Board Integrated Performance Report 27 September 2018 ... · Board Integrated Performance Report -...
Transcript of Board Integrated Performance Report 27 September 2018 ... · Board Integrated Performance Report -...
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
2 of 30Board Integrated Performance Report - September 2018
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
Finance Enablers Well Led
3 of 30Board Integrated Performance Report - September 2018
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
Finance Enablers Well Led
4 of 30Board Integrated Performance Report - September 2018
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
Finance Enablers Well Led
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.
5 of 30Board Integrated Performance Report - September 2018
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
Finance Enablers Well Led
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
6 of 30Board Integrated Performance Report - September 2018
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
Finance Enablers Well Led
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%
7 of 30Board Integrated Performance Report - September 2018
Serious Incident Numbers
SummaryNHS
ImprovementQuality
Business Unit
Change Programme
Finance Enablers Well Led
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
8 of 30Board Integrated Performance Report - September 2018
Workforce – Appraisal and Mandatory Training
SummaryNHS
ImprovementQuality
Business Unit
Change Programme
Finance Enablers Well Led
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
9 of 30Board Integrated Performance Report - September 2018
SummaryNHS
ImprovementQuality
Business Unit
Change Programme
Finance Enablers Well Led
Workforce – Mandatory Training – Role Specific
Measure Target Trajectory
Graph Key
Indicator
No.Indicator
17/18
outturn
18/19
TargetNumerator Denominator
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
10 of 30Board Integrated Performance Report - September 2018
SummaryNHS
ImprovementQuality
Business Unit
Change Programme
Finance Enablers Well Led
Workforce – Mandatory Training – Role Specific
Measure Target Trajectory
Graph Key
Indicator
No.Indicator
17/18
outturn
18/19
TargetNumerator Denominator
Current
Performance
FOT
18/19Graph
% Safeguarding
Children – Level 1
Training91.27% 80% 592 649 91.22%
% Safeguarding
Children – Level 2
Training75.13% 80% 865 1131 76.48%
% Safeguarding
Children – Level 3
- 3Yrs Training82.63% 80% 397 461 86.12%
% Safeguarding
Children – Level 3
- 1Yrs Training89.15% 80% 393 433 90.76%
% Safeguarding
Children – Level 4
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
11 of 30Board Integrated Performance Report - September 2018
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
Finance Enablers Well Led
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
12 of 30Board Integrated Performance Report - September 2018
SummaryNHS
ImprovementQuality
Business Unit
Change Programme
Finance Enablers Well Led
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
13 of 30Board Integrated Performance Report - September 2018
SummaryNHS
ImprovementQuality
Business Unit
Change Programme
Finance Enablers Well Led
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)
14 of 30Board Integrated Performance Report - September 2018
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
Finance Enablers Well Led
15 of 30Board Integrated Performance Report - September 2018
Service Dashboard
SummaryNHS
ImprovementQuality
Business Unit
Change Programme
Finance Enablers Well Led
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
16 of 30Board Integrated Performance Report - September 2018
SummaryNHS
ImprovementQuality
Business Unit
Change Programme
Finance Enablers Well Led
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 -
17 of 30Board Integrated Performance Report - September 2018
SummaryNHS
ImprovementQuality
Business Unit
Change Programme
Finance Enablers Well Led
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
18 of 30Board Integrated Performance Report - September 2018
SummaryNHS
ImprovementQuality
Business Unit
Change Programme
Finance Enablers Well Led
(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
Apr May Jun Jul Aug Sep Oct Nov Dec Jan Feb Mar
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
Apr May Jun Jul Aug Sep Oct Nov Dec Jan Feb Mar
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
Apr May Jun Jul Aug Sep Oct Nov Dec Jan Feb Mar
In Month Cash Balances
Plan Actual 2017/18
-
1
2
3
4
Q1 Q2 Q3 Q4
Quarterly Use of Resources
Plan Actual
19 of 30Board Integrated Performance Report - September 2018
Trust CIP Exceptions and Substitutions
SummaryNHS
ImprovementQuality
Business Unit
Change Programme
Finance Enablers Well Led
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
20 of 30Board Integrated Performance Report - September 2018
Informatics
SummaryNHS
ImprovementQuality
Business Unit
Change Programme
Finance Enablers Well Led
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
21 of 30Board Integrated Performance Report - September 2018
SummaryNHS
ImprovementQuality
Business Unit
Change Programme
Finance Enablers Well Led
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
22 of 30Board Integrated Performance Report - September 2018
Informatics
SummaryNHS
ImprovementQuality
Business Unit
Change Programme
Finance Enablers Well Led
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)
23 of 30Board Integrated Performance Report - September 2018
SummaryNHS
ImprovementQuality
Business Unit
Change Programme
Finance Enablers Well Led
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
24 of 30Board Integrated Performance Report - September 2018
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
Finance Enablers Well Led
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
25 of 30Board Integrated Performance Report - September 2018
Health and Safety – reporting Fire Safety – Fire Incidents
SummaryNHS
ImprovementQuality
Business Unit
Change Programme
Finance Enablers Well Led
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
26 of 30Board Integrated Performance Report - September 2018
SummaryNHS
ImprovementQuality
Business Unit
Change Programme
Finance Enablers Well Led
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.
27 of 30Board Integrated Performance Report - September 2018
SummaryNHS
ImprovementQuality
Business Unit
Change Programme
Finance Enablers Well Led
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.
28 of 30Board Integrated Performance Report - September 2018
SummaryNHS
ImprovementQuality
Business Unit
Change Programme
Finance Enablers Well Led
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.
29 of 30Board Integrated Performance Report - September 2018
SummaryNHS
ImprovementQuality
Business Unit
Change Programme
Finance Enablers Well Led
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.