Board Integrated Performance Report 27 September 2018 ... · Board Integrated Performance Report - September 2018 2 of 30 The purpose of this Integrated Performance Report is to assist

1 of 30Board Integrated Performance Report - September 2018

1.2 NHS Improvement

Segment

Board Integrated Performance Report

27 September 2018

August 2018 Data

Requires

Improvement

1.1 CQC Rating1.3 NHS Improvement

Finance Score

2

Agenda item: 12

Lead Director: Director of Finance, Contracting and Facilities &

Deputy Chief Executive

Presented for: Assurance

2

SummaryNHS

ImprovementQuality

Business Unit

Change Programme

Finance Enablers Well Led


The purpose of this Integrated Performance Report is to assist the Board in assessing the Trust’s performance and progress in

delivery of a broad range of key targets and indicators.

Board Action Key Highlights Slides

NHS Improvement Indicators

Exceptions • The waiting time target for people with a first episode of psychosis has not been met in July or August. The

slide outlines the underlying reasons and actions being taken. The NHS Improvement Intensive Support Team

visited the Early Intervention in Psychosis Team on 12 September. Their verbal feedback was very positive;

the full report is awaited.

• NHS Digital’s unexpected introduction of three new data items to the Data Quality Maturity Index data score for

2017/18 quarter 4, has resulted in a deterioration in the Trust’s score below the 95% threshold. Inclusion and

use of these new fields in mental health SystmOne will ensure improvement in the data quality for these data

items from August 2018 onwards.

4

5

Quality

Assurance

Information

• The August business unit performance meetings considered trajectories from operational business units and

corporate services to increase and maintain mandatory training and appraisal rates.

• There was one Duty of Candour incident in August 2018. A District Nurse removed a suture from a patient that

should not have been removed. The patient required readmission to hospital to have the suture replaced.

9 - 10

14

Business Unit

Information • The September business unit performance meetings have been cancelled as the Trust responds to a strategic

re-procurement exercise for Children’s Services.

• The service dashboard provides information relating to July 2018 and quarter 1. A deep dive into first

response and intensive home treatment will be provided to the October business unit performance meeting.

15

Change Programme

Exception • Significant transformation is underway across all operational business units. However the overall programme

continues to be red rated with projected shortfalls against a number of cost improvement schemes, most

notably the recurrent management of inpatient and medical locum cost pressures. A Care Closer to Home

business case responding to Mental Health Acute pathway pressures is due to be considered at the Finance

Business and Investment Committee during October. A workshop to scope opportunities to transform support

services is being held on 26 October.

16

SummaryNHS

ImprovementQuality

Business Unit

Change Programme



The purpose of this Integrated Performance Report is to assist the Board in assessing the Trust’s performance and progress in

delivery of a broad range of key targets and indicators.

Board Action Key Highlights Slides

Finance

Assurance

Exceptions

• Control Total – 2018/19 Performance: Surplus/(Deficit) Position: With a deficit of £581k at Month 5,

performance is £37k ahead of the planned deficit of £618k. The plan for 2018/19 included £1,195k non

recurrent Cost Improvements and required recurrent plans to be identified in-year principally linked to reduce

bed occupancy. The in-year position includes non recurrent mitigations of £1,506k (before the use of the high

risk CIP reserve). These mitigate under performance, mainly failure to reduce inpatient staffing and medical

locum pressures.

• The risk assessed forecast considered by the Executive is that the Trust will deliver a surplus of £388k,

representing over achievement of £100k against the Control Total by quarter 4, due to modest in-year

slippage on PDC, depreciation and recruitment to new roles, to secure access to £793k planned Provider

Sustainability Funding (PSF) and deliver a £1,181k composite surplus.

• Cash: Balances are £3.4m above plan at M05 reflecting underspending on capital expenditure and working

capital movements and taking into account receipt of unplanned 2017/18 Sustainability and Transformation

Funding incentives.

• Use of Resources (UoR): The actual UoR rating at Month 5 is ‘2’ which is better than planned.

• CIPs: CIPs are in line with plan in Month 5, however this is supported by non recurrent mitigations of £584k.

The forecast position includes a number of CIP schemes that are at risk of delivery during 2018/19, mainly

inpatients and medical staffing, that are supported by non recurrent mitigations of £2,006k. Recurrent plans

now need to be targeted to address the recurrent shortfall. The full high risk CIP reserve is required to

deliver the CIP plan in 2018/19.

• Workforce – Agency Controls: Agency expenditure caps are being achieved for total agency costs and

medical staffing expenditure year to date. There were 182 price and wage cap breaches at the end of August

(4 week month) all related to medical locums.

• Capital: Capital expenditure is £551k below plan at Month 5 due to slippage on Estates and IM&T schemes

that will be delivered later in the year. The capital plan will be fully committed in 2018/19.

17 - 19

Enablers

Assurance The 2018 Patient-Led Assessment of the Care Environment (PLACE) results are very positive, with the Trust

overall score and individual site scores all exceeding the national average benchmark scores for healthcare

organisations.

27

Summary and Recommendations

The Board is asked to consider the exceptions highlighted and note the proposed actions.

SummaryNHS

ImprovementQuality

Business Unit

Change Programme



Single Oversight Framework Operational Performance Metrics

Indicator M7: Data is provided in relation to the waiting time element of the standard for Early Intervention in Psychosis (EIP). This shows

patients who started treatment in August 2018 within two weeks of referral. The number of completed pathways in August 2018 was 24; 5 of

these clients were seen within two weeks. The number of incomplete pathways (patients waiting) at the end of August 2018 was 67; 54 of

these patients have been waiting for more than two weeks. The service is verifying the incomplete pathways numbers, following the transfer

from RiO to SystmOne.

Measure

Target

England

Benchmarking

figure

Graph Key

SummaryNHS

ImprovementQuality

Business Unit

Change Programme


Indicator

No.Indicator Target Data status

Q2 17/18

Outturn

Q3 17/18

Outturn

Q4 17/18

OutturnMay Jun Jul

3 Months

Rolling

Numerator

3 Months

Rolling

Denominator

Overall 3

months

rolling

National

Benchmark

M10

waiting time to begin

treatment (from IAPT

minimum data set)

- within 6 weeks

75.0%

Finalised -

May &

June.

Provisional -

July

96.3% 96.5% 97.4% 98.0% 98.0% 96.7% 1130 1158 97.5%

89.6% as at

June 18

Next publication date:

11/10/2018

M11

waiting time to begin

treatment (from IAPT

minimum data set)

- within 18 weeks

95.0%

Finalised -

May &

June.

Provisional -

July

99.2% 99.3% 99.4% 100.0% 99.0% 99.2% 1150 1158 99.3%

99.0% as at

June 18

Next publication date:

11/10/2018

Graph

60.0%

70.0%

80.0%

90.0%

100.0%

Jul17

Aug17

Sep17

Oct17

Nov17

Dec17

Jan18

Feb18

Mar18

Apr18

May18

Jun18

Jul18

85.0%

87.5%

90.0%

92.5%

95.0%

97.5%

100.0%

Jul

17

Aug

17

Sep

17

Oct

17

Nov

17

Dec

17

Jan

18

Feb

18

Mar

18

Apr

18

May

18

Jun

18

Jul

18

The service is experiencing increased demand, with an increase in referrals and the number of patients

entering treatment resulting from the extension of the age range up to 65. In 2018/19, Clinical

Commissioning Groups have made additional investment in EIP staffing. Although the service is now

almost fully recruited, there is a backlog of assessments. One of the EIP locality team vacancies has

been temporarily located with the assessment team to help clear the backlog of assessments.

Monitoring continues in the service quality and safety meeting, reporting into the business unit

performance meeting.


Indicator M22: The Data Quality Maturity Index (DQMI) mental health services dataset score (MHSDS) data score is a quarterly publication

from NHS Digital. There are 361 data items within the MHSDS. The score covers: ethnic category, GP code, NHS number, commissioner

code, gender and postcode. In August 2018, NHS Digital published the 2017/18 quarter 4 scores. Three new data items were included

(Mental Health Act legal status classification code, primary reason for referral, team classification), without prior notification. These additional

items have led to a deterioration in the score for most mental health providers. The Trust queried the changes with NHS Digital; NHS Digital

are in correspondence with NHS Improvement about the 95% threshold. There is a lengthy delay between dataset submission and

publication of the DQMI by NHS Digital. All quarter 1 dataset submissions have already been made and there is a limited window within which

to implement the necessary clinical system changes and data quality actions required to rectify the gaps for quarter 2. The new data items

have been activated mental health SystmOne. Data quality for the 3 new elements will show improvement from

August/September onwards.

Indicator M23: The Trust has relatively few inappropriate out of area bed days; all relate to the Psychiatric

Intensive Care Unit (PICU). For 2018/19, the Trust has agreed a trajectory that maintains PICU inappropriate

out of area placements at the 2017/18 baseline of 41 days per quarter, with review of PICU capacity across the

West Yorkshire and Harrogate resulting in elimination of inappropriate out of area placements by 2020/21.

Single Oversight Framework Operational Performance Metrics

Measure

Target

England

Benchmarking

figure

Graph Key

SummaryNHS

ImprovementQuality

Business Unit

Change Programme


Q3

17/18

Q4

17/18Q1 18/19 Q2 18/19 Q2 18/19 Q2 18/19

Outturn Outturn OutturnNumerator

Outturn

Denominator

OutturnOutturn

M22Data Quality Maturity Index (DQMI)

mental health services data set score 95.0% 98.4% 85.8% TBC TBC TBC TBC

Next publication

date:

TBC

M21

Proportion of people completing

treatment who move to recovery (from

IAPT minimum dataset)

50.0% 48.2% 51.5% 49.3%50.9%

(Primary)235 445 52.8%

52.3% as of

June 18:

Next publication

date 11/10/18

M3

Maximum time of 18 weeks from

point of referral to treatment (RTT) in

aggregate − patients on an incomplete

pathway

92.0% 96.0% 96.7% 97.7% 815 838 97.2%

87.8% as of July

18

Next publication

date 11/10/18

M23

Inappropriate out of area placements

for adult mental health services –

number of bed days patients have

spent out of area

41

Per Quarter

18/19144 4 62 4 0

Ensure that cardio-metabolic

assessment and treatment for people

with psychosis is delivered routinely in

the following service areas:

a) Inpatient Wards 90.0% 96.5%

b) Early Intervention in psychosis

services90.0%

Awaiting

results

c) Community mental health services

(people on Care Programme Approach)65.0% 88.9%

Indicator

No.Indicator Target Jul Aug Sept

National

BenchmarkGraph

M19

40.0%

45.0%

50.0%

55.0%

60.0%

Jul17

Aug17

Sep17

Oct17

Nov17

Dec17

Jan18

Feb18

Mar18

Apr18

May18

Jun18

Jul18

80.0%

85.0%

90.0%

95.0%

100.0%

Aug17

Sep17

Oct17

Nov17

Dec17

Jan18

Feb18

Mar18

Apr18

May18

Jun18

Jul18

Aug18


Airedale NHS Foundation Trust and Bradford Teaching Hospitals NHS Foundation Trust performance against the national standard for

Accident and Emergency (A&E) waits is provided to the Board for information. The Trust contributes to delivery of the target through a range

of services and interventions. The Trust continues to work actively with both Airedale NHS Foundation Trust and Bradford Teaching

Hospitals Foundation Trust, providing support within A&E departments and developing pathways designed to avoid admissions.

At the September meeting, the A&E Delivery Board is considering the 2018/19 winter plan and associated West Yorkshire Acceleration Zone

investment. Key priorities for Trust services are extending the hours operated by the A&E liaison service and additional community nursing

capacity at weekends. A further update will be included in the October Board integrated performance report.

Accident and Emergency Waiting Times

SummaryNHS

ImprovementQuality

Business Unit

Change Programme


Airedale NHS Foundation Trust

Indicator No.Indicator Target

Q2

17/18

Q3

17/18

Q4

17/19

Q1

18/19Jul-17 Aug-17 Sep-17 Oct-17 Nov-17 Dec-17 Jan-18 Feb-18 Mar-18 Apr-18 May-18 Jun-18 Jul-18 Aug-18

Total A&E attendances 16,533 16,841 15,680 17,488 5,770 5,225 5,538 5,547 5,416 5,878 5,420 4,751 5,509 5,433 6,312 5,743 6,089 5,784

Total attendances within 4 hours 15,546 15,591 14,503 16,236 5,519 4,868 5,159 5,221 5,029 5,341 5,017 4,340 5,146 5,013 5,870 5,353 5,580 5,193

M18a% of A&E attendances where service

user was admitted, transferred or

discharged within 4 hours

95% 94.0% 92.6% 92.5% 92.8% 95.6% 93.2% 93.2% 94.1% 92.9% 90.9% 92.6% 91.3% 93.4% 92.3% 93.0% 93.2% 91.6% 89.8%

Bradford Teaching Hospitals NHS Foundation Trust

Total A&E attendances 34,928 40,255 32,525 34,361 11,808 10,879 12,241 13,723 13,050 13,482 11,278 10,127 11,120 11,012 12,229 11,741 12,256 10,822

Total attendances within 4 hours 30,825 33,865 25,399 29,781 10,405 9,611 10,809 11,591 11,088 11,186 8,819 7,829 8,751 9,222 10,584 9,975 10,186 9,333

M18b% of A&E attendances where service

user was admitted, transferred or

discharged within 4 hours

95% 88.3% 84.1% 78.1% 86.7% 88.1% 88.3% 88.3% 84.5% 85.0% 83.0% 78.2% 77.3% 78.7% 83.7% 86.5% 84.9% 83.1% 86.2%


Serious Incident Numbers

SummaryNHS

ImprovementQuality

Business Unit

Change Programme


Serious Incident other: There were 2 “other” serious incidents,

Reporting Timescales: There were 3 SI reports completed in August 2018, Two took 16 weeks, one took 15 weeks to

resolve: Common to each was delays caused by capacity of investigators.

This data is monitored in more detail via the Quality and Safety Committee (QSC) on a quarterly basis.

Indicator No.

17/18Out-turn

This month's performance

18/19 Year to Date

Q3 28 4 21

0

1

2

3

4

5

6

7

8

Aug - 17 Sep - 17 Oct - 17 Nov - 17 Dec - 17 Jan - 18 Feb - 18 Mar - 18 Apr - 18 May - 18 Jun - 18 Jul - 18 Aug - 18

Aug - 17 Sep - 17 Oct - 17 Nov - 17 Dec - 17 Jan - 18 Feb - 18 Mar - 18 Apr - 18 May - 18 Jun - 18 Jul - 18 Aug - 18

Suspected Suicides 1 1 0 2 0 1 3 1 3 1 1 4 2

Serious incidents Other 1 5 1 1 0 1 1 1 1 7 0 0 2


Workforce – Appraisal and Mandatory Training

SummaryNHS

ImprovementQuality

Business Unit

Change Programme


Measure Target Trajectory

Graph Key

Indicator

No.Indicator

17/18

outturn

18/19

TargetNumerator Denominator

Current

Performance

FOT

18/19Graph

Q17 % Fire Training90.00%

(80%

target)

95% 2569 2797 91.85%

% Infection

Prevention Training88.22% 80% 2434 2797 87.02%

% Moving &

Handling Training87.33% 80% 2380 2689 88.51%

Q17a

% Information

Governance Training

- Substantive Staff

Only

95.37% 95% 2417 2573 93.94%

Q17b% Information

Governance Training

- Tertiary Staff Only

97.86% 95% 346 365 94.79%

Q17c

% Information

Governance Training

- Substantive and

Tertiary Staff

Combined

95.68% 95% 2763 2939 94.04%

Q18% Staff Receiving

Appraisal79.01% 80% 2046 2509 81.55%

70.0%

80.0%

90.0%

100.0%

Sep-17

Oct-17

Nov-17

Dec-17

Jan-18

Feb-18

Mar-18

Apr-18

May-18

Jun-18

Jul-18

Aug-18

70.00%

80.00%

90.00%

100.00%

Sep-17

Oct-17

Nov-17

Dec-17

Jan-18

Feb-18

Mar-18

Apr-18

May-18

Jun-18

Jul-18

Aug-18

70.0%

80.0%

90.0%

100.0%

Sep-17

Oct-17

Nov-17

Dec-17

Jan-18

Feb-18

Mar-18

Apr-18

May-18

Jun-18

Jul-18

Aug-18

70.00%

80.00%

90.00%

100.00%

Sep-17

Oct-17

Nov-17

Dec-17

Jan-18

Feb-18

Mar-18

Apr-18

May-18

Jun-18

Jul-18

Aug-18

70.0%

80.0%

90.0%

100.0%

Sep-17

Oct-17

Nov-17

Dec-17

Jan-18

Feb-18

Mar-18

Apr-18

May-18

Jun-18

Jul-18

Aug-18

70.0%

80.0%

90.0%

100.0%

Sep-17

Oct-17

Nov-17

Dec-17

Jan-18

Feb-18

Mar-18

Apr-18

May-18

Jun-18

Jul-18

Aug-18

70.0%

80.0%

90.0%

100.0%

Sep-17

Oct-17

Nov-17

Dec-17

Jan-18

Feb-18

Mar-18

Apr-18

May-18

Jun-18

Jul-18

Aug-18


SummaryNHS

ImprovementQuality

Business Unit

Change Programme


Workforce – Mandatory Training – Role Specific


Graph Key

Indicator

No.Indicator

17/18

outturn

18/19


Current

Performance

FOT

18/19Graph

% Equality &

Diversity Training84.56% 80% 2566 2781 92.27%

% Prevent Training 91.40% 80% 2588 2781 93.06%

% Risk Management

Training72.55% 80% 2186 2781 78.60%

% Safeguarding

Adults – Level 1

Training

90.81% 80% 606 656 92.38%

% Safeguarding

Adults – Level 2

Training77.48% 80% 1551 1875 82.72%

% Safeguarding

Adults – Level 3

Training83.33% 80% 127 149 85.23%

70.0%

80.0%

90.0%

100.0%

Apr-18

May-18

Jun-18

Jul-18

Aug-18

Sep-18

Oct-18

Nov-18

Dec-18

Jan-19

Feb-19

Mar-19

70.0%

80.0%

90.0%

100.0%

Apr-18

May-18

Jun-18

Jul-18

Aug-18

Sep-18

Oct-18

Nov-18

Dec-18

Jan-19

Feb-19

Mar-19

70.0%

80.0%

90.0%

100.0%

Apr-18

May-18

Jun-18

Jul-18

Aug-18

Sep-18

Oct-18

Nov-18

Dec-18

Jan-19

Feb-19

Mar-19

70.0%

80.0%

90.0%

100.0%

Apr-18

May-18

Jun-18

Jul-18

Aug-18

Sep-18

Oct-18

Nov-18

Dec-18

Jan-19

Feb-19

Mar-19

70.0%

80.0%

90.0%

100.0%

Apr-18

May-18

Jun-18

Jul-18

Aug-18

Sep-18

Oct-18

Nov-18

Dec-18

Jan-19

Feb-19

Mar-19

70.0%

80.0%

90.0%

100.0%

Apr-18

May-18

Jun-18

Jul-18

Aug-18

Sep-18

Oct-18

Nov-18

Dec-18

Jan-19

Feb-19

Mar-19


SummaryNHS

ImprovementQuality

Business Unit

Change Programme


Workforce – Mandatory Training – Role Specific


Graph Key

Indicator

No.Indicator

17/18

outturn

18/19


Current

Performance

FOT

18/19Graph

% Safeguarding

Children – Level 1

Training91.27% 80% 592 649 91.22%

% Safeguarding


Training75.13% 80% 865 1131 76.48%

% Safeguarding


- 3Yrs Training82.63% 80% 397 461 86.12%

% Safeguarding


- 1Yrs Training89.15% 80% 393 433 90.76%

% Safeguarding


Training

83.33% 80% 10 11 90.91%

Corporate Welcome tbc 80% 28 37 75.68%

Health & Safety tbc 80%

70.0%

80.0%

90.0%

100.0%

Apr-18

May-18

Jun-18

Jul-18

Aug-18

Sep-18

Oct-18

Nov-18

Dec-18

Jan-19

Feb-19

Mar-19

70.0%

80.0%

90.0%

100.0%

Apr-18

May-18

Jun-18

Jul-18

Aug-18

Sep-18

Oct-18

Nov-18

Dec-18

Jan-19

Feb-19

Mar-19

70.0%

80.0%

90.0%

100.0%

Apr-18

May-18

Jun-18

Jul-18

Aug-18

Sep-18

Oct-18

Nov-18

Dec-18

Jan-19

Feb-19

Mar-19

70.0%

80.0%

90.0%

100.0%

Apr-18

May-18

Jun-18

Jul-18

Aug-18

Sep-18

Oct-18

Nov-18

Dec-18

Jan-19

Feb-19

Mar-19

70.0%

80.0%

90.0%

100.0%

Apr-18

May-18

Jun-18

Jul-18

Aug-18

Sep-18

Oct-18

Nov-18

Dec-18

Jan-19

Feb-19

Mar-19

70.0%

80.0%

90.0%

100.0%

Apr-18

May-18

Jun-18

Jul-18

Aug-18

Sep-18

Oct-18

Nov-18

Dec-18

Jan-19

Feb-19

Mar-19


Measure Long term sickness threshold (2.5%) Long term sickness

Target Short term sickness threshold (1.5%) Short term sickness

Trend

Graph Key

Workforce – Labour Turnover, Vacancy and Absence

SummaryNHS

ImprovementQuality

Business Unit

Change Programme


Indicator

No.Indicator

17/18

outturn

18/19

TargetCurrent Performance

FOT

18/19Graph

Q19% Labour

Turnover11.30% 10% 11.30%

Q20% Sickness

absence rate 4.96% 4% 5.41%

Q21

% Vacancy rate (Budgeted WTE

less staff in post

WTE as a

percentage of

budgeted WTE)

9.82% 10% 6.65%

Indicator

No.Indicator

17/18

outturn

18/19

Target

Numer-

ator

Denom-

inator

Current

Perform-

ance

FOT

18/19Graph

Q21

% Recruitment

rate (Number of

posts being actively

recruited to as a

percentage of staff

in post)

7.48% 10% 335 3056 10.96%

8.00%

9.00%

10.00%

11.00%

12.00%

13.00%

Sep-17

Oct-17

Nov-17

Dec-17

Jan-18

Feb-18

Mar-18

Apr-18

May-18

Jun-18

Jul-18

Aug-18

0.00%1.00%2.00%3.00%4.00%5.00%6.00%7.00%

Sep-17

Oct-17

Nov-17

Dec-17

Jan-18

Feb-18

Mar-18

Apr-18

May-18

Jun-18

Jul-18

Aug-18

0.00%

2.00%

4.00%

6.00%

8.00%

10.00%

12.00%

Sep-17

Oct-17

Nov-17

Dec-17

Jan-18

Feb-18

Mar-18

Apr-18

May-18

Jun-18

Jul-18

Aug-18

0.00%

2.00%

4.00%

6.00%

8.00%

10.00%

12.00%

Aug-17

Sep-17

Oct-17

Nov-17

Dec-17

Jan-18

Feb-18

Mar-18

Apr-18

May-18

Jun-18

Jul-18


SummaryNHS

ImprovementQuality

Business Unit

Change Programme


Q23a - Safer Staffing: Inpatient Services – August 2018

Risks:

- Vacancy hotspots are still DAU, Thornton, Bracken and Heather (largely

qualified roles); meaning safe staffing levels cannot be sustained long term

without posts being permanently recruited to. The process of permanent

recruitment continues, with 58 qualified nursing posts currently being

recruited to (39 in pipeline), 30 support worker posts (23 in pipeline) and 13

OT/ OT Assistant posts (6 in pipeline).

- Sub optimal rostering may be impacting on bank and agency use.

Contingency & Mitigating Actions:

- Roster review / risk assessment in place on a daily basis

- Weekly ward meetings to forward plan rosters and re-distribute staff across

services . Redeployment s now recorded in the system to provide audit trail.

- Roster Development meeting to review roster performance, plan / monitor

strategic roster system changes with Inpatient wards and report into the

monthly Safer Staffing Steering Group. Current actions include pilot and

monitoring of 12 hour shift s, participation in testing for the national acuity

model for Mental Health; implementation of the SafeCare module within

HealthRoster (following completion of the acuity model testing – launch of

the acuity tool due October 2018). Performance monitoring actions include,

review of headroom, review of annual leave patterns, monitoring of unused

contract hours, monitoring of WTD breaches, and review of booking reasons

for bank and agency shifts.

- Full programme of recruitment fayres planned over the next 12 months.

The most recent recruitment day on the 16th June (focus on Specialist

Inpatient Services) resulted in a further 16 posts being recruited to. Further

recruitment days are scheduled; along with a recruitment campaign being

developed between BDCFT, the Pulse and Job Centre Plus (following a

similar campaign last year) to be planned for later this year.

- Proactive work around retention is ongoing and includes working closely

with universities to recruit newly qualified nurses, and a review of the

preceptorship programme, Additional MH nurse training placements

(increase to 36) also available this year. Retire and return and flexible

working is also being promoted via roadshows.

- The safer staffing steering group has just completed an annual safer staffing

review with each ward to look at skill mix possibilities and establishment

levels against need of the unit as recommended by the National Quality

Board – Safe, Sustainable and Productive Staffing document.

Narrative on staffing levels on 13 wards during August 2018

Exact/over compliant shifts - Over compliant shifts continue to be

monitored across all wards during weekly planning meetings within service.

Hotspots during August were on the Dementia Assessment Unit (DAU),

Clover (PICU), ATU, Thornton, Heather and Ashbrook wards due to acuity

(complexity of need) and the requirement for skill mix within the units. 36% of

shifts in August were requested for Specialing and Escorting over and above

baseline safer staffing requirements (3% decrease from July). Vacancy

remains the highest request reason for booking at 42%, (decreased from 44%

in July), hotspot areas remain as DAU, Thornton, Bracken and Heather.

Under compliant shifts - 42 incidents were reported relating to staffing

shortages in August 2018 (decrease of 6 from 48 in July), 1 recorded on the

Acute and 41 in Specialist inpatient services, mainly due to acuity, difficulty in

providing cover, and staff not attending shifts. All (IREs) incidents relating to

staff shortfalls however were managed locally or escalated and/or mitigated.

Sickness cover increased in August (from 4.6%) with 5.3% of bank and

agency bookings being attributed to sickness.

Non-compliant shifts – No shifts were identified as being non-compliant in

August.

94.29%

5.71%0.00%

Staffing Level Compliance

Exact/ Over Compliance Under Compliance Non Compliance

No. shifts

Exact/ Over Compliance 2246

Under Compliance 136

Non Compliance 0


SummaryNHS

ImprovementQuality

Business Unit

Change Programme


Q23a - Safer Staffing: Inpatient Services – August 2018

Main 2 Specialties

on each ward

Specialty 1

Total

monthly

planned

staff

hours

Total

monthly

actual

staff

hours

Total

monthly

planned

staff

hours

Total

monthly

actual

staff

hours

Total

monthly

planned

staff

hours

Total

monthly

actual

staff

hours

Total

monthly

planned

staff

hours

Total

monthly

actual

staff

hours

Fern710 - ADULT MENTAL

ILLNESS1080 981 720 877.5 360 444 1080 1032 90.8% 121.9% 123.3% 95.6% 458 3.1 4.2 7.3

Heather710 - ADULT MENTAL

ILLNESS1080 1038 1200 1372.5 360 360 1440 1416 96.1% 114.4% 100.0% 98.3% 631 2.2 4.4 6.6

Bracken710 - ADULT MENTAL

ILLNESS720 540 1080 1605 360 492 1080 1380 75.0% 148.6% 136.7% 127.8% 524 2.0 5.7 7.7

Ashbrook710 - ADULT MENTAL

ILLNESS720 819 1080 1758 360 420 1080 1704 113.8% 162.8% 116.7% 157.8% 716 1.7 4.8 6.6

Maplebeck710 - ADULT MENTAL

ILLNESS728 752 1068 1356 360 372 1080 1380 103.3% 127.0% 103.3% 127.8% 539 2.1 5.1 7.2

Oakburn710 - ADULT MENTAL

ILLNESS720 796 1080 1386 360 672 1080 1116 110.6% 128.3% 186.7% 103.3% 577 2.5 4.3 6.9

Baildon710 - ADULT MENTAL

ILLNESS900 795 1125 1170 279 279 558 577 88.3% 104.0% 100.0% 103.4% 279 3.8 6.3 10.1

Ilkley710 - ADULT MENTAL

ILLNESS810 773 1193 1178 279 279 558 558 95.4% 98.7% 100.0% 100.0% 311 3.4 5.6 9.0

Thornton710 - ADULT MENTAL

ILLNESS1080 998 2070 3255 279 279 837 1562 92.4% 157.2% 100.0% 186.6% 318 4.0 15.1 19.2

Assessment & Treatment

Unit (LD)

700 - LEARNING

DISABILITY893 863 1673 3353 279 279 837 1395 96.6% 200.4% 100.0% 166.7% 171 6.7 27.8 34.4

Clover (PICU)710 - ADULT MENTAL

ILLNESS450 593 900 1635 279 372 1116 2130 131.8% 181.7% 133.3% 190.9% 259 3.7 14.5 18.3

Step Forward (Rehab)710 - ADULT MENTAL

ILLNESS690 690 660 638 279 279 558 558 100.0% 96.7% 100.0% 100.0% 306 3.2 3.9 7.1

Dementia Assessment Unit

(DAU)

710 - ADULT MENTAL

ILLNESS900 908 3150 5438 878 878 1463 3276 100.9% 172.6% 100.0% 223.9% 526 3.4 16.6 20.0

Registere

d

midwives/

nurses

Care Staff Overall

Care StaffAverage

fill rate -

registered

nurses/

midwives

(%)

Average

fill rate -

care staff

(%)

Average

fill rate -

registered

nurses/

midwives

(%)

Average

fill rate -

care staff

(%)

Cumulative

count over

the month

of patients

at 23:59

each day

Ward name

Registered

midwives/nursesCare Staff

Registered

midwives/nurses

Day Night Day Night Care Hours Per Patient Day (CHPPD)


Quality Assurance

Indicator

NumberTarget

Target met this

month Yes/No

Q5 Never Events Yes

Q7 Meet Central Alert System (CAS) timelines Yes

Q10 No MRSA bacteraemia cases Yes

Q11 No Methicillin sensitive staphylococcus aureus (MSSA) bacteraemia cases Yes

Q12 No Clostridium difficile (C.diff) cases Yes

Q32 No Complaints to Information Commissioners Office (ICO) Yes

Q33 No Information Governance Serious Incidents (STEIS) Yes

Q34 Maintain Mixed sex accommodation status Yes

Q35 Meet Dental Referral To Treatment within 52 weeks Yes

Q37 Maintain Publication of the Formulary on Provider’s website Yes

Q38aMeet duty of candour requirement to notify the relevant person of a suspected or actual reportable

patient safety incidentYes

Q38b Number of duty of candour incidents One

SummaryNHS

ImprovementQuality

Business Unit

Change Programme



Service Dashboard

SummaryNHS

ImprovementQuality

Business Unit

Change Programme


Adult Physical Health Children's Services Mental Health Acute and Community Specialist/Admin/Dental

Indicator

Reporting

Period

Target (if

applicable)C

om

mu

nit

y N

urs

ing

an

d

Co

mp

lex

Care

Sp

ec

iali

st

Se

rvic

es

: C

on

tin

en

ce

,

Tis

su

e V

iab

ilit

y, F

all

s

Pa

llia

tive

Care

, H

os

pic

e a

t

Ho

me

, F

as

t T

rac

k

Po

dia

try

Sp

ee

ch

& L

an

gu

ag

e T

he

rap

y

Sa

feg

ua

rdin

g, L

oo

ke

d A

fte

r

Ch

ild

ren

, Y

ou

th O

ffe

nd

ing

Bra

dfo

rd S

ch

oo

l N

urs

ing

an

d

Sp

ec

iali

st

Sc

ho

ol N

urs

ing

Bra

dfo

rd H

ea

lth

Vis

itin

g

Bra

dfo

rd F

am

ily N

urs

e

Pa

rtn

ers

hip

Wa

ke

fie

ld S

ch

oo

l N

urs

ing

Wa

ke

fie

ld H

ea

lth

Vis

itin

g

Wa

ke

fie

ld F

am

ily N

urs

e

Pa

rtn

ers

hip

Ad

ult

Co

mm

un

ity M

en

tal

Hea

lth

(in

clu

din

g d

ua

l d

iag

no

sis

)

Ch

ild

& A

do

les

ce

nt

Me

nta

l

Hea

lth

Ea

rly I

nte

rve

nti

on

in

Ps

yc

ho

sis

Ps

yc

ho

log

ica

l T

he

rap

ies

Ac

ute

Care

Se

rvic

es

-In

pa

tie

nts

Fir

st

Res

po

ns

e

Inte

ns

ive

Ho

me

Tre

atm

en

t T

ea

m

Le

arn

ing

Dis

ab

ilit

ies

(Co

mm

un

ity)

Old

er

Pe

op

le C

om

mu

nit

y M

en

tal

Hea

lth

Ad

min

istr

ati

on

Se

rvic

es

Inp

ati

en

ts -

Sp

ec

iali

st

Se

rvic

es

Den

tal

Se

rvic

es

Number of incidents2018/19

quarter 1495 1 4 10 15 6 20 31 1 2 5 4 137 12 9 5 1009 9 32 16 31 40 770 55

Number of near misses2018/19

quarter 17 0 2 0 0 0 3 0 0 0 2 0 2 1 0 0 56 0 0 0 0 0 12 5

Number of serious incidents2018/19

quarter 11 0 0 0 1 0 1 0 0 0 0 0 3 0 0 0 2 1 1 0 2 0 0 0

Number of compliments2018/19

quarter 115 3 10 0 0 1 4 0 0 0 0 0 10 1 0 6 33 2 1 6 2 0 14 11

Number of complaints2018/19

quarter 10 0 0 0 0 0 0 0 0 0 0 0 5 1 0 2 2 2 0 0 0 0 0 1

Number of Friends and

Family Test responses

2018/19

quarter 1239 21 0 60 16 36 102 178 1 0 47 4 8 10 0 2 60 7 4 78 14 6 44 230

Friends & Family Test: %

likely to recommend the

service

2018/19

quarter 196% 100% 98% 94% 92% 91% 98% 100% 94% 100% 100% 100% 100% 82% 100% 50% 99% 100% 67% 82% 95%

Whole time equivalents (in

post)Jul-18 320.1 29.8 28.2 40.6 58.7 18.3 74.1 170.2 7.1 35.9 86.8 8.8 121.0 103.3 48.3 136.3 203.2 42.0 43.8 62.7 62.8 160.1 165.5 74.5

Safer staffing compliance/

staffing ratioJul-18

Comm

matronsFrom 2018/19

See

slides

See

slides

Sickness absence Jul-18 < = 4%

Turnover12 months

to Jul 18< = 10%

Fire safety training Jul-18 > = 95%

Infection prevention training Jul-18 > = 80%

Moving & handling training Jul-18 > = 80%

Information governance

trainingJul-18 > = 95%

Staff receiving appraisal Jul-18 > = 80%

Finance year to date

variance

2018/19

year to date

Finance forecast outturn

variance

2018/19

forecast

Contacts2018/19 Q1 93,124 4,324 3,541 18,868 6,828 12,499 4,318 105 2,968

Change ↑ ↑ ↓ ↓ ↑ ↓ ↓ ↓ ↓

Achievement of contractual

indicators

2018/19

quarter 1

Board walkabout visit(s) to

service in 2017/182017/18 Yes Yes No Yes Yes No Yes Yes No Yes Yes Yes Yes No No No No No No Yes Yes No Yes Yes

Board walkabout visit(s) to

service in 2018/192018/19 Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes


SummaryNHS

ImprovementQuality

Business Unit

Change Programme


Directors Business & Transformation Programme Monthly Summary

The purpose of Directors Business & Transformation Programme is to ensure effective project governance, delivery, monitor and

approve Project Initiation and risks, issues and exceptions and ensure a consistent approach to Quality Impact Assessments (QIA).

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

COST IMPROVEMENT PLAN - 2018-19 3-10% shortfall but with a plan to get back on track

>3% shortfall and robust plan in place

Service AreaDeputy

DirectorStatus

Planned

Target £

Achieved

YTD £

Achieved

YTD %

Forecasted

end year £

QIA

approved

QIA Not

Approved Aug July June

Programme Overview All

34% achieved in M5 h £1.5m are non recurrent mitigations. Currently

estimated for a £500k shortfall which will be covered by the £500k reserve.

List of additional CIP ideas now gathered and work underway to bring

forward sustainable CIP's and shape for 19/20

7,351,111 2,504,029 34% 6,851,004 5,484,111 1,867,000

2.3.1 Mental Health Acute & Community Simon Long

Care Closer to Home transformation progressing across all workstreams.

Review of vision to revise PID/Business case with a longer term view.

Workforce models reviewed at EMT Sept and QIA rescheduled for panel in

October. 2 shift trial in acute Inpatients shown positive survey response -

full report /feedback in October.

2,026,905 380,460 19% 1,041,505 1,061,905 965,000

1.7 Adult Physical HealthPhil

Hubbard

Diabetes pathway remodelling progressing. CIP savings on track -

underspends being offset against overall deficit 89,000 31,250 35% 155,917 89,000 -

3.8 Specialist Inpatient, Dental, adminAllison

Bingham

Progressing to plan with admin restructure work underway. Overspend on

DAU and ATU continue to be intensively supported and resource changes -

e.g pharmacy tech, rostering, shifts.

1,279,318 238,330 19% 510,324 401,318 878,000

1.8 Children's BradfordPhil

Hubbard

Re tender for 0-19 service work plan and support for staff

Forecasted Local Authority reductions, working towards Digital Innovation

starting with e-forms and web development however delay in tender

release and estimates

1,089,000 415,250 38% 1,088,750 1,089,000 -

1.9 Children's WakefieldPhil

Hubbard

Restructure complete

IT infrastructure still to complete - this has been a priority for a number of

months

94,000 75,833 81% 182,833 70,000 24,000

7.3-7.4 Estates & Facilities - Estates

Rationalisation

Andrew

Morris

Plan in place is to be QIA's in September and achieve all estates reduction

savings via estates management such as rent free periods, and 2017/18

recurrent schemes.

741,000 256,305.56 35% 723,417 741,000 -

7.5 ProcurementClaire

Risdon

Plan and approach was approved at QIA in August. Steering group still taking

place to finalise apportionment principles. 250,000 56,000 22% 250,000 250,000 -

7.9 HR Interpreting Services Fiona

Sherburn

On track to exceed forecasted savings however signficiant work underway to

deliver consistently across all services behaviour change/process changes

operationally

34,000 - 0% 34,000 34,000 -

Corporate Schemes (PMO, Finance,

Informatics, Quality, Performance, Occ Health,

HR)

All Corporate

Significant additional mitigations suggested and priorities to be confirmed at

Directors Business & Transformation in Oct 2018. A benchmarking peer

review for all corporate services is underway.

1,747,888 1,050,600 60% 2,756,558 1,564,888 -


SummaryNHS

ImprovementQuality

Business Unit

Change Programme


Finance Key Measures

Favourable variance

Adverse variance under £100k or 10%

Adverse variance £100k or 10% or greater

Note for RAG for CIPs – 10% variance is Amber, over 10% is Red

After taking into account the high risk CIP reserve performance is forecast to be £2,006k behind plan. A key focus

remains recurrent scheme delivery and/or substitution and is subject to FBIC scrutiny.

Plan ActualVariance

(Adv)/FavRAG Plan Actual

Variance

(Adv)/FavRAG

Surplus/(Deficit) including Technical Adjustments (618) (581) 37 1,081 1,181 100

Control Total Performance (618) (581) 37 1,081 1,181 100

CIPs (before High Risk Reserve) 2,517 2,517 0 7,351 6,851 (500)

Capital Expenditure 1,666 1,115 551 4,276 4,276 0

Cash Balance 15,883 19,264 3,381 16,230 16,230 0

Use of Resources 3 2 1 1 1 0

Forecast

£000's

Year to Date


SummaryNHS

ImprovementQuality

Business Unit

Change Programme


(1,500)

(1,000)

(500)

0

500

1,000

1,500

(500)

(400)

(300)

(200)

(100)

0

100

200

300

400

500

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

Ye

ar

to D

ate

Pla

n a

& A

ctu

al -

£0

00

's

In M

on

th P

lan

& A

ctu

al -

£0

00

's

Control Total Performance

In Month Plan In Month Actual YTD Plan YTD Actual

0

1,000

2,000

3,000

4,000

5,000

6,000

7,000

8,000

0

100

200

300

400

500

600

700

800

900

1,000


YT

D P

lan

& A

ctu

al -

£0

00

's

In M

on

th P

lan

& A

ctu

al -

£0

00

's

Cost Improvement Programmes

In Month Plan In Month Actual YTD Actual YTD Plan

Workforce KPIs - Agency Expenditure Cap

(Adv)/Fav

Variance

from Cap

£000's

RAGChange in

month

Total Agency Expenditure Cap in Month 29 Improvement

Medical Agency Expenditure Cap in Month (8) Deterioration

Workforce KPIs - Agency Expenditure Cap

(Adv)/Fav

Variance

from Cap

%

RAGChange in

month

Qualified Nursing Expenditure Cap - In Month 1.24% Improvement

Qualified Nursing Expenditure Cap - YTD 1.01% Improvement

Workforce KPIs - Price & Wage Cap BreachesNo. of

ShiftsRAG

Change in

month

Price Cap Breaches in Month - Medical 182 Decrease

Wage Cap Breaches in Month - Medical 182 Decrease

Price Cap Breaches in Month - Non Medical 0 No change

Wage Cap Breaches in Month - Non Medical 0 No change

Workforce KPIs - Average cost per WTE £000's RAGChange in

month

Average cost per WTE 39 Decrease

0

500

1,000

1,500

2,000

2,500

3,000

3,500

4,000

4,500

0

50

100

150

200

250

300

350

400

450

500


YT

D P

lan

& A

ctu

al -

£0

00

's

In M

on

th P

lan

& A

ctu

al -

£0

00

's

Capital Expenditure

In Month Plan In Month Actual YTD Actual YTD Plan8,000

10,000

12,000

14,000

16,000

18,000

20,000

22,000


In Month Cash Balances

Plan Actual 2017/18

-

1

2

3

4

Q1 Q2 Q3 Q4

Quarterly Use of Resources

Plan Actual


Trust CIP Exceptions and Substitutions

SummaryNHS

ImprovementQuality

Business Unit

Change Programme


Reason for Variance & Mitigating Actions

CIPs have under achieved by £584k in month 5 and forecast delivery risk of £2,006k, however this is projected to be fully mitigated by

non recurrent measures and by deploying the High Risk CIP reserve. The plan for 2018/19 included non recurrent CIPs of £1,195k

where recurrent plans are required to be identified – principally a bed occupancy reduction scheme.

The forecast reflects projected shortfalls against a number of schemes, including:

• Medical Staffing (£528k) due to the ongoing use of Locums to backfill vacancies, sickness and junior doctor gaps

• Acute Inpatients (£437k) due to the high usage of Agency and bank staff due to sickness, vacancies and observations. Mitigating

actions are being developed to utilise existing staff more effectively, improve retention and reduce the use of temporary staff.

• ATU, DAU, & Inpatients (£863k) due to the high usage of bank and Agency staff to cover sickness, vacancies, special observations

and maternity leave and (£36k) on Admin This is being mitigated by underspends within Dental and Admin £130k

Actions have commenced to identify recurrent solutions to address the £3,201k non recurrent CIP position in readiness for 2019/20.

These include developing the care closer to home business case, corporate benchmarking and establishing a CIP hopper to identify new

schemes for deployment in 2018/19.

Plan Actual

Variance

(Adv)/Fav Recurrent

Non

Recurrent

Green 5,484 5,235 (249) 4,040 1,195

Not yet due for QIA 24 24 0 24 0

Amber - Scheduled to QIA in July 1,843 86 (1,757) 86 0

Non Recurrent Mitigations 0 1,506 1,506 0 1,506

Total CIPs 7,351 6,851 (500) 4,150 2,701

High Risk Reserves 500 500 500

Total CIPs net of reserves 7,351 7,351 0 4,150 3,201

QIA RAG Status

Outturn £'000's


Informatics

SummaryNHS

ImprovementQuality

Business Unit

Change Programme


Programme Overview

Q3 Q4 Q1 Planned Activity Go Live &

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

GDPR ◊ ◊ ◊ 25/05/18

MH Implementation ◊ 31/10/18

Cyber Security Mar 19 &On Going

Wide Area Network ◊ Sep 2018

Wi-Fi ◊ Dec 2018

Call Centre review Scoping

Non-UK residents Scoping

Telecommunications Mar 19 &On Going

Student Nurses ◊ ◊ July 2018

Infrastructure Storage Oct 18 –Jan 2019

Infrastructure Networks ◊ ◊ Sep 2018

Little Minds Matter Scoping

Estates support ◊ Mar2019

Mobile Handsets ◊ Awaiting Approval

Key : Delivered On Track Effected Delivery At Risk ◊ = Milestone ---- Delay


SummaryNHS

ImprovementQuality

Business Unit

Change Programme


Informatics Key Statistics

Service Area Indicator Target April May June Details

IT Infrastructure

(connectivity)

Service availability (WAN) 99.5% >99.9% >99.9% >99.9%10 sites reconnected following failure

on Embed network in January 2018

Number of incidents 0 unk unk 3 New indicator

Telephony

(Mobile)Mobile combined data availability 99% 99.87% 99.51% 99.43%

SMS performance over 99% and

voice over 98% over the last 3

months

Asset Management Total number of computer devices N/ATotal:

3,063

Total:

3,188

Total:

3,243

Modernisation by replacing desktops

with laptops in particular Estate

rationalisation initiatives and student

nurses

Information

Governance &

Records

Management

Number of requests for personal

information received

(police/courts/patient related etc.)

Response

times with

40

calendar

days

(100%)

93/102

achieved

(91%)

74/93

achieved

(80%)

103/115

achieved

(90%)Implementation of GDPR from 25th

May with Subject Access Requests

response time from 40 to 28 days

Complexity of queries also

increasingInformation

Governance &

Records

Management

Number of requests for information

received under the Freedom of

Information Act

Response

times with

20

working

days

(100%)

93/104

achieved

(90%)

76/88

achieved

(86%)

65/72

achieved

(90%)

Cyber SecurityNumber of incidents

(reported externally)0 0 0 0

Risk: Mobile phones security

updates now ceased from Microsoft

Trial of a MDM solution


Informatics

SummaryNHS

ImprovementQuality

Business Unit

Change Programme


Work Force Target Q1 18/19 Trend Comments

Sickness 4% 4.18%Some long term absence affected part of the Team. These are

managed in accordance with Trust Policies

Mandatory training 80% 92.0% Downward trend and above trust target

Appraisal 80% 68.1%Restructure due to be implemented October 2018 which will

clarify roles and responsibilities as well as line management

responsibilities

Finance Status

RevenueUnderspent position on both pay (unfilled vacancies or timelag in recruitment activities between internal appointments and external backfills) and non-pay budgets.

Capital Underspend position addressed through reprofiling. End of year forecast on track to balance

Cost improvement Challenging CIP target of £448K, £348K saving have been identified so far.

Internal Audit – Q1 Status Notes

Management of Telephony Services and Contracts (2016/17)

On-hold

1 action remaining – work on-going on 2017/18 invoice cleansing with historical invoices and associated debt coming to light from Telephony Supplier. Expected to be cleared by end of 2018.

Mental Health Clinical System implementation

Completed Significant assurance

2018/19 internal audit programme on track, due to cover Information Governance, information systems, cyber security and service delivery and operations (starters/leavers and change process)


SummaryNHS

ImprovementQuality

Business Unit

Change Programme


Estates and Facilities Service Performance for Operational Services – Community Sites

Hotel Services – Cleanliness auditsEstate Maintenance – Response Performance

Patient Transport, Removal & Pest Control – Response Rates

Cleanliness audits within in-patient sites are undertaken on a monthly

basis. All cleanliness audits achieved the performance target of >90%.

The chart shows achievement of target response against all task priorities

within Estate Maintenance. 372 tasks were logged in August across all

priorities. One task on the 4 hour response time did not meet the target

timescale by less than 1 hour.

0%

20%

40%

60%

80%

100%

4 hrs 1 WD 3 WD 1 WK 2 WK 4+ WK

Food Services – Mealtime Assessments

Mealtime assessments are undertaken on a monthly basis; all wards

achieved and exceeded target performance. A selection of patient

comments received include: "All food here is fantastic and I like

everything “ and “everything was spot on” from Oakburn Ward, "I love the

food here it is always great“ and “all the food here is very nice” from

service users on Maplebeck and “I liked my lunch of chilli it was not too

spicy.” from a service user on Step Forward Centre.

0%

20%

40%

60%

80%

100%

Ashbrook Maplebeck Oakburn Clover SFC DAU Ilkley Thornton Baildon Bracken ACMHVisitorsCentre

Ass

ess

men

t sc

ore

targ

et

abo

ve 8

0%

All tasks are achieving performance target for response rates.

Key:

Target performance Achieving target

< 25% off target > 25% off target

Response rate: the % of reactive tasks completed by the deadline set

and agreed within Concept Evolution

0%

20%

40%

60%

80%

100%

PTS Pest Control Inpatient area Removals in patient area


Key:

Target performance Achieving target

< 25% off target > 25% off target

Response rate: the % of reactive tasks completed by the deadline set

and agreed within Concept Evolution

All tasks are achieving performance target for response rates.

The chart shows achievement of target response against all task priorities

within Estate Maintenance. 147 tasks were logged in August, all task

priorities met or exceeded KPI target performance.

0%

20%

40%

60%

80%

100%

PTS Pest Control Inpatient area Removals in patient area

SummaryNHS

ImprovementQuality

Business Unit

Change Programme


Estates and Facilities Service Performance for Operational Services – Community Sites

Cleanliness audits within BDCFT community properties are undertaken on

a quarterly basis by BDCFT. In this period all sites met and exceeded the

minimum performance target of 90%.

NHS Property Services (NHSPS) provide cleanliness audit assurance

where BFCFT services occupy NHSPS buildings; NHSPS reported no

exceptions in this period. Every 6 months BDCFT undertake either an

Infection Prevention Audit or a Cleanliness verification audit to validate

cleaning standards are being achieved.

Hotel Services – Cleanliness auditsEstate Maintenance – Response Performance

Patient Transport, Removal & Pest Control – Response Rates


Health and Safety – reporting Fire Safety – Fire Incidents

SummaryNHS

ImprovementQuality

Business Unit

Change Programme


Estates and Facilities: Health and Safety - Advisory Services

There has been one RIDDOR reportable incident in the past quarter.

The number of reported Health and Safety incidents remains relatively

consistent month to month.

Actions as a result of moderate or more severe incidents are shared with

teams involved in the incident to support service improvement and continued

safety of staff and service users.

Lessons learned following incidents are shared with teams

involved in the incident to support service improvement and

continued safety of staff and service users.

0 0 1 0 0

102

135

104 100121

5

0

73

2

0

50

100

150

H&S incidents with moderate or moresevere impact

H&S incidents with minor or no impact

RIDDOR reportable incidents

There have been 13 reported incidents related to fire alarm

activations from 1st June to 31st August 2018. There have been 6

fire incidents (detailed below) in this period.

Date Location Cause

11.06.18

Service user home

address

Service user accidently ignited

wallpaper rolls on stove

14.06.18 Ashbrook Ward

Service user set fire to paper

towel by phone box

14.06.18 Ashbrook Ward

Service user set fire in

incontinence pads in bathroom

05.07.18 Thornton Ward

Staff member accidentally set

fire to toast in toaster

06.07.18

Service user home

address

House next to community site

fire started spreading to building

22.07.18 ITC - Becklin Ward

Service User set fire to mattress

in room


SummaryNHS

ImprovementQuality

Business Unit

Change Programme


Estates and Facilities in Partnership with Operational Services: Environmental Risk Assessments

Estates Health, Safety & Security – Property Assessments Estates Fire Safety – Fire Risk Assessments

Operational Services in partnership with Estates & Facilities – Ligature Risk Assessments

Operational Services – Environment Risk Assessment Embeddedness

28 fire risk assessments have been completed between 1st

June 2018 and 31st August 2018.

Assessments are carried out as per the departmental fire safety

schedule.

There are no overdue risk assessments. There are a

number of ongoing actions which are within the 3 month

action plan.

35 health, safety & security property assessments have been

completed between 1st June 2018 and 31st August 2018.

Assessments are carried out as per the departmental assessment

schedule and tracker.

All risk assessments are in date, and currently there are no

outstanding actions that require escalation via Health and

Safety Group

Trust Policy requires that ligature risk assessments should be completed at a frequency in line with CQC guidance, at least every 12 months.

Operational services lead the Ligature assessment process, supported by Estates and Facilities, in partnership.

Ligature risk assessments within all inpatient areas comply with Policy and CQC requirements. There are 16 Inpatient areas for

which Ligature risk assessments are required; all are currently in date.

Ligature risk assessments within the privacy & dignity areas of community mental health & CAMHS areas commenced in April 2018 as a

new initiative. There are 11 properties in which ligature risk assessments are required; 10 are currently in date, the 1 exception is

Meridian House which is currently undergoing refurbishment. Ligature risk assessment is planned for completion prior to re-occupation by

CMHT.

Environmental risk assessment folders were introduced within inpatient areas in March 2018 to promote awareness, discussion and

responsiveness to all completed environmental risk assessments findings and associated action plans. The folders included risk

assessments completed at that point in time. Actions arising from risk assessments may relate to the estate/environment, or may require

operational input or response.

Operational services have ownership of the environmental risk assessment folders and undertake planned spot checks to ensure that folders

include all assessments that have been issued year to date and that Operational Service actions are completed and documented on

assessment.

Operational Service leads provide assurance that the latest copy of assessments are currently retained in the ward environment risk

assessment folders.


SummaryNHS

ImprovementQuality

Business Unit

Change Programme


Patient-Led Assessment of the Care Environment (PLACE)

Cleanliness Food

(overall)

Organisation

Food

Ward Food Privacy,

Dignity &

Wellbeing

Condition,

Appearance &

Maintenance

Dementia Disability

National Average 98.47% 90.17% 89.97% 90.52% 84.16% 94.33% 78.89% 84.19%

BDCFT Overall 98.95% 98.79% 95.69% 99.72% 96.80% 98.75% 88.71% 94.14%

Lynfield Mount

(includes Moorlands

View & DHH

buildings)

98.68% 98.91% 95.69% 99.62% 96.32% 98.58% 87.43% 93.97%

Airedale Centre for

Mental Health99.71% 98.43% 95.69% 100.00% 98.18% 99.23% 92.46% 94.64%

The below chart details Trust and locality PLACE performance against the national average across all healthcare organisations.

The results are very positive with BDCFT Overall and BDCFT individual site scores exceeding all National Average benchmark

scores.

The purpose of PLACE is to provide members of the public with a voice to improve NHS Services and, although we are very happy with the

results, there are Patient Assessor recommendations that the Trust will need to progress.

In line with PLACE requirements an action plan detailing these improvements is made public via the Trusts public-facing website.


SummaryNHS

ImprovementQuality

Business Unit

Change Programme


Assurance Reports from Committee Chairs

Assurance Report: Audit Committee 3 September 2018

Assurances

The Committee received and reviewed the annual report and accounts of the BDCFT Charitable Funds and received confirmation from the external

auditors that they would be issuing a “clean” audit report once the accounts and letter of representation had been signed. Subject to a couple of

minor amendments to the annual report, the Committee agreed to recommend to the Charitable Funds Committee that all of the documents were

appropriate for signature.

From Internal Audit, the Committee received three "significant assurance" reports and one “high assurance” report, covering:

• Clinical System Migration Project – Significant assurance

• Cost Improvement Programme – Significant assurance

• E-Rostering – Significant assurance

• Capital programme – High assurance

The Committee noted that most actions arising from internal audit reports were being cleared in accordance with the proposed timescales and,

where there are delays, these are either relatively minor or have good reason.

Assurances were also received in relation to:

• The programme to transfer continence services into a specialist service

• A review of the tendering and implementation processes for the Wakefield Children’s services

• Counter-fraud activity

• Losses and special payments - no significant untoward items.

• Waiver of standing orders - only used where necessary and in accordance with Standing Financial Instructions (SFIs)

Board to note: Matters of escalation

• The Committee noted that the internal audit report on E-Rostering had identified breaches of the Working Time Directive and referred this to

Finance, Business and Investment Committee (FBIC) for further investigation.

• The Committee noted that the internal audit report on the Clinical Information Migration project was limited in scope to project management

processes up to implementation. Therefore, it asked for a further report back from Internal Audit/FBIC in relation to issues and learning from

implementation.

• In view of concerns raised by Q&SC, the Committee asked FBIC to review the Medicines Management service level agreement.


SummaryNHS

ImprovementQuality

Business Unit

Change Programme


Assurance Reports from Committee Chairs

The Quality and Safety Committee (QSC) met on 3 August 2018 and 14 September 2018. As part of the transition between previous and

next QSC chairs, the August and September assurance reports are being prepared jointly by both chairs. Both reports will be tabled at the

Board meeting.

Documents

Board Integrated Performance Report 27 September 2018 ... · Board Integrated Performance Report - September 2018 2 of 30 The purpose of this Integrated Performance Report is to assist