£312,152£581,936 CQC Update Month: May 2015 Progress/successes in the last month Survey of Patient Experience at Night completed - 90% satisfaction in Cleanliness, Food, hydration, and Communication. Areas for improvement were in noise and Named Nurse. Included in Inpatient Action Plan and monitored through the Patient Experience Group. IPC Programme - Secret Shoppers (focus on hand hygiene including bare below the elbow) initial visits undertaken last week, which will be repeated on the last week of each month. Feed back will be provided to ward Matrons; provided at the Divisional Heads of Nursing’s meetings ; monthly IPC Committee; and to the Trust IPC Committee Dementia Strategy consultation to be concluded 30 June Anticipated date of Strategy completion 31 July. Responding to Feedback Policy ratified, adopted and implemented. Process in place for reporting to Patient Safety Committee. New metrics for complaints in place and RAP for CCG completed. Metrics to be included in Integrated Performance Report going forward. Interim Lead in place ensuring compliance with new process MCA DoLS Compliance 48%– April 2015 (867 with 413 achieved) Acute Physician 7 day working now in place. Greater focus on Ambulatory Care and expansion of services offered. Improvement in ALSO for non-elective by 0.5 day YTD since January Average free beds at 0800 has increased from 5 in November 2014 to 21 in April and March 2015 Day rooms and Quiet rooms - see update within Key Milestones Moving patients at night procedure - Procedure and SOP in place. Improvement from 25 avoidable moves from first week of April to 1 avoidable move week beginning 11 th May and week beginning 18 th May. Current performance is outperforming trajectory agreed as per CQINN scheme Paediatric Nurses recruitment continuing – Full complement for 24/7 provision expected from September Nursing Recruitment drive in Europe commenced. Since February 2015 recruited 18 RN’s, 3 x Band 6’s and 1 x Ward matron Appraisals – currently 84.34% against a target of 90% (31 March 2016) Training Needs Analysis – Statutory, Mandatory, CQC essentials is complete. All competences have been mapped and we are now just at the review stage to ensure all competences against an individual are correct. Mandatory Training – compliance is 91.91% against a target of 90% Substantive Microbiologist recruitment successful due to commence imminently date TBA Performance – Cara Charles Barks Workforce – Patricia Williamson Quality – Deirdre Fowler, Frances Carey, Catherine Hubbard

£312,152£581,936 CQC Update Month: May 2015 Issues/Challenges Paediatric CCS SLA agreed, but not yet signed off by CCS Staff Engagement officer leaving Trust in June DATIX DTOC Adult Safeguarding Review – revisit by NUH on 8 June % of transactional milestones in CQC Action Plan complete Survey of Patient Experience at Night report to be presented at DHON’s and Senior Ward Matrons Meeting and Patient Experience Group. Dementia Awareness Week 18 to 24 May with activities which included a Dementia Strategy Awareness Conference on 20 May This campaign included Guest Speakers and requested feedback on the HHCT Dementia Strategy to be fed into the consultation process. Review of Quiet Rooms and Breaking Bad News rooms conducted recommending the creation of a Day Room on Cherry Tree Ward refurbishment commenced. The Trust has agreed that the Day Rooms are multi functional and can be used as Breaking Bad News Rooms. ED Breaking Bad News Room which is deemed to be too small by the CQC are included in the ED renovation plans. Sufficient resource is available across the Trust Safety Culture Communications Plan currently being drawn up; will include focus on Whistleblowing, Stop the Line and Responding to Feedback 22 staff over the last 6 weeks have been recruited to the Trust through a local recruitment campaign and local engagement. Key Milestones /Decisions for May