Special Measures Action Plan Sherwood Forest Hospitals NHS Foundation Trust September 2014 KEY Delivered On Track to deliver Some issues – narrative disclosure Not on track to deliver 1

Sherwood Forest Hospitals - Our improvement plan & our progress What are we doing? The Trust entered the special measures programme and was selected following the higher than expected mortality rates at the Trust at the time, these are now within the expected range The Trust has been given a variety of recommendations. The initial Keogh Rapid Response Review identified 23 actions, 13 of which were classed as urgent. All these actions were deemed either Assured or Partly Assured by the Keogh Assurance review in December Subsequently the Trust has been re-inspected by the CQC, April 2014, who recommended to Monitor that the Trust remain in Special Measures for a further 6 months The Trust agreed an initial summary action plan to deal with these. The Trust has developed an action plan to address the issues raised in the CQC report and combined these with the actions from the Keogh review recommendations. We recognised all of the recommendations and are addressing them through current actions being taken to improve the quality of services. We envisage that improvements will be implemented and sustained in order for the Trust to be removed from Special Measure when re-inspected by the Chief Inspector of Hospitals. 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. The key themes of these recommendations are summarised by the headings below: Strengthen assurance processes and outcomes Leadership Accountability Safe Effective Caring Responsive Well - led This document shows our plan for making these improvements and demonstrates our progression against the plan. While we take forward our plans to address the recommendations, the Trust is in ‘special measures’. Oversight and improvement arrangements have been put in place to support changes required. Weekly Quality Improvement meetings, chaired by the Director of Nursing monitors the milestone plan and the outputs from task and finish groups. Evidence is submitted to provide assurance the action has been implemented. Monthly reports to Trust Management Board, Quality committee and Trust Board ensure oversight of the implementation. This document represents the Trusts initial response, detailed actions and progress. The Trust has a process in place to develop these over the coming months to give a more holistic view of improvements, demonstrating increased consistency and accountability together with reductions in variation. 2

Sherwood Forest Hospitals - Our improvement plan & our progress Who is responsible? Our actions to address the CQC Report recommendations have been agreed by the Trust Board. Our Chief Executive, Paul O’Connor ultimately responsible for implementing actions in this document. Other key staff are Executive Medical Director and Executive Director of Nursing, as they provide the executive leadership for quality, patient safety and patient experience. The Improvement Director assigned to Sherwood Forest Hospitals NHS Foundation Trust is Gillian Hooper, who will be acting on behalf of Monitor and in concert with the relevant Regional Team of Monitor to ensure delivery of the improvements and oversee the implementation of the action plan overleaf. Should you require any further information on this role please contact Ultimately, our success in implementing the recommendations of the CQC Trust wide Action plan will be assessed by the Chief Inspector of Hospitals, upon re-inspection of our Trust. If you have any questions about how we’re doing, contact Kerry Rogers, the Trust’s Director of Corporate Service on Ext 4007, or tr.nhs.uk How we will communicate our progress to you We will develop and 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: Sean LyonsSignature:Date: 1 st September 2014 Chief Executive Name: Paul O’ConnorSignature:Date: 1 st September

Sherwood Forest Hospitals - Our improvement plan Summary of Main Concerns Summary of Urgent Actions Required Agreed timescale for implementation External Support/ Assurance Progress against original timescale Revised deadline (if required) Strengthen assurance processes and outcomes Maintain Non Executive Director (NED) to Executive 3 monthly Confirm and Challenge Recommence NED formal and informal ward / department visits Agree new Board Assurance Framework (BAF) at September Trust Board Re-fresh corporate risk register in line with new BAF Embed the new process for Management of Serious Incidents Ensure existing plans to improve clinical productivity, transform service delivery and ensure quality improve are complimentary, robust and sustainable Oct 14 – Mar 15 Sept 14 – Mar 15 May – Sept 14 Sept – Nov 14 July – Dec 14 Oct 14 On track to deliver LeadershipSelf- assessment against the new Monitor guidance ‘Well-led framework for governance reviews’ Review Board effectiveness Continue planned Board Development programme Commence Executive Team development supported by East Midlands Leadership Academy, followed by Executive ‘Team Coaching. Evaluate buddying arrangement s c/o Newcastle Dec 14 Sept – Dec 14 Sept 14 – Mar 15 Feb 14 – Mar 15 On track to deliver AccountabilityExecutive accountability matrix agreed Nursing & Midwifery: All ward areas have Care & Comfort Boards in place Accountability DVD produced Standardised accountability handover record keeping introduced Standard operating procedure for accountability handover agreed Resource pack developed and 8 Practice Development Matrons recruited supporting all ward areas with implementation Completed July – Sept 14 On track to deliver 4

Sherwood Forest Hospitals - Our improvement plan Summary of Main Concerns Summary of Urgent Actions Required Agreed timescale for implementation External Support/ Assurance Progress against original timescale Revised deadline (if required) Safe Improve sharing and learning across the organisation Ensure accurate record keeping, particularly in relation to observations hydration and drug administration Improve the storage of medicines within ED and Medicine and ensure the Trust has a secure system for storing medicines. Reduce medicine omissions ensuring patients receive critical medicines according to the prescribed times and prescriptions Improve the recognition of the deteriorating patient reducing the risk of failure to rescue, whilst improving safety and outcomes for patients Improve the Mandatory Training compliance rate To embed the WHO checklist, particularly the briefing before and after surgery Ensure safe and sustainable staffing across the Trust Aug – Dec 2014 Aug - Dec 2014 Aug – Sept 2014 Aug – Dec 2014 Nov 2014 Oct – Dec 2014 July 2014 Sept – Nov 2014 Final implementation March 2016 On track to deliver EffectiveStandardise Care Pathways – protocols for transfer, escalation policies for ED and clinical. Undertake comprehensive pathway review through elective pathway transformation programme Training in practice – identify appropriate metrics of how staff use their knowledge from training to improve the quality of patient care Review appraisal documentation and data collection Implement End of Life Care Guidelines and plans Sept - Oct 2014 June – Dec 2014 Oct 2014 Oct – Nov 2014 Aug - Dec 2014 On track to deliver 5

Sherwood Forest Hospitals - Our improvement plan Summary of Main Concerns Summary of Urgent Actions Required Agreed timescale for implementation External Support/ Assurance Progress against original timescale Revised deadline (if required) CaringImprove the response rates for Family and FriendsJune – Sept 2014 On track to deliver ResponsiveImprove the complaint response times To be more responsive by reducing the delays in discharge Achieving consistently and sustaining all Referral to Treatment Times To improve patient experience within outpatients, addressing in particular communications from the Trust, minimising cancellations and ensuring the availability of all patient information for appointments To address concerns raised in relation to the provision of clinical administrative support Oct 2014 Sept 2014 – Jan 2015 Aug – Dec 2014 Oct 14 – Mar 2015 June – Sept 2014 On track to deliver Well-ledImprove communication between staff and management through the implementation of robust communication and feedback networks Undertake a trust wide cultural assessment Enshrine Quality for All behaviours in all that we do - cascade values and behaviours into the trust Effective Board Working and Engagement - implementing Board and governor training and development programmes Implement trust wide Leadership development strategy Sept – Dec 2014 Jul - Nov 2014 Oct – Dec 2014 Aug - Dec 2014 Sept – Dec 2014 On track to deliver 6

Sherwood Forest Hospitals - How our progress is being monitored and supported Oversight and improvement action Agreed Timescale for Implementation Action ownerProgress Replacement Improvement Director appointedAugust 2014MonitorDelivered Ensure existing plans to improve clinical productivity, transform service delivery and ensure quality improve are complimentary, robust and sustainable Oct 2014T C Exec On track to deliver 7