report to: board of directors (public)...2 recommendation to the board the board of directors is...

Report to: Board of Directors (Public)

Paper number: 3.2

Report for: Information / Discussion

Date: 30 March 2017

Report author: Jo Fernandes, Performance & Regulation Compliance Manager

Report of: Andy Stopher, Acting Chief Operating Officer

FoI status:

Strategic priorities supported:

Cultural pillar supported:

Report can be made public

Early and Effective Intervention / Helping people to live well / Research and Innovation

We keep things simple

Title: Board Performance Report Q3 2016/17

Executive Summary

This report shows performance against national and locally agreed targets and identifies and analyses under-performance and report actions plans. This report provides assurance on Trust-wide performance and compliance matters during quarter three 2016/17.

The performance issues that have been most central to the divisions have been bed management and IAPT recovery rates and these are considered in detail in the main paper.

In relation to quality indicators the Commissioning for Quality and Innovation (CQUINs) results in Q3 are favourable though analysis suggests documentation concerns.

Complaints performance showed response times improved slightly during this quarter. The serious incidents (SIs) outstanding investigations are now completed and all SI's are on track from January 2017.

The Trust met all Single Outcome Framework NHS Improvement indicators with the exception of the IAPT recovery rate in quarter three.

2

Recommendation to the Board

The Board of Directors is requested to:

To RECEIVE and CONSIDER this report which provides assurance on the areas of quality and performance.

Risk Implications

There are no new risks arising from this report. All previously known risks appear on the trust’s risk register.

Finance Implications

The bed management capacity issues are generating significant cost in terms of private placements that are not in the plan.

Equality and Diversity Impact / Single Equalities Impact Assessment

N/A

Board Performance Report Quarter 3 – 2016/17

Quality Governance

2

1. CQUIN Achievement

The CQUINs performance in Q3 shows the Trust met most of the agreed milestones with the exception of Medicines and Obesity

Prevention indicators. CQUIN 4.1 performance improved compared with Q2 however, we were unable to reach the 80% target for this

quarter. Regarding the indicator on Obesity Prevention, the analysis suggest strong documentation on Malnutrition Universal Screening

Tool but a shortfall on the other parameters. For these reasons we were unable to meet Q3 threshold on this indicator. The Carenotes

Revamp project aims at strengthening end-user interface and improving staff documentation process on our electronic patient record

(EPR) system by streamlining forms currently available. We are expecting the improvements on our EPR system will assist our staff to

enhance and promote better documentation ensuring the benefits will be experienced in the upcoming months.

Indicator Q1 Q2 Q3

1.1b Introduction of staff health & wellbeing initiatives Plan submission N/A N/A

1.2 Development of an implementation plan and implementation of a healthy

food & drink offer Unify submission N/A N/A

1.3 Improving the uptake of flu vaccinations for frontline clinical staff N/A N/A N/A

2.1 Improving Physical Healthcare to reduce premature mortality in people

with SMI: Cardio Metabolic Assessment and treatment for patients with

Psychosis

N/A N/A N/A

2.2 Improving Physical Healthcare to reduce premature mortality in people

with SMI: Communication with GPs N/A N/A 94%

3 Effective identification and management of substance use / misuse Submission to

Commissioners

Update submitted

to Commissioners

Update submitted

to Commissioners

4.1 Medicines 63% 38% 56%

4.2 Obesity Prevention and Management in hospital settings N/A

Data submitted to

Commissioners 0%

4.3 Smoking cessation care plans 53% 54% N/A

5.1 Prevention - Domestic Violence (Staff training) N/A 62% 80%

5.2 Prevention - Domestic Violence (patients) N/A Compliant N/A

6 Quality of Crisis Planning 60% 73% 80%

3

2. Patient Experience

Complaints

The Trust listens to concerns and respects the views of our service users, families and carers to help us learn, constantly develop and improve our services. In Q3, 28 formal complaints were received, demonstrating a reduction in the number of reportable complaints received compared to the previous quarter.

At the beginning of Q3 the Advice and Complaints Service began to pilot a set of proposals which aims to improve the timeliness of our

responses to complaints. One aspect of these proposals is to encourage the resolution of concerns informally at team level whenever

possible. This is (at least in part) why this quarter has seen a decrease in the number of formal complaints, alongside an increase in the

number of informal recorded complaints.

Under these proposals all complaints now have a 25 day timescale, with the exception of complex complaints where timeframes will be

negotiated individually with complainants. Where timeframes cannot be met and there are valid reasons for this, extensions should be

negotiated with complainants. The divisions have been reminded of the importance of prompt allocation of investigators, as this has

previously been a major cause of delay.

The Trust recognises the importance of responding to complaints in a timely way. The compliance for Q3 has built upon the

improvements already noted in Q2. 93% of formal complaints were acknowledged within three working days, exceeding the Trust target

of 90%. 78% were completed within 25 working days (or the agreed timeframe).

0

10

20

30

40

Total Complaints and Enquiries

Formal (to agreed timeframe) Informal Enquiry

0

10

20

30

40

Acute CMH R&R SAMH SMS

Complaints by Division

Formal (to agreed timeframe) Informal

02468

1012

Complaint outcomes

Not Upheld Partially Upheld Upheld

4

Improving the timeliness of responses remains a priority for the Trust and if the pilot proposals continue to show encouraging results they will be incorporated into policy.

The key issues identified from these complaints relate to clinical treatment, staff attitude, ‘admissions, discharge and transfer issues’ and effectiveness of communication as key themes.

Learning from complaints this quarter was identified in relation to a variety of issues including best practice when handing over a case from one staff member to another in the iCope service. The contact telephone numbers for the crisis teams will be consolidated into one number to avoid confusion. A review of the duty service in the CDAT team will take place to ensure that it is always covered during business hours. The Trust will continue to lobby for additional funding to support a more rapid and comprehensive 'long term (medical) conditions' offering either as part of a specialist clinical health psychology service, or within the generic iCope service.

Communication issues tend to run as a thread through many complaints. This covers a wide variety of issues and concerns, and relates to both communication between staff and service users, and between staff and staff. Complaints include telephones not being answered, messages not being returned and poor quality handover. Additionally to immediate actions and improvements being taken by specific teams, the Advice and Complaints Team highlight concerns raised relating to communication with the staff whenever possible. For example, in the Advice and Complaints Team newsletters, at the Trust induction and at divisional clinical quality forums.

A particular area of focus for the Advice and Complaints team is to improve processes for

sharing of learning across the organisation. The Complaints Team are working with the

Serious Incidents team to develop their team newsletter to ensure it is presented in an

easily shareable bulletin format for discussion at team meetings. The first of these bulletins

has been circulated and discussed at forums across the Trust. ‘Learning newsflashes’ are

being introduced to alert staff to immediate concerns identified from the complaints

process.

The Complaints Team are also introducing improved processes to monitor satisfaction with

the complaints process which will be launched at the beginning of the new business year.

Compliments received by the Advice and Complaints team in quarter three frequently

related to the quality of care.

5

Family and Friends Test

The Patient Reported Experience Measure (PREM) on Family and Friends Test (FFT) response rates show a favourable position and

compared with 2015/16 our response rate has increased by more than 100%. The benefits from the FFT initiatives in the previous years

have established a healthy engagement across inpatient and community teams. During this quarter the FFT results indicated 89% of our

service users would recommend the Trust to others if they needed similar care or treatment.

Trust Responses Total Eligible % Recommended

Barnet, Enfield and Haringey NHS Trust 623 8488 83.0%

Camden and Islington NHS Foundation Trust 198 2403 90.9%

Central North West London NHS Foundation Trust 803 20367 89.5%

East London NHS Foundation Trust 740 15533 89.5%

North East NHS Foundation Trust 365 51639 89.0%

Oxleas NHS Foundation Trust 468 9329 89.1%

South London and Maudsley NHS Foundation Trust 997 33232 81.8%

South West London and St Georges NHS Trust 79 7856 64.6%

West London NHS Trust 133 7332 94.0%

We have benchmarked against other London Mental Health trusts and scores in October were above 90% recommendation, placing

C&I the second best in London.

London Mental Health trusts FFT results for October 2016 (Source: NHS England):

0

100

200

300

400

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

FFT Response rate

16/17 15/16

0%

20%

40%

60%

80%

100%

Ap

r-1

5

May

-15

Jun

-15

Jul-

15

Au

g-1

5

Sep

-15

Oct

-15

No

v-1

5

De

c-1

5

Jan

-16

Feb

-16

Mar

-16

Ap

r-1

6

May

-16

Jun

-16

Jul-

16

Au

g-1

6

Sep

-16

Oct

-16

No

v-1

6

De

c-1

6

% Recommended FFT

6

3. Patient Safety

Incident reporting is key to delivering both staff and patient safety. It enables the Trust to learn and prevent recurrence by improving or

changing practice when necessary. A total of 1442 incidents were reported as occurring in quarter three. This represents a 19% drop

when compared to the same quarter last year. While it is evident there has been a reduction in incident reporting rates, approximately

half this reduction can be accounted for by changes in practice over the past year. A significant change has been the removal of the

requirement to report unwitnessed community falls, which is evident in a 77% reduction in the numbers of this type of incident being

reported by the SAMH division alone. Other significant changes have occurred in the reporting requirements within the Estates &

Facilities department, related to the management of the ENGiE contract through incident reporting. This has led to a significant reduction

in the numbers of low level smoking related incidents, low level security incidents and parking violations being reported by security staff.

77% of incidents reported in Q3 resulted in no harm which demonstrates a healthy patient safety culture within the Trust. This is

supported by the most recent National Reporting and Learning Service (NRLS) report which was published in October 2016, and

demonstrates that the Trust’s incident reporting rate is above national average at 46.36 incidents per 1000 bed days, compared to

37.54 national median. The report states that “Organisations that report more incidents usually have a better and more effective

safety culture. You can't learn and improve if you don't know what the problems are”.

We continue to seek ways of improving the data that we capture from incidents and this quarter the governance team have focused their

engagement with SAMH services to promote improvements in the quality of incident reports relating to Deaths. This work corresponds

with the requirements of the Mortality Review Group which reviews and monitors all death incidents reported in the Trust.

TOP 5 most frequently reported incidents remain similar to previous quarters. Namely these are:

• Violence/ aggression & general security;

• Patient journey (admission/ transfer/ discharge);

• Self–harm;

• Missing from care (including AWOL);

• Death

There has been a decrease in the number of incidents reported in the Estates and Facilities and Environmental Issues category which

has moved out of the top 5 most frequently reported incidents in Q3. This decrease is primarily as a result of a change in reporting

procedures within the Estates and Facilities department which has removed the requirement for parking violations to be reported on

Datix as incidents. This change came into effect from August 2016.

7

Restraints

On-going work streams with the Positive Management of Violence and Aggression (PVMA) Lead and Practice Development Team around positive and proactive care have led to an improved culture of reporting restraint in the trust; this on-going work has also directly correlated with a sustained reduction in prone restraint across the trust. We expect this downward trend to continue with further Positive and Proactive initiatives such as Injection Technique Training. This training was rolled out this month and currently has 34 inpatient staff trained and competent with a further 20 to be completed in April. Coral Ward and Sapphire ward has been specifically target for on the ward training as these two wards experience the highest level of restraint due to the nature of their service.

The Positive and Caring Environments work evidences a slight decrease in prone restraint during the last two years. In comparison with last year’s figures we have seen a 6% decline in prone restraints, prone down restrains showed 3% drop and seclusion data shows 6% average reduction.

0

5

10

15

20

25

30

35

40

45

50

All Restraint Prone Restraint

8

Violence and Aggression

01020304050607080

Assault (NoWeapon) -

patient on staff

Verbal Threat -patient on staff

Assault (NoWeapon) -patient on

patient

Damage toproperty

Generalaggression (e.g

throwingobjects) - patient

on staff

Top 5 Violence & Aggression Sub-category Q3 16/17

0

50

100

150

200

250

300

350

400

450

Q4 1516 Q1 1617 Q2 1617 Q3 1617

Violence & Aggression Incidents

The monitoring of Violence and Aggression incidents has shown in Q3 there was a

decrease in the number of incidents reported. A more detailed data set for monthly

monitoring is being suggested to Positive and Proactive with a detailed monthly reported

being present on the new criteria being presented in March 2017. If agreed the wider

data set will consist of the following breakdown; Month on month comparison, Division,

Police involvement, Team, Exact Location, Time and Location, If weapons were used,

Severity, Smoking related.

Staff are still actively encouraged to report all incidents including verbal and

harassment to the police.

All incidents of concern to be taken to Police Surgery / Local Security Management

Specialist, and can be raised by either team manager or designated staff member to

highlight issues related to the abuse.

All physical and persistent or threatening verbal abuse to have a formal debrief with the victim by ward manager to ensure adequate

support has been provided and an action Plan developed with the staff member to ensure their safety on the ward.

73%

3% 2%

12%

8% 2%

Violence & Aggression Incidents by Division Q3 16/17

Acute CMH Corporate R&R SMAH SMS

9

Serious Incidents

From October to December 2016 all outstanding Serious Incidents (SI’s) that required investigation were completed. This has meant that

from January 2017 Serious Incident (SI) reports are now completed within deadline. This accounts for the increased number of SI reports

completed in this quarter. Twenty seven Level 1 serious incident investigations were completed. Sixteen were investigations following the

death of a service user, one for attempted murder and four for violence and aggression. Nine serious incidents occurred within the Acute

Division this included a fire, an incident of self-harm, a delay in admission, a safeguarding issue and two incidents involving violence and

aggression. There were four deaths that occurred within the SMS division that were investigated; two deaths occurred cross division one

with SMS and Acute and one with SMS and CMHT. Six deaths were investigated for R&R division and one death for the SAMS Division.

It is rare that an investigation will show a direct causal relationship between the issues identified and the incident. More often

investigations will uncover areas for service improvement even though this did not lead to the incident taking place. Recommendations are

then made for service improvement.

The Associate Divisional Director for Acute has developed a Learning Lessons Workshop for the Acute Division, with support from the

Risk and Patient Safety Manager. The forum has been running for the last four months and is where preliminary reviews and final

investigation reports into serious incidents are discussed and the learning shared. Other Datix incident reports and follow-up actions are

also reviewed and discussed by the group. All staff from the Acute division are invited to attend and the group clarify specific learning and

goals for service improvement that are then disseminated to team meetings and supervision forums by way of a bulletin. The

implementation of this learning is then reviewed in the next monthly meeting. It is intended that service users are invited to attend future

workshops and that the other divisions within Camden and Islington NHS Foundation Trust have the opportunity to use this framework.

In this quarter, five themes of learning have emerged from serious incidents:

Allocation of care coordination

Timely and appropriate allocation of care co-ordination was seen as something that could have been improved in several incidents

reported in this period. Evidence and experience has demonstrated the benefits of well co-ordinated care to those with mental health

problems, particularly those with the most complex and enduring needs, can require help with other aspects of their lives, e.g. housing,

finance, employment, education and physical health needs. It was noted that when care co-ordination was in place for service users that

the work had been diligent, thoughtful and ensured that the service users were able to access further support from other services when

needed. Considerable work is being undertaken in both Community and R&R divisions to improve the quality and timeliness of care

planning.

10

Risk Assessment and Support and Recovery Care Plans

A number of investigations completed in the quarter identified the need for an emphasis on the quality and efficiency of risk

assessments, and support and recovery care plans particularly with those with severe of enduring mental health needs or for those

with a history of physical aggression towards others. Staff need to ensure that risk assessments are reviewed and updated regularly

so they contain the most up to date information on presenting risks. Specifically a Patient Safety Alert has been released concerning

helium as a method of suicide. Clear guidelines on what this method of suicide is with the aim of increasing awareness to clinicians to

prevent this type of suicide method occurring in the future; it also included a review of the clinical risk assessment and management

policy. The trust now includes helium in the risk assessment training.

Staffing levels/resource

When analysing contributory factors to incidents a number of investigations involving 1:1 care noted that when staff were on sick leave

that insufficient arrangements had been put in place to ensure full continuity of care during this period. A recommendation was made

to review arrangements for handover during periods of leave for staff to ensure handover is sufficiently detailed and the risk profile and

need for review during absences is considered and agreed.

Training

A more comprehensive, proactive and robust system for monitoring mandatory training is required at ward and Trust level to ensure

staff are competent in managing presenting risks such as fires (fire-marshal training) and high risk behaviours (suicide, drugs and

alcohol). For example, staff within the Substance Misuse division should now receive yearly overdose awareness training and are in

the process of being trained to provide a Naloxone kit to service users which is for emergency use of heroin overdose and reversal of

respiratory depression.

Family Involvement

There were a number of incidents identified from investigations completed in the quarter where there was evidence that services had

been responsive to service user’s family during the treatment period and following the serious incident that had occurred. For

instance, the Psychotherapy Service maintained contact with a service user’s mother when she got in touch with services expressing

concern. One area for improvement however highlighted in a number of reports is that all divisions need to be diligent in obtaining

next of Kin (NOK) details, including mobile number, home address and email address if it is agreed by the respective service users. It

is important that it is documented when service users do not wish to provide NoK details.

11

Non-Clinical Bed Moves

Alongside other Trusts both in London and other parts of the country, C&I continues to experience significant pressures on the available bed base. The Trust’s policy is absolutely clear that when a patient needs an inpatient admission, they will get one. This sometimes means that people need to be moved between beds for non-clinical reasons. Data presented below shows that despite an occupancy of between 98-99% in 2016-17 the number of bed moves has not increase significantly from last year, in fact shows a downward positive trend compared with previous years.

We focus on ensuring that when these moves happen, they happen safely and effectively, with comprehensive handovers. We continue

to work to ensure these do not happen during the evening or night-time, that patients are not moved more than twice, and that moves

for non-clinical reasons only occur when absolutely necessary. The inpatient management team applies strict rules for all non-clinical

bed moves and manages these moves closely. This includes escalation processes and conference calls to ensure any non-clinical bed

moves are planned appropriately. During recent months, despite the increased bed pressure reflected in these figures, we are pleased

that following an increase in our bed base since the previous year, we have achieved several months of managing demand within our

own bed base, which means that we have not had to transfer patients into hospital beds provided by other organisations.

0

10

20

30

40

50

60

70

80

90

Q2 Q3 Q4 Q1 Q2 Q3 Q4 Q1 Q2 Q3

2014/15 2015/16 2016/17

Non-Clinical Bed Moves

12

Compliance with NHS Improvement Indicators

13

The NHS Improvement Single Oversight Framework (SOF) replaced the Monitor risk assessment framework from 1 October 2016. The

tables below show the Trust’s performance in quarter three for NHSI nationally mandated performance indicators.

Service Performance Target Target Q3

Performance

Care Programme Approach (CPA) service users receiving follow-up contact within seven days of discharge from

hospital 95% 96.0%

CPA service users receiving formal review in the last 12 months 95% 95.9%

Admissions to inpatient services had access to crisis resolution home treatment teams 95% 99.2%

People experiencing a first episode of psychosis treated with a NICE approved care package within two weeks of

referral 50% 96.1%

MHSDS: Identifier metrics 95% 97.4%

MHSDS: Priority metrics 85% 88.9%

0%

1%

2%

3%

4%

5%

6%

Q1 Q2 Q3 Q4 Q1 Q2 Q3

2015/16 2016/17

Delayed Transfer of Care Delays Transfers of Care (DToC)

Despite the DToC indicator is no longer included within the

regulator’s framework we will continue to monitor this activity.

This measure offers additional information on our bed based

activity and impact delays of transfer have on inpatient

operational capacity. There was a steady increase on DToC in

Q2 and Q3 where most clients were waiting for social care waits

evidencing the external environment pressures. In January DToC

stood at 2.2%.

14

Service Performance Target – Improving Access to Psychological Therapies (IAPT) Target Q3

Performance

Proportion of people completing treatment who move to recovery:

Camden

Islington

Kingston

50%

49.0%

49.8%

52.8%

People with common mental health conditions referred to the IAPT programme will be treated within 6 weeks of

referral:

Camden

Islington

Kingston

75%

82.4%

81.8%

94.9%

People with common mental health conditions referred to the IAPT programme will be treated within 18 weeks of

referral :

Camden

Islington

Kingston

95%

98.8%

99.1%

99.0%

IAPT Waiting Times and Recovery Rate

The IAPT time standards were met across the three sites. The Recovery rate target is included within the CCG Outcomes Framework

and NHS Digital produces official statistics for this measure. Camden’s performance is slightly behind target though action plans have

been developed with jointly agreed actions already in place for Camden CCG and Islington CCG.

The Trust has identified discrepancies between IAPT local data and NHS Digital published reports, underlying problems relate to coding,

data timing and inputting issues. We have looked at internal processes and data submissions are now directly from IAPTUs engine. The

ICT team is investigating digital discrepancies between the IAPT data warehouse system and IAPTUs engine to address the reporting

gap and reduce data quality concerns. At present the IAPTUs submissions offers reasonable assurance in terms of waiting times and

recovery rates data submission. This work focuses on a recovery trajectory across the three services ensuring the systems in place

maximise data quality at the point of submission to NHS Digital.

We note that other London Mental Health providers are experiencing discrepancies between IAPT local data and NHS Digital data,

evidence suggests a 5% differential gap

15

Performance Challenges

Appendix 1 detail the full performance framework for 2016/17. The Quality dashboard on appendix 2 provides assurance on the

quality of care by reporting information on key quality indicators. This section highlights some of the key issues from quarter two

relating to the performance framework.

Key performance overview - Bed Pressures

C&I has experienced considerable bed pressures since the last report. This has included an increase in the need for female PICU

beds as well as overspill of acute service users into the private sector. This unusual position is related to a number of factors: high

levels of demand ( at the top of our normal variance for a number of weeks in a row), slightly less capacity with discharges ranging

from 20-25 instead of the required 27 over the same period, higher than usual percentage of formal service users suggesting a rise

in the number of acutely unwell service users. This backing up in the system reached a nadir in the week starting March 12th with

over 20 people waiting for a bed. Rising by the Wednesday to 30. On the Thursday the Trust instigated it’s Gold emergency

process meaning that extra resources were focussed on the issue from across the divisions. This resulted in a considerable

increase in the discharge rate and the creation of a temporary new team of reablement staff and practice development nurses

focussing on the practicalities of supporting safe discharge. Within 15 hours the pending list had reduced to 12 people. All of whom

were reassessed as safe in their current provision. The formal Bed Management monthly meeting will review the episode and

lessons learned, with commissioners ,and implement the findings.

In Q3 the Trust performed strongly against most targets, in particular we met most NHS Improvement targets during this period.

The assessment and advice team are witnessing a rising demand and the new practice model is seeking to offset waiting lists

increase and reduce response times to our clients. The new model started in November and we are expecting the operational

impact to be reflected during Q4.

The performance on Urgent and Inpatient care was strong and it suggests an activity increase across both pathways. Bed

occupancy rate is high and we haven’t met the local target during this financial year. Community services are experiencing more

referrals and activity and the Early Intervention service shows a steady caseload increase since Q4 15/16. These factors have

contributed for not achieving some targets.

16

Appendix 1: Performance against KPIs agreed with commissioners

Ref CCG Outcome KPI Source Target Q4 1516 Q1 Q2 Q3 Narrative & actions Trend

Camden 98.50% 98% 99% 80.4%

Islington 98.40% 100% 99% 82.0%

Camden 31% 62% 36% 33.33%

Islington 21% 54% 57% 18.42%

Camden 5.45 7.1 5.1 3.16

Islington 4.6 11 1.8 5.79

Camden 10.2 9.9 12.0

Islington 16.4 15.1 13.6

Camden 20% 27% 24% 21%

Islington 23% 21% 17% 27%

Camden

Islington

Intervention

The waiting time for patients who are in scope of MH currencies

remains favourable and is in line with previous performance.

DNA rates are broadly stable across both teams. As the

number of assessment slots available is decreasing, minor

variations in DNA rates will appear inflated.

84%

1.2.1

1.2.2

B ActivityLocal

Baseline

Waiting time for information and advice only

Local Activity

DNA rates for clinics / appointments in

assessment teams

Percentage of assessments assessing for

substance misuse needs

Team performance has improved slightly on Q2.

1. Assessment services

1.1.1

1.1.2

1.1.4

Access and wait

Local Activity

90%

Baseline

Proportion of GP referrals accepted by

assessment teams

Percentage of service users offered a first

assessment within 21 calendar days by Mental

Health Assessment and Advice Team

The difference in days between face to face

contact and first MH care cluster assignment

period that took place in the reporting month, for

people in scope for MH currencies at the start or

end of the reporting period

Local

MHLDDS

1.1.3

A

A

A

The Assessment and Advice service continues to struggle with

high rates of referrals for a small resource. The teams manage

more than 650 pieces of work each month. 42% of the activity

does not originate from GPs. Instead a significant proportion

comprises police, local authority and safeguarding contacts.

In response to the demands and increased waiting lists the

service implemented a new model of practice. There is a

greater focus on triage with patients who have previously been

treated by the Trust being referred on to the last known team

(as clinically appropriate) for a

decision/assessment/management plan and advice and

consultation to GPs. This is to create capacity within the

service to assess patients who are new to the organisation. As

a result, the percentage of GP referrals accepted for

assessment has fallen. This does not mean that GPs are not

receiving an appropriate response to their clinical concerns;

they are receiving advice and information.

The revised model was implemented in November. The impact

on assessments was noted in December however this was

offset by poor performance against targets earlier in the quarter.

The model remains under review in response to confirmation

that PBMH will roll out across Islington in the new financial

year. This implementation will have a significant impact on the

Camden arm. A

NA

97.2%NALocalF 89.29%

17


Camden 189

150

(25%)

106

(9%)

75

(7%)

Islington 141

98

(27%)

62

(7%)

42

(4%)

Onward referrals: GP Local Activity 28 49 15 7

Onward referrals: IAPT Local Activity 13 32 13 3

Onward referrals: R&R Teams Local Activity 4 7 7 4

Onward referrals: PD Local Activity 8 8 3 3

Onward referrals: CDAT Local Activity 6 5 6 0

Onward referrals: Other Local Activity 71 99 65 13

Camden NA 62% 73% 63%

Islington NA 79% 87% 86%

Intervention

The change in the model described above means that fewer

patients are assessed within the service with a greater

proportion being triaged on to the last known team.

Discharge and

outcomes

H*

A Baseline

H*

Trust

ActivityLocal

Number and percentage of assessments

completed in assessment services out of total

referrals

1.3.1

1.3.2

Memory service: Percentage of service users

who receive diagnosis within twelve weeks of first

appointment

Local

1.2.3 H*

H*

Note this is onward referral post assessment by the AAT and

does not include redirected service users which have reduced

as above.

The internal target was met for Islington, Camden continues to

experience an increase volume of assessments which is

impacting their performance.

N/A

1. Assessment services

18


Camden 98.5% 98.5% 100% 98.2%

Islington 99.3% 100% 100% 99.5%

Camden 57% 64% 60% 68%

Islington 62% 53% 66% 60%

Camden 467 487 422 407

Islington 452 520 429 449

Camden 60.0% 28.0% 36.0% 44.0%

Islington 84.0% 32.0% 36.0% 64.0%

There number of CRT assessments overall has remained

consistent with last quarter (856 compared with 851). There

was a decrease in assessments in December which

corresponds to a decrease in referrals during this period.

2.1.1

A

H* Number of assessments completed by CRT

teams2.1.3

Access and wait

2. Urgent care services

2.1.2

Percentage of admissions gatekept by CRT

VSMR

95%

Urgent CRT referrals seen within four hours

LocalReferrals seen within one day - Crisis Resolution

Teams (CRT)

BaselineLocalA2.1.4

Activity

Overall performance for the Trust for Q3 remains high at 99.2%

and exceeds the target.

The response rate has remained fairly consistent over the year

with around a 64% rate for Camden teams and 62% in

Islington.

The CRTs have completed an audit of DNA for all assessments

during Jan-Mar 2016. One of the findings was that unnecessary

engagement work is taking resources away from responding

quickly to new assessments. The recommendations focus on

three key themes: Improving clarity of thresholds, improving the

process of taking referrals and improving CRT staff interaction

with referrers. Figures indicated a 15% DNA rate, 25% of

which were GP referrals. 63% of those who DNA did not

require crisis input and 47.2% received more than 3 attempts to

contact prior to closing the referral.

CRT leads have advised Islington & Camden Commissioners

that we aim to treat GP referrals consistently with other

referrals. CRT & PCBMH have a joint presentation planned for

GPs in March providing a platform to assure GPs their referrals

will be responded to by the appropriate service.

Baseline

Crisis teams have completed a manual audit of 50 GP referrals

received in Q3 - 25 in the Camden CRTs and 25 in the Islington

CRT.

In Camden, 44% (11/25) had first contact directly with clients

within four hours in Camden and 64% (16/25) in Islington. This

is an increased response rate from Q2. There was a decrease

in referrals in December which may account for the increased

response times.

In Camden, 52% (13/25) these referrals were contacted within

four hours via the GP organising the assessment while the

client was present in the surgery and 28%(7/25) in Islington.

In Camden, 60% (15/25) of those audited GP referrals led to

home treatment and 68% (17/25) in Islington.

In total, 72%(36/50) of clients were assessed within 24 hours.

Of those 28% (14/50) not assessed within 24 hours, 36% (5)

were due to clients requesting a delay, 36% (5) were resourcing

issues for the team, 21% (3) client unavailable and 7% (1) were

DNA.

CMonitor/

VSMR

19


Camden 238 222 201 218

Islington 268 284 227 276

Camden 1.04 1.00 1.04 1.04

Islington 1.06 1.01 1.04 1.04

Camden N/A

Islington N/A

Camden 10.8% 9.2% 13.0% 11.0%

Islington 10.1% 8.6% 6.9% 11.7%

2.3.2

Trust

A

Incidents of delay to admission

Local Activity 30 48 47 192

In Q3 a new system for capturing 4 hour waits for a Trust bed

has been implemented by the Bed Management Team. Of 295

admissions in the quarter, 192 (65%) waited over four hours for

a bed. Of these waits, 68 (35%) were at A&E, 43 (22%) at a

service user’s home and 23 (12%) and 20 (10%) were waiting

on an medical ward.

This is base line data. The aim is for using this data to support

on-going plans to improve patient flow.

The performance dropped slightly when compared with Q2,

approximately 80% of service users under CPA have a crisis

plan in place.

The metric for the ratio of treatment episodes to service users

suggest the boroughs delivered 1.04 home treatment episodes

per service user.

81.31%

YE 750 per team

2.3.1

Percentage of people with admission within 14

days first treatment appointment

Number of treatment episodes by CRT

Discharge and

outcomes

Activity

MHLDDS Activity

VSMR

Local BaselineC

2.2.2

Ratio treatment episodes: service users

Local

H*

H*

The CRTs continue to over perform against the VSMR target.

Islington team has surpassed the year end target and overall

performance stands at 787 number of treatment episodes by

CRT.

Intervention

C

% of people with a crisis plan in place

77.75%

2. Urgent care services

This indicator shows the percentage of admissions within two

weeks of a home treatment episode.

An audit of current reporting in Q3 has identified that Crisis

House admissions were included. Revised figures show 8.61%

for Camden CRT and 9.49% for Islington CRT in Q3. A

percentage of 9.11% required admission overall.

2.2.3

2.2.1

80.29%

20


Camden65% 98% 70% 89%

Islington59% 39% 62% 88%

3.1.2 Trust

C

ALOS Sapphire (assessment ward)

Local <10 days 12.1 13.6 14.5 12.59

ALOS on Sapphire significantly decreased compared to the

previous two quarters although it still remains above the 10 day

target. There were 71 discharges in the quarter with 36 staying

over 10 days. One of the main factors impacting length of stay

is for patients waiting for treatment beds.

3.2.1 Trust

D

Manual audit of uptake of activities on 3 wards in

quarter one

Local baseline N/A 45% 39% 38%

Amber, Opal and Laffan were audited. Their uptake for activities

in Q3 were 50% for Laffan, 41% for Opal and 32% for Amber.

Activity is offered to all service users unless clinically indicated

otherwise. This works within a model where some patients are

too unwell to participate and some are further in recovery and

spending time off the ward; expected uptake is therefore up to

50%.

OT Leads provided a presentation to CQRG which led to a

Commissioner visit to services. Feedback from C&I Director of

Nursing and the Commissioner was very positive.

Strategic direction for OT and Activity Workers has been

agreed at a senior level. This comprises building on the existing

resource to develop a specialist hub alongside recruiting OTs to

Band 6 positions across all inpatient wards. We aim to develop

a genuine MDT offer in inpatient services and to improve quality

of care through this.

Camden

Islington

3.2.3 Trust

E

Incidents of prone restraint

NEL KPI Activity 30 32 33 37

There were 37 incidents in the quarter (36% of all restraints)

involving 28 service users. Rosewood Unit had 11 (30%), Coral

had 8 (22%) and Laffan had 5 (13%). Of the 37, 73% (27) of

these incidents involved administration of Intra Muscular

medication.

IM Medication is currently administered in a prone position.

New training allows administration via the deltoid muscle which

does not require prone restraint. E-learning was rolled out in

December and it is being followed by practical sessions in

January 2017.

The Trust's Positive and Proactive Group continue to monitor

the use of prone restraint on the wards.

Camden 22 20 25 37

Islington 41 25 14 20

97.0%

3.2.2 Acute division occupancy

F

H*

C Local Activity

Local 90%-95%

Number of individuals staying >50 days on

treatment ward

3. Inpatient services

Access and wait

3.1.1 Percentage of service users with MUST

completed within 72 hours of admission

Local 80%

Intervention

In total there were 57 individuals staying longer than 50 days on

treatment wards in the quarter. This is an increase from 39 in

Q2.

Modern Matrons have been asked to refocus their day-to-day

attention on the proactive management of service users staying

over 30 days and early discharges particularly for services

users that could continue their care in the crisis team or in the

crisis houses.

Bed pressures and bed occupancy continued to be challenging

during the quarter. This data is currently reported from bed

management reports.

3.2.4

98.8% 99.1%

During this quarter both Islington and Camden wards exceeded

the target for completing MUST within 72 hours. In September

16, the division implemented a daily system to monitor the

completion of MUST for all new admissions and the

performance suggest the new method is functioning and offers

assurance.

98.4%

21


Intervention

3.2.5 Trust

E

Non-clinical transfers (i.e. moves between wards

for non-clinical reasons)

Local Activity 124 53 42 46

During Q3 there were 46 non-clinical bed moves. This

compares with 42 in Q2. The increase can be accounted for by

the need to create an all male capacity on Emerald, beds

closed due to D&V in the month and high occupancy when

leave and AWOL beds are used at short notice.

The inpatient management team apply strict rules for all non-

clinical bed moves and manage these moves closely. This

includes escalation processes and conference calls to ensure

any non-clinical bed moves are planned appropriately. The Bed

Management Group record all non-clinical bed moves within the

Trust.

Camden 27.4 25.9 26.7 30.9

Islington 26.4 26.8 23.7 21.9

Camden N/A 38.1 36.5 52.6

Islington N/A 39 31.0 39.4

Camden 4.2% 13.9% 9.2% 12.5%

Islington 9.3% 10.0% 8.7% 9.6%

Camden 18.3% 24.7% 23.0% 23.8%

Islington 19.2% 18.8% 19.1% 16.7%

Camden

Islington

Camden 92.0% 95.9% 95.2% 95.6%

Islington 98.0% 95.7% 95.0% 96.4%

3.3.11

3.3.9

3.3.10

Activity

<7.5%

CCG

Outcomes

C

DTOC - Total OBD in the period

DTOC - Percentage OBD in the period

3.3.1 ALOS Treatment wards (trimmed 3-50 days,

excluding leave)

C

ALOS Treatment wards UNTRIMMED

3.3.3 Emergency psychiatric re-admissions 28 days

Trust

Trust

3.3.6 DTOC Total discharge within the period

`

C

C

Trust

Trust

C

DTOC Total number new DTOC in the period

3.3.4

3.3.2

Emergency psychiatric re-admissions 90 days

CCG

Outcomes

Local

<6.2%

<28

<10%

Local

CCG

Outcomes

CCG

Outcomes

CCG

Outcomes

232

Proportion of clients on CPA followed up within

seven days of inpatient discharge

Monitor 95%

Number and percentage of service users on CTO

recalled within three months of CTO start. Local

C

C <28

There were 319 admissions from the acute wards of which 59

had a prior discharge preceding their admission by a maximum

of 90 days of those 59, 33 were within 28 days.

Overall readmission rate was 10.34% in 28 days and 18.50% in

90 days.

During Q3 there were 11 new DTOC, 13 discharges and 20

individual patients delayed. The most significant delays are for

residential and nursing home placements.

Of the 20 individuals delayed:

15 are on SAMH wards and 5 on adult wards

9 (45%) were waiting for residential home placements

8 (40%) were waiting for nursing home placements

2 (10%) were waiting for a care package

1 (5%) were waiting for public funding

DTOC are monitored on a regular basis at weekly Adult and

SAMH Bed Management Meetings.

C

DTOC - Total number of individuals in the period

Monitor

<548 OBD/Q

CCG

Outcomes6

13

8

<6avg/Q

Discharge &

outcomes

3. Inpatient services

3.3.5

Trust

3.3.7

3.3.8

C

C

0.61%

93

1.37%

181

(2.76%)

The number of CTOs completed in Q3 was 234. Of those, 3

were recalled within 90 days. 226

(1.33%)

224

(3.13%)

6

14

3.56%

498

11

8

17

The performance trustwide for Q3 is 95.97 % with two fails in

Islington and three in Camden. Details of these fails have been

passed on to the relevant service managers and teams.

Non-CPA 7 day follow up was 57.8% this is consistent with

Q2.

ALOS at Huntley Centre has increased this quarter and did not

meet the 28 day target.

As in 3.2.3 Modern Matrons have been asked to refocus their

day-to-day attention on service users staying over 30 days and

early discharges. A workshop considering 'Inpatient

Thresholds' is being planned.

Untrimmed ALOS at has increase at Huntley Centre and

Highgate Mental Health Centre wards over the quarter.

14

756

5.10%

11

13

20

234

(1.28%)

22


Camden 10.2 10.6 9.5 11.1

Islington 13.6 9.1 14.4 7

Camden 72.7% 94.2% 87.7% 92.6%

Islington 48.7% 52.8% 83.3% 100.0%

Camden

Islington

Camden

13.8% 14.1% 14.3% 13.8%

Islington

12.6% 17.6% 18.7% 18.3%

Camden 96.8% 95.9% 96.8% 96.6%

Islington 96.6% 97.7% 95.3% 95.0%

Camden73.0% 72.0% 58.0% 72.7%

Islington84.0% 78.0% 74.0% 82.1%

Camden227 266 261 276

Islington236 252 262 244

Camden

51.0%

Islington

44.3%

Camden 21 39 35 54

Islington 22 22 23 48

Camden

IslingtonNA

A

82

53.1%B

B

F Local

Monitor

VSMR

Reviews Stepped up: The number of cluster

review periods that ended in the reporting month

that stepped up into another care cluster, for


end of the reporting month

MHLDDS

95%

4.2.7

G Baseline

4. Community-based treatment services

4.1.3

4.1.2 Percentage of EIS service users receiving

treatment in under two weeks

A Monitor 50%

4.2.1

H*

New EI cases of psychosis serviced by the EI

teams

Percentage BME access to 'talking therapies'

Local

Percentage of admissions without a crisis plan

Total Early Intervention (EI) patients on EIS

caseload

% SU with substance use assessment and

subsequent action plan (where necessary)

Care Programme Approach (CPA) reviews within

one year

DNA rates for clinics / team appts

Local

C

Baseline

57.2%

125

48.6%

49.77%

14.94%

4.2.6

57.5%

4.2.4

4.2.5

4.2.2

4.2.3

Local

VSMR

YE Target: 90 FT,

plus 6 CAMHS

Baseline

Activity

Baseline

The average wait time is calculated from the referral date to the

first attended face to face contact. In Q3 the average wait time

from referral to first attended face to face contact was 9 days.

Wait times are kept to a minimum through discussion at daily

handover. In the time between referral and first face to face,

there is usually a series of contacts via telephone and letter.

This measure refers to the number of first episode clients

referred to Early Intervention Services. The number of clients

referred in Q3 was 51. of those, 49 were assessed and

allocated within 2 weeks.

The 2011 census indicates a white to non-white ratio of

66%:34% in Camden and 68%:32% in Islington. Current

reporting on this measure would suggest that the services

perform well however further work is required to address data

quality and consistent recording of ethnicity across services

and the population. It is possible that improved data quality will

result in the percentage or service users from BME groups on

the caseload falling as accurate entry of the white cohort

improves.

This figure reports DNA rates for teams providing services to

some of the most difficult to engage clients (AOT - CM, AOT -

ISL, EIS - CM, EIS - ISL & Focus). DNA rates in these services

are often high due to the nature of the clients' presentations.

The teams use varied strategies to promote engagement and

attendance, including prompts and reminders and engagement

of social and professional networks.

Performance continues to be above target.

Overall performance stands at 78%. Please note data quality of

individual borough figures is impacted by some teams working

across both boroughs.

The number of clients seen by the Early Intervention Service

continue to rise.

This is the provisional figure for Q3. The information team are

currently looking into the specification of this measure, it has

been identified that a proportion of service users included in this

figure are not known to the Trust, this impacts our performance

as these clients should be out of scope.

Above target. Reported figures include CAMHS. There has been

an exponential increase from Q2 to Q3.

60.9%

60

Access and wait

Intervention

4.1.1 Average wait time for referral to first appointment

with community outreach teams

Local Baseline

23


Camden6611 5712 5733

Islington6414 5363 5153

Camden

Islington

Camden

Islington

Camden

Islington

Camden

Islington

Camden

Islington

Camden

Islington

Camden

74.9% 77.9% 76.5% 75.50%

Islington

74.1% 70.8% 68.7% 66.40%

Camden4.8% 5.1% 5.3% 5.13%

Islington6.6% 5.7% 5.5% 5.29%

Camden

Islington

Camden

1230 146 56

Islington

664 104 44

Camden 0.56% 3.02% 7.06%

Islington0% 5.19% 4.92%

Intervention

188

MHLDDS Baseline

The % of cluster review periods ending in

discharges that had HONOS recordedG

160

H*

Of those people assigned to a care cluster, the

number that were on a care Programme

Approach (CPA)MHLDDS Baseline

H*

% of in scope patients that were assigned to a

cluster

Baseline

MHLDDS Baseline

H*

% of people within the cluster review period

4.3.5

G

Reviews Discharged: The number of cluster


that resulted in discharge (or no following

cluster), for people in scope for MH currencies at

the start or end of the reporting month MHLDDS Baseline

4.3.4

G

Reviews Stepped down: The number of cluster


that stepped down into another care cluster, for


end of the reporting month

MHLDDS Baseline

NA

NA

NA

4.2.12

4.2.9

4.2.13

100.0%

Percentage of service users in settled

accommodation

MHLDDS Baseline

MHLDDS

The above as a proportion of the number of

mental health care clusters assigned to people

in scope for MH currencies at the end of the

reporting period

H*

People with an open Adult MH care spell in NHS

funded adult specialist mental health services

are the end of the reporting month

People in scope for MH currencies at the end of

the reporting month

NA

NA

NA

As above

NA

NA

100%

95.2%

100.0%

30.4%

37.0%

6877

105.1%

85

NA

NA

7092

102.8%

97.3%

32.4%

33.2%

The data discrepancies between local and NHS Digital are

understood and we are confident the figures reported represent

our activity. NHS Digital uses a different formula and rule to

generate our position which at the moment ICT is unable to

replicate. However, ICT is currently looking at options to

emulate NHS Digital data logic to ensure the data gap is

narrowed in future reports.

4.3.1

H*

% of people assigned to a cluster that have had

a valid ICD10 diagnosis recorded

MHLDDS Baseline

MHLDDS

4.3.2

4.3.3

Percentage of service users in employment

MHLDDS 6%D

73%MHLDDSC

4.2.8

Baseline

H*

H*

4.2.14

4.2.11

4.2.10

96.6%

6861

103.5%

35.0%

31.2%

MHLDDS Baseline

4. Community-based treatment services

Discharge and

outcomes

24

5. IAPT


Camden4.00% 3.48% 3.58% 3.88%

Islington4.36% 3.70% 4.31% 3.90%

Camden76.22% 81.20% 80.65% 85.71%

Islington81.66% 75.11% 78.17% 87.20%

Camden98.65% 97.81% 98.62% 99.13%

Islington99.37% 99.57% 99.85% 99.48%

Camden 441 375 401

Islington 408 345 291

Camden 10.30% 10.00% 10.00% 8.00%

Islington 12.70% 10.90% 11.00% 10.00%

Camden49.37% 48.50% 46.9% 49.1%

Islington48.80% 51.49% 45.8% 49.6%

Camden

55.96% 52% 55.14% 67.47%

Islington

56.15% 56% 57.04% 58.13%

Recovery rates vary month on month however the overall

trajectory is upward with the service making positive progress

towards recovery. Both services report a higher average

recovery rate in 16/17 year to date when compared with the

average of the same period last year.

Discrepancies between locally reported recovery performance

B

5.1.2

A

A

Discharge and

outcomes

Percentage of service users moving into recovery

across both Camden and Islington services

Local 50%G

G

Intervention

5.3.2 Reduction in severity on standardised measures

including: PHQ-9, Work and Social Adjustment

Scale, & GAD-7

Local

Mean reductions -

to be baselined

Q1 & Q2

This measure can be considered in two ways: as a percentage

of the entire IAPT cohort or just those who are at caseness.

• Camden:

Percentage of people making clinically significant change as a

proportion of those at caseness: 67% (336/498)

Percentage of people who make clinically significant change as

a proportion of all completing treatment: 58% (336/578)

Access and wait

DNA rates (lower better)

Local Activity

The number of people who receive psychological

therapies as a proportion of the target of 15%

who have depression or anxietyNational Activity

Waiting times target: 75% within 6 weeks

Waiting times target: 95% within 18 weeks Monitor

95%

75%

A

No people with LTC / MUS accessing IAPT

servicesLocal ActivityF

5.3.1

5.1.3

5.1.1 Both services are on track to meet commissioned IAPT Access

Targets with Islington reporting a cumulative access percentage

of 11.9% against the national target of 11.25% and Camden

reporting 10.94% against a commissioned target of 7.35%

All waiting time targets have been met based on locally

reported data.

Coding issues in Islington noted in Q1 have been rectified as

demonstrated by the improved performance in Q2 and Q3

against the 6 week waiting time target.

DNAs are broadly stable but slightly improved in both services.

No comparable data is available for Q4.

Camden has a specific long-term conditions provision which

accounts for the stronger performance. Islington has submitted 5.2.1

25

Indicator Target

Ap

r-16

Ma

y-1

6

Ju

n-1

6

Ju

l-16

Au

g-1

6

Se

p-1

6

Oc

t-16

No

v-1

6

De

c-1

6

Infection Prevention Control (IPC)

Methicillin-resistant Staphylococcus

aureus (MRSA)

Zero cases 0 0 0 0 0 0 0 0 0

Infection Prevention Control (IPC)

Clostridium Difficle (C.Diff)

Zero cases 0 0 0 0 0 0 0 0 0

Mixed Sex Accommodation (MSA)

Breaches

Zero cases 0 0 0 0 0 0 0 0 0

Falls* 90% of patients receive

a falls assessment

within 4 hours of

admission

100%

100%

100% 100%

45.0%

(77%

no

time-

frame)

42.9%

(85%

no

time-

frame)

85.7%

(100%

no

time-

frame)

65.2%

(96%

no

time-

frame)

40.7%

100%

no

time-

frame)

Medication errors 9% medication errors 2.8% 2.8% 6.3% 5.6% 3.8% 5.6% 5.1% 7.2% 5.9%

FFT Responses 20% response rate 27.3% 19.5% 27.3% 29.9% 23.4% 20.8% 27.8% 40.5% 31.3%

FFT Scores* 80% of positive

responses 81.0% 90.0% 91.9% 92.2% 89.8% 93.8% 91.4% 85.0% 90.8%

IAPT Waiting Times (ISL)* 75% within 6 weeks 78.9% 70.4% 75.6% 81.1% 76.6% 77.5% 80.9% 80.8% 82.7%

IAPT Waiting Times (ISL)* 95% within 18 weeks 99.2% 100% 99.5% 100% 100% 99.6% 97.9% 98.9% 99.5%

IAPT Recovery rates (ISL)* 50% 57.3% 49.5% 46.6% 46.3% 48.0% 43.2% 48.8% 49.4% 50.6%

IAPT Waiting Times (CAM)* 75% within 6 weeks 82.2% 80.9% 80.5% 77.9% 83.9% 80.6% 79.7% 82.2% 81.6%

IAPT Waiting Times (CAM)* 95% within 18 weeks 98.3% 97.1% 97.9% 98.8% 97.5% 99.6% 98.7% 99.5% 97.7%

IAPT Recovery rates (CAM)* 50% 48.5% 50.3% 47.3% 45.2% 46.3% 49.0% 45.6% 50.3% 51.8%

Central Alerts System (CAS) 100% compliance 100% 100% 86.6% 100% 100% 100% 100% 100% 100%

Medicines and Healthcare Products

Regulatory Agency (MHRA)

Compliance

100% compliance 100% 100% 100% 100% 100% 100% 100% 100% 100%

*Denotes also reported quarterly to Contract Review Group (CRG) as part of Schedule 4C Key Performance Indicator Dashboard

Appendix 2: Quality Dashboard for CQRG - NHS Standard Contract 2016/17

GREEN On or above target AMBER Below target (0.1% to 4.9%) RED Below target (5% or more)

Above targets to be RAG rated in accordance with the KEY below:

26

Indicator Record of activity

Ap

r-16

Ma

y-1

6

Ju

n-1

6

Ju

l-16

Au

g-1

6

Se

p-1

6

Oc

t-16

No

v-1

6

De

c-1

6

Violence & Aggression Number of incidents of violence or

aggression against staff 48 73 45 44 66 62 52 46 35

Restraint numbers Number of cases of restraint 14 43 30 25 35 35 36 29 38

Prone restraint numbers Number of cases of prone

restraint 6 16 10 4 18 11 7 11 19

Mental Capacity Act (MCA)

Assessments

Number of MCA assessments 107 94 105 88 111 94 108 107 112

Deprivation of Liberties

(DoLs) Authorisations

Number of DOLs Authorisations 2 6 1 5 2 1 3 0 2

Pressure Ulcers Prevalence of Grade 2 pressure

ulcers 0 0 0 0 0 0 1 0 0


ulcers 1 0 0 0 0 1 1 0 0


ulcers 0 0 0 0 0 0 0 0 0

27

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