1. Special Measures Action Plan Hinchingbrooke Hospital 30 March 2015 KEY Delivered and evidenced Delivered On track to deliver Not on track to deliver

2. Hinchingbrooke Hospital – Our Improvement Plan & our progress What we are doing? The Trust was rated as Inadequate following a CQC inspection visit on 16-18 September 2014 and 2 unannounced visits on 21 and 28 September 2014. The CQC carried out a comprehensive inspection of the acute core services provided by the Trust as part of the Care Quality Commission’s new approach to Hospital inspection. An Action Plan was developed to respond to the 7 Compliance Actions and Must Do and Should do recommendations as below Compliance Action 1 - Staffing Compliance Action 2 - Care and Welfare of People Compliance Action 3 - Assessing and Monitoring Compliance Action 4 - Safeguarding People Compliance Action 5 - Infection Control Compliance Action 6 - Respecting and Involving People Compliance Action 7 - Records Must Do and Should Recommendations 19 Must do’s 12 Should do’s Accountability for actions within each Compliance Area has been assigned to a named Executive Director to support implementation and change of pace. Each area has named responsible officers to deliver the change. The Trust weekly Quality Improvement Steering Group Meetings continue to provide a check and challenge. Monthly Oversight Meetings are in place led by the TDA core members include the CCG, Health watch, Local Councillors, NHEE and the Trust Executive Board.

3. Hinchingbrooke Hospital – Our Improvement Plan & our progress Who is responsible? Our actions to address the recommendations made by the CQC have been agreed by the Trust Board Our Chief Executive, Hisham Abdel Rahman, is ultimately responsible for implementing actions in this document. Other key staff are Deirdre Fowler, Director of Nursing, Catherine Hubbard, Medical Director, who will provide the executive leadership for quality, patient safety and patient experience. The Improvement Director has not yet been announced, but is expected to be in place by the 1 April 2015. The improvement Director will be acting on behalf of the TDA to ensure delivery of the improvements and oversee the implementation of the action plan summarised overleaf. Helen O’Connor was appointed in 5 January 2015 as the Deputy Director for Infection Prevention and Control and Quality Improvement. A second unannounced inspection by the CQC took place 2 January and the Trust is currently awaiting the report to be completed following factual accuracy. Ultimately our success in implementing the recommendations of the CQC Composite Action Plan will be assessed by the Chief Inspector of Hospitals, upon re-inspection of our Trust. For any initial questions you may have on how and what we are doing, please feel free to contact Anne Senior, Hinchingbrooke CQC Project Manager by email on annesenior1@nhs.net or calling her on 01480 418744 and she will take your concerns or queries to the appropriate person or PALS on 01480 428964 / hch-tr.pals@nhs.netannesenior1@nhs.nethch-tr.pals@nhs.net How will we communicate our progress to you? We will update this progress report every month while we are in special measures. There will be regular updates on NHS Choices and subsequent longer term actions may be included as part of a continuous process of improvement. Chair/Chief Executive Approval (on behalf of the Board Chair Name:SignatureDate Chief Executive Name : Hisham Abdel RahmanSignatureDate

4. CQC Composite Action Plan as at 30 March 2015 CQC Composite Action Plan KEY ISSUE % Complete 1Staffing 70% 2Care and Welfare of People 39% 3Assessing and Monitoring 55% 4Safeguarding people 71% 5Infection Control 88% 6Respecting and involving people 40% 7Records Reported in Compliance Action 2 MDMust Do 57% SDShould Do 76% CQC CAP - March 60%

5. Hinchingbrooke Hospital – Our Improvement Plan Summary of main concern Outstanding Summary of action and progress to date Timescale for Implementation External Support/ Assurance % Progress against original timescale Revised deadline (if required) Compliance Action 1 – Staffing Nursing Levels Paediatric Nurses Doctors Palliative Care A large scale skill mix review undertaken and presented to the Board. Workforce Plan for Nursing Staff and a further document which includes Medical Staff. NHS IQ 7 day Self Assessment submitted Medical Engagement Scale work ongoing Medical Director post outwith control of Trust Nursing Levels Each ward reviews their nursing levels three times a day and staffing flexed accordingly to meet patient dependency/acuity. Nursing levels reported monthly to the Board via Safer Staffing returns and Unify. Finalised the recruitment of 16 international nurses who are schedule to start on the wards from Monday 23 March 2015 Further recruitment campaign in Europe and India is currently being planned. Paediatric Nurses recruited 2 x Paediatric Nurses to ED with further recruitment taking place. Risk Assessment completed to provide Paediatric cover from 07.30 to 12:00, Holly ward covering outside these hours. SLA with CCS under review with amendment to contract to formalise this arrangement and implementation of a programme of rotation Palliative Care currently provides a 24 hour consultant on call service and a 7 day 9-5 face to face specialist nursing service. 24 Hours on call/consultant service is already provided by SLA with local hospices. Qelca training currently being undertaken Business Case for improved provision was discussed at Integrated Board on 27 Feb 2015. Complete 30 June 2015 N/A 31 March 2015 Ongoing 30 June 2015 14 Feb 2016 Complete CCS SLA 70% QELCA - Quality End of Life Care for All

6. Hinchingbrooke Hospital – Our Improvement Plan Summary of main concern Outstanding Summary of action and progress to date Timescale for Implementation External Support/ Assurance % Progress against original timescale Revised deadline (if required) Compliance Action 2 Care and Welfare of People Documentation Task and Finish Group in place undertaking a review of Documentation should be finished by June. 2015 This work is led by Helen O’Connor. Training The following Training has been added to the Core Induction Programme Documentation Indwelling catheters Recording of Water low VIP Scores Pressure ulcers DHON’s supporting with all training on wards. Training Needs Analysis with Training Trajectory will provide progress reports. Ward Handover Revised Ward Handover process in place – Handover moved from the bedside to enable a more thorough handover in confidence with effect from March 2015. SBAR Training plan in place SKINN Initiative Infection control initiative SKINN launched and continuing across the Trust for all staff groups. Communications with Staff registered letter of expectation sent to all nursing staff in January 2015 outlining roles and responsibility in particular on achieving standards of dignity and respect. Catherine Hubbard,Medical Director send an email to all Medical Staff in February 2015. Patient Experience Strategy Developed in partnership and adopted by Trust in March 2015 Dementia Strategy drafted and evaluated,though the decision to take this to a wider stakeholder group to ensure it meets the needs of patients and organisations supporting dementia outside the Trust has been taken 31 Dec 2015 30 Jun 2016 31 Jul 2015 Complete Complete with further actions 39%

7. Hinchingbrooke Hospital – Our Improvement Plan Summary of main concern Outstanding Summary of action and progress to date Timescale for Implementation External Support/ Assurance % Progress against original timescale Revised deadline (if required) Compliance Action 3 Assessing and Monitoring Full time Senior Leadership Frances Carey - Director of Governance and Risk appointed to FTC 23 October 2015 Good Governance Review GGI undertook a review of governance of the Trust in December 2014. recommendations have been converted into an action plan, Action Plan currently being implemented across the Trust PDCA cycle is scheduled for March 2016 Review and Revise Complaints Process Complaints process has not been reviewed due to the transition of Circle out of the Hinchingbrooke partnership. Complaints policy was written in line with Circle Operating Systems This action has been suspended until the revised structure and leadership of the Trust has been approved. Seek Level of Assurance via Internal Audit BDO Internal audit by BDO was undertaken in December 2014. findings from this review was presented at the Audit committee on 17 March 2015. Complete 30 Mar 2016 Suspended Complete 55% TBA

8. Hinchingbrooke Hospital – Our Improvement Plan Summary of main concern Outstanding Summary of action and progress to date Timescale for Implementation External Support/ Assurance % Progress against original timescale Revised deadline (if required) Compliance Action 4 Safeguarding People Mandatory Training Mandatory training on the Mental Capacity Act and Deprivation of Liberties commenced in October 2014. with a target of 90% by the end of November 2015. As at the end of February there were 26% of staff trained with a further 3 training courses scheduled for March 2015. External Review of Adult Safeguarding Procedures In November 2014 the Trust commissioned Nottingham University Hospital to undertaken a review of Adult safeguarding procedures at the Trust. Report received with recommendations implemented across the Trust in Feb 2015. A further review by NUH has been scheduled for June 2015. Ongoing programme of Adult Safeguarding Audits Standing Order Procedure in place to commence a programme of audits across the Trust led by the Trust Adult Safeguarding Lead. 30 Dec 2015 Complete 8 June 2015 Complete (end of first cycle 28 Feb 2015) NUH 71%

9. Hinchingbrooke Hospital – Our Improvement Plan Summary of main concern Outstanding Summary of action and progress to date Timescale for Implementation External Support/ Assurance % Progress against original timescale Revised deadline (if required) Compliance Action 5 Infection Control Senior Leadership in Infection Control Prevention Team Deputy Dipc Helen O’Connor appointed into Trust on a substantive contract in October 2014. Interim arrangements put in place with support of CCS prior to start date of substantive post holder. Substantive Microbiologist Locum recruited to post Recruitment process undertaken. Position offered and subsequently withdrawn Recruit with PHE post Infection Control initiatives Hand Washing Programme Secret Shoppers Stop the BUG Campaign Appreciative enquiry visit – 5 March 2015 outcomes of which have been developed into an action plan Actions have been implemented across the Trust Complete 28 Feb 2015 Ongoing Complete CCS Unison 88%

10. Hinchingbrooke Hospital – Our Improvement Plan Summary of main concern Outstanding Summary of action and progress to date Timescale for Implementation External Support/ Assurance Progress against original timescale Revised deadline (if required) Compliance Action 6 Respecting and Involving People Timely response to Call Bells Audit of call bells undertaken on wards which will continue on a quarterly basis to ensure compliance with response times. standard response time of two minutes set, audit checking the feasibility of standard. Food and Drink Charts and Support Workers Nutrition Nurse has led on the work to ensure food and drink charts are completed effectively Volunteer Lead and the Patient Experience Lead trained workers who can assist patients with additional support at mealtimes Mandatory Training Trust training programme has been amended to include nutrition and hydration training as mandatory. Intentional Rounding Intentional rounding document reviewed, revised and relaunched across the Trust. Document reviewed by all nurses including, PU Nurse, Nutrition Nurse and Adult Safeguarding lead to ensure document meets requirements of all areas. Recording of Nutritional Assessment Nutrition audit tool being developed led by the Nutrition Nurse to enable effective assessments to be made of compliance. Quarterly audits agreed. Patient Experience Strategy Strategy in Place Launch across the Trust Audit Effectiveness of Strategy Compassionate Practice Strategy ( 6 C’s) Compassionate Practice Strategy being developed Complete 30 June 2015 Complete 30 June 2015 Complete 30 June 2015 40%

11. Hinchingbrooke Hospital – Our Improvement Plan Summary of main concern Outstanding Summary of action and progress to date Timescale for Implementation External Support/ Assurance Progress against original timescale Revised deadline (if required) Compliance Action 7 Records This compliance action is being actioned, monitored and reported via compliance action 2

12. Hinchingbrooke Hospital – Our Improvement Plan – Must Do’s Summary of main concern Outstanding Summary of action and progress to date Timescale for Implementation External Support/ Assurance Progress against original timescale Revised deadline (if required) Improve and Drive an open Culture with the Trust for Safety of the Patients Stop the Line Process revised and relaunched Datix – Member of staff in place to roll out Trust Whistleblowing Process approved and launched Trust Governance Structure reviewed Many initiatives in place in. Joint meetings in place. Strategic Workforce Plan produced Complete Comp Action 3 Ongoing 30 April 2015 57% Improve Medicines Management Medicines Security All drug fridges locked and temperature checks done All drug cupboards locked IV fluids stored in tamper proof areas Medicines Administration Expert advice and guidance received from TDA Chief Pharmacist Releasing “Time to Care – Medicines “ being developed across all wards. Complete – Audit checks in place Monthly incident reviews – ongoing Ensure that all appropriate staff are adequately supported through appraisal, supervision and training to deliver care to patients Development of Maximising Work force Plan Development of Workforce and Engagement Strategy Launch and roll out new Appraisal System Clinical supervision opportunities Work in partnership with Staff Side Training Needs Analysis includes: Breaking bad news/difficult discussions Caring for people with dementia 31 June 2015 31 Aug 2015 30 April 2015 ongoing Complete Ensure all patients receive a timely referral to Palliative Care Service Amber Care Teaching and implementation of Amber Care Programme for all wards in place. Amber Care training has been part of mandatory/ Induction training for the last 18 months. End of life Policy In place with strong links to Macmillan and local hospice. Business case developed to strengthen service increasing consultant on site support. Complete

13. Hinchingbrooke Hospital – Our Improvement Plan – Should Do’s Summary of main concern Outstanding Summary of action and progress to date Timescale for Implementation External Support/ Assurance Progress against original timescale Revised deadline (if required) Review the checking o f Resus Equipment across the Trust Policy reviewed and relaunched Process reviewed and refreshed in ED Work continuing to strengthen the audit cycle Strengthened nursing leadership in ED Complete TBA Complete 76% Take action to ensure that when Pre alert telephones are received in ED that action is taken to ensure a timely response Standing Operating Procedure review – no change Notification from East of England Ambulance Service no issues No further action to be taken Complete Review the environment for having difficult discussions Facilities review, report and business case to be presented to board with proposals for creating rooms to enable suitable environment for breaking bad news across the Trust ( including ED) March 2015 Review Translation Services in Trust ( especially ED) to ensure that patients receive information appropriate to their needs Translation services reviewed across the Trust and refreshed information sent out to all departments. HHCT website amended to include provision for availability of information in other languages. Monthly usage report presented at Patient Experience Group Complete Discontinue practice of using day rooms as additional bed spaces Review complete and change of use to Day room on Apple Tree established. Reablement to follow shortly Review of internal bed escalation policy undertaken thereby protecting day room space across theTrust. 01 April 2015 Review the Clinical pathways for TOPS in the Acute Medical Ward Report received though further work required before presentation to Board. 28 Feb 2015 30 April 2015

14. Hinchingbrooke Hospital – How our progress is being monitored and supported Quality Improvement Steering GroupTimescale for implementation Action Owner Progress Ensure that Letter to all staff is included in orientation pack for agency staff. Copy to be sent to ID Medical 5 Feb 2015 HR Director OUTSTANDING – Escalated to Associate Director of Nursing, Midwifery and Quality HR to formally write to ID Medical to advise that any agency nurse who is unwilling to distribute medicines will be reported through the incident reporting system 5 Feb 2015 HR Director OUTSTANDING – Escalated to Associate Director of Nursing, Midwifery and Quality Discuss Catheter Care Bundles with Wendy Durham and Helen O’Connor 5 Feb 2015 Followed up 17 March 2015 Revised deadline 13 April 2015 CQC Project Manager In progress Revisit back boards of bed to make accessible 16 Feb 2015 Followed up 17 March 2015 Revised Deadline 13 April 2015 Associate Director of Nursing, Midwifery and Quality and Facilities Manager Report received – further work required – In progress Contact Sue Jarrett to request date for availability of financial information 16 Feb 2015 Followed up 17 March 2015 Revised deadline 13 April 2015 CQC Project Manager Report received – further work required – In progress When will training trajectory be available for oversight meetings 13 April 2015 Associate Director of HR - OD In progress

15. Hinchingbrooke Hospital – How our progress is being monitored and supported Integrated Board Actions ( Relevant to CQC Action Plan) Agreed Timescale for implementation Action OwnerProgress The board voted for the Trusts QGAF self assessment to be amended to score 1.0 for patient experience. 22 April 2015 Director of Risk and Governance In progress Meeting to be held to discuss options for recruiting a microbiologist with CH, HAR, EB and DF. 22 April 2015Chief ExecutiveIn progress CCB to meet with CH to discuss proposals for 7 day working and SDIPS for the 2015/16 contract. 22 April 2015Chief Operating OfficerIn progress Staffing paper to be reviewed to ensure appropriate trajectory and assumptions around turnover etc. EB to validate position. 22 April 2015HR DirectorIn progress DF to circulate Key Lines of Enquiry for Clinical Observation Visit taking place during April to Board for information. 15 April 2015 Director of Nursing, Midwifery and Quality / Facilities Manager In progress

16. Hinchingbrooke Hospital – How our progress is being monitored and supported Oversight Meeting Action LogTarget DateAction OwnerProgress Full QGAF Self Assessment to be completed30 April 2015HHCT - Director of Risk and Governance In progress Liaise with Quality Team and share summary of reinvestment for CQUINS group 29 April 2015HHCT – Chief Operating Officer In Progress Final staffing risk assessment paper was to be distributed to group 19 Feb 2015. Review by TDA has required a re-draft. To be circulated with papers for next meeting 6 March 2015 Completed: 19 March 2015 HHCT – HR Director/Director of Risk and Governance Complete Headlines/Enforcement from subsequent visit in January to be distributed to group once received 29 April 2015 HHCT - Director of Nursing, Midwifery and Quality and Facilities Manager In progress Details of group(s) requiring patient contribution to be sent to SS31 March 2015 HHCT - Director of Nursing, Midwifery and Quality and Facilities Manager Updated Complaints SOP to be presented at next Oversight Meeting 29 April 2015 HHCT - Director of Risk and Governance Face to face meeting to be arranged with JD, AS, JH, RT, AB and a Trust IT lead to fine tune the CAP document in time for the next meeting. 29 April 2015 HHCT - Director of Nursing, Midwifery and Quality and Facilities Manager In progress Discussion to be held with SH, AB & DF regarding the risk assessment analysis and presentation. 29 April 2015 TDA - Head of Delivery and Development/Deputy Clinical Quality Director – Midlands & East In Progress JH to provide the CCG’s report to AB. All visit reports to be tabled at the next meeting to allow participants time to consider the contents more fully. 19 March 2015 CCG – Director (Quality, Safety and Patient Experience Completed