of c.diff, but there were no lapses of care. 3 wards were closed to admissions during November due to the flu outbreak and 2 wards were closed in December due to norovirus – wards were re-opened quickly. The Trust was in the top 10 nationally, in respect of flu vaccinations given to staff. Work ongoing in relation to coronavirus in line with the national requirements.

Quality Dashboard Review The review of the Quality section of the monthly QPR Dashboard was presented, with amendments and revised metrics split into 3 priorities – Safe care delivered every time, Personalised, recovery focused care delivered with you, Accessible care delivered in local communities. Suggestions around feedback from service users, GIRFT information are to be incorporated. This will then form the quality section of the QPR.

The Committee will receive an updated dashboard for review at the next meeting.

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AGENDA ITEM COMMITTEE ACTION Continuous Improvement Quarterly Report Key continuous improvement programmes and projects provided together with an update on the locality transformation work and working towards a single point of access. Developing a continuous improvement strategy in the Trust.

The Committee will receive a quarterly update.

External Complaints Review and Action Plan Update An update on the action plan following the findings and recommendations of the independent review of the complaints function was provided. Whilst the majority of the actions were completed or on track – significant exception related to the PALs business case is being presented to the Executive Team the following week – the launch of the service will be delayed with the expectation that this will be functional by the end of July.

Out of Area Placements Quality Review The Trust has a reliance on the use of out of area placements and uses 3 main providers - Cygnet, Active Pathways and Priory Group. An appropriate monitoring system was set up to give a level of assurance. In November 2019, a new Out of Area Placements team was formed to ensure regular attendance at the provider hospital sites, face to face clinical reviews with patients, maintaining links with community teams and repatriation closer to home. The process is constantly reviewed. Suggestion to inform stakeholders eg Healthwatch was made to proactively inform the wider public.

Board Assurance Framework 2 strategic risks aligned to the Quality Committee. New BAF to be presented to the Board in April which will be more robust and aligned to the new governance changes.

The Committee will receive the new BAF at the April meeting, following Board.

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Board of Directors Agenda Item TB 112/20 Date: 27/03/2020

Report Title Mental Health Improvement Plan

Prepared By Russell Patton, Director of Operations

Presented By Russell Patton, Director of Operations

Action Required Noting

Supporting Executive Director Director of Operations

PURPOSE OF THE REPORT: Report Purpose To provide an update for the Board on a range of key

performance metrics linked to the urgent care mental health pathway.

Strategic Objective(s) this work supports

To provide high quality services

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

1.3 If we do not provide integrated physical and mental health services we will lose opportunities to improve patient outcomes

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

CQC Domain Well-led 1.0 Introduction This paper provides an overview to the Board of Directors on the key performance metrics. 2.0 Performance Update 2.1 Deep Dive - Progress against Key Metrics There is continued focus on the mental health urgent care pathway at both local and national level. The agreed data sets below monitor key measurable within the urgent care pathway, both to identify current performance trends and to gauge the impact of supportive actions intended to develop more efficient, effective and sustainable services that would meet the needs of key stakeholders including service users, cares, the Trust and the wider ICS system. The tables below sets out progress against key service metrics

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2.1 Home Treatment Team Caseload & Activity

*Data excludes South Cumbria due to separate reporting arrangements for this financial year

• Home Treatment Team caseloads equate to circa 25 wards of patients being home treated • It has noted in Board Reports that there was is emerging operating range of between 427 to 486

cases (with a notable exception of the period around New Year) • There is a variance in the ratios of patients to staff in teams, ranging from 2.4 patients per WTE

(Pennine) to 4.6 patients per WTE (Lancaster)

The improved Home Treatment Team activity level of January is seen again in February Daily activity was very slightly higher in February (137 contacts per day) than January (136 contacts

per day) Robust guidance and monitoring of patient activity recording February 2020 face-to-face activity is 27.4% higher than that of February 2019

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2.2 Mental Health Liaison Activity

Full team activity presented (A&E and ward-based activity) There has been 39.8% more face-to-face activity in 2019/20 to date than in the same period last

year Increased activity evident in line with expectations of increased investment This reflects the liaison role with patients admitted to acute Trust wards requiring more frequent

MHLT input for safe clinical management

Improved 1 hr performance over this period (50.7% compliance February 2019 to 75.7% in February 2020, and an increase from 74.6% in January 2020)

There was a slight decrease (though still compliance) in 4 hr performance with 96.1% in February 2020, compared to 96.4% in January 2020, and a marked improvement from February 2019’s 84.7%

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2.3 12 hour breaches

The total number of 12 hour breaches linked to Lancashire and South Cumbria increased in February to 32, compared to 28 in January

There was an increase in presentations at A&E, with the second highest number of presentations in the year

This data includes: o All LSC patients who breach 12 hours in an LSC Acute Trust A&E o All non-LSC patients who breach 12 hours in an LSC Acute Trust A&E o All LSC patients who breach 12 hours in a non-Lancashire Acute Trust A&E

Both the average and longest post-Decision to Admit (DTA) times are showing downward trends Both the average (20:56) and longest (40:00) breach times in February were lower than in January This is particularly notable given the increased pressure of breaches in February, and is associated

with the increase in OAPs, with early referral to OAP being a central mitigating action in the management of 12 Hour A&E Breaches

Analysis has been conducted of the pattern of mental health A&E 12 hour breaches Bed availability remains the predominant reason for 12 hour A&E Breaches There has been a shift in the pattern of breaches in more recent months:

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Data for the whole period June 2019 to February 2020 shows an obvious pressure point of Sundays This makes sense in terms of being a day when bed stock is most likely to be exhausted (both in

Trust and in OAPs)

2.4 Bed Utilisation

Reporting of the total daily bed demand by bed type is focussed The above graph reflects every Lancashire resident either in an adult mental health bed or

awaiting admission The bed types are:

o LSCFT Assessment Bed o LSCFT Acute Adult Mental Health Bed o LSCFT PICU o Contracted Priory Bed o Acute OAP o PICU OAP o An out of area NHS Bed o People waiting admission to a bed (solid red bars at top of stacked columns)

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This latter group represent a key clinical risk to be managed for the organisation The black horizontal line reflects the total bed capacity that LSCFT (excluding South Cumbria)

would have if inpatient capacity was commissioned at the population-weighted national average for Adult Acute, PICU, Long Term Complex Care, HDU and LD Admission & Assessment beds

o This equates to 391 beds o Average Trust bed demand since April 2019 has been 347 patients (88.7% occupancy at

national average bed capacity) o Trust bed demand peaked on 3 November at 386 patients (99.0% occupancy at national

average bed capacity) o The dotted red horizontal line shows LSCFT capacity if commissioned to the same level as

CNTW for population size This is shown as CNTW manage the total population inpatient requirements for the Trust footprint

(i.e. zero use of independent rehabilitation facilities)

OAP numbers reflect average of daily midnight bed state There is a clear downward trend from the early November peak, which was driven by high October

demand There is a visible increase in OAPs at the end of November at the time of three LSCFT wards being

closed due to influenza, and a similar pattern is seen after the closure of two Chorley Wards in early January

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• Temporary reduction in SIPU beds to enable building works to support improved environments has meant some additional capacity pressures through the latter part of January, which will continue into March

• Overall demand looks to be within typical ranges, but the loss of Trust capacity due to planned estates work and unplanned infection control measures is leading to increased OAPs pressures

2.5 Trust Bed Flow NHSE are requesting that Acute Ward Length of Stay data is presented as Median Lengths of Stay rather than Mean Length of Stay, as this is considered a more reliable indicator of underlying performance, less subject to skew from large outliers (e.g. discharge of a very long length of stay patient)

Monitoring of the Median Length of Stay on Trust Wards has therefore commenced:

*partial quarter data 

The median LOS for 2019 was 17 days, which is in line with the National Average (Mean length ofstay is notably higher than national average, though is skewed by Long-Term Complex Care caseson Acute Wards)

Notably, median LOS moved below the national average in Q2 and Q3, with a consequent increasein numbers of discharges/patients per bed

30 day re-admissions have remained below the 8.7% target over the period February Median Length of Stay for Adult Acute wards was 14.5 days, a slight increase February 20 Day Re-admission rate was notably closer to the 8.7% ceiling, being 8.1% 6.7%

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2.6 Stranded and Super Stranded Cased

 

 

Stranded case numbers have been stable since October 2019 Super Stranded cases have increased over January and February and require monitoring to see if

this is a significant trend of variance within a range The Head of Operations for the Mental Health Network continues to chair a weekly review with

commissioners of all Stranded and Super Stranded cases to include all ICS CCGs

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2.7 Access Line and 136 Usage

 

February saw a notable increase in police calls to the Mental Health Access Line compared to the previous month, with 201 calls (compared to 138 calls in January)

This compares to an average monthly police call rate of 124.5 for the months June to September (prior to increased staffing in the MHAL), so reflects a sustained increase in use of the Mental Health Access Line by police

The number of s136 detentions increased slightly in February, from 116 to 121 suggesting that the November fall in detentions was an exceptional month, and the typical range of detentions per month is 116-136

2.8 136 Usage and Breaches

There was a slight increase in detentions under s136 and s135 in February, with 120 detentions (compared to 116 in January)

Jun Jul Aug Sep Oct Nov Dec Jan Feb

Police calls to MHAL 124 137 124 113 193 139 144 138 201

Total Number of s136 Detentions 123 116 127 136 124 82 119 116 121

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The number of s136 & s135 breaches increased by 7 to a total of 16, of which 14 were in Trust s136 Suites (with 2 in A&E Departments)

The primary reason for breaches was bed availability

The key absence of any inpatient rehabilitation pathway means that the Trust average bed stock is significantly below the national benchmarked average, and completion of a commissioning process for inpatient rehabilitation is required for confidence of sufficient bed capacity to eliminate s136 breaches

Management monitoring and actions remain in place to minimise s136 breach numbers and Length of Stay

Both average length of stay for s136 breaches and longest length of stay of any s136 breach show improved performance but both have shown a decline in performance in February 2020

2.9 COVID-19 Capacity Building

In response to COVID-19 , further focus has been given to creating capacity within the trusts treatment wards, which will provide both admission capacity and flexibility in managing potential pressures linked to staff availability and patient presentations. There will be additional rapid development of revised discharge Standard Operating Procedures for Discharging from inpatient wards to maximise flow. This will not be at the expense of patient safety or quality, but will reflect the need for an extra-ordinary response to such extreme circumstances. Daily discharges have been tracked from the 28 February 2020, and demonstrate the increased flow from adult and older adult ward in the week commencing 16 March 2020. 

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3.0 Decision Required The Board is asked to note the contents of this report.

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Board of Directors Agenda Item TB 113/20 Date: 02/04/2020

Report Title Quality and Performance Report (QPR)

Prepared By

Presented By Phil Evans, Executive Director of Partnerships and Strategy

Action Required Noting

Supporting Executive Director Director of Partnerships and Strategy

PURPOSE OF THE REPORT: Report Purpose To appraise the Board of Directors of key elements and

themes from the Month 10 QPR

Strategic Objective(s) this work supports

To provide high quality services

Board Assurance Framework Risk 2.0 The Trust does not deliver safe, appropriate and therapeutic environments to deliver high quality services

CQC Domain Well-led 1.0 INTRODUCTION The Board of Directors are asked to note the QPR for month 10 with the following comments below:

The Trust is compliant with 9 of the 11 current NHSI metrics in month 10: o Inappropriate OAPs continues to exceed the current trajectory (which was agreed at the

start of 18/19) as it did not account for the absence of rehabilitation beds and the National Team’s hypothesis regarding the factors causing OAPs in Lancashire Actions to improve the OAPs position are being progressed as part of the system-wide action plan developed to respond to the NTW review. The Mental Health Improvement Plan Update paper, presented by the Executive Director of Operations, provides the detailed update on the action plan

o The latest position available (November 2019) of the Data Quality Maturity Index (DQMI), reported by NHS Digital, shows the Trust is non-compliant against the 95% standard (and the 90% - 95% for the CQUIN achievement) at 89.3% but is continuing a month on month improvement. The DQMI measures our performance against data submission to 36 fields. Due to lack of overall alignment with our systems to the national dataset, and the partial roll out of RiO (RiO PAS rolled out only) this is proving to be a complex, challenging piece of work. Currently there are 23 fields at 90% or above. Actions are in place to address each area, and based on the current assumptions of the impact of our interventions, it is expected that the minimum CQUIN standard may be achieved from Q3 onwards, however payment mechanisms are such that there is a risk to financial achievement for the year.

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There is an increase in the number of reported Delayed Transfers of Care (DTOC) from the Inpatient units, but this still remains under the maximum target of 7.5% of total occupied bed days. LSCFT have established a MH System Flow Meeting with partners such as CCGs and Local Authorities to more effectively manage stranded and super stranded patients to improve flow. The new process, introduced in Dec 2019 has identified a number of DTOCs previously not identified. It is expected that the number will increase into quarter 4 whilst this process is established.

As agreed with the regulator and Trust Board, South Cumbria metrics are presented separately in a dashboard under the Summary Dashboard section (page 10) and the combined performance for Lancashire and South Cumbria is presented in dashboards on page 12.

In line with the planned introduction of SPC methodology into the HR section of the QPR, SPC icons are now available on the Sickness and Training run charts. Alongside the introduction of SPC, a review of the content has been undertaken with positive feedback received. In response to feedback, references have been added at the side of the summary dashboards as to where additional narrative can be found. Further work will be undertaken with the new interim Executive Director Workforce and the new Executive Director for Nursing.

In line with comments received, the Quality section of the Summary Dashboards, now includes the 18-19 National Benchmarking mean in the ‘Target’ column, not so much as a target but to provide context to the number of incidents and to gauge the current performance against the mean of last year’s national average. These are only available for selected measures, and the National mean has been used to calculate the equivalent monthly value for the Trust based on bed numbers (or other unit) used to calculate the specific Benchmarking metric.

The Mental Health Improvement Plan metrics, which have previously been included in the Mental Health Improvement Plan Update paper, are now incorporated into the QPR and should be referenced in the context of the Mental Health Improvement Plan Update paper.

2.0 RECOMMENDATION The Board of Directors are asked to:

Note the content of the QPR Agree how actions are to be addressed as appropriate to LSCFT.

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Quality & Performance ReportM11 – February 2020

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Quality & Performance ReportContents

Section 1:- Summary Dashboards

• Statistical Process Control - Key• Trust Monthly Metrics Dashboards

Section 3:- Quality

• Quality – Safe• Quality – Effective• Quality – Experience

Section 3.1:- Commissioning for Quality & Innovation

• CQUIN Executive Summary

Section 4:- Workforce

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

Section 2:- Performance Activity

• Key Exceptions

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Summary DashboardsSection 1.

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Summary DashboardsStatistical Process Control - Key

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1.Summary DashboardsTrust Monthly Metrics Dashboard

NHS Improvement Indicators

Indicator Target Q1 19-20 Q2 19-20 Q3 19-20 Dec-19 Jan-20 Feb-20 Variation Assurance Narrative Location

MR01 - 7 Day Follow Up 95% 97.3% 96.1% 96.6% 96.4% 93.4% 96.4% N/A

MR03 - Delayed Transfers of Care ≤ 7.5% 0.98% 0.61% 1.80% 4.35% 5.50% 5.33% N/A

MR06 - RTT - Consultant Led (Incomplete Pathway) 92% 96.9% 96.3% 97.4% 97.1% 97.5% 96.7% N/A

MR13 - 2 week wait for Treatment for EIP Programme 56% 47.2% 70.4% 78.9% 87.0% 67.6% 73.3% N/A

MR14 - RTT - IAPT 6 Weeks 75% 95.6% 96.8% 97.2% 97.5% 96.8% 96.3% N/A

MR15 - RTT - IAPT 18 Weeks 95% 99.5% 99.6% 99.5% 99.6% 99.8% 99.7% N/A

MR16 - Inappropriate AMH OAPs OBDs (monthly target) 173 5284 2534 4976 1471 1618 1751 Mental Health Improvement

Plan

MR19 - IAPT Recovery 50% 50.7% 51.1% 52.0% 53.1% 50.6% 53.7% N/A

MR20 - Under 16s Admissions to Adult Facilities 0 0 0 0 0 0 0 N/A

MR21 - MSK Diagnostics (DM01) 99% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% N/A

The below NHSI indicator is reported 3 months in arrears N/A N/A N/A Sep-19 Oct-19 Nov-19

MR17 - DQMI Dataset Score (NHS Digital) 95% - - - 86.2% 89.2% 89.3% N/A

The below NHSI indicator is reported Annually N/A N/A N/AMR18 - Cardiometabolic Assessments (Annual) 2017/18 2018/19 2019/20 a. Inpatient Wards 90% - - - 89.0% 79.0% 95.0% N/A

b. EIP Services 90% - - - 63.0% 79.0% N/A N/A

c. Community Mental Health Services 65% - - - 73.0% 83.0% N/A N/A

SPC Not Applicable

SPC Not Applicable

SPC Not Applicable

SPC Not Applicable

SPC Not Applicable

Note: Exception reports are not included for those measures associated with the acute care pathway, as information is included within the Mental Health Improvement Plan paper instead.2019/20 Cardiometabolic Audit only included Inpatient Wards. To be re-audited in 2020 to include EIP and Community MH Services

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1.Summary DashboardsTrust Monthly Metrics Dashboard

Note: Exception reports are not included for those measures associated with the acute care pathway, as information is included within the Mental Health Improvement Plan paper instead.

National / Contractual Indicators

Indicator Target Q1 19-20 Q2 19-20 Q3 19-20 Dec-19 Jan-20 Feb-20 Variation Assurance Narrative Included

Gatekeeping - Access to Crisis Res. Home Treatment (%) 95% 100.0% 100.0% 99.1% 98.3% 100.0% 99.0% N/A

CPA 12 Month Reviews (%) 95% 96.5% 96.3% 96.3% 96.4% 95.8% 95.4% N/A

MHLT: 1 Hour Compliance (%) 95% 61.4% 67.7% 71.9% 77.2% 74.6% 75.7% Mental Health Improvement

Plan

MHLT: 4 Hour Compliance (%) 95% 90.2% 94.1% 94.5% 96.0% 96.4% 96.1% Mental Health Improvement

Plan

MHLT: Number of 12 Hour Breaches (includes S&O) 0 109 96 91 21 28 35 Mental Health Improvement

Plan

MHLT: % of 12 Hour Breaches (includes S&O) 0% 4.5% 4.1% 3.4% 2.4% 2.9% 3.4% Mental Health Improvement

Plan

MHLT: Longest Stay 12 Hour Breach N/A 221:14 213:06 216:16 49:51 44:58 40:00 Mental Health Improvement

Plan

MHLT: Average Length of Stay 12 Hour Breach N/A 87:01 83:17 70:54 19:39 22:51 20:56 Mental Health Improvement

Plan

Number of Section 135 Breaches (24 hrs) 0 7 3 2 0 2 0 Mental Health Improvement

Plan

% of Section 135 Breaches (24 hrs) 0% 58.3% 17.6% 20.0% 0.0% 40.0% 0.0% Mental Health Improvement

Plan

Number of Section 136 Breaches (24 hrs) 0 130 67 42 8 7 16 Mental Health Improvement

Plan

% of Section 136 Breaches (24 hrs) 0% 35.3% 18.5% 13.3% 6.9% 6.3% 14.0% Mental Health Improvement

Plan

Longest Stay Section 136 Breach N/A 808:36 519:39 262:28 77:10 69:00 72:35 Mental Health Improvement

Plan

Average Length of Stay Section 136 Breaches N/A 285:52 214:27 134:24 41:12 35:05 16:27 Mental Health Improvement

Plan

SPC Available March 2020

SPC Available March 2020

SPC Available March 2020

SPC Available March 2020

SPC Available March 2020

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1.Summary DashboardsTrust Monthly Metrics Dashboard

Note: Exception reports are not included for those measures associated with the acute care pathway, as information is included within the Mental Health Improvement Plan paper instead.

National / Contractual Indicators (continued)

Indicator Target Q1 19-20 Q2 19-20 Q3 19-20 Dec-19 Jan-20 Feb-20 Variation Assurance Narrative Included

Occupancy % - Mental Health Network (LCFT only) 85% 99.9% 98.1% 96.6% 95.9% 97.6% 96.3% Mental Health Improvement

Plan

Occupancy % - Perinatal Mental Health 85% 73.1% 92.4% 96.3% 98.0% 94.4% 98.3% Mental Health Improvement

Plan

Occupancy % - The Cove >70% <85% 91.2% 47.6% 60.2% 65.4% 56.5% 54.2% N/A

Readmission Rates % - 30 days <8.7% 7.4% 5.0% 6.6% 5.9% 6.0% 8.1% N/A

Readmission Rates % - 90 days <15% 15.7% 9.1% 9.7% 8.3% 12.4% 13.1% N/A

Eating Disorders: Percentage of Under 19s seen in 1 week (Urgent) 75% 61.5% 50.0% 100.0% 100.0% 100.0% 100.0% N/A

Eating Disorders: No. of Under 19s seen over 1 week (Urgent) 0 5 5 0 0 0 0 N/A

Eating Disorders: Percentage of Under 19s seen in 4 weeks (Routine) 85% 72.2% 95.2% 96.1% 100.0% 100.0% 100.0% N/A

Eating Disorders: No. of Under 19s seen over 4 weeks (Routine) 0 15 2 2 0 0 0 N/A

Acute & PICU OAPs OBDs 435 5299 2624 4977 1472 1633 1751 Mental Health Improvement

Plan

Children and Young People's OAPs OBDs N/A 121 92 23 0 0 0 N/A N/A

CYP Improving Access to CAMHS: No. of CYP receiving Treatment (Total number of CCG's compliant/Total number of CCG's)

8/8 8/8 8/8 8/8 8/8 8/8 8/8 N/A

SPC Available November 2020

SPC Not Applicable

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1.Summary DashboardsTrust Monthly Metrics DashboardNational / Contractual Indicators (continued)

Indicator Target Q1 19-20 Q2 19-20 Q3 19-20 Dec-19 Jan-20 Feb-20 Variation Assurance Narrative Included

Children's Community RTT (combined CITNS) 92% 80.7% 75.4% 78.7% 81.5% 82.8% 78.8%

Children's Mental Health RTA (combined CAMHS and CPS) 92% 91.3% 82.9% 84.6% 87.0% 85.6% 85.0%

ADHD - All < 18 Weeks 92% 27.8% 27.5% 27.3% 29.7% 30.2% 26.9%

ADHD - Number of Actual Referrals (Cumulative) 509 269 566 866 866 981 1047

IAPT Prevalence - Cumulative Target (End of Quarter 4 target is 19.0%) 17.42% 4.1% 8.3% 13.8% 13.8% 15.1% 16.3%

Adult Community Services - AHP RTT 92% 99.7% 99.7% 99.9% 100.0% 99.9% 99.8% N/A

Southport & Formby - AHP RTT 92% N/A N/A N/A 99.0% 99.0% 99.8% N/A

PBR Clustering - Any Cluster 95% 94.3% 93.4% 93.1% 92.8% 92.5% 92.2% N/A

Contract Variance: Mental Health Contract ±10% N/A N/A N/A -8.8% -6.2% -5.2% N/A

Contract Variance: Community Contract ±10% N/A N/A N/A 3.0% 3.0% 2.0% N/A

Contract Variance: Community Contract (Southport & Formby) ±10% N/A N/A N/A 5.0% 8.0% 8.0% N/A

Contract Variance: Children's Community Contract (baselines to be agreed for 19/20) ±10% N/A N/A N/A - - - N/A

SPC Not Applicable

SPC Not Applicable

SPC Not Applicable

SPC Not Applicable

SPC Available March 2020

SPC Not Applicable

Note: Exception reports are not included for those measures associated with the acute care pathway, as information is included within the Mental Health Improvement Plan paper instead.IAPT Prevalence (Cumulative) – A formula issue was identified which impacted the reported % from November 2019 onwards. This was as a result of the removal of St Helens data.

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1.Summary DashboardsTrust Monthly Metrics Dashboard

Trust Indicators

Indicator Target Q1 19-20 Q2 19-20 Q3 19-20 Dec-19 Jan-20 Feb-20 Variation Assurance Narrative Included

% MHLT Referrals known to service (currently open) N/A N/A 42.5% 64.4% 71.9% 69.0% 66.1% Mental Health Improvement

Plan

% MHLT Referrals Where Alcohol/Substance Misuse is a Factor N/A N/A 20.2% 39.0% 40.9% 38.7% 36.1% Mental Health Improvement

Plan

Crisis/HTT - Open Referrals to Service in Month (All Teams) N/A 776 579 716 716 782 861 N/A

Crisis/HTT - Total Number of Contacts N/A 23,993 25,009 25,086 8,592 8,942 8,823 N/A

Delayed Discharges (Number of Formal Delays) 39 2 2 24 24 37 41 N/A

Number of Ward Discharges (Acute Only) N/A 224 291 341 120 152 115 Mental Health Improvement

Plan

Stranded Patients (120-150 days) - Mental Health Network (Qtr as of qtr month end) N/A 29 36 26 26 24 22 N/A

Mental Health Improvement

Plan

Stranded Patients (150-180 days) - Mental Health Network (Qtr as of qtr month end) N/A 23 26 15 15 25 23 N/A

Mental Health Improvement

Plan

Superstranded Patients (180+ days) - Mental Health Network (Qtr as of qtr month end) 10 73 41 61 61 62 71 Mental Health Improvement

Plan

IAPT Waits (>26 week waits) 0 100 124 81 81 79 77

SPC Available March 2020

SPC Available July 2020

SPC Available July 2020

SPC Available March 2020

SPC Available March 2020

SPC Available March 2020

Note: IAPT Waits (>26 week waits) quarterly positions are a snapshot figure at the end of the quarter Exception reports are not included for those measures associated with the acute care pathway, as information is included within the Mental Health Improvement Plan paper instead;

MHDU Breaches no longer being reported. These beds have now closed in response to the CQC

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1.Summary DashboardsSouth Cumbria Monthly Metrics Dashboard

NHS Improvement IndicatorsIndicator Target Q1 19-20 Q2 19-20 Q3 19-20 Dec-19 Jan-20 Feb-20 Variation Assurance Narrative Included

MR01 - 7 Day Follow Up 95% 100.0% 89.9% 90.7% 100.0% 100.0% 89.5% N/A

MR03 - Delayed Transfers of Care ≤ 7.5% 16.03% 18.94% 15.57% 10.81% 18.14% 19.64% N/A

MR13 - 2 week wait for Treatment for EIP Programme 56% 81.3% 80.0% 90.0% 100.0% 100.0% 100.0% N/A

MR14 - RTT - IAPT 6 Weeks 75% 99.6% 99.9% 100.0% 100.0% 99.5% 100.0% N/A

MR15 - RTT - IAPT 18 Weeks 95% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% N/A

MR16 - Inappropriate AMH OAPs OBDs (monthly target) 1.66 1045 465 161 74 74 288 N/A

MR17 - DQMI Dataset Score (Self Assessment) 95% 91.3% 92.3% 92.9% 82.3% 82.8% 82.4% N/A

MR19 - IAPT Recovery 50% 61.6% 57.6% 56.9% 55.2% 53.8% 64.5% N/A

MR20 - Under 16s Admissions to Adult Facilities 0 0 0 0 0 0 0 N/ASPC Not Applicable

Note: MR13 – 2 week wait for Treatment for EIP. 3 patients have been excluded in the reported figure. This is due to them being a North Cumbria RIO number. An NHS number will be provided for validation going forwards.

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1.Summary DashboardsSouth Cumbria Monthly Metrics Dashboard

National / Contractual Indicators

Indicator Target Q1 19-20 Q2 19-20 Q3 19-20 Dec-19 Jan-20 Feb-20 Variation Assurance Narrative Included

CPA Reviews Within 12 Months 95% 95.6% 97.3% 97.4% 95.2% 99.3% 98.0% N/A

Gatekeeping - Access to Crisis Res. Home Treatment (%) 95% 94.4% 87.1% 97.3% 100.0% 100.0% 100.0% N/A

CPA 3 Day Follow Up 80% - - 83.1% 71.4% 100.0% 89.5% N/A

IAPT Prevalence - Cumulative Target (End of Quarter 4 target is 16.8%) 15.40% 5.18% 9.72% 13.37% 13.37% 14.62% 15.83% N/ASPC Not Applicable

SPC Not Applicable

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1.Summary DashboardsLancashire & South Cumbria Monthly Metrics Dashboard

NHS Improvement Indicators

Indicator Target Q1 19-20 Q2 19-20 Q3 19-20 Dec-19 Jan-20 Feb-20 Variation Assurance Narrative Included

MR01 - 7 Day Follow Up 95% 97.6% 95.4% 96.1% 96.7% 93.7% 95.8% N/A

MR03 - Delayed Transfers of Care ≤ 7.5% 2.01% 1.96% 2.70% 4.77% 6.31% 6.27% N/A

MR13 - 2 week wait for Treatment for EIP Programme 56% 51.6% 71.5% 80.0% 89.3% 71.1% 75.0% N/A

MR14 - RTT - IAPT 6 Weeks 75% 96.2% 97.3% 97.6% 97.9% 97.2% 96.9% N/A

MR15 - RTT - IAPT 18 Weeks 95% 99.6% 99.6% 99.6% 99.7% 99.8% 99.7% N/A

MR16 - Inappropriate AMH OAPs OBDs (monthly target) 175 6329 2999 5137 1545 1692 2039 N/A

MR19 - IAPT Recovery 50% 52.5% 52.0% 52.8% 53.4% 51.1% 55.6% N/A

MR20 - Under 16s Admissions to Adult Facilities 0 0 0 0 0 0 - N/ASPC Not Applicable

Note: MR13 – 2 week wait for Treatment for EIP. 3 patients have been excluded in the reported figure. This is due to them being a North Cumbria RIO number. An NHS number will be provided for validation going forwards.

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1.Summary DashboardsLancashire & South Cumbria Monthly Metrics Dashboard

National / Contractual Indicators

Indicator Target Q1 19-20 Q2 19-20 Q3 19-20 Dec-19 Jan-20 Feb-20 Variation Assurance Narrative Included

CPA Reviews Within 12 Months 95% 96.4% 96.3% 96.3% 96.4% 96.0% 95.5% N/A

Gatekeeping - Access to Crisis Res. Home Treatment (%) 95% 99.8% 99.2% 98.9% 98.5% 100.0% 99.0% N/A

CPA 3 Day Follow Up 80% - - 84.1% 81.5% 83.0% 85.2% N/A

IAPT Prevalence - Cumulative Target (End of Quarter 4 target is XX %) N/AData not available for Lancashire & South Cumbria

SPC Not Applicable

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1.Summary DashboardsTrust Quality Monthly Metrics DashboardSafety

Note: *The figures taken from the NHS Benchmarking report for use as an indicator of a typical English Trust’s performance in the full year 2018/2019. These will be updated in November 2020 following publication of the 2019/2020 report . NRLS will be introduced for comparative Serious Incident reporting**Incidents with Harm includes all levels of harm. Moderate and above = 176 (8.6% of all incidents)***Medication incidents include all incidents involving LSCFT patients, whether or not incident involved LSCFT staff action. Number of Mediation incidents of moderate harm or above = 5

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1.Summary DashboardsTrust Quality Monthly Metrics DashboardSafety

Note: The figures taken from the NHS Benchmarking report for use as an indicator of a typical English Trust’s performance in the full year 2018/2019. These will be updated in November 2020 following publication of the 2019/2020 report **There were two incidents of prone restraint in January. This was the same patient, on the same day, in PICU care

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1.Summary DashboardsTrust Quality Monthly Metrics DashboardSafety

Note: *The figures taken from the NHS Benchmarking report for use as an indicator of a typical English Trust’s performance in the full year 2018/2019. These will be updated in November 2020 following publication of the 2019/2020 report **Includes all incidents of actual and potential harm where there has been physical aggression. Of the 129, moderate to severe incidents = 6 117 of 169

1.Summary DashboardsTrust Quality Monthly Metrics DashboardSafety

Note: The figures taken from the NHS Benchmarking report for use as an indicator of a typical English Trust’s performance in the full year 2018/2019. These will be updated in November 2020 following publication of the 2019/2020 report

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1.Summary DashboardsTrust Quality Monthly Metrics DashboardEffectiveness

Note: The figures taken from the NHS Benchmarking report for use as an indicator of a typical English Trust’s performance in the full year 2018/2019. These will be updated in November 2020 following publication of the 2019/2020 report

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1.Summary DashboardsTrust Quality Monthly Metrics DashboardExperience

Note: The figures taken from the NHS Benchmarking report for use as an indicator of a typical English Trust’s performance in the full year 2018/2019. These will be updated in November 2020 following publication of the 2019/2020 report

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1.Summary DashboardsTrust Quality Monthly Metrics DashboardExperience

Note: The figures taken from the NHS Benchmarking report for use as an indicator of a typical English Trust’s performance in the full year 2018/2019. These will be updated in November 2020 following publication of the 2019/2020 report

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Performance ActivitySection 2.

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2.Performance ActivityCommunity Wellbeing – IAPT Prevalence & IAPT Waits

IAPT: Actions:AccessNone of the teams achieved the access target in February. The total number of referrals into the service in February was 3,449 and above the monthly target of 3,405. 1,988 new assessments were undertaken in January, against a target of 2562 new assessments per month. The year to date target is 30,733. To date the service have undertaken 27,305 new assessments, a shortfall of 3,428.

IAPT WaitsIn February 5,028 people were waiting for an appointment compared to 5,041 in January. 77 people were waiting over 26 weeks. The number of people waiting over 26 weeks have slightly reduced from 79 to 77 people. Additional measures have been put in place to recover performance including weekly reporting on actions taken to address long waits. The main reasons that have caused the current waits position are:

• Ongoing vacancies in both CBT and Counselling that are in the recruitment process, but have either not started in post or have been re-advertised

• Capacity of sub-contracts is being reviewed and reallocated to increase in areas where waits are highest

• The management of DNA/ Cancellations across the service is now being managed consistently but improvement in waiting times not be yet evident

• Staff are undertaking LTC training which is reducing capacity to see New patients for treatment between January and March (reducing PWP slots by 364 and CBT slots by 270) with further impact on CBT expected in May

Several waiting list management initiatives are being implemented across the service, namely; • Weekly team trajectories, twice weekly waiting list position updates and a change of

the waiting list management recording process. • Team leads to monitor staff diaries and ensure 2x New Slots/1.0 WTE are added.

To be supported by PPQ and sub-contract admin who are also to cleanse waits. • Recruitment to admin vacancies, review of admin process mapping/procedures,

including opt-ins, text reminders and letters and application of DNA policy.• Review of application of DNA policy during case-load review and supervision. • Increase use of digital services, namely Silvercloud. Service leads to meet with

Silvercloud representatives for further training and then to disseminate to staff. Service to consider direct access for self-referrals.

• Increase group uptake at Step 2 and Step 3. Senior PWPs to provide training around Step 2 groups. Step 2 staff to shadow successful group projects. Increase promotion of Step 2 groups externally.

• Ensure adequate estate portfolio. Overarching estates plan for service in progress; to identify gaps in estate availability.

• Service to agree an interface pathway with mental health network. MDT conversations are currently taking place. Definition of the Non-IAPT cohort to be agreed.

• Developing workforce strategy. Primarily the uplifted banding of CBT therapists and counsellors. Service continues to offer placements for PWP and CBT trainees. Service to evaluate the Assistant practitioner posts for efficacy.

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2.Performance ActivityChildren & Young People’s Wellbeing –ADHD

ADHD: Actions:The ADHD service continues to underperform against the 92% target. In M11, 73.1.8% of patients were waiting more than 18 weeks for assessment.

There have been 66 referrals in M11, this is a total of 1047 so far in 2019/20 compared to the contracted number of 556 per annum

Further to the Trust Board paper submitted in January 2020, the ADHD service is working towards a mutual decommissioning date of 1st July 2020. The service is now closed to referrals and no further new assessments will be undertaken due to the time needed to safely titrate medication. Staff in the service are being supported through this process in relation to other suitable alternative roles in the Trust. The CCGs are seeking a new provider of the service.

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2.Performance ActivityChildren & Young People’s Wellbeing –CITNS RTT & CAMHS Referral to Assessment

Narrative: Actions:In month 11, the CITN service continues to underperform against the 92% target.

The number of service users waiting over 18 weeks has increased in month 11 by 118. The overall waiting list has number has increased by 70.

Workforce challenges remain the primary driver for performance in occupational therapy, alongside some increase in demand Staffing challenges, turnover, delays due to some (on occasion repeated) unsuccessful attempts at recruitment, internal promotion and maternity leave. This is exacerbated by slow recruitment processes which can take 6 to 8 weeks to progress individual requests to recruit.

The recovery trajectory has been updated for Month 11.

In month 11 the referral to assessment performance for CAMHS/CPS teams did not achieve the 92% target. The number of service users waiting over 18 weeks has increased in month 11 by 2, the overall waiting list has decreased by 27. Of the 7 teams within the Emotional Wellbeing service, 4 are currently achieving the 92% 18 week RTT standard. The teams which are not achieving 92% is: Blackpool at 90.9%, Chorley, South Ribble (CSR) at 66.2% and Lancaster and Morecambe at 86.0%.

In Chorley & South Ribble; There is a high demand generally within this area for CAMHS, and pressures associated with long waits for ASD assessments. The ASD Pathway is being worked on intensively to introduce smooth processes between CAMHS and LD services and so increase capacity to manage the demand. We are also working closely with the neurodevelopmental pathway pan Lancashire.

The benefits of individual team initiatives and good practice is being shared to generate continued efficiencies to improve position.

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QualitySection 3.

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3.QualitySafety - ExceptionNo. of Incidents with HarmNo. of Incidents with Harm

Shift in no to low harm incidents consistent with previous 2 months due to training and daily scrutiny of moderate, severe and catastrophic harm incidents.This month have seen a reduction in the proportion of moderate, severe and catastrophic harm incidents.

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3.QualitySafety - ExceptionPhysical Violence (with harm) to Staff From PatientsPhysical Violence (with harm) to Staff From Patients

Lathom Suite reported most incidents this month (24) with one patient involved in 17 incidents.Next highest reporter was Avenham PICU (15)

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3.QualityEffective - ExceptionSection 132 rights attempted in 24 hoursSection 132 rights attempted in 24 hours

Health Informatics have completed the work to amend the function within NerveCentre which will prompt for rights immediately upon admission for all patients. This will flag as overdue after 4 hours to prompt for all patients to be read their rights in a timely manner.

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3.QualityExperience - ExceptionNumber of Compliments ReceivedNumber of Compliments Received

Drops in compliments are often due to recording of the compliments. This is undertaken by the network.

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3.1.CQUINExecutive SummaryCQUIN scheme Summary 2019/20

Feb-20

Scheme Plan % expected £ expected

£ Loss/

concern £ Total % expected £ expected

£ Loss/

concern £ Total

2Staff Flu Vaccinations £786,762 0% £0 £0 £0 0% £0 £0 £0

3aAlcohol and Tobacco a) Screening £212,299 100% £53,075 £0 £53,075 100% £53,075 £0 £53,075

3bAlcohol and Tobacco b) Tobacco Brief Advice £212,299 100% £53,075 £0 £53,075 100% £53,075 £0 £53,075

3cAlcohol and Tobacco c) Alcohol Brief Advice £212,299 100% £53,075 £0 £53,075 100% £53,075 £0 £53,075

472hr Follow up Post Discharge £485,696 0% £0 £0 £0 0% £0 £0 £0

5aMental Health Data: Data Quality Maturity Index £222,136 0% £0 £0 £0 0% £0 £74,045 £74,045

5bMental Health Data: Interventions £222,136 0% £0 £0 £0 0% £0 £0 £0

6Use of Anxiety Disorder Specific Measures in IAPT £421,127 0% £0 £0 £0 71% £99,867 £40,508 £140,376

SP1Southport & Formby Local CQUIN - CHC/PHB £79,541 0% £0 £0 £0 100% £26,514 £0 £26,514

7Three high impact actions to prevent Hospital Falls (Longridge only) £221,525 100% £55,381 £0 £55,381 100% £55,381 £0 £55,381

IMSK1Shared Decision Making £90,913 100% £22,728 £0 £22,728 100% £22,728 £0 £22,728

L&D1Personalised Care and Support Planning within Liaison & Diversion Services. £57,356 100% £14,339 £0 £14,339 100% £14,339 £0 £14,339

NHSE1Secure – Healthy Weight in Adult Services £363,078 100% £90,770 £0 £90,770 100% £90,770 £0 £90,770

NHSE2CAMHS PSS Inpatient Staff Training £50,757 100% £12,689 £0 £12,689 100% £12,689 £0 £12,689

NHSE3Perinatal £28,494 0% £0 £0 £0 100% £9,498 £0 £9,498

Total £3,666,420 100% £355,132 £0 £355,132 81% £491,011 £114,554 £605,565

[p-ewpo Plan % expected £ expected

£ Loss/

concern £ Total % expected £ expected

£ Loss/

concern £ Total

Mental Health £1,973,543 100% £210,390 £0 £210,390 78% £219,888 £62,852 £282,740

Community Wellbeing £1,336,313 100% £132,052 £0 £132,052 85% £258,433 £44,366 £302,799

South Cumbria £129,138 £0 £0 £0 £0 £0 £0

Children & Young People £227,426 100% £12,689 £0 £12,689 63% £12,689 £7,336 £20,025

Total £3,666,420 100% £355,132 £0 £355,132 81% £491,011 £114,554 £605,565

Qtr 2Qtr 1

Qtr 1 Qtr 2

Note: Once the outcome of submissions have been formalised, the values will turn red for confirmed loss and green for confirmed funding. Schemes that have been risk rated as Amber in the Quality & Safety Sub-Committee report are assumed to be achieved and included in the expected CQUIN values.

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3.1.CQUINExecutive SummaryCQUIN scheme Summary 2019/20

Feb-20

Scheme Plan % expected £ expected

£ Loss/

concern £ Total % expected £ expected

£ Loss/

concern £ Total % expected £ expected

£ Loss/

concern £ Total

2Staff Flu Vaccinations £786,762 0% £0 £0 £0 100% £786,762 £0 £786,762 100% £786,762 £0 £786,762

3aAlcohol and Tobacco a) Screening £212,299 100% £53,075 £0 £53,075 100% £53,075 £0 £53,075 100% £212,299 £0 £212,299

3bAlcohol and Tobacco b) Tobacco Brief Advice £212,299 100% £53,075 £0 £53,075 100% £53,075 £0 £53,075 100% £212,299 £0 £212,299

3cAlcohol and Tobacco c) Alcohol Brief Advice £212,299 100% £53,075 £0 £53,075 100% £53,075 £0 £53,075 100% £212,299 £0 £212,299

472hr Follow up Post Discharge £485,696 100% £242,848 £0 £242,848 100% £242,848 £0 £242,848 100% £485,696 £0 £485,696

5aMental Health Data: Data Quality Maturity Index £222,136 0% £0 £74,045 £74,045 0% £0 £74,045 £74,045 0% £0 £222,136 £222,136

5bMental Health Data: Interventions £222,136 100% £111,068 £0 £111,068 100% £111,068 £0 £111,068 100% £222,136 £0 £222,136

6Use of Anxiety Disorder Specific Measures in IAPT £421,127 100% £140,376 £0 £140,376 100% £140,376 £0 £140,376 90% £380,619 £40,508 £421,127

SP1Southport & Formby Local CQUIN - CHC/PHB £79,541 100% £26,514 £0 £26,514 100% £26,514 £0 £26,514 100% £79,541 £0 £79,541

7Three high impact actions to prevent Hospital Falls (Longridge only) £221,525 100% £55,381 £0 £55,381 100% £55,381 £0 £55,381 100% £221,525 £0 £221,525

IMSK1Shared Decision Making £90,913 100% £22,728 £0 £22,728 100% £22,728 £0 £22,728 100% £90,913 £0 £90,913

L&D1Personalised Care and Support Planning within Liaison & Diversion Services. £57,356 100% £14,339 £0 £14,339 100% £14,339 £0 £14,339 100% £57,356 £0 £57,356

NHSE1Secure – Healthy Weight in Adult Services £363,078 100% £90,770 £0 £90,770 100% £90,770 £0 £90,770 100% £363,078 £0 £363,078

NHSE2CAMHS PSS Inpatient Staff Training £50,757 100% £12,689 £0 £12,689 100% £12,689 £0 £12,689 100% £50,757 £0 £50,757

NHSE3Perinatal £28,494 100% £9,498 £0 £9,498 100% £9,498 £0 £9,498 100% £28,494 £0 £28,494

Total £3,666,420 92% £885,435 £74,045 £959,481 96% £1,672,198 £74,045 £1,746,243 93% £3,403,776 £262,644 £3,666,420

[p-ewpo Plan % expected £ expected

£ Loss/

concern £ Total % expected £ expected

£ Loss/

concern £ Total % expected £ expected

£ Loss/

concern £ Total

Mental Health £1,973,543 89% £502,721 £62,852 £565,573 93% £851,988 £62,852 £914,840 90% £1,784,988 £188,555 £1,973,543

Community Wellbeing £1,336,313 99% £304,728 £3,857 £308,585 99% £589,020 £3,857 £592,877 96% £1,284,233 £52,080 £1,336,313

South Cumbria £129,138 100% £32,285 £0 £32,285 100% £96,854 £0 £96,854 100% £129,138 £0 £129,138

Children & Young People £227,426 86% £45,702 £7,336 £53,038 95% £134,336 £7,336 £141,673 90% £205,417 £22,009 £227,426

Total £3,666,420 92% £885,435 £74,045 £959,481 96% £1,672,198 £74,045 £1,746,243 93% £3,403,776 £262,644 £3,666,420

Full YearQtr 4Qtr 3

Qtr 3 Qtr 4 Full Year

Narrative:The schemes and profiling for 2019/20 have been split to network level as summarised above. South Cumbria is now included in the above with a CQUIN value of £129k split between CQUIN 2 and 4 and full payment is expected.For all other contracts:There is now full achievement of the flu target of 80%. Scheme 5a is a challenge and leads are working on how this can be achieved, early indications would indicate full loss for the year of £222k. The clinical networks need to complete the data set provided by the BI report which will lead to an improved position. BI review found a number of fields that require manual population with actions to achieve this in place. Confirmation from CCG's that internal reports can be used is outstanding.Scheme 6 Use of Anxiety Specifc Measures in IAPT is at risk of not being fully achieved with current reports indicate that we would receive a partial loss in Q2. The remainder of the financial year it is assumed that the targets will be met.

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WorkforceSection 4.

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KPI PERFORMANCE OVERVIEW

The HR and L&OD Key Performance Indicators have been devised to update the Trust Board on the Trusts current performance against the agreed key workforce indicators and highlight any areas of concern and provide assurance by identifying the action taken to mitigate risk and improve performance.

Key Performance Indicators Trust Target 2020 01 2020 02

Trend

(Against

Previous

Month)

Total Workforce Expenditure£22,365,743

Budget£22,027,511 £22,279,681 p

Peripheral Workforce Reliance (Bank, Agency & Locum spend % of Total Pay Spend)

6.0% 10.99% 11.09% p

Operational Gap 5.0% 2.62% 2.74% p

Sickness Absence 4.5% 6.85% 6.40% q

Vacancy Rate 5.0% 9.84% 9.61% q

Turnover Rate 10.0% 15.97% 16.06% p

Appraisal Performance 80.0% 87.44% 87.44% p

Mandatory & Statutory Training

Compliance 80.0% 89.62% 89.87% p

Key Performance Indicators Trust Target 2019 Q1 2019 Q2

Trend

(Against

Previous

Quarter)

Engagement 7.40 7.00 6.80 q

Wellbeing 51.19% 50.63% q134 of 169

WORKFORCE EXPENDITURE

Total Workforce Expenditure against Established Budget

The HR and L&OD Key Performance Indicators have been devised to update the Trust Board on the Trusts current performance against the agreed key workforce indicators and highlight any areas of concern and provide assurance by identifying the action taken to mitigate risk and improve performance.

Workforce Expenditure against Established Budget

0

5

10

15

20

25

2019 12 2020 01 2020 02

£ m

illio

ns

Medical Agency

Agency

Bank

Core

Budget

Source Data: EFIN Finance Ledger

Business Area Established Budget £'sSpend on Core

Workforce £'s

Spend on Peripheral

Workforce £'s

Total Spend on

Workforce £'s

Budget & Expenditure

Variance £'s

Trend

(Against

Previous

Month)

Trust 22,365,743 19,809,048 2,470,633 22,279,681 -86,062 p

Mental Health 11,171,762 9,479,566 1,768,219 11,247,785 76,023 p

Community & Wellbeing 4,706,251 4,401,266 371,090 4,772,355 66,104 p

Children & Young People 2,456,820 2,290,008 73,230 2,363,238 -93,582 q

South Cumbria 1,426,609 1,195,269 193,857 1,389,126 -37,483 p

Support Services 2,604,301 2,442,939 64,238 2,507,177 -97,124 p135 of 169

Bank & Agency Pay Spend by Business Area

Agency & Bank spend is calculated as a percentage of thetotal salary spend.

Usually, a link can be seen between the level of expenditureon peripheral workforce (Bank, Agency and Locum), theVacancy Rate, Sickness Absence and Operational Gap.

PERIPHERAL WORKFORCE RELIANCE

Spend £ % Spend £ % Spend £ %

Trust 19,630,675 2,156,200 9.6% 385,190 1.7% 277,098 1.2% 2,818,489 22,449,164 12.55%

Mental Health 9,344,075 1,788,258 15.7% 207,345 1.8% 27,870 0.2% 2,023,474 11,367,549 17.80%

Community & Wellbeing 4,415,915 165,531 3.5% 113,047 2.4% 82,830 1.7% 361,408 4,777,324 7.57%

Children & Young People 2,275,517 72,599 3.0% 13,135 0.5% 76,075 3.1% 161,809 2,437,326 6.64%

South Cumbria 1,199,841 54,638 3.9% 48,080 3.5% 90,323 6.5% 193,041 1,392,882 13.86%

Support Services 2,395,326 75,174 3.0% 3,582 0.1% 0 0.0% 78,757 2,474,083 3.18%

Spend £ % Spend £ % Spend £ %

Trust 19,606,914 1,719,334 7.8% 511,095 2.3% 190,168 0.9% 2,420,597 22,027,511 10.99%

Mental Health 9,350,765 1,461,188 13.1% 273,562 2.5% 42,704 0.4% 1,777,454 11,128,219 15.97%

Community & Wellbeing 4,432,364 118,625 2.5% 170,133 3.6% 42,261 0.9% 331,019 4,763,383 6.95%

Children & Young People 2,285,929 42,082 1.8% -14,242 -0.6% 8,820 0.4% 36,661 2,322,590 1.58%

South Cumbria 1,157,460 45,384 3.3% 73,982 5.4% 96,383 7.0% 215,749 1,373,209 15.71%

Support Services 2,380,396 52,054 2.1% 7,659 0.3% 0 0.0% 59,714 2,440,110 2.45%

Total Core

Workforce

Spend £

2019 12

Flexible

Labour

Reliance %Business Area

Bank Agency Medical AgencyTotal

Peripheral

Workforce

Spend £

Total Spend £

Total Core

Workforce

Spend £

2020 01

Flexible

Labour

Reliance %Business Area

Bank Agency Medical AgencyTotal

Peripheral

Workforce

Spend £

Total Spend £

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Bank, £1,805,846

Agency, £402,818

Medical Agency,

£261,969

PERIPHERAL WORKFORCE RELIANCE

Bank & Agency Pay Spend by Business Area

Agency & Bank spend is calculated as a percentage of thetotal salary spend.

Usually, a link can be seen between the level of expenditureon peripheral workforce (Bank, Agency and Locum), theVacancy Rate, Sickness Absence and Operational Gap.

Bank & Agency Pay Spend

Overview:Spend on Peripheral Workforce has increased slightly in February when compared with theJanuary position and closes the month with a 11.09% reliance rate. Mental Health & SouthCumbria has followed the downward trend with Community & Wellbeing, Children & YoungPeople and Support Services showing slight increases.

Spend £ % Spend £ % Spend £ %

Trust 19,809,048 1,805,846 8.1% 402,818 1.8% 261,969 1.2% 2,470,633 22,279,681 11.09%

Mental Health 9,479,566 1,516,032 13.5% 137,036 1.2% 115,151 1.0% 1,768,219 11,247,785 15.72%

Community & Wellbeing 4,401,266 121,734 2.6% 167,658 3.5% 81,698 1.7% 371,090 4,772,355 7.78%

Children & Young People 2,290,008 64,917 2.7% -573 0.0% 8,885 0.4% 73,230 2,363,238 3.10%

South Cumbria 1,195,269 52,564 3.8% 85,057 6.1% 56,236 4.0% 193,857 1,389,126 13.96%

Support Services 2,442,939 50,598 2.0% 13,640 0.5% 0 0.0% 64,238 2,507,177 2.56%

Total Core

Workforce

Spend £

2020 02

Flexible

Labour

Reliance %Business Area

Bank Agency Medical AgencyTotal

Peripheral

Workforce

Spend £

Total Spend £

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PERIPHERAL WORKFORCE RELIANCE

Bank & Agency Pay Spend by Business Area

Agency & Bank spend is calculated as a percentage of thetotal salary spend.

Usually, a link can be seen between the level of expenditureon peripheral workforce (Bank, Agency and Locum), theVacancy Rate, Sickness Absence and Operational Gap.

Mental Health Network: Peripheral workforce reliance has decreased inFebruary. All clinical localities have seen a decrease in Peripheral Labour Reliance, with

the highest reductions being evidenced in Pennine and Secure Services. Thiscorrelates with the significant decrease seen in sickness absence across theNetwork and also within Secure Services.

Network Hot Spot Analysis:

Community & Wellbeing Network: Overall spend on Peripheral Workforcereports an increase in spend in February for the network. Reductions across thenetwork have been achieved with the exception of Dental services andSouthport. Southport and Formby bank and agency spend is largely attributed to the

ICRAS Service and usage correlates with the vacancies within that service. Reduction in Podiatry Agency usage continues Increased use in Dental Sessional services to improve UDA and wait list

Performance.

Children & Young People’s Wellbeing Network: The Network spend onperipheral workforce has increased slightly in February but at 3.10% is stillreporting below the target of 5%. The network report the reduction has been achieved following work

undertaken within integrated CAMHS

South Cumbria Network: Overall reliance on Peripheral workforce stands at13.96% at the close of February for the network. This is a decrease from theJanuary position. Vacancies are the main reason reported for the use of Bankand Agency workforce, and agency dominance is reflective of the geographybase recruitment challenges for this network. The Network are focussing on recruitment activity and have a second

recruitment event planned for early March. This event is aimed atattracting Nurses and Support to Nursing populations and will provide a onestop event for potential candidates where the interview, conditional offerand pre-employment checks will be processed the same day.

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OPERATIONAL GAPOperational Gap is the measure of absences that affect operational performance other thanSickness and Annual Leave.This section of the report considers employees who are absent from operational work for thefollowing reasons: Career Break, Maternity & Adoption, Paternity, Out on ExternalSecondment (Paid), Out on External Secondment (Unpaid), Suspend No Pay, Suspend With Pay.

Source Data: ESR

0.00

50.00

100.00

150.00

200.00

2019 03 2019 04 2019 05 2019 06 2019 07 2019 08 2019 09 2019 10 2019 11 2019 12 2020 01 2020 02

F

T

E

Mental Health Community & Wellbeing Children & Young People Support Services

Operational Gap by Business Area – 12 Month Trend

Indicator Heads FTE

Total Workforce 6566 5863.84

Mat / Adoption Leave 136 120.79

Career Break 12 10.77

Secondment 4 4.20

Suspension 8 7.76

Sickness Absence 390 341.10

Annual Leave 136 125.66

Total Workforce Gap 686 610.28

Active90.4%

Sickness Absence

5.4%Annual Leave

2.0%

Mat / Adoption

Leave 1.9%

Career Break0.2%

Suspension0.1%

Other0.4%

Total Operational Gap Analysis, by Reason – Position at Month End

139 of 169

OPERATIONAL GAP

Source Data: ESR Operational Gap by Business Area – Monthly Actuals by Business Area

Operational Gap is the measure of absences that affect operational performance other thanSickness and Annual Leave.This section of the report considers employees who are absent from operational work for thefollowing reasons: Career Break, Maternity & Adoption, Paternity, Out on ExternalSecondment (Paid), Out on External Secondment (Unpaid), Suspend No Pay, Suspend With Pay.

FTE

(Average in

Month)

Average No

Absent

Employees

Gap FTE

(Average in

Month)

Average No

Absent

Employees

Gap FTE

(Average in

Month)

Average No

Absent

Employees

Gap

Trust 5825.36 143.63 2.47% 5836.91 152.91 2.62% 5853.40 160.35 2.74%

Mental Health 2669.15 49.00 1.84% 2694.23 52.22 1.94% 2706.55 59.16 2.19%

Community & Wellbeing 1427.02 45.45 3.19% 1419.52 48.52 3.42% 1423.76 45.98 3.23%

Children & Young People 678.81 24.73 3.64% 679.97 25.73 3.78% 679.49 28.53 4.20%

South Cumbria 351.71 14.53 4.13% 349.33 10.91 3.12% 349.12 10.11 2.90%

Support Services 698.68 14.53 2.08% 693.86 15.53 2.24% 694.49 16.57 2.39%

Business Area

2019 12 2020 01 2020 02

140 of 169

Vacancy Management Network Rates and 3 Month Performance Comparison

The Vacancy Rate presents the % difference between the Trusts budgeted establishment and itsactual spent establishment. This measurement has been based on FTE and is one of themeasures referenced when assessing core workforce stability.

To enhance this measure, the Active Vacancy Rate has been supplied. This rate highlights the % ofbudgeted establishment vacancies that are being actively recruited to by the organisation.

VACANCY RATE

Source Data: EFIN and ESR

0.00%

5.00%

10.00%

2019 12 2020 01 2020 02

Vac

ancy

Rat

e

Vacancy Rate & WTE – Monthly Actuals by Business Area

BE FTE FTE In Post BE VR BE FTE FTE In Post BE VR BE FTE FTE In Post BE VR

Trust 6441.17 5828.75 9.51% 6485.64 5847.35 9.84% 6487.16 5863.84 9.61%

Mental Health 3060.11 2670.95 12.72% 3069.42 2702.03 11.97% 3076.84 2714.35 11.78%

Community & Wellbeing 1526.16 1427.02 6.50% 1552.43 1420.37 8.51% 1538.03 1424.61 7.37%

Children & Young People 713.90 678.81 4.92% 712.25 680.17 4.50% 720.45 679.69 5.66%

South Cumbria 398.22 351.71 11.68% 406.58 349.33 14.08% 406.58 349.12 14.13%

Support Services 742.78 700.26 5.72% 744.96 695.45 6.65% 745.26 696.07 6.60%

Business Area2020 022020 012019 12

141 of 169

Vacancy Management

VACANCY RATE

Source Data: EFIN and ESR

Network Hot Spot Analysis:

South Cumbria Network: The Budgeted Establishment Vacancy Rate hasincreased slightly in February and reports a closing position of 14.13%. This isdue to a small decrease of 0.21 FTE in Post.The Network have a targeted recruitment plan in place for Nursing andSupport to Nursing posts and will be holding a second recruitment event inearly march, aimed at Nurses and HCA’s. This event also includes theattraction to Bank. In inpatient areas in Barrow, controlled over recruitment to establishment

has been approved due to challenges with the fill rate at the close of the recruitment process.

The Employment Services team are making links with further education colleges to attract 3rd year health and social care students for clinical posts and are also attending an RCN event being held in Glasgow.

The Vacancy Rate presents the % difference between the Trusts budgeted establishment and itsactual spent establishment. This measurement has been based on FTE and is one of themeasures referenced when assessing core workforce stability.

To enhance this measure, the Active Vacancy Rate has been supplied. This rate highlights the % ofbudgeted establishment vacancies that are being actively recruited to by the organisation.

Community & Wellbeing Network: The Budgeted Establishment VacancyRate decreased against the January position and reports 7.37% in February.This is due to a decrease in establishment of 14.40 FTE following an increaseof 26.27 FTE in January. The hold on vacancies continues within Dental services due to live tenders

for Specialist and Urgent Care services. Southport & Formby are experiencing challenges in recruiting therapies,

and DN Team Leaders and in Central, with Podiatrists, SLT and Physio’s. Podiatry Vacancies continue to present a challenge across the network –

Apprenticeships in podiatry are being explored as a way to respond to thischallenge.

Finance and HR Colleagues continue to work closely to ensure that thedata appropriately reflects the Network Position.

Mental Health Network: The Budgeted Establishment Vacancy Rate hasdecreased against the January position and reports 11.78% in February.Recruitment continues to remain a challenge across the Network. The Network has seen 39 new starters in the month of January with the

biggest increase of new starters being in Secure Services (13). 15 of the new starter population are nurses.

The Harbour continues to seek newly qualified staff from their recruitment days in Scotland.

Children & Young Peoples Network: The Budgeted Establishment VacancyRate has increased in February to 5.66% due to an increase of 8.20 FTE inestablishment. It is anticipated that this figure will continue to reduce asrecruitment to vacant posts continues as a priority in the Network. Significant difficulties are being experienced in the recruitment and

retention of CAMHS practitioners and Clinical Psychologists at variousbands. In an attempt to remedy this alternative staffing models are beingconsidered.

The Network is commencing a piece of work to identify the barriers inattracting Consultant Psychiatrists and how the Trust’s offer can beenhanced.

142 of 169

Turnover – 12 Month Trend

The Turnover Rate is one of the indicators used to assess employee satisfaction with the Trust. Itis presented as a rolling 12 month figure, calculated at the end of each reporting period and iscalculated as follows:Total number of leavers ÷ total number of contracted employees.To provide the Board with a true picture of turnover activity in the Organisation, three measuresof turnover are reported: Overall Trust Turnover, BAU Turnover and TUPE Transfer Turnover.

TURNOVER

Source Data: ESR

Resignation74.8%

Retirement14.1%

Dismissal5.2%

End of FTC4.4%

Redundancy0.7% Ill Health

Retirement0.7%

BAU Turnover, 7.64%

TUPE Turnover, 8.42%

All Turnover, 16.06%

0.00%

2.00%

4.00%

6.00%

8.00%

10.00%

12.00%

14.00%

16.00%

18.00%

20.00%

2019 03 2019 04 2019 05 2019 06 2019 07 2019 08 2019 09 2019 10 2019 11 2019 12 2020 01 2020 02

BAU Turnover TUPE Turnover All Turnover

Business AreaHeadcount

2020 022019 12 2020 01 2020 02

Trust 5,838 15.96% 15.97% 16.06%

Mental Health 2,707 5.93% 5.79% 5.87%

Community & Wellbeing 1,424 16.71% 16.78% 16.73%

Children & Young People 679 62.76% 62.66% 62.90%

South Cumbria 349 4.15% 4.89% 6.62%

Support Services 679 10.62% 10.95% 10.69%

143 of 169

The Turnover Rate is one of the indicators used to assess employee satisfaction with the Trust. Itis presented as a rolling 12 month figure, calculated at the end of each reporting period and iscalculated as follows:Total number of leavers ÷ total number of contracted employees.To provide the Board with a true picture of turnover activity in the Organisation, three measuresof turnover are reported: Overall Trust Turnover, BAU Turnover and TUPE Transfer Turnover.

TURNOVER

Source Data: ESR

Leaving Reasons for Month

Leavers in Quarter by Staff Group

Business Area

Add Prof

Scientific and

Technic

Additional

Clinical Services

Administrative

and Clerical

Allied Health

Professionals

Estates and

Ancillary

Healthcare

Scientists

Medical and

Dental

Nursing and

Midwifery

Registered

Students

Trust 1 7 10 3 2 0 3 14 0

Mental Health 0 3 0 0 0 0 3 5 0

Community & Wellbeing 1 1 3 2 0 0 0 5 0

Children & Young People 0 2 0 0 0 0 0 4 0

South Cumbria 0 1 3 1 2 0 0 0 0

Support Services 0 0 4 0 0 0 0 0 0

Business Area Dismissal End of FTC Redundancy Resignation Retirement Grand Total

Trust 2 1 1 31 5 40

Mental Health 1 1 0 8 1 11

Community & Wellbeing 0 0 0 9 3 12

Children & Young People 1 0 0 5 0 6

South Cumbria 0 0 1 3 0 4

Support Services 0 0 0 6 1 7

144 of 169

Sickness Absence

SICKNESS ABSENCE

Source Data: ESR

The Sickness absence rate is calculated as follows:FTE Days Lost in Period/FTE Days Available in Period *100

Previous Year

Reduction Target

Upper Control Limit

Lower Control Limit

Trust Target

Actual, 6.40%

0.00%

1.00%

2.00%

3.00%

4.00%

5.00%

6.00%

7.00%

8.00%

9.00%

10.00%

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

2018 2019 2020

2019 12 2020 01 2020 02Rolling 12

Mths

% Long

Term

Absence

% Short

Term

Absence

Trust 7.52% 6.85% 6.40% 6.28% LT ST 533,471 36,992 3,133,635

Mental Health 9.38% 8.23% 7.49% 7.29% 63.46% 36.54% 246,549 20,658 1,660,524

Community & Wellbeing 7.08% 7.03% 6.68% 6.53% 62.39% 37.61% 129,656 8,986 791,907

Children & Young People 5.16% 4.47% 4.64% 4.45% 60.48% 39.52% 61,916 2,944 265,658

South Cumbria 5.96% 6.57% 5.08% 5.82% 25.85% 74.15% 31,877 1,876 155,808

Support Services 4.35% 3.64% 3.96% 3.88% 49.90% 50.10% 63,473 2,528 259,739

Business Area

Rates 2020 02 Total

Available FTE

Days in

Month

Total FTE Days

Lost To

Sickness in

Month

Estimated

Contracted

Salary Lost in

Month £

Trend

12mths

145 of 169

Sickness Absence

SICKNESS ABSENCE

Source Data: ESR

The Sickness absence rate is calculated as follows:FTE Days Lost in Period/FTE Days Available in Period *100

Hot Spot Analysis:

Children & Young People's Wellbeing Network: Sickness Absence hasincreased in February to 4.64% and is now just above the Trust Target of4.5%. Long and short term sickness absence is proactively monitored via

monthly case conference meetings providing increased visibility to CareGroup Managers with Service Managers leading on action plandevelopment supported by HR.

The Engagement and Wellbeing Agenda is firmly embedded within theNetwork.

Community & Wellbeing Network: Sickness Absence has improved inFebruary, reporting 6.68% at the close of the month.. 31 individuals have returned to work following long term sickness through

January. Two services benefitting from this with an improved absencerate are the Moving Well service (4.01%) and Dental services (2.24%)

The refreshed Network People Group will be supporting the network inrelation to absence management through the offer of intensive wraparound treatment for teams facing challenges.

There is a correlation in higher absence levels in areas of the networkexperiencing higher vacancy rates and challenges in relation to systemtransformation.

A wellbeing & absence management strategy and action plan is beingdeveloped to support managers in Pennine & North. This will facilitate adeeper analysis of hot spot areas, provide a targeted support plan and willcontribute to the development of a programme of wellbeing andengagement activities.

Mental Health Network: Sickness Absence has decreased in the Networkfor the third consecutive month, closing February at 7.49%. This rate ishigher than that seen for the same period in 2019 (6.60%) but does movethe network more in line with its improvement trajectory target for themonth. The biggest monthly decrease is in Central & West, closely followed by

Secure Services. The January 2020 rate is the second highest in the last 12 months, and is significantly higher than that seen for the same period in 2019 (7.07%).

Overview:February has seen a decrease in Sickness Absence, overall, and closes the month at 6.40%. Absence has decreased across all Networks with the exception ofChildren & Young People who have seen a slight increase.

South Cumbria Network: Sickness Absence has decreased in February andreports a closing rate of 5.08%. The Network have noted that there has beenan increase in Long Term Cases. Sickness Absence management is one of the Networks priorities and

there are 4 capability hearings currently being planned. A new HR Advisor has been appointed and commend in post in December

2019. This role will provided dedicated support to managers for sicknessabsence management.

146 of 169

Mandatory & Statutory Training

Mandatory Training covers 21 courses.These have been selected by LCFT as the mandatory trainingcourses to be published and shared with our commissioners andexternal stakeholders and are indicative of the safety and qualityof our services.

MANDATORY TRACKED TRAINING

Source Data: Training Tracker and ESR

Equ

alit

y &

Div

ers

ity

3yr

Fire

Saf

ety

1yr

He

alth

& S

afe

ty 3

yr

Info

rmat

ion

Go

vern

ance

1yr

Infe

ctio

n C

on

tro

l 1yr

Bas

ic L

ife

Su

pp

ort

1yr

Imm

ed

iate

/ E

nh

ance

d L

ife

Sup

po

rt 1

yr

Co

nfl

ict

Re

solu

tio

n 3

yr

Po

siti

ve &

Saf

e P

rogr

amm

e 1

yr

Safe

guar

din

g C

hild

ren

L2

3yr

Safe

guar

din

g C

hild

ren

L3

3yr

Safe

guar

din

g A

du

lts

L2 3

yr

Me

nta

l Cap

acit

y A

ct L

1 3

yr

Me

nta

l Cap

acit

y A

ct L

2 3

yr

Man

ual

Han

dlin

g L1

B 3

yr

Man

ual

Han

dlin

g L2

A 3

yr

Man

ual

Han

dlin

g L2

B 2

yr

WR

AP

3yr

Safe

guar

din

g C

hild

ren

L1

3yr

Safe

guar

din

g A

du

lts

L1 3

yr

Man

ual

Han

dlin

g L1

A 3

yr

Trust 95.5% 89.6% 95.9% 90.3% 91.0% 80.1% 80.7% 82.6% 72.8% 92.0% 89.5% 94.6% 95.8% 89.7% x 84.1% 79.6% 85.1% 86.6% 88.9% 91.9% 89.87%

Mental Health 96.7% 93.7% 97.7% 91.5% 93.9% 83.7% 83.1% 86.5% 75.5% 95.2% 93.7% 95.8% 96.6% 93.7% x 84.8% 91.7% 84.9% 91.8% 92.5% 93.6% 92.07%

Community & Wellbeing 96.7% 91.8% 96.3% 91.3% 91.0% 83.8% 82.7% 87.0% x 94.1% 93.8% 94.6% 96.3% 93.0% x 83.1% 81.8% 86.2% 94.6% 91.6% 93.9% 91.65%

Children & Young People 95.7% 93.1% 95.7% 92.7% 91.7% 86.2% 80.8% 89.4% 81.8% 94.8% 95.7% 94.6% 96.9% 94.6% x 84.3% 83.9% 86.2% 92.4% 91.7% 93.3% 92.65%

South Cumbria 89.8% 54.1% 91.1% 70.2% 66.0% 33.2% 29.6% 16.4% 36.0% 57.6% 27.6% 84.9% 57.8% 39.1% x 0.0% 38.8% 80.7% 18.3% 86.6% 87.5% 62.59%

Support Services 90.8% 84.1% 90.6% 90.9% 89.6% 69.3% x 77.8% x 100.0% 86.3% 89.9% 92.0% 86.8% x 66.7% 0.0% 84.2% 85.0% 84.7% 87.9% 87.14%

Business Area

All Staff Medical, Clinical & Clinical Support Staff Admin, Clerical & Estates

Total

147 of 169

Mandatory Training

Mandatory Training covers 20 core skills courses.These have been selected by LCFT as the core training that are tobe published and shared with our commissioners and externalstakeholders and are indicative of our service quality and safety.

MANDATORY TRACKED TRAINING

Source Data: Training Tracker and ESR

Hot Spot Analysis:

Children & Young People’s Wellbeing Network: The Network continue toachieve an overall compliance rate above the Trust Target of 80%, reporting92.65%. At the close of January, only Information Governance at 92.7% is belowthe Trust target. Subjects highlighted as below compliance targets continue to be discussed

with the relevant team leader and service manager during the weeklyoperational meetings and areas for improvement and actions are agreed.

Support is available to managers to achieve and maintain compliance rates. The Network has reported to the Mandatory Training Team some areas

where mandatory training mapping to position appears to be inaccurate.

Mental Health Network: The Network are achieving the Trusts overall Trainingcompliance rate of 80%, reporting 91.73%. The following subjects remainbelow trust target: Information Governance (at 92.8% and very close to target),Immediate Life Support (79%) and Positive and Safe (73%). Improvementscontinue to be reported in training compliance within the Mental HealthNetwork.

Immediate/Enhanced Life Support has seen an increase in compliance rate(+4%) through the month.

Pennine Locality recorded the biggest increase in compliance for the secondconsecutive month.

Community & Wellbeing Network: The Network continue to achieve an overallcompliance rate above the Trust Target of 80%, reporting 91.65%. At the closeof January, only Information Governance at 91.3% is below the Trust target. IG Training compliance continues to improve and is nearing the compliance

target of 95% The Network has been working closely with the Quality Academy to target

hotspot areas and challenges relating to course requirement alignments andsystem updates.

South Cumbria Network: Mandatory Training performance has been availablesince January 2020, providing the Network with a baseline compliance position.Compliance across the South Cumbria Network reports an overall complianceposition of 62.59% for February (up from 59.81% in January) with 14 hotspotcourses. Managers are now focussing on compliance and improving theperformance position. Work is underway with the Network and Quality Academy to address

training gaps. A process has been agreed to ensure that South Cumbria Workforce are

able to provide evidence of having completed training, where applicable,and have that recorded against their training record.

Positive and safe training is planned to take place in February and Marchcovering all clinical staff.

148 of 169

Overall Appraisal Performance Source Data: ePDR System & Doctors Appraisal System

The Appraisal data presented has been designed to highlight the % initiation of AnnualPerformance Objectives (Appraisal) for the relevant Performance Review Year and demonstratethe PDR process is ‘live’ through the measurement of periodic PDR review and performanceyear end PDR closure.

APPRAISAL RATE

87.36%

12.64%

Overall Appraisal Compliance

% Compliant % Non Compliant

Business AreaActive

HeadcountCompliant % Compliant

Trust 5967 5213 87.36%

Mental Health 2876 2564 89.15%

Community & Wellbeing 1617 1456 90.04%

Children & Young People 748 668 89.30%

Support Services 726 543 74.79%

0

1000

2000

3000

4000

5000

6000

Trust Mental Health Community &Wellbeing

Children & YoungPeople

Support Services

Act

ive

He

adco

un

t

Overall Appraisals

Compliant Non Compliant

149 of 169

Appraisal Rate – Non Medical & Dental PDR Appraisals Source Data: ePDR System

The Appraisal data presented has been designed to highlight the % initiation of AnnualPerformance Objectives (Appraisal) for the relevant Performance Review Year and demonstratethe PDR process is ‘live’ through the measurement of periodic PDR review and performanceyear end PDR closure.

APPRAISAL RATE

87.30%

12.70%

Overall Appraisal Compliance

% Compliant % Non Compliant

0

1000

2000

3000

4000

5000

6000

Trust Mental Health Community & Wellbeing Children & Young People Support Services

Act

ive

He

adco

un

t

PDR Appraisals

Signoff With Objectives & Review Taken Place With Objectives Not Compliant With PDR Process New Starters Not Registered on PDR New Starters Registered on PDR

Business AreaActive

HeadcountCompliant % Compliant

% Non

Compliant

12mth

Rolling %

Compliant

Trust 5797 5061 87.30% 12.70% 87.44%

Mental Health 2743 2431 88.63% 11.37% 88.88%

Community & Wellbeing 1600 1439 89.94% 10.06% 89.94%

Children & Young People 730 650 89.04% 10.96% 89.04%

Support Services 724 541 74.72% 25.28% 74.86%

150 of 169

Appraisal Rate – Doctors Appraisals Source Data: Doctors Appraisal System

The Appraisal data presented has been designed to highlight the % initiation of AnnualPerformance Objectives (Appraisal) for the relevant Performance Review Year and demonstratethe PDR process is ‘live’ through the measurement of periodic PDR review and performanceyear end PDR closure.

APPRAISAL RATE

100.00%

0.00%

Overall Appraisal Compliance

% Compliant % Non Compliant

Business AreaActive

HeadcountCompliant % Compliant

Trust 170 170 100.00%

Mental Health 133 133 100.00%

Community & Wellbeing 17 17 100.00%

Children & Young People 18 18 100.00%

South Cumbria 2 2 100.00%

0

20

40

60

80

100

120

140

160

180

Trust Mental Health Community & Wellbeing Children & Young People Support Services

Act

ive

He

adco

un

t

Doctors Appraisals

Completed Medical Appraisal Process Exempt

151 of 169

Source Data: ESR, Staff Friends & Family Survey

Staff Friends & Family Test – Quarter 2 Performance

ENGAGEMENT & WELLBEING

The Staff Friends and Family Test (FFT) provides NHS Trusts with an internal ServiceImprovement Tool that uses the knowledge and experience of its Employees. The StaffFFT provides our employees with an opportunity to, anonymously, feedback their viewson us, as their employer. The test runs four times a year in LCFT and is open to allemployees.

Network HeadcountTotal

Responses

Response

Rate %Trend

Question 1

Performance(Target 70%)

TrendQuestion 2

Performance(Target 70%)

TrendEngagement

Score(Target 7.40)

TrendWellbeing

Score Trend

Overall 6032 1101 18.25% q 70.30% q 54.50% q 6.8 q 50.63% q

Children & Young People 770 160 20.78% p 81.25% p 60.00% q 7.4 q 55.97% q

Community & Wellbeing 1747 326 18.66% q 77.91% p 54.91% q 6.9 q 49.35% q

Mental Health 2772 403 14.54% q 60.79% q 49.38% q 6.5 q 48.44% q

Support Services 743 212 28.53% q 68.40% q 59.43% p 6.8 q 52.73% q

152 of 169

Source Data: ESR, Staff Friends & Family SurveyEngagement– Quarter 2 Performance

ENGAGEMENT & WELLBEING

The Staff Friends and Family Test (FFT) provides NHS Trusts with an internal ServiceImprovement Tool that uses the knowledge and experience of its Employees. The StaffFFT provides our employees with an opportunity to, anonymously, feedback their viewson us, as their employer. The test runs four times a year in LCFT and is open to allemployees.

Agree Neither Agree or Disagree Disagree

Negative response target (15%) Positive response target (70%)

Trend

1101

762

195

144

1101

726

254

121

1101

598

241

262

1101

636

277

188

1101

907

133

61

1101

870

172

59

1101

777

186

138

1101

734

220

147

1101

631

292

178

Invo

lve

me

nt

I am able to make

suggestions to improve the

work of my team /

department.

There are frequent

opportunities for me to show

initiative in my role

I am able to make

improvements happen in my

area of work.

Response Performance

Ad

voca

cy

Care of patients / service

users is my organisation’s

top priority

If a friend of relative needed

treatment, I would be happy

with the standard of care

provided by this

organisation.

I would recommend my

organisation as a place to

work.

Mo

tiva

tio

nI look forward to going to

work.

I am enthusiastic when I am

working.

Time passes quickly when I

am working.

69.21%

65.94%

54.31%

57.77%

82.38%

79.02%

70.57%

66.67%

57.31%

17.71%

23.07%

21.89%

25.16%

12.08%

15.62%

16.89%

19.98%

26.52%

13.08%

10.99%

23.80%

17.08%

5.54%

5.36%

12.53%

13.35%

16.17%

0.00% 20.00% 40.00% 60.00% 80.00% 100.00%

6.8

Engagement Score

153 of 169

Source Data: ESR, Staff Friends & Family Survey

Wellbeing – Quarter 2 Performance

ENGAGEMENT & WELLBEING

The Staff Friends and Family Test (FFT) provides NHS Trusts with an internal ServiceImprovement Tool that uses the knowledge and experience of its Employees. The StaffFFT provides our employees with an opportunity to, anonymously, feedback their viewson us, as their employer. The test runs four times a year in LCFT and is open to allemployees.

Negative response target (15%) Positive response target (70%)

Qw1

Qw2-3

No Yes, definitely Yes, to some extent

Yes No

Disagree Neither Agree or Disagree AgreeQw4-7

Trend

1101

317

602

182

1101

806

295

1101

598

503

1101

860

151

90

1101

882

169

50

1101

805

192

104

1101

767

214

120

1101

299

348

454

Response Performance

Does Lancashire Care NHS

Foundation Trust take

positive action on health and

wellbeing?

In the last 12 months have

you experienced

musculoskeletal problems

(MSK) as a result of work

activities?

During the last 12 months

have you felt unwell as a

result of work related stress?

We

llb

ein

g

My Line Manager, or someone

at work, seems to care about

me as a person

I receive the respect I deserve

from my colleagues at work

My immediate manager

encourages me at work

I have a choice in deciding

how to do my work

I have unrealistic time

pressures

28.79%

73.21%

54.31%

78.11%

80.11%

73.12%

69.66%

27.16%

54.68%

13.71%

15.35%

17.44%

19.44%

31.61%

16.53%

26.79%

45.69%

8.17%

4.54%

9.45%

10.90%

41.24%

0.00% 20.00% 40.00% 60.00% 80.00% 100.00%

154 of 169

Board of Directors Agenda Item TB 114/20 Date: 02/04/2020

Report Title Finance Report

Prepared By Shannon Carroll, Financial Services Director

Presented By Bill Gregory, Chief Finance Officer

Action Required Noting

Supporting Executive Director Chief Finance Officer

PURPOSE OF THE REPORT: Report Purpose To summarise and analyse actual and forecast financial

performance and standing of the Trust, the implications and any proposed management action.

Strategic Objective(s) this work supports

To provide excellent value for money in a financially sustainable way

Board Assurance Framework Risk 7.0 The Trust does not achieve financial performance sufficient to maintain resilience and sustainability

CQC Domain Effective

155 of 169

Summary

Actual Plan Var Forecast Plan VarSustainability

EBITDA 12,814 15,079 -2,265 15,211 17,121 -1,910 Operational Deficit -1,205 -607 -598 -320 -0 -320 Surplus/(Deficit) (inc Technical Adj) 7,190 -607 7,797 8,075 -0 8,075

CIPs (against Trust Plan) 9,586 9,035 551 10,827 10,073 754Cash and Liquidity 26,932 21,960 4,972 19,566 17,493 2,073Capex 8,316 9,585 -1,269 14,084 13,503 581UOR

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

The year to date position is at £1.2m deficit, which includes the PSF loss of £0.3m (associated with the whole system’s financial performance), £0.6m behind plan. This is £0.3m behind plan excluding PSF, and £0.6m having accounted for that. The technical adjustment relates to the previously described absorption of South Cumbria (See the Matters Section).Whilst the above table maintains a forecast for delivery of the control total (after allowing for the loss of system PSF) the reality is that a significant year end shortfall of c£3.4m, excluding the loss of system PSF, to the control total is developing which will manifest without further mitigation. Of those areas deteriorating, we have £0.3m attributable to continued pressures on wards, and a further deterioration in the OAPs charges and some challenge on non-contract charges. Contra to this are gains on Mental Health medics of £0.1m, funding for the Secure Forensic Team of £0.2m, £0.2m for recruitment delays, £0.2m for other clinical and £0.2m of other gains. This resulted in an overall year end improvement of £0.2m. The Trust is seeking £2.5m of income for stranded patients from commissioners which is the substantial part of the remaining gap.All parts of the Trust have been challenged to deliver additional savings, and we have seen some traction realised. The recent improvement allows some belief that the control total can still be realised and it is not proposed that our forecast of financial compliance to the ICS and NHSE/I is altered this month. The positions as presented do not account for the impact of any charges in respect of COVID 19 which could have a detrimental impact, but the costs and consequences are still being determined, but should be funded by NHSEI. We are expecting to incur c£0.1m in the financial year and have submitted the detail to NHSEI for reimbursement.The Use of Resources (UoR) metric is rated at 3, in line with plan at this stage, but should the Trust meet its financial plans and targets, as currently expected, the Trust will have a rating of 2.

Current Out-Turn

Sustainability

The Trust is currently reporting an outturn in line with plan. This is contingent on a number of matters and the Trust needs to retain focus on these (see below).• Meetings with commissioners have emphasised the requirement for early identification of stranded patients and the need to appropriately follow protocol.• Ensure current CIP schemes are delivered and significant additional programmes identified• Ensure the improvement in clinical service positions are maintained• Ensure implementation of MHIS schemes• Recruit to establishment on ward to avoid additional charges for bank and, in particular, agency staff.• Deliver additional savings to address the base case position and provide contingency.• Ensure expenditure on COVID 19 is captured and recovered.

Forecasting and Key Actions

KeyMajor ConcernsMinor concerns, within toleranceIn line with planNHSI RatingNo evident concernsMinor concern, potentially requiring scrutinyMajor concern, requiring scrutinySignificant Risk, action required

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Summary (continued)

e

This table shows the current range of outturns for the Trust• If we take system failure of the control as a given, the Trust will lose £424k.• In addition, the Trust was given an additional £101k of PSF money in 19/20.• The net impact is that the Trust can only now secure a maximum PSF of £2.7m (£2,660k in best case).• If the Trust manages to achieve it's control total of -£3m, it's PSF payments will take it to £0.3m deficit.• The Trust would not be expected to make good any system failing to claim its own PSF• The Trust has a likely forecast of £3.4m behind it's control total, the gap within our control to address.• The range is up to £5.7m from target• Stranded Patient income has been removed from the base case and is now viewed as an upside.• The Trust expects relief against the impact of changes to discount rate, as this is beyond our control• The Trust is also reviewing other upsides which could lead to further gains• These additional amounts are not without risk and require careful consideration before enactment

Capital and Financing

Cash continues significantly ahead of plan, with high levels result mainly from working capital gains, PSF bonus monies and capital phasing, which more than compensate for increases to capital and financing requirements. As a result the Trust is remains significantly ahead of plan (c£5m). This will reduced and will continue reduce as transient working capital gains reduce and capital and financing align, but assuming the Trust achieves its revenue targets for the year cash the forecast is still expected to exceed plan.

CIPs

Cash and Liquidity

CIPS are slightly ahead on delivery now at month 11 (year to date) and again ahead of plan for the forecast. This is built into the position and the Trust is reviewing schemes and supporting networks to drive through more savings, reduce waste and deliver further contingency for the position.

Capex shows a variance from plan of £1.3m, within tolerance, but given increases due to external funding this leaves a significant amount to spend in March. Both IT and Estates have acknowledged the challenge and are confident that with the plans in place the overall position is manageable. Pressures continue around backlog maintenance, but with the sale of Sharoe Green and given the spend remaining the main risk remaining now revolves around plans to spend to forecast.

The UoR is currently 2 against a plan of 2, with only performance against plan and agency ratings being behind plan. The performance against plan rating will likely continue at 2, as we no longer expect system PSF. The agency rating will likely continue at 3 as much of this is attributable to Cumbria which will not be incorporated into our ceiling by NHSEI until 20/21. That being said, assuming current pressures and risks are addressed and I&E performance achieves (or exceeds) forecast the Trust will achieve a UoR of 2 in line with the plan.

Use of Resources (UoR) risk ratings

Scenarios

Worst Case Forecast Best CaseSensitivities £000s £000s £000s

Gap to claim LSCFT specific PSF -3,363 -3,363 -3,363

OAPs / Stranded Patients Slippage -1,500Estates CIP -350 150IT Equipment 180Children & Younger People network Income 85Super stranded 2,500Relief on Discount Rate 300Balance Sheet Flexibility 150CQUIN Slippage -200

Residual Gap to Bridge -5,413 -3,363 2

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Statement of Comprehensive Income

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

Month 10Actual Plan Variance Variance

£'m £'m £'m £'m

Income 330.6 314.3 16.3 10.9

Pay (243.2) (240.7) (2.5) (0.8)Non Pay (74.5) (58.4) (16.1) (11.6)Total Costs (317.7) (299.2) (18.5) (12.4)

EBITDA 12.8 15.1 (2.3) (1.6)

Capital Charges (12.7) (14.2) 1.6 1.3Financing (1.4) (1.5) 0.1 0.1

Operational surplus / (deficit) (1.2) (0.6) (0.6) (0.2)

Gain on Transfer by Absorption 8.4 0.0 8.4 8.4

Surplus/(Deficit) (inc Technical Adj) 7.2 (0.6) 7.8 8.2

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

Unmitigated Annual Month 10Forecast Plan Variance Variance

£'m £'m £'m £'m

Income 362.2 343.5 18.7 18.5

Pay (268.0) (262.9) (5.1) (5.6)Non Pay (83.2) (63.5) (19.7) (19.2)Total Costs (351.2) (326.4) (24.9) (24.8)

EBITDA 11.0 17.1 (6.2) (6.2)

Capital Charges (14.1) (15.5) 1.5 1.5Financing (1.5) (1.6) 0.1 0.1

Net surplus / (deficit) (4.6) (0.0) (4.6) (4.6)

Gain on Transfer by Absorption 8.4 0.0 8.4 8.4

Surplus/(Deficit) (inc Technical Adj) 3.8 (0.0) 3.8 3.8

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

Month 10Forecast Plan Variance Variance

£'m £'m £'m £'m

Income 366.5 343.5 23.0 21.7

Pay (268.0) (262.9) (5.1) (5.6)Non Pay (83.3) (63.5) (19.8) (18.0)Total Costs (351.3) (326.4) (24.9) (23.6)

EBITDA 15.2 17.1 (1.9) (1.9)

Capital Charges (14.1) (15.5) 1.5 1.5Financing (1.5) (1.6) 0.1 0.1

Net surplus / (deficit) (0.3) (0.0) (0.3) (0.3)

Gain on Transfer by Absorption 8.4 0.0 8.4 8.4

Surplus/(Deficit) (inc Technical Adj) 8.1 (0.0) 8.1 8.1

Year To Date (Current)

Annual

-5,000

-4,000

-3,000

-2,000

-1,000

0

1,000

Gap

PSF

(Ups

ide)

Supe

rstr

ande

d

Esta

tes

CIPs

IT e

quip

men

t

CYP

SLA

reco

verie

s

Men

tal H

ealth

Deve

lopm

ents

Net

risk

s

-4,260 897 2,501 150 180 83 100 800 -451

Income – Year to date income is ahead of plan due to some commissioner developments and funding of additional OAPs. Cumbria income is now included for the last four months.The year end base position is £18.7m ahead plan. The is mainly attributable the transfer of Cumbria services, but also to commissioner developments, and funding for OAPS. Additional funding has been allocated nationally of c£2.9m to support the urgent care pathway, plus £2.1m of more local funding.The upside includes the balance of the PSF income to take it to the full amount due from delivering the control total and £2.5m of funding for stranded patients.

Pay - The year to date pay is now over plan by £2.5m. The investments in mental health were expected to be higher than was finally agreed but the Cumbria pay for five months bridges the gap to plan and some developments are now manifesting.The base year-end variance of £5.1m is dominated by the development funding agreed in this years settlement, but more significantly by the pay in the Cumbria transfer.The upside is consistent with the base position

Non-Pay - Year to date non-pay is £16.1m beyond plan, dominated by OAPs and Priory , some phasing of pressures funding and some slippage of charges from the previous year's agreement. Additionally, we have now seen five months of Cumbria costs.The base outturn is £19.7m above plan for non-pay driven in the main by subcontracted healthcare (OAPs, although some income compensates), slippage on CIPs, additional estates costs and Cumbria costs.The upside assumes minor delivery of some additional CIP and cost curtailment.

Capital Charges and Financing are at this stage expected to be c£1.6m underspent due to estate revaluation.

Gain on Transfer by Absorption relates to transfer of Cumbria assets.

158 of 169

Statement of Financial Position

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

Actual Plan Variance£'m £'m £'m

Fixed Assets 219.1 231.6 -12.5Other Long Term Assets 0.2 0.4 -0.2Non Current Assets 219.3 232.0 -12.7

Stock 0.1 0.1 0.0Trade Debtors 25.2 20.5 4.7Other Current Assets 0.5 2.1 -1.6Cash 26.9 22.0 5.0Current Liabilities -42.8 -34.6 -8.3Current Assets and Liabilities 9.9 10.1 -0.2

Provisions and other Long Term Liabilities -1.7 -1.6 -0.1Loans -47.6 -47.6 0.0Non Current Liabilities -49.3 -49.2 -0.1

Total Net Assets Employed 179.9 192.9 -13.0Financed By:PDC 112.9 114.6 -1.7 External funding to be drawn with final sign off (note all PDC was drawn down in I&E Reserve 2.2 8.1 -5.9Other Reserves 64.8 70.2 -5.5

Taxpayers Equity 179.9 192.9 -13.0

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

Forecast Plan Variance£'m £'m £'m

Fixed Assets 223.9 233.2 -9.3Other Long Term Assets 0.2 0.4 -0.2Non Current Assets 224.1 233.6 -9.5

Stock 0.1 0.1 0.0Trade Debtors 23.2 19.5 3.7Other Current Assets 0.5 0.0 0.5Cash 19.6 17.5 2.1Current Liabilities -34.4 -28.9 -5.4Current Assets and Liabilities 8.9 8.1 0.9

Provisions and other Long Term Liabilities -1.5 -1.6 0.1Loans -46.4 -46.4 0.0Non Current Liabilities -47.9 -48.0 0.1

Total Net Assets Employed 185.1 193.7 -8.6Financed By:PDC 117.3 114.8 2.5I&E Reserve 3.2 8.8 -5.6Other Reserves 64.6 70.1 -5.5

Taxpayers Equity 185.1 193.7 -8.6

Forecast in line with plan.

Annual

With additional capital funding provisionally agreed, the gain attributable to cash as a result of 2018/19 PSF bonus produces gains in underling cash. This is reduced by deferred receipt of AHfS disposals and capital charges changes (See also Cash Flow and Liquidity).

In year I&E performance is forecast to be broadly in line with plan (reduced slightly for loss of system PSF). The differences are mainly due to impact of Cumbria transfer and differences/transfers on reserves as a result of the impact of brought forward revaluations not included in plan.

Includes allocations for Energy efficiency (£0.4m), Cumbria GDE (£0.2m) and Avondale (£1m) and Cybersecurity £0.8m.

Forecast capital increases are higher than original plan with £2.5m additional expenditure and funding agreed. The primary difference however is due to the impacts of brought forward revaluations not included in plan and the impact of associated depreciation savings offset by the Cumbria transfer of £8.4m.

Year To Date (Current)

In line with plan

Capex is £1.3m behind plan. The primary difference is due to impacts of brought forward revaluations not included in plan and the impact of associated depreciation savings offset by an increase of c£8.4m in relation to the Cumbria transfer.

Mainly due to impact of Cumbria transfer and differences/transfers on reserves due to impact of brought forward revaluations not included in plan. Impact for in year I&E operating performance being behind plan is marginal (c£0.6m).

Overall liquidity is broadly in line with plan with bonus PSF gains offset by timing differences. Cash remains high due to working capital gains with higher than planned levels creditors and deferred income offset to some degree by higher than planned levels of debtor/accrued income. Earlier than planned disposal of AHfS (Share Green) is also contributing (see also Cash Flow and Liquidity).

159 of 169

Statement of Cash Flow

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

Actual Plan Variance£'m £'m £'m

Opening cash balance 30.3 20.0 10.3 Opening cash levels high (see WC below)

Surplus/(deficit) after tax 7.2 -0.6 7.8Non Cash Flows 5.6 15.7 -10.1

Operating Cash Flows before WC 12.8 15.1 -2.3

Changes to WC -3.9 -0.9 -3.1Reversal of the temporary gains in 2018/19 accounts now starting to manifest as temporary masking by transient gains in 2019/20 reduce (see also liquidity).

CF from operations 8.9 14.2 -5.3

Capital and Investment Activities -6.9 -8.2 1.3Financing and Other -5.4 -4.0 -1.4

Capital and Financing -12.3 -12.3 0.0

Net cash inflow/outflow -3.4 1.9 -5.3

Closing cash balance 26.9 22.0 5.0

Forecast Statement of Cash Flow (Forecast v Plan)

Forecast Plan Variance£'m £'m £'m

Opening cash balance 30.3 20.0 10.3 Opening cash levels high (see WC below)

Surplus/(deficit) after tax 8.1 0.0 8.1Non Cash Flows 7.1 17.1 -10.0

Operating Cash Flows before WC 15.2 17.1 -1.9

Changes to WC -7.5 -2.5 -5.0

Main variance from plan is due to timing: temporary gains in 2018/19 resulted in a high cash balance, these reverse in 2019/20 returning balances and cash to normal levels (some opening gains remain, mainly as a result of 2018/19 PSF bonus monies).

CF from operations 7.7 14.6 -6.9

Capital and Investment Activities -12.7 -8.5 -4.1Financing and Other -5.8 -8.6 2.8

Capital and Financing -18.5 -17.1 -1.3

Net cash inflow/outflow -10.8 -2.5 -8.2

Closing cash balance 19.6 17.5 2.1

Main differences on capital is due to an increase of £2.4m in externally funded capital spend and deferral of receipts from AHfS including the phasing of the Junction (transacted in 2018/19 and therefore opening cash), with financing benefiting from additional funding and the changes in capital charges as a result of the revaluation (see non cash above).

Year To Date (Current)

Annual

I&E operating performance is slightly behind plan (including system PSF). There is also a negative impact of changes to capital charges as a result of revaluations, but these manifest as gains in financing (see also forecast).

Capex is behind plan and Sale of Sharoe Green also generates gains. These are offset by negative impact of sale of junction ahead of plan (in 2018/19) and delayed utilisation of external funding. Some real gains on financing due to reduction in PDC Dividend.

After removing system PSF forecast I&E performance is slightly behind plan. There is also a negative impact of changes to capital charges as a result of revaluations, but these manifest as gains in financing (see below).

160 of 169

Cash and Liquidity

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

£26.9m £22.0m £5.0m £19.6m £17.5m £2.1m

Debt Analysis*

Invoice Age 1-30 31-90 90+ Total

Local Authorities £0.1m £0.2m £0.7m £0.9mNon NHS £0.1m £0.3m £0.2m £0.7mNHS £4.4m £3.8m £5.0m £13.1m

Total £4.6m £4.3m £5.9m £14.7m

Local Authorities £0.4m £0.1m £0.6m £1.1mNon NHS £0.3m £0.2m £0.3m £0.8mNHS £4.5m £3.3m £4.4m £12.2m

Total Last Month £5.2m £3.6m £5.3m £14.1m

Year To Date (Current) Annual

*Note that phasing adjustments, contract variations, accruals and PSF monies are uninvoiced and therefore excluded from Debt Analysis.

0.000

5.000

10.000

15.000

20.000

25.000

30.000

35.000

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

Cash Forecast

Strategic Headroom Operating Headrooom Minimum Threshold

Actual/Forecast Plan

Debt Movement

The Trade Debt position £0.6m is higher than that at month 10, this is attributable to NHS Debt with reductions in both local authority and Non NHS categories:

• 1-30 day debt has increased mainly due to a combination of invoicing of additional NHS funding, recharges and OAPs, but outstanding AHSN recharges and NHSE block are also high.

• 31-90 days debt has seen increases due to the aging of some of last months high levels of current debt, and with 61-90 debt being fairly typical this is not yet considered to be of concern.

• 90+ day debt has seen some progress but this has been masked by the shift of debt re continence recharges and OAPs from 31-90, £0.9m of this has since been settled. Discussions with commissioners to resolve issues with super stranded are ongoing.

Work on all areas will continue, with focus expected to remain on NHS debt to facilitate year end.

Note 90+ debt is now reported in detail to the Finance and Performance Committee including thematic and risk analysis.

Cash Variances

Cash levels show a decrease on last month of £3.6m but remain £5.0m ahead of plan (£9.5m last month). As expected transient gains on working capital have fallen significantly, but despite the fall they continue to contribute a net c£3.5m and together with the bonus monies from 18/19 PSF (£2.5m) and the receipts for Sharoe more than compensate for the I&E and net capital/financing positions.

Forecast cash balance is currently expected to be at least c£2.1m ahead of plan, higher if transient gains continue as expected:

• Risks to cash as a result of I&E performance are currently assumed to be managed and the forecast assumes management actions to maintain plan are achieved.

More detailed Cash flows are presented quarterly to Finance and Performance Committee, but even downside scenarios indicate cash levels will give the required headroom.

161 of 169

Finance Use Of Resource Metric

FINANCE AND USE OF RESOURCES RATING

Plan Actual Plan Forecast 1 2 3 4 Weighting

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

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

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

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

Agency rating 2 3 2 3 0.00% 25.00% 50.00% >=50% 20%

Overall 2 2 2 2 100%

Year to Date Annual

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

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

The UoR is currently 2 against a plan of 2, with only performance against plan and agency ratings being behind plan. The performance against plan rating will likely continue at 2, as we no longer expect system PSF. The agency rating will likely continue at 3 as much of this is attributable to Cumbria which will not be incorporated into our ceiling by NHSEI until 20/21. That being said, assuming current pressures and risks are addressed and I&E performance achieves (or exceeds) forecast the Trust will achieve a UoR of 2 in line with the plan.

• Capital Service is currently a 3 against a plan of 3, a deterioration in operating performance of c£3.0m would be required to decrease the rating to 4.• Liquidity is currently a 1 against a plan of 1, a deterioration in the liquidity metric of c£9.8m would be required to reduce the rating to 2. • I&E Margin rating is currently 3 against a plan of 3, a deterioration in operating performance of c£2.2m would be required to decrease the rating to 4.• I&E Variance from Plan is currently 2, an improvement in operating performance of c£0.5m would increase the rating to 1.• Agency is currently 3 against a plan of 2, a decrease in agency costs of c£0.6m would be required increase the rating to 2.

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Income and Expenditure - Services

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

Actual Plan Variance£'m £'m £'m

Mental Health Services 126.0 121.5 -4.5Staffing is underspending in most non-inpatient areas. Inpatients and in particular, Secure, are experiencing pressures. OAPS is overspent.

Community Services 51.6 52.1 0.5There is some slippage on CIPs more than compensated for by additional income and non-pay underspends.

Children And Family Services 24.6 23.7 -0.9The Network is struggling to convert prior years savings into it's recurrent position.

Cumbria 5.6 5.8 0.3 There is a £0.3m underspend after five months.

Corporate and Reserves 48.8 51.8 3.0Impacted by holding reserves still to be applied and increased costs due to the Cumbria transfer.

Net Network Position 256.6 255.0 -1.6

Forecast Income and Expenditure - Services (Forecast v Plan)

Forecast Plan Variance£'m £'m £'m

Mental Health Services 150.3 145.5 -4.8Staffing pressures, and OAPs overspends, partly offset by gains on income for stranded patients. New developments recruited to.

Community Services 62.0 62.5 0.5Some pay pressures from CIP slippage, but compensated for by vacancies, non-pay underspends and additional income.

Children And Family Services 29.5 28.6 -0.8There is an expectation that the service continues to struggle to shed costs associated with Universal and CIP slippage

Cumbria 8.3 8.8 0.4Direct clinical costs for Cumbria are at this point expected to be slightly underspent in relation to direct clinical costs.

Corporate and Reserves 61.0 63.7 2.6Some gains on reserves, but most pressures now fully distributed. Corporate and estate costs for Cumbria introduce additional costs.

Net Network Position 311.2 309.2 -2.0

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

Year To Date (Current)

Annual

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Staffing

0

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400

600

800

1,000

1,200

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

Agency Spend by Type

Medical and Dental Nursing, midwifery and health visiting staff

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

Managers and infrastructure support Other

Agency Ceiling

12,000

14,000

16,000

18,000

20,000

22,000

24,000

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

Staffing Spend by Category

Substantive Bank Agency Plan Total

Staffing Spend

• The ward pressures were addressed by funding to align with the Hurst work. There is some pressure on wards still and the Hurst work is being revisited.

• The Trust plan assumed very significant investment from commissioners. This has started to filter through and significant recruitment has taken place to the extent that staffing costs are now exceeding plan.

• We have seen an overall increase in the use of temporary staffing as development roles are recruited to and backfill used.

Agency Spend

• Agency expenditure continues to be dominated by medical and dental expenditure, although this has increased on previous months, and nursing costs which have again increased in February as recruitment continues on developments

• Cumbria staffing increases the overall agency spend by over £140k, a £30k reduction over January.

• The Trust has revised its agency outturn to £8.9m per annum to acknowledge the additional medic costs and Cumbria. The Agency Ceiling is £6.3m and is not expected to be revisited in year.

• Overall expenditure is expected to exceed the agency ceiling by c£2.6m for the year, 40%.

164 of 169

Month Month Month MonthFeb 2020 Jan 2020 Feb 2020 Jan 2020

11 10 Note 11 10 Note

Agency Spend 662 634 Note 1 Bank Spend 1,814 1,726

Network Analysis Network AnalysisMental Health 292 316 - Note 2 Mental Health 1,516 1,461 - Note 2Children & Young Peoples 8 -5 - Note 3 Children & Young Peoples 65 42 - Note 3Community & Wellbeing 249 212 - Note 4 Community & Wellbeing 122 119 - Note 4Cumbria 141 170 - Note 4 Cumbria 53 45 - Note 4Corporate Services -30 -60 - Note 5 Corporate Services 57 58 - Note 5

Actual 662 634 Actual 1,814 1,725

1

2

3456

The Trust has been given a ceiling by NHS Improvement for agency spend. This target is £6.3m for the year. At the end of period 11, the Trust is £2.2m, or 36% above it's ceiling, and £1.1m above plan. A revision to the target to account for Cumbria will not occur this year so pressure remains. The new Use of Resources rating measures agency against target and contains trigger points. Key trigger points are a requirement for 50% and 25% or better for ratings of 3 and 2 respectively. An individual rating of at least 3 is required to obtain an overall rating of 2 (see also Use of Resources section). We expect of exceed our plan and control total by some distance.

Corporate Services is net of the charge levied for agency staff. Agency spend is negligible with the exception of minor amounts in Health Informatics.

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

High vacancy levels are being supported by bank and agency, which when added to acuity and occupancy levels on wards, mean overall staffing costs remain high. Temporary staffing has increased this month, however the shift is small and mainly relates to bank.Mental Health Networks bank and agency costs are primarily due to the level of acuity and vacancies on inpatient wards which are being recruited to, and from filling medical posts with agency. Temporary staffing has increased on the previous month across most areas due to pressures from backfill for the newly commissioned developments.Children and Young Peoples temporary staffing remains relatively minor, with the change in agency due to the release of provisions for historic medic charges..Community and Wellbeing sees a slight increases in temporary staffing, although there is a slightly improved Network position.Cumbria are currently making significant use of medics and nursing agency to cover vacancies proportion to size. There has been decreased agency on the previous month.

Agency Ceiling Apr May Jun Jul Aug Sep Oct Nov Dec Jan Feb YTD Total ProjectionCeiling 527 527 527 527 527 527 527 527 527 527 527 5,797 6,323Actual 531 563 664 795 677 866 1,070 758 661 634 662 7,881 8,873Plan 627 627 627 627 626 625 617 617 617 617 617 6,844 7,462Variance Act to Plan 96 64 -37 -168 -51 -241 -453 -141 -44 -17 -45 -1,037 -1,411% of Ceiling 136% 140%% of Plan 115% 119%

Apr May Jun Jul Aug Sep Oct Nov Dec Jan Feb Mar2017/18 1312 1268 1625 1365 1481 1813 1388 1322 1795 1266 1488 1963

2018/19 1556 1825 1601 1527 2081 1814 1627 1972 1584 1410 2035 1679

2019/20 1884 1554 1931 1704 1692 2001 1693 1727 2168 1726 1814

0

500

1000

1500

2000

2500

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

2017/18 647 691 711 704 825 863 774 706 809 790 672 703

2018/19 609 692 642 718 579 607 745 534 588 550 500 1041

2019/20 531 563 664 795 677 866 1070 758 661 634 662

0

200

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

CIP Achievement (£)

Notes

Overall delivery of CIPs are slightly ahead of plan at month 11, albeit much reliant on non-recurrent schemes.

The forecast outturn is now also slightly ahead of plan. This is built into the overall financial position.

Compensatory schemes are being formulated to cover failing schemes and this needs to continue in addition to developing long term transformational programmes.

Additionally, the Trust needs to convert pipeline schemes into real and tangible gains.

The Trust has challenged all services and departments to achieve additional in year savings and targets have been communicated.

Work is progressing on identifying transformational programmes for next year, however it is already a stretch for them to be effective from 1st April.

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100%Scheme Annual YTD Plan YTD Actual Variance Outturn YE Variance RecurrentWard Premium £400 £400 £400 £0 £400 £0 £400Ward Skill Mix £450 £413 £413 £0 £450 £0 £450OAPs Reduction £500 £417 £0 -£417 £0 -£500 £0Other Mental Health £1,266 £1,136 £1,103 -£33 £1,274 £8 £1,160District Nursing £800 £737 £20 -£717 £22 -£778 £22Other Community £399 £362 £318 -£44 £348 -£51 £311Children & Young Peoples £1,195 £1,059 £862 -£197 £951 -£244 £325Corporate £1,278 £1,169 £2,122 £953 £2,527 £1,249 £1,267Estates £396 £361 £386 £25 £423 £27 £423Land Disposals / Non Rec £1,500 £1,250 £725 -£525 £900 -£600 £00-19 £1,768 £1,621 £1,771 £150 £1,932 £164 £1,932Procurement Savings £121 £111 £458 £347 £500 £379 £500New Schemes £0 £0 £1,008 £1,008 £1,100 £1,100 £1,100Total £10,073 £9,035 £9,586 £551 £10,827 £754 £7,890

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OUT OF AREA ACTIVITY

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6 The Trust believes it has secured a commitment from commissioners regarding liability for LD and Rehab patients who no longer benefit from our interventions. This arrangement is currently being tested with some push back on the appropriateness of charging by commissioners. The Trust has arranged meetings with commissioners and appraised NHSE of the position, and is seeking £2,5m to be included in the upside but has not included any in this regard in the base case.

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

The Trust has incurred additional pressure on services. The original plan assumes a large drop in OAPs aligned to the appropriate placement of stranded LD and Rehab patients. This has slipped significantly exposing the Trust to financial pressure.The current position indicates the Trust will spend c£17.2m on OAPs, £4.4m in excess of LCFT funding after accounting for the recharge of stranded patients. The forecast is being reviewed as it has been suggested that it lacks robustness and is overly pessimistic given current bed occupancy.

There is a fund of c£5m for OAPs, financed 50:50 by the Trust and Lancashire CCGs. The commitment from CCGs is however open ended on a 50:50 basis.

We are including figures for the additional activity at the Priory (Cottam) where it is above commissioner funding.

19/20 Beds beyond Commissioned Capacity

April May June July August September October November December January February March TotalAcute 31 25 28 19 15 28 41 52 42 47 51 59PICU 13 12 17 15 9 7 9 11 7 8 10 13Total Inapp OAPs 44 37 45 34 24 35 50 63 49 55 61 72App OAPs 27 33 34 32 33 36 40 37 41 42 47 44Total Beds 71 70 79 66 57 71 90 100 90 97 108 116Acute £773 £757 £812 £688 £573 £829 £1,209 £1,006 £900 £1,144 £1,232 £1,375 £11,298PICU £315 £302 £416 £333 £229 £160 £216 £261 £165 £199 £236 £323 £3,155Cottam Ward above trajectory £161 £167 £161 £167 £167 £161 £167 £264 £258 £258 £269 £258 £2,458Calico £81 £106 £112 £300Total Cost (£'000s) £1,330 £1,332 £1,501 £1,188 £969 £1,150 £1,592 £1,531 £1,323 £1,601 £1,737 £1,956 £17,210Charge to CCGs (incl stranded) £500 £662 £838 £500 £709 £702 £1,209 £795 £1,032 £810 £1,178 £1,314 £10,248Charge to LCFT £830 £670 £663 £688 £260 £448 £383 £736 £291 £791 £559 £642 £6,962

Trajectory

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Plan Actual Plan ForecastFeb 2020 Feb 2020 Variance Out-turn Variance

£'m £'m £'m £'m £'m £'m

Integrated AMH 0.00 0.05 0.05 0.00 0.21 0.21

IT SchemesCore IT Schemes (inc RTCs) 1.93 2.21 0.28 2.10 2.29 0.19GDE Schemes 1.72 1.47 -0.26 2.12 2.12 0.00Cybersecurity 0.00 0.00 0.00 0.82 0.82 0.00

Estate and infrastructure Schemes 5.24 4.56 -0.68 7.03 7.40 0.37

Energy Efficiency Schemes 0.00 0.00 0.00 0.44 0.44 0.00

Contingency and Other 0.70 0.04 -0.66 1.00 0.81 -0.19

Total 9.59 8.32 -1.27 13.50 14.08 0.58

Capital Expenditure

Capital Expenditure and ForecastsYear to date shows a variance from plan of £1.3m, within tolerance (15%), but given the overall increases due to external funding this leaves a significant amount to spend in March. Estates have acknowledged the challenge but with plans in place are confident that the overall position is manageable. IT have also have sound plans in place and are confident that remaining GDE and the newly allocated Cybersecurity monies will be spent. The total Capital Programme remains broadly consistent with M10 when taking into account the additional externally funded Cybersecurity scheme and with the sale of Sharoe Green in 2019/20 and confirmation of external funds is within capital resource limits. Pressures continue around backlog maintenance, but with the sale of Sharoe Green and given the spend remaining the main risk remaining now revolves around plans to spend to forecast.

Plan and FundingThe plan and forecast now includes additional external funding of £2.5m for confirmed allocations re the Energy Efficiency Fund (£0.4m), additional cover to support capital pressures re Avondale (£1m, secured through dialogue with NHSEI), additional GDE monies for Cumbria (£0.2m, total now £2.1m) and Cybersecurity (£0.8m). The forecast is further supported by capital receipts from the sale of Sharoe Green meaning that key programmes and objectives can now be met from within the overall funding envelope.

AnnualYTD

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MATTERS

ID Meeting Date Paper Status

2017/01 Jul-17 VerbalIncluded

2019/02-01 Jul-19 Verbal Included

2019/02-02 Jul-19 VerbalPartial

2019/02-03 Jul-19 VerbalPartial

2019/02-04 Jul-19 VerbalIncluded

2019/02-05 Jul-19 VerbalIncluded

2019/03-01 Jul-19 VerbalExcluded

2019/03-01 Jul-19 VerbalIncluded

2019/03-02 Jul-19 Verbal

Included

2019/03-03 Jul-19 Verbal

Excluded

2019/03-04 Oct-19 Verbal

Included

2019/03-05 Jan-20 Verbal

Excluded

2019/03-06 Feb-20 Verbal

Excluded

2019/03-07 Mar-20 VerbalIncluded

2019/03-08 Mar-20 VerbalExcluded

Meeting Date Date originally raisedStatus Figures included or not

Light Blue Comment updated

Dark Blue Comment unchanged

The capital receipts for Ridge Lea are excluded from forecasts. Though the disposal and associated capital receipt for Sharoe Green iscurrently included, profits have been excluded while the position is being finalised.

In February the Trusts has attracted external funding for cybersecurity of £0.8m to be spent 2019/20, this has been reflected in bothCapital Expenditure and Funding forecasts. This concerns a hosted IT service and the funding is on behalf of the system.

OAPs trajectories have been revised and shared with commissioners. These include assumptions on stranded patients. Costs forpatients identified as stranded are now being charge to CCGs. Income for this is not in the base position, but modelled as an upside.

The mental health contract for 19/20 is agreed and the developments are being introduced into the position as they commence

The Trust has been notified that there will be a further PSF distribution to the Trust in relation to 2018/19 of c£100k. This increase isincluded in forecasts but is excluded from control total calculations.

SubjectA number of disputes require resolution and have been submitted for mediation, these include West Lancs and Fylde Coast CCGs. TheTrust is awaiting responses from the commissioners. Though some debt remains in mediation the expected exposure/risk has beenaccounted for appropriately and has been discussed at FRG.

15% of PSF funding is contingent on the Lancashire and South Cumbria health system achieving it's control total. There is nowsignificant uncertainty around delivery of this given the issues being flagged in the health economy and it has been removed from theposition (£423k is currently assumed to be non-recoverable in the forecast). Whilst this impacts the Trusts financial position it doesnot impact on the Trusts performance against the control total.

2018/19 PSF monies were paid in July.

The Trust is conducting a full revaluation of its estate. This will result in changes to fixed asset values and their expected lives at theyear end. Asset values may increase or decrease as a result, impairments will impact the I&E position but will represent technicaladjustments and not impact underlying performance against plan and control total. Whilst changes to values and asset lives willimpact on 2020/21 capital charges it will not impact 2019/20.

The Trust has taken over the services of South Cumbria for mental health. £8.4m of assets transferred as part of this. Guidance fromNHSE/I is that this should be accounted for on an absorption basis. The Trust therefore has a (below the line) non-cash backed creditto income and expenditure of that amount , and a debit to fixed assets of that value on the balance sheet.

The Trust has been notified of a change to Treasury Discount rates which will impact on the valuation of the Trusts provisions. Theexact value has yet to crystallise but the Trust ahs received assurances from NHSEI that impact due the change in discount rate willnot be included in the calculation for PSF at year end. The Trust is effectively allowed to miss its control total by this amount (only).

Given the demands on the capital programme, and with particular regard to pressures re Avondale, A&E Liaison and Cumbria, we arein continued dialogue with NHSEI. Additional funding of c£1m was agreed for Avondale and is now reflected in forecasts.

The Trust is expected to incur costs in relation to its endeavours in dealing with COVID 19. The precise costs, and accounting and recharge arrangements are still being confirmed but expected to be reimbursed to the Trust.

It was reported in July that Julian Kelly (Chief Financial Officer for NHS England and NHS Improvement) wrote to Trusts about the overcommitment of NHS capital and a proposed reduction to capital spend of c20% across the NHS. This is now considered unlikely totake place and has been excluded from capital forecasts.

Increased scrutiny by HM Revenue and Customs on the NHS, and in particular those with arm’s length vehicles has led to a challengeby HMRC as to LCFTs VAT treatment on transactions with RRCS. With the assistance of its VAT advisors the Trust presented itsresponse and has now received an assessment for £722k from HMRC. The Trust has asked its VAT advisors to assist with an appealand help assess and quantify the risk involved.

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