April 2015 - Berkshire Healthcare NHS Foundation Trust

Transcription

BERKSHIRE HEALTHCARE NHS FOUNDATION TRUST
TRUST BOARD MEETING HELD IN PUBLIC
10:00am on Tuesday 14 April 2015
Boardroom, Fitzwilliam House,
Skimped Hill Lane, Bracknell, RG12 1BQ
AGENDA
Lead
Paper
Timing
1.
Welcome
Chair
1
2.
Apologies
Chair
1
3.
Declaration of Any Other Business
Chair
1
4.
Declarations of Interest
i. Amendments to Register
ii. Agenda Items
Chair
Chair
1
1
Chair
5
5.
Minutes of previous meeting – 10 March 2015
1. To approve
2. Matters arising
6.
Quality
1. Quality Visit Report – Reading Older People’s
Community Mental Health Team
7.
8.
9.
Executive Update
1. Executive Report
HM
14/04/Q73
10
JE
14/04/ER136
15
Performance Management
1. Month 11 2014/15 Finance Report
2. Month 11 2014/15 Performance Report
3. Finance, Investment & Performance Committee
– 30 March 2015
4. Risk Register
AG
AG
ML
14/04/PM298
14/04/PM299
Oral report
10
10
5
AG
14/04/PM300
5
Corporate Governance
1. Trust Seal
2. Trust Constitution
3. Council of Governors – Update
AG
JT
JH
14/04/CG292
14/04/CG293
Oral
1
5
5
10.
Any Other Business
11.
Date of Next Meeting:
12 May 2015
12.
CONFIDENTIAL ISSUES:
To consider a resolution to exclude press and public
from the remainder of the meeting, as publicity
would be prejudicial to the public interest by reason
of the confidential nature of the business to be
conducted.
Chair
Minutes of a Board Meeting Held in Public on Tuesday 10 March 2015
Board Room, Fitzwilliam House
Present:
John Hedger
Keith Arundale
Julian Emms
Chris Fisher
Alex Gild
Mark Lejman
Ruth Lysons
Helen Mackenzie
Bev Searle
David Townsend
Angela Williams
Justin Wilson
Non-Executive Director (Chair)
Non-Executive Director
Chief Executive Officer
Director of Finance, Performance & Information
Director of Nursing & Governance
Director of Corporate Affairs
Chief Operating Officer
Medical Director
In Attendance:
John Tonkin
Company Secretary
Observers:
Mark Davison, Director IM&T
Sabia Hussain, appointed Governor, Slough Borough Council
Verity Murricane, public Governor, West Berkshire
15/062
Welcome and Introductions
John Hedger welcomed everyone to the meeting. It was noted that two
Governors were in attendance: Sabia Hussain and Verity Murricane. Mark
Davison, Director of IM&T was also welcomed to the meeting as an observer.
15/063
Apologies for absence
An apology for absence was received from Professor Rodney Phillips, NonExecutive Director
15/064
Declarations of Any other Business
There was no other business declared.
15/065
Declarations of Interest
i.
Amendments to register – none declared
ii.
Agenda items – none declared
15/066
Minutes of Previous Meeting
The Minutes of the Board meeting held in public on Tuesday 10 February 2015
were confirmed as a correct record.
15/067
Matters Arising
The Board noted the schedule of Matters Arising provided within the Agenda
papers and the following updates were noted:
1. Feedback on complaint outcomes: Helen Mackenzie advised that
feedback is provided to clinicians involved in individual complaints or
incidents and that going forward, it had been agreed that the Medical
Director would be advised of any doctors involved in complaints so that
k:\company secretary\trust board\board meetings 2015-16\april 14 2015\minutes of a board
meeting held in public on tuesday 10 march 2015.docx
1
he could maintain a watching brief.
2. Quality Visit programme: Helen Mackenzie reported that the issues raised
with regard to service coverage and programme administration were
being addressed in a current review of arrangements.
3. Trust Constitution: It was noted that the Council of Governors had
approved the amendments to the Trust Constitution although a number of
matters had been raised which would require clarification with the
lawyers. A final update would be provided to the Board in April.
4. Action Plan arising from joint Council of Governor/Non-Executive Director
workshop: The Chairman advised that a meeting of the Governor
Reference Group was being set up with the purpose of developing
proposals to address issues arising from the workshop. Once the draft
recommendations are available they will be presented to the Board for
comment before finalisation with the Council of Governors.
15/068
Quality Visit Report – Sorrel Ward
Board members received and noted the quality visit report provided by Mark
Lejman in respect of his visit to Sorrel Ward on 7 January 2015.
Mark Lejman commented that he had found the visit very encouraging and also
educational and that he had observed staff working extremely hard to make the
patients feel as comfortable as possible. He had however identified that staff
were under significant pressure given the challenging environment on the ward.
Board members discussed ways in which support was being given to help staff
undertake their duties in challenging environments. Members also enquired
whether the pressured nature of some Trust environments affected staff turnover
levels and whether appropriate additional action could help mitigate this. Julian
Emms commented that the Trust did know the areas of highest risk and hence
potential pressure, and the most effective way of managing this was through
ensuring an appropriate culture existed where staff were supported and did feel
at ease in raising issues or concerns. In addition, in terms of providing staff with
an opportunity to change their working environment, the revised staff appraisal
and personal development review process which has been cascaded throughout
the organisation did focus on opportunities for career development and on
identifying action which might be taken to help staff undertake their individual
roles and responsibilities.
Angela Williams drew attention to the reference in the report to a single female
patient being on the ward at the time of the visit. Julian Emms noted that whilst
the Trust did do everything possible to mitigate such instances (for example
through sourcing appropriate out of area placements), these were not always
available and the Trust’s primary concern would be to ensure the safety and
appropriate care of individual patients.
The Board noted the quality visit report.
15/069
Quality Assurance Committee
The Board received and noted the unconfirmed minutes of the meeting of the
Quality Assurance Committee held on 26 February 2015.
In the absence of Professor Rodney Phillips, John Hedger drew attention to a
number of areas of particular interest including the Committee’s consideration of
the updated Quality Concerns report provided by the Director of Nursing &
Governance. In particular, the addition of a concern relating to the demand
2
pressure on the Trust’s Crisis Resolution and Home Treatment Team.
John Hedger noted that the Committee had considered the report an extremely
useful development and one that provided good assurance to the wider Board on
the processes in place for the identification and mitigation of quality related
concerns.
The Committee had also received the quarter 3 reports on Serious Incidents
Requiring Investigation and Infection Prevention & Control, together with
summary reports in respect of four clinical audits as noted in the minutes.
Chris Fisher enquired with regard to the forthcoming CQC inspection of the Trust
asking when the Board might receive an update on the approach being taken
with regard to organisational preparation. It was agreed that an update should be
provided identifying areas of particular focus and the preparations being made at
either the June or July Board meetings.
ACTION 1:
Helen Mackenzie
Resolved to receive and noted the unconfirmed minutes of the Quality Assurance
Committee meeting held on 26 February 2015.
15/070
Staff Survey Results - 2014
Bev Searle presented the Board with a report highlighting key results from the
2014 Staff Survey, and also identifying key areas of actions planned as a result.
The Board noted that compared to the 57 similar Trusts, Berkshire Healthcare
had:
• 11 issues in the top (best) 20% of similar Trusts
• 8 issues better than average
• 4 issues at the average
• 3 issues worse than average
• 2 issues in the worst 20%
• 3 issues improved (significantly)
• 3 issues deteriorated (significantly) since 2013.
It was pleasing to note that given staff engagement had been targeted by the
Board as a key area for improvement, the 2014 results did show significant
achievement and that the Trust had surpassed its target of achieving upper
quartile performance across the whole of the organisation. Bev Searle added that
given the significant demands being faced by staff in terms of activity levels, the
results were even more encouraging.
It was acknowledged that there were a number of areas where further work
would be required particularly in relation to the percentage of staff working extra
hours and the percentage of staff having equality and diversity training within the
past twelve months. There would be a focus on supporting the health and
wellbeing of staff including setting meaningful realistic measurable goals aligned
with the Trust’s values and behaviours.
Whilst the number of staff having an appraisal within the previous twelve months
represented the best score at 96%, there was still more to be done with regard to
the nature of appraisals with only 48% saying they had received a well-structured
appraisal within the last twelve months although this was significantly better than
the previous year which had been 40%.
3
Angela Williams welcomed the largely positive results and the significant
improvements secured but did note that staff working extra hours did feature as
an issue on occasions during quality visit. She enquired whether sufficient was
being done to address this if it was affecting staff wellbeing. Julian Emms noted
that it was a quite complicated position with it being acknowledged that in
organisations with high levels of staff engagement, it was often the case that staff
would deliver discretionary effect and, looking at other indicators, it did not
appear that this was having a detrimental effect in general. However, locality
directors had been asked to consider, within their own areas, what further action
may be required to address the issue and to mitigate any adverse impacts on
staff wellbeing. Helen Mackenzie noted that in particular areas such as
community nursing, the level of demand did drive the need for additional work
and in many cases it was not possible for this to be offset in terms of time off in
lieu and therefore it was recognised that the Trust needed to support teams
where there was a risk of excessive working hours.
Ruth Lysons drew attention to Indicator KF21 with 39% of staff reporting good
communication between senior management and staff noting that this result may
be more to do with a lack of clarity of who respondents considered to be senior
management. It was agreed that the results did not provide clarity on this but it
was clear that it did not relate to line management.
With regard to Indicators KF12 (the percentage witnessing potential harmful
errors) and KF15 (percentage agreeing that they would feel secure raising
concerns about unsafe clinical practice) it was noted that the Trust had seen
improvement compared with the previous year and in the case of KF7, was
performing at the best level compared with similar Trusts but this would remain
an area of focus and the encouraging performance would not be allowed to drive
any complacency.
Resolved to receive and welcome the results of the 2014 NHS Staff Survey.
15/071
West Berkshire Homicide – action plan progress report
Helen Mackenzie presented a report providing the Board with an update on
progress in the implementation of actions taken in response to the
recommendations from the external review of the west Berkshire homicide in
March 2012.
The Board was reminded that they had received the external review report in
April 2014 and, whilst not finding that the incident had been predictable or
preventable, the external reviewer had made nine recommendations in light of
their findings and an action plan had been developed as a result.
The Board was provided with the latest update position with regard to all actions
and it was noted that only one remained red: Reference R6 relating to the need
to seek agreement with partner agencies for a joint protocol governing when an
inter-agency investigation is required and how it should be conducted.
Helen Mackenzie was able to confirm that the protocol had been written and
circulated at the end of January 2015 with a number of comments received from
unitary authorities in the month of February. As a consequence, the protocol had
been revised and had been further circulated with a view to achieving sign off by
the 25 March. The Board would be advised on the completion of this action at the
April Board meeting.
ACTION 2:
Helen Mackenzie
4
15/072
Staff Turnover Analysis
Bev Searle introduced a paper briefing the Board on performance against the
staff turnover target, the issues, effectiveness of action taken in 2014/15 and the
appropriateness of current target levels.
It was noted that staff turnover rates had continued to increase in 2014/15
reaching 17.6% although with rates varying across localities and staff groupings.
It was noted that this variation was recognised within the locally developed action
plans and that from the analysis so far, the three top reasons for leaving were
relocation, promotion and work-life balance.
It was further noted that the analysis had identified that turnover rate for staff with
less than 2 years’ service was significantly higher than expected although a straw
poll of Trusts in the south of England suggested that many were also
experiencing a rise in turnover of staff and facing similar challenges particularly
given the national shortage of certain staff types.
As well as providing an analysis from work undertaken to date via exit interviews,
the paper also proposed that the Trust continue to monitor turnover percentage
but as part of a basket of measures to inform the setting of more meaningful
targets and with actions implemented to address regretted turnover being
included with, and monitored through, the Trust’s Strategy Implementation Plan.
Angela Williams welcomed the information provided within the report but noted
that in a number of areas, greater granularity was required if the Trust was to be
sure that appropriate action could be identified to address contributory factors.
It was recognised that the reasons for staff leaving were multi-faceted and that
the Trust was operating in a geographic area where there were many other
employers offering significant opportunities for staff to leave to secure career
progression, better work-life balance etc. A priority would be for the Trust to
target action in areas particularly where staff turnover was a particular concern
either in terms of the impact on operating costs or quality of service delivery or
both.
It was agreed that the current report whilst helpful was only a first step in
securing actionable information and work would continue to support this.
Ruth Lysons added that it might be helpful to be clear on what might be a primary
reason for somebody leaving as well as understanding any secondary level
reasons and providing an analysis which clearly identified these separately.
In conclusion, the Board welcomed the information provided in the analysis report
and approved the recommendation with regard to future performance targets. It
was also agreed that further analysis work would continue and that the Board
would be kept apprised of the outcome of this at key stages of the year.
15/073
Finance Summary Report – Month 10 2014/15
Alex Gild presented the financial summary report in respect of Month 10 noting
that a largely stable position remained adding that the report had been
considered in detail by the Finance, Investment & Performance Committee when
it met on 25 February 2015. The Board was updated with regard to key
performance information including:
YTD Continuity of Service rating (COS):
• COS 4 (plan COS 4)
5
o Debt Service Cover Ratio 1.95 (rating of 3)
o Liquidity metric 4.1 (rating of 4)
YTD income & expenditure:
• Plan: £282k net surplus
• Actual: £447k net surplus
• Variance: £164k favourable
Month 10: £58k underspend
Key variances:
• Reserve release (per profiled forecast) c.£120k
• OAPs: ongoing position including acute overspill and higher than anticipated
independent hospital placements c.-£154k
• MH Inpatients and CRHTT: ongoing staff backfill c.-£64k
• The remainder of the favourable variance is principally due to vacancies in the East
localities.
YTD M10: £164k underspend
Key adverse variances:
• OAPs: ongoing challenge (forecast to continue) c.-£736k
• Adult Inpatient staffing across the West: recruitment and retention continue to be
problematic c.-£585k
• Medical Staffing & Junior Doctors c.-£307k
The variances above are offset by the profiled reserve release and vacancies but there
are underlying CIP challenges.
Forecast outturn:
The forecast outturn remains at a £0.8m surplus. This principally reflects the
improvement in run rate in recent months, the vacancy position, and capital reprofiling;
this forecast is achieved after budgeted contingency release of £1.1m.
Cash: Month 10: £18,194k (plan £13,438k)
The positive variance reflects strong receivables / payables management and the reprofiling of capital expenditure.
Capital expenditure: YTD Month 10: £3,986k (plan £4,671k)
Estates and IM&T expenditure is under strong scrutiny to support both the yearend
position and the budget setting process for FY15/16. The forecast has been reduced to
£7.3m for year end and may be challenged further.
Mark Lejman advised that the Finance, Investment & Performance Committee
had been pleased to note a stable and positive year end expectation and a
strong cash position which represented a very positive outcome in respect of
2014/15 given the challenges faced during the year. The question of agency cost
and staff vacancies had been discussed at some length within the Committee but
members had been assured that processes were in place to ensure that the
reliance on agency staff in operational areas did not jeopardise quality of care.
The Committee had also received an update with regard to the financial planning
position and timetable for 2015/16.
Alex Gild drew attention to the briefing he had provided within the Executive
Report to the Board highlighting the delay to national planning and the
requirement on Trusts to choose one of two tariff options for 2015/16 in light of
the rejection of the original Monitor proposals.
6
The Board noted that in mitigation to the tariff delay and planning uncertainty
created, NHS England and Monitor had made available an enhanced tariff offer
(ETO) which reduced the tariff efficiency for providers from 3.8% to 3.5% and
amended prices favourable for acute emergency and specialist activity with a
cost to commissioners of an estimated additional £500m in 2015/16. It was noted
that the impact on Berkshire commissioners was likely to see an increase in their
acute hospital funding pressure thereby reducing resources available to mental,
community health and other non-acute services.
It was noted that providers were alternatively able to select a default tariff rollover
(DTR) option effectively maintaining the 2014/15 prices with a lower implied
efficiency requirement of 1.9% whilst a revised tariff was considered. However,
and significantly, the DTR did not allow providers to access CQuIN payments at
2.5% of contract which in the case of the Trust, was worth around £4m. DTR
therefore would have resulted in a significantly more adverse financial impact
compared to the ETO and therefore the Chief Executive and Finance Director
had considered that the only appropriate option available for the Trust was to
select the enhanced tariff offer.
The Board was further advised that as a result of the delay to tariff confirmation
and the likely adverse impact to commissioners, Monitor had written to
foundations trusts confirming draft 2015/16 operating plans would be due in April
with final plans in May 2015.
Due to the planning delay and the impact on budget setting, it had been agreed
that the Finance, Investment & Performance Committee should review and agree
the financial plan and budget at its meeting on 30 March 2015 with the full Board
receiving the final financial plan for 2015/16 at its April meeting. In light of the
developments, the Board agreed for initial sign-off of the 2015/16 Annual Plan by
the Finance, Investment & Performance Committee at its March meeting with
ratification being provided through the April Trust Board.
Non-Executive Directors welcomed the detailed briefing on the implications of the
tariff and planning delay and acknowledged that at this stage it was not possible
to be clear on the implications in terms of additional funding support to the Trust
from Berkshire CCGs. Julian Emms confirmed that negotiations were continuing
and that the Trust would seek to secure the best possible settlement but noting
that the changed landscape did pose significant risk to the Trust’s financial
situation in 2015/16.
Resolved to receive and note the Month 10 Financial Summary Report.
15/074
Performance Assurance Framework – Month 10 2014/15
Board members received and noted the Month 10 Performance Report. Mark
Lejman highlighted that this had been scrutinised in detail by the Finance,
Investment & Performance Committee at its February meeting.
The key areas of discussion were highlighted within the Committee meeting
minutes but overall the Committee had been satisfied that performance remained
stable and largely positive.
Keith Arundale noted that in relation to the mock CQC inspection of Campion
Ward, there was reference to two agency members of staff being in charge of a
shift. Helen Mackenzie confirmed that whilst this was the case, the Trust was
taking action to ensure, as far as practicable, that there was always a permanent
staff member available on each shift. However, to provide further assurance on
7
quality of care, she did add that in a number of cases the agency staff in question
had been working for the Trust for a considerable period and were able to fulfil
the requirements of the role in these circumstances.
Keith Arundale also highlighted the use of agency staff within the Crisis
Resolution and Home Treatment Team. It was confirmed that in all cases these
would be individuals with appropriate acute mental health nursing experience.
Keith Arundale further highlighted the deterioration against the Friends & Family
test in respect of west Berkshire. Helen Mackenzie explained that she believed
this was due to the fact that the one of the wards at WBCH had accommodated a
very challenging patient and this had undoubtedly affected the views of other
patients on the unit. She believed that this was linked to the deterioration in
performance but she was making further enquiries.
15/075
Risk Register
The Board noted that no new severe risks had been added to the Corporate Risk
Register since its last meeting.
Mark Lejman left the meeting at this point.
15/076
Executive Report
The Board received the Chief Executive’s report on key matters of significance
and the following in particular were discussed:
Never Events
The Board noted that no Never Events had been reported since the last meeting
of the Board.
Freedom to Speak Up
The Board had been provided with the Executive Summary from the Robert
Francis review into whistleblowing which had been published in February 2015.
The key recommendations and principles included within the report were noted.
With regard to the reference to a whistleblowing guardian, it was noted that the
Trust would await central guidance with regard to this role but the Board
remained convinced that the most significant factor in encouraging staff to speak
up about concerns was by promoting an open culture and environment where
staff could be confident that they would be both encouraged and supported in
raising issues or concerns with regard to patient care and safety. The Trust had
done much to develop such a culture and had also ensured that it had a very
clear and easily accessible process for staff to whistle blow where they felt this
was required including through the adoption of an independent channel for
whistleblowing concerns. Angela Williams commented that a further channel for
staff might be through their normal trade union representation although this did
not currently feature within general whistleblowing protocols.
Helen Mackenzie believed that the Trust did have a robust process for concerns
to be highlighted and that this was reinforced by the work undertaken within the
Trust around values and behaviours although it was accepted that more might be
done to reinforce this with managers in the organisation. Julian Emms added that
the Trust would be considering its response to the report and that this would be
presented to the Board in due course and in the light of any central guidance
received.
Orchid Ward – safe staffing
Board members were pleased to see that as a result of the interim review of
8
staffing on Orchid Ward, that an additional 2.5 registered nurses and 1.8 care
workers had been added to the establishment from April 2015.
Lessons Learned from NHS Investigations into matters relating to Jimmy Saville
The Board noted that the lessons learned report commissioned by the Secretary
of State for Health had been published and it was expected that all Trusts would
receive communication from Monitor and the CQC asking them to reflect on the
recommendations and to report back with an action plan within 3 months. The
Board would be kept advised of the Trust’s proposed response.
Care Certificate
Noting the Trust’s involvement with regard to the introduction of the Care
Certificate for all care assistant roles, members were disappointed to note that
this was not an accredited qualification and it was agreed that the Director of
Corporate Affairs would make enquiries to see whether this position could be
revised.
ACTION 3:
Bev Searle
Resolved to receive and note the Chief Executive’s report.
15/077
Implementing the Trust’s 5 Year Business Strategy
The Board received and noted the latest progress report on the implementation
of the Board Strategy as at end January 2015.
It was noted that good progress was being made with the majority of initiatives
being delivered to expected timeframes. Currently there were 2 red rated
initiatives meaning a significant risk that action would not be delivered or that
serious delays would arise in respect of the delivery of significant workstreams in
the Optimising Estates initiative and the delivery of one area of the Trust’s cost
improvement plan relating to the achievement of the planned savings in mental
health out of area placements. The rationale in respect of these matters was set
out within the report and was noted by the Board.
15/078
Use of Trust Seal
The Board noted that the Trust Seal had not been used since the last meeting of
the Board.
15/079
Council of Governors
John Hedger advised the Board that the Council of Governors Appointments &
Remuneration Committee had recently held a long listing meeting in respect of
the recruitment process for two Non-Executive Directors. There had been a good
number and quality of candidates available and following initial screening
interviews with selected candidates by the independent recruitment consultant, a
short listing meeting would be taking place in early April.
15/080
Professor Rodney Phillips
John Hedger reminded the Board that this would be the final Board meeting prior
to the departure of Professor Rodney Phillips and it was therefore appropriate for
the contribution made by Professor Phillips to be acknowledged and the Board’s
thanks to be recorded. Professor Phillips had brought a particular style and
authority to the Board in light of his significant clinical experience. He had also
made a very significant contribution to the work of the Quality Assurance
Committee since its creation, and had proved a very able chairman following the
departure of Peter Warne.
9
The Board placed on record their sincere appreciation for the invaluable
contribution made by Professor Phillips and he was wished well for the future.
15/081
Date of Next Meeting
Tuesday, 14 April 2015.
15/082
Confidential Issues
The Board resolved to exclude press and public from the remainder of the
meeting on the basis that publicity would be prejudicial to the public interest by
reason of the confidential nature of the business to be conducted.
I certify that this is a true, accurate and complete set of the Minutes of the business
conducted at Board meeting held on 10 March 2015.
Signed………………………………………………………….Date………………………………….
(John Hedger, Chair)
10
WORKING PAPERS
BOARD OF DIRECTORS: 14/04/2015
AREA: Board Minutes
ITEM:
Action
Point
Summary
Reference
Topic
1
Page 3, Min
15/069
2
Page 4, Min
15/071
Quality Assurance
Committee – CQC
Inspection
West Berkshire
Homicide
3
Page 9, Min
15/076
Executive Report – Care
Certificate
MA Key:
Matters Arising from 10 March 2015
MA
X

X
Actions
Report of Trust preparations
to be provided to Board –
June/July 2015
Completion of final action
relating to sign-off of joint
protocol to be confirmed to
April Board
Enquiries to be made
regarding scope for
certificate to become an
accredited qualification
X – at a later date
- at this meeting
o – addressed in meeting agenda
To Note:
k:\company secretary\trust board\board meetings 2015-16\april 14 2015\matters arising.docx
Director
HM
HM
BS
14/04/Q73
Trust Board Paper
Board Meeting Date
14 April 2015
Title
Quality Visit Report – Older People’s Community
Mental Health Team
Purpose
To receive the report of the quality visit undertaken
by Helen Mackenzie
Business Area
Corporate
Author
Company Secretary
Relevant Strategic
Objectives
1. To provide accessible, safe and clinically
effective services that improve patient experience
and outcomes of care
CQC Registration/Patient
Care Impacts
Providing additional Board level assurance on patient
safety and quality of care
Resource Impacts
None
Legal Implications
None
SUMMARY
Board members conduct quality visits to Trust
services and localities throughout the year and
reports are produced which are circulated to all
Board members for information. At each Board
meeting one report is selected for spotlighting. The
attached report has been provided by
ACTION REQUIRED
To receive and note the report and discuss any
matters raised.
Quality Visit to Reading Older People’s Community Mental Health
Team, 14th January 2015
The team is based in the Hazelwood building on the Prospect Park Hospital site. I parked
with ease but I was early (9.30am). I was met by administrators, Laura Spray and Rachel
Holt who were very welcoming and friendly. I was expected and whilst waiting for Sue
Adams, Community Psychiatric Nurse and Team Leader, I was able to look at the photo
board in reception which identified all the staff within the Reading team. The reception was
warm, bright and clean.
Sue collected me very quickly and took me upstairs to collect her equipment ready to go out
and visit some patients.
I had the opportunity to meet the following staff before we went out - Annette Mullally, Alison
Hiscock, Alex Douglas Gilbert, Nafera Kamera, Sunday Johnson and Bev Cumberbatch.
They were in an integration meeting with the physical health community matrons to discuss
patients which both services visit. The staff calculated that perhaps 6% of patients on their
caseloads were seen by both physical and mental health services. These meetings are held
quarterly.
I also met Elizabeth Ferguson, speech and language therapist, Fleur Newton, psychologist
and Alice Tomlin, psychology assistant. All expressed good satisfaction from working with
the patients.
Finally I met Louise Costello, CPN and Nurse Prescriber. Louise told me that she used her
prescribing qualification frequently.
Hazelwood as a premise seems very good; it is modern and purpose built. If I were a patient
entering the building I would be pleased with its construct.
Sue worked with the RBH for many years as a general nurse but mainly in oncology/
haematology services and, following a personal experience decided to change direction and
took on her mental health nurse training. She completed a placement following with the
Reading CMHTOP and successfully applied to work with them as a CPN in the home
treatment team (HTT) and since then she has successfully achieved promotion and currently
works as the acting team lead for the HTT. Because of pressures in the service, she also
carries longer term patients on her caseload as well. Her current caseload is 39 but just
recently it was 45. 39 patients on her caseload is still too many when compared with other
locality HTT’s who have caseloads of between 15 – 20. Sue described the challenge of
reducing her caseload further because of demands and vacancies. Her manager is
supportive of the reduction in caseload, it is just a question of how. Sue finds her dual nurse
qualification really helpful because she is able to help the team manage physical health
issues as well.
Sue loves working with older people and enjoys her job. One of Sue’s responsibilities is to
gate keep the older people’s mental health beds – this is successful because the HTT is
predominantly able to keep patients at home. Sue confirmed that the diagnosis of dementia
is increasing and that they get many referrals from primary care. When I visited West
Berkshire recently the team there said that they needed more referrals from primary care.
Sue receives management supervision on a monthly basis and believes that this could move
to bi-monthly for all clinical staff. Clinical supervision happens on weekly on a Wednesday in
the HTT meeting when all patients on the HTT caseload are discussed. In discussions about
discharging from the caseload Sue explained that they are seeing some patients being rereferred to the service within a few months after they had been discharged from service.
I visited a gentleman who had Parkinson’s disease with neurological complications including
the development of Lewy Bodies Dementia. He was resident in Life care residential home in
Reading which has had a number of safeguarding concerns. Sue explained very clearly her
role in managing the safeguarding issues. The gentleman was presenting behavioural
problems and had recently developed a pressure ulcer which the district nurses were
treating on a regular basis. Sue had a long conversation with him. I have to be honest I
found it hard to understand the gentleman. In her interaction Sue considered all his needs
and respected his dignity although also challenged him to consider how his behaviour could
be improved. One of the carers had a long conversation with Sue in which she advised other
ways of doing things. The home was functional and clean but lacked any elements of
homeliness. It was a stark reminder to me as to how some older adults without family, or
perhaps needing more care than can be safely delivered at home, have to go into homes
which are not necessarily the environment they would chose to be in.
I then visited an older lady at home. We were lucky because she let us in, sometime she
doesn’t. This lady’s memory was very poor. Sue felt it had deteriorated since her last visit.
Her home was warm and clean but she was very bothered by a bill that had just arrived. Sue
took responsibility for trying to resolve the bill with the council. Sue was able to find some
family contact numbers in a carers book because up until that point the service had not been
able to speak to the lady’s family. It was clear that her daughter was bringing her food and
that the family had organised carers to come and help their mum to take her medication
twice a day. Again I observed compassionate care in challenging circumstances.
We did try to visit a further patient but he was out shopping with his nephew. She did tell me
about a couple who had been found the previous week living in a car and the wife developed
pneumonia and had to go into hospital. Her husband would not leave and social services
could not get anywhere with either of them because of their previous experience. They both
had mental health issues. With Sue’s skills she was able to persuade them both to go into a
double room in a care home.
I spent 2 hours with Sue and had a brilliant time. It was so good to be out seeing patients in
the company of such a skilled nurse. Sue obviously loves her job and gets plenty of job
satisfaction.
Helen Mackenzie
Director of Nursing & Governance
14/04/ER136
Trust Board Paper
Board Meeting Date
14 April 2015
Title
Executive Report
Purpose
This Executive Report updates the Board of Directors
on significant events since it last met.
Business Area
Corporate
Author
Chief Executive
Relevant Strategic
Objectives
N/A
Care Impacts
N/A
Resource Impacts
None
Legal Implications
None
SUMMARY
This Executive Report updates the Board of Directors
on significant events since it last met.
ACTION REQUIRED
To note the report and seek any clarification.
14/04/ER136
Trust Board Meeting 14 April 2015
EXECUTIVE REPORT
1. Never Events
Directors are advised that no ‘never events’ have occurred since the last meeting of
the Board.
Executive Lead:
Helen Mackenzie
2. System Leadership
An initiative aimed at development of leadership of the Health and Social Care
System in Berkshire West has been established as part of the Berkshire West 10
Integration Programme.
This includes membership of the national Systems
Leadership - Local Vision programme, which is a collaboration between a number of
national bodies (including the Department of Health, Local Government Association,
NHS Confederation, NHS England, NHS Leadership Academy, Public Health
England, Social Care Institute for Excellence, Association of Directors of Adult Social
Services, Association of Directors of Public Health etc.) and local public services in
participating localities.
The programme aims to assist in the development of a solution to a locally determined
intractable issue through leadership development, and through this process to
develop leadership capability at a system wide level. It provides two experienced
“enablers” and participation in a learning network facilitated by the Kings Fund. A
number of systems have already participated in the programme, and Berkshire West
is part of a second “wave”.
Our system enablers, Matt Gott and Jill Barrow, have carried out a programme of
interviews with Chief Officers and other senior leaders from the Berkshire West 10
Partnership organisations. The findings from these interviews are informing work to be
undertaken by representatives of participating organisations to build relationships,
confirm our shared vision, values, direction, accountabilities, and responsibilities for
action.
Our Five Year Strategy Refresh highlighted the need for system-wide change to
achieve sustainability of service provision, and this initiative provides an important
opportunity to develop our leadership capability at a system-wide level. A progress
update on this work, which is currently at an early stage, will be provided to the Trust
Board in May.
Executive Lead:
Julian Emms
k:\company secretary\trust board\board meetings 2015-16\april 14 2015\1404er136 exec report.docx
1
3. Reading Social Care Integration
Work is continuing to explore opportunities for greater integration of community
mental health services in Reading. Although progress has been much slower than
anticipated by both Berkshire Healthcare and Reading Borough Council, the potential
for TUPE transfer remains, and legal advice is currently being sought about this by the
Council. In addition, there is a need to determine what joint commissioning options
would be required as part of any potential agreement. However, as previously
reported, any financial benefits appear limited and therefore work is in progress to
develop a joint plan to enable required efficiencies to be achieved without
deterioration of frontline services. The aim is to establish more preventative options
and more efficient ways of working, informed by engagement with CCGs, voluntary
sector and service users and carers. The outcome of this work will be reported to the
Council’s Adult Social Care, Children’s Services and Education (ACE) Committee in
June 2015 with recommendations for next steps.
The Reading Integration Board has been established as the forum with responsibility
for oversight of integration planning (including Better Care Fund and the Berkshire
West 10 Integration programme) and is accountable to the Reading Health and
Wellbeing Board. Work in progress includes:
•
•
•
•
Reviews of current pathways including joint work on access to services.
Review of skill mix and local options for support, including crisis support,
intermediate care and prevention.
Development of the Reading Resource Guide in collaboration with service
users and carers. This guide includes information on alternatives to hospital
admission and how to access advice and support.
Promotion of staff, service user and carer engagement in development of
effective integrated services. A survey of staff views has been undertaken and
results are being analysed at the time of writing. Representation of service
users and carers at key groups is also being progressed.
Further progress reports on integration with social care will be provided to the Board
on a twice yearly basis, including all six geographical localities. These will also include
emerging risks and opportunities for innovation.
Executive Lead:
Bev Searle
4. Values Based Recruitment
Following the successful implementation of Values Based Appraisal, we have been
working on the development of Values Based Recruitment (VBR). Our staff have been
working with Talent Works, who have provided excellent support in terms of the
development of materials and the overall approach to VBR. Talent Works (who work
with the NHS Leadership Academy and a number of NHS Trusts) have reported that
we have made good progress and are considered to be one of a few Trusts to be in a
strong position to successfully implement VBR effectively. 30 recruiting managers
have recently attended training sessions aimed at introducing a values based
approach, familiarisation with new documentation, enhancing interviewing skills and
utilising additional recruitment tools such as role play exercises. This was received
well and plans are now being developed to roll this approach out more widely across
the Trust.
2
Our Human Resources Team have been reviewing current processes to ensure
readiness for wider implementation to include clear messaging to candidates about
the approach the Trust is taking and updating existing recruitment documentation for
internal use, the website and recruitment marketing purposes. Care has been taken
to ensure any changes do not impinge on existing recruitment
timescales. Throughout April and May, the VBR materials developed to date will be
piloted as opportunities arise. The VBR Development Group will convene on 24th
April for a final review of process, materials and pilot activity. Involvement of service
users and patients in the recruitment process will also be discussed – this is a core
requirement of the national VBR framework and consideration is to be given as to how
they can influence the process effectively. A communications plan has been
developed to inform all recruiting managers about the expectations in relation to VBR,
and the formal launch will take place in June.
Executive Lead:
Bev Searle
5. Safe Staffing
In addition to the monthly safe staffing reporting, twice a year the Director of Nursing
is required to provide information to the Board as to how a safe environment for
patients, on our wards, has been maintained over the last 6 months. A detailed paper
was presented to the Finance, Investment and Performance Board Committee in
March. Mark Lejman, Non-Executive Director and chair of the Committee will provide
more information in his report.
Over the last six months the Director of Nursing and Governance has declared the
ward to be safely and capably staffed.
Executive Lead:
Helen Mackenzie
6. Winterbourne Review
The Winterbourne Review Report was published in December 2012 with the
recommendation that health and social care commissioners review all current hospital
placements and support everyone who is inappropriately placed in hospital to move to
community based support as quickly as possible and no later than 1st June 2014.
Nationally and locally this was not achieved and it has since been recognised that the
task was more complex than first expected.
The revised target for the Berkshire system is to reduce the number of people with
learning disabilities who have been in health / hospital based services (both locally
and out of area) prior to April 2014 by 50% by June 2105. Berkshire Healthcare
Foundation Trust has worked closely with commissioners to ensure those people who
were able to be discharged were returned to closer to home services in Berkshire for
their care and this target has already been achieved.
There remain a total of 14 patients in this cohort (of patients in health services prior to
April 2014). One person is expected to be discharged into a community based
service on 13th April. There is still work ongoing with the other people placed out of
county however six are still not ready for discharge and therefore appropriately remain
in hospital and another remains in active treatment at Little House. Two patients
remain in Campion Ward because the local authorities are unable to find appropriate
placements for their care at the moment and there are a further four patients out of
area because services do not exist locally which could meet their needs (including 2
3
people who would like to remain out of county – as they have lived in their current
location for many years – discussions are underway with the relevant CCG).
In January 2015 the Department of Health published Transforming Care for People
with Learning Disabilities – Next Steps. One of the recommendations from this report
involved empowering people and their families by giving them the means to challenge
their admission or continued placement in inpatient care through an admission
gateway process and Care and Treatment Reviews, reducing the number of
admissions and speeding up discharges.
Ten care and treatment reviews have been completed for our patients and this
process has gone very well. The review process expects very high standards of care
from providers and gaps in services have been found. A provider is expected to
address these gaps within a defined timescale and this is monitored. The Trust now
has an up to date profile for all our patients supported by placement matrices. Social
services are fully involved.
The gaps in services include a lack of local facilities and limited wrap around
community services which would enable a patient to remain at home with bespoke
services.
For BHFT services we provide good discharge planning however there are delays in
getting funding agreed by commissioners and there are differing messages at a local
level between East and West Clinical Commissioning Groups and the six local
authorities. This results in patients remaining in our assessment and treatment
services for too long and in some cases, years.
Executive Lead:
Helen Mackenzie
7. Annual Plan Submission Timetable
In response to the publication of the proposed 2015/16 National Tariff, a significant
number of acute foundation trusts expressed their concerns about the impact on their
resilience. In mid-February Monitor offered trusts an option to choose between an
Enhanced Tariff or a Default Rollover Tariff by 4 March 2015. The original annual
planning timetable required trusts to submit a high level (“draft”) financial annual plan
summary by 27 February, to sign contracts by 11 March, and submit the full annual
plan by 10 April 2015. Monitor therefore announced a revised annual planning
timetable to accommodate the delay in agreeing the 2015/16 tariff, including:
•
•
High level annual summary plan to be submitted to Monitor by 7 April 2015
Full Annual Plan Report to be submitted to Monitor by 14 May 2015
The Trust’s summary plan was submitted on time to Monitor. The 2015/16 Annual
Plan Report will be presented at the May Board meeting for approval, prior to
submission to Monitor.
Executive Lead:
Bev Searle
8. Medical Revalidation
Medical Revalidation continues to proceed satisfactorily. During 2014/15 47 doctors with
a prescribed connection with the Trust were due to be revalidated. Among these,
4
recommendations have been made for 43 doctors during the year. All recommendations
have been accepted by the General Medical Council. There have been 6 deferrals with 2
deferred doctors subsequently revalidated in year and 4 carried over to 2015/16.
Reasons for deferral have related to inadequate information being provided to make a
recommendation. In one case the recommendation has been deferred due to an ongoing
investigation into the doctor’s practice. There have been no cases of non-engagement.
At month 11 82% of doctors with a prescribed connection have had an enhanced medical
appraisal during the year to date. A significant proportion of community health doctors
have appraisal dates in March. The overall Trust medical appraisal rate for the past 12
months is 98%.
The Trust has adequate numbers of trained appraisers and an active and well-attended
appraiser forum group. Engagement of doctors with quality improvement activities has
continued to develop and improve. A patient / public representative, Karen Swaffield has
joined the revalidation group and provides advice on the process from a PPI perspective.
During the year ahead she will contribute to the evaluation of some aspects of appraisal
information with respect to quality improvement and advise the Responsible Officer and
team on patient experience and involvement with respect to medical revalidation.
An arrangement for incorporating Trust values, associated behaviours and objectives into
the appraisal process for doctors is established.
The Responsible Officer is satisfied that the resources, policies and processes in place
are adequate to comply with the revalidation requirements and support doctors’
development to enhance the quality of patient care.
Executive Lead:
Justin Wilson
9. Smoke Free - Update
On 1st March the first milestone in the Smoke Free initiative was achieved with the staff
smoke free policy coming into effect requiring staff to abstain from tobacco during their
working day. The latest staff update briefing is attached as an appendix to this report.
Executive Lead:
Helen Mackenzie
10. Jimmy Savile ‘Lessons Learned’ Report
Following the publication of the ‘lessons learned’ report commissioned by the Secretary of
State for Health, Monitor has written to Foundation Trust Chief Executives asking them to
read the report and to assess the relevance of recommendations to individual Trusts – a
copy of the letter is appended to this report.
Trusts have also been asked to respond to Monitor by 15 June with an overview of any
necessary actions taken or in train as a result of the recommendations. The Board will be
provided with sight of the response prior to submission.
Executive Lead:
Julian Emms
5
11. Mental Health Crisis Care Concordat
In February 2014 the Department of Health published a Mental Health Crisis Care
Concordat. The Concordat is a joint statement written and agreed by key stakeholders
that describes what people experiencing a mental health crisis should be able to expect of
the public services that respond to their needs. There is an expectation that local
partnerships between the NHS, Local Authorities and Criminal Justice agencies should
work to embed the Concordat principles into service planning and delivery by agreeing
and delivering their own mental health crisis declaration.
At a local level, Local Authorities, Health Services and Criminal Justice agencies are
expected to:
•
•
•
Deliver local declarations which reflect the principle set out in the Concordat
Establish a clear, local action plan for continuous improvement which addresses
the specific needs of the area
Ensure oversight of the declaration and implementation of the action plan within
the system
As reported in February, organisations across Berkshire signed and published a local
declaration at the end of December 2014. Since then work has focused on developing a
detailed multi–agency action plan, which is intended to set out clearly what individuals
experiencing a crisis in the county should expect. The Berkshire action plan was
uploaded at the end of March to the national Crisis Care Concordat website and a local
multiagency group has been established in order to monitor progress as well as refine
and update the plan.
The plan is included as an appendix to this report for information.
Executive Lead:
Julian Emms
Presented by:
Julian Emms
Chief Executive
April 2015
6
Going Smoke Free –March 2015 update for staff
What have we achieved to date?
On 1st March our first major milestone was achieved and the staff smoke free policy came into
effect, this means that all staff are now expected to:
•
Temporarily abstain from tobacco during their working day with or without support from
stop smoking services Or undertake a serous quit attempt with support and appropriate
nicotine replacement therapy if they would like this option to ensure that none of our
staff:
o smell of smoke during working hours
o are seen smoking during working hours
o have un-official breaks throughout their working day to smoke
We recognise that this is not easy for some of our staff and anyone not following the policy can
expect to have supportive conversations with their manager in the first instance, however
continued failure to comply with the policy will result in more formal HR processes being
followed.
Further information about going smoke free or smoking cessation support can be found at:
http://www.smokefreelifeberkshire.co.uk
Or
http://teamnet.berkshire.nhs.uk/twp/smokefree/Pages/home.aspx
To support the staff smoke free policy we have updated the job description template, there is
now reference to this in all adverts, the interview checklist now includes a reminder to advise
applicants of the smoke free policy and a new paragraph will be included in terms and
conditions.
Any staff with queries about going smoke free can contact: goingsmokefree@berkshire.nhs.uk
We have produced business cards that are currently being printed for staff and managers to
give colleagues as a reminder of the key elements of the policy and where to get support if
required.
What’s next?
Over the next few months we will be implementing the patient aspects of going smoke free
All patients will be expected to:
o Temporarily abstaining from tobacco during their stay or treatment with support
including Nicotine replacement provided by the trust and advice from stop smoking
services
OR
o Temporarily abstaining without support
OR
o Undertaking a serious quit attempt with support from stop smoking services and
appropriate Nicotine replacement therapy
To achieve this we are:
•
•
•
•
•
•
•
•
•
•
•
•
•
•
Replacing signage on all of our sites - this has been ordered
Removing smoking shelters from our sites.
Putting NRT protocols in place and ensuring that there is a supply of NRT for inpatients
wards to achieve provision of NRT for patients who would like this within 30 mins of
admission
Commencing an inpatient implementation group to review therapeutic activities and
support changes to achieve going smoke free across our inpatient wards (the contact for
this is Elaine Williams)
Providing training via e-learning from yoodoo (remaining clinical staff will be receiving
an email in next couple weeks) and also brief interventions training around ask advise
and act methodology at http://elearning.ncsct.co.uk/vba-launch
In contact with other trusts including Oxford Health and Camden and Islington who have
gone live with smoke free policies for patients during March to gain learning that can
shape our approach
Supporting our champions and have provided conflict resolution / challenging
conversations training and set up a forum which will have a drop in session monthly to
allow champions to meet and discuss issues with smoke free organisation lead
Keeping the intranet and internet up to date with relevant information
Providing our stakeholders with a briefing document - this is available on the internet
and intranet and will be given to our local Healthwatch and Public Health leads
Encouraging all managers to have going smoke free as a standing item on all agendas/
team meetings
Planning a launch day on 1st July
Currently designing information for users of our services
Discussing our plans with patient forums and will be engaging them in the review of
information, changes to activities on the wards etc.
Agreeing standard information to include in all patient letters that alerts them to our
smoke free policy and expectations for users of our services
2
13 March 2015
To all foundation trust chief executives
Wellington House
133-155 Waterloo Road
London SE1 8UG
T: 020 3747 0000
E: enquiries@monitor.gov.uk
W: www.GOV.UK/monitor
Dear colleague,
You will know that, following the death of Jimmy Savile and subsequent allegations of his
wrongdoing at NHS organisations, the Department of Health launched an inquiry into his
activities across the NHS. In total, 44 reports have now been published following
investigations triggered by this exercise.
While many of these actions took place a long time ago and, in some cases, at institutions
that no longer exist, everyone within the NHS has a responsibility to make sure nothing like
this can ever happen again.
The Secretary of State for Health asked Kate Lampard QC to produce a ‘lessons learned’
report, drawing on the findings from all published investigations to identify areas of potential
concern across the NHS. The report was published on 26 February and includes 14
recommendations for the NHS, the Department of Health and wider government. The full
report can be found here.
The Secretary of State for Health has accepted in principle 13 of these recommendations, 10
of which apply to NHS trusts and foundation trusts. Although the Secretary of State did not
accept recommendation 6 on Disclosure and Barring (DBS) checks, organisations are asked
to consider the use of these checks (standard or enhanced) where appropriate. The
recommendations are summarised in Annex A.
I ask you to read this report, assess the relevance of its recommendations to your own
organisation and take any action necessary to protect patients, staff, visitors and volunteers.
Given the severity of this issue, it is important to be able to demonstrate the improvements
made to safeguarding across the system. I therefore ask that you respond to this letter by
5pm Monday, 15 June 2015 with an overview of any necessary actions that you have taken
as a result of the recommendations in the report or, where these are in progress, the date by
which they will be completed.
If you wish, you may use the template attached. Please send your response by email to:
MonitorJSlearnings@monitor.gov.uk
Thank you for your assistance in this matter.
Yours sincerely
David Bennett
Chief Executive, Monitor
Annex A
Report on actions in response to Kate Lampard’s report into Themes and lessons learnt from NHS investigations into matters relating to
Jimmy Savile
NAME OF TRUST:
(add more lines to the table if necessary)
Recommendation
Issue identified
Planned Action
Progress to date
Due for
completion
I confirm that this NHS foundation trust Board reviewed the full recommendations in Kate Lampard’s lessons learnt report
SIGNED:
DATE:
CE NAME:
Please return to MonitorJSlearnings@monitor.gov.uk by 5pm Monday 15 June 2015. If you have any questions or queries you may also use
this email address to send them to us.
Annex A: Themes and lessons learnt from NHS investigations into matters relating to
Jimmy Savile
Recommendations for NHS trusts and NHS foundation trusts
R1 All NHS hospital trusts should develop a policy for agreeing to and managing visits by
celebrities, VIPs and other official visitors. The policy should apply to all such visits without
exception.
R2 All NHS trusts should review their voluntary services arrangements and ensure that:
• they are fit for purpose;
• volunteers are properly recruited, selected and trained and are subject to appropriate
management and supervision; and
• all voluntary services managers have development opportunities and are properly
supported.
R4 All NHS trusts should ensure that their staff and volunteers undergo formal refresher
training in safeguarding at the appropriate level at least every three years.
R5 All NHS hospital trusts should undertake regular reviews of:
• their safeguarding resources, structures and processes (including their training
programmes); and
• the behaviours and responsiveness of management and staff in relation to safeguarding
issues to ensure that their arrangements are robust and operate as effectively as possible.
R7 All NHS hospital trusts should undertake DBS checks (including, where applicable,
enhanced DBS and barring list checks) on their staff and volunteers every three years. The
implementation of this recommendation should be supported by NHS Employers.
R9 All NHS hospital trusts should devise a robust trust-wide policy setting out how access by
patients and visitors to the internet, to social networks and other social media activities such
as blogs and Twitter is managed and where necessary restricted. Such policy should be
widely publicised to staff, patients and visitors and should be regularly reviewed and updated
as necessary.
R10 All NHS hospital trusts should ensure that arrangements and processes for the
recruitment, checking, general employment and training of contract and agency staff are
consistent with their own internal HR processes and standards and are subject to monitoring
and oversight by their own HR managers.
R11 NHS hospital trusts should review their recruitment, checking, training and general
employment processes to ensure they operate in a consistent and robust manner across all
departments and functions and that overall responsibility for these matters rests with a single
executive director.
R12 NHS hospital trusts and their associated NHS charities should consider the adequacy of
their policies and procedures in relation to the assessment and management of the risks to
their brand and reputation, including as a result of their associations with celebrities and
major donors, and whether their risk registers adequately reflect such risks.
R13 Monitor, the Trust Development Authority, the Care Quality Commission and NHS
England should exercise their powers to ensure that NHS hospital trusts,(and where
applicable, independent hospital and care organisations), comply with recommendations 1,
2, 4, 5, 7, 9, 10 and 11.
R14 Monitor and the Trust Development Authority should exercise their powers to ensure
that NHS hospital trusts comply with recommendation 12.
BERKSHIRE ACTION PLAN
1. Commissioning to allow earlier intervention and responsive crisis services
No.
Action
1.
Frimley Health Care NHS Trust and BHFT to produce a
joint business case for investment to improve access to
Liaison Psychiatry Service for all ages at Wexham Park
Hospital in Berkshire East.
Evaluate CAMHS Psychological Medicine service pilot at
Royal Berkshire and Wexham Park Hospital, this will
enable rapid response and assessment to those aged
under18 years presenting at A&E with self-harm.
2.
Timescale Led By
Outcomes
Matching Local Need with a suitable Range of Services - Commissioners
June 2015
Frimley Health NHS
Foundation Trust/BHFT/East
Berkshire CCGs
When a person present at Wexham Park
Hospital with mental health needs, they will
have access to a mental health assessment.
May 2015
East Berkshire Clinical
Commissioning Groups
Children and Young People access multi
agency assessment and CAMHs help in a
timely manner.
Fewer admissions, reduced length of stay.
Information gathered from the pilot will
help understand how the service has helped
and supported children and young person.
Any Lessons learned will shape future commissioning
intentions and service configuration.
3.
4.
Parity of Esteem Business Cases is being developed by
both East Berkshire & Berkshire West CCGs for
investment in 2015/16.
A mental health specialist will work jointly with the police
in the West of Berkshire to assess individuals who come
to their attention as presenting with possible mental
health issues
June 2015
East Berkshire and Berkshire
West CCGs
This will meet the parity of esteem
investment plan and improve mental health
service across Berkshire.
June 2015
Berkshire Healthcare Trust
Fewer individuals will be detained by
the police, in the West of Berkshire,
under the mental health act and taken
to a place of safety. The most
appropriate response to the situation
will be made at the first point of contact
1
and consequently individuals will have a
better experience when they are seen
by the Police in a crisis.
5.
6.
7.
Mental Health Crisis Services Response Times
All patients referred urgently to our Berkshire Crisis Response
Home Treatment Team [CRHTT] from the Trusts Common Point
of Entry [CPE] service (our referral service) are contacted
within 4 hours.
Crisis calls received directly by CRHTT from patients or relatives
will be responded to within 1 hour by the service and where a
visit is clinically required this will happen in 2 hours.
Royal Berkshire Hospital A&E - referrals from A/E staff to the
Mental Health A/E Liaison team will be assessed within two
hours of referral providing the patient is well enough to
undertake the assessment
On-going
Patients will be contacted within four hours
improving patient and relative satisfaction.
On-going
1 April 2015
Patients and carers will feel supported by
the service because they know what service
they can expect to receive.
All patients will receive timely and
appropriate care for their mental health
need whilst in A&E.
Responsive Ambulance Times
8.
The current South Central Ambulance Services (SCAS)
contract is being reviewed to agree on data sets in
transporting mental health patient to a place of safety
April 2015
SCAS Contract Lead CSU
Establish an effective process to monitor
compliance with the commissioned service
specification.
9.
To review current demands and arrangements in place to
support mental health patients under section 136,
(urgent) 135 (planned) to be taken to a place of safety by
Ambulance Services within the Thames Valley Region
SCAS to work with Thames Valley Police and Mental
Health Trusts via the Protocol In Partnership Group to
agree a joint protocol on the above
April 2015
South Central Ambulance
Service - Chief Operating
Officer
A review process to be agreed by all parties.
2
10.
11.
Review and update contracts as appropriate when they are
renewed to include specific standards on mental health
responses based on the national guidance, this will ensure that
there is specific reference to the standards and measures
recorded formally in any relevant contracts that SCAS is party
to
SCAS to review and agree with Berkshire Healthcare the
demand and capacity required to enable SCAS to plan
sufficient and appropriate resources. SCAS to agree a local
protocol for response to different situations i.e. protocol for
non-emergency transfers and, emergency transfers, HCP
response
commenced
August 2014
the action is
ongoing
Service - Chief Operating
Officer
Patients will receive appropriate and timely
transport to support their mental health
needs as outlined in the NHS Standard
Contract
January –
March 2015
Service -Regional Operations
Director North
Patients will receive mental health services
which are appropriately resourced with a
joined up service approach
2. Access to support before crisis point
No.
Action
Timescale
Led By
Improve Access to Support via Primary Care
Outcomes
12.
Develop a comprehensive
training package for
General Practitioners in
Mental Health.
Autumn 2015
Health Commissioners
GPs will be better equipped to understand
patient’s mental health condition so that
they can support and sign-post patients to
most appropriate services.
13.
A specialist training
programme will be
provided to GP’s and
teachers which will help
them spot emerging
mental health issues in
April 2015
Mental Health issues in children and
young people are more likely to be
identified at an early stage in education
and primary care settings and be dealt
with appropriately.
3
children and young
people and give them
the confidence to know
how best to manage the
situation.
14.
Social Services Contribution to Improved Emergency Duty response Times
The emergency duty
service will respond within
4 hours in line with the
Joint Working Protocol.
Response times will be
monitored.
On-going
Bracknell local authority on
behalf of all six unitary
authorities
Patients will receive appropriate care in a
timely basis. If response times exceed four
hours then appropriate actions will be taken
to ensure that it is reduced.
During the working week,
any social care response
would come from the
relevant community
mental health team for the
locality.
3. Urgent and emergency access to crisis care
No.
Action
15.
Clinical Commissioning
Groups to work with NHS
England and BHFT to
disaggregate the Berkshire
Adolescent Service block
contract into Tier 3 and
Tier 4 activity
Timescale
Led By
Improve CAMHs Alternatives to Admission and Access to Tier 4 Beds
May 2015
Clinical Commissioning
Groups/Local Authority &
Education Department
4
Outcomes
Children and young person who are very
unwell are placed in Berkshire and do not
have to be in hospital long way from home.
NHSE to seek additional
investment to enable
Berkshire Adolescent Unit
(BAU) to open 24/7
By summer 2015
NHS England
NHSE seek additional
investment to increase the
number of Tier 4 beds in
Berkshire
By March 2017
NHS England
CCGs to consider options
for enhancing crisis care at
Tier 3
March 2015
Clinical Commissioning Groups
CCGs and BHFT to evaluate
the pilot projects funded
by NHSE over the winter,
additional CAMHs duty
clinics at weekends and
bank holidays, enhanced
Early Intervention in
Psychosis Service and a
psychological medicines
service for under 18’s at
Wexham Park Hospital
April 2015
Clinical Commissioning Groups
Every Acute Hospital in Berkshire will have
an NHS Mental Health Worker.
Improved quality of response when people are detained under Section 135 and 136
of the Mental Health Act 1983
Improved Ambulance Response Times for S135 & S136 Detentions
Improved Training and Guidance for Police Officers
5
16.
Thames Valley Police will
ensure that all frontline
officers and staff who may
deal with people with
mental health problems,
receive updated training by
Autumn 2015.
17.
To continue to work with
partners to reduce the
likelihood of crisis
interventions being required
for individuals who use
drugs and alcohol.
Autumn 2015
Thames Valley Police
5,000 Thames Valley Police officers and
staff will receive training to improve their
ability to support persons suffering a
mental health crisis.
Response from Community Substance Misuse Service Providers
April 2015
Public Health DAAT Leads/Local
Authority
6
To maintain a high return on investment
in the prevention of drug and alcohol
related hospital admissions.
4. Quality of treatment and care when in crisis
No.
18.
19.
20.
Action
Timescale
Led By
Outcomes
Summer 2015
Thames Valley
Police
The use of police cells as places of safety falling to below 5% of Section 136
detainees ensuring patients are accommodated in an appropriate health
facility.
Review Police use of Places of Safety under the Mental Health Act 1983 and Results of Local Monitoring
Thames Valley Police will work with
partners to ensure that custody is
only used as a place of safety on an
exceptional basis (below 5%)
Develop further Alternatives to Admission (NHS & Local Authority)
We have established three crisis beds September 2014
Berkshire
The facility will offer residents of the West of Berkshire a more personal,
at Yew Tree Lodge in Reading run by
Healthcare Trust
less institutional alternative to hospital admission when in crisis.
Care UK as alternative to hospital
admission.
Use of Restraint
Our staff at Prospect Park Hospital
September 2015
Berkshire
The training will mean that our staff will use different techniques to reduce
who has direct contact with patients
Healthcare Trust
the use of restraint in the wards. This will improve patient experience.
will receive Promoting Safer &
Therapeutic Services (PSTS) training.
21.
Calming (de-escalation) areas will be
introduced to all mental health ward
environments.
June 2015
Berkshire
Healthcare Trust
22.
All mental health inpatient and crisis
response home treatment team staff
will be trained in Breakaway
techniques so that they are able to
safely manage situations where an
acutely unwell patient may be a risk
to staff and others.
December 2015
Berkshire
Healthcare Trust
7
Patients who are very agitated and who potentially might be violent and
aggressive will have a dedicated area on each ward to receive individual
care. This will promote privacy and dignity, reduced the use of restraint and
an overall improved patient experience.
Staffs are supported to maintain both their own personal safety and that of
their patients.
23.
On the rare occasions when restraint
is used, our staff will only use
techniques and interventions that
are designed not to cause pain or
injury and maintain the principles of
dignity and respect for patients. All
patients will receive a de brief
following such an event.
April 2014
Berkshire
Healthcare Trust
Patients will be helped to understand the reasons why restraint was used.
Patients will also tell staff how it felt to be restrained and together they will
agree a joint plan of what to do should another incident occur to try and
avoid the use of restraint in the future.
24.
Clinical Staff at the Royal Berkshire
Hospital in A&E department and
other relevant wards and
departments will receive Conflict
Resolution Training using a scenario
based approach relevant to the
patient cared for.
September 2015
Royal Berkshire
Health Care
Foundation Trust
The training will mean that our staff will use de-escalation techniques to
minimise the need for restraint. This will improve patient experience.
25.
Security Staff do not restrain patients
unless there is a serious risk of them
harming themselves or other people.
They are trained in techniques and
interventions that are designed not
to cause pain, to maintain privacy
and dignity and they work with
clinical staff to ensure patient safety.
Where ever possible the patient or
their family is given an opportunity to
discuss the reasons for using
restraint and there is a team debrief
to learn lessons.
September 2014
Royal Berkshire
Health Care FT
Patients will only be restrained when it is absolutely necessary and when
they are episode of restraint this will be looked at by the security, clinical
and safeguarding team to learn lessons about avoiding using restraint
whenever possible.
26.
Police officers should not be
deployed to restrain persons
suffering mental illness unless there
Spring 2015
Thames Valley
Police
The use of police to restrain persons in mental health crisis, both in a
health care setting and in the community, is significantly reduced.
8
is a serious and imminent risk of
harm to any person or serious
damage to any property.
27.
Improve Primary Care response to
Mental Health Crisis by providing
education to GPs in all 7 CCGs in
Berkshire so that each GP knows who
it is appropriate to refer and to
phone for urgent referrals
Primary care response
September 2015
Clinical
Improved timeliness and quality of referrals to CPE
Commissioning
Better training are available for GPs in primary care to support clinicians to
Groups (CCGs)
manage mental health patients who present in crisis
Provide increased Primary Care
education in Mental Health issues –
i.e. Mental Health Masterclasses in
Berkshire west and Berkshire East.
On-going support from Mental
Health Qualified Clinicians into GP
Practices.
September 2015
Support GPs to have better understanding of mental health conditions and
the use of appropriate treatment packages to prevent mental health crisis
in primary care settings
Establish DXS system in Primary Care
Computer IT systems to guide GPs in
Berkshire West to support better
management of Mental Health
problems and monitor to see if
response is improving
November 2015
Deliver an enhanced level of IT software system to support access to
patient records
Better GP signposting i.e. to
Access to debt/welfare advisors in
Primary Care Settings and support.
September 2015
Primary Care Clinicians can make direct referrals to debt/welfare advisors
for those with finance problems
Explore increased use of Peer
mentors & peer navigators to
support access to services and
decrease DNA rates.
June 2015
Mental Health patients have access to peer mentoring in the community
via voluntary sector providers
9
Sharing of patient records with NHS
Providers and Emergency Services so
that when patients contact in crisis,
their primary care records can be
accessed easily.
November 2015
Better record sharing system are in place to allow emergency services to
access patients records both for primary care and secondary care
10
5. Partnership Working
No.
28.
Action
Timescale
Led By
Outcomes
Monitoring Progress and Planning Future System Improvements
Expand the Emergency Department
November 2014
Royal Berkshire
To provide a ward environment for those patients requiring treatment
of the Royal Berkshire Hospital to
Foundation NHS
within the Emergency Department post 4 hours with the expectation that
provide a new Observation Unit. This
Trust
they will be discharged home. Promoting privacy and dignity and an
will be made up of 8 beds (2 bays of
improved patient experience. A significant number of patients attending ED
4 beds) to provide single sex
with mental health problems fall into this category.
accommodation and 5 ambulatory
The Observatory Unit and Mental Health Assessment Room will improve
chairs. The facility will have a mental
the working conditions for both ED staff and the Acute Mental Health
health assessment room that is
Liaison Team and support better care for their patients.
compliant with National Standards, a
side room with shower facilities
Provide office accommodation for
the new Acute Mental Health Liaison
Service based at the Royal Berkshire
Hospital
October 2014
Royal Berkshire
Health Care FT
A working environment, adjacent to Emergency Department colleagues and
the Older Peoples Mental Health Liaison Team that will promote
multidisciplinary, and partnership working and lead to improved holistic
care of patients with mental health problems who attend the Emergency
Joint Clinical Governance
arrangements for the ED and newly
commissioned Psychological
Medicine Service at Royal Berkshire
Health Care FT
October 2014
Royal Berkshire
Health Care FT
Provide a forum for close partnership working where key performance
indicators, clinical incidents, complaints and patient experience in relation
to the care of mental health patients can be monitored and a culture of
continuous improvement fostered. There is patient representation on the
ED Clinical Governance Committee.
A comprehensive safeguarding
training strategy that includes
mental capacity assessment and
mental health act training and
addresses the knowledge and
competencies of the work force in
relation to care of mental health
patients who have acute and chronic
April 2015
Royal Berkshire
NHS FT
A work force that has the knowledge and skills to support mental health
patients with acute physical health needs, respecting their rights and
recognising when and how to make reasonable adjustments to ensure they
have access to appropriate care.
11
physical health needs requiring
admission to hospital.
29.
Royal Berkshire FT will be able to
‘flag’ individual crisis care plans
shared by Berkshire Health Care FT
on the A&E electronic patient record
system.
April 2015
Staff at A&E will be able to understand what the most appropriate care is
for an individual when they are in crisis.
The Crisis Care Concordat should be
placed on the agenda of Local
Safeguarding Adults Boards, which
have a statutory basis under the
st
Care Act 2014 from 1 April 2015.
April 2015
Concordat to be circulated to DASS in Berkshire for the attention of the
Safeguarding Co-ordinator.
Mental capacity awareness needs to
be supplemented by consideration
of the potential for Deprivation of
Liberty Safeguards to be applied, for
example, in certain cases of informal
admission.
April 2015
All Unitary Authorities in Berkshire
The Concordat will be of interest and
relevance to the work of our Health
and Wellbeing Boards, some of
which may wish to endorse the
concordat individually for their area.
April 2015
Concordat to be circulated to Health and Wellbeing Board Chairs in each of
the 6 areas.
We will share individual crisis care
plans with the police and ambulance
service regarding patients who are
frequently in contact with our
September 2015
Berkshire
Healthcare Trust
12
The police and ambulance service will be able to understand what the most
appropriate care for an individual is when they are in crisis.
mental health and emergency
services.
13
14/04/PM298
Trust Board Paper
Board Meeting Date
14 April 2015
Title
Financial Summary Report – Month 11 2014/15
Purpose
To provide the Month 11 2014/15 financial position to the
Trust Board
Business Area
Finance
Author
Relevant Strategic
Objectives
3. - Strategic Goal: To deliver financially sustainable
services through efficient provision of clinical & non-clinical
services
CQC
Registration/Patient
Care Impacts
N/A
Resource Impacts
None
Legal Implications
Meeting regulatory requirements
SUMMARY
ACTION REQUIRED
The Financial Summary Report included provides the
Board with a summary of the Month 11 2014/15 (February
2015) financial position.
The Board is invited to note the following summary of
financial performance and results for Month 11 2014/15
(February 2015):
YTD Continuity of Service rating (COS):
• COS 4 (plan COS 4)
o Debt Service Cover Ratio 2.04 (rating of 3)
o Liquidity metric 4.4 (rating of 4)
YTD income & expenditure:
• Plan: £340k net surplus
• Actual: £443k net surplus
• Variance: £103k favourable
1
Month 11: £61k overspend
Key variances:
• Impairments re three properties c.-£545k
• Pre-close provision review £507k
• MARs accrual c.-£161k
• Reserve release (per profiled forecast) c.£120k
YTD M11: £103k underspend
Key variances:
• OAPs: ongoing challenge (forecast to continue) c.-£778k
• Adult Inpatient staffing across the West: recruitment and
retention continue to be problematic c.-£533k
• Medical Staffing & Junior Doctors c.-£372k
The variances above are offset by the profiled reserve release
and vacancies.
Forecast outturn:
The forecast outturn is £0.2m surplus which is a movement of
-£0.6m since M10 reflecting a review of the balance sheet and
yearend risk position.
Cash: Month 11: £18,248k (plan £12,767k)
The positive variance reflects strong receivables / payables
management and the re-profiling of capital expenditure.
Capital expenditure: YTD Month 11: £4,979k (plan £6,380k)
Estates and IM&T expenditure is under strong scrutiny to support
the yearend position and c/forward into FY15/16. The forecast
has been reduced to £6.6m for yearend.
2
BERKSHIRE HEALTHCARE NHS FOUNDATION TRUST
Finance Report
Financial Year 2014 / 15
Month 11 (February 2015)
Purpose
This document provides the Board and Executive with information giving the financial performance as at 28th February 2015 (Month 11).
Document Control
Version
Date
Author
Comments
1.0
16.03.15
Nikola Pollard
First Draft
2.0
17.03.15
Tom Stacey
Second Draft
3.0
18.03.15
Anne-Marie Vine-Lott
Final for Exec
This document is considered to be Commercial in Confidence and is therefore not to be disclosed outside of the Trust without the prior consent of the Author
or a Director of the Trust.
Distribution:
All Directors
All staff needing to see this report
Document References
Document Title
Date
Published By
Page 2 of 5
CONTENTS
1.
Executive Summary Financial Performance ………………….....................4
2.
Annex………………………………………………………………………………..5
Page 3 of 5
1.0
Summary Financial Performance – Month 11
Page 4 of 5
2.0 Annex
Page 5 of 5
14/04/PM299
Trust Board Paper
Board Meeting Date
14 April 2015
Title
Performance Summary Scorecard and Trust
Performance Report – Month 11, 2014/15
Purpose
To provide the Month 11 for 2014/15 performance
summary scorecard and Trust performance report
Business Area
Trust-wide Performance
Author
Relevant Strategic
Objectives
2 - To provide safe, clinically effective services that
meet the assessed needs of patients, improve their
experience and outcome of care and consistently
meet or exceed the standards of CQC and other
stakeholders
Care Impacts
All relevant essential standards of care
Resource Impacts
None
Legal Implications
None
Summary
The enclosed performance reports provide
information against the Trust’s Performance
Scorecard summary and detailed performance report
for February 2015.
Month 11 2014/15 EXCEPTIONS:
The following Trust Performance Scorecard
Summary indicator groupings are Amber rated:
The 3 “amber” indicator groupings have been rated
on a subjective basis.
•
•
•
People – AMBER
Service Efficiency – AMBER
Contractual Performance - AMBER
Further detail on the subjective amber ratings is
narrated within the section commentary of the
performance report.
1
The following individual performance indicators
are highlighted by exception as red with their link
to the Trust Performance Scorecard Summary
identified in brackets:
•
•
US-05 - Self-Harm incidents (User Safety)
US-07 - Mental Health: Absconsions on MHA
section (User Safety)
•
US-08 - Medication errors / incidents (User
Safety)
PM-02 - Staff Turnover (People)
PM-04 – Sickness (People)
PM-17 - Mandatory Training: Deprivation of
Liberty Safeguards (People)
PM-20 - PINs (Monthly) (People)
SE-01 - DNA Rate (Service Efficiency)
SE-03 - Mental Health: Acute Average LoS
(bed days) (Service Efficiency)
SE-03a - Mental Health: Acute Average LOS
Snapshot (Service Efficiency)
SE-06 - Mental Health: Acute Occupancy rate
(exc. HL) (Service Efficiency)
SE-12a - Ethnicity Recording CHS % Ethnic
Codes (adults) (Service Efficiency)
SE12b - Ethnicity Recording CHS % Ethnic
Codes (children) (Service Efficiency)
SE-13 - Health Visiting: New Birth Visits
Within 14 days (Service Efficiency)
SE-15 - Mental Health Clustering within target
(6 and 12 months) (Service Efficiency)
•
•
•
•
•
•
•
•
•
•
•
•
A breakdown of the Electronic Staff Record data was
not available from the supplier for month 11 reporting
re Staff Turnover and Sickness in the People
grouping so provisional figures – indicators to be
updated at Month 12 for 2014/15.
ACTION REQUIRED
2
The Board is asked to note the above.
Performance Scorecard Summary:
Year 2014 - 2015; M11 February 2015
Ref
Mapped
indicators
CR
Overall
Performance
Over ride
Subjective
CQC Registration
Green
No
N/A
Indicators
UE
UE-01 to UE-03
User Experience
Green
No
N/A
US
US-01 to UE-18
User Safety
Green
No
N/A
P
PM-01 to PM-27
People
Amber
No
Yes
MA-01 to MA-15
Monitor Authorisation (non-financial)
Green
Yes
N/A
MA-16
Monitor Authorisation (financial)
Green
No
N/A
ME
ME-01
Governors, Membership, GP & Other Stakeholders
Green
No
N/A
SE
SE-01 to SE-16
Service Efficiency
Amber
No
Yes
CP
CP-01
Contractual Performance
Amber
No
Yes
MA
Key :
Red indicates the measures for this indicator are not meeting planned target levels for the current period being
measured
Red
R
Amber
Amber indicates the measures for this indicator are at risk of meeting planned target levels for the current period
being measured
Green
Green indicates the measures for this indicator are meeting or exceeding the planned target levels for the current
period being measured
A
G
The trajectory will either be green, amber or red depending on whether the measures for this
indicator are moving towards or achieving the target by year end.
Page 1 of 3
•
Mapping Rules to be applied to the indicator set for the performance scorecard summary
The mapping rules to be applied to the performance scorecard categories are detailed below:% rules based approach
o
o
o
Green
Where 50% or more of the mapped indicators are RED rated, the summary performance scorecard indicator will be RED.
Where 50% or more of the mapped indicators are AMBER rated, the summary performance scorecard indicator will be AMBER.
Where 50% or more of the mapped indicators are RED and / or AMBER rated, the summary performance scorecard indicator will be AMBER at best.
For example:
A performance scorecard category has 5 indicators mapping into itand these indicators have the following performance reported in the month:2 RED rated (40%)
2 AMBER rated (40%)
1 GREEN rated (20%)
Based on the first two mapping principles, the 50% rule would not apply but clearly the scorecard category should not be GREEN.
Based on the third rule, the scorecard performance could be rated as RED or AMBER
Over riding prinicples based approach
There are indicators within the detailed performance indicator report where the over ride rule applies.
This is driven by severe sanction or breach usually linked to regulatory compliance requirements within the Trust.
Year 2014 - 2015; M11 February 2015
·
Mental Health CPA review within 12 months and 7 day follow up
·
Mental Health new EIP cases (Year to Date)
·
Mental Health Home Treatment Team gate keeping
·
MHMDS – identifiers
·
MHMDS – Outcomes
·
CIDS data completeness – RTT information
·
CIDS data completeness – Referral Information
·
CIDS data completeness – Treatment activity information
· CQC conditions
· A&E maximum waiting time of 4 hours
Red performance against any of the above indicators turns the summary performance scorecard indicator red.
•
Other
There are 2 performance scorecard categories where no detailed performance indicators exist. These categories are:·
·
CQC Registration
Governors, membership, GPs and other stakeholders
·
CQC Registration
Although there are no performance indicators that map into the Trust performance scorecard for this category,
the performance against this indicator is clearly defined and summarised as:· Green performance scorecard rating denotes compliance with all essential CQC standards.
· Amber performance scorecard rating denotes low to moderate risk of non compliance with the essential CQC standards.
· Red performance scorecard rating denotes high risk of non compliance or confirmed non compliance with more than 2 of the essential CQC standards.
This performance is reported through the Trust Governance team using CQC Provider Compliance Assessment documents for each location.
o Governors, membership, GPs and Other Stakeholders – The Company Secretary and the Executive provide an overall view of performance against this indicator.
The rating for each of these categories is the responsibility of the Executive Director and agreed through the Trust Formal Executive Group.
Subjective
Where appropriate, Lead Directors may override mapping rules and this will be indicated on the performance scorecard summary.
BHFT Performance Assurance Framework
February 2015
BHFT Executive PAF Feb 2015 - DRAFT v2.xlsx
Page 1 of 45
Glossary
Frequency key
Description
Frequency (Freq)
M
Monthly
Q
Quarterly
QS
Quarterly snapshot
R12m
Rolling 12 month figure
R6m
Rolling 6 month figure
RQ
FYTD
Icon Key
Colour
Description
3
Red
3
Amber
2
Green
Rolling 3 month figure (quarter)
Fiscal year to date
Data Quality Key
Data Assurance Audit.
DA
Data Confidence Rating :
• High/Green = no data issues identified.
• Moderate/Amber = potential issues that could affect assurance of figures.
• Low/Red = data issues that will affect assurance, further work required.
• Purple = New or amended indicators where assurance is not yet available.
• No colour- awaiting audit and/or audit results.
• Any Moderate, Low or new indicators will have a DQIP in place.
Page 2 of 45
CQC Registration
Commentary
Performance Scorecard rating :
Green
Intelligent Monitoring
No further reports have been published since the new CQC intelligent monitoring report published on 20th November 2014. The next report is due in May 2015.
The Trust is in Band 3.
CQC Internal Compliance
There are no new reports available for this month.
Page 3 of 45
User Experience
Commentary
Green
The percentage of complaints acknowledged within three working days (not including date of receipt) is 95% for February 2015 (18/19).
Of the 19 complaints received in February 2015, 2 complaints were rated as high risk these were one each for WAM (CAMHS) and Slough (Slough Walk In Centre). There were 2 complaints which were rated as
moderate, 1 each for the Bracknell (Talking Therapies) and Mental Health Inpatients and Urgent Care (Adult Acute Inpatients). There was one secondary complaint received in February 2015. There were four
formal complaints received which were led by other organisations.
In addition the Trust also received a hard final copy from the Parliamentary Health Service Ombudsman (PHSO) of a partially upheld complaint relating to reported delay of a DVT by Westcall. An apology has been
sent and an action plan devised.
An analysis of the 19 complaints closed within an agreed timescale which include those which were re-negotiated showed that the Trust achieved 95%, which is lower than 100% achieved in January 2015.
The average number of days to resolve a complaint closed during February 2015 was 28 days, an improvement in performance from 34 days in January 2015.
Friends and Family Test - MIU has seen an decrease in response rates to 7%. Slough walk in centre and GP rates have now been included. A briefing by the Executive Director of Nursing and Governance will be
sent reminding staff of the importance of the Friends and Family Test.
In February 2014, 87% patients would recommend our Minor Injuries Unit, 72% patients would recommend the Walk In Service at the Slough Walk in Centre, 100% would recommend the GP service at the Slough
Walk In Centre and 87% would recommend our CHS inpatient wards.
Page 4 of 45
User Experience
UE_01
Target
Complaints : Number
Total by month
40
<25 /month
Freq
Sector
Last 12m avg
Mar-14
Apr-14
May-14
Jun-14
Jul-14
Aug-14
Sep-14
Oct-14
Nov-14
Dec-14
Jan-15
Feb-15
M
Total
19.9
15
20
20
21
25
19
23
21
21
14
24
16
M
MH IP & UC
4.0
4
6
2
8
4
4
5
4
5
2
2
2
M
Bracknell
2.5
1
2
4
0
2
2
4
4
1
2
5
3
M
Slough
1.5
1
1
2
1
2
3
1
0
1
1
3
2
M
WAM
2.8
1
1
2
1
7
1
3
5
3
3
5
1
M
West Berks
2.6
5
4
2
3
2
1
3
3
4
2
1
1
10
M
Reading
2.4
1
2
1
3
3
2
2
4
1
2
5
3
5
3.6
2
25
2
25
6
25
4
25
5
25
4
25
5
25
1
25
5
25
2
25
3
25
4
25
0
M
Wokingham
Target
UE_01a
Complaints resolved within agreed timescale of complainant (%) : Percent
Target
90%
DA
35
30
Moderate
25
20
15
Total by month
100%
Freq
Sector
Last 12m avg
Mar-14
Apr-14
May-14
Jun-14
Jul-14
Aug-14
Sep-14
Oct-14
Nov-14
Dec-14
Jan-15
Feb-15
M
Total
#N/A
#N/A
87%
82%
96%
85%
84%
92%
100%
100%
88%
100%
95%
M
MH IP & UC
#N/A
#N/A
100%
100%
75%
67%
#N/A
100%
100%
100%
88%
100%
100%
M
Bracknell
#N/A
#N/A
0%
0%
100%
100%
100%
75%
100%
100%
100%
100%
100%
M
Slough
#N/A
#N/A
100%
#N/A
100%
#N/A
50%
100%
100%
100%
100%
100%
100%
DA
95%
90%
85%
80%
M
WAM
#N/A
#N/A
100%
100%
100%
100%
67%
83%
100%
100%
75%
100%
80%
M
West Berks
#N/A
#N/A
100%
75%
100%
100%
100%
100%
100%
100%
100%
100%
100%
M
Reading
#N/A
#N/A
75%
#N/A
100%
100%
75%
100%
100%
100%
67%
100%
-
M
Wokingham
#N/A
#N/A
100%
100%
100%
100%
83%
100%
100%
100%
100%
100%
100%
#N/A
90%
#N/A
90%
100%
90%
#N/A
90%
100%
90%
100%
90%
#N/A
90%
92%
90%
100%
90%
100%
90%
90%
100%
90%
90%
75%
70%
n/a
65%
60%
55%
50%
M
Corporate
Target
45%
40%
Page 5 of 45
UE_02
Patient Experience : Percent
Target
75%
Sector
Freq
Total by month
100%
Mar-14
Apr-14
May-14
Jun-14
Jul-14
Aug-14
Sep-14
Oct-14
Nov-14
Dec-14
Jan-15
Feb-15
DA
90%
80%
Total
Q
87%
#N/A
#N/A
82%
#N/A
#N/A
90%
#N/A
#N/A
95%
#N/A
#N/A
n/a
70%
60%
50%
21
Target
75%
75%
75%
75%
75%
75%
75%
75%
75%
75%
75%
75%
The percentage above represents the number of service users who have rated the services as good or better.
Services include:
CHS and MH inpatients, Audiology, Community Matrons, Continence, COPD Outreach, CTPLD,
Day Hospitals at St Marks and Upton, Diabetes, Dietetics,
Hi Tech Care, Intermediate Care, Palliative care, Minor Injuries Unit, Mobility, MS Nurses, New Entrants,
Physiotherapy Community and MSK, Podiatry, Public Health Dietetics, Adult Speech and Language Therapy,
Sexual Health, Slough Walk In Centre, Tissue Viability, ECT and CMHT.
Page 6 of 45
UE_03
How likely are you to recommend our department to friends and family if they needed similar care or treatment : Percent
Target
85%
Total by month
100%
Freq
Sector
Last 12m avg
Mar-14
Apr-14
May-14
Jun-14
Jul-14
Aug-14
Sep-14
Oct-14
Nov-14
Dec-14
Jan-15
Feb-15
M
Total
95%
97%
98%
98%
97%
97%
90%
97%
99%
98%
87%
92%
85%
M
MIU
96%
98%
98%
99%
98%
97%
99%
97%
99%
100%
87%
90%
90%
M
Wokingham
91%
79%
83%
100%
100%
91%
85%
97%
88%
92%
88%
100%
84%
85%
M
Reading
91%
92%
93%
78%
100%
100%
92%
100%
90%
92%
83%
81%
90%
80%
M
West Berks
90%
100%
100%
88%
94%
94%
91%
74%
100%
93%
85%
69%
97%
M
Slough
99%
89%
100%
100%
92%
100%
100%
100%
121%
94%
100%
tbc
94%
M
WAM
94%
100%
90%
94%
100%
92%
86%
94%
96%
100%
87%
100%
85%
M
swihc: wic
#N/A
#N/A
#N/A
#N/A
#N/A
#N/A
#N/A
#N/A
90%
tbc
96%
99%
72%
M
22
swihc: GP
Target
#N/A
DA
95%
90%
High
75%
70%
65%
#N/A
#N/A
#N/A
#N/A
#N/A
#N/A
#N/A
100%
tbc
100%
85%
100%
85%
85%
85%
85%
85%
85%
85%
85%
85%
85%
85%
85%
swihc = Slough Walk-in Health Centre.
swihc: wic = walk-in patients.
swihc: GP = patients registered with the GP practice at swihc.
60%
October 2014 - Jubilee Ward figure has been checked with the ward and is correct, whist 14 requests were made for feedback, 17 responses were received. December 2014 MIU data amended
UE_03b
Target
Friends & Family Test response rate (Number of responses as a percentage of the number given the questionnaire) : Percent
Total by month
100%
15%
Freq
Sector
Last 12m avg
Mar-14
Apr-14
May-14
Jun-14
Jul-14
Aug-14
Sep-14
Oct-14
Nov-14
Dec-14
Jan-15
Feb-15
M
Total
#N/A
#N/A
37%
41%
41%
18%
22%
37%
34%
94%
22%
31%
6%
80%
M
MIU
#N/A
#N/A
33%
39%
39%
15%
19%
34%
31%
15%
21%
14%
7%
70%
M
Wokingham
#N/A
#N/A
88%
100%
100%
100%
100%
100%
100%
93%
100%
100%
86%
60%
Reading
#N/A
#N/A
63%
53%
72%
80%
80%
70%
77%
72%
67%
81%
91%
M
DA
90%
50%
n/a
M
West Berks
#N/A
#N/A
92%
64%
72%
55%
71%
83%
75%
58%
54%
69%
88%
M
Slough
#N/A
#N/A
100%
100%
54%
59%
79%
39%
tbc
65%
68%
tbc
71%
30%
M
WAM
#N/A
#N/A
100%
94%
100%
87%
70%
76%
94%
94%
100%
100%
100%
20%
M
swihc: wic
#N/A
#N/A
#N/A
#N/A
#N/A
#N/A
#N/A
#N/A
tbc
tbc
tbc
tbc
2%
10%
M
29
swihc: GP
Target
#N/A
#N/A
#N/A
#N/A
#N/A
#N/A
#N/A
#N/A
tbc
tbc
tbc
tbc
1%
15%
15%
15%
15%
15%
15%
15%
15%
15%
15%
15%
15%
swihc = Slough Walk-in Health Centre.
swihc: wic = walk-in patients.
swihc: GP = patients registered with the GP practice at swihc.
40%
0%
December 2014 - No data for Donnington ward has been received.
Page 7 of 45
User Safety
Commentary
Green
There were 6 SIRIS reported in February 2015. Of these 2 were apparent suicides (both Bracknell CMHT clients), 2 unexpected deaths (both CRHTT East clients), 1 patient from Snowdrop ward detained under the
Mental Health Act who had been AWOL for over 72 hours and 1 admission of a minor to Snowdrop ward.
The number of assaults on staff decreased to 53 in the rolling quarter to February 2015, place of safety (4) and Rowan (3) and Sorrell (2) wards reported the highest number of incidents in February 2015 . In
February 2015, one assualt on a staff member on Daisy ward was rated as moderate, all other incidents in February 2015 were rated as low or minor. The assaults were carried out by 46 separate patients during
the rolling quarter.
Patient to Patient Assaults has decreased in Adult Mental Health services in the rolling quarter from 33 to 29, with 10 of the 29 assaults reported on Daisy Ward alone. One incident on Daisy ward was rated as
moderate. In addition there was one assault by a patient against their ex partner in West Berks, which was also rated as moderate.
Learning Disability Patient to Patient Assaults has remained at 5 in the rolling quarter to February 2015. All 5 incidents rated as low risk. Two incidents were reported in February 2015, however one incident
appears to be incorrectly coded as the assault was on a member of ISS staff at Prospect Park Hospital.
Slips Trips and Falls. Falls continue to be above the target per 1,000 bed days on Rowan, Sorrell, Oakwood, Henry Tudor and Donnington. Falls safe plan - All community inpatient wards are trialling a revised form
of the current Traffic Light Assessment Tool and Falls Prevention Care Plan along with a coloured wristband system. Evidence from this initiative piloted in an NHS Trust in Kent produced a 50% reduction in falls on
the wards. Planning around use of the revised Traffic Light Assessment Tool and Falls Prevention Care plan is underway and the training and implementation will follow once the wristbands, which have been
ordered, are delivered. Actions for Oakwood ward have included examining whether further assistive technologies may reduce the number of falls and changes to staff working hours as falls on the ward tend to
occur between the hours of 6pm to 10pm. Orchid ward are working with the community nurse specialist for equipment to address the physical health needs of the patients.
Medication errors reporting decreased in the rolling year to February 2015.
Self Harm -These have increased from January 2015. In February 2015, all incidents were rated as low or moderate. Bluebell ward reported the highest number of self harm incidents both for rolling quarter (33)
and in month (15). Of those reported on Bluebell in February 12 of the 15 self harm incidents were by 3 patients.
AWOLS and Absconsions – AWOLS have decreased slightly and Absconsions have increased slightly in the rolling quarter to February 2015. In February 2015 there were 3 AWOLS -2 were reported on Rose Ward
and 1 on Snowdrop ward. Snowdrop had the highest reported absconsions with 3 in February 2015, a decrease from 6 in December 2014. Absconsions have increased from 16 in December 2014, to 3 in January
2015, to 7 in February 2015.
PMVA (Control and Restraint of Mental Health patients) - Incidents have been reported across Acute Mental Health, Place of Safety, Psychiatric Intensive Care Unit. In February 2015, 10 Patients required PMVA
techniques, Bluebell ward reported 11 usages, Place of Safety 6 and Daisy 5.
Prone restraint - There were 7 individual clients for whom prone restraint was needed. Of the 18 uses, 8 were reported by Bluebell ward, 3 in Daisy and APOS, 2 on Sorrell, and 1 each on Campion and Snowdrop.
Page 8 of 45
2015, to 7 in February 2015.
PMVA (Control and Restraint of Mental Health patients) - Incidents have been reported across Acute Mental Health, Place of Safety, Psychiatric Intensive Care Unit. In February 2015, 10 Patients required PMVA
techniques, Bluebell ward reported 11 usages, Place of Safety 6 and Daisy 5.
Prone restraint - There were 7 individual clients for whom prone restraint was needed. Of the 18 uses, 8 were reported by Bluebell ward, 3 in Daisy and APOS, 2 on Sorrell, and 1 each on Campion and Snowdrop.
Learning Disabilities Strategy for Crisis Intervention and Prevention - One client was responsible for 14/16 incidents.
Seclusion - In Mental Health, 3 clients were responsible for the 7 incidents of seclusion in February 2015. The longest period in seclusion was 29 hours 55 minutes, but there were a total of 3 episodes of seclusion
over 8 hours in February 2015.
Page 9 of 45
User Safety
US_01
Target
Mental Health: Physical assaults on staff : Number
Mental Health: Green < 60,
Amber 60 - 70,
Total by month
80
Red > 70
70
Freq
Sector
Last 12m avg
Mar-14
Apr-14
May-14
Jun-14
Jul-14
Aug-14
Sep-14
Oct-14
Nov-14
Dec-14
Jan-15
Feb-15
RQ
Total
55.0
52
49
51
52
51
56
52
56
68
65
55
53
60
RQ
MH IP & UC
53.5
52
48
49
49
49
55
52
55
67
62
53
51
50
RQ
Bracknell
0.0
0
0
0
0
0
0
0
0
0
0
0
0
RQ
Slough
0.5
0
0
0
0
0
0
0
0
0
2
2
2
RQ
WAM
0.3
0
0
1
2
0
0
0
0
0
0
0
0
RQ
West Berks
0.1
0
1
0
0
0
0
0
0
0
0
0
0
20
RQ
Reading
0.3
0
0
0
1
1
1
0
0
0
0
0
0
10
DA
40
High
30
RQ
0.5
0
0
1
1
1
0
0
1
1
1
0
0
Wokingham
0
36 Target
60
60
60
60
60
60
60
60
60
60
60
60
In 2013/14 NHS Benchmarking of Mental Health services - the Trust was below the mean for the number of incidents of physical violence to staff at 384 incidents of physical violence to staff per 100,000 bed days against a mean
of 597 incidents per 100,000 bed days.
US_02a
Target
Mental Health: Physical patient to patients assaults : Number
Amber 35 - 40,
Total by month
60
Red > 40
Freq
Sector
Last 12m avg
Mar-14
Apr-14
May-14
Jun-14
Jul-14
Aug-14
Sep-14
Oct-14
Nov-14
Dec-14
Jan-15
Feb-15
RQ
Total
30.8
42
49
33
27
22
26
34
21
23
31
33
29
RQ
MH IP & UC
29.8
41
48
31
25
21
25
33
21
22
31
32
28
RQ
Bracknell
0.3
0
0
2
1
0
0
0
0
1
0
0
0
RQ
Slough
0.0
0
0
0
0
0
0
0
0
0
0
0
0
RQ
WAM
0.1
0
0
0
0
0
1
0
0
0
0
0
0
RQ
West Berks
0.2
1
1
0
0
0
0
0
0
0
0
0
0
RQ
Reading
0.4
0
0
0
1
1
0
1
0
0
0
1
1
DA
50
40
30
High
20
10
RQ
0.0
0
0
0
0
0
0
0
0
0
0
0
0
Wokingham
0
44 Target
35.0
35.0
35.0
35.0
35.0
35.0
35.0
35.0
35.0
35.0
35.0
35.0
In 2013/14 NHS Benchmarking of Mental Health services - the Trust was just above the mean for the number of incidents of physical violence to patients at 303 incidents of physical violence to patients per 100,000 bed days to
patients against a mean of 293 incidents per 100,000 bed days.
US_02b
Learning Disability: Physical patient to patients assaults : Number
Target
Learning & Disability: Green < 35,
Amber 35 - 40,
40
Red > 40
30
Freq
Sector
Last 12m avg
Mar-14
Apr-14
May-14
Jun-14
Jul-14
Aug-14
Sep-14
Oct-14
Nov-14
Dec-14
Jan-15
Feb-15
DA
RQ
Total
7.5
11
14
14
10
7
5
6
6
4
3
5
5
High
35
35
35
35
35
35
35
35
35
35
35
35
52
Target
Total by month
20
10
0
Page 10 of 45
Freq
US_03
Reported incidents per 1,000 beds : Number
Target
Green > 29,
Sector
Last 12m avg
Amber 22 - 28,
Mar-14
Total by month
45
Red < 22
Apr-14
May-14
40
Jun-14
Jul-14
Aug-14
Sep-14
Oct-14
Nov-14
Dec-14
Jan-15
Feb-15
DA
35
30
25
20
M
Total
33.3
28
41
36
36
34
28
33
37
28
33
34
33
High
15
10
5
0
53 Target
29
29
29
29
29
29
29
29
29
29
29
29
The above data shows the reported incidents per 1,000 bed days with the targets set based on average reporting for the year. In the NRLS most recent report published in September 2012 BHFT was found to be in the lower
levels of reporters and this is under investigation. High levels of incident reporting are encouraged as learning from low level incidents is thought to reduce the likelihood of more serious incidents.
US_04
Target
Slips, trips and falls (monthly per 1,000 Occupied Bed Days) : Number
Total by month
25
Targets 8 Per 1000 for CHS, 5.2 for Mental Health
Freq
Sector
Last 12m avg
Mar-14
Apr-14
May-14
Jun-14
Jul-14
Aug-14
Sep-14
Oct-14
Nov-14
Dec-14
Jan-15
Feb-15
M
Total
#N/A
#N/A
14.2
5.9
4.8
4.0
4.7
7.7
5.8
4.3
6.1
5.8
6.3
M
Daisy
#N/A
#N/A
3.1
0.0
0.0
0.0
0.0
0.0
0.0
0.0
0.0
0.0
1.7
M
Bluebell
#N/A
#N/A
0.0
0.0
0.0
0.0
0.0
2.8
3.5
5.5
0.0
1.3
1.4
M
Snowdrop
#N/A
#N/A
1.5
1.5
6.4
0.0
0.0
0.0
0.0
1.6
3.1
0.0
1.7
M
Sorrel
#N/A
#N/A
0.0
0.0
3.5
0.0
0.0
4.7
4.3
17.1
6.2
6.2
20.6
M
Rowan
#N/A
#N/A
4.9
2.7
2.6
5.1
0.0
4.2
0.0
7.6
11.7
16.4
10.6
M
Charles
#N/A
#N/A
0.0
#N/A
#N/A
#N/A
#N/A
-
-
-
-
#N/A
#N/A
M
Papist Way
#N/A
#N/A
0.0
#N/A
#N/A
#N/A
#N/A
-
-
-
-
#N/A
#N/A
M
Rose
#N/A
#N/A
0.0
0.0
0.0
1.6
1.6
3.5
0.0
0.0
0.0
0.0
0.0
M
Orchid
#N/A
#N/A
10.2
12.3
10.3
3.9
6.2
18.2
9.0
10.2
4.6
4.6
0.0
M
Little House
#N/A
#N/A
15.5
0.0
0.0
0.0
5.8
0.0
0.0
0.0
4.6
22.7
0.0
M
Campion
#N/A
#N/A
0.0
9.9
0.0
0.0
4.4
0.0
0.0
6.3
0.0
0.0
0.0
M
Oakwood
#N/A
#N/A
10.0
8.1
7.9
3.8
10.3
15.5
13.8
5.0
11.7
8.8
19.3
M
Jubilee
#N/A
#N/A
3.8
5.0
3.4
3.9
5.5
5.8
1.8
0.0
4.0
4.8
1.7
M
Henry Tudor
#N/A
#N/A
7.3
6.1
11.3
11.8
9.0
5.2
6.5
1.9
9.3
6.6
8.4
M
Donnington
#N/A
#N/A
3.9
6.7
2.4
10.9
5.6
8.4
10.8
3.8
5.7
4.5
8.9
M
Highclere
#N/A
#N/A
5.9
12.4
7.1
8.9
6.5
7.0
9.7
5.2
11.7
12.9
11.7
M
BAU
#N/A
#N/A
0.0
0.0
0.0
0.0
0.0
0.0
0.0
0.0
0.0
9.1
0.0
Ascot
#N/A
#N/A
14.5
2.7
10.7
3.1
9.3
16.1
9.5
10.4
16.1
7.6
0.0
#N/A
?
#N/A
?
0.0
?
6.8
?
4.0
?
4.4
?
4.9
?
4.1
?
1.3
?
2.5
?
6.2
?
6.0
?
6.9
?
M
M
54
Windsor
Target
DA
20
15
High
10
5
0
Page 11 of 45
US_05
Self Harm incidents : Number
Target
Total by month
Amber 50 - 60,
70
Red > 60
Freq
Sector
Last 12m avg
Mar-14
Apr-14
May-14
Jun-14
Jul-14
Aug-14
Sep-14
Oct-14
Nov-14
Dec-14
Jan-15
Feb-15
RQ
Total
55.4
42
41
48
50
43
47
66
69
64
57
66
72
RQ
MH IP & UC
41.1
37
33
33
30
24
34
47
48
48
46
54
59
RQ
Bracknell
6.8
4
5
10
11
11
4
6
9
7
3
4
7
RQ
Slough
0.3
0
0
0
1
2
1
0
0
0
0
0
0
RQ
WAM
2.8
3
1
1
1
2
4
8
7
2
1
1
3
RQ
West Berks
0.4
0
0
0
0
0
0
1
1
1
0
1
1
RQ
Reading
8.9
19
9
12
17
20
18
0
2
3
4
2
1
10
2.1
0
1
2
3
2
2
3
RQ
Wokingham
74 Target
60
60
60
60
60
60
60
Excludes Learning Disability.
There was 1 for January 2015 that was entered in category 'Other' that was unable to be classified into a locality, yet.
2
60
3
60
3
60
3
60
1
60
0
DA
60
50
40
High
30
20
US_06
Target
Freq
Mental Health: AWOLs on MHA section : Number
Amber 15 - 20,
Total by month
25
Red > 20
Sector
Last 12m avg
Mar-14
Apr-14
May-14
Jun-14
Jul-14
Aug-14
Sep-14
Oct-14
Nov-14
Dec-14
Jan-15
Feb-15
RQ
Total
15.1
17
16
20
11
14
10
17
17
17
15
14
13
RQ
Daisy
3.8
2
4
6
6
5
4
5
4
4
2
2
1
RQ
Bluebell
3.6
3
1
3
3
4
1
3
5
7
7
4
2
RQ
Ward 10
#N/A
-
#N/A
#N/A
#N/A
#N/A
#N/A
-
-
-
-
#N/A
#N/A
RQ
Snowdrop
#N/A
3
4
5
1
3
3
5
5
4
1
#N/A
1
RQ
Rose
3.0
5
6
5
1
2
1
1
-
1
1
4
6
RQ
Sorrel
1.7
1
1
1
0
0
1
2
2
1
4
4
3
RQ
Jasmine
#N/A
0
#N/A
#N/A
#N/A
#N/A
#N/A
0
-
-
-
#N/A
#N/A
RQ
Rowan
0.0
0
0
0
0
0
-
0
0
0
0
0
0
RQ
Charles
#N/A
0
#N/A
#N/A
#N/A
#N/A
#N/A
-
-
-
-
#N/A
#N/A
RQ
Papist Way
#N/A
0
0
-
-
-
-
-
-
-
-
#N/A
#N/A
0.0
0
15
0
15
0
15
0
15
0
15
0
15
0
15
0
15
0
15
0
15
0
15
0
15
DA
20
15
High
10
5
RQ
82
Orchid
Target
0
Page 12 of 45
US_07
Mental Health: Absconsions on MHA section : Number
Target
Amber 15 - 25,
Total by month
30
Red > 25
Freq
Sector
Last 12m avg
Mar-14
Apr-14
May-14
Jun-14
Jul-14
Aug-14
Sep-14
Oct-14
Nov-14
Dec-14
Jan-15
Feb-15
RQ
Total
19.9
13
17
16
18
19
25
21
20
17
24
23
26
6
RQ
Daisy
3.5
4
4
4
1
3
3
3
2
2
5
5
RQ
Bluebell
10.8
4
7
7
14
12
16
13
15
11
12
10
9
RQ
Ward 10
#N/A
#N/A
#N/A
#N/A
#N/A
#N/A
#N/A
#N/A
#N/A
#N/A
#N/A
#N/A
#N/A
RQ
Snowdrop
2.0
3
4
2
1
1
3
2
1
2
1
1
3
RQ
Rose
1.7
1
1
2
2
3
2
3
2
1
1
1
1
RQ
Sorrel
0.1
0
0
0
0
0
1
0
0
0
0
0
0
RQ
Jasmine
#N/A
#N/A
#N/A
#N/A
#N/A
#N/A
#N/A
#N/A
#N/A
#N/A
#N/A
#N/A
#N/A
RQ
Rowan
0.0
0
0
0
0
0
0
0
0
0
0
0
0
RQ
Charles
#N/A
#N/A
#N/A
#N/A
#N/A
#N/A
#N/A
#N/A
#N/A
#N/A
#N/A
#N/A
#N/A
RQ
Papist Way
#N/A
0
0
#N/A
#N/A
#N/A
#N/A
#N/A
#N/A
#N/A
#N/A
#N/A
#N/A
0
25
0
25
0
25
0
25
0
25
0.0
0
0
0
0
0
0
0
RQ
Orchid
94 Target
25
25
25
25
25
25
25
January 2015 -Rolling Quarter Total includes 6 additional absconsions - 2 from Campion Unit and 4 from Little House.
US_08
Target
Freq
Sector
DA
25
20
15
High
10
5
0
Medication errors / incidents : Number
Green = Increase,
Last 12m avg
Total by month
Amber = Decrease of <=10,
Mar-14
Apr-14
May-14
700
Red = Decrease of >10
Jun-14
Jul-14
600
Aug-14
Sep-14
Oct-14
Nov-14
Dec-14
Jan-15
Feb-15
DA
500
400
300
R12m
Total
#N/A
#N/A
637
642
636
658
639
605
582
619
624
655
599
High
200
100
0
106 Target
#N/A
Green
Amber
Green
Red
Red
Red
Green
Green
Green
Red
In 2013/14 NHS Benchmarking of Mental Health services - the Trust was above the mean for the number of drug administration errors per 100,000 at 338 incidents of drug administration errors per 100,000 bed days against a
mean of 146 drug administration errors per 100,000 bed days.
Description
Last 12m avg
Mar-14
Apr-14
May-14
Jun-14
Jul-14
Aug-14
Sep-14
Oct-14
Nov-14
Dec-14
Jan-15
Feb-15
DA
Target
Freq:
US_09. Medication errors
/ incidents : Moderate :
Number
#N/A
#N/A
4
4
5
4
1
2
3
2
2
1
1
High
TBC
R12m
US_10. Medication errors
/ incidents : High / Major
/ Severe : Number
#N/A
#N/A
0
0
0
0
0
0
1
1
1
1
1
High
TBC
R12m
Page 13 of 45
Description
Last 12m avg
Mar-14
Apr-14
May-14
Jun-14
Jul-14
Aug-14
Sep-14
Oct-14
Nov-14
Dec-14
Jan-15
Feb-15
DA
Target
Freq:
US_11. MRSA
Bacteraemia : Number
0.0
0
0
0
0
0
0
0
0
0
0
0
0
High
0 pa
M
US_12. C.Difficile :
Number
0.1
0
0
0
0
0
0
0
0
1
0
0
0
High
2014/15:
2 East & 4 West
M
US_13. Noro Virus :
Number
3.3
12
3
19
0
0
0
0
0
0
0
3
3
High
N/A
M
US_14
Number of suicides in the last 12 months : Number
Target
Amber 17 - 22,
Total by month
30
Red > 23
25
Freq
Sector
Last 12m avg
Mar-14
Apr-14
May-14
Jun-14
Jul-14
Aug-14
Sep-14
Oct-14
Nov-14
Dec-14
Jan-15
Feb-15
DA
20
15
R12m
Total
15.7
15
15
14
13
15
15
17
18
16
17
16
17
n/a
10
5
0
112
Target
US_15
Target
17
17
17
17
17
17
17
17
17
17
17
17
Mental Health: Suicides in month : Number
Total by month
10
No Target
9
Freq
Sector
Last 12m avg
Mar-14
Apr-14
May-14
Jun-14
Jul-14
Aug-14
Sep-14
Oct-14
Nov-14
Dec-14
Jan-15
Feb-15
M
Total
1.4
0
2
0
0
3
0
5
1
1
3
0
2
8
M
MH IP & UC
0.5
0
2
0
0
2
0
0
0
1
1
0
0
7
M
Bracknell
0.3
0
0
0
0
1
0
1
0
0
0
0
2
M
Slough
0.0
0
0
0
0
0
0
0
0
0
0
0
0
M
WAM
0.1
0
0
0
0
0
0
1
0
0
0
0
0
M
West Berks
0.2
0
0
0
0
0
0
1
0
0
1
0
0
M
Reading
0.1
0
0
0
0
0
0
0
1
0
0
0
0
0
1
0
0
DA
6
5
n/a
4
3
2
0.3
0
0
0
0
0
0
2
0
M
Wokingham
113 Target
February 2015: A retrospective annual review will review actual vs alleged suicides for the year based on outcomes from investigations.
1
0
Page 14 of 45
US_16
Newly acquired grade 3 pressure ulcers: Community : Number
Target
No Target
Total by month
10
Freq
Sector
Last 12m avg
Mar-14
Apr-14
May-14
Jun-14
Jul-14
Aug-14
Sep-14
Oct-14
Nov-14
Dec-14
Jan-15
Feb-15
M
Total
1.2
2
2
0
3
2
2
2
1
0
0
0
0
M
Bracknell
0.1
0
0
0
0
1
0
0
0
0
0
0
0
M
Slough
0.2
1
0
0
0
0
0
1
0
0
0
0
0
M
WAM
0.0
0
0
0
0
0
0
0
0
0
0
0
0
M
West Berks
0.1
1
0
0
0
0
0
0
0
0
0
0
0
M
Reading
0.4
0
1
0
1
0
2
1
0
0
0
0
0
0.4
0
1
0
2
1
0
0
1
0
0
0
0
DA
8
6
n/a
4
2
M
121
Wokingham
Target
US_16a
Target
0
Newly acquired grade 3 pressure ulcers: in-patient wards : Number
Total by month
10
Target = 0
Freq
Sector
Last 12m avg
Mar-14
Apr-14
May-14
Jun-14
Jul-14
Aug-14
Sep-14
Oct-14
Nov-14
Dec-14
Jan-15
Feb-15
M
Total
0.3
1
0
1
0
0
0
0
1
0
0
0
0
M
Oakwood
0.1
0
0
0
0
0
0
0
1
0
0
0
0
M
Jubilee
0.0
0
0
0
0
0
0
0
0
0
0
0
0
M
Henry Tudor
0.0
0
0
0
0
0
0
0
0
0
0
0
0
M
Donnington
0.0
0
0
0
0
0
0
0
0
0
0
0
0
M
Highclere
0.0
0
0
0
0
0
0
0
0
0
0
0
0
M
Ascot
0.0
0
0
0
0
0
0
0
0
0
0
0
0
M
Windsor
0.2
1
0
1
0
0
0
0
0
0
0
0
0
M
Daisy
0.0
0
0
0
0
0
0
0
0
0
0
0
0
M
Bluebell
0.0
0
0
0
0
0
0
0
0
0
0
0
0
M
Snowdrop
0.0
0
0
0
0
0
0
0
0
0
0
0
0
M
Rose
0.0
0
0
0
0
0
0
0
0
0
0
0
0
M
Sorrel
0.0
0
0
0
0
0
0
0
0
0
0
0
0
Rowan
0.0
0
0
0
0
0
0
0
0
0
0
0
0
0.0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
DA
9
8
7
M
M
128
New Orchid
Target
6
5
n/a
4
3
2
1
0
Page 15 of 45
US_17
Newly acquired grade 4 pressure ulcers: Community : Number
Target
No Target
Total by month
10
Freq
Sector
Last 12m avg
Mar-14
Apr-14
May-14
Jun-14
Jul-14
Aug-14
Sep-14
Oct-14
Nov-14
Dec-14
Jan-15
Feb-15
M
Total
0.8
0
1
2
0
1
0
1
0
2
2
1
0
M
Bracknell
0.2
0
0
0
0
0
0
0
0
1
1
0
0
M
Slough
0.1
0
0
0
0
0
0
1
0
0
0
0
0
M
WAM
0.2
0
0
0
0
1
0
0
0
0
1
0
0
M
West Berks
0.1
0
0
0
0
0
0
0
0
1
0
0
0
M
Reading
0.2
0
0
1
0
0
0
0
0
0
0
1
0
0.2
0
1
1
0
0
0
0
0
0
0
0
0
M
143
Wokingham
Target
US_17a
Target
DA
8
6
n/a
4
2
0
Newly acquired grade 4 pressure ulcers: in-patient wards : Number
Total by month
10
Target = 0
Freq
Sector
Last 12m avg
Mar-14
Apr-14
May-14
Jun-14
Jul-14
Aug-14
Sep-14
Oct-14
Nov-14
Dec-14
Jan-15
Feb-15
M
Total
0.2
0
0
1
0
0
0
0
0
0
1
0
0
M
Oakwood
0.0
0
0
0
0
0
0
0
0
0
0
0
0
M
Jubilee
0.0
0
0
0
0
0
0
0
0
0
0
0
0
M
Henry Tudor
0.0
0
0
0
0
0
0
0
0
0
0
0
0
M
DA
9
8
7
Donnington
0.1
0
0
0
0
0
0
0
0
0
1
0
0
M
Highclere
0.1
0
0
1
0
0
0
0
0
0
0
0
0
M
Ascot
0.0
0
0
0
0
0
0
0
0
0
0
0
0
M
Windsor
0.0
0
0
0
0
0
0
0
0
0
0
0
0
M
Daisy
0.0
0
0
0
0
0
0
0
0
0
0
0
0
M
Bluebell
0.0
0
0
0
0
0
0
0
0
0
0
0
0
M
Snowdrop
0.0
0
0
0
0
0
0
0
0
0
0
0
0
M
Rose
0.0
0
0
0
0
0
0
0
0
0
0
0
0
M
Sorrel
0.0
0
0
0
0
0
0
0
0
0
0
0
0
M
Rowan
0.0
0
0
0
0
0
0
0
0
0
0
0
0
0.0
0
0.0
0
0.0
0
0.0
0
0.0
0
0.0
0
0.0
0
0.0
0
0.0
0
0.0
0
0.0
0
0.0
0
0.0
6
5
n/a
4
3
2
1
M
150
New Orchid
Target
0
Page 16 of 45
Description
US_18. Mental Health:
Preventing and
Managing Violence and
Aggression : Number
Sector
Mar-14
Apr-14
May-14
Jun-14
Jul-14
Aug-14
Sep-14
Oct-14
Nov-14
Dec-14
Jan-15
Feb-15
DA
Target
Freq:
Total
13
25
26
31
24
9
26
45
26
34
24
28
n/a
No Target
M
MH IP & UC
13
25
26
31
24
9
26
45
26
21
24
28
n/a
No Target
M
In 2013/14 NHS Benchmarking of Mental Health services - the Trust was below the mean for the number of incidents of restraint at 513 incidents of restraint per 100,000 bed days against a mean of 834 incidents per 100,000
bed days.
Description
US_18a. Learning
Disability Strategy for
Crisis Intervention &
Prevention : Number
Description
Prone( Face Down)
Restraint : Number
Sector
Mar-14
Apr-14
May-14
Jun-14
Jul-14
Aug-14
Sep-14
Oct-14
Nov-14
Dec-14
Jan-15
Feb-15
DA
Target
Freq:
Total
#N/A
#N/A
#N/A
75
43
65
47
25
31
25
25
16
n/a
No Target
M
Sector
Mar-14
Apr-14
May-14
Jun-14
Jul-14
Aug-14
Sep-14
Oct-14
Nov-14
Dec-14
Jan-15
Feb-15
DA
Target
Freq:
Total
5
12
10
14
7
4
14
15
10
15
12
18
n/a
No Target
M
MH IP & UC
5
12
10
14
7
4
14
15
10
15
12
18
n/a
No Target
M
In 2013/14 NHS Benchmarking of Mental Health services - the Trust was just below the mean for the number of incidents of seclusion of patients at 147 incidents of face down restraint per 100,000 bed days to patients against
a mean of 237 incidents per 100,000 bed days and a median of 163 incidents per 100,000 bed days.
Description
Seclusion : Number
Sector
Mar-14
Apr-14
May-14
Jun-14
Jul-14
Aug-14
Sep-14
Oct-14
Nov-14
Dec-14
Jan-15
Feb-15
DA
Target
Freq:
Total
5
10
23
0
18
34
40
36
11
9
23
8
n/a
No Target
M
MH IP & UC
5
10
23
0
18
7
8
22
11
9
23
7
n/a
No Target
M
LD
#N/A
#N/A
#N/A
#N/A
#N/A
27
32
14
0
0
0
1
n/a
No Target
M
This indicator shows where a member of staff had to take action to manage the level of violence and aggression a patient was exhibiting. In 2013/14 NHS Benchmarking of Mental Health services - the Trust was just below the
mean for the number of incidents of seclusion of patients at 187 incidents of seclusion per 100,000 bed days to patients against a mean of 198 incidents per 100,000 bed days.
Over the past 2 years there has been a high level reported use of the seclusion facility at Campion. This has related specifically to the care of an individual with particularly challenging behaviour. A placement was sought and
this patient was moved on the 14th October 2014. For Mental Health the 23 episodes of seclusion were for a total of 6 clients.
Description
Sector
Mar-14
Apr-14
May-14
Jun-14
Jul-14
Aug-14
Sep-14
Oct-14
Nov-14
Dec-14
Jan-15
Feb-15
DA
Target
Freq:
US_21. NICE Guidelines :
Percent
Total
77%
77%
73%
73%
77%
70%
72%
70%
70%
73%
73%
73%
High
see below
M
The target consists of 2 parts (1) Technology Appraisals and (2) All Other Nice Guidance. For (1) Green = 100% compliant, Amber New guidance has been published and is being reviewed for implementation within 3 mths, Red =
guidance not in place at 3 mths. For (2) Green = 80%+ compliant, Amber = 60-79% compliant and Red = <59% compliant with all other Nice guidance. The Trust 100% compliant (Green) on Technology Appraisals.
Page 17 of 45
People
Commentary
Amber
Performance in this category drives an "amber" rating on the performance scorecard summary on a subjective basis. Of the 22 indicators, 4 are red ( Staff turnover, Deprivation of Liberty Safeguards Training, PINS
and provisional sickness data), 4 are amber (Information Governance, Safeguarding Children, PDP and DBS), 8 are green including (Gross vacancies, Statutory training - Fire, Manual Handling, Health and Safety,
Mandatory training - Infection Control, Safeguarding Adults, Clinical Risk and PMVA, Mental Capacity Act, Medical Appraisals, and Days Taken for Recruitment).
Sickness Absence
• The overall Trust sickness rate for February is 4.04% and continues the downward trend in the overall sickness rate since October 2014. The sickness rate of 4.04% comprises a long term sickness rate of 2.43% and
a short term sickness rate of 0.9%. There has been a slight increase in the long term sickness rate in the last month (when compared to the final January figure of 2.38%) and a decrease in the short term sickness
rate from 1.93% in January.
• The focus has been on optimising return to work. Individuals with a Bradford Factor of 100+ and those on long term sick have been the priority, and this work has enabled the original figure of 296 (those with
Bradford Factor of 100+ over six months) to be reduced by over 80, and approximately 20 reaching the Bradford Factor of 100+. All of the cases with a Bradford Factor of 100+ and those on long term sickness
absence are being actively managed. Each locality has identified a SMT lead for sickness absence and fortnightly meetings are taking place with the HR Manager to monitor progress and agree actions as required.
Best practice is beginning to be embedded in the localities with more ownership from service managers and an increase to an average of 70% in more timely referrals to Occupational Health. Consequently, the
interim HR Manager working on sickness absence management has been let go.
• In order to meet identified training needs, a Power Point presentation will be rolled out to localities, with input from locality HRMs as required. Additionally, intranet guidelines will also be sent to admin support
staff with responsibility for updating ESR records.
• The main reasons for absence remain anxiety/stress/depression, which accounts for 24.6% of sickness in February and represents an increase since January (from 20.3%. Musculoskeletal & back problems,
accounts for 16.4% of sickness in February (consistent with last month).
• A total of 325 managers and staff have attended the resilience training which was introduced last year to assist with the high level of stress related sickness absence. Effectiveness of the training will be evaluated
at the year end.
• The pilot for fast tracking staff with MSK absence to a physiotherapist is due to go live by the end of March..
Turnover
• For the six months ending February, there have been 294.89 wte leavers; 10.0% were retirements, 81.8% were for other voluntary reasons. By comparison, the figures for the six months ending January 2015
were: total leavers 282.50 wte, retirements 9.8% and 80.8 % for other voluntary reasons.
• An analysis of the reasons for leaving this month shows that the most common reason for staff leaving the Trust is relocation (29%) for the sixth consecutive month. This was followed by work life balance, which
was given as the reason by 15% of leavers in February.
As reported to the March Trust Board, the recommended actions are to continue with Locality action plans and monitor their effectiveness; set up a HR-led project to address the high level of turnover in staff with
less than two years’ service; inform the setting of meaningful turnover targets by monitoring turnover levels and their effect on a basket of service and staff metrics; and (through the workforce planning project)
ensure the outputs from workshops prioritise retention strategies for the piloted staff groups (community nursing, mental health inpatient wards, CRHTT and CMHTs.
Recruitment
• The Trust turnaround time for February was 51 days based on 81 starters. 7 of the 8 localities achieved an average turnaround time of 55 days or less, with only Wokingham not achieving a 55 day turnaround (58
days).
• The percentage of vacancies recruited within 55 days in February was 64%, which is an increase on previous months (January was 48%, December was 61% and November was 58%). In Slough and Wokingham the
percentage of vacancies filled within 55 days or less was 80% and 75% respectively.
Page 18 of 45
DBS - There was one member of the East Berkshire Crisis Resolution and Home Treatment team who was phased return from long term sickness and has had no contact with patients from the time that his DBS
Recruitment
• The Trust turnaround time for February was 51 days based on 81 starters. 7 of the 8 localities achieved an average turnaround time of 55 days or less, with only Wokingham not achieving a 55 day turnaround (58
days).
• The percentage of vacancies recruited within 55 days in February was 64%, which is an increase on previous months (January was 48%, December was 61% and November was 58%). In Slough and Wokingham the
percentage of vacancies filled within 55 days or less was 80% and 75% respectively.
DBS - There was one member of the East Berkshire Crisis Resolution and Home Treatment team who was phased return from long term sickness and has had no contact with patients from the time that his DBS
certificate expired on 1st February 2015. The Director of Nursing and Governance was made aware and the line manager has provided assurances that the staff member did not have patient contact until the DBS
certificate renewal was in place.
NMC Registration (PINS) - A member of CAMHS staff registration lapsed whilst they were on long term sick leave. This was renewed on 4th March 2015.
Statutory and Mandatory Training
Information Governance training remains below target. Mental Capacity Act target has been reduced to 45% due to lack of resource to deliver training to all required staff within this financial year. There is a
contractual requirement for 80% of new starters to receive Mental Capacity Act and Deprivation of Liberty and training for these staff members began in September 2014. So far 89% of new starters have received
Mental Capacity Act training and 83% of news starters have received Deprivation of Liberties Safeguards training.
Hotel and Estates staff are required to do Level 1 Safeguarding Adults Training. For Safeguarding Children training at induction and then 3 yearly and bespoke training took place in January 2015. For Infection
control the ward based domestic and portering staff are required to do training every 2 years. Estates staff are only required to do Infection Control Training at induction. Actions are underway to ensure
compliance levels improve. A meeting was held on 27th March 2015, to look at reporting issues for this group with further work ongoing to establish correct compliance levels.
Page 19 of 45
People
Description
PM_01. RIDDOR
incidents : Number
Target
Freq:
#N/A
Low
Q
#N/A
#N/A
Low
Q
0
#N/A
#N/A
Low
Q
1
#N/A
#N/A
Low
Q
Sector
Mar-14
Apr-14
May-14
Jun-14
Jul-14
Aug-14
Sep-14
Oct-14
Nov-14
Dec-14
Jan-15
Feb-15
Total
8
#N/A
#N/A
3
#N/A
#N/A
8
#N/A
#N/A
7
#N/A
MH IP & UC
2
#N/A
#N/A
0
#N/A
#N/A
1
#N/A
#N/A
3
Bracknell
0
#N/A
#N/A
0
#N/A
#N/A
1
#N/A
#N/A
Slough
1
#N/A
#N/A
0
#N/A
#N/A
0
#N/A
#N/A
DA
High
WAM
1
#N/A
#N/A
1
#N/A
#N/A
2
#N/A
#N/A
1
#N/A
#N/A
Low
Q
West Berks
0
#N/A
#N/A
0
#N/A
#N/A
1
#N/A
#N/A
1
#N/A
#N/A
Low
Q
Reading
1
#N/A
#N/A
2
#N/A
#N/A
1
#N/A
#N/A
1
#N/A
#N/A
Low
Q
Wokingham
3
#N/A
#N/A
0
#N/A
#N/A
2
#N/A
#N/A
0
#N/A
#N/A
Low
Q
RIDDOR - includes 1 incident reported to HSE but was not reportable (this was LD services in Reading)
PM_02
Target
Staff Turnover (% YTD) : Percent
Total by month
20%
< 11.3%
Freq
Sector
Last 12m avg
Mar-14
Apr-14
May-14
Jun-14
Jul-14
Aug-14
Sep-14
Oct-14
Nov-14
Dec-14
Jan-15
Feb-15
M
Total
16.1%
14.9%
15.5%
15.2%
15.2%
15.7%
16.2%
16.4%
16.5%
16.7%
16.8%
16.8%
17.2%
16%
M
MH IP & UC
18.6%
17.5%
17.9%
17.9%
17.9%
19.7%
19.8%
16.6%
18.0%
19.7%
20.7%
19.2%
18.2%
14%
M
Bracknell
15.3%
15.0%
14.6%
14.5%
14.9%
15.1%
15.4%
15.5%
15.0%
15.1%
15.6%
16.0%
17.0%
12%
M
Slough
12.3%
8.6%
11.1%
11.7%
12.0%
13.4%
12.9%
12.6%
12.3%
12.2%
12.7%
14.0%
14.5%
10%
M
WAM
16.7%
17.8%
17.3%
17.0%
16.5%
15.6%
16.8%
17.5%
16.0%
16.1%
17.3%
16.4%
16.3%
M
West Berks
16.3%
12.6%
13.7%
14.4%
14.1%
15.1%
15.0%
18.5%
17.4%
17.7%
18.3%
19.1%
19.1%
6%
M
Reading
17.5%
14.8%
16.7%
16.0%
15.6%
15.6%
17.0%
17.7%
18.9%
19.1%
19.5%
19.8%
19.6%
4%
M
Wokingham
15.5%
13.6%
14.6%
15.4%
14.6%
14.4%
14.2%
14.5%
15.9%
17.6%
16.9%
16.4%
18.0%
14.5%
13.4%
M
Corporate
182 Target
11.3%
February 2015 - % Excluding MARS is 16.7%.
14.2%
11.3%
14.0%
11.3%
13.5%
11.3%
14.4%
11.3%
15.0%
11.3%
14.2%
11.3%
13.8%
11.3%
15.2%
11.3%
15.7%
11.3%
15.4%
11.3%
15.0%
11.3%
DA
High
18%
8%
2%
0%
Page 20 of 45
PM_03
Gross vacancies (% WTE) : Percent
Target
< 10.0%
Total by month
12%
Freq
Sector
Last 12m avg
Mar-14
Apr-14
May-14
Jun-14
Jul-14
Aug-14
Sep-14
Oct-14
Nov-14
Dec-14
Jan-15
Feb-15
M
Total
9.4%
8.0%
10.5%
10.2%
10.0%
9.8%
9.6%
8.6%
9.7%
9.8%
9.8%
8.8%
8.3%
M
MH IP & UC
17.4%
14.6%
17.4%
17.0%
16.8%
17.9%
20.6%
18.3%
17.5%
18.1%
18.5%
17.9%
14.4%
M
Bracknell
9.9%
5.8%
11.9%
12.1%
11.4%
9.5%
9.0%
10.3%
11.2%
10.0%
9.6%
8.1%
9.5%
M
Slough
9.3%
6.3%
10.1%
10.4%
10.7%
12.1%
12.6%
11.1%
8.6%
7.1%
8.8%
6.9%
6.8%
M
WAM
9.5%
7.0%
10.2%
11.8%
9.8%
9.6%
7.9%
9.3%
10.9%
10.0%
10.4%
9.3%
7.8%
M
West Berks
7.5%
6.8%
8.6%
7.4%
9.0%
10.5%
10.2%
3.5%
8.3%
7.7%
6.9%
4.7%
6.1%
M
Reading
11.2%
10.8%
10.8%
8.8%
9.0%
10.0%
9.3%
10.6%
12.5%
14.2%
12.5%
13.5%
12.7%
M
Wokingham
9.7%
9.2%
13.3%
9.6%
11.2%
9.6%
9.8%
6.9%
8.6%
9.8%
10.7%
8.6%
8.5%
6.1%
6.2%
10%
7.4%
10%
9.8%
10%
7.5%
10%
7.7%
10%
4.6%
10%
3.8%
10%
4.5%
10%
5.9%
10%
6.0%
10%
5.3%
10%
4.7%
10%
DA
10%
M
191
Corporate
Target
PM_04
Target
8%
6%
n/a
4%
2%
0%
Sickness : Percent
Total by month
5%
< 3.00%
Freq
Sector
Last 12m avg
Mar-14
Apr-14
May-14
Jun-14
Jul-14
Aug-14
Sep-14
Oct-14
Nov-14
Dec-14
Jan-15
Feb-15
M
Total
3.79%
3.47%
3.76%
2.83%
3.51%
3.49%
3.79%
4.06%
4.28%
3.98%
4.18%
4.03%
4.04%
M
MH IP & UC
5.3%
5.5%
5.7%
4.0%
3.7%
4.1%
4.6%
5.2%
6.1%
5.4%
7.3%
7.4%
4.4%
M
Bracknell
3.2%
3.0%
2.9%
2.4%
3.0%
3.0%
3.3%
3.4%
4.1%
3.3%
3.3%
3.2%
3.1%
M
Slough
4.1%
3.2%
4.0%
3.0%
3.5%
3.9%
3.5%
4.0%
4.4%
4.8%
4.7%
6.0%
4.8%
M
WAM
3.8%
3.0%
3.4%
3.8%
3.3%
3.2%
4.1%
3.8%
4.8%
4.5%
4.3%
3.8%
3.7%
DA
4%
3%
n/a
2%
M
West Berks
4.3%
4.8%
5.2%
4.5%
4.1%
3.9%
3.1%
4.3%
4.5%
4.5%
3.9%
4.8%
4.3%
M
Reading
4.6%
3.2%
4.2%
3.5%
4.1%
5.4%
5.4%
5.5%
5.0%
5.0%
4.5%
4.3%
5.2%
M
Wokingham
4.7%
3.9%
3.4%
3.3%
4.1%
4.8%
5.4%
5.2%
5.1%
5.1%
6.1%
5.5%
4.4%
2.9%
3.2%
3.0%
3.3%
3.0%
3.3%
3.0%
3.5%
3.0%
2.8%
3.0%
2.1%
3.0%
3.0%
3.0%
3.0%
3.0%
2.7%
3.0%
2.7%
3.0%
2.2%
3.0%
2.9%
3.0%
Description
Sector
Mar-14
Apr-14
May-14
Jun-14
Jul-14
Aug-14
Sep-14
Oct-14
Nov-14
Dec-14
Jan-15
Feb-15
DA
Target
Freq:
PM_05. Sickness Short
term (<1 week) : Percent
Corporate
#N/A
0.80%
0.55%
0.84%
0.70%
0.74%
0.96%
0.96%
0.98%
1.09%
0.96%
0.90%
High
TBC
M
PM_06. Sickness Long
Term (>4 weeks) :
Percent
Total
#N/A
2.08%
1.83%
1.94%
2.25%
1.42%
2.38%
2.50%
2.32%
2.30%
2.11%
2.43%
High
TBC
M
M
200
Corporate
Target
1%
0%
Page 21 of 45
PM_07
Statutory Training: Fire : Percent
Target
Green > 85%,
Amber 70 - 85%,
Total by month
100%
Red < 70%
Freq
Sector
Last 12m avg
Mar-14
Apr-14
May-14
Jun-14
Jul-14
Aug-14
Sep-14
Oct-14
Nov-14
Dec-14
Jan-15
Feb-15
M
Total
86.4%
85%
85%
86%
88%
88%
86%
86%
88%
88%
86%
86%
85%
M
MH IP & UC
82.7%
80%
81%
84%
86%
85%
86%
79%
83%
80%
81%
79%
88%
M
Bracknell
86.4%
86%
86%
86%
88%
89%
89%
89%
91%
80%
83%
84%
86%
M
Slough
86.7%
83%
83%
84%
87%
87%
87%
84%
90%
88%
89%
97%
82%
M
WAM
84.7%
87%
88%
85%
87%
86%
84%
83%
84%
80%
83%
84%
85%
M
West Berks
91.6%
91%
91%
95%
95%
93%
92%
91%
93%
89%
89%
89%
91%
M
Reading
89.6%
87%
89%
92%
92%
92%
92%
90%
91%
87%
88%
88%
87%
M
Wokingham
84.6%
81%
82%
83%
84%
86%
87%
86%
89%
84%
84%
84%
86%
Corporate
83.8%
M
211
Target
PM_08
Target
81%
80%
83%
86%
85%
82%
84%
86%
80%
84%
87%
88%
85%
85%
85%
85%
85%
85%
85%
85%
85%
85%
85%
85%
High
70%
60%
50%
Green > 85%,
Amber 70 - 85%,
Total by month
Red < 70%
Last 12m avg
Mar-14
Apr-14
May-14
Jun-14
Jul-14
Aug-14
Sep-14
Oct-14
Nov-14
Dec-14
Jan-15
Feb-15
M
Total
95.7%
95%
95%
95%
97%
96%
96%
95%
96%
96%
96%
96%
95%
M
MH IP & UC
96.7%
96%
97%
98%
99%
97%
99%
96%
96%
96%
97%
96%
94%
M
Bracknell
95.8%
95%
95%
94%
97%
95%
96%
97%
96%
95%
97%
96%
97%
M
Slough
95.2%
94%
95%
95%
97%
96%
95%
93%
95%
96%
97%
96%
94%
M
WAM
95.7%
95%
96%
95%
96%
96%
95%
95%
95%
96%
96%
97%
97%
M
West Berks
97.3%
97%
97%
98%
98%
97%
96%
95%
98%
98%
98%
98%
98%
M
Reading
97.7%
96%
97%
98%
98%
99%
99%
98%
98%
97%
98%
98%
98%
M
Wokingham
93.6%
91%
92%
92%
93%
94%
94%
95%
96%
94%
93%
94%
95%
Corporate
93.8%
Target
80%
100%
Sector
M
90%
Statutory Training: Health & Safety : Percent
Freq
220
DA
93%
92%
92%
96%
95%
94%
95%
94%
93%
94%
94%
94%
85%
85%
85%
85%
85%
85%
85%
85%
85%
85%
85%
85%
DA
90%
80%
High
70%
60%
50%
Page 22 of 45
PM_09
Statutory Training: Manual Handling : Percent
Target
Green > 85%,
Amber 70 - 85%,
Total by month
100%
Red < 70%
Freq
Sector
Last 12m avg
Mar-14
Apr-14
May-14
Jun-14
Jul-14
Aug-14
Sep-14
Oct-14
Nov-14
Dec-14
Jan-15
Feb-15
M
Total
93.9%
93%
93%
93%
94%
94%
94%
94%
95%
95%
94%
94%
94%
M
MH IP & UC
93.6%
92%
93%
94%
96%
94%
96%
93%
93%
91%
94%
93%
95%
M
Bracknell
94.5%
96%
94%
95%
95%
95%
92%
96%
96%
93%
95%
93%
95%
M
Slough
93.0%
92%
93%
92%
94%
93%
92%
92%
94%
92%
94%
95%
93%
M
WAM
93.0%
95%
96%
90%
91%
92%
91%
92%
93%
93%
95%
94%
94%
M
West Berks
96.4%
95%
96%
96%
98%
96%
96%
95%
97%
96%
97%
97%
98%
M
Reading
95.7%
94%
93%
95%
96%
97%
97%
97%
97%
94%
97%
96%
96%
M
Wokingham
92.2%
90%
91%
91%
92%
93%
94%
94%
95%
92%
94%
93%
88%
92.8%
91%
85%
91%
85%
91%
85%
95%
85%
94%
85%
93%
85%
94%
85%
93%
85%
92%
85%
93%
85%
93%
85%
93%
85%
DA
95%
M
229
Corporate
Target
PM_10
Mandatory Training: Infection Control : Percent
Target
Green > 85%,
Amber 70 - 85%,
85%
80%
Total by month
100%
Sector
Last 12m avg
Mar-14
Apr-14
May-14
Jun-14
Jul-14
Aug-14
Sep-14
Oct-14
Nov-14
Dec-14
Jan-15
Feb-15
M
Total
90.9%
92%
92%
92%
92%
91%
92%
89%
89%
90%
91%
91%
91%
M
MH IP & UC
91.6%
90%
93%
93%
94%
94%
96%
91%
91%
90%
90%
89%
89%
M
Bracknell
91.6%
95%
94%
95%
93%
94%
95%
86%
87%
90%
91%
90%
90%
M
Slough
91.1%
89%
89%
89%
91%
92%
93%
91%
89%
92%
93%
94%
92%
M
WAM
92.3%
94%
95%
93%
93%
92%
92%
89%
90%
93%
93%
92%
91%
M
West Berks
94.0%
96%
95%
95%
95%
92%
93%
92%
93%
96%
95%
94%
93%
M
Reading
93.5%
95%
96%
96%
95%
94%
93%
94%
91%
92%
92%
91%
92%
M
Wokingham
91.8%
92%
93%
95%
93%
94%
93%
92%
89%
90%
90%
91%
91%
74.7%
79%
85%
78%
85%
67%
85%
78%
85%
79%
85%
80%
85%
69%
85%
69%
85%
68%
85%
71%
85%
77%
85%
81%
85%
Corporate
Target
High
Red < 70%
Freq
M
238
90%
DA
95%
90%
High
85%
80%
75%
Page 23 of 45
PM_11
Mandatory Training: Information Governance : Percent
Target
Green > 95%,
Amber 80 - 95%,
Total by month
100%
Red < 80%
Freq
Sector
Last 12m avg
Mar-14
Apr-14
May-14
Jun-14
Jul-14
Aug-14
Sep-14
Oct-14
Nov-14
Dec-14
Jan-15
Feb-15
M
Total
92.4%
91%
91%
92%
93%
93%
93%
92%
93%
93%
93%
92%
93%
90%
M
MH IP & UC
90.3%
91%
91%
92%
93%
93%
93%
90%
90%
88%
88%
87%
87%
85%
M
Bracknell
93.4%
91%
92%
92%
92%
95%
93%
95%
95%
94%
94%
93%
94%
80%
M
Slough
93.7%
93%
94%
94%
95%
94%
96%
93%
93%
94%
94%
92%
93%
75%
M
WAM
92.8%
90%
90%
93%
93%
94%
94%
95%
93%
92%
93%
93%
93%
M
West Berks
93.3%
91%
91%
91%
92%
92%
93%
95%
95%
95%
95%
94%
95%
65%
M
Reading
96.4%
95%
96%
97%
97%
96%
96%
97%
97%
97%
97%
95%
97%
60%
M
Wokingham
94.8%
96%
95%
96%
96%
96%
97%
91%
97%
94%
94%
91%
94%
55%
90.4%
92%
95%
93%
95%
94%
95%
93%
95%
93%
95%
92%
95%
87%
95%
88%
95%
87%
95%
88%
95%
88%
95%
90%
95%
M
247
Corporate
Target
PM_12
Target
DA
High
95%
70%
50%
Mandatory Training: Safeguarding Children : Percent
Green > = 95%,
Amber 80 -< 95%,
Total by month
100%
Red < 80%
Freq
Sector
Last 12m avg
Mar-14
Apr-14
May-14
Jun-14
Jul-14
Aug-14
Sep-14
Oct-14
Nov-14
Dec-14
Jan-15
Feb-15
M
Total
92.8%
90%
91%
92%
92%
93%
93%
94%
94%
94%
94%
94%
94%
90%
M
MH IP & UC
95.9%
94%
96%
97%
98%
96%
98%
95%
96%
95%
95%
95%
94%
85%
M
Bracknell
94.0%
92%
92%
92%
92%
94%
94%
94%
96%
95%
95%
96%
96%
80%
M
Slough
92.4%
89%
88%
91%
92%
93%
93%
96%
92%
93%
94%
94%
93%
DA
95%
75%
High
M
WAM
93.4%
92%
93%
92%
92%
92%
92%
97%
92%
98%
93%
94%
94%
M
West Berks
96.4%
93%
94%
97%
97%
97%
97%
97%
98%
98%
99%
97%
94%
65%
M
Reading
96.3%
95%
96%
97%
97%
98%
98%
98%
98%
97%
97%
92%
93%
60%
M
Wokingham
92.4%
90%
91%
92%
91%
93%
93%
94%
95%
92%
92%
92%
94%
55%
77.3%
77%
95%
77%
95%
66%
95%
78%
95%
81%
95%
78%
95%
72%
95%
73%
95%
68%
95%
81%
95%
86%
95%
90%
95%
M
256
Corporate
Target
70%
50%
Page 24 of 45
PM_13
Mandatory Training: Safeguarding Adults : Percent
Target
Green > 85%,
Amber 70 - 85%,
Total by month
100%
Red < 70%
Freq
Sector
Last 12m avg
Mar-14
Apr-14
May-14
Jun-14
Jul-14
Aug-14
Sep-14
Oct-14
Nov-14
Dec-14
Jan-15
Feb-15
M
Total
91.1%
89%
91%
91%
91%
92%
93%
90%
91%
90%
91%
91%
92%
M
MH IP & UC
89.4%
87%
88%
88%
88%
90%
90%
87%
90%
90%
92%
93%
91%
M
Bracknell
94.3%
94%
95%
94%
94%
94%
95%
94%
95%
94%
94%
93%
95%
M
Slough
90.9%
86%
88%
91%
91%
91%
92%
91%
91%
92%
93%
93%
92%
M
WAM
93.0%
91%
93%
92%
93%
93%
93%
92%
93%
93%
94%
94%
95%
M
West Berks
95.0%
96%
96%
97%
97%
97%
98%
94%
95%
92%
93%
92%
93%
M
Reading
94.9%
94%
94%
95%
96%
96%
97%
94%
94%
93%
95%
94%
96%
M
Wokingham
90.9%
90%
92%
93%
92%
93%
93%
91%
90%
87%
88%
90%
92%
69.8%
70%
85%
75%
85%
59%
85%
75%
85%
77%
85%
79%
85%
66%
85%
66%
85%
67%
85%
68%
85%
67%
85%
68%
85%
M
265
Corporate
Target
PM_14
Target
DA
95%
90%
High
85%
80%
75%
Mandatory Training: Clinical Risk : Percent
Green > 85%,
Amber 70 - 85%,
Total by month
100%
Red < 70%
Freq
Sector
Last 12m avg
Mar-14
Apr-14
May-14
Jun-14
Jul-14
Aug-14
Sep-14
Oct-14
Nov-14
Dec-14
Jan-15
Feb-15
M
Total
91.7%
92%
92%
91%
90%
90%
95%
89%
90%
90%
93%
94%
95%
M
MH IP & UC
94.6%
93%
96%
95%
95%
94%
95%
93%
94%
93%
97%
96%
95%
M
Bracknell
92.6%
93%
93%
92%
92%
90%
89%
90%
95%
94%
95%
94%
95%
M
Slough
89.2%
100%
96%
96%
85%
83%
87%
85%
82%
84%
90%
92%
92%
M
WAM
92.7%
97%
95%
93%
92%
92%
91%
92%
87%
92%
93%
93%
96%
M
West Berks
96.6%
95%
94%
93%
93%
98%
100%
98%
98%
98%
98%
98%
98%
M
Reading
91.0%
91%
90%
89%
89%
89%
89%
91%
93%
90%
92%
94%
94%
M
Wokingham
92.2%
100%
100%
95%
93%
93%
92%
86%
84%
82%
91%
95%
95%
80.9%
83%
79%
79%
77%
77%
M
services
274 Target
85%
85%
85%
85%
85%
February 2015: Other health services Junior Doctors remains at 52% for Clinical Risk Training
75%
85%
89%
85%
76%
85%
80%
85%
82%
85%
88%
85%
86%
85%
Other health
DA
90%
80%
High
70%
60%
50%
Description
Sector
Mar-14
Apr-14
May-14
Jun-14
Jul-14
Aug-14
Sep-14
Oct-14
Nov-14
Dec-14
Jan-15
Feb-15
DA
Target
Freq:
PM_15. Mandatory
Training: PMVA : Percent
Bracknell
91.1%
90.0%
91.0%
93.4%
93.2%
91.9%
93.2%
94.7%
95.2%
94.9%
94.2%
94.0%
High
Green > 85%,
Amber 70 - 85%,
Red < 70%
M
Page 25 of 45
PM_16
Mandatory Training: Mental Capacity Act : Percent
Target
≥30% by end of Q1,
Total by month
55%
≥45% by end of Q4
50%
Freq
Sector
Last 12m avg
Mar-14
Apr-14
May-14
Jun-14
Jul-14
Aug-14
Sep-14
Oct-14
Nov-14
Dec-14
Jan-15
Feb-15
M
Total
#N/A
#N/A
28%
27%
28%
33%
34%
31%
35%
35%
40%
44%
52%
M
MH IP & UC
#N/A
#N/A
36%
36%
37%
44%
46%
49%
51%
52%
58%
60%
61%
M
Bracknell
#N/A
#N/A
18%
18%
18%
22%
25%
25%
30%
30%
33%
36%
44%
M
Slough
#N/A
#N/A
17%
16%
14%
17%
19%
20%
32%
33%
37%
44%
53%
M
WAM
#N/A
#N/A
19%
17%
19%
22%
23%
24%
30%
30%
35%
37%
41%
M
West Berks
#N/A
#N/A
45%
45%
42%
45%
46%
33%
38%
39%
35%
51%
60%
15%
M
Reading
#N/A
#N/A
36%
34%
36%
41%
44%
39%
43%
43%
45%
54%
59%
10%
M
Wokingham
#N/A
#N/A
33%
32%
32%
38%
39%
33%
30%
31%
49%
39%
53%
5%
#N/A
#N/A
45%
6%
45%
7%
45%
9%
45%
14%
45%
17%
45%
16%
45%
15%
45%
14%
45%
23%
45%
17%
45%
20%
45%
M
284
Corporate
Target
PM_17
Mandatory Training: Deprivation of Liberty Safeguards : Percent
Target
DA
45%
40%
35%
30%
25%
n/a
20%
0%
Total by month
≥ 60% by end of Q3,
(Red / green is based on 80%)
≥80% by end of Q4
90%
Freq
Sector
Last 12m avg
Mar-14
Apr-14
May-14
Jun-14
Jul-14
Aug-14
Sep-14
Oct-14
Nov-14
Dec-14
Jan-15
Feb-15
M
Total
#N/A
#N/A
#N/A
15%
16%
23%
25%
28%
37%
39%
44%
47%
51%
M
MH IP & UC
#N/A
#N/A
#N/A
3%
6%
12%
16%
20%
30%
32%
38%
41%
44%
M
Bracknell
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
N/A
N/A
60%
M
Slough
#N/A
#N/A
#N/A
18%
16%
29%
29%
33%
47%
51%
53%
53%
57%
50%
M
WAM
#N/A
#N/A
#N/A
16%
18%
18%
18%
34%
43%
46%
53%
64%
68%
M
West Berks
#N/A
#N/A
#N/A
24%
24%
32%
32%
33%
35%
35%
40%
46%
57%
30%
M
Reading
#N/A
#N/A
#N/A
26%
28%
35%
41%
39%
48%
49%
53%
54%
58%
20%
M
Wokingham
#N/A
#N/A
#N/A
19%
17%
22%
24%
35%
49%
53%
57%
58%
68%
10%
#N/A
#N/A
80%
#N/A
80%
9%
80%
11%
80%
28%
80%
28%
80%
19%
80%
19%
80%
19%
80%
19%
80%
14%
80%
15%
80%
0%
Description
Last 12m avg
Mar-14
Apr-14
May-14
Jun-14
Jul-14
Aug-14
Sep-14
Oct-14
Nov-14
Dec-14
Jan-15
Feb-15
DA
Target
Freq:
PM_16a. Mental
Capacity Act, new
starters : Number
#N/A
#N/A
#N/A
#N/A
#N/A
#N/A
#N/A
76%
76%
84%
85%
83%
89%
n/a
TBC
M
PM_17a. Deprivation of
Liberty Safeguards, new
starters : Number
#N/A
#N/A
#N/A
#N/A
#N/A
#N/A
#N/A
78%
78%
82%
83%
83%
83%
n/a
TBC
M
M
293
Corporate
Target
DA
80%
70%
n/a
40%
Page 26 of 45
PM_18
PDP (% of staff compliant) (quarterly) : Percent
Target
Green > 95%
Total by month
End of Sept 2014
100%
Freq
Sector
Last 12m avg
Mar-14
Apr-14
May-14
Jun-14
Jul-14
Aug-14
Sep-14
Oct-14
Nov-14
Dec-14
Jan-15
Feb-15
M/Q
Total
75%
72%
1%
12%
57%
91%
93%
96%
97%
97%
96%
95%
93%
80%
M/Q
MH IP & UC
72%
67%
0%
4%
20%
93%
96%
97%
98%
99%
97%
96%
93%
70%
M/Q
Bracknell
75%
69%
1%
11%
55%
96%
96%
98%
98%
96%
95%
94%
92%
60%
M/Q
Slough
76%
73%
3%
15%
53%
93%
92%
95%
98%
99%
97%
97%
93%
M/Q
WAM
75%
69%
0%
19%
61%
87%
90%
95%
97%
97%
95%
95%
92%
M/Q
West Berks
78%
76%
2%
13%
71%
97%
98%
98%
98%
97%
98%
98%
95%
M/Q
Reading
74%
70%
1%
8%
49%
90%
92%
97%
97%
96%
96%
95%
94%
M/Q
Wokingham
76%
77%
1%
11%
62%
92%
93%
93%
95%
99%
96%
95%
93%
78%
72%
95%
2%
95%
14%
95%
72%
95%
87%
95%
95%
95%
98%
95%
98%
95%
99%
95%
99%
95%
98%
95%
96%
95%
Description
Last 12m avg
Mar-14
Apr-14
May-14
Jun-14
Jul-14
Aug-14
Sep-14
Oct-14
Nov-14
Dec-14
Jan-15
Feb-15
DA
Target
Freq:
PM_19. DBS Checks:
renewals in line with
trust policy : Percent
97%
92%
94%
98%
94%
97%
95%
99%
100%
100%
99%
98%
98%
High
100%
M
PM_20. PINs (Monthly) :
Percent
99%
100.0%
100.0%
97.0%
100.0%
100.0%
100.0%
100.0%
99.3%
100.0%
97.3%
100.0%
99.0%
High
100%
M
PM_21. Medical
Appraisals (in
preparation for revalidations) : Percent
#N/A
94%
99%
96%
95%
96%
#N/A
94%
94%
98%
98%
99%
98%
High
85%
M
PM_21a. Medical
Revalidations that have
taken place in year : X / Y
n/a
#N/A
2/47
5/47
7/47
14/47
15/47
19/47
25/47
27/47
30 / 47
33/47
43/47
High
47
M
M/Q
Corporate
304 Target
DA
90%
50%
High
40%
30%
20%
10%
0%
Page 27 of 45
PM_22
Days taken for recruitment (Average) : Number
Target
55 days
Total by month
60
Freq
Sector
Last 12m avg
Mar-14
Apr-14
May-14
Jun-14
Jul-14
Aug-14
Sep-14
Oct-14
Nov-14
Dec-14
Jan-15
Feb-15
M
Total
54.4
56
53
57
58
52
55
55
57
51
52
56
51
M
MH IP & UC
53.6
58
48
52
55
61
46
54.4
66
56
46
50
51
M
Bracknell
55.4
62
45
47
68
54
63
49
57
61
49
55
55
M
Slough
54.7
55
49
91
50
38
54
58
53
53
51
59
45
M
WAM
58.4
61
55
79
55
56
55
62
51
57
57
58
55
M
West Berks
59.9
71
59
110
52
54
48
63
38
40
50
82
52
M
Reading
56.4
50
62
60
52
57
60
51
63
60
68
49
45
M
Wokingham
55.5
53
51
48
60
60
71
63
58
43
44
57
58
M
Corporate
46.9
51
50
45
66
41
35
41
58
39
43
47
47
55
55
55
55
55
55
55
55
55
55
55
55
DA
55
High
50
45
317
Target
Page 28 of 45
Monitor Authorisation
Commentary
Green
New Cases for Early Intervention in Psychosis (EIP)
A Parity of Esteem for additional funding Early Intervention In Psychosis services was made to commissioners on 9th March 2015 and the Trust is awaiting a response.
Page 29 of 45
Monitor Authorisation
MA_01
Target
Mental Health: 7 day follow up : Percent
Total by month
100%
95%
Freq
Sector
Last 12m avg
Mar-14
Apr-14
May-14
Jun-14
Jul-14
Aug-14
Sep-14
Oct-14
Nov-14
Dec-14
Jan-15
Feb-15
M
Total
97.8%
93%
96%
99%
98%
97%
97%
99%
97%
99%
98%
100%
100%
M
Bracknell
100.0%
100%
100%
100%
100%
100%
100%
100%
100%
100%
100%
100%
100%
M
Slough
97.7%
92%
93%
100%
100%
100%
100%
94%
100%
100%
93%
100%
100%
M
WAM
99.5%
100%
100%
100%
94%
100%
100%
100%
100%
100%
100%
100%
100%
M
West Berks
99.7%
100%
96%
100%
100%
100%
100%
100%
100%
100%
100%
100%
100%
M
Reading
96.5%
85%
97%
94%
100%
97%
100%
100%
89%
96%
100%
100%
100%
M
Wokingham
97.9%
88%
94%
100%
100%
100%
100%
100%
100%
100%
93%
100%
100%
DA
95%
High
90%
Quarter to date
97.9%
96%
96%
97%
98%
97%
97%
98%
100%
98%
98%
100%
100%
M
Total
85%
326 Target
95%
95%
95%
95%
95%
95%
95%
95%
95%
95%
95%
95%
February 2015: Note: the acceptable exclusions for these indicators are as follows: (i) patient dies within 7 days of discharge, (ii), where legal precedence has forced the removal of the patient from the country, iii) patients
discharged to another NHS inpatient psychiatric ward.
MA_02
Target
Mental Health: Delayed transfers of care (Monitor target) Monthly and Quarterly : Percent
Total by month
8%
< 7.50%
Freq
Sector
Last 12m avg
Mar-14
Apr-14
May-14
Jun-14
Jul-14
Aug-14
Sep-14
Oct-14
Nov-14
Dec-14
Jan-15
Feb-15
M
Total
1.7%
4.6%
1.3%
1.3%
1.4%
1.3%
1.2%
1.2%
1.4%
1.4%
1.8%
1.9%
1.9%
M
MH IP & UC
0.1%
1.2%
0%
0%
0%
0%
0%
0%
0%
0%
0%
0%
0%
M
Bracknell
0%
0%
0%
0%
0%
0%
0%
0%
0%
0%
0%
0%
0%
M
Slough
0%
0%
0%
0%
0%
0%
0%
0%
0%
0%
0%
0%
0%
M
WAM
0%
0%
0%
0%
0%
0%
0%
0%
0%
0%
0%
0%
0%
M
West Berks
0.9%
11.0%
0%
0%
0%
0%
0%
0%
0%
0%
0%
0%
0%
M
Reading
5.3%
10.7%
4.6%
4.3%
4.7%
3.8%
4.1%
0%
4.6%
5.3%
7.7%
7.0%
6.9%
M
Wokingham
0%
0%
0%
0%
0%
0%
0%
0%
0%
0%
0%
0%
0%
DA
7%
6%
5%
4%
High
3%
2%
1%
Quarter to date
1.6%
3.74%
1.30%
1.30%
1.34%
1.30%
1.23%
1.24%
1.36%
1.37%
1.51%
1.85%
1.86%
M
0%
Total
334 Target
7.5%
7.5%
7.5%
7.5%
7.5%
7.5%
7.5%
7.5%
7.5%
7.5%
7.5%
7.5%
Delayed transfers of care (Monitor target) is Mental Health delays only (Health & Social Care), calculation = number of days delayed in month divided by OBDs (inc HL) in month. New calculation used from Apr-12.July QTD figure
amended.
Page 30 of 45
MA_03
RTT (Referral to treatment) waiting times - Community: non-admitted : Percent
Target
95% <18 weeks
Total by month
100%
Freq
Sector
Last 12m avg
Mar-14
Apr-14
May-14
Jun-14
Jul-14
Aug-14
Sep-14
Oct-14
Nov-14
Dec-14
Jan-15
Feb-15
DA
M
Total
99.7%
98.5%
98.9%
98.9%
100.0%
100.0%
100.0%
100.0%
100.0%
100.0%
100.0%
100.0%
100.0%
High
95%
95%
95%
98%
96%
94%
92%
343 Target
95%
95%
95%
95%
95%
95%
95%
95%
95%
Waits here are for consultant led services in what was East CHS, Diabetes, and Consultant Led Paediatric services from referral to treatment (stop clock).
MA_04
RTT (Referral to treatment) waiting times - Community: incomplete pathways : Percent
Target
92% <18 weeks
Total by month
100%
Freq
Sector
Last 12m avg
Mar-14
Apr-14
May-14
Jun-14
Jul-14
Aug-14
Sep-14
Oct-14
Nov-14
Dec-14
Jan-15
Feb-15
DA
M
Total
100.0%
99.4%
100.0%
100.0%
100.0%
100.0%
100.0%
100.0%
100.0%
100.0%
100.0%
100.0%
100.0%
High
92%
92%
92%
92%
92%
92%
92%
92%
92%
92%
92%
92%
95%
90%
85%
344
Target
MA_05
Target
Mental Health: CPA Review within 12 months : Percent
Total by month
100%
95%
Freq
Sector
Last 12m avg
Mar-14
Apr-14
May-14
Jun-14
Jul-14
Aug-14
Sep-14
Oct-14
Nov-14
Dec-14
Jan-15
Feb-15
M
Total
96.4%
97.1%
96.3%
96.7%
96.6%
95.1%
94.4%
96.7%
96.8%
96.3%
97.3%
97.1%
96.4%
M
Bracknell
97.9%
96.3%
95.8%
96.8%
98.9%
98.9%
99.4%
98.9%
98.4%
96.0%
98.8%
98.2%
98.8%
M
Slough
95.3%
95.5%
97.0%
96.4%
96.4%
94.4%
95.3%
95.3%
96.7%
95.4%
95.0%
93.9%
91.8%
M
WAM
97.0%
100.0%
100.0%
100.0%
95.5%
89.2%
90.0%
94.6%
98.2%
100.0%
100.0%
96.9%
100.0%
M
West Berks
96.6%
97.7%
94.7%
97.6%
97.5%
94.9%
91.0%
96.4%
96.9%
98.9%
96.9%
99.0%
98.0%
M
Reading
97.1%
98.8%
97.8%
99.6%
96.1%
94.9%
93.1%
99.6%
94.2%
96.0%
98.2%
99.1%
98.1%
DA
98%
96%
High
94%
92%
95.6%
97.4%
95.4%
90.8%
94.3%
96.1%
92.0%
92.9%
96.0%
95.7%
98.9%
98.9%
98.9%
M
Wokingham
90%
345 Target
95%
95%
95%
95%
95%
95%
95%
95%
95%
95%
95%
95%
February 2015 - There are 33 clients awaiting a formal CPA review out of a total of 942 clients who have been on CPA for 12 months. Slough had 24 clients awaiting a formal CPA review at the end of February 2015, however
their internal monitoring shows that the Reviews may have been done but require outcoming and validation on RiO. This figure has increased by 6, and the locality have been chased to ensure that CPAs are outcomed and
validated.
Page 31 of 45
MA_06
Mental Health: Early Intervention in Psychosis (EIP) new cases (year-to-date) : Number
Target
99
Total by month
160
140
Freq
Sector
Target
Mar-14
Apr-14
May-14
Jun-14
Jul-14
Aug-14
Sep-14
Oct-14
Nov-14
Dec-14
Jan-15
Feb-15
M
Total
99
136
11
19
28
32
37
51
56
65
77
98
111
120
M
Bracknell
11
15
2
3
3
3
3
4
5
6
6
6
12
100
M
Slough
22
25
2
3
4
6
6
7
7
8
8
20
22
80
M
WAM
18
20
0
1
3
4
5
6
9
9
12
12
13
M
West Berks
10
15
1
2
3
3
4
7
7
11
14
17
17
M
Reading
25
23
2
2
2
3
4
7
7
8
10
11
13
M
Wokingham
M
352
CAMHS
Target
Description
MA_07. Mental Health:
CR/HTT gate keeping of
inpatient admissions :
Percent
Moderate
DA
60
40
13
20
3
3
7
7
9
11
11
11
12
12
14
20
N/A
18
99
1
99
5
99
6
99
6
99
6
99
9
99
10
99
12
99
15
99
20
99.0
20
99
0
Sector
Mar-14
Apr-14
May-14
Jun-14
Jul-14
Aug-14
Sep-14
Oct-14
Nov-14
Dec-14
Jan-15
Feb-15
Total
100.0%
97.8%
100.0%
97.6%
99.1%
98.9%
96.4%
97.6%
96.9%
97.7%
95.7%
98.6%
Quarter to
date total
DA
Target
Freq:
95%
M
95%
RQ
High
98.4%
97.8%
98.9%
98.5%
99.1%
99.0%
98.1%
97.6%
96.7%
97.0%
95.7%
97.0%
February 2015 1 miss is being investigated.
Description
Last 12m avg
Mar-14
Apr-14
May-14
Jun-14
Jul-14
Aug-14
Sep-14
Oct-14
Nov-14
Dec-14
Jan-15
Feb-15
DA
Target
Freq:
MA_08. MHMDS
identifiers : Percent
99.8%
99.8%
99.8%
99.8%
99.8%
99.8%
99.8%
99.8%
99.8%
99.8%
99.8%
99.7%
99.8%
High
97%
M
MA_09. MHMDS
Outcomes : Percent
99.2%
99.3%
99.3%
99.3%
99.3%
99.4%
99.4%
99.3%
99.1%
99.1%
99.1%
99.2%
99.1%
High
50%
M
Description
Last 12m avg
Mar-14
Apr-14
May-14
Jun-14
Jul-14
Aug-14
Sep-14
Oct-14
Nov-14
Dec-14
Jan-15
Feb-15
DA
Target
Freq:
MA_10. CIDS Data
Completeness - referral to
treatment information :
Percent
72.4%
73.0%
71.0%
72.0%
73.0%
72.0%
72.0%
73.0%
73.0%
72.0%
74.0%
72.0%
72.0%
High
50%
M
MA_11. CIDS Data
Completeness - referral
information : Percent
62.5%
63.0%
62.0%
62.0%
63.0%
62.5%
63.0%
63.0%
63.0%
62.0%
62.0%
62.0%
62.0%
High
50%
M
MA_12. CIDS Data
Completeness - treatment
activity information :
Percent
98.0%
98.0%
98.0%
99.0%
98.0%
98.4%
99.0%
98.0%
98.0%
98.0%
98.0%
97.0%
97.0%
High
50%
M
Page 32 of 45
Description
Last 12m avg
Mar-14
Apr-14
May-14
Jun-14
Jul-14
Aug-14
Sep-14
Oct-14
Nov-14
Dec-14
Jan-15
Feb-15
DA
Target
Freq:
MA_13. A&E: maximum
wait of four hours from
arrival to
admission/transfer
/discharge : Percent
99.5%
99.4%
97.3%
99.8%
99.8%
99.7%
99.8%
99.8%
99.7%
99.6%
99.4%
99.9%
99.4%
n/a
95% seen in <=4
hours
M
Description
Mar-14
Apr-14
May-14
Jun-14
Jul-14
Aug-14
Sep-14
Oct-14
Nov-14
Dec-14
Jan-15
Feb-15
DA
Target
Freq:
MA_14. Access to Healthcare for People
with LD : RAG
Green
#N/A
#N/A
Green
#N/A
#N/A
Green
#N/A
#N/A
Green
#N/A
#N/A
n/a
Score out of 24
Q
This was rescored at the most recent Learning Disability Service Improvement Group 21 out of 24. There is no Monitor target so is rated as green.
Description
Last 12m avg
Mar-14
Apr-14
May-14
Jun-14
Jul-14
Aug-14
Sep-14
Oct-14
Nov-14
Dec-14
Jan-15
Feb-15
DA
Target
Freq:
MA_15a. C. Diff due to
lapses in care : Number
#N/A
#N/A
0
0
0
0
0
0
0
0
0
0
0
n/a
0
M
MA_15b. Total C.Diff YTD
(including: cases deemed
not to be due to lapse in
care and cases under
review) : Number
#N/A
#N/A
0
2
4
5
5
6
6
7
7
7
7
n/a
0
FYTD
MA_15c. C. Diff cases
under review : Number
#N/A
#N/A
0
0
0
1
0
2
1
2
0
0
0
n/a
0
M
Description
Mar-14
Apr-14
May-14
Jun-14
Jul-14
Aug-14
Sep-14
Oct-14
Nov-14
Dec-14
Jan-15
Feb-15
DA
Target
Freq:
MA_16. Continuity of Services Risk
Rating : Number
4
4
4
4
4
4
4
4
4
4
4
4
-
3
M
Page 33 of 45
Governors, Membership, GPs and Other Stakeholders
Commentary
Green
Membership is 58.5% public members and 41.5% staff. Membership increased due to various recruitment drives including World Mental Health Day, Reading Pride, the Ascot recruitment fair, mail out of
membership to all sites and to PALS officers.
A joint meeting of the Council of Governors and the Non Executive Directors was held in February 2015 where topics included the Trust's forthcoming independent Governance review and discussion on supporting
governors discharge statutory responsibility. A Quartlery Council of Governors meeting also took place where Governors received an update on the Trust's Carers strategy.
There were media stories on the Trust's collaboration on Silver Cloud which allows clinicians in the Talking Therapies service to develop personalised programmes to tackle issues such as co-morbid anxiety and
depression. The Trust's purchase of Microsoft Lync also featured in the IT news. In addition the mother of a CAMHS client has started an anorexia awareness group in WAM, and plans for a cancer unit at West
Berks Community Hospital also featured in the local news.
ME_01
Target
Trust Membership : Number
Total by month
10800
10,000
10700
Freq
Sector
Last 12m avg
Mar-14
Apr-14
May-14
Jun-14
Jul-14
Aug-14
Sep-14
Oct-14
Nov-14
Dec-14
Jan-15
Feb-15
DA
10600
10500
10400
10300
10200
M
Total
10361
10082
10074
10045
10187
10012
10228
10485
10643
10600
10714
10635
10627
n/a
10100
10000
9900
9800
9700
9600
373
Target
10000
10000
10000
10000
10000
10000
10000
10000
10000
10000
10000
10000
Page 34 of 45
Service Efficiency
Commentary
Amber
There are 16 indicators within this category, 3 of which relate directly to the quality account and are therefore included but do not have targets assigned.
Of the remaining 13 indicators, 2 are rated as “Green” including , MH Non acute occupancy and CHS Length of stay, 1 is amber (CHS Occupancy) 8 are rated “Red”, MH Crisis Plans, DNA rates ,MH Acute Occupancy, MH
Readmissions, MH Acute Average and Snapshot Length of Stay, Ethnicity recording for CHS, and New Birth Visits and 1 of which does not have a target (waiting times).
The one indicator without a target is “Referral to treatment waiting times”.
DNA rates have decreased to 5.30%. The DNA rates are driven by the Common Point of Entry (33% which was 36 out of 109 appointments offered) Specialist Services in Bracknell (16.0% the same as January 2015), Children
and Families Services across the localities, CAMHS 11.5% (an increase from 10% in January 2015). Specialist Services and IAPT have met and developed an action plan which includes additional reminders to clients, additionally
they are looking at whether they are recording DNAs appropriately. In CPE, they have now made it clearer to clients, how to cancel an appointment and are amending letters to reflect this.
CHS Inpatient Average Length of Stay - these are impacted by the lack of onward accommodation such as nursing homes or care packages being provided to clients in their own homes as well as complexity of clients on
inpatient wards. There are also a number of clients awaiting decisions on continuing health care funding. The services are also continuing to support the local acute hospitals in this area during winter pressures.
Mental Health Acute Occupancy, Average Length of Stay and the acute snapshot length of stay are above target which again indicates that there are a number of complex clients requiring onward accommodation/placement.
The twice weekly teleconference calls continue and have been daily due to the sustained pressure on beds. In addition the localities the Head of Inpatient and Urgent Care sends each locality a report with their bed usage, and
there is also a monthly report on clients whose lengths of stay are over 29 days. At 16th March 2015 – there were 29 clients considered to be potential delayed transfers of care awaiting onward accommodation this is an
increase of 9 from the same date in February 2015 and represents 32% of the Trusts adult acute beds. By ward there are 10 potential delays on Snowdrop and 7 each on Bluebell and Daisy wards, 5 on Rose ward. 8 of the 29
potential delays are clients from WAM, 7 for Bracknell, 5 for Reading , 4 each for Wokingham and Slough. 7 of the 29 potential delayed transfers of care are homeless. The situation has been exacerbated by waiting lists at the
two private providers of long term mental health care, Rosebank and the Cloisters, as there are 5 clients awaiting placements there. The Trust no longer provides any rehabilitation beds.
MH Readmission rates – have reduced to 8% with only Reading and Wokingham above target. It is worth noting however that this is reported here over a rolling 6 month period and the number of emergency readmissions
have reduced significantly from a high of 21 in July 2014 to 6 in September 2014 and 8 in October 2014 and 10 each in November 2014 and December 2014 6 in January 2015 and 5 in February 2015. The interim Locality
Director for Bracknell has developed a 5 point protocol for clients thought to be at high risk of readmission, characteristics included isolation, dual diagnosis of substance misuse, and clients with a personality disorder. It is
thought this group would benefit from follow up on day 2 after discharge and support for 28 days following discharge. Drug and alcohol issues feature prominently in readmissions.
Ethnicity recording for CHS. The Equality and Diversity Manager has confirmed that there is no need for services to backdate data for clients who have been discharged. The data shown here reflects the change.
NHS Benchmarking – The Mental Health Benchmarking report for 2013/14 was launched on 7th November 2014. Community Health Service Benchmarking information was published in March 2015 and has been sent to the
SIG. A paper will be prepared for the April 2015 Finance, Investment and Risk Executive.
CHS Clinical Outcomes and Indicators - work remains ongoing, the Trust has feedback on the indicators for scheduled care and also attended an event on District Nursing for which we are awaiting an output.
Clustering - includes data on clustering within the past six months for adult and older adult mental health services. For those in Memory Clinic services clustering should take place once a year. A 95% target by 31st March 2015
has been set. The localities are setting aside time to do this and significant progress has been made.
Health visiting - The target is 95% for Q4 but the Trust is not yet at full staffing complement and have not stopped delivering the new-born hearing screening as yet so these are mitigating circumstances as to why not meeting it
fully .The commissioners are aware and are happy with our progress and other Trust's in the South are also struggling to achieve this target.
System Resilience - Both Frimley Health (Heatherwood and Wexham Park) and Royal Berkshire Hosptals have had infection control issues, with three of their wards affected. One ward at each hospital remained closed as at
13th March 2015. Both hospitals were on red status on 13th March 2015, and the Trust's Henry Tudor ward was also closed due to infection control issues.
Page 35 of 45
Health visiting - The target is 95% for Q4 but the Trust is not yet at full staffing complement and have not stopped delivering the new-born hearing screening as yet so these are mitigating circumstances as to why not meeting it
fully .The commissioners are aware and are happy with our progress and other Trust's in the South are also struggling to achieve this target.
System Resilience - Both Frimley Health (Heatherwood and Wexham Park) and Royal Berkshire Hosptals have had infection control issues, with three of their wards affected. One ward at each hospital remained closed as at
13th March 2015. Both hospitals were on red status on 13th March 2015, and the Trust's Henry Tudor ward was also closed due to infection control issues.
Page 36 of 45
Service Efficiency
SE_01
Target
DNA Rate : Percent
Total by month
8%
5%
7%
Freq
Sector
Last 12m avg
Mar-14
Apr-14
May-14
Jun-14
Jul-14
Aug-14
Sep-14
Oct-14
Nov-14
Dec-14
Jan-15
Feb-15
M
Total
5.8%
5.50%
5.89%
5.34%
5.57%
5.65%
5.70%
6.38%
5.53%
5.96%
7.50%
5.67%
5.30%
6%
M
Bracknell
7.9%
7.90%
8.21%
7.98%
8.04%
7.71%
8.12%
8.72%
7.70%
8.39%
6.80%
7.65%
7.89%
5%
M
Slough
5.7%
5.19%
4.91%
4.63%
5.48%
6.32%
5.76%
5.64%
6.00%
6.40%
6.80%
5.50%
5.71%
M
WAM
5.8%
3.96%
4.46%
5.72%
5.38%
6.49%
7.21%
6.31%
6.30%
5.60%
6.10%
5.68%
5.84%
M
West Berks
5.1%
5.77%
6.03%
4.93%
4.86%
4.59%
4.96%
5.11%
4.60%
4.80%
5.00%
5.21%
4.81%
2%
M
Reading
4.7%
4.59%
5.08%
4.38%
4.63%
4.40%
4.47%
4.68%
4.70%
5.10%
4.70%
4.84%
4.36%
1%
M
Wokingham
4.1%
3.48%
3.29%
2.77%
4.79%
4.46%
3.96%
4.58%
4.10%
5.50%
4.00%
4.15%
4.11%
0%
5%
5%
5%
5%
5%
5%
5%
5%
5%
5%
5%
5%
374
Target
SE_02
Target
4%
High
3%
CHS Inpatient: Average LoS (bed days) : Number
Total by month
40
< 28 days
Freq
Sector
Last 12m avg
Mar-14
Apr-14
May-14
Jun-14
Jul-14
Aug-14
Sep-14
Oct-14
Nov-14
Dec-14
Jan-15
Feb-15
M
Total
28.6
28
27
30
34
28
27
29.07
29
29
29
26
27
M
Slough
20.4
18
24
19
31
18
20
24.81
19
18
18
16
19
M
WAM
25.1
27
35
20
21
33
26
23.96
22
23
23
24
23
M
West Berks
32.0
35
26
42
37
28
25
31.59
37
30
30
30
33
M
Reading
31.3
25
24
25
36
31
36
35.36
35
35
39
26
28
M
Wokingham
30.3
31
34
33
38
29
16
26.16
30
34
28
34
30
28
28
28
28
28
28
28
28
28
28
28
28
381
DA
Target
SE_03
Mental Health: Acute Average LoS (bed days) : Number
Target
< 30 days
DA
35
30
25
20
High
15
10
5
0
Total by month
35
30
Freq
Sector
Last 12m avg
Mar-14
Apr-14
May-14
Jun-14
Jul-14
Aug-14
Sep-14
Oct-14
Nov-14
Dec-14
Jan-15
Feb-15
M
Total
27.3
25
26
27
33
26
25
26
28
25
24
30
32
M
Daisy
22.6
18
15
23
23
23
27
26
25
21
16
26
28
M
Bluebell
30.7
30
34
23
29
27
24
24
26
27
34
45
45
M
Snowdrop
#N/A
#N/A
#N/A
#N/A
#N/A
#N/A
#N/A
23
27
23
23
19
22
33
30
34
30
M
27.7
25
26
26
24
22
20
32
35
30
25
Rose
387 Target
30
30
30
30
30
30
30
30
30
30
In 2013/14 NHS Benchmarking the Trust average length of stay of 29 days excluding home leave was below the national mean of 32.4 days and median of 31 days.
DA
25
20
15
High
10
5
0
Page 37 of 45
SE_03a
Mental Health: Acute Average LoS Snapshot : Number
Target
< 30 days
Total by month
60
50
Freq
Sector
Last 12m avg
Mar-14
Apr-14
May-14
Jun-14
Jul-14
Aug-14
Sep-14
Oct-14
Nov-14
Dec-14
Jan-15
Feb-15
M
Total
45.6
32
37
43
42
45
46
47
46
54
52
56
47
40
M
Daisy
57.3
44
43
51
49
56
57
57
53
85
83
80
29
30
M
Bluebell
47.9
30
31
46
62
51
48
48
50
49
47
56
57
M
Snowdrop
37.0
28
33
35
27
41
40
40
34
35
35
43
53
10
40.6
26
30
43
30
37
30
30
30
24
30
42
30
42
30
45
30
50
30
50
30
48
30
50
30
0
M
392
Rose
Target
SE_04
Target
DA
n/a
20
Mental Health: Readmission rate within 28 days : Percent
Total by month
15%
< 9%
Freq
Sector
Last 12m avg
Mar-14
Apr-14
May-14
Jun-14
Jul-14
Aug-14
Sep-14
Oct-14
Nov-14
Dec-14
Jan-15
Feb-15
R6m
Total
11.8%
12%
12%
12%
11%
14%
14%
14%
13%
12%
12%
9%
8%
R6m
Bracknell
9.3%
10%
10%
10%
7%
4%
11%
12%
16%
16%
7%
7%
2%
R6m
Slough
13.1%
10%
8%
11%
14%
16%
17%
16%
19%
17%
14%
8%
8%
R6m
WAM
12.1%
11%
9%
10%
10%
16%
17%
17%
15%
14%
13%
8%
6%
R6m
West Berks
8.7%
11%
15%
15%
13%
11%
10%
9%
4%
3%
4%
5%
5%
R6m
Reading
12.7%
16%
13%
10%
11%
16%
15%
13%
13%
13%
11%
10%
12%
12.3%
14%
12%
16%
14%
8%
11%
13%
11%
11%
15%
13%
R6m
Wokingham
397 Target
9%
9%
9%
9%
9%
9%
9%
9%
9%
9%
9%
The Trust is again amongst the highest for use of readmissions in 2013/14 NHS Benchmarking as the Trust had 13.3% readmissions against a national median of 8.8%
10%
9%
DA
10%
SE_05
Target
0%
> =95% Light Red
88-<95% Amber
Total by month
80%- < 88% Green
100%
< 80% Red text
90%
Sector
Last 12m avg
Mar-14
Apr-14
May-14
Jun-14
Jul-14
Aug-14
Sep-14
Oct-14
Nov-14
Dec-14
Jan-15
Feb-15
M
Total
87.5%
91%
84%
87%
82%
82%
88%
86%
87%
87%
90%
93%
92%
M
Slough
84.3%
85%
79%
88%
98%
75%
80%
79%
83%
77%
79%
94%
96%
M
WAM
85.9%
89%
95%
88%
89%
91%
75%
80%
82%
75%
90%
88%
89%
M
West Berks
88.4%
91%
92%
88%
86%
82%
91%
88%
85%
88%
90%
91%
89%
M
Reading
93.3%
88%
86%
91%
96%
97%
97%
92%
93%
96%
94%
94%
95%
83.5%
96%
90%
68%
90%
80%
90%
52%
90%
70%
90%
88%
90%
85%
90%
89%
90%
92%
90%
92%
90%
95%
90%
95%
90%
Wokingham
Target
5%
CHS in-patients: Occupancy rate : Percent
Freq
M
404
High
DA
80%
70%
60%
50%
High
40%
30%
20%
10%
0%
Page 38 of 45
SE_06
Mental Health: Acute Occupancy rate (exc. HL) : Percent
Target
< 90%
Total by month
100%
90%
Freq
Sector
Last 12m avg
Mar-14
Apr-14
May-14
Jun-14
Jul-14
Aug-14
Sep-14
Oct-14
Nov-14
Dec-14
Jan-15
Feb-15
M
Total
90.6%
93%
96%
89%
73%
93%
93%
97%
80%
90%
93%
93%
98%
M
Daisy
94.0%
93%
100%
102%
95%
97%
95%
98%
83%
84%
92%
92%
98%
M
Bluebell
89.5%
90%
96%
88%
87%
88%
92%
96%
69%
89%
92%
92%
96%
M
Snowdrop
87.6%
96%
92%
83%
33%
94%
94%
97%
83%
93%
95%
95%
96%
M
93.2%
93%
97%
85%
91%
94%
93%
97%
89%
Rose
410 Target
90%
90%
90%
90%
90%
90%
90%
90%
In the 2013/14 NHS Benchmarking the Trust occupancy of 91% during the year was just below the mean of 92% and the median of 93%.
92%
90%
93%
90%
93%
90%
102%
90%
SE_07
Mental Health: Non-Acute Occupancy rate (exc. HL) : Percent
Target
< 90%
DA
80%
70%
60%
50%
High
40%
30%
20%
10%
0%
Total by month
100%
90%
Freq
Sector
Last 12m avg
Mar-14
Apr-14
May-14
Jun-14
Jul-14
Aug-14
Sep-14
Oct-14
Nov-14
Dec-14
Jan-15
Feb-15
M
Total
71.1%
72%
72%
65%
74%
72%
72%
76%
68%
69%
72%
76%
65%
80%
M
Sorrel
60.4%
61%
59%
51%
64%
69%
60%
62%
50%
65%
69%
69%
46%
70%
M
Jasmine
#N/A
#N/A
#N/A
#N/A
#N/A
#N/A
#N/A
#N/A
-
-
#N/A
#N/A
#N/A
60%
M
Rowan
67.3%
69%
68%
60%
64%
64%
74%
77%
60%
66%
69%
69%
67%
50%
M
Charles
#N/A
#N/A
#N/A
#N/A
#N/A
#N/A
#N/A
#N/A
-
-
#N/A
#N/A
#N/A
M
Papist Way
#N/A
78%
78%
#N/A
#N/A
#N/A
#N/A
#N/A
-
-
#N/A
#N/A
#N/A
M
Orchid
84.1%
98%
91%
87%
90%
91%
87%
90%
80%
73%
77%
77%
68%
M
Daisy Detox
30.2%
53%
22%
16%
43%
15%
40%
42%
39%
15%
32%
32%
14%
M
Eating Disorders
#N/A
#N/A
#N/A
#N/A
#N/A
#N/A
#N/A
#N/A
-
-
#N/A
#N/A
#N/A
90%
90%
90%
90%
90%
90%
90%
90%
90%
90%
90%
90%
Sector
Mar-14
Apr-14
May-14
Jun-14
Jul-14
Aug-14
Sep-14
Oct-14
Nov-14
Dec-14
Jan-15
Feb-15
Total
26
26
26+
29
26
26
26
26+
26+
26+
26+
Bracknell
16
20
20
20
22
20
13
2.1
28
26
32
DA
High
40%
30%
20%
10%
0%
415
Target
Description
SE_08. CHS Referral to
treatment waiting times
(maximum/weeks)
(Monthly) : Number
Target
Freq:
26+
TBC
M
26
TBC
M
TBC
M
TBC
M
DA
Slough
0
0
0
0
0
0
0
0
0
9
9
4
WAM
26
26
26+
26
26
26
26
26+
26+
26+
26+
26+
West Berks
24
24
25
29
24
28
19
19
19
8.6
10
14
TBC
M
Reading
12
12
18
15
15
15
6.4
16
5.8
9.1
8.7
16.4
TBC
M
Wokingham
<6
<6
<6
6
<6
13
12
11
9.6
11
11
9
TBC
M
High
Page 39 of 45
Description
Mar-14
Apr-14
May-14
Jun-14
Jul-14
Aug-14
Sep-14
Oct-14
Nov-14
Dec-14
Jan-15
Feb-15
DA
Target
Freq:
SE_09. Outcomes for MH Service Users
on CPA: Settled Accommodation :
Percent
83%
#N/A
#N/A
80%
#N/A
#N/A
83%
#N/A
#N/A
83%
#N/A
#N/A
n/a
TBC
QS
SE_10. Outcomes for MH Service Users
on CPA: Employment : Percent
13%
#N/A
#N/A
11%
#N/A
#N/A
11%
#N/A
#N/A
11%
#N/A
#N/A
n/a
TBC
QS
SE_11. Number of Males accessing
talking therapies and completing
treatment : Percent
33%
#N/A
#N/A
42%
#N/A
#N/A
30%
#N/A
#N/A
31%
#N/A
#N/A
High
TBC
Q
The figures for Outcomes for Mental Health Service Users on CPA in Settled Accommodation and in Employment are derived from the Mental Health Minimum Data set the data set is due to be sent at the end of February 2015
and the figures will be available then.
SE_12a
Adult CHS valid ethnicity : %
Target
Total by month
100%
≥ 90%
Freq
Sector
Mar-14
Apr-14
May-14
Jun-14
Jul-14
Aug-14
Sep-14
Oct-14
Nov-14
Dec-14
Jan-15
Feb-15
M
Total
#N/A
#N/A
#N/A
#N/A
#N/A
#N/A
#N/A
77%
78%
82%
81%
83%
DA
90%
80%
70%
M
Bracknell
#N/A
#N/A
#N/A
#N/A
#N/A
#N/A
#N/A
60%
62%
68%
70%
72%
M
Reading
#N/A
#N/A
#N/A
#N/A
#N/A
#N/A
#N/A
81%
81%
83%
80%
82%
60%
50%
M
Slough
#N/A
#N/A
#N/A
#N/A
#N/A
#N/A
#N/A
80%
80%
91%
89%
92%
M
West Berkshire
#N/A
#N/A
#N/A
#N/A
#N/A
#N/A
#N/A
88%
88%
90%
89%
90%
M
Windsor Ascot & Maidenhead
#N/A
#N/A
#N/A
#N/A
#N/A
#N/A
#N/A
94%
95%
94%
94%
93%
M
Wokingham
#N/A
#N/A
#N/A
#N/A
#N/A
#N/A
#N/A
77%
75%
80%
75%
81%
Target
90%
90%
90%
90%
90%
90%
90%
90%
90%
90%
90%
90%
n/a
40%
30%
20%
10%
0%
477
Page 40 of 45
SE_12b
Child CHS valid ethnicity
Target
≥ 90%
Freq
Sector
Mar-14
Apr-14
May-14
Jun-14
Jul-14
Aug-14
Sep-14
Oct-14
Nov-14
Dec-14
Jan-15
Feb-15
M
Bracknell Total
#N/A
#N/A
#N/A
#N/A
#N/A
#N/A
#N/A
67%
78%
70%
78%
68%
valid ethnicity : %
DA
M
Bracknell
#N/A
#N/A
#N/A
#N/A
#N/A
#N/A
#N/A
82%
87%
83%
86%
80%
valid ethnicity, 0-2 : %
M
Bracknell
#N/A
#N/A
#N/A
#N/A
#N/A
#N/A
#N/A
54%
70%
65%
71%
67%
M
Bracknell
#N/A
#N/A
#N/A
#N/A
#N/A
#N/A
#N/A
57%
62%
56%
62%
57%
valid ethnicity, 5 & over : %
#N/A
#N/A
#N/A
#N/A
#N/A
#N/A
#N/A
68%
59%
78%
62%
79%
valid ethnicity : %
Reading Total
M
M
Reading
#N/A
#N/A
#N/A
#N/A
#N/A
#N/A
#N/A
88%
89%
89%
89%
89%
M
Reading
#N/A
#N/A
#N/A
#N/A
#N/A
#N/A
#N/A
33%
28%
52%
36%
60%
M
Reading
#N/A
#N/A
#N/A
#N/A
#N/A
#N/A
#N/A
34%
31%
43%
32%
46%
#N/A
#N/A
#N/A
#N/A
#N/A
#N/A
#N/A
64%
81%
63%
81%
61%
valid ethnicity : %
Slough Total
M
M
Slough
#N/A
#N/A
#N/A
#N/A
#N/A
#N/A
#N/A
74%
88%
74%
88%
73%
M
Slough
#N/A
#N/A
#N/A
#N/A
#N/A
#N/A
#N/A
52%
67%
48%
78%
50%
M
Slough
#N/A
#N/A
#N/A
#N/A
#N/A
#N/A
#N/A
59%
67%
58%
67%
55%
#N/A
#N/A
#N/A
#N/A
#N/A
#N/A
#N/A
63%
54%
74%
58%
75%
valid ethnicity : %
M
West Berkshire Total
n/a
M
West Berkshire
#N/A
#N/A
#N/A
#N/A
#N/A
#N/A
#N/A
82%
85%
85%
87%
85%
M
West Berkshire
#N/A
#N/A
#N/A
#N/A
#N/A
#N/A
#N/A
33%
27%
52%
33%
58%
M
West Berkshire
#N/A
#N/A
#N/A
#N/A
#N/A
#N/A
#N/A
38%
26%
39%
27%
37%
#N/A
#N/A
#N/A
#N/A
#N/A
#N/A
#N/A
69%
63%
71%
63%
73%
valid ethnicity : %
M
Total
M
#N/A
#N/A
#N/A
#N/A
#N/A
#N/A
#N/A
81%
84%
84%
82%
78%
M
#N/A
#N/A
#N/A
#N/A
#N/A
#N/A
#N/A
62%
65%
61%
66%
67%
M
#N/A
#N/A
#N/A
#N/A
#N/A
#N/A
#N/A
62%
44%
63%
44%
69%
#N/A
#N/A
#N/A
#N/A
#N/A
#N/A
#N/A
69%
57%
81%
60%
82%
valid ethnicity : %
M
Wokingham Total
M
Wokingham
#N/A
#N/A
#N/A
#N/A
#N/A
#N/A
#N/A
89%
90%
91%
90%
91%
M
Wokingham
#N/A
#N/A
#N/A
#N/A
#N/A
#N/A
#N/A
34%
26%
49%
33%
60%
M
484
Wokingham
Target
#N/A
90%
#N/A
90%
#N/A
90%
#N/A
90%
#N/A
90%
#N/A
90%
#N/A
90%
31%
90%
33%
90%
28%
90%
31%
90%
30%
90%
Page 41 of 45
SE_13
Health Visiting: New Birth Visits Within 14 days : Percent
Target
2014/15
Q1 ≥55%
Q2 ≥70%
Q3 ≥85%
Q4 ≥95%
Total by month
(Dotted line is Q4 target)
(formatting based on Q4 target)
Freq
Sector
Last 12m avg
Mar-14
Apr-14
May-14
Jun-14
Jul-14
Aug-14
Sep-14
Oct-14
Nov-14
Dec-14
Jan-15
Feb-15
M
Total
71%
44%
45%
57%
69%
74%
79%
74%
79%
77%
83%
82%
91%
M
Bracknell
76%
36%
51%
67%
72%
80%
84%
83%
88%
82%
85%
91%
93%
M
Slough
77%
42%
55%
70%
81%
83%
89%
83%
87%
84%
82%
84%
92%
M
WAM
64%
37%
31%
37%
73%
77%
76%
66%
68%
65%
71%
80%
86%
M
West Berks
77%
58%
65%
66%
75%
72%
83%
73%
80%
84%
86%
83%
94%
M
Reading
69%
47%
46%
56%
66%
65%
71%
73%
76%
74%
86%
80%
89%
M
Wokingham
65%
37%
26%
51%
48%
70%
83%
65%
81%
69%
78%
80%
94%
95%
95%
95%
95%
95%
95%
95%
95%
95%
95%
95%
95%
DA
100%
90%
80%
70%
60%
50%
n/a
40%
30%
20%
10%
441
Target
SE_14
Target
0%
MH: Crisis Plans : Percent
Total by month
120%
85%
Freq
Sector
Last 12m avg
Mar-14
Apr-14
May-14
Jun-14
Jul-14
Aug-14
Sep-14
Oct-14
Nov-14
Dec-14
Jan-15
Feb-15
M
Total
#N/A
#N/A
91%
90%
90%
88%
92%
91%
91%
90%
89%
83%
95%
M
Bracknell
#N/A
#N/A
98%
98%
97%
93%
95%
94%
95%
91%
96%
89%
97%
M
Slough
#N/A
#N/A
93%
93%
91%
90%
93%
92%
90%
90%
91%
84%
96%
M
WAM
#N/A
#N/A
97%
94%
95%
93%
96%
92%
90%
85%
71%
99%
100%
M
West Berks
#N/A
#N/A
91%
89%
88%
86%
91%
89%
92%
92%
92%
84%
84%
M
Reading
#N/A
#N/A
85%
85%
84%
83%
87%
88%
88%
87%
84%
71%
95%
M
Wokingham
#N/A
#N/A
85%
83%
86%
86%
94%
92%
93%
91%
90%
88%
99%
85%
85%
85%
85%
85%
85%
85%
85%
85%
85%
85%
85%
DA
100%
80%
60%
n/a
40%
448
Target
20%
0%
Page 42 of 45
SE_15
Mental Health Clustering within target : Percent
Target
≥ 95%
Total by month
100%
Freq
Sector
Last 12m avg
Mar-14
Apr-14
May-14
Jun-14
Jul-14
Aug-14
Sep-14
Oct-14
Nov-14
Dec-14
Jan-15
Feb-15
M
Total
#N/A
#N/A
#N/A
#N/A
#N/A
#N/A
#N/A
#N/A
48%
54%
60%
70%
81%
DA
90%
80%
M
Bracknell
#N/A
#N/A
#N/A
#N/A
#N/A
#N/A
#N/A
#N/A
50%
59%
63%
68%
80%
M
Newbury
#N/A
#N/A
#N/A
#N/A
#N/A
#N/A
#N/A
#N/A
50%
50%
56%
65%
74%
60%
M
Reading
#N/A
#N/A
#N/A
#N/A
#N/A
#N/A
#N/A
#N/A
43%
42%
48%
70%
89%
50%
M
Slough
#N/A
#N/A
#N/A
#N/A
#N/A
#N/A
#N/A
#N/A
38%
47%
55%
75%
75%
M
WAM
#N/A
#N/A
#N/A
#N/A
#N/A
#N/A
#N/A
#N/A
60%
75%
81%
84%
92%
70%
n/a
40%
30%
20%
M
#N/A
Wokingham
#N/A
#N/A
#N/A
#N/A
#N/A
#N/A
#N/A
51%
52%
60%
66%
69%
10%
M
#N/A
MH IP & UC
#N/A
#N/A
#N/A
#N/A
#N/A
#N/A
#N/A
57%
67%
82%
85%
86%
0%
508 Target
95%
95%
95%
95%
95%
95%
95%
95%
95%
95%
95%
95%
This is the percentage of clients who have been clustered within 1) 6 months for adult and older adults 2) 12 months for memory clinic clients, Localities currently receive bi-weekly reports with cases which are outside the time
frames mentioned above.
SE_16
Alternate Place of Safety : Number
Target
TBC
Sector
Freq
Total by month
120
Mar-14
Apr-14
May-14
Jun-14
Jul-14
Aug-14
Sep-14
Oct-14
Nov-14
Dec-14
Jan-15
Feb-15
DA
100
80
60
Total
Q
#N/A
#N/A
#N/A
103
#N/A
#N/A
106
#N/A
#N/A
98
#N/A
#N/A
n/a
40
20
0
463
Target
TBC
TBC
TBC
TBC
TBC
TBC
TBC
TBC
TBC
TBC
TBC
TBC
Page 43 of 45
Contractual Performance
Commentary
Amber
The CQuIN value for 2014-15 is £3.6m, all CQuINs have now been agreed with the exception of the NEL- East trajectory for Q4 (agreed in principle but not yet formerly varied in the contract). The Hospital @
Home CQuIN value is to be spread across other CQuINs, the spread proposal is under consideration by BHFT, we will aim to close the variation once H@H spread is agreed. CAMHS does not have a CQuIN this year,
the value was allocated across other CQuINs for 14-15.
In recent communication from the CCGs on Q1 and Q2 position it advised that we had only reached partial achievement on Frail Elderly Pathway Development and Implementation (HWPFT(5B)) with a potential
retained value by the CCG of £28,802.96; we have successfully challenged this position and been advised that we now fully compliant. In the same communication it advised that we had partially achieved CRHTT
CQUIN (11) with a potential retained value by the CCG of £10.053.51; this was challenged as patient choice impacted our achievement, the CCG have reviewed our position and agreed CQuIN met. The Trust
submitted Quarter 3 data on the 28th January 2015 and reviewed with commissioners on the 26th February 2015, there was no indication of any CQUIN not achieved at Quarter 3. At this time it is recommended
that a provision is made for Mandated CQuIN 3 Cardio Metabolic, Local 8 Psychological Intervention, and Local 11 Urgent Care – a total provision £220K but this may be increased depending on communications
over forthcoming days.
As previously noted, commissioners are increasingly stringent with regards to CQuIN delivery and related funding.
All Local CQUIN content for 2015/16 have been agreed and they are: Children Transition , Hydrate, Engagement in Activity, Smoking Cessation,7 Day Working, value spread will be discussed once any Mandated
CQuINs are understood and agreed.
Page 44 of 45
CQUINS
Description
Mar-14
Apr-14
May-14
Jun-14
Jul-14
Aug-14
Sep-14
Oct-14
Nov-14
Dec-14
Jan-15
Feb-15
DA
CQUIN #
Friends and Family Test –
Implementation of staff Friends and
Family Test : RAG
#N/A
Amber
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n/a
01a
Friends and Family Test - Early
Implementation – Outpatient and Day
Case Departments : RAG
#N/A
Amber
Amber
Amber
Amber
Amber
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Amber
Amber
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n/a
01b
Friends and Family Test - Phased
Expansion : RAG
#N/A
Amber
Amber
Amber
Amber
Amber
Amber
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Amber
Amber
Amber
Amber
n/a
01c
Safety Thermometer - Reduction in
pressure ulcers : RAG
#N/A
Amber
Amber
Amber
Amber
Amber
Amber
Amber
Amber
Amber
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n/a
2
Cardio Metabolic Assessment for
Patients with Schizophrenia : RAG
#N/A
Amber
Amber
Amber
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n/a
04a
Reduction in Non elective admissions
East - Frail Elderly Heatherwood and
Wexham Park Foundation Trust : RAG
#N/A
Amber
Amber
Amber
Amber
Amber
Amber
Amber
Amber
Amber
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n/a
Local 5a
Reduction in Non elective admissions
East - Frimley Park Foundation Trust :
RAG
#N/A
Amber
Amber
Amber
Amber
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Amber
Amber
Amber
Amber
Amber
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n/a
Local 5b
System wide liaison - Participation in
integrated working with the Frimley
System : RAG
#N/A
Amber
Amber
Amber
Amber
Amber
Amber
Amber
Amber
Amber
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n/a
Local 05c
7 day working : RAG
#N/A
Amber
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n/a
Local 7
Psychological Interventions in Secondary
Care : RAG
#N/A
Amber
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Amber
Amber
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n/a
Local 8
Employment Support : RAG
#N/A
Amber
Amber
Amber
Amber
Amber
Amber
Amber
Amber
Amber
Amber
Amber
n/a
Local 9
Smoking : RAG
#N/A
Amber
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n/a
Local 10
CRHTT/Urgent Care : RAG
#N/A
Amber
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Amber
Amber
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Amber
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Amber
Amber
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n/a
Local 11
Page 45 of 45
14/04/PM300
Trust Board Paper
Board Meeting Date
14 April 2015
Title
Risk Register
Purpose
This paper notifies any new severe risks added to the
corporate risk register
Business Area
Corporate
Author
Relevant Strategic
Objectives
2 – To provide accessible, safe and clinically
effective services which improve patient experience
and outcomes of care
3 - To deliver sustainable services based on sound
financial management.
Care Impacts
Supports Trust’s risk management process.
Resource Impacts
None
Legal Implications
None
SUMMARY
This paper advises that one new severe risk has
been added to the corporate risk register since the
last meeting of the Board. The Ligature Risk profile is
attached for noting.
ACTION REQUIRED
To note the update.
1
Likelihood (Target)
Consequence (Target)
Risk level (Target)
Target Date
Last Updated Date
Review date
Minor
Moderate
30/06/2015
17/03/2015
08/05/2015
Progress to Target Risk
Review of differences on risk profile of wards completed.
Quotes being obtained for refurbishment of wards which have
not been done. Audit tool for community sites being
developed. Risk assessment of community sites to be
completed and siteaudits completed as required.
Risk level (current)
Assurance Gap Action
N/A
Almost Certain
Assurance Gaps
None
Consequence (current)
Control Gap Action
N/A
High
Is this a standing risk
Positive Assurance
Control Gaps
Ligature risk audits. Monitoring of None
SIRI's. Supervision of community
site areas.
Likelihood (current)
Risk level (initial)
Yes
Control Assurance
Active management is being maintained
through daily reporting on bed states report
issued to management team. Maintain
monitoring daily and weekly. take actions as
required during levels in spikes in occupancy
levels. review undertaken of long stay
patients and proactive work on bed
availability to retain some capacity. Review of
pressure points and mitigating actions to
reduce numbers undertaken. Plans being
actioned by Locality Directors as priority item.
Bed pressures have reduced and focus will be
maintained to ensure availability of beds. Two
weeks conference calls being maintained
with Regional Director. Action plans
implemented if bed occupancy starts to
increase. Periodic reviews of long stay
patients. Executive join conference call
periodically. Executive meeting reports.
Moderate
Consequence (initial)
Severe
Controls in place
Twice weekly review of numbers of each
ward and at each locality with
operational team from all relevant
services. Action plans to address issues
identified. Regular papers to Exec. Daily
bed state reports issued to Operational
Leadership Team. Twice weekly
conference calls with inpatient urgent
care and CMHTs to review discharge
plans.
Likely
Likelihood (initial)
Relevant Strategic Objectives
To provide accessible, safe
and clinically effective
services.
Major
Description
Mental Health In patient areas are
subject to regular ligature risk audit.
There are differences in the risk
profile of wards following
refurbishment work completed on
wards. Community sites have not
been subject to a ligature risk review.
Likely
Title
Ref
ID
2693
Ligature Risks
Manager
David Townsend
BHFT Assurance Framework - March 2015
14/04/CG292
Trust Board Paper
Board Meeting Date
14 April 2015
Title
Use of Trust Seal
Purpose
This paper notifies the Board of use of the Trust Seal
Business Area
Corporate
Author
Relevant Strategic
Objectives
N/A
Care Impacts
N/A
Resource Impacts
None
Legal Implications
Compliance with Standing Orders
SUMMARY
Board members are advised that the Trust Seal has
not been used since the last Board meeting.
ACTION
To note the update.
14/04/CG293
Trust Board Paper
Board Meeting Date
14 April 2015
Title
Revision of Trust Constitution
Purpose
This paper seeks final Board approval of minor
amendments to the Trust’s constitution following
consideration by the Council of Governors
Business Area
Corporate
Author
Company Secretary
Relevant Strategic
Objectives
N/A
Care Impacts
N/A
Resource Impacts
None
Legal Implications
Compliance with Standing Orders and relevant
statutory and regulatory requirements
SUMMARY
In February 2015 the Board considered and
approved, subject to approval by the Council of
Governors, revisions to the Constitution following a
thorough review.
In considering the revision, Council made a number
of requests/suggestions which have been reviewed
in conjunction with the Trust’s lawyers and these
further changes are set out in the appendix below for
Board approval.
The Board is also asked to approve the addition of
the British Red Cross as a Partnership organisation
to membership of the Council of Governors.
ACTION
The Board is invited:
1. To approve the amendments indicated.
2. Formally approve the addition of the British
Red Cross as a partnership organisation to
the Council of Governors.
APPENDIX
Summary of Proposed Changes to Trust Constitution – April 2015
Page/Para No.
Section/Area
Proposed Change
Page 8, Clause
12.1.9
Council of Governors disqualification
criteria
Suggestion to remove as reasons for disqualification as a member of the Council of Governors:
• Members of a local authority overview and scrutiny committee for health matters
• Members of local Healthwatch
There is no requirement for such individuals to be disqualified and not removing the criteria would
have a direct impact on a number of existing Council members. Declaration of interest provisions
would guide and control any potential conflict situations.
Page 8, Clause
12.1.11
Ditto
Suggestion to improve wording relating to disqualification due to mental disorder/illness – revised
to:
“he lacks capacity within the meaning of the Mental Capacity Act 2005 to carry out all the duties
and responsibilities of a Governor”.
It was felt that the existing wording “he is incapable by reason of mental disorder, illness or injury of
managing and administering his property and affairs” was insensitive.
Page 9, Clause
12.5.4.5
Ditto
Suggestion to revise wording relating to reasons to enable Council to terminate a Governors term
of office to:
“his continuing as a Governor would or would be likely to prejudice the ability of the Council of
Governors to discharge its duties and responsibilities efficiently and effectively”.
It was felt that the existing wording “it would not be in the best interests of the Council of Governors
for him to continue in office as a Governor” was to widely drawn.

April 2015 - Berkshire Healthcare NHS Foundation Trust

Transcription

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