oversight – performance report 25 september 2015 august reporting period v

Oversight – Performance Report

25 September 2015 August 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 August 2015Version 1.0

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 number100% Contract Hours % N/A 74.00% 81.00% 80.00% 63.00% 98.00% 79.20%

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% 96.53% 87.42%

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 1 8

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% 97.70% 105.82%

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%

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

101.06% 96.30% 103.00% 100.98% 97.59% 97.66% 95.13% 96.70% 98.55%

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% 10.23% 10.78%

Trajectory

Less 10% ( green ) Nursing & midwifery 9.62% 10.82% 12.09% 13.05% 12.68% 11.78% 12.87% 13.52% 12.05%

Trajectory

Less 10% ( green ) Other clinical incl HCAs 17.86% 18.11% 17.48% 12.88% 13.32% 13.76% 14.30% 13.85% 15.20%

Trajectory

Less 10% ( green ) Non-clinical 15.90% 15.55% 17.74% 18.39% 20.73% 19.91% 20.87% 21.00% 18.76%

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 4 0 9

Trajectory 5 5 5 5



Compliance Action 2 - Care and Welfare of PeopleMixed Sex Breaches 0 0 0 0 1 0 1 0 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% 97.90% 96.97%

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

4 MEWS and MEOWs completion greater 80% - 85% (green)

Data collection has commenced in May

83.00% 81.00% 100.00% 88.00%

Trajectory 80% 80% 80% 80% 80% 85% 85%

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

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

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

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

10 Fluid chart compliance 100% 87.00% 85.00% 80.00% 84.00%

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

11 % of delegates completed catheter care bundle training, 1.29% 2.94% 2.90% 8.42% 13.45% 5.80%

Trajectory

% of delegates attending improving waterlow training, Includes SKINN Training 40.29% 43.17% 42.30% 42.69% 45.71% 41.73%

Trajectory

% of delegates Completed HII VIP training Employee Mapping underway, % data due June. 21 59 95 170 22.85% 22.85%

Trajectory

15 No. of HCAI Cdif YTD 11 No of Cases 2 0 0 0 0 1 1 1 5

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 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% 1.30% 2.73%

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% 93.00% 89.00% 100.00%

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%

YTD

from

Apr

il 20

15



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

ombudsman Level0 0 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 97 760

Available in September Trajectory

Theatres & Critical Care 39 28 34 26 32 39 33 53 284


ISMR 91 67 54 49 60 51 42 58 472


GI & GS 43 50 48 46 49 48 73 46 403


EENT 6 4 9 3 13 10 5 8 58


Musculoskeletal 46 52 35 47 39 44 30 30 323


Womens Services 61 43 72 37 82 79 59 26 459


Support Services 5 8 18 10 12 18 25 14 110


Non-Clinical Services 12 6 11 10 15 13 5 14 86


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

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% 48% 38%

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% 100.00% 99.77%

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% 95.65% 96.51%

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% 96.00% 90.50%

Trajectory 80% 80% 80% 80%

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% 14.28%

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% 24.55% 46.00%

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% 45.76% 47.41%

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

Friends and Family satisfaction score - Emergency 94.00% 94.00% 95.32% 93.19% 95.36% 94.37%

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

Friends and Family satisfaction score - Maternity 98.00% 97.00% 97.44% 95.14% 96.30% 96.78%

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% 97.21% 96.44%



Compliance Action 6 - Respecting and Involving PeopleTrajectory 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% 81.21% 83.08%


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

98.25% 97.25% 97.45% 98.08% 97.19% 97.64%


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

20.54% 19.23% 19.23% 20.27% 20.00% 19.85%


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

38.19% 76.17% 76.39% 75.43% 71.12% 67.46%


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

92.15% 96.46% 96.68% 97.33% 96.43% 95.81%


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

58.19% 69.59% 70.86% 75.43% 77.98% 70.41%


greater 90% ( green ) Fire Safety - 1 Year 83.44% 81.35% 82.61% 82.00% 80.65% 82.01%


greater 90% ( green ) Mental Capacity Act - 3 Years 46.66% 49.89% 50.32% 61.57% 65.33% 54.76%


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

17.55% 17.89% 18.10% 24.00% 23.99% 20.30%


greater 90% ( green ) PREVENT - 3 Years 27.88% 26.21% 26.47% 24.51% 24.51% 25.92%


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

92.77% 93.61% 94.18% 94.91% 94.61% 94.02%


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

95.92% 95.89% 96.36% 94.69% 96.00% 95.77%


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

78.19% 54.75% 55.16% 57.70% 61.29% 61.42%



43.46% 25.53% 24.62% 48.20% 47.96% 37.95%


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

89.97% 90.26% 90.60% 87.91% 89.57% 89.66%


greater 90% ( green ) Information Governance - 1 Year

85.60% 85.40% 85.90% 84.90% 86.50% 85.66%




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% 95.65% 97.28%

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 ) 96.00% 83.00% 91.00% 100.00% 92.50%

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

29 Medication omissions Drugs not given 18 9 11 4 14 11 19 19 105

Available September Trajectory

30 % of completed appraisals greater 80% ( green ) 56.00% 76.00% 91.00% 84.34% 80.00% 75.60% 78.21% 81.33% 77.81%

Available September ( esr ) Trajectory

% of Doctors Revalidation 100.00% 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% 87.55% 88.91%

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 36 50 496

Trajectory 73 73 73 55 55 55 37 37 37

Ward DashboardKey: Less than 90%

August 2015 Less than 95%Greater than 95%

Ward Dashboard AAU APT ATU BRH CCC CHT JPR PEAR SSU WNT Total

Infection Prevention ControlEnvironment Cleanliness 94.7% 95.5% 100.0% 97.7% 95.9% 95.6% 97.2% 100.0% 90.0% 88.9% 96.9%Hand Hygiene 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0%Is there evidence that all 5 patients were screened for MRSA on admission or in the OPD? 100.0% 100.0% 75.0% 100.0% 90.9% 100.0% 88.9% 100.0% 100.0% 100.0% 95.4%Compliance with the C.diff pathway. N/A N/A 100.0% 100.0% N/A N/A N/A N/A 50.0% 100.0% 87.5%Catherter care Bundle Compliance 100.0% 100.0% 0.0% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 66.7% 72.0%PVC Care Bundle Compliance 100.0% 100.0% 100.0% 100.0% 0.0% 100.0% 50.0% N/A 100.0% 100.0% 71.4%Sepsis Bundle Compliance N/A N/A N/A N/A N/A N/A 0.0% 100.0% N/A N/A 50.0%

Patient ExperienceLenth of Stay ( Incl Zero bed days ) 0.45 12.2 3.02 3.11 N/A 12.17 6.66 8.03 4.06 9.28 3.44Friends and Family Reponse Rate ( Trajectory Q2 34% ) 47.0% 63.2% 26.3% 76.9% 5.4% 100.0% 21.2% 97.2% 58.3% 35.8% 19.3%Friends and Family Satisfaction Score 98.3% 100.0% 100.0% 96.7% 92.4% 100.0% 100.0% 97.1% 92.9% 97.1% 96.5%Call Bells Response > 90% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 0.0% 100.0% 60.0% 100.0% 83.3%

SafeguardingMCA & DOLS Training Compliance ( Trajectory 70% ) 51.9% 78.4% 64.2% 65.0% 72.5% 76.7% 56.0% 75.0% 47.2% 70.6% 65.7%Adult Safeguarding Training 100.0% 95.0% 92.0% 96.0% 100.0% 100.0% 97.0% 100.0% 100.0% 100.0% 98.0%Safeguarding Children Level 1 Training 98.0% 95.0% 97.0% 100.0% 95.0% 100.0% 95.0% 100.0% 98.0% 97.0% 97.5%

Red Flag EventsHospital Acquired Pressure Ulcers ( 2 - 4 ) - Attributable 0 0 1 0 0 0 0 0 0 1 2Number of Unplanned omission in providing patient medications. 0 1 0 0 0 0 0 0 4 4 9Delay of more than 30 minutes in providing pain relief. 0 0 0 0 0 0 1 0 0 0 1Number of Patient vital signs not assessed or recorded as outlined in the care plan. 0 0 0 0 0 0 0 0 0 0 0Fluid Balance Chart 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 80.0% 100.0% 0.0% 50.0% 83.0%Delay or omission of regular checks Intentional Rounding on patients in the care plan. 100.0% 100.0% 100.0% 100.0% 80.0% 80.0% 100.0% 100.0% 100.0% 100.0% 96.0%RN/RM Planned vs Actual fill rate ( Safer Staffi ng ) 92.7% 96.2% 96.3% 86.8% 88.4% 95.6% 92.8% 138.8% 95.5% 94.2% 96.7%HCA Planned vs Actual fill rate ( Safe Staffi ng ) 92.6% 115.0% 93.5% 81.3% 75.8% 93.1% 90.3% 93.7% 119.2% 93.5% 97.7%Sickness Levels 0.3% 7.0% 3.8% 3.7% 4.2% 2.9% 7.7% 5.7% 4.4% 1.1% 3.4%Appraisal Rates 74.0% 81.0% 84.0% 94.0% 83.0% 83.0% 90.0% 50.0% 28.0% 100.0% 81.0%Staff Turnover 12.3% 2.8% 20.6% 4.7% 5.0% 29.5% 40.6% 23.7% 17.5% 5.2% 15.6%Mandatory Training 94.7% 91.3% 84.6% 97.4% 91.2% 96.5% 83.3% 88.4% 91.4% 92.6% 90.1%Number of Falls with Significant Harm 0 0 0 0 0 0 0 0 0 0 0Number of Falls 3 2 2 3 0 4 3 8 7 3 35Record Keeping 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0%

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-15ID Metric Target Notes

Compliance Action 1 - Staffing7 No. of Clinical CAMH Breaches - ED 0 0 0 1 2 3 0 1 1

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%) Campaign commenced 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. • On 5th October, the final 4 EU nurses will commence employment, . • • The Philippines recruitment trip proved very successful with 120 candidates being interviewed, 45 of which will be joining the

Trust in 3 cohorts from April 2016. These staff will fill current vacancies and allow cover for expected turnover in 2016/17.• 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


Compliance Action 1 - Staffing13 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%

Trajectory

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

Trajectory

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

Trajectory

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

Trajectory

Staffing

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.


Compliance Action 1 - Staffing32 No. of staff attending QELCA Training

(Quality End of Life Care for all) greater 2 ( green ) Target 5 per every 2 months,

YTD 255 4 0

Trajectory 5 5 5

Care and Welfare of People – requested an update 2/10/2015

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.


Compliance Action 2 - Care and Welfare of People9 No. of pressure Ulcers on all wards 0 Avoidable (1/2) 1 1 2 2 1 0 0 2

Trajectory 0 0 0 0 0 0 0 0

Care and Welfare of People

Fluid Chart Compliance

The fluid balance documentation assessment was rolled out on two wards in June, four wards in July, and the remaining wards in August as part of the clinical assessment tool.

Clinical educators have a training plan to raise awareness, theoretical sessions & ward based training.

Heightened emphasis on identification of Avil & importance of effective fluid balance monitoring.

Lessons learnt from SI’s discussed at ward sisters meeting & all suitable forums.

MEWS algorithm updated to empower nurses to escalate concerns.

Non compliance will be managed via Trust Performance Management process


Compliance Action 2 - Care and Welfare of People10 Fluid chart compliance 100% 87.00% 85.00% 80.00%


Care and Welfare of People

Issue: Performance 1 Apr – 31 Aug is three cases against a monthly trajectory of 4

Action taken We always perform multidisciplinary RCAs which include the CCG presence. The findings are shared with the DHoNs and matrons at their monthly meeting, the Trust IPCC committee and individual consultants share with their colleagues. Information is sent to the TDA - Debra Adams. Themes emerging: lack of effective antimicrobial stewardship and delayed sampling


Compliance Action 2 - Care and Welfare of People15 No. of HCAI Cdif YTD 11 No of Cases 2 0 0 0 0 1 1 1

Trajectory 0 0 0 0 0 0 0 0

SafeguardingJan-15 Feb-15 Mar-15 Apr-15 May-15 Jun-15 Jul-15 Aug-15

ID Metric Target NotesCompliance Action 4 - Safeguarding

21 % of delegates attending MCA and DoLs Training Quarterly YTD 0% 26% 44% 48% 51% 56% 63% 67%

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

Apr-15

May-15

Jun-15Jul-1

5

Aug-15

Sep-15

0%

20%

40%

60%

80%

100%

120%

Additional Clinical ServicesAllied Health Pro-fessionalsHealthcare Scien-tistsMedical & DentalNursing & Mid-wifery Registered

Oct-14

Dec-14

Feb-15

Apr-15

Jun-15

Aug-15

0%

20%

40%

60%

80%

TrajectoryActual

Trust’s overall compliance as at 30.09.15 as 75% vs. a trajectory of 80%. 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 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 90% 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.

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

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

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

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

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

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

Respecting and Involving People


Compliance Action 6 - 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%


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

98.25% 97.25% 97.45% 98.08% 97.19%


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

20.54% 19.23% 19.23% 20.27% 20.00%


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

38.19% 76.17% 76.39% 75.43% 71.12%


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

92.15% 96.46% 96.68% 97.33% 96.43%


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

58.19% 69.59% 70.86% 75.43% 77.98%


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


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


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

17.55% 17.89% 18.10% 24.00% 23.99%


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


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

92.77% 93.61% 94.18% 94.91% 94.61%


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

95.92% 95.89% 96.36% 94.69% 96.00%



78.19% 54.75% 55.16% 57.70% 61.29%



43.46% 25.53% 24.62% 48.20% 47.96%


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

89.97% 90.26% 90.60% 87.91% 89.57%


greater 90% ( green ) Information Governance - 1 Year

85.60% 85.40% 85.90% 84.90% 86.50%


Respecting and Involving People August 201511 % of delegates attending UTI Indwelling Catheter Training

% of delegates attending Improving Water Low Training

% of delegates attending VIP training

13.45%. Revised Catheterisation training commenced in March ’15. 108 delegates have so far been trained. Catheterisation training is now part of the new Trust Induction Programme, plus, 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.

45.71%. Revised 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.

22.85%. Currently 186 delegates have been trained. Revised 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.

14 No of delegates attending updated SKINN Initiative Training 53 delegates trained in August 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 45.71% compliance with this competency. Electronic Staff Record (ESR) remapping underway to ensure correct job roles are identified as requiring this training.

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

82% - Fire Safety 86% - Infection Control 80% - Moving & Handling – NB: % now includes practical & theory requirements 88% - Information Governance 96% - Safeguarding Children Level 1 95% - Safeguarding Vulnerable Adults 90% - Equality & Diversity 67% - MCA & DOLS 25% - Prevent Basic Awareness 24% - Prevent WRAP

Respecting and Involving PeopleAssignments for Positions

with Competence

Requirements

% Assignments

that Fulfil Competence

Requirements for Position

Competence Requirement

Gap

Notes:

Competence Name

NHS|MAND|Fire Safety - 1 Year| 1,726 80.65% 334 Fire Safety for Non Clinical Staff moved to E Learning - communication ongoing. Scheduled onto Partnership Days. Non compliance escalation communicated at dvisional level

291|LOCAL|IPC Refresher (Clinical Staff) - 1 Year| 1,224 81.21% 230 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| 463 97.19% 13 Compliant

291|LOCAL|M&H Low Risk (Non Clinical) e-learning - 3 Year| 448 96.43% 16 Compliant

291|LOCAL|M&H High Risk (Non Clinical) Practical + Theory - 2 Year| 70 20.00% 56 Change of competence and frequency. Subject lead scheduling and completing additional training.

291|LOCAL|M&H Low Risk (Clinical) Practical + Theory - 2 Year| 232 71.12% 67 Change of competence and frequency. Remapping taken place. Communication continues.

NHS|MAND|Moving & Handling for People Handlers - 1 Year| 940 77.98% 207 Remapping taken place. Communication at dvisional level taking place.

NHS|MAND|Information Governance - 1 Year| 1,726 86.50% 233 Elearning and self assessment booklet available. Communication ongoing.

NHS|MAND|Safeguarding Adults Level 1 - 3 Years| 1,726 94.61% 93 Compliant

NHS|MAND|Safeguarding Children Level 1 - 3 Years| 1,726 96.00% 69 Compliant

NHS|MAND|Safeguarding Children Level 3 - 1 Year| 196 47.96% 102 New Safeguarding Children Leads for the Trust and Women's Services appointed in March '15. Initial competency mapping completed on Electronic Staff Record but further mapping required to confirm data accuracy. Programme of training opportunities advertised Trust w ide - both local and via LSCB availability, plus national elearning content. Trajectory in place to achieve compliance by January '16.

NHS|MAND|Equality, Diversity and Human Rights - 3 Years| 1,726 89.57% 180 Elearning and self assessment booklet available. On-going communication at dvisional level.

NHS|MAND|Mental Capacity Act - 3 Years| 874 65.33% 303 Target of 90% is by October. Trajectory in place.

291|LOCAL|Prevent Basic Awareness - 3 Years| 1,726 23.99% 1,312 New competency. Compliance required by 2017. Elearning package to be introduced. Subject lead currently prioritising MCA & DOLS trajectory.

NHS|MAND|PREVENT - 3 Years| 102 24.51% 77 Only required by personnel w ho need safeguarding children level 3. Compliance required by 2017. Subject lead currently prioritising MCA & DOLS trajectory.

Respecting and Involving PeopleCompliance Action 6 - Respecting and Involving People

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%

Trajectory 19% 19% 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%

Trajectory 64% 64% 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%

Trajectory 59% 59% 61% 61% 61%

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

Trajectory 90% 90% 90% 90% 90%

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

Trajectory 90% 90% 90% 90% 90%

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

Trajectory 90% 90% 90% 90% 90%

Emergency – the response rate is a combined score from AAU and ED. AAU have achieved 47.2% response rate whilst ED have achieved 5.6%. Relocation of volunteer resource continues to impact on issuing and retrieval of FFT cards. This resource was not reinstated in August, however a revised process in ED which includes nomination of a daily FFT patient champion who actively encourages all team members to collect comments and data from Patients. The achievement is then reviewed by the Ward Sister on the next day, and any actions to improve are implemented.

Maternity – there have been a slight improvement since last month. Ward clerk one admin vacancy has impacted on the distribution and collation of forms. This will be monitored by the Associate director of Nursing, Midwifery and Quality

Inpatients – the response rate is a combined score from the inpatient wards on the trust. High response rates in most wards especially PEAR (Reab) (97%) and CHT (100%), lower response rate on Juniper (21%), ATSU (26%) and Daisy ward (17%) further investigations are being undertaken by HHCT informatics as there may be a discrepancy with ED admissions and Inpatient admission data which may be impacting on these returns.

Trust Total – Responses received rate 33% Satisfaction Rate 97%


Compliance Action 6 - Respecting and Involving PeopleShould Do

33 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% 87.55%

Should do

ED Resus Trolley Compliance Audit Action planSep-15

1. The Issue

2. Next Steps

DATE AREA OF IMPROVEMENT ACTION NEEDED RESPONSIBILITY DUE DATE STATUS Update/Comments

01/09/2015 Trolley 3 often missed

Allocate one person to check all three Resus trollies rather than being shared between Paed and Adult nurses.

DM 21-Sep-15 One person now checking all three trollies.

01/09/2015 Checks not all completed

Allocated person must inform the Coordinator if they have not checked and signed all three trollies.

DM 21-Sep-15 Staff member responsible for checking all three trollies must escalate to te Coordinator if they have been unable to complete.

01/09/2015 Assurance

Add Resus trolley checks to the Coordinator's daily report, so that they also check and sign that the trollies have all been checked.

DM 21-Sep-15 Added to Coordinators log. Logs are collected and checked by Matron or Service Manager

01/09/2015 Staff responsibility

Hold staff to account if they are nominated person and checks are not done DM 30-Sep-15

Matron will do weekly checks to monitor compliance of Resus trolley checks.

Failure to receive 100% compliance with Resus trolley daily checks in August

Should do

X Ray Resus Trolley Compliance Audit Action plan

1. The Issue

2. Next Steps

DATE AREA OF IMPROVEMENT ACTION NEEDED RESPONSIBILITY DUE DATE STATUS Update/Comments

01/09/2015 Checks not all completed

Appropriate rostering of staff to check trolley R next to their name on their white board. Also Name of designated person to be written on white board above trolley (on order). On call staff on Saturday and Sunday to do the daily check. Dates of weekly and monthly checks to be written in checking book . Also written on white board above trolley. Reminder poster for weekend staff to do the daily checks displayed in staff room and Room 1.

TS 21-Sep-15

Intermittent compliance checks by Tina & Therese

01/09/2015 Assurance Dates of weekly check written in checking book. Will also be written on white board above trolley.

TS 21-Sep-15

01/09/2015 Staff responsibility

Copy of Action plan to be shared at Monday Morning Staff Meeting. Provide training / support to fill in check sheets if required

TS 30-Sep-15

Failure to receive 100% compliance with Resus trolley daily checks in August

Must 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

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

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

Date All moves Avoidable moves Proportion Moves per date Target Proportion Target01/04/2015 652 80 12.27% 73 11.46%01/05/2015 587 34 5.79% 73 11.46%01/06/2015 621 55 8.86% 73 11.46%01/07/2015 579 36 6.22% 55 8.60%01/08/2015 620 50 8.06% 55 8.60%

Variation Report - as at 18 September 2015

Compliance Action Ref

Area Action Milestone Accountable ResponsibleDate to be delivered

Revised Estimated

delivery dateReason for Delay

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. Audit report expected by early week commencing 18

September 2015

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

TDA Clinical Observation Visit – 28 August 2015

Key Areas of Focus• Risk Registers and BAF to

be strengthened• Executive Portfolios• Consistency of Practices

across the Trust• Expected Discharge Date

• Pharmacy working hours• Amnesty on out of date

and multiple posters• Clarity on Audits• Medication safety

(Treatment centre practice of preparing drugs)

Areas of Good Practice

Individual reports for each ward produced, and improvement plans in place to address any identified areas for improvement.

The Improvement plans and reported and monitored at the weekly Quality Improvement Plan working group meeting.

oversight – performance report 25 september 2015 august reporting period v

Documents

ed staff

safeguardingcompliance

monitoringcompliance

staffingcompliance action

staff capacity

staff friendliness

temporary staff

cqc action plan