North Cumbria University Hospitals NHS Trust : Our improvement plan & our progress Message from the Chair – Gina Tiller North Cumbria University Hospitals NHS Trust was identified as one of the 14 hospitals across the country because of higher than expected mortality rates. As a result, the Prime Minister, David Cameron, requested Professor Sir Bruce Keogh, Medical Director of NHS England to fully review each hospital trust. The purpose of the Keogh Review was to help those trusts identified as having a higher than average mortality ratio on their journey of improvement. In May the review took place at North Cumbria and a risk summit was then held in June, with representatives from all of the health service and regulators. This was to discuss what the review panel found during their visits and what urgent actions, over and above those actions already taken by the Trust, needs to be accelerated. The Keogh review has provided us with further opportunities to really scrutinise our performance and approaches to patient care and we have wholeheartedly welcomed the Keogh report and fully support its recommendations. What is clear now is that we are beginning on a long journey of improvement at North Cumbria and the Keogh Review team clearly recognised this alongside the changes that have already been made, or are in development, which will positively impact on patient care. This summary action plan provides a focus for short-term improvements on immediate issues. We envisage our improvement plan going beyond Keogh deadline dates to ensure that when the Chief Inspector of Hospitals, Prof Sir Mike Richards inspects, that the Trust is ready. Once the actions identified here have been completed, the Trust will set out a longer-term plan to maintain progress and ensure that the actions lead to measurable improvements in the quality and safety of care for patients. (Please note that the Chief Inspector of Hospitals inspection commences North Cumbria University Hospitals Trust from the 29th April 2014) Change will not happen overnight, nor will it be easy. But change must happen and must be, at all times, in the very best interests of patients. The Trust’s focus as it begins this journey of improvement will be on: Putting the patient at the heart of everything Supporting patients and staff to challenge the status quo Investing in services for the long term Developing staff to achieve a culture of continuous improvement. The weaknesses highlighted by Keogh must be transformed into areas of strength so that North Cumbria can rebuild confidence in local hospital services and, most crucially, regain the trust of local communities. To do this, the health system in Cumbria is committed to working much better together. This will ensure that, collectively, there is a long and lasting impact on the way hospital services are provided which will ultimately make a positive change on the health outcomes for people living in north Cumbria – something they rightly deserve. We will continue to keep all of our stakeholders fully updated as we progress our safety and quality improvements. There will also be regular updates on NHS Choices and subsequent longer term actions will be included as part of a continuous process of improvement.

North Cumbria University Hospitals NHS Trust : Our improvement plan & our progress What are we doing? In July 2013, the Keogh Review made recommendations in eight core areas to help improve the quality and safety of our services for patients in North Cumbria. Specifically, the Keogh Review said that we need to: Carry out a full review of the Trust’s corporate risk, business assurance framework and quality governance plans Review leadership capability and develop a formal organisational development plan for all staff Ensure robust arrangements for serious incident investigations Review staffing levels to ensure safe care is delivered Ensure mandatory training is supported Promotion of a more supportive and open culture Review of estates capability and capacity Review infection control policies and practices with full organisational ownership This ‘plan & progress’ document shows how we already making these improvements and demonstrates how we’re progressing against the plan. This document builds on the ‘Key findings and action plan following risk summit’ document which we agreed immediately after the review was published on NHS Choices (click here) While we take forward our plans to address the Keogh recommendations, the Trust is in ‘special measures’ and continues to work closely with the NHS Trust Development Authority (TDA), with our acquisition partner Northumbria Healthcare NHS Foundation Trust and with NHS Cumbria Clinical Commissioning Group (CCG). Oversight and improvement arrangements have been put in place to support changes required Who is responsible? Our actions to address the Keogh recommendations have been agreed by the Trust Board Our Chief Executive Ann Farrar is ultimately responsible for implementing actions in this document. Other key staff include Dr Jeremy Rushmer who is Interim Medical Director. Dr Dean Spencer from the NHS Trust Development Authority is supporting us to implement our actions for improvement Ultimately, our success in implementing the recommendations of the Keogh plan will be assessed by the Chief Inspector of Hospitals who will re-inspect our Trust in the coming months. If you have any questions about how we’re doing, please contact ann.farrar@ncuh.nhs.uk How our progress is being monitored and supported We will update this progress report on the first day of every month while we are in special measure and provide a monthly stakeholder update and regular briefings as we implement changes. Progress on our improvement will be reported at our Trust Board meetings every month which are open for the public to attend. (Timescale: From September 2013; Owner: Trust) Appointment of a senior representative by the TDA, who will provide expertise to the Trust Board and check that we're meeting our promises to deliver our improvement plan. (Timescale: By October 2013; Owner: TDA). Access support from partnership working as appropriate with the Academic Health Science Network, NHS Improving Quality and the NHS Leadership Academy. (Timescale: By April 2014; Owner: NHS England). Signed by the Chair of the Trust (on behalf of the Board)

North Cumbria University Hospitals NHS Trust Our improvement plan This table shows the actions we’re taking to address the concerns about the quality of our services which were raised in the Keogh report. It also shows how we are progressing against our actions. Summary of Keogh Concerns Summary of Urgent Actions Required North Cumbria University Hospitals NHS Trust Agreed Timescale External Support/ Assurance Progress B/G/R/ narrative 1. Inadequate governance, and pace and focus of change to improve overall safety and experience of patients Full review of the Trust’s corporate risk, business assurance framework and quality governance plans, to include: a. consolidation of key risks at a corporate level; b. clinical business unit level . Full review of leadership capability and development of a formal organisational development plan for all staff, to include:* a. review of the leadership structure to ensure that the capability and capacity gaps are filled; b. Implementation of a formal programme of organisational development and support for management staff; End July 2013 March 2014 CQC to provide independent review of appropriate CQC outcomes to verify full compliance. TDA to complete the review of the Executive Leadership. Development of Organisational Development Plan in conjunction with Northumbria Healthcare NHS Foundation Trust, NHS Institute, Health Education England, Kings Fund and Monitor. Please note that there are serious issues regarding leadership gaps and capacity in many areas of the Trust and this requires urgent attention to ensure we have the right people fulfilling the right leadership roles. New leadership team now in place New Chair appointed DoN will take up position in May 2014 Surgical BUD appointed and will join the Trust in June 2014. Implementation of appropriate performance management system. Pilot and evaluate 30% of wards. Sept 2013 Northumbria Healthcare NHS Foundation Trust to confirm capacity to implement a system for Board to Ward performance management.

North Cumbria University Hospitals NHS Trust Summary of Keogh Concerns Summary of Urgent Actions Required North Cumbria University Hospitals NHS Trust Agreed Timescale External Support/ Assurance Progress B/G/R/ narrative 2. Slow and inadequate responses to serious incidents and a culture which does not support openness, transparency and learning Ensure robust arrangements for serious incidents investigations, to include: a. Developing the serious incident investigations process, including a review of all outstanding investigations. b. Increase resources in the complaints team to ensure that all complaints are appropriately responded to within 25 working days. Oct 2013 TDA to approve immediate actions following never events and recommend appropriate support on broader issues and how to improve. TDA Quality Team to provide capacity support to conclude outstanding reviews. TDA to engage best practice in complaints handling from an organisational perspective and to identify additional short term capacity to clear backlog of complaints. 3. Staffing shortfalls and other workforce issues across both nursing and medicine which may be compromising patient safety Review staffing levels to ensure safe care is delivered, to include: a. Staffing arrangements in the Trust should be urgently reviewed to ensure they meet minimum standards. Any review should be concluded rapidly to minimise the impact on staff morale. The nursing review completed and reported to the ward managers and the Trust Board in October 2013. A high focus on recruitment has resulted in more nurses working on the wards but more are still required and we continue to take active steps b. New Consultants have joined the Trust but we continue to have too many locums in our medical teams (surgery team posts almost full) and so recruitment continues promoting a North Cumbria service and more modern models of care which attract potential candidates Ensure mandatory training is supported. a. Staff should be allowed time to complete mandatory training. b. Mandatory training programmes should be revisited to include a face-to-face element where appropriate. Oct 2013 Revised to March 2014 March 2014 TDA to undertake a review of staffing levels and provide continuing support on capacity and capability issues. On track Good progress made

North Cumbria University Hospitals NHS Trust Summary of Keogh Concerns Summary of Urgent Actions Required North Cumbria University Hospitals NHS Trust Agreed Timescale External Support/ Assurance Progress B/G/R/ narrative 4. Lack of support for staff and effective, honest communication from a middle and senior management level Promotion of a more supportive and open culture, to include: a. An increased emphasis on an open, honest and supportive culture throughout the Trust. b. Introduction of a development programme for senior and middle management. c. Implement Organisational Development Plan. The organisational development programmes are positively received by the staff and developing confidence and skills to support them deliver better quality. The better outcomes will be monitored and reviewed by March 2014 Revised to March 2014. CCG/AT to agree Quality Standards. NE Leadership Academy to support senior clinical leaders and develop individuals into high performing teams. Northumbria Healthcare NHS Foundation Trust to work in partnership on the consistent application of professional standards to address concerns raised regarding individual and team relationships e.g., bullying allegations. 5. Failure in governance to ensure adequate maintenance of the estate and equipment Review of estates capability and capacity, to include: a. an urgent review of the estates department to ascertain competence and capability, including, an assessment of current arrangements relating to water management and equipment maintenance. b. an independent assessment of all theatres for compliance with relevant standards. c. an urgent review of the Trust’s compliance status for the SSD and endoscopy, involving the DIPC. d. governance arrangements for decontamination should be reviewed, and form an integral part of the Infection Control Committee agenda. e. implement a formal, annual deep clean programme. End September 2013 TDA to approve action plans prepared by the Trust in response to the issues raised, including, external validation of all equipment. 6. Significant weaknesses in infection control practices Review infection and control policies and practices with full organisational ownership, to include:* a. A review of infection control practices including the infection control policy, implementation, governance and audits. b. Adopt a more multi-disciplinary approach to infection control, including more involvement from Estates. c. De-clutter wards to allow better cleaning and an improved patient environment. d. Urgently secure all drug fridges, and ensure food and drink are stored separately from drugs. A regular audit programme should be introduced to monitor this. *The outcome for this activity will ensure: 40% of wards are fully compliant with our infection control core bundle Perform at national average for healthcare aquired infection C.Diff Reducing levels of surgical site infections Please note that we expect to be at 50% in December and 75% March End October 2013 TDA infection control team to provide external support on best practice and assess progress. Northumbria Healthcare NHS Foundation Trust supporting the delivery of a robust real time performance management system for the full range of compliance standards.

How we’re checking that our improvement plan is working This table shows how and when we are checking that the actions we’re taking are making a real difference in our hospitals. Oversight and improvement action Timescale Action owner Progress Monthly accountability meeting with Monitor/TDA to track delivery of action plan. Aug 2013 to July 2014 Trust chief executive Partnership working with Northumbria Healthcare NHS Foundation Trust to help embed best practice in North Cumbria and improve the quality and safety of care From July 2013 Appointment of senior representative from the TDA, who will provide expertise to the Trust Board and check that we’re meeting our promises to deliver our improvement plan. September 2013 TDA Meetings of the Trust Board – every two months we openly report progress on the Trust action plan and improvements which are being made to quality and safety. Monthly – from July 2013 Trust chair Regular updates for stakeholders and the public about how the Trust is improving via briefings to local media and meetings of our shadow council of governors. Ongoing / monthly – from July Agreement and regular reporting of quality measures to demonstrate that the actions are leading to improved quality of care for patients Monthly from July An external quality governance review was carried out in July 2013 and reported to the Trust board with work ongoing to complete recommendations. Quarterly Scrutiny of our new ways of working and of the quality of our services is delivered by a Quality Surveillance Group (QSG) composed of the Trust CE, NHS England Area Team, CCGs as well as Northumbria Healthcare. Sept 2013 to July 2014 Trust chief executive /Special Measures Director/AT/CCGs Re-inspection Early July 2014 CQC Key for progress reports Blue -delivered Green – on track to deliver Narrative – disclose delays/risks/plan to recover Red – not on track to deliver