This Report Is for Publication

COG JUN/2016 This report is for publication Council of Governors Quality & Performance Summary Report Month 1 of 2016-17 9TH June 2016 Objective: The objective of this report is to provide a summary of the Trust's level of compliance against statutory Performance, Quality and internally set priorities at Month 1 (April) of 2016/17 and to identify the areas of underperformance that may need to be investigated and addressed locally. The Council is asked to: Note the report for information. Executive summary:

 The Trust achieved all Monitor Indicators in Month 1 of 2016/17. However, performance against the target for CPA Reviews has been declining and will be monitored closely to avoid a breach in the future.  The Trust continues to be compliant with the Monitor access times measures - ‘Early Intervention in Psychosis (EIP)’ Patients waiting less than 2 weeks, ‘Referral to Treatment’ and IAPT waiting times targets. Work is being undertaken with the Divisions to monitor other waiting times areas not covered by national targets. This will be reported in the current report from next month.  Jameson Division did not achieve one Monitor indicator, a decline in performance from the previous month. Goodall Division continued to underperform against three Monitor indicators for a consecutive month. Diggory Division did not achieve one Monitor indicator – CPA Reviews, this was mainly due to underperformance in Milton Keynes Mental Health and Offender Care.  The Trust’s performance against its Internal Priorities Indicators remained at nine out of ten indicators achieved. At divisional level, Jameson and Diggory continued to achieve all of their Internal Priorities indicators. Goodall Division achieved eight out of nine internal priorities indicators, continuing to underperform against the target for CAMHS 18 week waits from Referral to Treatment.  Performance against the three indicators subject to the NWL CCG Performance Notice deteriorated in Month 1. Hillingdon Mental Health did not meet the target for care plans to GP within 2 weeks. In Westminster and Harrow the target MHT Timeliness was not achieved  In Month 1, Offender Care is again flagged and so is Brent Mental Health for underperformance against Monitor Indicators, as well as having one of the highest reports of complaints, restraints, sickness and vacancy and turnover rates in the Trust. Learning Disabilities is also highlighted for a consecutive month as the service continues to underperform against Monitor indicators.  Trustwide bed occupancy (excluding leave) in Adult Acute mental health services was at 96% in Month 1, a significant reduction by 17% since monitoring began in February 2015.

Responsible Director: John Vaughan Director of Strategy and Performance Date: 20th May 2016 1. INTRODUCTION was also not achieved in Brent Mental Health due to recording errors, This report summarises the Trust’s performance at Month 1 (2016/17) as well as a lapse in process. The implications of mis-recording against Monitor and the Trust’s Internal Priorities, as well as overall gatekeeping were discussed with the responsible staff member and performance against contractual KPIs set by commissioners. Further learning needs identified. The process issues are being discussed insight is drawn from looking at workforce (sickness, staff and corrective measures will be taken subsequently. vacancy/turnover rates), complaints and, this month restraints and AWOLs, to highlight areas of potential correlation and/or concern. Monitor RAG Methodology This is done at summary level only and further analyses of these All Indicators achieved areas are discussed in the HR and Safety Reports. This month, we 1 Indicator not achieved also introduce a section presenting the bed occupancy rates in the 2+ Indicators not achieved Trust which was previously reported through the CQC Report. Not applicable or No data Monthly Performance Monitor 2. MONITOR INDICATORS January February March April Jameson 2.1 PERFORMANCE FOR MONTH 1 Brent MH The Trust is compliant with all Monitor indicators in Month 1 of Harrow MH 2016/17. In each Division, there were areas of underperformance K&C MH against Monitor indicators and these are presented below. The Trust- Westminster MH wide overview and Divisional overview pages of the Trust Integrated Learning Disabilities Dashboard have been attached as Appendix B (I – IV). A Goodall performance trending chart is attached as Appendix A. Also attached Hillingdon MH is a glossary of terms/abbreviations commonly used in the Trust’s Hillingdon Community Health reports, as Appendix C. IAPT Camden Community 2.2 SUMMARY FOR MONTH 1 CAMHS London Eating Disorders 2.2.1 Jameson Division Rehabilitation (Horton) At divisional level, Jameson is not compliant with one Monitor Diggory indicator in Month 1. The target for New EIP Cases was not met by Milton Keynes MH the Division due to underperformance in Brent and Harrow Mental Milton Keynes Community Health. In Harrow Mental Health this was due to the service receiving Addictions only one appropriate referral. The service will monitor EIP caseloads Offender care and the acceptance of new cases on a weekly basis. In Brent Mental Sexual Health Health underperformance was due to insufficient referrals received by the team. Discussions have been held with the Single Point of Access Learning Disabilities did not achieve the target for CPA Reviews and team to ensure they are aware of the need to refer all suspected first Delayed Transfer of Care (DTOC), for the fourth month. The target onset psychosis cases directly to EIP. The target for Gatekeeping for CPA reviews was not achieved due to a data recording error and 2 lack of an agreed CPA process. A staff training issue was identified Milton Keynes Mental Health also did not achieve the target for and addressed. A CPA pathway with Health and Social Care teams is Delayed Transfer of Care for a consecutive month. This was being agreed. The service’s underperformance against the target for attributed to ongoing placement issues. Staff will continue to follow up DTOC was due to issues with social care. Discharge dates for the on beds available and discuss the immigration issue (pertaining to concerned patients are pending. one patient) with the Trust solicitors.

2.2.2 Goodall Division Offender Care also failed to achieve the target for Data The Division did not achieve three Monitor indictors in Month 1 - 7 Completeness: Identifier, for a consecutive month. This was as a Day Follow-Up (CPA), CPA Reviews and EIP 2 Weeks Wait - result of particular patients recorded as having no registered GP. This mainly due to underperformance in Hillingdon Mental Health and was discussed with the teams to ensure this data is captured if the Eating Disorders. This is discussed further below. client has registered with a practice.

Hillingdon Mental Health did not achieve the target for CPA Reviews for a consecutive month. This was attributed to reduced capacity in 3. TRUST INTERNAL PRIORITIES AND the CMHT teams following the service redesign and an increase in DIVISIONAL KEY PERFORMANCE INDICATORS new referrals. Additional staff members have been recruited to assist with the backlog and team administrators are running daily local reports to ensure that all patients have a CPA booked within 12 3.1 PERFORMANCE FOR MONTH 1 months of their previous review. The service also failed to achieve the The Trust continues to underperform against the target for CAMHS target for EIP 2 Week Waits. This was due to recording errors. 18 week waits from Referral to Treatment. This and other areas of Support will be given to the EIP Team to ensure that the pathway is underperformance are discussed below under the respective completed within 2 weeks and recorded promptly and accurately. divisions.

Eating Disorders did not achieve the target for 7 Day Follow-Up (CPA Only) for a consecutive month. This was due to errors with data 3.2 SUMMARY FOR MONTH 1 recording. This has been addressed with the staff members concerned and additional training provided where appropriate. The 3.2.1 Jameson Division process for recording this information across the service has also Jameson Division continued to achieve all of its internal priorities been amended to ensure this error does not occur again in the future. indicators in Month 1, despite underperformance in Brent Mental Health and K&C Mental Health. In Brent, underperformance was 2.2.3 Diggory Division against the target for Emergency readmissions for a second month. The Division did not achieve the Monitor indicator – CPA Reviews in This was mainly due to patients being admitted as a result of Month 1. This was due to underperformance in Milton Keynes Mental deterioration in their mental health, but also due to a recording error. Health and Offender Care. In Milton Keynes Mental Health this was All emergency readmissions will be flagged on the weekly mainly due to errors with data recording. A meeting with the service performance dashboard and discussed in weekly operational is taking place in May to address these issues. In addition, one to one managers' meeting. In addition, discussions regarding the readmitted training will be carried out with the Recovery and Rehab staff as part patients' discharge plans will take place between the relevant care co- of the ‘service by service’ review. In Offender Care, ordinators - with involvement from the Home Treatment Team. This underperformance was owing to a lack of up to date recording on will ensure that discharge planning is as robust as possible to prevent JADE. This has now been addressed. 3 readmission of these patients. The data entry error was discussed Internal Priorities RAG Methodology with the concerned staff member to prevent future occurrence. 0 - 1 Indicator Not Achieved for less than 3 months 2 Indicators Not Achieved in month or failure of 1 indicator for a 3 K&C Mental Health did not achieve the target for Cluster Validity. month period This was due to staff failing to check and update clustering validity for More than 2 indicators not achieved in the month or more than 1 all patients and patients’ clustering not completed at point of handover indicator not achieved for a 3 month period. from inpatient hospital or the Home Treatment Team. To improve and Not Applicable or No Data standardise processes and procedures, in order to ensure consistency and timeliness, the services will build in mechanisms for Monthly Performance Internal Priorities renewal of clusters and weekly reports will be run to monitor January February March April performance. Jameson 3.2.2 Goodall Division Brent MH At divisional level, Goodall achieved eight out of its nine internal Harrow MH priority indicators. The division continues to underperform against the K&C MH target for - CAMHS 18 week waits from Referral to Treatment. In Westminster MH Month 1 this was due to the continuing demand for services Learning Disabilities exceeding capacity. This has been raised with commissioners as part Goodall of the 16/17 contract negotiation process and a trajectory agreed to Hillingdon MH increase performance to target by M6. Additional funding has been agreed with commissioners which will support reducing waiting times. Hillingdon Community Health In addition, the Trust is actively recruiting a number of different posts IAPT agreed with commissioners, which will support reducing the backlog Camden Community in patients waiting. CAMHS London Eating Disorders In the division, Hillingdon Mental Health did not achieve the target for Rehabilitation (Horton) 7 Day Follow-Up (All) due to four patients who were unreachable. Diggory Teams have been reminded of the correct procedure to follow when Milton Keynes MH patients are difficult to contact. Milton Keynes Community Another area of underperformance in the division was in Hillingdon Addictions Community Health were the target for District Nursing Referrals Offender care contacted within Timescale was not achieved for the third month. Sexual Health This has been attributed to on-going issues with data entry since SystmOne go-live. Following further training and guidance significant Also in the division, Eating Disorders did not achieve the target for 7 improvement in performance has been observed. This measure is Day Follow-Up (All), for the same reasons outlined in the Monitor being closely monitored by the service, with further support/training indicators section 2.2.2. provided to any areas underperforming.

4 3.2.3 Diggory Division 4.3 Diggory Division At divisional level, Diggory achieved all of its internal priorities In the division there have been no performance notices issued indicators for a consecutive month. There were areas of against contractual KPIs and there are no emerging issues. Whilst underperformance in the division as highlighted in the table above, Milton Keynes CCG have agreed to wait until the end of Q1 to decide but these are not discussed in detail in this report. This is because if further action is required regarding the provision and quality of these indicators are not reported at the Trust level and only appear at reports from SystmOne, the CCG is pleased with the progress made service speciality level. The Division is currently reviewing their to date. selected internal priorities KPIs and a paper will be submitted to the committee next month. 5. CONTEXTUAL INDICATORS This section is introduced this month and presents workforce and safety measures for contextual purposes only. The safety measures 4. PERFORMANCE AGAINST CONTRACTUAL KPIs include AWOLs, restraints and complaints and workforce covers for CCGs sickness, staff turnover and vacancy rates. This section provides an update on the overall performance of the Divisions against the contractual KPIs with our commissioners. The 5.1 SAFETY aim is to report on any issues that have been flagged as a concern in In Month 1 there were two incidents of a detained patient going performance and also provide assurance overall when no issues AWOL from the ward, both occurred in Westminster Mental Health. exist. There were a total of 117 restraints reported in the Trust in Month 1. 4.1 Jameson Division Brent Mental Health reported 33 restraints in April, of which 11 were In Month 1, the division achieved all of the performance notice KPIs in prone restraints, the highest in the Trust. Wards have indicated that Central London and West London CCGs. The target for MHT the introduction of the Park Royal site going Smoke Free on 04 April Timeliness was not achieved in Westminster and Harrow. The may have contributed alongside an increased level of acuity. K&C boroughs monitor their KPI performance on a weekly basis and Mental Health reported 24 restraints (12 prone restraints), an increase Westminster are rolling out additional training sessions around KPIs from the previous month. Learning Disabilities reported 13 restraints for staff in June to raise awareness and support staff in meeting the and Offender Care 11 (an increase from zero restraint reported in the requirements. previous month, and the highest number of restraints from the service reported since April 2015). However, six of the restraints in Offender Care were attributed to one patient. 4.2 Goodall Division In Hillingdon Mental Health, referrals into the service have been In Month 1, the Trust received 54 complaints, an increase from the higher than anticipated post service redesign. This combined with the previous month. The highest reporters per 1000 patients seen are number of vacancies in the service has had an impact on listed below and chiefly consist of the Trust’s mental health services. performance against the target for care plans to GP within 2 weeks. To address this, locum staff will be recruited to deal with the backlog.

5 Almost all the services highlighted above have shown decreases in Areas with highest Complaints per sickness rates compared to the previous month, with the exception of complaints per 1000 Number of 1000 patients Sexual Health and Milton Keynes. Sickness rates remain highest in patients seen – April Complaints Users seen seen K&C Mental Health and Offender Care. With the exception of Westminster MH 13 3048 4.27 Westminster Mental Health, all services reporting high sickness rates also showed underperformance against Monitor and Internal Priorities Offender Care 6 2476 2.42 indicators. This suggests some correlation between high staff Harrow MH 6 2751 2.18 sickness rates and performance in these services. Hillingdon MH 5 2929 1.71 Trust-wide vacancy rates and staff turnover in December was 15.5% Brent MH 5 3348 1.49 and 20.5% respectively, a marginal increase from the previous month. Kensington & Chelsea MH 4 2771 1.44 Services with the highest vacancy rates are presented below. Vacancy rates in the Trust continue to be highest in Offender Care Westminster Mental Health reported the most complaints in the Trust, and Brent Mental Health. followed by Offender Care and Harrow Mental Health. Brent, Hillingdon and K&C mental health services also featured. Areas with highest Staff turnover – March Vacancy rate Turnover 5.2 WORKFORCE Offender Care 29.90% 17.95% Sickness, staff turnover, vacancy figures are reported a month in arrears so this report will look at data from March 2016. Services with Brent MH 28.87% 23.00% relatively high rates are discussed below. There are separate specific Addictions 26.53% 23.50% Safety and Human Resources reports which provide richer analysis Westminster MH 23.62% 17.00% and trends in these topics. Harrow MH 22.36% 14.10% The Trustwide sickness rate in March remained at 3.4%. Below are Rehab 19.96% 10.50% the services in the Trust reporting high sickness rates. Hillingdon MH 19.34% 16.30%

Areas with High Sickness 12 month Rolling Addictions services consistently report the highest turnover rate in the Rates January February March Trust. This is due to significant movement in staff as a result of lost contracts. 1.3 Kensington & Chelsea MH 5.10% 4.98% 4.86% Offender Care 4.20% 4.19% 4.15% 1.1 Brent MH 4.50% 4.19% 4.00% 2.1 Hillingdon MH 4.30% 4.09% 4.08% Sexual Health 4.05% 4.00% 4.03% Milton Keynes 3.90% 3.94% 4.00% LD 3.68% 3.69% 3.40% Westminster MH 3.50% 3.45% 3.40% 6 6. Bed Occupancy not achieve one Monitor indicator mainly due to underperformance in Bed occupancy (excluding leave) in the Adult Acute services has Milton Keynes Mental Health and Offender Care. decreased by 4% to 96% in April, the lowest recorded at Trust level. There has been an overall reduction by 17% since February 2015. The Trust achieved nine out of ten of its Internal Priorities Indicators in Month 1. At divisional level, Jameson and Diggory achieved all of Bed Occupancy their Internal Priorities indicators. Whereas Goodall Division achieved eight out of nine internal priorities indicators, continuing to (Excluding leave) January February March April underperform against the target for CAMHS 18 week waits from 102% Kensington & Chelsea MH 104% 105% 104% Referral to Treatment. Westminster MH 101% 103% 105% 101% Hillingdon MH 99% 102% 103% 99% At the end of Month 1, performance against the three indicators subject to the NWL CCG Performance Notice deteriorated. Hillingdon Harrow MH 103% 102% 99% 97% Mental Health did not meet the target for CPA Reviews within 12 Brent MH 98% 102% 99% 95% months and care plans to GP within 2 weeks. In Westminster and Milton Keynes 100% 100% 89% 77% Harrow the target MHT Timeliness was not achieved. Additional TRUSTWIDE 101% 102% 100% 96% training will be provided in June to raise awareness and support staff in meeting the requirements. The highest bed occupancy was reported in K&C Mental Health (102%), followed closely by Westminster (101%), and lowest in Milton Brent Mental Health and Offender Care are flagged as areas of Keynes (77%). This area has been actively managed in a number of concern due to underperformance against Monitor indicators for 2-3 ways by the bed management group. This includes reviews of consecutive months, as well as having high reports of complaints, individual patients staying longer than 100 days and discharge restraints, and sickness and vacancy rates in the Trust. In addition, planning processes. Learning Disabilities is also highlighted for the consecutive month as the service continues to underperform against two Monitor indicators – DTOC and CPA Reviews for many months without any 7. CONCLUSION improvement. The service has been asked to undertake a deep dive In Month 1 of 2016/17, the Trust is achieving all Monitor indicators. analysis of these areas. Actions will be implemented to address this However, performance against the target for CPA Reviews has been shortfall and performance is expected to improve in the coming deteriorating in recent months and in Month 1 was marginally above months. the target. For that reason, it is flagged as an emerging area of concern for the Trust. All divisions are asked to monitor this weekly Trustwide bed occupancy (excluding leave) in the Adult Acute mental and address any underperformance proactively. health services was at 96% in Month 1 of 2016/17, an overall reduction by 17% since February 2015. The bed management group Jameson Division did not achieve one Monitor indicator due to continues to centrally monitor bed usage in the Trust. underperformance in Brent and Harrow Mental Health, against the target for New EIP Cases. This was mainly due to insufficient EIP referrals to the teams. Goodall Division continued to underperform against three Monitor indicators and this was mainly down to Hillingdon Mental Health and Eating Disorders. Diggory Division did

7 Appendix A – Month 1 (April) Trend Chart

Monitor RAG Rating All Indicators achieved 1 Indicator not achieved 2+ Indicators not achieved Not applicable or No data

8 Monthly Performance Monitor Internal Priorities January February March April January February March April Jameson Brent MH Harrow MH K&C MH Westminster MH Learning Disabilities Goodall Hillingdon MH Hillingdon Community Health IAPT Camden Community CAMHS London Eating Disorders Rehabilitation (Horton) Diggory Milton Keynes MH Milton Keynes Community Addictions Offender care Sexual Health Appendix B. i: CNWL Divisional Integrated Dashboard – Month 1 (April)

10 Appendix B. ii: Jameson - Divisional Integrated Dashboard – Month 1 (April)

11 Appendix B. iii: Goodall - Divisional Integrated Dashboard – Month 1 (April)

13 Appendix B. IV: Diggory - Divisional Integrated Dashboard – Month 1 (April)

15 Appendix C: Commonly used NHS Acronyms

Acronym Definition ABT Assessment and brief treatment teams ASIP Accelerated service improvement AWOL Absent without leave CAMHS Child and Adolescent Mental Health Service CCG Clinical Commissioning Group CCH Camden Community Health CMHTs Community Mental Health Teams CPA Care Programme Approach CQUIN Commissioning for Quality and Innovation CRT Community recovery teams DoLS Deprivation of liberty standards DTOC Delayed Transfer of Care EIP Early intervention in psychosis HCH Hillingdon Community Health HTT Home Treatment Team IAPT Improved access to psychological therapies LD Learning Disabilities MHA Mental Health Act PALS Patient Advice and Liaison Service PICU Psychiatric intensive care unit QIAs Quality Impact Assessments SI Serious incidents SPA SPA - Single Point of Access SSOC Shifting settings of care RRT Rapid Response Teams