Oversight – Performance Report 23 July 2015 June reporting period V

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

New dashboard available with July data

IndicatorRedApple TreeATSUBirchCCUCherry TreeOutPatientsPRUNETShort StayWalnut Percentage of compliance with hand hygiene standardsRed < 90%100.00% Compliance with sharps auditRed < 90%92.00% % Compliance with outcome 8 standardsRed < 85%95.00% 97.00%94.00%95.00% 92.00% Compliance with saving lives urinary catheter care bundleRed < 90%95.00% % VTE Assessment scoreRed < 100%100.00% 96.00% %88.31% Prophylaxis scoreRed < 100% % Staff appraisals (by all groups)Red < 75%49.00% 90.00%73.00%85.00%90.00%80.00%96.00%80.00% Sickness (by all groups)Red > 4%5.57% 4.41%5.46% 4.00% Staff mandatory training (by professional group)Red < 75%77.00% %87.00%98.00%95.00%90.00%94.00%88.00% Percentage of relevant staff trained in safeguarding children processes (by professional group and level of training) Red < 75%91.00% % 90.00% Percentage of relevant staff trained in safeguarding adults processes, including Mental Capacity Act Red < 75%81.00% % 90.00% Audit score documentation standardsRed <60%80.00% %95.00%80.00% %95.00%80.00% Number of medication incidentsRed > Central Venous Catheter - InsertionRed < 95% % Central Venous Catheter - OngoingRed < 95% % Peripheral LinesRed < 95%95.00% % Peripheral Lines OngoingRed < 95%95.00% % Ventilated Pats - OngoingRed < 95% % Ventilated Pats - ObserveRed < 95% % Urinary Cathater InsertionRed < 95%100.00% Urinary Cathater OngoingRed < 95%90.00% % Ward Dashboard

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 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

Care and Welfare of People Issue Single sex breach occurred on CCC as no bed to transfer patients to and delay in recognition of issue by nurse in charge of CCC on the day. Action taken Flow chart devised with easy to follow actions and awareness of issue raised within CCC. Now located in new unit with individual rooms, so no single sex breaches will occur in future

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.

Care and Welfare of People Number of MRSA The one MRSA that was reported in April 2015 has been removed following arbitration with NHS England as unavoidable.

Care and Welfare of People Issue: This years target is from April to end March. According to our monthly trajectory we are below the ceiling. At the end of July we have had no more than 5 cases. To date we have reported 2. Action taken C.diff policy reviewed and implemented. Isolation policy reviewed and implemented. IPCN allocated specific wards and visit all patients with diarrhoea every day to support and guide staff.

Respecting and Involving People

Safeguarding MCA & DOLS Compliance – 30 June 2015

Restrictive physical intervention – covered under mandatory MCA/DoLs Training Best Interest decisions and Advocacy service for patients - emphasised during training to reduce variation Safeguarding

Must Do Issue: 1.Retaining straps for drug trolleys not available (on order – awaiting delivery) 2.Medicine cupboard and fridge doors left unlocked on three wards (3 wards out of 12) 3.Medicines left unattended on work surfaces (isolated incident) Action taken: 1.Straps ordered by Facilities to be fitted when delivered to trust. 2.Policy requirements highlighted on all wards. Performance monitored at Senior Nurse Meetings with sanctions as per Trust Policy. Pharmacy staff raising issues with senior nurses during visits. 3.Action in place to ensure Lockable TTO cupboards on all wards. Ordered and awaiting delivery 4.New secure pharmacy returns bins to be installed. Currently on order and awaiting delivery. 5.From July Pharmacy now undertaking monthly medicine storage and security audits across all wards reporting through nurse management & medication safety committee

Must Do Jan-15Feb-15Mar-15Apr-15May-15Jun-15 ID MetricTargetNotes 28 Drug fridge temps and range incorrect daily – monthly aggregategreater 90% ( green )Initial Data from 4 wards, then from all wards 96.00%83.00% Issue: 1.Awareness of daily monitoring requirement Action taken: 1.Fridge temperature monitoring form updated with escalation process and requirement for daily monitoring 2.Pharmacy staff checking compliance with monitoring requirements on ward visits and prompting compliance 3.Nurse in charge daily checklist implemented in ward areas and monitored as part of the electronic clinical assurance tool/dashboard 4.Performance monitored at Senior Nurse Meetings with sanctions as per Trust Policy.

Should do Issue 1.Compliance with daily checks Action taken 1.Wards with non compliant areas are rechecked on a monthly basis until performance returns within target 2.Escalated to Patient Safety Group 14 July Performance monitored at Senior Nurse Meetings with sanctions as per Trust Policy. 4.Performance is predicted to be 95% compliant in August

Must Do SOP introduced 30/4/15 1.The Moving Patients at night SOP was launched formally on 30 April 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. 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 is in line with the agreed trajectory as part of our CQINN scheme

Cherry Tree Ward Actions following recent Whistleblowing incident Escalated to external stakeholders Registered as Serious Incident Commenced internal HR investigation Duty of candour as appropriate Sanctions as per Trust protocol including exclusion from duty Strengthened Site Management Team/Exec scrutiny Beds reduced from 30 to 20 Interim Senior Nurse Leader deployed CPFT Learning and Development support for intensive dementia training Dayroom facilities in development to allow for recreational and diversional activities. Opportunity for developmental /rotational posts with CPFT Exploration of opportunity to develop activity co-ordinators Further learning from the SI report will be shared following report submission

Unannounced Visits, Peer Reviews, Health watch feedback Analysis against CQC Composite Action Plan The attached report is an analysis of the feedback received from unannounced visits, Peer Reviews, and Health Watch. This has been analysed against the Actions and Milestones being delivered in the CQC Composite Action Plan, and therefore are being addressed. The 27 other items are “one off” themes that have been addressed as part of the wider quality improvement agenda. CQC CAP Reference AreaOccurrences 1.1Adult Safeguarding8 2.1Call Bell2 2.1Communication4 2.1Documentation4 2.2Equipment Checking 1 2.2Governance1 2.3Medicines Adminstration1 3.3Medicines Security19 4.1Nutrition and Hydration1 6.1SHOULD DO3 6.2 Staff supervision and training2 AIMD 2Staffing7 AIMD 3Training1 AISD 3Ward Handover process1 Other 27 Hot spots Medicines Security Adult Safeguarding Staffing Data period: Sept 2014 to 15 July 2015