oversight – performance report 17 november 2015 october reporting period v

Oversight – Performance Report

17 November 2015 October 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

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.

Jan-15 Feb-15 Mar-15 Apr-15 May-15 Jun-15 Jul-15 Aug-15 Sep-15 Oct-15ID Metric Target Notes

7 No. of Clinical CAMH Breaches - ED 0 0 0 1 2 3 0 1 1 2 1

Trajectory 0 0 0 0 0 0 0 0 0 0

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


13 Staff Turnover by Professional Group Less 10% ( green ) Medical & dental 11.04% 10.91% 10.53% 10.23% 11.11% 11.17% 11.05% 10.23% 11.36% 11.36%

Trajectory

Less 10% ( green ) Nursing & midwifery 9.62% 10.82% 12.09% 13.05% 12.68% 11.78% 12.87% 13.52% 14.80% 14.66%

Trajectory

Less 10% ( green ) Other clinical incl HCAs 17.86% 18.11% 17.48% 12.88% 13.32% 13.76% 14.30% 13.85% 20.04% 19.47%

Trajectory

Less 10% ( green ) Non-clinical 15.90% 15.55% 17.74% 18.39% 20.73% 19.91% 20.87% 21.00% 22.44% 22.54%

Trajectory

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-15 Feb-15 Mar-15 Apr-15 May-15 Jun-15 Jul-15 Aug-15 Sep-15 Oct-15ID Metric Target Notes Compliance Action 2 - Care and Welfare of People

9 No. of pressure Ulcers on all wards 0 Avoidable (1/2) 1 1 2 2 1 0 0 2 2 1

Trajectory 0 0 0 0 0 0 0 0 0 0

0 Avoidable (3/4) 0 0 0 0 0 0 1 0 0 0

Trajectory 0 0 0 0 0 0 0 0 0 0

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.


Compliance Action 4 - Safeguarding21 % of delegates attending MCA and DoLs Training Quarterly YTD 0% 26% 44% 48% 51% 56% 63% 67% 75% 83%

Trajectory 30% 35% 44% 48% 44% 54% 63% 70% 80% 90%

Oct-14 Nov-14 Dec-14 Jan-15 Feb-15 Mar-15 Apr-15 May-15 Jun-15 Jul-15 Aug-15 Sep-15 Oct-15

by month 26 43 43 60 69 69 73 86 74 65 82 86

Cumulative 26 69 112 172 241 310 383 469 543 608 690 776 Actual Cumulative 101 130 173 217 217 374 416 443 509 584 662 759 829

Oct-14 Nov-14 Dec-14 Jan-15 Feb-15 Mar-15 Apr-15 May-15 Jun-15 Jul-15 Aug-15 Sep-15 Oct-15

Trajectory 3% 8% 13% 20% 28% 36% 44% 54% 63% 70% 80% 90%

Actual 0% 0% 0% 0% 26% 44% 48% 51% 56% 63% 67% 75% 83%

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%


Level 3 Safeguarding Monthly 23% 42% 48% 52% 62%

Trajectory 23% 34% 34% 54% 64%

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


Safeguarding Children Level 2 - 1 Year Monthly 55% 58% 61% 61% 64%

90% Trajectory

Level 2 Safeguarding - Trajectory

Sep-15 Oct-15 Nov-15 Dec-15 Jan-16 Feb-16 Mar-16 by month 60 90 100 100 60 70 80 Cumulative 820 910 1010 1110 1170 1240 1320 Actual by Month 120 Actual Cumulative 880

Sep-15 Oct-15 Nov-15 Dec-15 Jan-16 Feb-16 Mar-16 Trajectory 66% 73% 81% 90% 94% 100% 106% Actual 61% 64%

Jan-15 Feb-15 Mar-15 Apr-15 May-15 Jun-15 Jul-15 Aug-15 Sep-15 Oct-15ID Metric Target Notes 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 )Audits 99.19% 99.21% 99.75% 100.00% 100.00% 100.00% 100.00% 100.00% 100.00% 99.21%

Trajectory 100% 100% 100% 100% 100% 100% 100% 100% 100% 100%

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

Respecting and Involving People31 Compliance against Training needs Analysis for statutory,

mandatory and essential clinical skil ls traininggreater 90% ( green ) IPC Refresher

(Clinical Staff) - 1 Year86.26% 82.57% 83.06% 82.31% 81.21% 76.14% 72.28%

Available in September Trajectory

greater 90% ( green ) IPC Refresher (Non Clinical Staff) - 2 Years

98.25% 97.25% 97.45% 98.08% 97.19% 96.78% 94.87%


greater 90% ( green ) M&H High Risk (Non Clinical) Practical + Theory - 2 Year

20.54% 19.23% 19.23% 20.27% 20.00% 20.29% 48.61%


greater 90% ( green ) M&H Low Risk (Clinical) Practical + Theory - 2 Year

38.19% 76.17% 76.39% 75.43% 71.12% 71.12% 73.78%


greater 90% ( green ) M&H Low Risk (Non Clinical) e-learning - 3 Year

92.15% 96.46% 96.68% 97.33% 96.43% 97.11% 96.88%


greater 90% ( green ) Moving & Handling for People Handlers - 1 Year

58.19% 69.59% 70.86% 75.43% 77.98% 74.89% 70.50%


greater 90% ( green ) Fire Safety - 1 Year 83.44% 81.35% 82.61% 82.00% 80.65% 77.49% 75.14%


greater 90% ( green ) Mental Capacity Act - 3 Years 46.66% 49.89% 50.32% 61.57% 65.33% 73.79% 81.60%


greater 90% ( green ) Prevent Basic Awareness - 3 Years

17.55% 17.89% 18.10% 24.00% 23.99% 25.56% 33.98%


greater 90% ( green ) PREVENT - 3 Years 27.88% 26.21% 26.47% 24.51% 24.51% 24.30% 21.93%


greater 90% ( green ) Safeguarding Adults Level 1 - 3 Years

92.77% 93.61% 94.18% 94.91% 94.61% 94.76% 93.94%


greater 90% ( green ) Safeguarding Children Level 1 - 3 Years

95.92% 95.89% 96.36% 94.69% 96.00% 95.22% 92.41%


greater 90% ( green ) Safeguarding Children Level 2 - 1 Year

78.19% 54.75% 55.16% 57.70% 61.29% 63.90%


greater 90% ( green ) Safeguarding Children Level 3 - 1 Year

43.46% 25.53% 24.62% 48.20% 47.96% 51.79% 61.50%


greater 90% ( green ) Equality, Diversity and Human Rights - 3 Years

89.97% 90.26% 90.60% 87.91% 89.57% 89.12% 87.09%


greater 90% ( green ) Information Governance - 1 Year

85.60% 85.40% 85.90% 84.90% 86.50% 84.11% 82.90%


Respecting and Involving PeopleManagement Report – October 2015 October 2015 11 % of delegates attending UTI Indwelling Catheter Training

% of delegates attending Improving Water Low Training

% of delegates attending VIP training

36.23%. Catheterisation training commenced in March ’15. 292 delegates have so far been trained. Catheterisation training is now part of the new Trust Induction Programme, 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. Trajectory in place to achieve compliance by 31.03.16.

51.59%. 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. Trajectory in place to achieve compliance by 31.03.16.

39.68%. Currently 319 delegates have been trained. 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. Trajectory in place to achieve compliance by 31.03.16.

14 No of delegates attending SKINN Initiative Training 71 delegates trained in October 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 51.59% compliance with this competency. Electronic Staff Record (ESR) remapping underway to ensure correct job roles are identified as requiring this training. Trajectory in place to achieve compliance by 31.03.16

31 Compliance against Trust Needs Analysis for statutory, mandatory and essential clinical skills training

78% - Fire Safety 81% - Infection Control 80% - Moving & Handling – NB: % now includes practical & theory requirements 83% - Information Governance 93% - Safeguarding Children Level 1 95% - Safeguarding Vulnerable Adults 88% - Equality & Diversity 83% - MCA & DOLS 34% - Prevent Basic Awareness 22% - Prevent WRAP

Nichola Guy - Learning Manager – 06.11.15

Respecting and Involving PeopleAssignments for Positions

w ith Competence Requirements

% Assignments that Fulfil Competence Requirements for

Position

Competence Requirement

Gap

Notes:

Competence Name

NHS|MAND|Fire Safety - 1 Year| 1,766 75.14% 439 Fire Safety for Non Clinical Staff via E Learning - communication ongoing. Scheduled onto Partnership Days. Non compliance escalation communicated at dvisional level

291|LOCAL|IPC Refresher (Clinical Staff) - 1 Year| 1,212 72.28% 336 Further compliance mapping on ESR required to check data accuracy. Subject lead aw are of current compliance level.

291|LOCAL|IPC Refresher (Non Clinical Staff) - 2 Years| 468 94.87% 24 Compliant

291|LOCAL|M&H Low Risk (Non Clinical) e-learning - 3 Year| 448 96.88% 14 Compliant

291|LOCAL|M&H High Risk (Non Clinical) Practical + Theory - 2 Year| 72 48.61% 37 Change of competence and frequency. Department specif ic training ongoing.

291|LOCAL|M&H Low Risk (Clinical) Practical + Theory - 2 Year| 225 73.78% 59 Change of competence and frequency. Remapping taken place. Communication continues.

NHS|MAND|Moving & Handling for People Handlers - 1 Year| 939 70.50% 277 Remapping taken place. Communication at dvisional level taking place.

NHS|MAND|Information Governance - 1 Year| 1,766 82.90% 302 Elearning and self assessment booklet available. Communication ongoing by dedicated staff w ithin governance team.

NHS|MAND|Safeguarding Adults Level 1 - 3 Years| 1,766 93.94% 107 Compliant

NHS|MAND|Safeguarding Children Level 1 - 3 Years| 1,766 92.41% 134 Compliant

NHS|MAND|Safeguarding Children Level 3 - 1 Year| 200 61.50% 77 Programme of training opportunities advertised Trust w ide - both local and via LSCB, plus national elearning content. Trajectory in place to achieve compliance by January '16.

NHS|MAND|Equality, Diversity and Human Rights - 3 Years| 1,766 87.09% 228 Elearning and self assessment booklet available. On-going communication at dvisional level.

NHS|MAND|Mental Capacity Act - 3 Years| 875 81.60% 161 Target of 90% is by October. Trajectory in place.

291|LOCAL|Prevent Basic Awareness - 3 Years| 1,766 33.98% 1,166 New competency. Compliance required by 2017. Elearning package launched Oct '15. Subject lead currently prioritising MCA & DOLS trajectory.

NHS|MAND|PREVENT - 3 Years| 114 21.93% 89 Compliance required by 2017. Subject lead currently prioritising MCA & DOLS trajectory.

Respecting and Involving People

• 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%


23 Friends and Family Test Responses received - Emergency Response Rates 10.00% 13.00% 14.00% 13.00% 17.00% 23.68% 13.95% 9.61% 20.91% 12.12%

Trajectory 19% 19% 20% 20% 20% 20% 20%

Friends and Family Test Responses received - Maternity Response Rates 40.00% 11.00% 75.00% 74.00% 55.00% 64.64% 23.77% 24.55% 66.82% 64.88%

Trajectory 64% 64% 66% 66% 66% 66% 66%

Friends and Family Test Responses received - In patients Response Rates 41.00% 53.00% 43.00% 43.00% 47.00% 52.82% 53.72% 45.76% 50.00% 41.88%

Trajectory 59% 59% 61% 61% 61% 61% 61%

Friends and Family satisfaction score - Emergency 94.00% 94.00% 95.32% 93.19% 95.36% 94.61% 95.32%

Trajectory 90% 90% 90% 90% 90% 90% 90%

Friends and Family satisfaction score - Maternity 98.00% 97.00% 97.44% 95.14% 96.30% 95.10% 96.99%

Trajectory 90% 90% 90% 90% 90% 90% 90%

Friends and Family satisfaction score - In patients 97.00% 96.00% 95.77% 96.24% 97.21% 96.60% 97.94%

Trajectory 90% 90% 90% 90% 90% 90% 90%

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


Must Do30 % of completed appraisals greater 80% ( green ) 56.00% 76.00% 91.00% 84.34% 80.00% 75.60% 78.21% 81.33% 77.01% 77.99%

Available September ( esr ) Trajectory

Jan-15 Feb-15 Mar-15 Apr-15 May-15 Jun-15 Jul-15 Aug-15 Sep-15 Oct-15ID Metric Target Notes Compliance Action 2 - Care and Welfare of People

34 No. of avoidable transfers in the Trust after 10pm. Number of Moves 89 82 70 80 36 60 51 62 49 67

Trajectory 73 73 73 55 55 55 37

Date All moves Avoidable moves Proportion Moves per date Target Proportion Target01/04/2015 733 86 11.73% 73 11.46%01/05/2015 666 36 5.41% 73 11.46%01/06/2015 684 60 8.77% 73 11.46%01/07/2015 645 51 7.91% 55 8.60%01/08/2015 667 62 9.30% 55 8.60%01/09/2015 661 49 7.41% 55 8.60%01/10/2015 690 67 9.71% 37 5.73%

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

Variation Report - as at 11 November 2015

Compliance Action Ref

Area Action Milestone Accountable ResponsibleDate to be delivered

Revised Estimated

delivery dateReason for Delay Effect on Action

NO VARIATIONS TO PLAN TO REPORT

oversight – performance report 17 november 2015 october reporting period v

Documents

safeguardingcompliance

monitoringcompliance

staffingcompliance action

idme action

cqc action plan

number of pressure ulcers

ed staff

hour performance