1. Oversight – Performance Report 17 November 2015 October 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

3. 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.

4. Staffing Actions taken In the period July to September only 9 exit surveys have been completed; 1-2 years being the most common length of service (38.46%) with 6-12 months being the second most common (23.08%). The top 2 reasons for leaving were Improved Work Life Balance (38.46%) & Higher Pay (30.71%) with Career Change, Relocation, Family/Personal Problems & Role not meeting expectations all coming in at third place (23.08%) Staff Friendliness continues to be reported at 100% whereas staffing levels, communication and opportunities for career progression all scored low however 72.73% would recommend Hinchingbrooke as an employer Average time to hire from NHS jobs reports is 53 days this is comparable within region Our final EU Nursing cohort arrived in October 2015 with 5 nurses still pending NMC Registration. There have been no drop outs from the 45 Filipino nurses we have made conditional offers to and have a reserve list of 20 should we need to increase those we recruit. These nurses will join us in 3 cohorts from April 2016 and fill current vacancies and allow cover for expected turnover in 2016/17. HCAs on the tracked wards remain fully established A number of local recruitment and promoting health careers have been set up through November & December Have achieved 50% of our Apprenticeship target

5. 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. Jan-15Feb-15Mar-15Apr-15May-15Jun-15Jul-15Aug-15Sep-15Oct-15 ID MetricTargetNotes Compliance Action 2 - Care and Welfare of People 9 No. of pressure Ulcers on all wards0Avoidable (1/2)1122100221 Trajectory0000000000 0Avoidable (3/4)0000001000 Trajectory0000000000

6. Safeguarding Trust overall compliance as at 31.10.15 as 83% vs. a trajectory of 90%. The 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 try and 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 100% 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.

7. Safeguarding Plan to achieve above 90% compliance: Level 3 training package developed - Named nurse and Named midwife have worked collaboratively to develop a programme for the level 3 safeguarding training to incorporate current relevant level 3 topics. Monthly plan - There is a safeguarding level 3 training day scheduled every month until January 2016 where the staff compliance will be assessed and an ongoing programme of level 3 training days will be developed to ensure all staff requiring level 3 safeguarding training remain compliant. This will allow training packages to be updated. External speakers - Have been arranged to teach on these days to provide knowledge on a range of specialist topics and to promote multi- agency discussion. Rostered - All staff requiring level 3 have been rostered on to the training days in advanced. This enables a multi-agency attendance to each day. compliance Elearning - Is available to all staff, username and passwords are available from learning and development. This has been publicised to staff through the paediatric newsletter. LSCB sessions - LSCB have been booked to deliver level 3 safeguarding training days in the trust. Staff requiring level 3 are encouraged to book onto these days to further increase their knowledge base on current safeguarding issues. Communication - Has been sent out as all user to clarify training requirements for staff groups. All Consultants and secretaries have been emailed to raise awareness for the need to attend. Risk Assessment - This has been completed to assess and monitor progress to reflect level of compliance in the trust. Trajectory - Put in place to monitor and action any slippage from achieving 100%

8. Safeguarding Plan to achieve 100% compliance Mandatory Training – There are 2-3 mandatory training days per month which include safeguarding level 2 training. Depending on month, 60 – 100 staff will be trained. Elearning – is available to all staff, username and passwords are available from learning and development. This has been publicised to staff through the paediatric newsletter. Level 3 safeguarding training – as more staff are trained in level 3 this will automatically allocate the level 2 safeguarding children competency. Additional level 2 sessions – Progress will be monitored and extra level 2 sessions can be made available to achieve compliance DHON meetings – The level 2 safeguarding compliance will be presented at DHON meetings to raise awareness. Email matrons – Learning and development will email matrons to inform them of non-compliant staff in their areas. Level 2 training dates - (including induction) have been advertised to staff through the paediatric newsletter. Partnership sessions – level 2 safeguarding training can be delivered at department partnership sessions

9. Jan-15Feb-15Mar-15Apr-15May-15Jun-15Jul-15Aug-15Sep-15Oct-15 ID MetricTargetNotes Compliance Action 2 - Care and Welfare of People Compliance Action 5 - Infection Control 16 Compliance with Handwashing Audit - (Unchallenged 5 minutes of Handwashing) greater 80% ( green )Audits99.19%99.21%99.75%100.00% 99.21% Trajectory100% Infection Control 99.71% achievement is above the 80% target for this measure. The trajectory is 100% which has been met consistently for the last 6 months. This will be reviewed within the next month. This metric is now collected through Ward Sister weekly checks and reported on the Ward Dashboard. An increase in the number of checks has led to a slight increase in non compliance. The ward dashboard indicates that both Apple Tree and Walnut did not attain the 100% trajectory though both were above the 80% target reporting 97% and 95.8% compliance rates respectively

10. Respecting and Involving People

13. The trust has exceeded its target satisfaction score of 95% by 2%. Cherry and Juniper missed the ward satisfaction target, 86% and 88% respectively. Cherry response rate fell below the ward target of 55% of eligible patients with only 30%. MSSU and Walnut failed to reach the 55% target response rate. Walnut missed the target by 10 returns and MSSU by 27 returns. Apple in comparison exceeded the target response rate by collecting a further 10 responses which contributed to the total inpatient response rate of 60%. ED has failed to match the success of Septembers' response rate and achieved 12.12%. The response rate has not effected the satisfaction score and ED has reached the 95% trust target. Based on current trend ED will exceed the national average satisfaction score YTD 88% by 7% Inpatients response rate has consistently exceeded the national average and October is the highest YTD 60.19%. Compared to national average response rate of 26% the teams have set targets at ward level of 55%. Building on the successes of the response rate Inpatients continue to surpass both the national average and the Trust Satisfaction Score target of 95%. October 97%. Maternity services implemented measures in early October to increase the response rate by setting an individual Trust target of 22%, based on the national average YTD. Octobers response rate of 25.37% is the highest since April. October is the first month since June that Maternity Services have not reached 100% satisfaction score. Maternity services satisfaction score of 98% remains strong against the national average of 96%

14. Must do In order to meet the 90% compliance by March 2016 the following actions are planned.  Provide further reminders to department managers of staff in their department with outstanding appraisals requesting these are completed as a matter of urgency. Escalating non-compliance to Director level or equivalent level  Request department managers provide data held at department level be sent to Workforce Development to ensure all data is recorded centrally on ESR  Remind managers that completion of Appraisals must be recorded on the ESR system by using Manager self-service. This forms part of the Appraisal process and is a responsibility of being an Appraiser. Training is available if managers are uncertain how to access and use Manager Self-Service  Explore with the Executive Team the implementation of a standard objective for all managers to ensure all staff in their team have completed a yearly Appraisal and statutory and mandatory training. Non achievement of this objective would be escalated to Director or equivalent level  Highlight to managers that completion of Appraisals and maintaining compliance is their responsibility

15. Jan-15Feb-15Mar-15Apr-15May-15Jun-15Jul-15Aug-15Sep-15Oct-15 ID MetricTargetNotes Compliance Action 2 - Care and Welfare of People 34 No. of avoidable transfers in the Trust after 10pm. Number of Moves89827080366051624967 Trajectory 73 55 37 Should 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