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 Report
Published Data for August 2015
Version 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
ID
Metric
Target
Total
Notes
Compliance Action 1 - Staffing
1
% of Paed staff working in department from 7am to 12pm in
line with required number
6
% of Child ED arrival to assessment within 15 Mins
7
No. of Clinical CAMH Breaches - ED
100%
Contract Hours %
Trajectory
greater 80% ( green ) Percentage of Patients
Trajectory
0
Trajectory
12
PLANNED V ACTUAL for all Nursing Staff (to show staffing
arrangements in place to meet needs of patients) Perm +
Agency
greater 90% ( green ) HCA
( Contract Hours % )
Trajectory
greater 90% ( green ) Nursing & Midwifery
( Contract Hours % )
Trajectory
13
Staff Turnover by Professional Group
Less 10% ( green )
Medical & dental
N/A
74.00%
N/A
70%
92.41% 87.59% 87.37% 78.58%
81.00%
75%
80.40%
80.00% 63.00% 98.00%
75%
80%
80%
79.20%
90%
90%
100%
100%
84.38% 92.08% 96.53%
80%
80%
80%
80%
80%
80%
80%
80%
0
0
1
2
3
0
1
1
0
0
0
0
0
0
0
0
87.42%
80%
80%
80%
80%
0
0
0
0
8
114.49% 113.23% 93.53% 107.22% 110.74% 109.37% 100.28% 97.70%
90.0%
90.0%
90.0%
90.0%
90.0%
101.06% 96.30% 103.00% 100.98% 97.59%
90.0%
90.0%
90.0%
90.0%
11.04% 10.91% 10.53% 10.23%
90.0%
90.0%
90.0%
90.0%
105.82%
90.0%
90.0%
90.0%
90.0%
97.66% 95.13% 96.70%
90.0%
90.0%
90.0%
98.55%
90.0%
90.0%
90.0%
90.0%
11.11%
11.17% 11.05% 10.23%
10.78%
10.82% 12.09% 13.05%
12.68%
11.78% 12.87% 13.52%
12.05%
17.86% 18.11% 17.48% 12.88%
13.32%
13.76% 14.30% 13.85%
15.20%
15.90% 15.55% 17.74% 18.39%
20.73%
19.91% 20.87% 21.00%
18.76%
Trajectory
Less 10% ( green )
Nursing & midwifery
9.62%
Trajectory
Less 10% ( green )
Other clinical incl HCAs
Trajectory
Less 10% ( green )
Non-clinical
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
Trajectory
5
4
0
5
5
5
9
5
Oversight Report
Published Data for August 2015
Version 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
ID
Metric
Compliance Action 2 - Care and Welfare of People
Mixed Sex Breaches
Target
0
Trajectory
3
PEWS Observation Completion - 20% sample patients.
4
MEWS and MEOWs completion
9
No. of pressure Ulcers on all wards
0
0
0
1
0
1
0
0
0
0
0
0
0
0
0
0
greater 95% ( green )
Trajectory
0
Fluid chart compliance
10
YTD from April 2015
0
0
0
95%
95%
95%
96.97%
95%
95%
95%
95%
83.00% 81.00% 100.00%
80%
80%
80%
Avoidable (1/2)
1
1
2
2
1
0
0
2
Trajectory
0
0
0
0
0
0
0
0
Avoidable (3/4)
0
0
0
0
0
0
1
0
Trajectory
0
0
0
0
0
0
0
0
100%
88.00%
80%
80%
85%
85%
0
0
0
0
0
0
0
0
92%
95%
97%
100%
9
1
87.00% 85.00% 80.00%
Trajectory
11
2
0
96.00% 97.00% 97.90%
greater 80% - 85% Data collection has
(green)
commenced in May
Trajectory
0
Total
Notes
% of delegates completed catheter care bundle training,
84.00%
85%
87%
89%
2.90%
8.42%
13.45%
5.80%
42.30% 42.69% 45.71%
41.73%
1.29%
2.94%
40.29%
43.17%
21
59
95
170
22.85%
Trajectory
% of delegates attending improving waterlow training,
Includes SKINN Training
Trajectory
% of delegates Completed HII VIP training
Employee Mapping underway, % data due June.
22.85%
Trajectory
15
No. of HCAI Cdif
No. of MRSA
17
YTD 11
0
No of Cases
2
0
0
0
0
1
1
1
Trajectory
0
0
0
0
0
0
0
0
No of Cases
0
0
0
0
0
0
0
0
Trajectory
0
0
0
0
0
0
0
0
0.82%
1.50%
1.69%
4.51%
3.30%
6.51%
2.19%
1.30%
0.00%
0.77%
0.42%
1.23%
0.47%
0.93%
0.00%
0%
0%
0%
0%
0%
0%
0%
% of catheter related UTI's - All
5
0
0
0
0
0
0
0
0
0
2.73%
Trajectory
% of catheter related UTI's - New
1%
Trajectory
18
% compliance with Ward Audit - Recording of Waterlow
19
DNAR audit - Engagement with Carers
90%
0.55%
0%
0%
0%
0%
0%
90%
90%
90%
90%
93.00% 89.00% 100.00%
Trajectory
greater 80% ( green) Available from April, 2
Monthly
Trajectory
85%
73.00%
90.00%
75%
77%
87%
90%
81.50%
79%
80%
80%
Oversight Report
Published Data for August 2015
Version 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
ID
24
Metric
Compliance Action 3 - Assessing and Monitoring
No. of complaints at Local level and progressing to
ombudsman Level
Target
New cases in the month that the Trust is aware of.
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
94
65
88
98
121
93
104
97
760
39
28
34
26
32
39
33
53
284
91
67
54
49
60
51
42
58
472
43
50
48
46
49
48
73
46
403
6
4
9
3
13
10
5
8
58
46
52
35
47
39
44
30
30
323
61
43
72
37
82
79
59
26
459
5
8
18
10
12
18
25
14
110
12
6
11
10
15
13
5
14
86
Quarterly YTD
0%
26%
44%
48%
51%
56%
63%
67%
Trajectory
30%
35%
44%
48%
44%
54%
63%
70%
Quarterly
57%
66%
Trajectory
50%
65%
Trajectory
25
No. of incidents reported monthly
Acute Medicine
Available in September
Total
Notes
0
0
0
0
0
Trajectory
Theatres & Critical Care
Available in September
Trajectory
ISMR
Available in September
Trajectory
GI & GS
Available in September
Trajectory
EENT
Available in September
Trajectory
Musculoskeletal
Available in September
Trajectory
Womens Services
Available in September
Trajectory
Support Services
Available in September
Trajectory
Non-Clinical Services
Available in September
Trajectory
Compliance Action 4 - Safeguarding
21
22
% of delegates attending MCA and DoLs Training
Adult Safeguarding Audit completion
Level 3 Safeguarding
80%
44%
80%
90%
100%
100%
66%
80%
Monthly
23%
42%
48%
Trajectory
23%
34%
34%
38%
54%
64%
74%
84%
Compliance Action 5 - Infection Control
16
Compliance with Handwashing Audit - (Unchallenged 5
minutes of Handwashing)
greater 80% ( green Audits
)
Trajectory
99.19% 99.21% 99.75% 100.00% 100.00% 100.00% 100.00% 100.00%
100%
100%
100%
100%
100%
100%
100%
100%
99.77%
100%
100%
100%
100%
Oversight Report
Published Data for August 2015
Version 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
ID
Metric
Compliance Action 6 - Respecting and Involving People
Target
2
Response to Call Bells ( inside 2 mins )
greater 90% ( green ) Audits
5
Fluid and Nutrition Assessments for Adults ( screening )
greater 90% ( green ) Qrtly - All Wards
20
Audit of Intentional Rounding Document
greater 80% ( green ) Data collection has
commenced in May
Trajectory
23
Friends and Family Test Responses received - Emergency
Trajectory
91.98% 97.37% 95.83% 98.81%
90%
90%
90%
90%
96.25%
90%
91%
Response Rates
Trajectory
Response Rates
Trajectory
Friends and Family Test Responses received - In patients
Response Rates
Trajectory
Friends and Family satisfaction score - Emergency
Trajectory
Friends and Family satisfaction score - Maternity
Trajectory
Friends and Family satisfaction score - In patients
98.04% 98.15% 95.65%
90%
90%
90%
96.51%
90%
90%
90%
90%
93%
Trajectory
Friends and Family Test Responses received - Maternity
Total
Notes
92.00%
60%
86.00%
80%
10.00% 13.00% 14.00% 13.00%
19%
40.00% 11.00% 75.00% 74.00%
64%
41.00% 53.00% 43.00% 43.00%
17.00%
19%
55.00%
64%
47.00%
59%
59%
94.00%
94.00%
90%
90%
98.00%
97.00%
90%
90%
97.00%
96.00%
90%
100%
80.00% 100.00% 96.00%
80%
80%
23.68% 13.95%
20%
20%
90.50%
80%
9.61%
20%
14.28%
20%
20%
20%
21%
66%
66%
66%
67.0%
61%
61%
61%
63%
90%
90%
90%
90%
90%
90%
90%
90%
64.64% 23.77% 24.55%
66%
66%
66%
46.00%
52.82% 53.72% 45.76%
61%
61%
61%
47.41%
95.32% 93.19% 95.36%
90%
90%
90%
94.37%
97.44% 95.14% 96.30%
90%
90%
90%
95.77% 96.24% 97.21%
96.78%
96.44%
Oversight Report
Published Data for August 2015
Version 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
ID
Metric
Compliance Action 6 - Respecting and Involving People
Target
Trajectory
31
Total
Notes
90%
90%
86.26%
82.57%
83.06% 82.31% 81.21%
83.08%
98.25%
97.25%
97.45% 98.08% 97.19%
97.64%
20.54%
19.23%
19.23% 20.27% 20.00%
19.85%
greater 90% ( green ) M&H Low Risk (Clinical)
Practical + Theory - 2 Year
Available in September
Trajectory
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
Available in September
Trajectory
92.15%
96.46%
96.68% 97.33% 96.43%
95.81%
greater 90% ( green ) Moving & Handling for
People Handlers - 1 Year
Trajectory
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%
46.66%
49.89%
50.32% 61.57% 65.33%
54.76%
17.55%
17.89%
18.10% 24.00% 23.99%
20.30%
27.88%
26.21%
26.47% 24.51% 24.51%
25.92%
92.77%
93.61%
94.18% 94.91% 94.61%
94.02%
95.92%
95.89%
96.36% 94.69% 96.00%
95.77%
78.19%
54.75%
55.16% 57.70% 61.29%
61.42%
43.46%
25.53%
24.62% 48.20% 47.96%
37.95%
89.97%
90.26%
90.60% 87.91% 89.57%
89.66%
85.60%
85.40%
85.90% 84.90% 86.50%
85.66%
Compliance against Training needs Analysis for statutory,
mandatory and essential clinical skills training
Available in September
greater 90% ( green ) IPC Refresher
(Clinical Staff) - 1 Year
greater 90% ( green ) M&H High Risk (Non Clinical)
Practical + Theory - 2 Year
Available in September
Available in September
Trajectory
Trajectory
greater 90% ( green ) Safeguarding Children Level 2
- 1 Year
Available in September
Trajectory
greater 90% ( green ) Safeguarding Children Level 3
- 1 Year
Available in September
Trajectory
greater 90% ( green ) Equality, Diversity and
Human Rights - 3 Years
Available in September
Trajectory
greater 90% ( green ) Information Governance - 1
Year
Available in September
90%
Trajectory
greater 90% ( green ) Safeguarding Children Level 1
- 3 Years
Available in September
90%
Trajectory
greater 90% ( green ) Safeguarding Adults Level 1 3 Years
Available in September
90%
Trajectory
greater 90% ( green ) PREVENT - 3 Years
Available in September
90%
Trajectory
greater 90% ( green ) Prevent Basic Awareness - 3
Years
Available in September
90%
Trajectory
greater 90% ( green ) Mental Capacity Act - 3 Years
Available in September
90%
Trajectory
greater 90% ( green ) IPC Refresher
(Non Clinical Staff) - 2 Years
Available in September
Trajectory
Available in September
90%
Trajectory
Oversight Report
Published Data for August 2015
Version 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
ID
Metric
Must Do
Target
Total
Notes
26
% 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%
27
Compliance with Medicine Administration Audits
Medicines Audit - Security/Storage
greater 90% ( green ) Quarterly
74.00%
78.00%
76.00%
Trajectory
85.00%
87%
Medicines Audit - Clinical safety/Admin
greater 90% ( green ) Quarterly
88.00%
97.00%
28
Drug fridge temps and range incorrect daily – monthly
aggregate
greater 80% ( green )
29
Medication omissions
Trajectory
Trajectory
85%
Trajectory
Available September
30
% of completed appraisals
9
11
4
90%
90%
83.00% 91.00% 100.00%
80%
80%
80%
80%
14
11
19
19
92.50%
80%
80%
80%
80%
105
Trajectory
greater 80% ( green )
Available September ( esr )
18
90%
92.50%
87%
96.00%
Drugs not given
90%
56.00% 76.00% 91.00% 84.34%
80.00%
75.60% 78.21% 81.33%
77.81%
Trajectory
% of Doctors Revalidation
100.00% 100.00%
100%
100%
100.00%
100%
100%
100%
100%
Should Do
33
Compliance with daily Resuscitation Equipment Checks
(Audit)
34
No. of avoidable transfers in the Trust after 10pm.
greater 95% ( green ) Specific wards each month.
All wards each Quarter.
Trajectory
Number of Moves
Trajectory
89
82
70
95.00%
83.00%
89.00% 90.00% 87.55%
85%
85%
85%
85%
90%
80
34
55
36
50
73
73
73
55
55
88.91%
90%
95%
95%
95%
55
37
37
37
496
Ward Dashboard
Key:
Less than 90%
August 2015
Ward Dashboard
Less than 95%
Greater than 95%
AAU
APT
ATU
BRH
CCC
CHT
JPR
PEAR
SSU
WNT
Total
94.7%
100.0%
100.0%
N/A
100.0%
100.0%
N/A
95.5%
100.0%
100.0%
N/A
100.0%
100.0%
N/A
100.0%
100.0%
75.0%
100.0%
0.0%
100.0%
N/A
97.7%
100.0%
100.0%
100.0%
100.0%
100.0%
N/A
95.9%
100.0%
90.9%
N/A
100.0%
0.0%
N/A
95.6%
100.0%
100.0%
N/A
100.0%
100.0%
N/A
97.2%
100.0%
88.9%
N/A
100.0%
50.0%
0.0%
100.0%
100.0%
100.0%
N/A
100.0%
N/A
100.0%
90.0%
100.0%
100.0%
50.0%
100.0%
100.0%
N/A
88.9%
100.0%
100.0%
100.0%
66.7%
100.0%
N/A
96.9%
100.0%
95.4%
87.5%
72.0%
71.4%
50.0%
0.45
47.0%
98.3%
100.0%
12.2
63.2%
100.0%
100.0%
3.02
26.3%
100.0%
100.0%
3.11
76.9%
96.7%
100.0%
N/A
5.4%
92.4%
100.0%
12.17
100.0%
100.0%
100.0%
6.66
21.2%
100.0%
0.0%
8.03
97.2%
97.1%
100.0%
4.06
58.3%
92.9%
60.0%
9.28
35.8%
97.1%
100.0%
3.44
19.3%
96.5%
83.3%
51.9%
100.0%
98.0%
78.4%
95.0%
95.0%
64.2%
92.0%
97.0%
65.0%
96.0%
100.0%
72.5%
100.0%
95.0%
76.7%
100.0%
100.0%
56.0%
97.0%
95.0%
75.0%
100.0%
100.0%
47.2%
100.0%
98.0%
70.6%
100.0%
97.0%
65.7%
98.0%
97.5%
0
0
0
0
100.0%
100.0%
92.7%
92.6%
0.3%
74.0%
12.3%
94.7%
0
3
100.0%
0
1
0
0
100.0%
100.0%
96.2%
115.0%
7.0%
81.0%
2.8%
91.3%
0
2
100.0%
1
0
0
0
100.0%
100.0%
96.3%
93.5%
3.8%
84.0%
20.6%
84.6%
0
2
100.0%
0
0
0
0
100.0%
100.0%
86.8%
81.3%
3.7%
94.0%
4.7%
97.4%
0
3
100.0%
0
0
0
0
100.0%
80.0%
88.4%
75.8%
4.2%
83.0%
5.0%
91.2%
0
0
100.0%
0
0
0
0
100.0%
80.0%
95.6%
93.1%
2.9%
83.0%
29.5%
96.5%
0
4
100.0%
0
0
1
0
80.0%
100.0%
92.8%
90.3%
7.7%
90.0%
40.6%
83.3%
0
3
100.0%
0
0
0
0
100.0%
100.0%
138.8%
93.7%
5.7%
50.0%
23.7%
88.4%
0
8
100.0%
0
4
0
0
0.0%
100.0%
95.5%
119.2%
4.4%
28.0%
17.5%
91.4%
0
7
100.0%
1
4
0
0
50.0%
100.0%
94.2%
93.5%
1.1%
100.0%
5.2%
92.6%
0
3
100.0%
2
9
1
0
83.0%
96.0%
96.7%
97.7%
3.4%
81.0%
15.6%
90.1%
0
35
100.0%
Infection Prevention Control
Environment Cleanliness
Hand Hygiene
Is there evidence that all 5 patients were screened for MRSA on admission or in the OPD?
Compliance with the C.diff pathway.
Catherter care Bundle Compliance
PVC Care Bundle Compliance
Sepsis Bundle Compliance
Patient Experience
Lenth of Stay ( Incl Zero bed days )
Friends and Family Reponse Rate ( Trajectory Q2 34% )
Friends and Family Satisfaction Score
Call Bells Response > 90%
Safeguarding
MCA & DOLS Training Compliance ( Trajectory 70% )
Adult Safeguarding Training
Safeguarding Children Level 1 Training
Red Flag Events
Hospital Acquired Pressure Ulcers ( 2 - 4 ) - Attributable
Number of Unplanned omission in providing patient medications.
Delay of more than 30 minutes in providing pain relief.
Number of Patient vital signs not assessed or recorded as outlined in the care plan.
Fluid Balance Chart
Delay or omission of regular checks Intentional Rounding on patients in the care plan.
RN/RM Planned vs Actual fill rate ( Safer Staffing )
HCA Planned vs Actual fill rate ( Safe Staffing )
Sickness Levels
Appraisal Rates
Staff Turnover
Mandatory Training
Number of Falls with Significant Harm
Number of Falls
Record Keeping
Staffing
Jan-15 Feb-15 Mar-15 Apr-15 May-15 Jun-15 Jul-15 Aug-15
ID
Metric
Compliance Action 1 - Staffing
7
No. of Clinical CAMH Breaches - ED
Target
0
Notes
0
0
1
2
3
0
1
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.
1
Staffing
Jan-15 Feb-15 Mar-15 Apr-15 May-15 Jun-15 Jul-15 Aug-15
Metric
Compliance Action 1 - Staffing
ID
Staff Turnover by Professional Group
13
Target
Less 10% ( green )
Notes
Medical & dental
11.04% 10.91% 10.53% 10.23%
11.11%
11.17% 11.05% 10.23%
10.82% 12.09% 13.05%
12.68%
11.78% 12.87% 13.52%
17.86% 18.11% 17.48% 12.88%
13.32%
13.76% 14.30% 13.85%
15.90% 15.55% 17.74% 18.39%
20.73%
19.91% 20.87% 21.00%
Trajectory
Less 10% ( green )
Nursing & midwifery
9.62%
Trajectory
Less 10% ( green )
Other clinical incl HCAs
Trajectory
Less 10% ( green )
Non-clinical
Trajectory
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
Staffing
Jan-15 Feb-15 Mar-15 Apr-15 May-15 Jun-15 Jul-15 Aug-15
ID
Metric
Compliance Action 1 - Staffing
No. of staff attending QELCA Training
(Quality End of Life Care for all)
32
Target
greater 2 ( green )
Notes
Target 5 per every 2 months,
YTD 25
Trajectory
5
4
0
5
5
5
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.
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
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)
Care and Welfare of People – requested an update 2/10/2015
Jan-15 Feb-15 Mar-15 Apr-15 May-15 Jun-15 Jul-15 Aug-15
ID
Metric
Compliance Action 2 - Care and Welfare of People
9
No. of pressure Ulcers on all wards
Target
0
Notes
Avoidable (1/2)
1
1
2
2
1
0
0
2
Trajectory
0
0
0
0
0
0
0
0
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.
Care and Welfare of People
Jan-15 Feb-15 Mar-15 Apr-15 May-15 Jun-15 Jul-15 Aug-15
ID
10
Metric
Compliance Action 2 - Care and Welfare of People
Fluid chart compliance
Target
Notes
100%
87.00% 85.00% 80.00%
Trajectory
85%
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
87%
89%
Care and Welfare of People
Jan-15 Feb-15 Mar-15 Apr-15 May-15 Jun-15 Jul-15 Aug-15
ID
15
Metric
Compliance Action 2 - Care and Welfare of People
No. of HCAI Cdif
Target
Notes
YTD 11
No of Cases
2
0
0
0
0
1
1
1
Trajectory
0
0
0
0
0
0
0
0
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
Safeguarding
Jan-15 Feb-15 Mar-15 Apr-15 May-15 Jun-15 Jul-15 Aug-15
0%
26%
44%
48%
51%
56%
63%
67%
Trajectory
30%
35%
44%
48%
44%
54%
63%
70%
Dec-14
Jan-15
Feb-15
Mar-15
Apr-15
May-15
Jun-15
Jul-15
26
43
43
60
69
69
73
86
74
65
Cumulative
Actual
Cumulative
26
69
112
172
241
310
383
469
543
608
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
3%
8%
13%
20%
28%
36%
44%
54%
63%
70%
0%
0%
0%
26%
44%
48%
51%
56%
63%
67%
Trajectory
Actual
0%
Aug-15
Trajectory
Actual
Aug-15
Nov-14
by month
100%
80%
60%
40%
20%
0%
Jun-15
Oct-14
Quarterly YTD
Apr-15
% of delegates attending MCA and DoLs Training
Notes
Feb-15
Target
Dec-14
21
Metric
Compliance Action 4 - Safeguarding
Oct-14
ID
Trust’s overall compliance as at 30.09.15 as 75% vs. a trajectory of 80%.
120%
Additional Clinical
Services
100%
80%
60%
Allied Health
Professionals
40%
20%
Sep-15
Aug-15
Jul-15
Jun-15
May-15
Apr-15
0%
Healthcare
Scientists
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.
Respecting and Involving People
Jan-15
ID
31
Metric
Compliance Action 6 - Respecting and Involving People
Compl i ance agai nst Trai ni ng needs Anal ysi s for statutory,
mandatory and essenti al cl i ni cal ski l l s trai ni ng
Available in September
Target
greater 90% ( green ) IPC Refresher
(Cl i ni cal Staff) - 1 Year
May-15
Jun-15
Jul-15
Aug-15
86.26%
82.57%
83.06%
82.31%
81.21%
98.25%
97.25%
97.45%
98.08%
97.19%
20.54%
19.23%
19.23%
20.27%
20.00%
38.19%
76.17%
76.39%
75.43%
71.12%
Trajectory
greater 90% ( green ) IPC Refresher
(Non Cl i ni cal Staff) - 2 Years
Available in September
Trajectory
greater 90% ( green ) M&H Hi gh Ri sk (Non Cl i ni cal )
Practi cal + Theory - 2 Year
Available in September
Feb-15 Mar-15 Apr-15
Notes
Trajectory
greater 90% ( green ) M&H Low Ri sk (Cl i ni cal )
Practi cal + Theory - 2 Year
Available in September
Trajectory
greater 90% ( green ) M&H Low Ri sk (Non Cl i ni cal )
e-l earni ng - 3 Year
Trajectory
92.15%
96.46%
96.68%
97.33%
96.43%
Available in September
greater 90% ( green ) Movi ng & Handl i ng for
Peopl e Handl ers - 1 Year
Trajectory
58.19%
69.59%
70.86%
75.43%
77.98%
Available in September
greater 90% ( green ) Fi re Safety - 1 Year
83.44%
81.35%
82.61%
82.00%
80.65%
46.66%
49.89%
50.32%
61.57%
65.33%
17.55%
17.89%
18.10%
24.00%
23.99%
27.88%
26.21%
26.47%
24.51%
24.51%
92.77%
93.61%
94.18%
94.91%
94.61%
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%
89.97%
90.26%
90.60%
87.91%
89.57%
85.60%
85.40%
85.90%
84.90%
86.50%
Available in September
Trajectory
greater 90% ( green ) Mental Capaci ty Act - 3 Years
Available in September
Trajectory
greater 90% ( green ) Prevent Basi c Awareness - 3
Years
Available in September
Trajectory
greater 90% ( green ) PREVENT - 3 Years
Available in September
Trajectory
greater 90% ( green ) Safeguardi ng Adul ts Level 1 3 Years
Available in September
Trajectory
greater 90% ( green ) Safeguardi ng Chi l dren Level 1
- 3 Years
Available in September
Trajectory
greater 90% ( green ) Safeguardi ng Chi l dren Level 2
- 1 Year
Available in September
Trajectory
greater 90% ( green ) Safeguardi ng Chi l dren Level 3
- 1 Year
Available in September
Trajectory
greater 90% ( green ) Equal i ty, Di versi ty and
Human Ri ghts - 3 Years
Available in September
Trajectory
greater 90% ( green ) Informati on Governance - 1
Year
Available in September
Trajectory
Respecting and Involving People
August 2015

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.

% of delegates attending UTI Indwelling Catheter Training

% of delegates attending Improving Water Low 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.

% of delegates attending VIP 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
11
Respecting and Involving People
Assignm ents
%
Com petence Notes:
for Positions Assignm ents Requirem ent
w ith
that Fulfil
Gap
Com petence Com petence
Requirem ents Requirem ents
for Position
Com petence Nam e
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%
291|LOCAL|IPC Refresher (Non Clinical Staff) - 2 Years|
463
97.19%
230 Further compliance mapping on ESR required to check data accuracy. Subject lead
aw are of current compliance level.
13 Compliant
291|LOCAL|M&H Low Risk (Non Clinical) e-learning - 3 Year|
448
96.43%
70
20.00%
291|LOCAL|M&H Low Risk (Clinical) Practical + Theory - 2 Year|
232
71.12%
NHS|MAND|Moving & Handling for People Handlers - 1 Year|
940
77.98%
56 Change of competence and frequency. Subject lead scheduling and completing
additional training.
67 Change of competence and frequency. Remapping taken place. Communication
continues.
207 Remapping taken place. Communication at dvisional level taking place.
NHS|MAND|Inform ation 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%
NHS|MAND|Safeguarding Children Level 1 - 3 Years|
1,726
96.00%
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.
1,726
89.57%
180 Elearning and self assessment booklet available. On-going communication at dvisional
level.
874
65.33%
303 Target of 90% is by October. Trajectory in place.
1,726
23.99%
102
24.51%
291|LOCAL|M&H High Risk (Non Clinical) Practical + Theory - 2 Year|
NHS|MAND|Safeguarding Children Level 3 - 1 Year|
NHS|MAND|Equality, Diversity and Hum an Rights - 3 Years|
NHS|MAND|Mental Capacity Act - 3 Years|
291|LOCAL|Prevent Basic Aw areness - 3 Years|
NHS|MAND|PREVENT - 3 Years|
16 Compliant
93 Compliant
69 Compliant
1,312 New competency. Compliance required by 2017. Elearning package to be introduced.
Subject lead currently prioritising MCA & DOLS trajectory.
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 People
Trust Total – Responses received rate 33% Satisfaction Rate 97%
Compliance Action 6 - Respecting and Involving People
23
Friends and Family Test Responses received - Emergency
Response Rates
Trajectory
Friends and Family Test Responses received - Maternity
Response Rates
Trajectory
Friends and Family Test Responses received - In patients
Response Rates
Trajectory
Friends and Family satisfaction score - Emergency
Trajectory
Friends and Family satisfaction score - Maternity
Trajectory
Friends and Family satisfaction score - In patients
Trajectory
10.00% 13.00% 14.00% 13.00%
19%
40.00% 11.00% 75.00% 74.00%
64%
41.00% 53.00% 43.00% 43.00%
17.00%
19%
55.00%
64%
47.00%
59%
59%
94.00%
94.00%
90%
90%
98.00%
97.00%
90%
90%
97.00%
96.00%
90%
90%
23.68% 13.95%
20%
9.61%
20%
20%
64.64% 23.77% 24.55%
66%
66%
66%
52.82% 53.72% 45.76%
61%
61%
61%
95.32% 93.19% 95.36%
90%
90%
90%
97.44% 95.14% 96.30%
90%
90%
90%
95.77% 96.24% 97.21%
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.
90%
Should do
Jan-15 Feb-15 Mar-15 Apr-15 May-15 Jun-15 Jul-15 Aug-15
ID
Metric
Compliance Action 6 - Respecting and Involving People
Should Do
33
Compliance with daily Resuscitation Equipment Checks
(Audit)
Target
Notes
greater 95% ( green ) Specific wards each month.
All wards each Quarter.
95.00%
83.00%
89.00% 90.00% 87.55%
ED Resus Trolley Compliance Audit Action plan
Sep-15
1. The Issue
Failure to receive 100% compliance with Resus trolley daily checks in August
2. Next Steps
DATE
01/09/2015
AREA OF IMPROVEMENT
Trolley 3 often missed
ACTION NEEDED
Allocate one person to check all
three Resus trollies rather than
being shared between Paed and
Adult nurses.
RESPONSIBILITY DUE DATE STATUS
DM
21-Sep-15
One person now checking 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.
DM
21-Sep-15
Added to Coordinators log. Logs are collected and checked by Matron
or Service Manager
DM
30-Sep-15
Matron will do weekly checks to monitor compliance of Resus trolley
checks.
Allocated person must inform the
Coordinator if they have not
checked and signed all three trollies.
01/09/2015
01/09/2015
01/09/2015
Checks not all completed
Assurance
Staff responsibility
Add Resus trolley checks to the
Coordinator's daily report, so that
they also check and sign that the
trollies have all been checked.
Hold staff to account if they are
nominated person and checks are
not done
Update/Comments
Should do
X Ray Resus Trolley Compliance Audit Action plan
1. The Issue
Failure to receive 100% compliance with Resus trolley daily checks in August
2. Next Steps
DATE
01/09/2015
AREA OF IMPROVEMENT
ACTION NEEDED
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
Checks not all completed 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.
RESPONSIBILITY DUE DATE STATUS
TS
Update/Comments
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.
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
21-Sep-15
TS
30-Sep-15
Must Do
Jan-15 Feb-15 Mar-15 Apr-15 May-15 Jun-15 Jul-15
ID
34
Metric
Target
No. of avoidable transfers in the Trust after 10pm.
Notes
Number of Moves
89
82
70
80
34
55
65
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
Date
All moves
01/04/2015
652
01/05/2015
587
01/06/2015
621
01/07/2015
579
01/08/2015
620
Avoidable moves
80
34
55
36
50
Proportion
12.27%
5.79%
8.86%
6.22%
8.06%
Moves per date Target Proportion Target
73
11.46%
73
11.46%
73
11.46%
55
8.60%
55
8.60%
Variation Report - as at 18 September 2015
Compliance Action
Ref
Area
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.
6.3
Action
Task and finish group to
review current
documentation and
develop revised format
Milestone
Accountable
Responsible
Three Phased approach:
Complete Revised document
1) Risk Assessment
Complete revised
documentation
3) Nursing Care Plans
Director of Nursing,
Midwifwery and
Quality
Develop Strategy
Director of Nursing,
Midwifwery and
Quality
Revised
Estimated
delivery date
Reason for Delay
31/05/2015
21/08/2015
Risk Assessment document revised and
currently at printers. Revised date for
implementation middle of August
18/08/2015
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
Deputy DIPC,
DHON's and Ward
Matrons
To review the ward
handover process and
develop, implement and
Assurance that the practice is
embed a revised process
embedded
that provides information
on all patients to all staff
across the ward
Ensure patients
are treated with To develop a compassion
dignity and
in Practice Strategy
respect
Date to be
delivered
Led by DHON MSK for Trust
Wide
Implementation
07/07/2015
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
30/09/2015
September which will provide the assurance
that the proess is embedded. Audit report
expected by early week commencing 18
September 2015
30/07/2015
The revised Nursing Midwifery Strategy will be
31/08/2015 developed in line with the 6c's and is currently
in the process of validation prior to launch.
TDA Clinical Observation Visit – 28 August 2015
Key Areas of Focus
•
• Risk Registers and BAF to
•
be strengthened
• Executive Portfolios
•
• Consistency of Practices
•
Areas of Good Practice
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)
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.