oversight – performance report 20 august 2015 july reporting period v

Oversight – Performance Report

20 August 2015 JULY 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

Oversight ReportPublished Data for July 2015Version 1.2

Jan-15 Feb-15 Mar-15 Apr-15 May-15 Jun-15 Jul-15 Aug-15 Sep-15 Oct-15 Nov-15 Dec-15 TotalID Metric Target Notes

Compliance Action 1 - Staffing1 % of Paed staff working in department from 7am to 12pm in

l ine with required numberContract Hours % N/A 74.00% 81.00% 80.00% 63.00% 74.50%

Trajectory N/A 70% 75% 75% 80% 80% 90% 90% 100% 100%

6 % of Child ED arrival to assessment within 15 Mins greater 80% ( green ) Percentage of Patients 92.41% 87.59% 87.37% 78.58% 80.40% 84.38% 92.08% 86.11%

Trajectory 80% 80% 80% 80% 80% 80% 80% 80% 80% 80% 80% 80%

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

Trajectory 0 0 0 0 0 0 0 0 0 0 0 0

12 PLANNED V ACTUAL for all Nursing Staff (to show staffi ng arrangements in place to meet needs of patients) Perm + Agency

greater 90% ( green ) HCA ( Contract Hours % )

114.49% 113.23% 93.53% 107.22% 110.74% 109.37% 100.28% 106.98%

Trajectory 90.0% 90.0% 90.0% 90.0% 90.0% 90.0% 90.0% 90.0% 90.0% 90.0% 90.0% 90.0%

greater 90% ( green ) Nursing & Midwifery( Contract Hours % )

101.06% 96.30% 103.00% 100.98% 97.59% 97.66% 95.13% 98.82%

Trajectory 90.0% 90.0% 90.0% 90.0% 90.0% 90.0% 90.0% 90.0% 90.0% 90.0% 90.0% 90.0%

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% 10.86%

Trajectory

Less 10% ( green ) Nursing & midwifery 9.62% 10.82% 12.09% 13.05% 12.68% 11.78% 12.87% 11.84%

Trajectory

Less 10% ( green ) Other clinical incl HCAs 17.86% 18.11% 17.48% 12.88% 13.32% 13.76% 14.30% 15.39%

Trajectory

Less 10% ( green ) Non-clinical 15.90% 15.55% 17.74% 18.39% 20.73% 19.91% 20.87% 18.44%

Trajectory

32 No. of staff attending QELCA Training (Quality End of Life Care for all)

greater 2 ( green ) Target 5 per every 2 months, YTD 25

5 0 4 0 9

Trajectory 5 5 5 5 5

Compliance Action 2 - Care and Welfare of PeopleMixed Sex Breaches 0 0 0 0 1 0 1 0 2

Trajectory 0 0 0 0 0 0 0 0 0 0 0 0

3 PEWS Observation Completion - 20% sample patients. greater 95% ( green ) 96.00% 97.00% 96.50%

Trajectory 95% 95% 95% 95% 95% 95% 95%

4 MEWS and MEOWs completion greater 80% (green) Data collection has commenced in May

83.00% 81.00% 82.00%

Trajectory 80% 80% 80% 80% 80% 80% 80%

9 No. of pressure Ulcers on all wards 0 Avoidable (1/2) 1 1 2 2 1 0 0 7

Trajectory 0 0 0 0 0 0 0 0 0 0 0 0

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

Trajectory 0 0 0 0 0 0 0 0 0 0 0 0

10 Fluid chart compliance 100% Data collection has commenced in May. Initial 2 wards

87.00% 85.00% 86.00%

Trajectory 85% 87% 89% 92% 95% 97% 100%

11 % of delegates Completed HII catheter Training, 1.29% 2.94% 2.90% 8.42% 3.89%

Trajectory

% of delegates attending improving water low training, Includes SKINN Training 40.29% 43.17% 42.30% 42.69% 41.73%

Trajectory

% of delegates Completed HII VIP training Employee Mapping underway, % data due June. 21 59 95 170 170

Trajectory

15 No. of HCAI Cdif YTD 11 No of Cases 2 0 0 0 0 1 1 4

Trajectory 0 0 0 0 0 0 0 0 0 0 0 0

No. of MRSA 0 No of Cases 0 0 0 0 0 0 0 0

Trajectory 0 0 0 0 0 0 0 0 0 0 0 0

17 % of catheter related UTI's - All 0.82% 1.50% 1.69% 4.51% 3.30% 6.51% 2.19% 2.93%

Trajectory

% of catheter related UTI's - New 1% 0.00% 0.77% 0.42% 1.23% 0.47% 0.93% 0.00% 0.55%

Trajectory 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0%

18 % compliance with Ward Audit - Recording of Waterlow 90% Data collection has commenced in May

93.00% 89.00%

Trajectory 85% 87% 90% 90% 90% 90% 90%

19 DNAR audit - Engagement with Carers greater 80% ( green) Available from April, 2 Monthly

73.00% 90.00% 81.50%

Trajectory 75% 77% 79% 80% 80%

Compliance Action 3 - Assessing and Monitoring24 No. of complaints at Local level and progressing to

ombudsman Level0 0 0 0 0 0 0 0

Trajectory 0 0 0 0 0 0 0 0 0 0 0 0

25 No. of incidents reported monthly Acute Medicine 94 65 88 98 121 93 104 663

Available in September Trajectory

Theatres & Critical Care 39 28 34 26 32 39 33 231


ISMR 91 67 54 49 60 51 42 414


GI & GS 43 50 48 46 49 48 73 357


EENT 6 4 9 3 13 10 5 50


Musculoskeletal 46 52 35 47 39 44 30 293


Womens Services 61 43 72 37 82 79 59 433


Support Services 5 8 18 10 12 18 25 96


Non-Clinical Services 12 6 11 10 15 13 5 72


Compliance Action 4 - Safeguarding21 % of delegates attending MCA and DoLs Training Quarterly YTD 0% 26% 44% 48% 51% 56% 63% 41%

Trajectory 30% 35% 44% 48% 44% 54% 63% 70% 80% 90% 100% 100%

22 Adult Safeguarding Audit completion 80% Quarterly 57% 66% 66%

Trajectory 50% 65% 80%

Level 3 Safeguarding Monthly 23% 42% 33%

Trajectory 23% 34% 34% 54% 64% 74% 84%

Compliance Action 5 - Infection Control16 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% 99.74%

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

New cases in the month that the Trust is aware of.

Compliance Action 6 - Respecting and Involving People2 Response to Call Bells ( inside 2 mins ) greater 90% ( green ) Audits 91.98% 97.37% 95.83% 98.81% 96.25% 98.04% 98.15% 96.63%

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

5 Fluid and Nutrition Assessments for Adults ( screening ) greater 90% ( green ) Qrtly - All Wards 91% 93% 92.00%


20 Audit of Intentional Rounding Document greater 80% ( green ) Data collection has commenced in May

86.00% 80.00% 100.00% 88.67%


23 Friends and Family Test Responses received - Emergency Response Rates 10.00% 13.00% 14.00% 13.00% 17.00% 23.68% 13.95% 14.95%

Trajectory 19% 19% 20% 20% 20% 20% 20% 20% 21%

Friends and Family Test Responses received - Maternity Response Rates 40.00% 11.00% 75.00% 74.00% 55.00% 64.64% 23.77% 49.06%

Trajectory 64% 64% 66% 66% 66% 66% 66% 66% 67.0%

Friends and Family Test Responses received - In patients Response Rates 41.00% 53.00% 43.00% 43.00% 47.00% 52.82% 53.72% 47.65%

Trajectory 59% 59% 61% 61% 61% 61% 61% 61% 63%

Friends and Family satisfaction score - Emergency 94.00% 94.00% 95.32% 93.19% 94.13%

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

Friends and Family satisfaction score - Maternity 98.00% 97.00% 97.44% 95.14% 96.90%

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

Friends and Family satisfaction score - In patients 97.00% 96.00% 95.77% 96.24% 96.25%

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

31 Compliance against Training needs Analysis for statutory, mandatory and essential clinical skil ls training

greater 90% ( green ) IPC Refresher (Clinical Staff) - 1 Year

86.26% 82.57% 83.06% 82.31% 83.55%


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

98.25% 97.25% 97.45% 98.08% 97.76%


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

20.54% 19.23% 19.23% 20.27% 19.82%


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

38.19% 76.17% 76.39% 75.43% 66.55%

Available in September Trajectorygreater 90% ( green ) M&H Low Risk (Non Clinical)

e-learning - 3 Year92.15% 96.46% 96.68% 97.33% 95.65%


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

58.19% 69.59% 70.86% 75.43% 68.52%


greater 90% ( green ) Fire Safety - 1 Year 83.44% 81.35% 82.61% 82.00% 82.35%


greater 90% ( green ) Mental Capacity Act - 3 Years 46.66% 49.89% 50.32% 61.57% 52.11%


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

17.55% 17.89% 18.10% 24.00% 19.38%


greater 90% ( green ) PREVENT - 3 Years 27.88% 26.21% 26.47% 24.51% 26.27%

Available in September Trajectorygreater 90% ( green ) Safeguarding Adults Level 1 -

3 Years92.77% 93.61% 94.18% 94.91% 93.87%


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

95.92% 95.89% 96.36% 94.69% 95.72%


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

78.19% 54.75% 55.16% 57.70% 61.45%



43.46% 25.53% 24.62% 48.20% 35.45%


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

89.97% 90.26% 90.60% 87.91% 89.69%

Available in September Trajectorygreater 90% ( green ) Information Governance - 1

Year85.60% 85.40% 85.90% 84.90% 85.45%


Must Do26 % of wards reporting Drug Cupboard/Trolley secure greater 90% ( green ) Audits 98.93% 98.03% 98.21% 98.15% 95.00% 96.08% 98.15% 97.51%

Trajectory

27 Compliance with Medicine Administration AuditsMedicines Audit - Security/Storage

greater 90% ( green ) Quarterly 74.00% 78.00% 76.00%

Trajectory 85.00% 87% 90% 90%

Medicines Audit - Clinical safety/Admin greater 90% ( green ) Quarterly 88.00% 97.00% 92.50%

Trajectory 85% 87% 90% 90%

28 Drug fridge temps and range incorrect daily – monthly aggregate

greater 80% ( green ) Initial Data from 4 wards, then from all wards

96.00% 83.00% 91.00% 90.00%

Trajectory 80% 80% 80% 80% 80% 80% 80% 80%

29 Medication omissions Drugs not given 18 9 11 4 14 11 19 86

Available September Trajectory

30 % of completed appraisals greater 80% ( green ) 56.00% 76.00% 91.00% 84.34% 80.00% 75.60% 78.21% 77.31%

Available September Trajectory

% of Doctors Revalidation Not Currently Available 100.00% 100.00%

100% 100% 100% 100% 100% 100%

Should Do33 Compliance with daily Resuscitation Equipment Checks

(Audit)greater 95% ( green ) Specific wards each month.

All wards each Quarter.95.00% 83.00% 89.00% 90.00% 89.25%

Trajectory 85% 85% 85% 85% 90% 90% 95% 95% 95%

34 No. of avoidable transfers in the Trust after 10pm. Number of Moves 89 82 70 80 34 55 65 475

Trajectory 73 73 73 55 55 55 37 37 37

Document Author: Informatics, Template Version 1.0, Creation Date: 12th August 2015 13:00

Ward Dashboard

AAU Apple Tree ATSU Birch CCU Cherry Tree ED Juniper OutPatients PRUNET Reablement Short Stay Walnut

Percentage of compl iance with hand hygiene standards Red < 90% 100.00% 100.00% 90.00% 100.00% 100.00% 100.00% 100.00% 100.00% 100.00% 100.00% 100.00% 100.00% 100.00%

Compl iance with outcome 8 s tandards Red < 85% 86.00% 98.00% 97.00% 95.00% 97.00% N/A 92.00% 98.00% 89.00% 93.00%

Compl iance with saving l ives urinary catheter care bundle

Red < 90% 100.00% 100.00% 98.00% 100.00% 100.00% 100.00%N/A N/A

100.00% 100.00% 100.00% 100.00%

VTE Assessment score Red < 100%

100.00% 100.00% 100.00% 100.00% 97.60%N/A N/A

100.00% 100.00% 93.08%

Prophylaxis score Red < 100%

98.00% 100.00% 100.00% 100.00%N/A N/A

100.00% 100.00%N/A

Staff appraisa ls (by a l l groups) Red < 75% 94.00% 70.00% 64.00% 95.00% 64.00% 95.00% 90.00% 100.00% 80.00% 84.00% 96.00% 83.00%

Sickness (by a l l groups) Red > 4% 8.17% 4.76% 3.27% 2.46% N/A 9.68% 2.00% 5.10% 1.00%

Staff mandatory tra ining (by profess ional group) Red < 75% 100.00% 80.00% 90.00% 55.00% 89.00% 98.00% 100.00% 82.55% 100.00% 90.00% 86.00% 93.62% 100.00%

Percentage of relevant s taff tra ined in safeguarding chi ldren processes (by profess ional group and level of tra ining)

Red < 75% 80.00% 90.00% 100.00% 98.00% 100.00%N/A

94.12% 100.00% 90.00% 98.73% 100.00%

Percentage of relevant s taff tra ined in safeguarding adults processes , including Mental Capaci ty Act

Red < 75% 100.00% 90.00% 95.00% 100.00% 100.00%N/A

94.12% 100.00% 90.00% 98.73% 90.00%

Audit score documentation standards Red <60% 100.00% 100.00% 90.00% 100.00% 100.00% 80.00% N/A 100.00% N/A 100.00% 95.00% 100.00%

Number of medication incidents Red > 3 0 1 7 1 1 3 0 13 0 1 2 9 2

Centra l Venous Catheter - Insertion Red < 95% N/A N/A N/A N/A 100.00% N/A N/A N/A N/A N/A N/A N/A N/ACentra l Venous Catheter - Ongoing Red < 95% N/A N/A N/A N/A 100.00% N/A N/A N/A N/A N/A N/A N/A N/APeriphera l Lines Red < 95% 100.00% 95.00% 98.00% 100.00% 100.00% 100.00% 100.00% 100.00% 100.00% 100.00%

Periphera l Lines Ongoing Red < 95% 100.00% 100.00% 98.00% 100.00% 100.00% 100.00% 100.00% 100.00% 100.00% 100.00%

Surgica l Si te Infections - Pre-op Red < 95% N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/ASurgica l Si te Infections - Peri -op Red < 95% N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/AVentilated Pats - Ongoing Red < 95% N/A N/A N/A N/A 100.00% N/A N/A N/A N/A N/A N/A N/AVentilated Pats - Observe Red < 95% N/A N/A N/A N/A 100.00% N/A N/A N/A N/A N/A N/A N/AUrinary Cathater Insertion Red < 95% 100.00% 95.00% 100.00% 100.00% 100.00% 100.00% 100.00% 100.00% 100.00%

Urinary Cathater Ongoing Red < 95% 100.00% 95.00% 100.00% 100.00% 100.00% 100.00% 100.00% 100.00% 100.00%

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

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

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.

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 2016.• 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


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%

Trajectory

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

Trajectory

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

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

Trajectory

StaffingJan-15 Feb-15 Mar-15 Apr-15 May-15 Jun-15 Jul-15

ID Metric Target Notes32 No. of staff attending QELCA Training

(Quality End of Life Care for all) greater 2 ( green ) Target 2 per month, YTD 25 5 0 4 0

Trajectory 5 5 5 5

25 places booked for the year and all 25 spaces allocated to staff. As detailed below. (1 place in June was not filled as the RN didn’t receive the joining instructions)

Date of Training

No of Delegates

20 Apr -24 Apr 2015

5

1 June - 5 June 2015

5

28 Sept to 2 Oct

5

16 Nov – 20 Nov

5

8 Feb – 12 Feb 5

Total 25

Original trajectory in place for 5 attendees per month though it was advised early into the training programme that St Johns Hospice do not have the staff capacity to run training every month and therefore the Trust has scheduled staff onto the available dates provided by the hospice.

The trajectory on the report should be amended to reflect this information.

Care and Welfare of PeopleJan-15 Feb-15 Mar-15 Apr-15 May-15 Jun-15 Jul-15

ID Metric Target Notes9 No. of pressure Ulcers on all wards 0 Avoidable (1/2) 1 1 2 2 1 0 0

Trajectory

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

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.

The chart shows the number of hospital acquired avoidable grade 2, 3 and 4 pressure ulcers since 2009/2010.

Each financial year is represented by a different colour.

The straight red line through the centre represents the mean number of pressure ulcers which the Trust aims to stay below to ensure we are reducing harm to our patients.

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.


10 Fluid chart compliance 100% Data collection has commenced in May. Initial 2 wards

87.00% 85.00%

Trajectory 85% 87%

Care and Welfare of People

Issue: The Trust reported one case in July this is on line with the annual trajectory of no more than 4 at this point in the financial year.

Action taken A route cause analysis was performed. The learning has been shared with the Division Heads of Nursing and Matrons, Link Practitioners, Clinical Governance and Workforce Committee and will be discussed at the Trust IPC Committee on 19 August.


15 No. of HCAI Cdif YTD 11 No of Cases 2 0 0 0 0 1 1

Trajectory

Month Trajectory Cumulative Current position April 2015 2 2 0 May 2015 0 2 0 June 2015 1 3 1 July 2015 1 4 1 August 2015 0 4 September 2015 1 5 October 2015 1 6 November 2015 1 7 December 2015 1 8 January 2016 1 9 February 2016 1 10 March 2016 1 11

Respecting and Involving PeopleJan-15 Feb-15 Mar-15 Apr-15 May-15 Jun-15 Jul-15

ID Metric Target Notes31 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%


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

98.25% 97.25% 97.45% 98.08%


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

20.54% 19.23% 19.23% 20.27%


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

38.19% 76.17% 76.39% 75.43%


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

92.15% 96.46% 96.68% 97.33%


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

58.19% 69.59% 70.86% 75.43%


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


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


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

17.55% 17.89% 18.10% 24.00%


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


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

92.77% 93.61% 94.18% 94.91%


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

95.92% 95.89% 96.36% 94.69%



78.19% 54.75% 55.16% 57.70%



43.46% 25.53% 24.62% 48.20%


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

89.97% 90.26% 90.60% 87.91%


greater 90% ( green ) Information Governance - 1 Year

85.60% 85.40% 85.90% 84.90%


Respecting and Involving People July 2015 11 % of delegates attending UTI Indwelling Catheter Training

% of delegates attending Improving Water Low Training

% of delegates attending VIP training

8.42%. Catheterisation training commenced in March ’15. 67 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)

42.69%. Water Low training is covered within SKINN Training. This subject is scheduled onto Trust Induction, plus Statutory, Mandatory & Essentials Training Day (clinical staff attend this annually)

IV Cannulation training contains VIP training information

Currently 170 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)

14 No of delegates attending SKINN Initiative Training 67 delegates trained in July 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. Requirement mapping on ESR is now complete. The Trust currently has 42.69% compliance with this competency.

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

82% - Fire Safety 86% - Infection Control 79% - Moving & Handling – NB: % now includes practical & theory requirements 85% - Information Governance 96% - Safeguarding Children Level 1 94% - Safeguarding Vulnerable Adults 90% - Equality & Diversity 63% - MCA & DOLS 21% - Prevent Basic Awareness 24% - Prevent WRAP

5 PLACES LEFT: Venepuncture & Cannulation Training, 17/08/2015 There are 5 places still available on the V&C training taking place on Monday 17th August 2015, 13.00 – 16.30. If possible, please could you book either yourselves or your staff onto this training due to the increased demand for Venepuncture & Cannulation.

Respecting and Involving PeopleJan-15 Feb-15 Mar-15 Apr-15 May-15 Jun-15 Jul-15

ID Metric Target Notes23 Friends and Family Test Responses received - Emergency Response Rates 10.00% 13.00% 14.00% 13.00% 17.00% 23.68% 13.95%

Trajectory 19% 19% 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%

Trajectory 64% 64% 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%

Trajectory 59% 59% 61% 61%

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

Trajectory

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

Trajectory

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

Trajectory

Emergency – the response rate is a combined score from AAU and ED. AAU have achieved 52% response rate whilst ED have achieved 9.12%. Relocation of volunteer resource impacted on issuing and retrieval of FF cards. This resource has now been reinstated and new targets have been set and will be monitored by ECC Service Manager.

Maternity – the Maternity ward has been extremely busy with capacity issues for both Midwifes and administration support. This has impacted on the distribution and collation of forms. Additional administration support has been sourced which will see an increase in the response rates next month.

Inpatients – the response rate is a combined score from the inpatient wards on the trust. High response rates in most wards especially Reab and CHT, lower response rate on Daisy ward that is being investigated and actions to be put in place to address.

Must DoJan-15 Feb-15 Mar-15 Apr-15 May-15 Jun-15 Jul-15

ID Metric Target Notes30 % of completed appraisals greater 80% ( green ) 56.00% 76.00% 91.00% 84.34% 80.00% 75.60% 78.21%

We have commenced a data cleanse of ESR to ensure staff are allocated appropriately, and for local data to be added to ESR so that the central record is accurate. Completing this activity will have a positive impact on our completion rate

Must Do

SOP introduced 30/4/15w/c All moves Avoidable moves Q2 Cquin target 06/04/2015 43 25 2013/04/2015 33 24 2020/04/2015 17 7 2027/04/2015 21 11 2004/05/2015 31 16 2011/05/2015 12 1 2018/05/2015 7 2 2025/05/2015 14 9 2001/06/2015 26 12 2008/06/2015 22 9 2015/06/2015 37 15 2022/06/2015 23 11 2029/06/2015 35 15 1506/07/2015 42 25 1513/07/2015 40 11 1520/07/2015 38 9 1527/07/2015 38 16 15

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 Call3. Variation in avoidance of moves is directly related to Trust activity and available capacity.

• Two periods of underperformance in July• Week of 6th July – directly related to one day whereby the trust had 166 attendances and 48 admissions resulting in later moves affiliate with

secondary ward rounds and generation of later discharges• Week of 27th July – higher occupancy in the trust as overall percentage , backlog of DTOCs and lower discharges resulted in capacity pressures and

later bed moves4. Actions taken – trial of trolleys in AAU, successfully seen this week AAU siting at 2-3 inpatients by 6pm in the evening which enables all ED admissions

straight to AAU and minimises further hospital moves5. The Trust continues to implement improvements associated with ECIST recommendations and management of medically fit in order to create bed capacity

earlier in the day6. Performance improvement remains in line with the agreed trajectory as part of our CQIN scheme


34 No. of avoidable transfers in the Trust after 10pm. Number of Moves 89 82 70 80 34 55 65

Variation Report - as at 10 August 2015

Compliance Action Ref

Area Action Milestone Accountable ResponsibleDate to be delivered

Revised Estimated

delivery dateReason for Delay Effect on Action

1.2

Inflexible staffi ng

arrangements were in place in

the medical directorate to

meet the needs of patients

To ensure interim arrangements in place

which will continue until appointment of new

medical director

Interim Director in post with appointment until substantive

post recruitedChief Executive HR Director Apr-16

Recruitment campaign concluded with no successul appointment to post. Current MD to

remain in post. Expected to readvertise Sept/Oct ( appointment to post date forecast to

be April 2016)

No effect on action

Three Phased approach: Complete Revised document

1) Risk Assessment31/05/2015 21/08/2015

Risk Assessment document revised and currently at printers. Revised date for

implementation middle of August

Complete revised documentation

3) Nursing Care Plans18/08/2015

Review of Care Plans complete, send out for review by DHON's with a deadline of 12 Aug 2015. The next step after this date will be

printing and distribution to wards

To review the ward handover process and develop, implement and

embed a revised process that provides information on all patients to all staff

across the ward

Assurance that the practice is embedded

07/07/2015 30/09/2015

Process reviewed, revised handover process in place, rolled out across all wards. Spot

checks for assurance have been undertaken in June with audit to be completed by

September which will provide the assurance that the proess is embedded

6.3

Ensure patients are treated with

dignity and respect

To develop a compassion in Practice Strategy

Develop StrategyDirector of Nursing,

Midwifwery and Quality

Led by DHON - MSK for Trust

Wide Implementation

30/07/2015 31/08/2015The revised Nursing Midwifery Strategy will be developed in line with the 6c's and is currently

in the process of validation prior to launch.

2.1

The Trust is failing to plan

and deliver care that meets the

needs of service users

who are at risk due to pressure area, catheter

care, intravenous

care, and the risk associated with bed rails.

Deputy DIPC, DHON's and Ward

Matrons

Director of Nursing, Midwifwery and

Quality

Task and finish group to review current

documentation and develop revised format

The recent PLACE survey shows that the Trust exceeded the national average in all areas

Cherry Ward (update)

Offer of permanent ward matron made.

Mental Health Trainer - CPFT attended Cherry 12 August to provide feedback following the dementia care mapping they facilitated. The results were extremely positive and demonstrated that Cherry made significant improvements in the care and interaction with dementia patients. The results have demonstrated true engagement from the staff in improving the value during inpatient stays.Follow upfour follow up training days provided by CPFTFacilitation of one day training to staff on Dementia care Facilitation of several ‘on the job sessions’ on Cherry Tree ward. Request for the Mental Health training – CPFT to attend the ISMR partnership session in early October.

oversight – performance report 20 august 2015 july reporting period v

Documents

ed staff

safeguardingcompliance

staffingcompliance action

monitoringcompliance

staff capacity

staff friendliness

temporary staff

cqc action plan