Mock-up Board Report by lev23508

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									                                                                      MONITOR COMPLIANCE FRAMEWORK
                                          FINANCIAL RISK                                                                         CONSTITUTION AND
Director of Finance:                        Dave Tomlinson                                                  Deputy Chief Executive:
Financial Risk Score                                                                                    >3 There are no issues re. provision of Mandato
Achievement of Plan                          EBITDA Achieved (cf plan)                               >85%
Underlying Performance                       EBIDTA Margin                                          5%-9%
Financial Efficiency                         Return on assets exc. Dividend                           >5%
                                             I&E surplus margin net of dividend                    1% - 2%                                     MEMBER
Liquidity                                    Liquidity Ratio (Days)                               >25 days                       Growing a Represen
Comment: It is clear that the availability of the £6m lodgement in 2008/09 significantly improved           Deputy Chief Executive:
overall risk ratings and that the 2009/10 is more challenging. Nevertheless a satisfactory score has been
achieved for the two months to date.                                                                               New Members
                                                                                                              Members Leaving
Average score 3.7 – 4.
The reduced I&E margin in 2009/10 makes associated risk ratings more sensitive                                   Public Members
                                                                                                                   Staff Members
                                  MONITOR MENTAL HEALTH INDICATORS
Director of Nursing:                         Patrick Sullivan                                                     Total Members
Compliance with National Core Standards                                                  44 of 44 Compliant Target March 2010
eCPA Patients receiving follow-up contact with 7 days of discharge from hospital                     93.2%                Membership Numbers
Minimising delayed transfers of care                                                                  3.0%     15000

Admissions to inpatient services had access to crisis resolution home treatment




                                                                                                            Members
                                                                                                               10000
teams                                                                                                98.7%
Maintain level of crisis resolution teams set in 03/06 planning round (or                                       5000

subsequently contracted with PCT)                                                                       Yes
                                                                                                                   0
Comment                                                                                                               D   J   F    M      A   M   J


                                                                                                                                  Total



                                                                                                                                                      HUMAN RE
                                                                                                          Director of Human Resources:
                                                                                                                                   Sickness Absence


                                                                                                           9%
              CARE QUALITY COMMISSION - PERFORMANCE ASSESSMENT 2009/10                                     8%

Deputy Chief Executive:           Shirley Saunders                                                         7%
                                                                                                           6%
                         A    M       J      J      A      S      O      N      D      J      F      M     5%
Access to CRHT                                                                                             4%

CPA 7-day Follow-up                                                                                        3%
                                                                                                           2%
CAMHS Protocol                                                                                             1%
Data Quality-Ethnic Gp                                                                                     0%
                                                   0%

Patient Experience                                      A   M   J   J   A   S   O   N   D   J   F   M



                                                  % Staff with a RTW
                                                  Interview (Target
NHS Staff Satisfaction                            100%)
Comment                                           Bank & Agency Spend
                                                  Comment:




                         INFORMATION GOVERNANCE
Director of Finance:         Dave Tomlinson
Comment
                                                                                                                                                                                                                                                    QUALITY OF CARE INDICATORS
                                                                                                                                                                                                                                          Director of Nursing: Patrick Sullivan
            Health Care Acquired Infections                                                                                                                                                                         Serious Untoward Incidents                 Commissioning for Quality Indicators (
                                                                    HCAI per 1,000 Bed Days
                                                                                                                                                                                                                       SUI
                                                                                                                                                                                                                                              Current Month    Commentary:
                                                                                                                                                                                        12
                                                                                                                                                                                                                                                                              No Reported
6



5                                                                                                                                                                                       10                                                                                            999
                                                                                                                                                                                         8
                                                                                                                                                                                                                                                                       Reported in 2 Days
4

                                                                                                                                                                                                                                                                                      999
3                                                                                                                                                                                        6


2                                                                                                                                                                                        4                                                                                    No Completed
                                                                                                                                                                                                                                                                                       999
1                                                                                                                                                                                        2
                                                                                                                                                                                                                                                                       Completed in 45 days
0                                                                                                                                                                                        0
                                                                                                                                                                                                                                                                                       999
            A       M       J       J           A       S       O       N       D       J       F   M   A   M   J       J   A       S       O       N       D       J       F       M        A M   J   J   A   S O N D   J   F M A M   J   J   A   S O N D   J   F M



Falls                                                                                                                                                                                   Complaints/PALS Feedback
                                                                                                Falls
                                                                                                                                                                                        The three main areas highlighted by patient feedback this month were:
    3.5                                                                                                                                                                                 1. Xxxxxxxxxxxxx
        3                                                                                                                                                                               2. Yyyyyyyyyyyyyyy
    2.5                                                                                                                                                                                 3. Zzzzzzzzzzzzzzz
        2


    1.5


        1


    0.5


        0

                A       M           J       J       A       S       O       N       D       J   F   M   A   M   J   J       A   S       O       N       D       J       F       M




Drug Safety                                                                                                                                                                             Surveys/Audits                                                  Commentary:
                                                                                    Drug Safety
                                                                                                                                                                                        The following surveys/audits were carried out during the month:
    9

    8

    7

    6

    5

    4

    3

    2

    1

    0

                A       M       J       J       A       S       O       N       D       J       F   M   A   M   J   J       A   S       O       N       D       J       F   M




Annual Measures/External Reports During the Current Month
                                                    LCFT Media
                  20


                  15


                  10




No. of Articles
                   5


                   0


                   -5


                  -10


                  -15


                  -20
                        Dec 08 (18)   Jan 09 (31)    Feb 09 (17)   M
                                  WORKING WITH COMMISSIONERS                                                                                                              TRUST REP
Key Targets                                                                                                        Media Coverage
Early Intervention: No. of people receiving early intervention services                                        707 The following two charts show the number o
Assertive Outreach: Number of people on caseload                                                               663 coverage of the Trust a) over time since De
                                                                                                                   other Trusts in the North-West
Bed Occupancy - Secure Services                                                                               93%
Bed Occupancy - CAMHS Tier 4                                                                                  98%                                                         LCFT Media
Bed Occupancy - Harvey House                                                                                  64%
                                                                                                                                        20
Annual Healthcheck
No. people with newly diagnosed cases of 1st episode psychosis receiving early intervention                                             15

                                                                                                            5 PCT's
                                                                                                                                        10
Number of Crisis episodes                                                                                   5 PCT's




                                                                                                                      No. of Articles
                                                                                                                                         5
No drug misusers currently in treatment & no successfully discharged in period - compared to
plan                                                                                                          85%                        0

                       Commissioning for Quality & Innovation (CQUIN) Payment
Director of Finance:                              Dave Tomlinson
                                                                                                                                         -5


Comment                                                                                                                                 -10

No CQUIN payments are yet due
                                                                                                                                        -15


                                                                                                                                        -20
                                                                                                                                              Dec 08 (18)   Jan 09 (31)    Feb 09 (17)   M



                                          Activity/Demand
Contract VariationsAgreed with East Lancashire PCT for Eating Disorder Services and Deprivation of
                   Liberty Standards


                                                                                   Average Length of Stay
Bed Occupancy                                                             Adult                                 40
Adult/Older Adult                          84%                            Older Adult                           77
                                                                                                              Commentary:




                                                                                  LCFT PLAN OBJECTIVES

                                                                AIM: Deliver high-quality, person-centred, compassionate services
                                                                                                             Executive Owner

1. Progress towards highest standards of compliance with NICE guidance                                                 MM

2. Improve the quality of our services and care in all areas that fall short of upper quartile performance              SS
3. Establish a new set of values that support the behaviours & customer service standards required for
all staff                                                                                                            HTM/MS
4. Design and implement new service models for inpatient, community and secure service provision that
allow us to deliver person-centred care                                                                                 SS
5. Design approaches that better involve Service Users & Carers and build on their knowledge so that we
can evaluate & re-design consistent services and give them a better experience of the care pathway
                                                           AIM: Maintain the highest standards of financial, corporate & clinical governance
                                                                                                                       Dec
6. Maintain existing ‘excellent’ ratings and ensure that processes and ways of working deliver the
financial plan and targeted surpluses for re-investment                                                             DT/PS/SS
7. Develop a framework for integrated governance that satisfies external regulators and the Board
requirements                                                                                                            DH
8. Develop the capability of Trust staff, processes and systems to continuously deliver efficiency savings
and quality improvements and meet the standards of Corporate and Financial good governance                             HTM
9. Develop the Annual Business Planning framework to identify emerging priorities and risks and
integrate all functions and enabling strategies to deliver the core objectives                                          DT
10. Build the capability to manage commercial knowledge to support strategy, decision-making, change
programmes and marketing activity                                                                                DT
11. Review and revise the delegated authorities to support high quality, effective and timely decision-
making across the organisation
                                                           AIM: Safeguard the welfare & promote the well-being of patients & staff
                                                                                                                Dec

12. Develop evidence-based clinical pathways which are robust and safe for our patients and staff                  SS
13. Develop management leadership capabilities so that we can support each other in delivering patient
care                                                                                                               MS
14. Ensure that we investigate each serious incident and justified complaint in an open and timely
manner and learn from the experience in order to reduce the likelihood of future re-occurrence                     PS
15. Deliver our Equality and Diversity strategy and plan to ensure evidenced-based accessibility to our
services                                                                                                           MS
16. Working with commissioners we will design our services to help the community focus upon
prevention and well-being                                                                                          SS
                                                                 AIM: Maintain and enhance the reputation of the organisation.
                                                                                                                  Dec

17. Develop a Reputation Management Strategy and Plan and take forward actions in Quarter 1                        SS
18. Develop a marketing capability and resources to inform business strategy, development, service
planning, relationship management and promotion of Trust                                                           DT
19. Take forward training and development programmes to support customer service and relationship
management                                                                                                        MS
20. Membership development plan is actioned to ensure membership is representative of the community
and we engage with Board of Governors to promote the Trust                                                         SS
                                                                           1st January 1901
ORK
            CONSTITUTION AND AUTHORISATION
hief Executive:                   Shirley Saunders
 no issues re. provision of Mandatory Services




                         MEMBERSHIP
            Growing a Representative Membership
hief Executive:                 Shirley Saunders
             Current Month      Comment: Data is currently only
                             20 available for Public Members, hence the
                              0 large discrepancy between the March
                                2010 target 0f 12,827 and the current
                           5199 Membership of 5199 on the chart.
                              0 However, even with the anticipated
                                addition of c3,000 Staff Members to the
                           5199 figures, the Trust needs to take all
                          12827 opportunities to encourage more of its
                                constituency to become Members. The
   Membership Numbers
                                total recorded Membership has grown
                                from 5113 to 5199 between January &
                                June 2009. 271 new Members have been
                                recruited and 185 have left/been
                                removed from the Membership list
                J   J    A   S
                                during this period.
                                 O   N   D   J   F   M


                    Target March 2010



                                     HUMAN RESOURCES
f Human Resources:                           Maggie Stainton
      Sickness Absence                                          Staffing
                                                         4000

                                                         3500

                                                         3000

                                                         2500

                                                         2000

                                                         1500

                                                         1000

                                                         500

                                                           0
          M   A   M   J   J   A   S   O   N   D   J   F   M
                                                                    A   M   J   J   A   S   O   N   D   J   F   M   A   M   J   J   A   S   O   N   D   J   F   M




                                                              Average No of Days
                                                          50% to Recruit (Target x)
gency Spend                                                   No of Grievances
 t:
S

sioning for Quality Indicators (CQUIN)
 tary:




tary:
                            LCFT Media Coverage




Dec 08 (18)   Jan 09 (31)    Feb 09 (17)   Mar 09   Apr 09 (30)   May 09   (19)
                                            (19)
                            TRUST REPUTATION

wing two charts show the number of items, and the tone of, the media
 of the Trust a) over time since December and b) benchmarked against
 sts in the North-West

                            LCFT Media Coverage




Dec 08 (18)   Jan 09 (31)    Feb 09 (17)   Mar 09   Apr 09 (30)   May 09   (19)
                                            (19)
tary:




nate services
                       Apr   May   June




 clinical governance
                       Apr   May   June
patients & staff
                   Apr   May   June




ganisation.
                   Apr   May   June
LANCASHIRE CARE FOUNDATION TRUST: QUALITY ACCOUNT MOCK-UP
STANDARDS

Core       Description of key component
Standard                                                       A M J   J   A S O N D J   F   M
C1a        Patient Safety                                                                        Commentary:
C1b        Patient Safety Alerts
C2         Child protection
C3         NICE Guidance/Interventional procedures
C4a        Infection control
C4b        Medical devices
C4c        Decontamination of medical devices
C4d        Medicines management
C4e        Waste Disposal
C5a        NICE Technology appraisals
C5b        Clinical Supervision and leadership
C5c        Clinicians update skills
C5d        Clinical Audit
C6         Partnerships/cooperation with other agencies
C7a & c    Clinical and corporate Governance
C7b        Code of openness/use of resources
C7e        Equality and diversity
C8a        Whistle blowing
C8b        Personal development programmes
C9         Records management
C10a        Employment checks
C10b       Compliance with professional codes of practice
C11a       Recruitment and training
C11b       Mandatory training
C11c       Continued professional development
C12        Research governance
C13a       Staff attitudes/respect and dignity
C13b       Consent
C13c       Confidentiality
C14a       Formal complaints procedures/information
C14b       Complaints/discrimination
C14c       Complaints/learning the lessons
C15a       Food/Catering
C15b       Nutrition
C16        Information
C17        Involvement of service users and carers
C18        Access and choice
C20a       Care environments
C20b       Privacy and dignity
C21        Cleanliness
C22a&c     Reducing health inequalities/partnerships
C22b       Reducing health inequalities/Public Health Annual
C23        Health promotion
C24        Emergency planning
                                                                                                                             SAFETY
             6
                                                 HCAI per 1,000 Bed Days
                                                                                                                                                                   Commnetary:
HCAI         5




per 1,000
             4


             3




bed days     2


             1


             0


                 A   M   J   J   A   S   O   N   D    J    F     M     A   M   J   J   A   S   O   N   D   J   F   M




                                                               SUI                                                     Current Month                     Percent
SUI                                                                                                                                               999
            12


            10
                                                                                                                       No Reported
             8
                                                                                                                       Reported in 2 Days         999
                                                                                                                       No Completed               999
             6


             4


             2
                                                                                                                       Completed in 45 days       999
             0

                 A   M   J   J   A   S   O   N   D    J    F     M     A   M   J   J   A   S   O   N   D   J   F   M




Falls




Drug
Safety




POMH UK 1. Lithium
            2. Xxxxxxxxx
            3. Yyyyyyyyy
            4. Zzzzzzzzzzz
Annual Measures:
Patient Safety from Staff Questionaire                                                                                 X              No of violent incidents against staff
Percentager of staff with appraisal                                                                                    Y%             Level & Type of Patient violence
% of staff with mandatory training completed                                                                           Z%
                                                    PATIENT EXPERIENCE

Young                                                            Commentary:
People in
Adult                                    Number

                                        Reduction



Estates     Number of Women-Only Day Areas          X

            Provision of single Sex Accommodation   Y



Internal                            Key Questions                                           2007       2008   2009 %
Patient                                              1   2   3   4   5   6   7
Survey      Community                                                            Copy of
                                                     1   2   3   4   5   6   7   Care
            Adult I/P                                                            Plan
                                                     1   2   3   4   5   6   7
            Older Adult I/P                                                      Medicine
                                                     1   2   3   4   5   6   7
            Secure                                                               Explaine
                                                     1   2   3   4   5   6   7
            SMS                                                                  Q3?

Carers                                                                           Q4?
Assessme
                                      Offered
                                                                                 Q5?
                                      Completed


Young                                               08/09 09/10 Other
People
            LOS Young People admitted to The
            Junction


Annual Measures                                                                  07/08 08/09       % change
Patients who felt they were treated with dignity & respect
Number of Patients who had their complaint referred to Ombudsman
                                                        EFFECTIVENESS
            Develop Care Metrics for MH Services       Trust Priority Audits
                                                       A
            Plan & Implementation Timetable            B
                                                       C
                                                       D
                                                       E
                                                       F
                                                       G
                                                       H
                                                       I
                                                       J
                                                       K
                                                       L
                                                       M
                                                       N
                                                       O
                                                       P
                                                       Q
                                                       R
                                                       S
                                                       T
Annual Measures
Royal College of Psychiatrist Standards: Peer Review
Natioal Audit:
Treatment Resistant Schizophrenia
Incontinece
Health Promotion
Regional Audit
Physical Health

								
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