1. Oversight – Performance Report 20 August 2015 JULY reporting period V

2. Overview The purpose of this presentation is to provide context/word so support the performance of the metrics reported in CQC Dashboard in response to address the compliance areas of the CQC Action Plan as listed below: Compliance Action 1 : Staffing Compliance Action 2 : Care and Welfare of People Compliance Action 3 : Assessing and Monitoring Compliance Action 4 : Safeguarding Compliance Action 5 : Infection Control Compliance Action 6 : Respecting and involving patients Must Do’s Should Do’s

9. Ward Dashboard

10. Staffing Issue ED patient delays in treatment longer than 4 hours, therefore not complying with ED 4 hour performance when associated with CAMH Breaches Action The CAMH Paediatric and Adolescent Emergency Response service is currently provided to the Trust by CPFT and the Trust is contributing to the design and development of the CCG wide clinical pathway. ED staff complete a dynamic risk assessment for patients and this is an integral element of the pathway and on ward referral when appropriate. The department ensures the patient is safe while in their care and maintains regular contact with CAMH until allocation, consultation, intervention, discharge or transfer to specialist inpatient facility.

11. Staffing Actions taken In the period April to June 19 exit surveys have been completed ; 1-2 years was the most common length of service (31.58%) with 6-12 months being the second most common (26.32%) We are starting a campaign to ensure more exit interviews are completed. Main 5 reasons for leaving were - better career opportunities, higher pay, career change, take up training/education and improved work life balance. Staff friendliness and colleague appreciation both scored 100% and 73.68% would recommend Hinchingbrooke as an employer. Internal Recruitment and Retention Surveys are being set up. Successful recruitment campaign for Band 5 ward based nurses in Italy has resulted in 16 offers of employment, 12 of which will be joining the Trust during July / August and the remainder in October. A recruitment team will be travelling to the Philippines at the end of August, looking to recruit 45 nurses in three cohorts from April 2016. HCAs fully established - not currently in post - 31 going through recruitment process starting between July and August. Establishment of Workforce Effectiveness Project to address attraction, retention with a view to reducing temporary staff spend. “Grow our own” – collaborative with Health Education England

12. Staffing 25 places booked for the year and all 25 spaces allocated to staff. As detailed below. (1 place in June was not filled as the RN didn’t receive the joining instructions) Date of Training No of Delegates 20 Apr -24 Apr 2015 5 1 June - 5 June 2015 5 28 Sept to 2 Oct 5 16 Nov – 20 Nov 5 8 Feb – 12 Feb5 Total25 Original trajectory in place for 5 attendees per month though it was advised early into the training programme that St Johns Hospice do not have the staff capacity to run training every month and therefore the Trust has scheduled staff onto the available dates provided by the hospice. The trajectory on the report should be amended to reflect this information.

13. Care and Welfare of People Since the Trust now has 2 x TVN’s in post (1 WTE, 1PTE since July 2014) who have been working on pressure ulcer reduction it has shown to have dramatically reduced the number of pressure ulcers and keep them consistently low to date. We plan to continue this work with the aim to eliminate all hospital acquired avoidable grade 2, 3 and 4 pressure ulcers within the Trust. The chart shows the number of hospital acquired avoidable grade 2, 3 and 4 pressure ulcers since 2009/2010. Each financial year is represented by a different colour. The straight red line through the centre represents the mean number of pressure ulcers which the Trust aims to stay below to ensure we are reducing harm to our patients.

14. Care and Welfare of People Fluid Chart Compliance The Trust is undertaking a phased implementation of an electronic system for capturing patient observations via electronic handover tool. Additionally the Trust is implementing an electronic dashboard to capture clinical KPI’s from ward to board level. The fluid balance documentation assessment was rolled out on two wards in June, four wards in July, and the remaining wards in August. The implementation of these solutions, will improve metric collation and ultimately patient observation tracking on the wards. It is anticipated that live alerts will be functional as soon as mobile phones are purchased. Jan-15Feb-15Mar-15Apr-15May-15Jun-15Jul-15 ID MetricTargetNotes 10 Fluid chart compliance100%Data collection has commenced in May. Initial 2 wards 87.00%85.00% Trajectory 85%87%

15. Care and Welfare of People Issue: The Trust reported one case in July this is on line with the annual trajectory of no more than 4 at this point in the financial year. Action taken A route cause analysis was performed. The learning has been shared with the Division Heads of Nursing and Matrons, Link Practitioners, Clinical Governance and Workforce Committee and will be discussed at the Trust IPC Committee on 19 August.

16. Respecting and Involving People

17. 5 PLACES LEFT: Venepuncture & Cannulation Training, 17/08/2015 There are 5 places still available on the V&C training taking place on Monday 17 th August 2015, 13.00 – 16.30. If possible, please could you book either yourselves or your staff onto this training due to the increased demand for Venepuncture & Cannulation.

18. Respecting and Involving People

19. Emergency – the response rate is a combined score from AAU and ED. AAU have achieved 52% response rate whilst ED have achieved 9.12%. Relocation of volunteer resource impacted on issuing and retrieval of FF cards. This resource has now been reinstated and new targets have been set and will be monitored by ECC Service Manager. Maternity – the Maternity ward has been extremely busy with capacity issues for both Midwifes and administration support. This has impacted on the distribution and collation of forms. Additional administration support has been sourced which will see an increase in the response rates next month. Inpatients – the response rate is a combined score from the inpatient wards on the trust. High response rates in most wards especially Reab and CHT, lower response rate on Daisy ward that is being investigated and actions to be put in place to address.

20. Must Do We have commenced a data cleanse of ESR to ensure staff are allocated appropriately, and for local data to be added to ESR so that the central record is accurate. Completing this activity will have a positive impact on our completion rate

21. Must Do SOP introduced 30/4/15 1.The Moving Patients at night SOP was launched formally on 30 April 2015. 2.Escalation is via the Site Manager to GM and a Director on Call 3.Variation in avoidance of moves is directly related to Trust activity and available capacity. Two periods of underperformance in July Week of 6 th July – directly related to one day whereby the trust had 166 attendances and 48 admissions resulting in later moves affiliate with secondary ward rounds and generation of later discharges Week of 27 th July – higher occupancy in the trust as overall percentage, backlog of DTOCs and lower discharges resulted in capacity pressures and later bed moves 4.Actions taken – trial of trolleys in AAU, successfully seen this week AAU siting at 2-3 inpatients by 6pm in the evening which enables all ED admissions straight to AAU and minimises further hospital moves 5.The Trust continues to implement improvements associated with ECIST recommendations and management of medically fit in order to create bed capacity earlier in the day 6.Performance improvement remains in line with the agreed trajectory as part of our CQIN scheme

23. The recent PLACE survey shows that the Trust exceeded the national average in all areas

24. Cherry Ward (update) Offer of permanent ward matron made. Mental Health Trainer - CPFT attended Cherry 12 August to provide feedback following the dementia care mapping they facilitated. The results were extremely positive and demonstrated that Cherry made significant improvements in the care and interaction with dementia patients. The results have demonstrated true engagement from the staff in improving the value during inpatient stays. Follow up four follow up training days provided by CPFT Facilitation of one day training to staff on Dementia care Facilitation of several ‘on the job sessions’ on Cherry Tree ward. Request for the Mental Health training – CPFT to attend the ISMR partnership session in early October.