1. Oversight – Performance Report 25 September 2015 August 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%) Campaign commenced 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. On 5 th October, the final 4 EU nurses will commence employment,. The Philippines recruitment trip proved very successful with 120 candidates being interviewed, 45 of which will be joining the Trust in 3 cohorts from April 2016. These staff will fill current vacancies and allow cover for expected turnover in 2016/17. 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 – requested an update 2/10/2015 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.

14. Care and Welfare of People Fluid Chart Compliance The fluid balance documentation assessment was rolled out on two wards in June, four wards in July, and the remaining wards in August as part of the clinical assessment tool. Clinical educators have a training plan to raise awareness, theoretical sessions & ward based training. Heightened emphasis on identification of Avil & importance of effective fluid balance monitoring. Lessons learnt from SI’s discussed at ward sisters meeting & all suitable forums. MEWS algorithm updated to empower nurses to escalate concerns. Non compliance will be managed via Trust Performance Management process

15. Care and Welfare of People Issue: Performance 1 Apr – 31 Aug is three cases against a monthly trajectory of 4 Action taken We always perform multidisciplinary RCAs which include the CCG presence. The findings are shared with the DHoNs and matrons at their monthly meeting, the Trust IPCC committee and individual consultants share with their colleagues. Information is sent to the TDA - Debra Adams. Themes emerging: lack of effective antimicrobial stewardship and delayed sampling

16. Safeguarding Trust’s overall compliance as at 30.09.15 as 75% vs. a trajectory of 80%. Trust introduced the training as mandatory in October 2014 – delivered as ad hoc training. From April 2015 the training became part of the Trust’s Induction Programme and from July was scheduled onto the annual Statutory Mandatory & Essential Training Day. Enhanced electronic communication took place during September to increase attendance, this included ‘all user’ emails, emails to managers and emails to individuals requiring this competency. Two extra dates have been scheduled into the October programme to try and increase compliance. The Trust is aiming for 90% by the end of November 2015 and will monitor progress on a monthly basis as part of the overarching mandatory training programme. Compliance is reported to Trust Board as part of the Integrated Performance and Quality report.

17. Respecting and Involving People

18. August 2015 11  % of delegates attending UTI Indwelling Catheter Training  % of delegates attending Improving Water Low Training  % of delegates attending VIP training  13.45%. Revised Catheterisation training commenced in March ’15. 108 delegates have so far been trained. Catheterisation training is now part of the new Trust Induction Programme, plus, Mandatory & Essentials Training Day (clinical staff attend this annually). Electronic Staff Record (ESR) remapping underway to ensure correct job roles are identified as requiring this training.  45.71%. Revised Water Low training is covered within the SKINN competency. This subject is scheduled onto Trust Induction, plus Statutory, Mandatory & Essentials Training Day (clinical staff attend this annually). Electronic Staff Record (ESR) remapping underway to ensure correct job roles are identified as requiring this training.  22.85%. Currently 186 delegates have been trained. Revised VIP training is also now part of the new Trust Induction Programme, plus Statutory, Mandatory & Essentials Training Day (clinical staff attend this annually). IV Cannulation training also contains VIP training information. 14  No of delegates attending updated SKINN Initiative Training  53 delegates trained in August 2015. This training is part of the Statutory, Mandatory & Essentials Training Day that clinical staff attend annually. It is also scheduled onto the Trust Induction Programme. This training also covers Improving Water Low training. The Trust currently has 45.71% compliance with this competency. Electronic Staff Record (ESR) remapping underway to ensure correct job roles are identified as requiring this training. 31  Compliance against Trust Needs Analysis for statutory, mandatory and essential clinical skills training  82% - Fire Safety  86% - Infection Control  80% - Moving & Handling – NB: % now includes practical & theory requirements  88% - Information Governance  96% - Safeguarding Children Level 1  95% - Safeguarding Vulnerable Adults  90% - Equality & Diversity  67% - MCA & DOLS  25% - Prevent Basic Awareness  24% - Prevent WRAP

19. Respecting and Involving People

20. Emergency – the response rate is a combined score from AAU and ED. AAU have achieved 47.2% response rate whilst ED have achieved 5.6%. Relocation of volunteer resource continues to impact on issuing and retrieval of FFT cards. This resource was not reinstated in August, however a revised process in ED which includes nomination of a daily FFT patient champion who actively encourages all team members to collect comments and data from Patients. The achievement is then reviewed by the Ward Sister on the next day, and any actions to improve are implemented. Maternity – there have been a slight improvement since last month. Ward clerk one admin vacancy has impacted on the distribution and collation of forms. This will be monitored by the Associate director of Nursing, Midwifery and Quality Inpatients – the response rate is a combined score from the inpatient wards on the trust. High response rates in most wards especially PEAR (Reab) (97%) and CHT (100%), lower response rate on Juniper (21%), ATSU (26%) and Daisy ward (17%) further investigations are being undertaken by HHCT informatics as there may be a discrepancy with ED admissions and Inpatient admission data which may be impacting on these returns. Trust Total – Responses received rate 33% Satisfaction Rate 97%

21. Should do

23. Must Do 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 and we continue to see good use of the escalation framework and reporting by the overnight site managers when movements occur 3.The trust continues to embed utilisation of trolleys in AAU to support rapid assessment of patients as well as the philosophy of ensuing AAU is largely emptied by 5pm at night. 4.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 5.Performance improvement remains in line with the agreed trajectory as part of our CQIN scheme

25. TDA Clinical Observation Visit – 28 August 2015 Key Areas of Focus Risk Registers and BAF to be strengthened Executive Portfolios Consistency of Practices across the Trust Expected Discharge Date Pharmacy working hours Amnesty on out of date and multiple posters Clarity on Audits Medication safety (Treatment centre practice of preparing drugs) Areas of Good Practice Individual reports for each ward produced, and improvement plans in place to address any identified areas for improvement. The Improvement plans and reported and monitored at the weekly Quality Improvement Plan working group meeting.