Trust Board Quality & Performance Report

May 2016

Date: 1st July 2016 Status: Final

Current Version: 1.0

Transparency : Public

Commissioned by: Clive Field, Director of Finance and Performance

Distribution & approvals history

Version Distributed to Date Action required / taken

0.1 Dawn Chamberlain COO 30/06/2016 Approval

1.0 Trust Board 01/07/2016 For scrutiny and approval

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Contents 1. Introduction 2

2. Executive Summary 3

3. APPENDIX 1: Monitor Performance 20 4. APPENDIX 2: Safe Domain 26 5. APPENDIX 3: Effective Domain 31 6. APPENDIX 4: Caring Domain 40 7. APPENDIX 5: Responsiveness 45 8. APPENDIX 6: Well Led 52 9. APPENDIX 7: Benchmarking 57 10. APPENDIX 8: Exception Reports 60 11. APPENDIX 9: Explanation of Data Quality Assurance Scores 79 12. APPENDIX 10: Summary of Assurance against Performance Indicators 83

13. APPENDIX 11: Waiting Times by Directorate/Team level 89

14. APPENDIX 12: CQC Intelligent Monitoring Report (Feb 2016) 92

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Introduction

The Quality and Performance Report provides a monthly position on the Trust’s integrated quality and performance metrics. The dashboard is set out in six domains: Monitor, and the five Care Quality Commission (CQC) domains of Safe, Effective, Caring, Responsive and Well Led. Narrative is provided on areas of good performance and concern, together with trend analysis and benchmarking where available. In order to provide assurance on data validation, a RAG-rated system of evidenced assurance against every metric can be found in appendix 10.

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Executive Summary

The Trust Quality and Performance Report reflects the five domains defined by the CQC together with the national Monitor targets – please refer to the Quality and Performance Report and associated Quality and Performance Dashboard in relation to this Executive Summary. References such as ‘M1’ refer to the measures on the Dashboard. Key risks – Quality, Finances and Reputation: Care Quality Commission (CQC) update The Trust received the CQC draft reports on 19th May 2016 and these were checked for factual accuracy and returned to CQC within their 2 week deadline. The final reports were published on the CQC website on 16th June 2016. The Trust received an overall rating of “requires improvement” and 7 out of 10 core services were rated as “good”. The Trust received no enforcement notices. The reports gave 5 new requirement notices (see Appendix 6 for further details) with 15 individual “must do’s” and 78 “should do’s”. The must do’s and should do’s are listed in the separate Board report accompanying the improvement plan, together with how these map onto the requirement notices. Improvement plans have been developed utilising staff engagement events and focused discussion at senior leadership conferences. Once the improvement plan has been approved by the Trust Board, it will be presented to the CQC and Trust stakeholders at the Quality Summit on 27th July 2016. One further requirement notice issued in April 2016 is still in place for mandatory and statutory training on Avalon which the Director of Nursing is in discussion with CQC with regards to the timescales for removing this notice. It should be highlighted that the Care Quality Commission inspectors noted in their report the strength of work in the Acute inpatients services, CAMHS community services and Learning Disability community services as well as many of the Specialist Services. The report reinforced that staff were caring and that the Trust is well-led with the skills required to make any changes needed. The Quality & Performance report will be developed over the coming months to align with the Trust plans to move into Service Line Management later this year. The proposed divisions are Acute & Urgent Care, Community Adults, CAMHS, Cognition & Frailty and National Services so reporting will need to reflect these service areas. This revised report will be available in draft form for the October Board and final version for the November Board. An overview of quality and performance measures in relation to community services is provided below.

Code Indicator Target 2015-16 Year to Date

2016-17 Actions to Improve

M1

Community follow up within

seven days post inpatient

discharge

95% 95.7% 95.6% Achieved

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M3 % Annual CPA

Review 95% 98.8% 98.8%

The Trust has implemented a new report at 9 months to assist teams to prevent CPA review cases from breaching at 12 months. The HSCIC have revised reporting in 2016/17 and now include cases that are validated late and reporting is based on snap shot of caseload. The Trust is compliant with revised HSCIC reporting and the old methodology has been removed from Board reporting

M7

Compliance with Monitor

Learning Disability Standards

100% 100% 100% Achieved in 2015/16 and performance being maintained in 2016/17.

M10

Referral to Treatment – Incomplete

pathway (waiting to commence treatment)

92% 94.6% 94.6% Achieved in 2015/16 and performance being maintained in 2016/17.

M12 Face to face gatekeeping

95% 99.0% 98.2% Achieved in 2015/16 and performance being maintained in 2016/17.

C14 % CPA patients

in settled accommodation

61% 84.4% 85.2% Achieved in 2015/16 and performance being maintained in 2016/17.

C15 % CPA

Patients in employment

7.1% 9.5% 9.5% Achieved in 2015/16 and performance being maintained in 2016/17.

C17 Collaborative Crisis Plan

90% - 82.9%

In 2015/16 the Trust reported compliance against crisis plans and achieved 90% compliance rate. The Trust however has archived the old crisis plan forms and has moved to reporting against collaborative crisis plans. Performance is on an upward trajectory here and is monitored at DPR. As new to Board an exception report will be provided (in the next month to update on progress).

R2

% adult CMHT clients assessed within 28 days

80% 79.0% 80.2%

There has been an overall improvement in performance against this metric since autumn 2015 following the introduction of a single point of access in Kingston and Richmond and tighter referral management protocols in Sutton. The Wandsworth commissioners have agreed to a single point of access model which is expected to commence in September 2016. YTD position is currently compliant with target.

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R3/R4

% Urgent referrals to be seen within seven days for adults and older adults

71% 15-16

90% 16-17

83.% 86.5%

WAA only

In 2015/16 the Trust met its compliance target for seeing clients within seven days of referral. The target for 16/17 is more challenging at 90% and adults and older people are now reported separately. The denominator is generally low on this indicator and in May 2016 five breach cases were reported; all breaches are subject to audit and are being investigated.

R8

% CAMHS clients seen within 8 weeks of referral

80% 72.7% 83.6% Achieved at year end (87.9% in March 2016) and into 16/17.

R9

% CAMHS Urgent referrals seen within 7 working days

95% 88.3% 93.0%

Two breaches reported in year so far. Denominator is generally low on this metric and is currently rated amber. In-month position for May 2016 was compliant.

Demand for Adult Acute beds (E4, E5 & M8) Over the last year there has been an unprecedented demand for acute mental health beds nationally and this has impacted London in particular. The demand for adult acute beds in 2015-16 and into 2016-17 has exceeded the Trust bed capacity and the Trust has had to admit clients to beds in other NHS Trusts and private hospitals. Since Ellis ward opened on the Springfield site in April 2016 there has been a reduction in the numbers clients admitted to East London Foundation Trust or private hospital; it is a little early to draw conclusions and the Trust continues to monitor the impact. Bed Occupancy including out of area use and excluding leave is presented in the chart below. The chart shows an increase in bed occupancy in November 2015 (week 23) following the introduction of recording of out of area placements on the Trust’s RiO clinical system. The chart shows occupancy rate at a consistent level above 105%.

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As the demand for beds exceed the total number of available beds there have been periods where adult acute clients have been placed in older people’s wards and this has been controlled through a clear clinical protocol. In 2016-17 there have been just two days used by adult acute clients on older people’s wards.

Length of Stay Increase and Variation across Acute Wards Over the last year the average length of stay has been increasing; and the rate of increase has slowed over the last three months.

The length of stay measures are difficult to interpret; very long stays are increasing and the number of discharges with a length of stay longer than 180 days has increased from 34 to 59 over the last 12 months.

The Trust continues to implement a number of improvements to the acute care pathway system and these are articulated separately in the Urgent Care Pathway Implementation Plan also included in the July Trust Board papers. The Trust has undertaken an audit to understand barriers to discharge which impact on length of stay. The audit considered current patients with a length of stay of over 180 days and patients discharged during 2015-16 following duration of stay that exceeded 350 days. The audits found that severity of need and resistance to treatment rather than difficulties in discharging to appropriate accommodation were the main factors contributing to the length of stay. Those clients with the longest length of stay tend to be resistant to treatment and this requires a long period of admission. These clients tend to have a diagnosis of schizophrenia/bipolar disorder and undergo numerous medication trials. In addition findings

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suggested that barriers to discharge once medically fit were not a factor in these cases. An audit on those patients with longest length of stay will be repeated on a quarterly basis as sample sizes were low. In addition the Trust has undertaking analysis on client with a LOS > 90 days. The chart below highlights and increase in average LOS for this cohort; the mean level increasing from 157 – 190 days. Discharge levels for the cohort have remained constant.

In recent months there has been an increase in the number of delayed transfer of care patients in the cohort between 90 and 180 days, particularly in Kingston and Richmond. At the time of writing there were thirty one delayed transfer of care and fifteen of those cases were Kingston (9) Richmond (6) clients. There is a current lack of residential placement provision in Kingston and Richmond which is contributing to increased delayed transfer of care levels. The Kingston and Richmond Directorate continues to work collaboratively with commissioners and local authority colleagues in order to facilitate appropriate placements for the delayed clients.

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In addition there has been an increase in the number of forensic patients who are unable to be discharged due to funding rather than medical reasons. The Trust is working with commissioners in order to progress.

The prevention of admission is a significant way of reducing bed pressures but effective discharge planning to reduce length of stay will arguably have a greater impact on demand/capacity flows. The Trust is working with Birch Health Foundation (a specialist consultancy in developing lean systems) with frontline staff from the Acute Care Pathway to develop quality improvements and innovative solutions based on Lean systems thinking; staff presented to Trust senior staff and Executive Directors the output of this work in June 2016. One of the biggest factors impacting on length of stay variation is the lack of standardised lean systems and processes across the Acute Care Pathway. The Trust commissioned Birch Foundation to provide accredited training to a group of frontline leaders across the acute care pathway to develop lean system solutions locally; the output of their work was presented to the Chief Operating Officer and Medical Director in June 2016 and this work will be taken forward through the Purposeful Admissions work-stream under the Urgent Care Programme Board – details are set out in the Urgent Care Pathway Implementation Plan also found within the July Trust Board papers. As part of the acute care pathway work supported by Birch a better understanding of variation in length of stay is being progressed through workshops with inpatient consultants; the first workshop was held in June 2016 in partnership with Birch Foundation and the second workshop is planned for September 2016. It has been agreed as an output from the first workshop that Length of Stay variation needs to be presented across a 2-year timeline to understand trends and compare across wards robustly. The Acute Inpatient Consultants will receive revised dashboards in August and final versions will be agreed in September; these will be presented as ‘run charts’ of data over time that will distinguish between predictable variation in performance and unexpected variation which may have been caused by unforeseen events. The reports will allow consultants to ‘drill-down’ into the data to view outliers in the data and address directly. The agreed metrics for the revised dashboards will include average length of stay, readmission rates, delayed transfers of care and patients under section. The reports will

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allow for the comparison of a single set of metrics across all wards as well as showing all indicators for a single ward. There is significant work being progressed across London in relation to understanding urgent care for mental health and to developing collaborative plans to mitigate the bed pressures; the Trust’s Chief Operating Officer and Medical Director are both in London-wide leadership roles in relation to this work. Recruitment of Nurses (W5) The London Human Resources Development Network highlight significant issues in recruiting to nursing posts in community services and general practice, mental health, rehabilitation, CAMHS, specialist children’s nursing, neonatal nursing, Emergency Nurse Practitioner’s & Advanced Nurse Practitioner’s in urgent emergency care. The retention rates of newly qualified RMNs is only 56% across the NHS. The Trust’s vacancy rate at the end of May 2016 was 19.6% however nursing vacancy levels remains at 25.7%. Additional issues linked to nursing recruitment are highlighted below.

Previously there had been an individual and not a coordinated recruitment drive across community teams often resulting in no appointments.

Selection criteria and thresholds from the hiring managers at times have been too restrictive. The Trust has introduced standardised testing to further assist with the selection process.

Trust overall turnover rate for nursing staff is (17.6%) which is above the Trust’s 15% target. The chart demonstrates the overall increase in nursing turnover with current mean having increased from 13.5% to 19% but there has been month on month reduction over last three months.

All directorates bar Wandsworth (12.4%) are above target. Specialist Services is experiencing the highest level of nursing turnover (25.6%).

The chart above highlights increase in nursing staff turnover in 2015/16 across all directorates. The Trust is conscious of the need to retain staff and recruitment and retention strategies are being developed and will be issued to Trust Board in July 2016. In addition a preceptorship programme for newly qualified nursing staff is in place in order for them to receive developmental support whilst starting their careers. The current London turnover threshold for nursing is 17.7%.

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The rise in turnover has increased this has led to an increase in the nursing vacancy rate which has slightly increased to 25.7%. As clinical services are not fully established there has been increased agency usage/spend although the Trust has moved to mitigate the financial risk by increasing the numbers of staff available via the staff bank. In April 2016 the Trust spent £464k on nursing agency which is 28k (6.4%) higher than the monthly average in 2015/16. The number of nurse starters and leavers by month are shown in the chart below. The Trust had higher numbers leaving over the last two years however the overall trend is downward. The successful recruitment of nurses has been on an upward trend and this is demonstrated over the last seven months where newly recruited nursing staff has mostly exceeded the leavers.

An analysis on nursing starters between January – mid May 2016 shows that the numbers of nursing start offers has risen to 88 an increase of 27 (44%) when compared to same period in 2015. This is highlighted in the chart below. This incorporates nursing staff recruited both inside and outside the nursing recruitment campaign.

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Since the start of the recruitment campaign in January 2016 the trust has made 149 offers of appointment to prospective candidates of which 89 (59.7%) have been recruited; 50 (33.5%) of the offered have commenced employment with the Trust and 10 (6.7%) of candidates have withdrawn from the process. It is expected that the numbers starting will further increase as the recruitment campaign progresses further into the year.

Nurse Role Offered Employment

Started Cleared with Start Dates

Booked

Pre-Employment

Checks

Withdrawn

Inpatient Bank Band 5

13 7 0 5 0

Inpatient substantive Band 5

98 29 27 38 4

CPN Band 6 31 12 9 6 5

HTT Band 6 5 2 2 1 1

Community Team Leader Band 7

2 1 1 0 0

Total 149 (+13) 50 (+23) 39 (+8) 50 (-20) 10 (+2)

Please note: as figures reported cumulatively (+/-) denotes change from previous month). Actions to Mitigate Vacancies

In-year the Trust introduced assessment centres to improve the candidate selection processes and so increase the number of nurses being recruited. The frequency of assessment centres has increased from one per month to three times per week.

The nursing recruitment process has been redesigned and the Trust now interview nurses within one week of applying for a job.

The recruitment team has also been given short term funding for two Band 4 HR Administrators.

In addition there is currently a nursing recruitment campaign for five hard-to-fill positions:

1. Inpatient Band 5 Registered Nurses 2. Bank Band 5 Registered Nurses 3. Home Treatment Teams Band 6 4. Community Nurse Practitioners Band 6 5. Community Team Leaders Band 7

The Human Resources Team have produced a currently developing the recruitment and retention strategy that was approved at EMC on 21/06/16 and will be discussed during July’s Board meeting with a schedule for implementation in quarter two 2016/17. The recruitment campaign is now live on various forms of social media and the Trust has high quality brochures and information in place. The time to recruit (measured from vacancy to unconditional offer) has fallen from 142 days to an average of 56 days. The average time to recruit across NHS Trusts participating in the London Streamline project is 50.6 days. The Trust has now signed up to participate in the

London HR Transformation programme which replaces the Streamline Project.

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The following actions relating to strategy development and recruitment fairs are highlighted below.

The Trust has developed a recruiting strategy for all other Trust staff groups. The strategy is scheduled to be launched in quarter 2, 2016/17

The Trust has developed a retention strategy to slow down the pace of leavers. The strategy is scheduled to be launched in quarter 2, 2016/17.

OMNI recruitment consultancy has completed their analysis of the Trust’s recruitment function and their recommendations have been incorporated into the Corporate Services Review and design of the future recruitment function.

Waiting Times Waiting times continue to be reduced across the Trust with just one wait of over 30 weeks outside of the CAMHS Neurodevelopment service – see appendix 11. All service users waiting over 18 weeks are regularly reviewed by the team manager and consultant. Personal contact is made with people waiting over 18 weeks and on occasions they are reprioritised based on need rather than by length of wait. Currently there are 185 people waiting over 18 weeks out of 3131 people waiting altogether. Of these 137 are in CAMHS with 135 in the CAMHS Neurodevelopment service. The CAMHS commissioners have confirmed that the Trust business case (highlighting that demand is far outstripping capacity) is being reviewed at their next meeting. Board Assurance Framework (W9) The Trust currently has one remaining high risk item

The bed pressures risk remains at risk score 16 – although there is positive assurance of the mitigations in place and the risk score will be reviewed at the next Trust Board review of the BAF Directorate News CAMHS A workshop for primary school age children was held on 17th June at Polka Theatre to explore emotional wellbeing and health. A similar event was undertaken for secondary school children previously. Specialist Services Wisteria received positive feedback from the Quality Network for Inpatient CAMHS following a recent inspection; the service is currently in the process of applying for accreditation. Performance Review Against Monitor Targets and the Five Domains An overview of performance against monitor and the five domain metrics is given below.

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The Trust is compliant in 46 out of 74 (62.2%) of in-month metrics and 46 out of 77 (59.7%) on YTD metrics. Forecast position 49 out of 77 (63.6%) on metrics. An explanation in regard to non-compliance is given below. Monitor: In May 2016 the Trust was compliant in all ten (100%) Monitor targets. Please see monitor section for further details. Safe Domain: In-month the Trust is meeting ten of the twelve (83.3%) safe domain metrics. Non-compliant metrics are: Serious Incidents (S3): In May 2016 ten serious incidents were recorded which is six

above target. The number of serious incidents does fluctuate but has increased in quarter 4 2015/16 and into 2016/17. Reported position can change post review by Serious Incident Governance Group.

Self-harm incidents (S6): May saw a further rise by 3 (4.7%) in reported self-harm incidents to 66 (26 above target) and remains rag rated red. Overall levels of harm in majority of cases remain low. A further exception report has been provided.

Effective Domain: Of the nine in-month metrics five are compliant (55.6%). The four non-compliant are: Cluster accuracy/Quality (E2): Performance has improved slightly to 83.5% however

performance remains considerably below target mainly due to high levels of expired and invalid clusters. In order to mitigate the Trust is targeting improvement in the cognitive impairment cluster 18 (cluster to be reviewed annually) and cluster 19 (six monthly review). Service users on cluster 19 may not be on CPA and therefore clinically may not require a 6 monthly review. There is a need to review and re-cluster to 18 where appropriate. Email cluster reminders to clinicians for cluster 18 cohort are to be issued at the ten month period in order to improve the position for annual review within this cluster. The PBR lead is targeting teams with the most invalid/out of date clusters and is providing additional advice support in those areas. There has been an increase in the number of service users not allocated to a cluster. It was hoped that the introduction of assessment teams would improve allocation to a cluster following initial assessment. The processes within the assessment teams will require review to understand what could be contributing to the drop in performance. A revised exception report for mental health tariff valid clusters has been provided.

HoNOS Assessed (Specialist Services Directorate only) (E3): The position deteriorated in May 2016 by (12.6%); and remains rag rated red. The denominator is generally low on this metric as it relates to a single directorate. The main issues for

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non-compliance was that the HoNOS not being completed or not being completed within the agreed seven day period (post first or second appointment). An audit on breach cases has been completed and the findings have been shared with PBR Lead and Specialist Services in order to review and implement practice guidance/support for recording HoNOS at assessment.,

Adult Acute length of stay (E4): Average length of stay has increased to 35.7 days

(rolling 12 month metric) and position appears to be plateauing with an increase of only 0.2% over the last two months; a revised exception report was provided to the April Trust Board. The Trust has reduced the number of short stay admissions (0-5 days) by (7.4%) over last two years and DTOC rates have continued to decrease. An audit analysis has highlighted that cases with longest adult acute length of stay tend to be treatment resistant rather than having accommodation barriers once medically fit. Further audits will be conducted quarterly to further evidence position. See earlier narrative within the Executive Summary.

Efficient Ward staffing (E9): Performance of hours used against plan did improve in May 2016; a (0.1%) decrease was reported. Position remains amber rag rating (0.5%) above 105% compliance threshold. Position does fluctuate month on month as increases in nursing hours is affected by the levels of observation and client acuity. A summary by ward is provided in the effective domain section of this report.

Caring Domain: Five of the fifteen (33.3%) rag rate metrics were compliant in May 2016. The ten non-compliant are: Number of incidents where restraints used C1): The number of physical

interventions recorded increased to 38 (just two above threshold) and has moved to amber rating. The level of harm recorded remains low 36 (94.7%) had no or low harm recorded. One case had medium harm while the other case had not recorded level of harm.

Prone Restraint (C2): The number of prone restraints recorded fell to 14 (a decrease by 6 on previous month) following review by the Physical Intervention Lead for the Trust. Mean reported level is 6.6 per month.

It should be noted that the Director of Nursing has established a Restrictive Practice group to be led by the Head of Nursing and one of the responsibilities of the group will be to review the physical intervention metrics currently reported to Board. The future physical intervention reporting will provide more detailed analysis incorporating rapid tranquilisation, physical intervention for nasal gastric feeding, prone restraint and seclusion. In addition all elements will be incorporated in a single monthly exception in order to provide assurance to Board on the use and practice of physical intervention. Reporting is expected to commence in October 2016.

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Number of seclusions used (C3): Twenty one episodes of seclusion were recorded in May 2016 – an exception report has been provided.

Complaints Responded to within 25 days: The Trust increased target to 95%

following agreements with commissioners. The Trust was 90% compliant in May. The Trust incurred four breaches and delays in response were attributable to the following; delay in receiving information from service (CAMHS); one case where Patient Experience Team where there was a delay in receipt of complaint from Service (Kingston and Richmond Directorate) and one case where draft response was issued for Executive sign off on the 25th day hence slight delay in issue as this was unable to be authorised within the limited time given.

Acknowledgements within three working days (c7): The Trust has moved to a

100% target for complaint’s acknowledgements; to reflect the target agreed with commissioners. In May 89% of complaints were responded to within three working days and delays in acknowledgment were attributable to a clinical service delay in notifying Patient Experience Team of a complaint and staff sickness in Patient Experience Team resulting in a delay in issue of one acknowledgment.

Real Time Feedback – Inpatient responses (C10): The number of real time feedback

response fell by 81 (13.5%) on previous and position is rag rated red with YTD position rated amber. Response levels are subject to month on month variation.

Real Time Feedback – General Satisfaction (C11): Inpatient general satisfaction level

did improved in May 2016 and is now RAG rated amber.

Real Time Feedback Reporting is under review post feedback from May’s extended EMC. Reporting in the next few months will move to a quarterly report on themes derived from feedback and also incorporate PALS, compliments and complaints. The first report to Board will be required at the end of quarter two.

Physical Health Assessments (C16): The Target has been amended to 98% to align

with the new commissioner’s schedule for 2016/17. In May the position was rag rated red at 91.7%. There is a need ensure systems for review in ward areas are robust as there is little room for any error. Clients unwilling/unable to consent to physical health assessment within the period need to be documented on the physical health assessment form. A revised exception report is included.

Collaborative Crisis Plan (C17): This is a new metric to Board and exception reporting

will commence in next month’s report. The Trust has moved to report on collaborative

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crisis plans as this is more reflective of clinical practice. The Trust is currently at 83% compliance against a 90% target for clients on CPA. Performance is on upward trajectory as shown in the following chart.

Carers Assessments (C19): The target has increased to 85% to align with the local commissioner’s contract schedule for 2016/17. The Trusts position is currently at 72.8% (12.2%) below the increased target. As the target has been increased by 25% for 2016/17 the Trust has set some target trajectories for the year which will increase each quarter; this is highlighted below and an exception report provides further detail.

The metric applies to boroughs where section 75 agreements with local authorities are in place. Currently this is Merton, Kingston and Richmond; however Richmond Section 75 agreement will terminate on the 30th June 2016. The Trust expects to see an upward trajectory on this metric over the coming months and a dashboard report will be made available to further assist services.

Responsiveness: Fourteen of the eighteen year to date (77.8%) rag rated metrics are compliant in May 2016. The four non-compliant are highlighted below.

% Urgent Referrals referred to adult secondary care assessed within seven days

(R4): In 2016/17 the target for urgent referrals being seen with seven days has increased to 90% for both adults and older people which are now reported separately. The current YTD position is rag rated red.

In May 32 out 37 (86.5%) of urgent referrals were seen within seven days. A summary of breach cases is provided in the Responsiveness section of the report.

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% Urgent CAMHS Referrals Seen Within 5 Working Days of Referral (R8): CAMHS services saw 22/23 (95.7%) urgent referrals within the five working day period; the one breach case was subsequently seen after nine days.

Absconded Escorted Leave (R11): The Trust is just 0.5 above threshold for this indicator and is rag rated amber. In May five absconds were recorded which is just one above threshold.

IAPT Recovery Rate (R14): IAPT recovery rate year to date is (47.7% which just 2.3%

below target). Position does fluctuate month on month as demonstrated in the chart below with Wandsworth IAPT exceeding target and Sutton Uplift being just below.

Well Led Domain: The Trust Board requested a further review on issues of non-compliance for the Well Led section. An update on the summary table is provided below

Indicator Code

Indicator Target 2015/16 Year to Date

16/17 Improvement Actions

W1

CQC Intelligent Monitoring - Elevated Risks

0 1 1

The Trust received an elevated risk from CQC following the National Audit of Schizophrenia where Trust monitoring of alcohol in-take was below average.

The Trust has implemented an action plan to address. Only the CQC can lift the Elevated Risk. Action plan to mitigate is in place,

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W2

CQC Intelligent Monitoring – Requirement Notices

0 5 6

The Trust was issued with five requirement notices following a Chief Inspector's Hospital Visit in May 2015. In May 2016 the CQC confirmed that the requirement notices has been lifted post the Chief Inspectors visit in March 2016. The additional requirement notice in relation to mandatory training requirements for Avalon remains. As alluded to in key risks section the CQC provided the Trust with formal feedback of its inspection in June 2016. Five new requirement notices were issued (which gives the Trust a total of six). Improvement plans to mitigate the requirements notices are being developed and progressed.

W3 % Sickness 4.60% 4.20% 4.5% Position compliant YTD – only one breach in target (February 2016) reported in last two years.

W4 Turnover Rate

15.00% 16.70% 16.2%

The Trust monitors reasons for leaving and encourages staff to complete an exit interview in order to understand the reasons behind staff leaving the organisation. The Trust is developing a retention strategy which is due to be launched in quarter 2 2016/17. A preceptorship programme for newly qualified nursing staff is in place in order to provide them with further support.

W5 Vacancy rate 12.40% 19.60% 19.4%

Nursing recruitment campaign has been initiated. Co-ordinated approach for recruitment i.e. nursing recruitment managed through Human Resources / assessment centres have commenced and are now run three times per week A new focus on Community vacancies has been launched. A recruitment strategy is due to be implemented in quarter 2 2016/17.

W6 Mandatory and

Statutory Training

95.00% 84.50%

85.7%

Position remains at 85.7% and an exception report will be required next month if there is no improvement. In order to improve mandatory training compliance the following actions have been implemented:- Additional classroom based courses providing a 25% increase in capacity for each course. Where there is not enough internal capacity to deliver training this will be outsourced i.e. Safeguarding Children Level 3 Training in 2016/17 is to be provided by external an provider.

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W7

Reports of Physical Violence

Against Staff

40.0 48.8

40.5

A new reducing restrictive practice working group has been formed chaired by the Deputy Director of Nursing. This working group will look to develop a restrictive practice dashboard, the quality governance arrangements will be clarified and the target is under review.

W8

Reports of Physical Violence

Against clients

30.0 35.6

51.5 As in indicator W7

W10

Financial Stability

Strategy and Risk (FSSR) – Calculated in

accordance with TDA rules.

2 4 2

The FSRR is in line with the plan. This is lower during the first half of the year because the budget is phased to expect small deficits initially during the year and this would be offset by surpluses after the second quarter.

W11

Earnings Before Interest Tax, Depreciation

and Amortisation

(EBITDA) -£m

1.8

14.7 (Target

Year end

14.4)

1.2

There is a £0.5m overspend after two months principally due to high agency costs and the underachievement of savings plans. The Trust has plans to address these issues and will be monitoring progress against these plans.

W12 Savings

100% Year end

(3% YTD)

64% 4%

Majority of saving planned for second half of the year; plans not sufficiently advanced as yet to provide assurance that the year-end position can be achieved.

W13 Capital. Spend as a % of plan

100% Year end (6%YTD)

62% 5%

The non-achievement in 2015-16 was due to exceptional non recurrent circumstances following a request from the DoH for the Trust to underspend against capital budgets. The Trust plans to spend the capital budget in 2016-17 and will monitor progress on a monthly basis.

W14 Cash - £m

13.6 Year End

17.4 YTD

18.4 (target 17.9)

18.7

Cash is in line with the plan. Cash will reduce by end of year majorly because of payments for capital expenditure and PDC.

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Appendix 1: MONITOR PERFORMANCE

The Trust is compliant with 10/10 (100%) of the Monitor targets both in- month and YTD. Seven Day Follow Up (M1): The Trust has been above the target for over two years.

Grant Thornton conducted an audit of the Trust’s reported performance in May 2015 and there were no method concerns raised.

% Annual CPA Review (HSCIC Monthly Snapshot): The HSCIC have now adopted a revised methodology for reporting CPA – based on snap shot of CPA caseload and the Trust is compliant with revised reporting position. Mean position over last two years is 98.8%

However there remains a number of patients who wait longer than 12 months to receive a review, in May there were 34 over CPA reviews and the numbers have been increasing each month since June 2015.

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The issue is routinely discussed at monthly Directorate Performance Review meetings. A summary of overdue CPA reviews in May 2016 is shown below.

Team CPA is overdue

Kingston & Richmond 8

Richmond CMHT TRiP 3

South Kingston CMHT 3

North Kingston CMHT 1

Lilacs 1

Sutton & Merton 14

Sutton and Cheam RST 7

Wandsworth MH Learning Disability Team 3

Merton MH Learning Disability 1

Carshalton & Wallington RST 1

Sutton and Merton Challenging Behaviour 1

Sutton MH Learning Disability Team 1

Specialist Services 0

Wandsworth 12

East Wandsworth CMHT 5

Central Wandsworth & West Battersea CMHT 2

Putney & Roehampton CMHT 1

Rose (Vine) 1

Wandsworth Complex Needs Service 1

Wandsworth Early Intervention 1

Ward Two (Old Bluebell) 1

Total 34

Learning Disabilities Monitor Standards (M7): The Trust is compliant against the

six monitor standards. Updates on the Learning disabilities standards are provided quarterly and the next up-date is scheduled for July’s report.

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Delayed Transfer of Care (DTOC) (M8): Although overall position remains compliant there has been an upward trend since February 2016 (see first chart). Mean DTOC rate is 3.1% however this has increased over the last seven months to 3.7%.

Trust patients who are resident in Kingston and Richmond local authority have a historically higher rate pf delay transfer of care. At the time of reporting three boroughs Kingston, Richmond and Sutton were above target. In Kingston and Richmond the main issue is a lack of suitable housing/residential care within those London boroughs.

The table below highlights the position reported in Week 10 2016/17. In week 10 the Trust had 34 clients reported as a delayed transfer of care; this is the highest number reported since weekly monitoring commenced in April 2015. The longest delays are subject to scrutiny at the weekly Executive Management Committee and the Chief Operating Officer provides senior management oversight on delayed transfer of care.

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The increase seen in May 16 is in part attributable to the Forensic service. There were five new cases added in May attributable to health funding issues. The management of delayed transfer of care in Specialist Services is being aligned with other Trust Directorates to ensure system reporting is assured and robust.

LA Number of

patients Total DTOC Days Longest DTOC New DTOCS

Kingston 9 223 2-55 2

Merton 3 319 45-181 0

Richmond 6 300 3-107 1

Sutton 4 140 10-62 0

Wandsworth 8 224 3-68 2

Associate LA 0 0 - 0

Other LA 4 72 3-39 2

Trust 34 1278 2 - 181 7

The Trust does work collaboratively with commissioners and local authority colleagues to ensure and delays are progressed and discharged efficiently but inevitable delays occurs be it a funding issue or via the location of suitable placement/accommodation.

Referral to Treatment (M10): The Trust is compliant against the incomplete pathway

target. Referral to treatment is reported a month in arrears so it is aligned to the submission of validated data to the Department of Health.

The Trust remains above target but there has been a decline in performance since January 2016. In May 2016 there were 185 breaches of which 135 (72.9%) relate to the CAMHS Neurodevelopment Team. In order to mitigate the Trust has recruited additional staff to the Neurodevelopment Team who are currently addressing the back log of breach cases. The Trust has also issued a paper to commissioners requesting service resource be enhanced.

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A summary of Trust’s waiters at the end of May 2016 is given below; the longest current waiter at the time of reporting was 46 weeks (see appendix 11 for a report on waiting times by clinical team).

Face to Face Gatekeeping (M13): All admissions were face to face gate kept in May

2016 and the Trust continues to remain well above the national target.

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APPENDIX 2: SAFE

The Trust is compliant in month on ten of the twelve (83.3%) safe domain metrics.

Incident Reporting (S1): There has been an overall increase in the reporting of incidents in the Trust since the successful implementation of electronic incident recording and adoption of a reporting culture. Performance remains comfortably above target.

Number of lower level Patient Safety incidents (S2): Patient Safety data is published every 6 months by the National Reporting Learning System (NRLS). The Trust aims to be within the Top 25% of Trust reporting which demonstrates a good patient safety culture and the Trust has set a monthly target of 325 PSI’s in order to achieve this. The last published data shows the Trust as an “average” reporter. The number of incidents varies each month and the Trust consistently remains above target.

Serious Incidents (S3): In May 2016 10 serious incidents were reported which is 5 (100%) increase on April 2016 and 4 above threshold. Of the 10 incidents reported on STEISS 4 were recorded as suspected suicide and three were unexpected deaths. The other incidents reported were a physical assault on a member of the public, an abscond and an attempted suicide.

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The reporting of deaths has increased, particularly in older peoples services, as a result of an increased awareness of when a death should be reported. The Medical Director chairs the mortality group mortality data is reviewed. This is also shared with commissioners. The Trust benchmarks well nationally on both the numbers reported and timely completion of investigation of serious incident reports. The Trust is in the lowest quartile for the number of serious incidents reported (averaging 14 per 100,000 bed days (exc leave) plus face to face contacts) where national average is 26. Timeliness for completion of investigation has achieved 100% and is the best in London. The Trust is highlighted in red (T08) and other London Mental Health Trusts are green. It should be noted that timeliness of serious incidents reporting has now moved to 60 days for all serious incidents.

(Chart source NHS benchmarking).

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Unexpected Deaths (S4): The Trust has quarterly Mortality Committees chaired by the Medical Director. The Committee receives quarterly reports including data on expected and unexpected deaths, homicide, suicide and attempted suicide. The Committee also commissions detailed reviews into themes arising e.g. physical health. The reporting includes information on community deaths of older people who may be in receipt of mental health services, cared for in a nursing or residential setting.

As numbers are small (2 in May) it is not possible to determine themes on this basis. Outcomes are reported to the quality Standards Assurance Committee when available.

Falls resulting in harm (S5): The indicator is based on the National NHS Safety Thermometer which is used to measure and reduce harm from caused by falls. It is a two year Quality Account target commencing in 2014-15 which aims to drive behavioural change among staff to improve the physical health of mental health service users on inpatient wards and put in place improvement programmes to respond to any harms or hazards identified. The Trust is required to complete quarterly audits of fall incidents that occurred in the previous quarter as part of a two year strategy to improve the monitoring and treatment received. Numbers of falls resulting in harms continues on downward trend and below the expected level. Level of harm remains low overall with eight of the ten incidents recorded as low and two with moderate harm. For every fall the risk assessment will be reviewed and falls assessment updated.

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Self-harm Inclusive of attempted suicide (s6): The Trust undertakes quarterly Mortality Committee meetings chaired by the Medical Director. The committee receives quarterly reports including data on expected and unexpected deaths, homicide, suicide and attempted suicide (serious self-harm). Learning events have been held during the course of the year and additional learning resources are being developed following staff feedback via Listening into Action. The Trust is in early stages of developing online training which will be accessible to staff be via video link and podcast. Additionally an intranet page is to be set up on InSite as a forum for staff to share their experiences; this will be available in the coming months.

All serious incident of self harm are reviewed by SIGG and a detailed Post Incident Review will be requested to include the level of intent, detailed follow up with the patient. The service concerned will also be requested to include details of previous self harm and the Quality Governance department will cross reference against reported incidents.

In May 2016 the number self-harm incidents increased to 66 and 62 (93.9%) of cases the level of harm on patient was recorded as low; three cases of moderate and one case of severe harm. It should be noted that the Trust promotes a reporting culture on incidents so an increase is not necessarily a bad thing. An updated exception report is provided.

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Medication errors (S7): In May 2016 two medication errors were reported and position is

below threshold in both cases level of harm recorded was low. The expected level of errors remains 4-5 per month.

Pressure Ulcers (S8): There was no pressure ulcers recorded in May 2016.

Number of Duty of Candour Breaches (S9): There were no duty of candour breaches

reported in May 2016.

Number of never events in month (S10): There have been no never events reported in May 2016.

Number of RIDDOR reports in month (S11): In May one RIDDOR incident was reported which is below threshold of two.

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APPENDIX 3: EFFECTIVE DOMAIN

The Trust is compliant in four of the nine (44.4%) effective domain metrics.

Cluster Accuracy and Quality (E1): Position improved slightly to 83.6%. The Trust has implemented changes in practice particular for organic clusters (18 and 19) clinical teams will now need to review suitably (in cluster 19) and re-cluster clients in (cluster 18) within ten months. A refreshed exception report has been provided.

HoNOS at Assessment (E2): This indicator only applies to Specialist Services.

Performance decreased in May by (12.6%) to (76.3%) and is rag rated red. An audit review has found that breach cases either did not have a HoNOS recorded at assessment or the HoNOS was recorded outside the 7 day timescale. The audit findings have been shared with Specialist Services and the Mental Health Tariff lead to ensure practice issues are progressed. An exception report was provided last month.

Average Length of stay and bed occupancy – adult acute (E4): The metric for length of stay has been amended to a rolling 12 month metric. The previous method of reporting was disproportionately affected by a small number of clients with a long length of stay. Average length of stay is currently RAG rated red and position remains at 35.7 days. An exception report was provided in February’s Board report.

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Bed occupancy (E5): Issues around bed management are discussed in the risk section of the executive summary.

Adult Acute Placements in other NHS/Non NHS Hospitals ) (E3): In 2016/17 there have

been twenty eight admissions to non-Trust beds nineteen admitted to Newham Centre for Mental Health and nine to Non NHS beds. At the time of writing the Trust had eight clients in non-Trusts beds five clients with East London Foundation Trust and three clients in private hospitals.

CQUIN & Quality Account (E6-E8):

CQUIN 2016/17

Indicator June 2016 Update

Staff Wellbeing – Wellbeing Initiatives

The introduction of health and wellbeing initiatives covering physical activity, mental health and improving access to physiotherapy for people with MSK issues. NB: This is a national indicator

Quarter 1 – Achieved The Health and Wellbeing Strategy was approved by EMC on 28th June 2016. The strategy to be submitted to the commissioners, as required, for the August CQRG

Staff Wellbeing – Healthy Eating

Part a

Providers will be expected achieve a step-change in the health of the food offered on their premises in 2016/17, including: a. The banning of price

promotions on sugary drinks and foods high in fat,

Quarter 1 – Achieved Facilities have provided the answers to the below 11 questions. 1. Name of franchise holder 2. Name of supplier or vendor(s) 3. Type of sales outlet (restaurant, café, vending,

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sugar and salt (HFSS)1. The majority of HFSS fall within the five product categories: pre-sugared breakfast cereals, soft drinks, confectionery, savoury snacks and fast food outlets;

b. The banning of

advertisement on NHS premises of sugary drinks and foods high in fat, sugar and salt (HFSS);

c. The banning of sugary

drinks and foods high in fat, sugar and salt (HFSS) from checkouts; and

d. Ensuring that healthy

options are available at any point including for those staff working night shifts.

Part b Providers will also be expected to submit national data collection returns by July based on existing contracts with food and drink suppliers. This will cover any contracts covering restaurants, cafés, shops, food trolleys and vending machines or any other outlet that serves food and drink. NB: This is a national indicator

shop/store, trolley service) 4. Start date of existing supplier contract 5. End date of existing supplier contract 6. Remaining length of contract (time to expiration) with external supplier(s) 7. Total contract value 8. Value of contract for the financial year 2015/16 9. Profit share agreements that are in addition to the contract value (percentage of profit that is received by the NHS Provider from the supplier) 10. Free text box: Contract break clauses 11. Volume of Sugar Sweetened Beverages sold Responses submitted by Trust CQUIN Lead, via UNIFY, on 29th June 2016.

Staff Wellbeing – Flu Vaccination

Achieving an uptake of flu vaccinations by frontline clinical staff of 75% NB: This is a national indicator

Quarter 1 – No Target for Q1.

Psychiatric Decision Unit (PDU)

Improving outcomes for people experiencing a mental health crisis by pilot of Psychiatric Decision Unit

Quarter 1 – On track to achieve Q1 target An Independent Patient Engagement Lead has been sourced with the assistance of the procurement team. Five venues have been booked for the 5 borough engagement

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programme for July 2016. Posters have been distributed to service user groups, care groups, PROSPER members, local charities, local Healthwatch and local Mental Health Champions.

Street Triage

Commission Street Triage for all five boroughs and develop sector-wide specification as part of the out-of-hours workstream.

Quarter 1 – Small risk of not achieving Q1 target Implementation plan for Merton has been completed and is in progress for Kingston. Internal Trust workshop held on the 27th June 2016. Operational Policy currently being produced by Jimmy Cangy. Recruitment is in process, Kingston currently waiting for Met Police to complete vetting process. Merton on track to implement street triage in Q1. Out-of-hours project group established, including operational leads, clinical, CQUIN and service user representation.

Crisis Café

Design and implementation of a minimum of two Recovery/crisis cafes procured from Third Sector Partner.

Quarter 1 – Achieved Project group established including Operational, Clinical, CQUIN, Contracting and Procurement Leads, and Service User Representation. Market Warming Event held on the 14th June 2016 at Springfield Hospital. It was well attended by Third Sector Organisations.

Physical Health – Cardio Metabolic Assessment (CMA)

To demonstrate Cardio metabolic Assessment and Treatment for Patients with Psychoses in the following areas:

a) Inpatient Wards

b) Early Intervention Psychosis Services

c) Community Mental

Health Services (Patients on CPA)

NB: This is a national indicator

Quarter 1 – Achieved A SRO, an inpatient clinical lead and an EIS clinical lead have all been identified. A community clinical lead still needs to be identified. Inpatient and EIS Physical Health Training is currently being offered to Health Care Assistants. Diabetes e-learning is available to all clinicians. Trust CQUIN lead attended ward managers development day and community nurses development day and provided information on Cardio Metabolic Assessment including its rationale, the aim of the CQUIN and how to record a complete assessment on RiO. The Physical Health Improvement form on Open RiO was developed and released in 2015. The form allows clinicians to record all CMA parameters. Guidance on how to complete the form was produced in Q4 2015/16 and is available on InSite. The National Audit of Schizophrenia Report on Open RiO has been configured and was released in May 2016. The Trust CQUIN Lead, the CMA Clinical Lead and the Information Management team have reviewed other

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methods of systematic feedback to supplement the National Audit of Schizophrenia Report. Completion of the Physical Health Improvement form on RiO can now be measured and performance will be provided to management. Community Services Identification and development of clear pathways for interventions and signposting for all cardio-metabolic risk factors required. Currently the Trust has a clear pathway for obesity. Physical health training plan for community services currently being developed. Progress report and training plan to be submitted to commissioners, as required, for the August CQRG.

Trust Quality Priorities 2016/17

Indicator June 2016

Coordinated Inpatient Discharge

This two year theme aims to improve the quality and coordination of discharge planning for inpatient service users.

This indicator aims to:

Ensure that best practice standards of discharge planning are applied across inpatient settings

Provide high quality and comprehensive information and support for service users leaving inpatient settings

Make best use of electronic systems to support discharge processes.

Quarter 1 – Achieved Discharge standards currently being updated by Trust CQUIN Lead and Acute Care Coordination Manager. ‘My shared pathway’ service user information has been developed by Secure Service Modern Matron, secure services OT and Hume Ward Manager. Task Management System Steering group established. Discharge Standards and ‘My shared pathway’ service user information to be submitted to commissioners, as required, for the August CQRG.

Adult Autism

Improving the identification of service users with mental health issues who have a diagnosis of autistic spectrum disorder within local

Quarter 1 – On track to achieve Q1 target Baseline audit on people identified with adult autism provided by Information

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mainstream services

Management and currently being analysed by Trust Learning Disabilities Lead and Trust CQUIN Lead. Adult Autism training plan in development. Audit report and training plan to be submitted to commissioners, as required, for August CQRG.

Improving Safety

It is essential that when treating and caring for people we do so in a safe environment, protecting them from avoidable harm. The Secretary of State for Health set out the ambition of halving avoidable harm in the NHS over the next three years, and saving 6,000 lives as a result. This is supported by the sign-up-to-safety campaign that aims to listen to patients, carers and staff, learn from what they say when things go wrong and take action to improve Intended Outcome

Reduce the rate of serious self-harm and violent serious incidents

Collaboratively develop materials, processes and initiatives to support the improvement of safety for service users and staff within the Trust.

Quarter 1 – On track to achieve Q1 target Project group to be established Baseline audit has been conducted measuring: Rate of serious self-harm Rate of Violence – Patient on Patient Rate of Violence – Patient on Staff Rate of Violence – Staff on Patient Baseline audit of sign up to safety to be conducted Audit report to be submitted to commissioners, as required, for August CQRG.

Specialist Services 2015/16

Indicator May 2016 Update

MH2 Recovery Colleges for Medium and Low Secure Patients

The establishment of co-developed and co-delivered programmes of education and training to complement other treatment approaches in adult secure services. This approach supports transformation and is central

Quarter 1 – On track to achieve Q1 target Action plan to be submitted to NHS England, as required, in July 2016.

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to driving recovery focused change across these services.

MH3 Reducing Restrictive Practices within Adult Low and Medium Secure Services

The development, implementation and evaluation of a framework for the reduction of restrictive practices within adult secure services, in order to improve service user experience whilst maintaining safe services. Services. This will include demonstrating recovery orientated practice in identifying, planning and achieving goals and outcomes with deaf mental health service users. As with other standardised packages this tool will also allow staff to assess and measure the effectiveness of the specialist services they deliver.

Quarter 1 – On track to achieve Q1 target Action plan to be submitted to NHS England, as required, in July 2016.

MH4 Improving CAMHS Care Pathway Journeys by Enhancing the Experience of Family/Carer

Implementation of good practice regarding the involvement of family and carers through a CAMHS journey, to improve longer term outcomes.

Quarter 1 – On track to achieve Q1 target Action plan to be submitted to NHS England, as required, in July 2016.

MH5 Benchmarking Deaf CA & Adult MH Services and Developing Outcome Performance Plans and Standards

Developing outcome benchmarking processes across all providers, followed by performance planning and standard setting. As appropriate, the networked implementation of this scheme should be separate for deaf Child and Adolescent mental health services and for deaf Adult mental health services. This CQUIN scheme is intended to cover the four community arms of the Child and Adolescent service, consisting of ten teams and Corner House, the inpatient unit.

Quarter 1 - On track to achieve Q1 target Specialist Services Business Manager to attend national conference. Draft set of Indicators to be submitted to NHS England, as required, in July 2016.

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This CQUIN is likewise intended to cover the Adult community services, consisting of six teams, three Adult inpatient acute admission services and three secure services.

Secure Service Transformation and Repatriation of London Secure Services

At any one time significant numbers of patients (adults and CAMHS) from London are admitted to specialised services outside London Region (Out of Area Admissions OOA) increasing the likelihood of fragmented care pathways, longer lengths of stay and lack of connection with local communities, families and services. The responsibility for meeting the costs of OOA admissions sits with the Region where the patient is placed so increasing the financial burden on that Region. Although London imports OOA from other regions and meets the costs of this activity, this is outweighed by the volume of patients London exports. In 2015-16 a financial reconciliation across all specialised mental health activity showed that London’s OOA activity value exceeded its imported OOA activity value by £6.5m.

Quarter 1 – On track to achieve Q1 target

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Efficient Ward Staffing/Safe Staffing (E9): Actual hours used decreased to 105.5% in May 2016 – a decrease of (0.1%) on the previous month. Position remains rag rated amber just (0.5%) above green rag rated threshold.

Ward Planned Hours

Actual Hours

%

Halswell Ward 3309 4601 139.0%

Wisteria (EDS Inpatient CAMHS)

2858.2 3681.2 128.8%

Turner Ward 3775.8 4650.8 123.2%

Arc - Aquarius Ward 3768.2 4494.3 119.3%

Ruby Ward (Seymour) 3413.5 4028.2 118.0%

BlueBell (Old Church) 3022.5 3507.3 116.0%

EDS National Service Inpatient

4390.5 4808.6 109.5%

Lilacs Ward 3641 3812.5 104.7%

Crocus Ward 3599.4 3729.8 103.6%

Ward 3 3690.5 3747.1 101.5%

Hume Ward 3285.5 3285.5 100.0%

Ward 2 Acute 3547.2 3540 99.8%

Phoenix Ward 3095.5 3073.5 99.3%

Azaleas Ward 3315.5 3267.1 98.5%

OCD/BDD NCG Inpatient & Outpatients

2758.6 2706.6 98.1%

Deaf Child Inpatient Corner Hse

1346.5 1311.3 97.4%

Ward 1 (13 Bed) PICU 6531.1 6310.4 96.6%

Laurel Ward 3433.7 3239.5 94.3%

Rose Ward 3666.7 3409.5 93.0%

Lavender Ward 3677.2 3404 92.6%

Jupiter Ward 3696.7 3294.3 89.1%

All Wards 73822.8 77902.5 105.5%

Over performance against nursing hours is attributable to client acuity and increased levels of observation. All Trust wards were safely staffed in May 2016.

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APPENDIX 4: CARING DOMAIN

In May 2016 the Trust was compliant against five out of the fifteen (33.3%) caring metrics.

Use of Physical Intervention – (c1): Individual categories of physical interventions will be

reported separately from September 2016 (including rapid tranquilisation, prone restraint, naso-gastric feeding and seclusion). A monthly exception report will be provided incorporating all physical intervention metrics in order to provide the Board with a more informed position on physical interventions and to provide assurance on practice.

Prone restraint (C2): Fourteen prone restraints were reported in May 2016 which is six

fewer than previous. Target of zero tolerance is under is review as it is not reflective of clinical practice. As alluded to in the above physical intervention metrics will be reported separately in Board in to provide assurance on physical intervention levels and clinical practice. The Trust has a zero target for prone restraint. The revised definition provided by the National Reporting Learning Service is that incidents of restraint that involve a service user being placed face down or chest down for any period (even if briefly prior to being turned over) should be defined as prone restraint. Similarly, if a service user falls or places themselves in a face down or chest down position during a restrictive intervention, this should be defined as a prone restraint. All prone restraints are reviewed and followed up by the Proactive Physical Intervention Lead.

Seclusions use (C3): Eighteen incidents of seclusion were recorded in May 2016; position remains rag rated red an exception report is provided.

Safe Staffing (S12): No wards were unsafely staffed in May 2016.

Complaints responded to within 25 days (C6): Target for Complaints has increased to

95% compliance for 2016/17. Position improved by (13%) in May up to 90% and is now rag rated amber.

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Complaints acknowledged within 3 days (C7): In May 89% of complaints were acknowledged within 3 working days this has improved by (11%) on previous month. The four delays in response were attributable to the Patient Experience team not being notified promptly of the complainant by the clinical service, Patient Experience had to ascertain name of the compliant as it wasn’t clear from initial correspondence and two cases were attributable to staff sickness within the patient experience team.

Compliments (C8): 192 compliments were received in May 2016 position remains comfortably above target.

Number of PALS enquiries (C9): There were 30 concerns received in May 2016, an

increase of twelve on previous month. Position remains above target; 97% were resolved within five working days.

Real Time Feedback – Responses (C10-C12): Responses and General Satisfaction Score Inpatients: In May the number of responses decreased by 30 (9.6%) to 518 which is below target.

Inpatient satisfaction average satisfaction score increased to 57 which is below target but now rag rated amber.

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Community satisfaction score year in May was 85 and position remains compliant. From September RTF metrics will no longer be reported at Board; themed analysis from real time feedback, complaints PALS and compliments will form a quarterly themed report which will be added to Board as a new appendix.

The Patient Friends and Family Test (FFT) (C13) is a National Requirement for mental health Trusts since January 2015 and is collected at discharge on inpatient wards and CPA review or Discharge in the Community. In May 98 responses were received.

Physical Health Assessments (C16): PHA recording within 48 hours decreased by 4% on

last month to (91.7%). Position is now rag rated red and an exception report has been provided,

% CPA clients with a Collaborative Crisis plan recorded: The Trust has changed the metric on crisis planning to the reporting of collaborative crisis plans for clients on CPA. The change in reporting was required in order to align with current clinical practice; the previous methodology was aligned to recording of old crisis plans which have now been archived in the clinical record. The performance is on an upward trajectory and is monitored monthly at Directorate Performance Review; an exception will be provided in next month’s report to further inform on position.

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Safeguarding Adults (C18): In May 2016 there were 72 safeguarding alerts reported.

% of Carers of Clients on CPA who have been offered a carers assessment (C19): For 2016/17 a new target has been agreed with Commissioners of (85%). The Trust is currently at 72.8% and will look to improve position in the coming months. An exception report has been provided.

Patient – Led Assessments of the Care Environment: The official assessments were

undertaken between February and May 2015. The dates for each site are allocated by the Health and Social Care Information Centre (HSCIC). The CQC are advised of our results and may use them as a tool to target areas when they do their own inspections. In addition Facilities Management also undertake an internal PLACE like assessments to ensure there is continual monitoring of the Trust’s environment throughout the year.

PLACE assessment findings and action plans are fed back to the ward to progress and ensure completion. There is funding from Capital Projects for larger works that are identified during the assessments.

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In terms of benchmarks the Trust is above the national and London average for cleanliness and privacy, dignity and well-being. However the scores for food and condition, appearance and maintenance are below both the national and London average.

Dementia is a new category and scores the environment on suitability for patients with dementia; this includes decoration, signage, flooring type. Trust benchmarks above national and London average here.

Dementia %

2014 2015 2014 2015 2014 2015 2014 2015 2015

SWLSTG 98.41 97.41 91.8 86.52 87.72 92.37 88.31 88.36 82.83

National Average 97.25 97.57 88.79 88.49 87.73 86.03 91.97 90.11 74.51

London Mental

Health Trust

average score

NA 97.09 NA 89.45 NA 90.43 NA 89.09 81.47

Trust

Condition, Appearance,

Maintenance %Cleanliness % Food %

Privacy, Dignity,

Wellbeing %

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RERAPPENDIX 5: RESPONSIVENESS

The Trust is compliant in fourteen out of eighteen (77.8%) year to date responsiveness domain metrics. Year to date is reported as the contract metrics are not reported in an in month format.

Zero Tolerance for 52 Week Breach (R1): No breaches were reported in April 2016

(reported month in arrears).

Patients Assessed within 28 Days (R2 & R3):

Access waits to adult CMHT’s have improved over recent months and remain above target. In Kingston and Richmond a single point of access for referrals was implemented in November 2015 and this significantly improved access times. In Wandsworth position remains under target and audit findings for May 2016 have shown inconsistency in recording on the clinical system which needs to be addressed. In addition referral rates in Wandsworth have increased and this has impacted on access waiting times. The development of a single point of access in Wandsworth has been approved by commissioners and Wandsworth Management are recruiting a Project Manager to co-ordinate the service development and roll out. The service is scheduled to commence in September 2016 and is expected to reduce waiting times. In Merton position was under target for the first time since January 2015 as a result of staff sickness and an increase in referrals.

For Older people the target has increased to 80% for 2016/17. Currently all boroughs except Kingston meet the target.

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CMHT Type CCG Target YTD May 2016

Adult CMHT

Adult CMHT Target 80.7% 80.8%

Kingston

80%

88.5% 94.0%

Merton 80.5% 75.9%

Richmond 89.5% 88.4%

Sutton 85.7% 88.9%

Wandsworth 72.8% 72.5%

Older People (inc CMHT and Memory Assessment)

All OP Target 86.2% 90.2%

Kingston

80%

71.8% 76.9%

Merton 85.9% 97.0%

Richmond 86.7% 89.2%

Sutton 94.2% 97.9%

Wandsworth 92.2% 95.6%

% Adult Urgent Referrals within 7 Days (r4): The target for 2016/17 has been increased

to 90%. The Trust position in May 2016/17 was 86.5% where 32/37 clients were seen within seven days. A summary on the breach cases is below. There is a need ensure appointments are booked and outcomed.

Client CCG Team Referred to Breach Reason

Client 1

Wandsworth

East Wandsworth

Appointment logged as urgent appointment but notes indicate that on screen appointment should have been booked as routine.

Client 2 Team attempted to contact within 7 days – notes indicate client subsequently seen as a routine appointment

Client 3 Two attempts to contact within 7 days – seen on 8th day.

Client 4 Duty team tried to contact client within 7 days. Client not engaging and there were concerns for well-being which led to subsequent admission under MHA.

Client 5 Central Wandsworth West Battersea

Client DNA’d first appointment and moved out of area – discharged post discussion with GP.

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Local Contract Performance (R5): Cost and volume plan has yet to be agreed with commissioners.

NHS England Contract (R6): Specialist services are within 5% threshold for inpatient

services.

% CAMHS Non-Urgent referrals seen within 8 weeks (R7): In May the Trust improved performance by (1.6%) on previous month and continues to meet 80% target in all boroughs. A summary of May’s performance is provided below.

CCG Number seen within 8 weeks

Number Seen %

Kingston 21 24 87.5%

Richmond 25 27 92.6%

Sutton 30 31 96.8%

Merton 15 18 83.3%

Wandsworth 16 19 84.2%

Other 4 4 100.0%

Total 111 123 90.2%

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Urgent CAMHS Referrals (R8): Twenty two out of out of twenty three urgent referrals (95.7%) referrals were seen within the required five working day and position is now compliant. The one breach case occurred with the Wandsworth CAMHS service and attempts to engage within the period were made. The client was subsequently seen on the 9th working day.

EIS Clients treated within two weeks of referral (R9): The commencement of treatment for new EIS clients remains above target at 73%. Mean performance is currently at 64%.

Abscond - from escorted leave (R10): Five absconds from escorted leave were recorded in May 2016 and position is now RAFG rated amber.

Abscond - failure to return from leave (R11): There was one incident recorded of failure to return from leave reported in may; which mirrors last months position and remains compliant.

Absconded from the ward (R12): There were two reported abscond from ward in May 2016. Position remains complaint.

DNA Rate all services (R13): Position remains compliant.

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Improved Access to Psychological Therapies Metrics (IAPT)

Access (R15): In May 2016 both Sutton Uplift and Wandsworth IAPT met their population access requirements.

IAPT Service Target YTD

Numbers entered

Treatment YTD

Population Target

% Forecast Population Entering

Treatment

Sutton Uplift 564

(282 per month) 623

(282 per month) 15% 16.6%

Wandsworth 924

(462 per month) 1149

(472 per month) 12.6% 15.7%

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Recovery (R14): In 2016/17 the national target is for (50%) of IAPT clients to reach recovery by the end of their treatment. IAPT services ideally should treat less complex clients, typically clients with a mental health cluster between (1-4). Recovery rate does fluctuate month on month either above or below target (see chart).

A breakdown of performance in May is given below; Sutton clients in the cluster 5-7 cohort are now assessed and treated within the recovery support team model. Wandsworth IAPT continues to work with more complex clients that have a cluster of 5 or above.

Service Cluster May 2016 Target

Sutton Uplift 1-4 48.9% (n=174)

50%

Wandsworth IAPT

All 51.6% (n=223)

1-4 56.1% (n=187)

5+ 0.0% (n=5)

No cluster 44.1% (n=31)

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IAPT Referral to Treatment Waiting Times: (May 2016) (R15-R16)

Service Sutton IAPT Wandsworth IAPT

% Seen within 6 weeks 96.3% 99.5%

Target 75% 75%

% Seen within 18 weeks 97.5% 99.2%

Target 95% 95%

New waiting time targets for IAPT services have been implemented in 2015/16. The measures relate to clients that have completed their treatment and such clients must have had at least two treatment appointments within the IAPT service. Both Trust IAPT services were compliant in month and also in year.

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APPENDIX 6: WELL LED

The Trust is compliant in four out of thirteen (30.8%) year to date well led metrics.

Care Quality Commission Intelligent Monitoring – Number of elevated Risks (W1): Intelligent monitoring replaced the Care Quality Risk Profile in November 2014. The Trust has been issued with its first elevated risk. The elevated risk relates to the Trust Performance in the second round of the National Audit of Schizophrenia. The audit reported that the Trust performance for monitoring alcohol intake was considerably lower than the national average. Plans to mitigate are in place (see April 2015 exception report).

Care Quality Commission Requirement Notice (W2): The 5 requirement notices issued

with the inspection reports on 16th June 2016 are:- 1. Regulation 13 HSCA (RA) Regulations 2014 Safeguarding service users from abuse and improper treatment Forensic inpatient wards Service users were not protected from abuse and improper treatment because the provider operated restrictive practice with the use of time management practices, which had not been recognised as seclusion practices. Patients subject to these practices did not meet the safeguards set out in the MHA Code of Practice. Child and adolescent mental health wards Service users were not protected from abuse and improper treatment because the provider operated practices, which had not been recognised as seclusion practices. Patients subject to these practices did not meet the safeguards set out in the MHA Code of Practice. This was a breach of 13(5)(7). 2. Regulation 12 HSCA (RA) Regulations 2014 Safe care and treatment Care and treatment was not provided in a safe way and the trust done all that was reasonably practicable to mitigate the risks. Rehabilitation mental health wards The trust had not ensured that all risks identified in risk assessments had associated plans to mitigate this risk. Community based mental health services for older people Care and treatment should be provided in a safe way for patients. There must be the proper and safe management of medicines. Medication at Sutton, Merton and Richmond was not stored, administered and transported in a safe manner at all times. Community based mental health services for adults of working age Care and treatment must be provided in a safe way for patients The trust did not ensure that individual patient risk assessments were updated to reflect current risk. The trust did not ensure there are safe systems for the administration, storage and transportation of medication. This was a breach of Regulation 12 (2) 3. Regulation 18 HSCA (RA) Regulations 2014 Staffing

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Rehabilitation mental health wards The trust had not ensured sufficient numbers of suitably qualified, competent, skilled and experienced staff being deployed and that they had the appropriate supervision and support to enable them to carry out their duties they are employed to perform. The trust had not ensured that staff were receiving regular supervision to enable them to carry out their role. The trust had not supported the managers to be effective leaders to implement a recovery-orientated approach across all the rehabilitation services. Community based mental health services for adults of working age Staff need to receive appropriate support, training and supervision to enable them to carry out the duties they are employed to perform. The trust had not ensured that staff were receiving regular supervision to enable them to carry out their role. Wards for older people with mental health problems The trust had not ensured sufficient numbers of suitably qualified, competent, skilled and experienced staff being deployed and that they had the appropriate supervision and support to enable them to carry out their duties they are employed to perform. The trust had not ensured that staff on Crocus ward were receiving regular 1:1 supervision. Mental health crisis services The trust had not ensured that staff had the appropriate supervision and support to enable them to carry out their duties they are employed to perform. The trust had not ensured that staff were receiving regular supervision to enable them to carry out their role. This was a breach of Regulation 18 (2)(a) 4. Regulation 9 HSCA (RA) Regulations 2014 Person-centred care Rehabilitation mental health wards On some wards patients were not receiving appropriate care to support their recovery and rehabilitation and meet their needs. The trust did not ensure that the operational policies promoting rehabilitation were implemented on all the wards. This included providing a range of therapeutic activities that supported people with their rehabilitation. This was a breach of Regulation 9(1)(a)(b) 5. Regulation 17 HSCA (RA) Regulations 2014 Good Governance Community based mental health services for older people Systems or processes must be established and operated effectively to ensure compliance.

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In the Kingston team administration support was not working well and letters were not reaching patients and GPs in a timely manner, and information needed to deliver care was not always available to staff when they needed it. Community based mental health services for adults of working age Systems or processes must be established and operated effectively. In the Kingston team administration support was not working well and letters were not reaching patients and GPs in a timely manner which could also impact on patients receiving details of their next appointment. Changes in the configuration of teams, meant that team managers were not always receiving performance information that related correctly to their current team. This was a breach of regulation 17(1) As alluded to earlier in key risks section improvement plans have been developed utilising staff engagement events and focused discussion at senior leadership conferences. Once the improvement plan has been approved by the Trust Board, it will be presented to the CQC and Trust stakeholders at the Quality Summit on 27 July 2016.

Physical violence against staff (W7): The number of reported incidents increased in May

to 43 (two above target) and is now rag rated amber. The Trust continues to closely monitor physical violence levels as this is key for staff safety.

All incidents of violence towards staff are reviewed by the Incident Governance Team. The nature and degree of harm and level of ongoing risk is reviewed and further information is sought either from the incident reporter or the manager who is responsible for managing the incident. A range of support and interventions can be provided by the Quality Governance department. These include:-

Confirmation that the staff who have been involved are being supported including physical health checks where required, access to staff counselling services, facilitated debrief, information and support with reporting the incident to the police where appropriate.

The trust Virtual Risk Team will offer support with reviewing and managing risk following an incident. In serious incidents this is offered directly from the Quality

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Governance department and can also be requested by teams themselves. This can also include input from the Management of Violence and aggression Lead, trust Security Lead and the Clinical Risk Modern Matron

The Quality Governance also offers support with facilitated debriefs and learning following incidents.

Incidents where staff have been physically assaulted or threatened and intimidated will be taken to the weekly SIGG meeting for review and discussion. Further information may be requested and a RCA level investigation may be initiated to identify further learning.

Where there have been a number of incidents reported in a specific area or the same patient or patient group are involved, this will be escalated to the Modern Matron and Operational Manager and also followed up by the VRT.

Continuing incidents and incidents of actual physical injury will be highlighted in the trust weekly Risk Intelligence report.

Physical violence against clients (by clients) (W8): May 2016 saw a rise in numbers of

violent incidents to 59 a (34%) increase on previous month. Position is rag rated red and an exception report is provided.

Support mechanisms for clients are in place (similar to above) however safeguarding adults processes would also apply. As a minimum, all incidents involving physical violence to patients are reviewed for Serious Incidents Governance Group by the safeguarding adults lead for the trust. Reporting did exceed the upper confidence limit in May; Ward 1 had an increase in incidents. The Head of Nursing has conducted a fifteen steps visit in June post this increase. A revised exception report has been provided.

Turnover (W4): Staff turnover remains just above target at (16.0%) position has decreased by (0.4%) on previous month.

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Vacancy Rate (W5): In May 2016 the Trust overall vacancy rate position increased to 19.6% and remains considerably above 12.4% target.

Sickness rate (W3): Sickness rate is 4.5% - just below target (March position) as 16/17 position is under reporting and data is being reconciled with Human Resources..

Mandatory Training (W6): Mandatory training compliance remained at (85.7%) in May 2016. Position remains rag rated red.

Finance (W10-W14): Please see the separate Finance report.

Board Assurance Framework (W9): The Trust currently has one remaining high risk item

The bed pressures risk remains at risk score 16 – although there is positive

assurance of the mitigations in place and the risk score will be reviewed further after this is sustained.

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APPENDIX 7: BENCHMARKING

Mental Health and Learning Disabilities Minimum Mental Health Data Set: The data is taken from the Health & Social Care Information Centre (HSCIC) November 2015 publication.

KPI

South West London and St George's

Mental Health NHS Trust

London Average

CPA 18-69 in settled accommodation

72% 69%

CPA 18-69 in employment

9% 5%

CPA HoNOS recorded 95% 92%

CPA for 12 months with review

95% 92%

Data quality on ethnic group

97% 89%

Completeness of MHMDS

97% 89%

7-day follow up 97% 81%

Average 80% 74%

Rank 2

The Trust continues to perform well in comparison with other London Trust’s on key indicators based on the Mental Health Services Data Set. The Trust is currently ranked 2nd in London having previously been ranked first. The position for settled accommodation has deteriorated and on investigation it appears the submission to the HSCIC was under reported in November & December 2015. This was attributable to the inclusion of revised data codes that are part of the new Mental Health Services Dataset which were only permitted within submissions from January 2016 onwards. The Head of Performance and IM&T has reviewed position and will ensure the next submission will include all missing data. The HSCIC have recently published an update to the Mental Health Services data set and this will be added to Board next month.

NHS Benchmarks Adult Acute Beds per 100,000 – MH22 is the new Trust bench-marking code

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National Reporting & Learning System: Nation Reporting of patient safety incidents.

NHS Benchmarking (2014/15)- Violence Against Staff

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The Trust benchmarks below average for reporting violent incidents against staff reporting 161 per 100,000 plus face to face contacts; national mean is 206. CQC Community Teams: Patient Satisfaction Score

The Trust satisfaction score of 73 is above the national average of 68.9%for client’s community team’s satisfaction rate and is the best in London.

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APPENDIX 8: Exception Reports

Performance Exception Report

Indicator Target Apr 16 YTD

Position 2016/17 Forecast

S6 Self-harm incidents (including attempted suicide)

40 63 66 50

Executive Director Operational Lead Completed By Date

Vanessa Ford Ian Higgins Theresa Pardey/ Gwyn Davies

22/06/2016

Reason for variation

The Trust encourages a positive reporting culture of incidents. The national evidence shows that Trusts that have a high reporting culture show improved learning, better patient safety and ultimately a reduction in serious harm. The Trust has moved from being in the bottom 25% of reporting Trust to the middle 50%.

The chart shows the upward trend in the reporting of self-harm incidents.

There has been a slight reduction in self-harm incidents reported this month.

Wisteria reported 9 Incidents of Self-Harm, (6 Self-Harm Cuts and 3 Self Harm-Other) these 9 incidents involved 2 patients. One of the Self-Harm -Cuts was recorded as Moderate harm as the patient required treatment in A&E the remaining 8 incidents were reported as Low Harm. The CAMHS Modern Matron and trust NAMED Nurse for Safeguarding have continued to liaise with St George’s with regards to these incidents.

Aquarius Ward reported (8 incidents involving 5 patients) these included Self Harm – Ligature, Cuts and Other). They were of Low Harm and did not require referral to acute Hospital for assessment or treatment.

All of the incidents were immediately identified and were all safely managed and followed up with the young person in detail.

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Virtual Risk team support has been offered.

There was one incident of Severe Harm, involving a community patient who fell out of 3rd floor flat and suffered a fractured hip. This incident will be investigated using Root cause Analysis (RCA) methodology.

Following each incident of self-harm, risk is reviewed and plans updated. An appointment will be made for individual follow up post each episode of self-harm.

The Serious Incident Governance Group (SIGG) will now request a Post Incident Review report for all moderate harm incidents of self-harm. This will include details of previous self-harm incidents, level of intent, care plan following the incident and details of the patients understanding of the incident.

For those moderate/severe harm incidents or continuing incidents of self-harm, the Patient Safety Team will also recommend that Virtual Risk is offered.

The Trust is engaged with local suicide prevention groups in Wandsworth and Kingston. Merton & Sutton are developing a group liaising with South West trains.

For patients who have a history of repeated incidents of self-harm, collaborative plans across wards, HTT and community teams are recommended and are occurring. This is supported by the Borough Care Pathway meetings and support from the Virtual Risk Team.

Training options have involved ‘Connecting with people’, an organisation that offers a wide variety of training in suicide prevention and self-harm, including specific advanced training in the following modules: Self-Harm Response and Suicide Response Part 1. Trust staff attended ‘Connecting with People' training on the 19th October 2015.

The degree of harm within over the last 3 months is demonstrated in the table below

Degree of harm Mar 16 Apr 16 May 16

3-Low(Min. Harm-Patient Req. Extra Ob) 68 60 62

4-Moderate (Short Term Harm) 2 3 3

5-Severe(Permanent Or Long Term Harm) 0 0 1

Total 70 63 65 Breakdown of self-harm incidents reported in May 2016:

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Impact Service User Outcomes

Risk to patients life if the harm goes unmanaged. Ward has in place an appropriate Risk Management Plan for each patient.

Financial Position

n/a

Regulator/Commissioner Requirements

n/a

Key Actions to be Taken

Action Date Due

Review of forecast number under review and agreed to provide separate groups that provide a breakdown of impact: Low, moderate or high.

30th June 2016 Completed

To Team Managers to be contacted by Quality Governance Admin staff to encourage their teams to follow up incidents of self-harm post reporting of the incident.

Monthly

The Trust Suicide Prevention Strategy is to be reviewed by the Mortality Committee.

30th July 2016

Development of an in-house training using the learning from the ‘Connecting with people’ course. This option requires further work due to cost and staff resources, particularly if using externally provided material. This would be a ‘Train the Trainer’ course so that the material would be used to embed and complement the Trust’s own existing clinical risk training as well as, to train some of our own staff in one off sessions.

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Initial scoping plan July 2016

Justin O’Brien producing a self-harm training film package with Oxford University Mental Health.

Completion planned July

2016.

Detailed analysis on self-harm reporting to be undertaken by the Mortality group within 6 months and shared with Quality Standards Assurance Committee.

30th September 2016

The Trust has established a Quality Account to Reduce levels of self-harm and suicide by reviewing current processes and policies following incidents of self-harm including feedback from service users and staff.

30th March 2017

Forecast Performance Level By Month

Target to be reviewed as above with focus on the degree of harm and a +-5% variation will trigger an exception.

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Monitoring Integrated Governance Committee

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Performance Exception Report

Indicator Month Plan

May 2016

YTD Plan

2016/17 Forecast

C3 Number of seclusions used 7 18 7 6.6

Executive Director Operational Lead Completed By Date

Vanessa Ford Sharon Spain Sharon Spain 30/06/2017

Reason for variation

Number of seclusions breached target in May 2016 and 18 is the highest number of seclusion episodes since reporting commenced to Board. Seclusion data is subjected to monthly audit so only validated position is reported to the Trust Board. Of the 18 reported incidents, 9 (50%) have been reported from Ward 1 and 9 (50%) were from Forensics medium secure units in the Shaftsbury clinic. Ward 1 has reported 9 incidents involving different patients. This indicates the level of acuity that the ward has been managing for the past number of months. This has also been highlighted in weekly trust Risk Intelligence. Forensics services seclusion involved 5 client’s (one client having more than one episode). The Trust’s Virtual Risk Team have been working closely with Forensic services in regard to safe management of their more difficult client’s.

The table below shows the number of seclusions by ward. It should be noted that duration of seclusion has been derived via progress notes. For future assurance this should be gathered through audit and cross reference with the ward seclusion logs.

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Wards/ Date of Seclusion

Episodes of seclusion

Duration of seclusion

Comment

Halswell 1

04.05.16 Episode 1 24 Hours 24 Minutes

Safety for other others and self

Ruby ward 3

Episode 1 8 Hours 35 Minutes

Client became threatening and verbally aggressive towards staff and threw objects at staff through the day. This lead to the seclusion.

Episode 2 1 Day 15 Minutes

Client was secluded after physically attacking member of staff. Client had also damaged equipment earlier in the day.

Episode 3 7 Hours 5 Minutes

Client became quite paranoid towards staff and threatened to attack any staff that followed them. Post call with family became agitated and Emergency team had to be called. Client secluded for own safety

Turner Ward

5

Episode 2 days To keep patient safe from harm to others and self-due to deterioration in mental Health.

Episode 2 days To keep patient safe from harm to others and self due to deterioration in mental Health.

Episode 2 days To keep patient safe from harm to others and self due to deterioration in mental Health.

Episode 2 days To keep patient safe from harm to others and self due to deterioration in mental Health.

Episode 2 days To keep patient safe from harm to others and self due to deterioration in mental Health.

Ward 1 9

1st May 2016

Episode 1 2 Hours 50 Minutes

Client became physically aggressive, other de-escalation method proved unsuccessful. Seclusion was initiated. Nursing and medical reviews adhered by

3rd May 2016

Episode 2 6 hours 17 Minutes

Client was presenting as imminent risk to others, other de-escalation method proved unsuccessful. Seclusion was initiated. Nursing and medical reviews adhered by but ward manager to follow up proper documentation process with staff

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involved.

14th May 2016

Episode 3 5 Hours 11 Minutes

Client was presenting as imminent risk to others, other de-escalation method proved unsuccessful. Seclusion was initiated. Nursing and medical reviews adhered to.

16th May 2016

Episode 4 6 Hours 40 Minutes

Client became physically aggressive, other de-escalation method proved unsuccessful. Seclusion was initiated. Nursing and medical reviews conducted as per policy.

20th May 2016

Episode 5 3 Hours Client was presenting as imminent risk to others, other de-escalation method proved unsuccessful. Seclusion was initiated. Nursing and medical reviews adhered by but ward manager to follow up proper documentation process with staff involved.

21 May 2016

Episode 6 5 Hours 45 Minutes SR

Client attacked fellow patients, other de-escalation method proved unsuccessful. Seclusion was initiated. Nursing and medical reviews conducted as per policy.

24 May 2016

Episode 7 8 Hours 1 Minute

Client became physically aggressive, other de-escalation method proved unsuccessful. Seclusion was initiated. Nursing and medical reviews conducted as per policy.

26 May 2016

Episode 8 8 hours 45 minutes

Client was presenting as imminent risk to others, other de-escalation method proved unsuccessful. Seclusion was initiated. Nursing and medical reviews conducted as per policy.

30 May 2016 Incident took place 29 May but reported 30 May

Episode 9 1 hour 35 minutes

Client became physically aggressive, other de-escalation method proved unsuccessful. Seclusion was initiated. Nursing and medical reviews conducted as per policy.

Total 18

Ruby ward seclusions once clients was secluded on two occasions in May

Turner Ward – One client has three separate seclusion episodes in May 2016.

Ward 1 – 2 clients had two episodes of seclusion in May 2016

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Impact Service User Outcomes

Seclusion is used only when the client is particularly distressed/aroused; duration of seclusion needs to be minimised with regular review as per policy in order to minimise any client distress.

Financial Position

n/a

Regulator/Commissioner Requirements

n/a

Key Actions to be Taken

Action Date Due

1. The trust Seclusion Policy is in the final stages of a further review. This includes the definition and use of seclusion in CAMHS

TBC by Nursing Directorate

2. Repeat incidents of seclusion for specific patients should lead the service to arrange a shared review with the Virtual Risk Team.

Ongoing and to be reviewed by the Q.G. department via incident reporting.

3. The DoN has commenced a Trust restrictive practice group which will ensure appropriate monitoring and

governance drive down the level of restrictive practices across the organisation – It will review the clinically use of

• Number of seclusions

• Number of Prone restraints

• Number of Rapid Tranquilisations administered

(medicine & route) & that physical monitoring is done in

accordance with Trust RT Policy

• Number of other ‘forced’ interventions- such as blood

taking and NG tube feeding

• Number of restraints across all areas

• Themes and high risk areas

Monthly reports to IGG.

4. The trust Medical Director has reviewed the standard and sight lines of all seclusion facilities and has made initial recommendations.

20th April 2016.

5. DoN is reviewing the metrics for seclusions and other aspects of restrictive practice.

October 2016

Forecast Performance Level By Month

July 2016 7

Monitoring Integrated Governance Committee

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Performance Exception Report

Indicator Month Plan

May 2016

YTD Plan

2016/17 Forecast

E2 MH Tariff - % Patients with valid, up to date clusters

95% 83.5% 90% 86%

Executive Director Operational Lead Completed By Date

Emma Whicher Justin Earl Clinical Lead Justin Earl 27/06/2016

Reason for variation

This indicator considers whether a client has a valid and in date cluster. This is an internal metric. Of the 9104 clusters, 1501 are invalid (16.5%). Of those that are invalid, 1004 (66.9%) are due to the cluster having expired. This is a marginal increase on the February report. The other main reasons for invalid clusters are outlined in the table below which shows the data by borough. The green arrows represent an improvement and the red arrows a deterioration in performance compared to the data from February 2016.

1. As a proportion of the invalid clusters, expired clusters continue to show an

increasing trend although the deterioration is less significant :

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July 2015 43.8%

Sept 2015 60.4%

Dec 2015 65.6%

Feb 2016 66.2%

May 2016 66.8%

This has occurred despite staff receiving weekly emails alerting them when clusters are due to expire.

Analysis of clusters in date over time lends to increase in overdue clusters and highlights a decrease in compliance rate. Step change analysis highlights a 4% drop in mean position; currently the mean is 86%.

2. There has been an increase in the number of service users not allocated to a

cluster. It was hoped that the introduction of assessment teams would improve allocation to a cluster following initial assessment. The processes within the assessment teams will require review to understand what could be contributing to the drop in performance.

3. Reviewing performance over the past 12 months, there have been the following improvements:

Reduction in the total number of people in clusters 1-4 along with a reduction in new allocations to these clusters;

Reduction in the number of people in cluster 11, along with a reduction in the percentage of those in cluster 11 on CPA

4. Kingston has demonstrated the best performance across all the domains. 5. The post of the expert trainer has been vacant since mid-Feb 2016. This

results in limited capacity to deliver focused training. This may be a factor in the worsening performance in relation to clusters expiring. The deterioration in accuracy of clustering is likely to continue if this post remains vacant. The process of recruiting is thus a priority.

Impact Service User Outcomes

There is limited impact on clients as the service continues to offer interventions beyond the expiry of the cluster.

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Financial Position

Although we are still on block contracts, and there is currently no impact financially where clients are not within a valid cluster but are being provided a package of care; the current guidance from Monitor is that 16/17 is a year of preparation for new contracting models based on clusters in 17/18.

Regulator/Commissioner Requirements

For discussion under the MH Tariff steering group and on the work plan.

Key Actions to be Taken

Action Date Due

1. Awaiting decision as to whether Mental Health Clustering training will be established as mandatory training. This is considered critical due to the central importance of clustering to the Trust financially in terms of costing and pricing. This will include foundation/basic training (face-2-face classroom training) for all new starters and the expectation of refresher training every 2 years (utilising the e-Learning package that is now available).

Ongoing (since October 2015)

2. The Clinical Lead is focusing on improving the clinical utility of HoNOS which may help clinicians see the clinical value of clustering

June 2016 - ongoing

3. Staff to be reminded of the importance of using the clustering dashboard in order to identify and correct invalid clusters. NB Training package has been revised to incorporate this.

June 2015 to March 2016 -

ongoing

4. Clinical lead to re-evaluate strategy for engaging clinicians. This will include working with Medical Director to support inclusion of team clinical performance in consultant appraisals and more regular attendance and presentation at:

Medical Staff Committee Meetings (MSCs)

Consultants’ Meetings

Clinical Directors meeting

April 2016 Ongoing

5. A detailed action list that clinicians can implement to address the expired clusters and prevent clusters expiring has been developed by the clinical lead and expert trainer and is available to clinical staff. This will be disseminated through the team managers.

April 2016 Refreshed June

2016

6. Clinical lead will undertake focused work with the teams that have the poorest performance to develop workable solutions.

June 2016 onwards

7. A move to a rolling programme of reviewing cluster 18 patients every 10 months is underway

April 2016

8. Clinical lead will review practice in Merton to establish if good practice can be disseminated to other boroughs.

July 2016

9. A focused programme of audits will be carried out by the Mental Health Tariff team to better understand the performance issues and offer targeted feedback to teams and boroughs.

April – August 2016

10. The role of expert clinical trainer is currently vacant. The process of recruitment to this role will be made a priority.

April 2016 Ongoing

11. Work is underway to systematically review cluster 19 patients across older adult services (requiring 6 month reviews). Where appropriate the greater accuracy of

August 2016

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cluster 18 will be considered (Cluster 18 requires reviewing every 12 months)

12. Investigate the development of automated validation check within the algorithm in RIO which provides notification of whether a cluster is valid or invalid in real time.

December 2016

13. The Mental Health Tariff to review basic cluster rules and assure this is aligned with the pan London position

August 2016

Forecast By When Performance

September 2016 86%

Monitoring Performance is monitored at monthly Directorate Performance Review.

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Performance Exception Report

Indicator Month Plan

May 2016

YTD Position

2016/17 Forecast

E3 % Carers Offered an assessment 50% 72.7% 60% 85%

Target – Locally negotiated target with Commissioners

Executive Director Operational Lead Completed By Date

Dawn Chamberlain Mark Clenaghan Gwyn Davies 22/06/2016

Reason for variation

The target has been amended to 85% for 2016/17 an increase of 25% on previous year. The Trust does not expect to meet target straight away however does expect to see progression throughout the year. Target trajectory for the Trust is highlighted below.

The Trust is currently below required level in Q1. It should be noted that Richmond cases will cease to be reported at the end of June as the Section 75 agreement with the London Borough of Richmond ends of the 30th June.

The indicator only applies to Merton Kingston and Richmond where existing section 75 arrangement are in place. From that point only Kingston and Merton services will be reported on.

In year there will need to be a refresh for carers and their offer of an assessment. In Quarters two and three was a sharp decline in performance this was attributable to the offer exceed the 12 month time limit. There is a need to ensure teams refresh existing offer/assessment

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for carers within the 12 month period.

Impact Service User Outcomes

This is positive as the assessment should lead to carers being offered further support where required.

Financial Position

-

Regulator/Commissioner Requirements

Reported on local contract schedule for Commissioners.

Key Actions to be Taken

Action Date Due

IM&T to develop a user friendly Dashboard Report to assist teams with identification of carers that require an offer of carers assessment.

June 2016

Boroughs with section 75 agreement (Kingston & Merton) to put in place plans to ensure revised carers offered target is met.

June 2016

Forecast By When Performance

September 2016 80%

December 2016 85%

Monitoring Monthly Directorate Performance Review

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Performance Exception Report

Indicator Month Plan

May 2016

YTD Positio

n

2016/17 Forecas

t

C16 % clients whom have had a physical Health Assessment completed within 48 hours of admission

98.0% 91.7% 93.0% 94.4%

Executive Director Operational Lead Completed By Date

Dawn Chamberlain Mark Clenaghan Mark Clenaghan/ Gwyn Davies

24/06/2016

Reason for variation

In 2016/17 the target has increased to 98% this target has been set via negotiations with commissioners. Trust is rag red rated PHA assessment completion within 48 hours. Currently no boroughs are compliant with the new 98% target. New target is very difficult to attain as denominator in month is generally low and will only take a very small number of breach cases in order to miss target. In order to meet compliance on this indicator two assessment forms need to be completed. The Physical Health Assessment form (usually completed by a doctor and the physical health monitoring form which is usually complete by the nursing staff. Both must be completed within 48 hours in order to count. A summary of performance over time is given below, overall trend is upwards however position has deteriorated over the last three months:-

In May 2016, 4 physical health assessments (PHA’s) and 21 monitoring forms were missing/incomplete and therefore not compliant with metric requirements.

PHA’s are generally completed on admission and there is a need to ensure the correct forms are completed and not just documented in progress notes.

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PHA admissions report on “MY Dashboard “allows managers to review missing data items efficiently – there is need to reinforce its use on a regular basis with ward managers

Summary on ward areas breaches in May 2016 is given below – please note that reporting on this metric is a based on an aggregate of the two completed forms which is then divided by 2.:-

Impact Service User Outcomes

Clients physical as well as mental health state are required to be monitored. Client’s physical health can impact on recovery so important to ensure client is physically well and monitored. Evidence suggests that physical health assessments are undertaken but that evidence not always captured, as these assessments may not be documented in the correct section of Rio.

Financial Position

None directly.

Regulator/Commissioner Requirements

Reported in Directorate Performance Review.

Key Actions to be Taken

Action Date Due

Ward managers to ensure My Dashboard PHA report is monitored daily in order to pick up new cases and review and breeches.

June 2016

Ward Managers to address local recording issues with medical and nursing staff.

June 2016

Audit of Ward 1 and Jupiter breaches to be undertaken and recommendations on practice to be implemented

June 2016

Forecast By When Performance

September 2016 94.4%

Monitoring PHA monitored at Directorate Performance Review but there is a need to ensure robust weekly monitoring at ward level.

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Performance Exception Report

Indicator Target May 2016 YTD

Position 2016/17 Forecast

W8 Physical Violence Against clients (client on client physical violence)

30 59 52.5 33

Local Target based on 2014/15 average outturn

Executive Director Operational Lead Completed By Date

Vanessa Ford Ian Higgins, Serious Incident Lead Investigator and Named Nurse

Theresa Pardey 24/06/2016

This month the majority of the reported incidents 39.0% (n=23) occurred on Ward 1. A fifteen steps visit was undertaken and violent outbreaks discussed during the visit. The Ward One incidents were reviewed and involved multiple patients however 1 patient was involved in 8 incidents and 2 patients in 6 incidents. Safeguarding Leads reviewed follow-up actions with Ward Managers, i.e. ensuring support is provided to the victims of assault and by asking the victim what they would like to happen, i.e. reporting to the police.

Two incidents resulted in moderate harm with a bleeding nose and bleeding mouth following the assault. The police were called in 1 of the 2 incidents of moderate harm.

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The indicator is under review as the forecast of 40 incidents is exceeded in part, due to increased incident reporting trends and encouraged (therefore numbers increase). A 2016/2017 Trust Quality Priority is to reduce harm resulting from violent incidents and so breakdown of actual harm will be monitored monthly to measure outcome and impact on patients. Level of harm against this (therefore a reduction in harm). Currently in the majority of cases, the degree of Harm was None (69%) and Low (22%) and Near Miss (0%).

Actual Harm Mar 16 Apr 16 May 16

1-Near Miss 2 - -

2-None(No Harm Occurred) 23 30 41

3-Low(Min. Harm-Patient Req. Extra Ob)

3 14 13

4-Moderate (Short Term Harm) 0 1 2

Not recorded 0 1 3

Total 28 46 59

All incidents involving client on client violence are reviewed by the Quality Governance department and the Safeguarding Adults lead for the trust. Advice and recommendations are provided with regards to raising Safeguarding Vulnerable Adults alerts and reporting incidents to the police. The trust Virtual Risk Team can be accessed by Trust staff, particularly when there are repeat incidents or themes identified. The Conflict reduction/PPI Lead trainer also does a face to face review with individuals, ward teams, patients and patient groups following such incidents as a means of support ,debriefing and learning following assaults. One of the identified themes from reviews is the challenges of acutely unwell people being admitted as an emergency and the impact that this can have on the other patients already on the ward. A number of the incidents reported appear to be in response to this dynamic. The development of the Psychiatric Decisions Unit and Crisis House through the Acute Care Pathway may, in turn, impact on acute admissions so may contribute to a reduction of violent incidents. A report on the 2015/2016 patient on patient’ incidents is to be submitted to commissioners in July 2016 following internal Trust review. This will provide a baseline for comparison with 2016/2017 figures.

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Impact Service User Outcomes

Poor Experience of Trust Services.

Financial Position

Potential claims

Regulator/Commissioner Requirements

n/a

Key Actions to be Taken

Action Date Due

Virtual Risk Team provides support, guidance and training on how staff and managers should respond to such incidents on request.

Ongoing

Completion of the 2015/2016 report on violent incidents for Commissioners.

27 July 2016

Performance forecast to be reviewed to ensure interpretation of reported incidents is not distorted by increased incident reporting culture. Joint action on Performance Team and Quality and Governance Team.

July 2016

Listening into Action event arranged for staff to share experiences of being involved in incidents to support developments of learning, guidance and training needs.

27 July 2016

Quality Governance team to support development of guidance and training on how staff and managers should respond to these incidents and when they should be reported to external agencies

September 2016

Following review of recommendation(s) from the April 2016 safeguarding audit to be implemented. Led by Safeguarding Adults Lead.

September 2016

Forecast By When Performance

Mar 2017 – the degree and impact of harm to patients and staff to be reduced and staff continued to further improve reporting.

33

Monitoring IGG

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APPENDIX 9: Explanation of Data Quality Assurance Scores

Assurance of quality and performance indicators

Explanation of data quality assurance scores and key principles

1. Background

Data and Information - The Trust has in place a comprehensive data and information

assurance programme, which is developed and delivered by the Information Governance

Group, chaired by the Senior Information Responsible Officer (SIRO).

Information sourcing should be automated where possible. Quality and performance data

included on dashboards should:

Be sourced from a single database to ensure consistency and traceability.

Be the primary source of data.

Have documented definitions.

Have documented workflows and business rules for production.

A kite-mark will accompany the dashboard to provide visual assurance on quality of a performance indicator.

The kite-mark is a visual indicator that acknowledges the variability of data and makes an explicit assessment of the quality of evidence on which the performance measurement is based.

Each measure is assessed as ‘sufficient’, ‘insufficient’ or ‘not yet assessed’ on seven distinct elements. For each element a colour code shows the strength of assurance. Each measure has an equal weighting. An overall assessment is reported in the Quality and Performance Dashboard.

2. Elements of the kite-mark:

Timeliness – This is the time taken between the end of the data period and when the information can be produced and reviewed. The acceptable data lag will be different for different performance indicators. Data should be captured as quickly as possible after the event or activity and must be available for the intended use within a reasonable time period. Data must be available quickly and frequently enough to support information needs and to influence the appropriate level of service or management decisions.

Monitoring – This is the degree to which the trust can drill down into data in order to review and understand operational performance. The level to which the trust needs to drill down into the data will vary for different performance indicators. Some information should always be available at patient level for performance monitoring purposes. Whereas some information may be sufficient if it is available at speciality level for all specialties or even trust level for performance monitoring purposes.

Completeness – There are two aspects to completeness. This is the extent to which all of the expected attributes of the data are populated but also the extent to which all of the records for the relevant population are provided.

Validation – This is the extent to which the data has been validated to ensure it is accurate and in compliance with relevant requirements. For example, correct application of rules and definitions. The level of validation required will vary from indicator-to-indicator and will depend on the level of data quality risk. Final validation is classified as sufficient where validation has been completed and where the indicator has received final approval from responsible individuals.

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Audit – This is the extent to which the integrity of data (completeness, accuracy, validity, reliability, relevance, and timeliness) has been audited by someone independent of the KPI owner (for example, Internal Audit, External Audit, Clinical Audit or Peer Review) and the extent to which the assurance provided from the audit is positive.

Reliability – This is the extent to which the data is generated by a computerised system, with automated IT controls, or a manual process. It also relates to the degree of documentation outlining the data flow, i.e. documented process with controls and data flows mapped. Data should reflect stable and consistent data collection processes across collection points and over time, whether using manual or computer based systems or a combination. Managers and stakeholders should be confident that progress toward performance targets reflects real changes rather than variations in data collection approaches or methods.

Relevance – This is the extent to which the data is captured for the purposes for which it is used. This entails periodic review of the selection of key performance indicators to reflect changing needs, such as new strategic objectives. For example, is this indicator the right indicator by which to measure performance against a strategic objective?

3. Sufficient/Insufficient criteria

Each indicator should be assessed as ‘sufficient’ ‘insufficient’ or ‘not yet assessed’. The assessment is based on a positive response to the criteria in the table below. Where an attribute is marked as ‘insufficient’ or ‘not yet assessed,’ the KPI owner should explain the issue, why it exists and the remedial action to be taken.

Attributes for each indicator

Sufficient Insufficient

Timeliness Where data is available daily for an indicator, up-to-date data can be produced, reviewed and reported upon the next day. Where data is only available monthly, up-to-date data can be produced, reviewed and reported upon within one month. Where the data is only available quarterly, up-to-date data can be produced, reviewed and reported upon within three months. Where data is only available annually, data being produced, reviewed and reported upon is no more than 12 months old.

Where data is available daily for an indicator, up-to-date data can be produced, reviewed and reported upon the next day. Where data is only available monthly, up-to-date data can be produced, reviewed and reported upon within one month. Where the data is only available quarterly, up-to-date data can be produced, reviewed and reported

Monitoring Where relevant, the trust is able to drill down into the data down to the right level (for example, speciality or patient level) to inform decision making on operational performance. Additionally, where the trust is able to drill down into the data to the right level, the KPI owner is able to provide assurance that this information is reviewed on a regular basis at that level (i.e. board, sub-committees,

The trust is either: 1.Not able to drill down into the data down to speciality or patient level where required; or 2. able to drill down into the data but the KPI owner cannot provide assurance that this information is appropriately reviewed at different levels.

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Attributes for each indicator

Sufficient Insufficient

divisions, service lines, consultants)

Completeness Fewer than 3% blank or invalid fields in expected data set. This standard applies unless a different standard is explicitly stated for a KPI within commissioner contracts or through national requirements. Additionally, the KPI owner can provide assurance that effective controls are in place to ensure that 100% of records are included in population. In other words, no individual records are omitted from the population due to fraud or error.

More than 3% blank or invalid fields in expected data set Inadequate assurance or no assurance that effective controls are in place to ensure that 100% of records are included within the total population.

Validation The trust has agreed upon procedures in place for the validation of data for the KPI. A sufficient amount of the data, proportionate to the risk, has been validated by the trust to ensure data is: • accurate; and • in compliance with relevant rules and definitions for the KPI. The KPI owner is responsible for determining what a ‘sufficient’ amount of data validation is.

Either: 1. No validation has taken place; or 2. an insufficient amount of data has been validated as determined by the KPI owner; or 3. Validation has found that the KPI is not accurate or does not comply with relevant rules and definitions. Commentary should be available to indicate which of the above is the case

Audit The data quality of the KPI has been audited in the last 3 years and either: • positive assurance was received; or • recommendations have been completed and successfully followed up by audit.

1. The data quality of the KPI has not been reviewed by audit in the last 3 years; or 2. the data quality of the KPI has been reviewed by audit in the last 3 years but: • negative assurance was received; and • recommendations have not yet been followed up by audit. Commentary should be available to indicate which of the above is the case

Reliability Mostly a computerised system, with IT automated controls, and therefore less prone to human error. Automated controls may include field validation, system interface reconciliations and system configuration. Process is fully documented with controls and data flows mapped

Mostly a manual system, with no IT automated controls, and therefore more prone to human error. Process is not documented. Process has changed during the last 12 months therefore there is an increased risk that data is not consistent between reporting periods.

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Attributes for each indicator

Sufficient Insufficient

Process is stable and consistent over the last 12 months. Where data is processed by a third party, the trust has received assurance over the processes and controls in place at the third party to ensure data quality.

Where data is processed by a third party, the trust has not received assurance over the processes and controls in place at the third party to ensure data quality. Commentary should be available to indicate which of the above is the case.

Relevance This indicator is relevant to the measurement of performance against the: • Performance area • Performance question • Strategic objective

This indicator is no longer relevant to the measurement of performance against the: • Performance area • Performance question • Strategic objective

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APPENDIX 10: Summary of Assurance on Performance Indicators

84

85

86

87

88

89

APPENDIX 11: Directorate Team Waiting Times

Waiting Times for Commencement of Treatment: May 2016

Waiting Times by Directorate, Service Type and Team

90

91

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Appendix 12: Draft CQC Intelligent Monitoring Report

The CQC Intelligent Monitoring Report currently shows one elevated risk (Trust has action in place) and one amber risk in relation to written complaints. The risk in relation to mental health learning disabilities minimum data set was been removed in the final version.

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