The Shared Agenda of Group Committees in Common (CiC)

Transcription

1 Salford Royal NHS Foundation Trust (SRFT) & Pennine Acute Hospitals NHS Trust (PAT) AGENDA: Part 1 1. Patient Story The Shared Agenda of Group Committees in Common (CiC) Monday, 25 th September at 10:00am Humphrey Booth Lecture Theatre, Mayo Building, Salford Royal, Stott Lane, SALFORD M6 8HD 2. Chairman s Opening Remarks Chairman 3. Apologies for Absence Chairman 4. Declarations of Interest All 5. Minutes of Previous Meeting (Part 1) - held on 31 st July 2017 Chairman 6. CEO Report, including Chief Executive High-level Performance Metrics and Chief Officers Care Organisation presentations with focus on the three national priorities: A&E Standard 62 Day Cancer Standard Financial Plan 7. PAT Improvement Plan: Progress Report & CQC Preparation Chief Delivery Officer (update CQC presentation at meeting) 8. Urgent Care: Winter Planning Chief Delivery Officer and (presentation at meeting) Chief Officers 9. Northern Care Alliance Transforming Recruitment Chief Strategy & OD Officer 10. SCAPE Assessment Recommendation Chief Officer - Salford 11. Reports from Standing Committees: Group Audit Committee Vice-Chairman - meeting held on 8 th September Group Executive Committees: Chief Executive Risk and Assurance Committee - meetings held on 21 st August and 18 th September Any other business (Part 1) 13. Date and Time of the Next Meeting: Monday, 30 th October 2017 from 10am 1/2 1/112

2 Venue: Humphrey Booth Lecture Theatre, Level 1, Mayo Building, Salford Royal NHS Foundation Trust. Resolution: To exclude the press and public from the meeting at this point on the grounds that publicity of the matters being reviewed would be prejudicial to public interest, by reason of the confidential nature of business. The press and public are requested to leave at this point. 2/2 2/112

3 Meeting of the Group Committees in Common Draft Shared Minutes: Part 1 Held in Public Monday 31 st July 2017 Humphrey Booth Lecture Theatre, Mayo Building, Salford Royal. Present: Mr Jim Potter, Chairman Sir David Dalton, Group Chief Executive Officer Mrs Jude Adams, Group Chief Delivery Officer Mr Chris Brookes, Group Chief Medical Officer Mrs Diane Brown, Senior Independent Director Mrs Rowena Burns, Non-Executive Director Mrs Elaine Inglesby-Burke CBE, Group Chief Nursing Officer Mr Raj Jain, Group Chief Strategy and Organisational Development Officer Mrs Chris Mayer CBE, Non-Executive Director Dr Matt Makin, North Manchester Care Organisation Medical Director Mrs Donna McLaughlin, Chief Officer Oldham Care Organisation Mr Ian Moston, Group Chief Finance Officer Dr Chris Reilly, Non-Executive Director Dr Hamish Stedman, Non-Executive Director Mr James Sumner, Chief Officer Salford Care Organisation Mrs Nicky Tamanis, Bury & Rochdale Finance Director Mr John Willis CBE, Vice-Chairman Mrs Jane Burns, Director of Corporate Services and Group Secretary Mrs Rebecca McCarthy, Deputy Group Secretary Apologies for Absence: Mr Damien Finn, Chief Officer North Manchester Care Organisation Mr Steve Taylor, Chief Officer Bury & Rochdale Care Organisation No. Item Action 1. Welcome The Chairman welcomed everyone present to the meeting of the Group Committees in Common and confirmed this was a shared meeting of committees established by the Boards of Salford Royal NHS Foundation Trust and Pennine Acute Hospitals NHS Trust. The Chairman confirmed that the meeting would be held in two parts: a first part open to members of the public, and a second part in private session for confidential matters. 2. Patient Story The Group Committees in Common listened to Patient Story Number 102 read by the Chief Officer Salford Care Organisation. 1/13 3/112

4 No. Item Action Opening Matters 3. Chairman s Opening Remarks Non-Executive Director Resignation: Rowena Burns The Chairman formally thanked Mrs Rowena Burns for her contribution as a Non-Executive Director, noting that this would be her last meeting. The Chairman highlighted that Rowena had been a Non-Executive Director since 2013 and that her input had been invaluable during this time. The Chairman wished Rowena all the best for her future endeavours. Salford Health Watch Annual Report 2016/17 The Chairman confirmed that the Salford HealthWatch Annual Report 2016/17 had been included as a paper for information. The Chairman commented that the report highlighted engagement conducted in the Salford Royal waiting areas used by Patients for Non-Emergency Transport and improvements made to help the discharge lounge process. In addition, the Chairman confirmed that the report detailed the involvement of patients and the public in the tender process for the Salford Royal inpatient catering service. Defence Medical Welfare Service The Chairman confirmed that he had attended the unveiling ceremony of a new plaque paying tribute to six members of staff who were killed when the then Hope Hospital was hit in the Christmas Blitz of Apologies for Absence The Group Committees in Common accepted apologies for absence as recorded above. 5. Declarations of Interest The Chairman requested that officers declared any actual or potential conflict of interest relevant to their role as a member of the Group Committees in Common and in particular to any matter being discussed at the meeting. There were no interests declared. 6. Minutes of the Previous Meeting The Chairman confirmed that Part 1 of the previous meeting held on 26 th June 2017 had been open to members of the public. The draft minutes, recorded of that session, were reviewed by the Group Committees in Common and approved as a true and correct record. 7. Matters Arising In response to the Senior Independent Director requesting that the outcome and actions from the Group Committees in Common Away Day held on 21 st June 2017 were made visible, the Group Secretary confirmed that actions highlighted on the distributed Workshop Summary Sheet would be transferred to the Board Action Sheet. 8. CEO Report including Interim High-Level Performance Metrics 2/13 4/112

5 No. Item Action The Chief Executive Officer presented the high level key performance indicators and provided further detail on the performance of each Care Organisation alongside key strategic and operational matters. He advised the Group Committees in Common that work was progressing well with respect to the transition arrangements to establish Care Organisations, including further clarity on structures and governance systems. 7.1 Operational Performance The Chief Executive Officer reported that operational performance against key standards was generally positive and highlighted that recovery plans for the 4 hour standard at the Salford, North Manchester and Oldham Care Organisations had been supported by NHS Improvement and the Greater Manchester (GM) Partnership. The Chief Executive Officer highlighted matters for focussed attention, most notably the requirement for additional capacity in order to reduce high occupancy levels. The Chief Executive Officer emphasised that the recovery plans would require whole system action to lower delayed transfers of care (DToC), including robust primary care deflections at North Manchester and Oldham, and repatriation of Neuro and Stroke patients at Salford. The Chief Executive Officer stressed that, notwithstanding improved monthly performance against the 4 hour standard, this matter continued to be the top priority and was subject to daily review by the Care Organisation Chief Officers. In response to the Vice-Chairman querying the key causal factor/s of the improved performance at Salford Care Organisation during July, the Salford Care Organisation Chief Officer confirmed that, despite an increase in attendances, the implementation of additional bed capacity and escalation ward, alongside occupancy controls, had resulted in improved performance. In response to the Vice-Chairman further querying the ability to sustain improved performance, the Salford Care Organisation Chief Officer expressed his belief that additional bed capacity would assist the implementation of winter escalation plans. With respect to the Salford Care Organisation, a Non- Executive Director sought further information regarding progress made against DToC within Salford and Greater Manchester. The Salford Care Organisation Chief Officer referred to the commencement of four workstreams, each utilising Quality Improvement methodology, to support patient flow and reduce the number of stranded patients in Salford; resulting in a reduction from 116 to 93 stranded patients (on average) per week to date. He added that further reduction was anticipated as The Limes estate issues were resolved. With respect to DToC across GM, the Chief Executive Officer confirmed that the GM Partnership had agreed to conduct a piece of work on this significant matter, as it was not possible to reconcile the number of stranded patients across GM at this time. A Non-Executive Director expressed his view that a single methodology with respect to repatriation to Care Organisations within the Group must be established, and that sight of all patients waiting to be repatriated across GM should be a priority. The Chief Executive Officer concurred and reiterated that the four Care Organisations were clear regarding patients requiring repatriation; however other hospitals within GM were unable to provide this information and therefore a GM wide position could not be reconciled. He restated the importance of resolving this matter, specifically for the Salford Care Organisation due to its role as a Major Trauma and Stroke Centre, emphasising that not all variables were within control of the Salford Care Organisation and would require GM Partnership discipline. Referring to the continued challenge in achieving the 4 hour standard at North 3/13 5/112

6 No. Item Action Manchester and Oldham Care Organisations, a Non-Executive Director sought further information regarding action taken to improve performance in the respective Care Organisations. With regards to the North Manchester Care Organisation, the Chief Executive Officer described the expansion of acute assessment beds by early October 2017, and influx of Registered Nurses during September enabling the required movement of wards. The Chairman referred to the considerable number of agency staff within the Emergency Department at North Manchester and sought view as to whether the future of the North Manchester Care Organisation may be impacting the ability to recruit permanent staff. The Chief Executive Officer offered his view that uncertainty regarding the long term future of North Manchester was impacting the ability to recruit medical staff specifically, from an already limited supply of emergency/acute medical staff. The Chief Medical Officer echoed this view, and emphasised the importance of services remaining safe and the sickest patients receiving care within a high acuity centre. With respect to the Oldham Care Organisation, the Chief Executive Officer acknowledged the dip in performance and significant challenge regarding patient flow due to high occupancy levels. He informed the Group Committees in Common that the planned deflection schemes in partnership with Oldham CCG had not materialised and would be implemented as part of the winter planning. Furthermore, he added that full expansion of the ambulatory care model at weekends and evenings had not been possible due to inability to secure the required workforce. The Chief Executive Officer confirmed additional schemes were being developed in line with the agreed trajectory and advised that a further briefing regarding actions being taken to improve performance would be provided to the Group Committees in Common. 7.2 The Limes The Chief Executive Officer provided contextual information regarding the transfer of The Limes from Aspire to Salford Royal NHS Foundation Trust (SRFT) as providers of the Integrated Care Organisation. He informed the Group Committees in Common that prior to SRFT assuming responsibility, a survey had been undertaken to estimate the required resources to re-register with the CQC as an intermediate bedded unit with the provision of nursing care, and that the survey had highlighted several areas where the building did not meet statutory health and safety requirements. The Chief Executive Officer confirmed that a plan had been enacted to correct all immediate remedial concerns and that a decision had been taken to not use the upper floor (17 beds), therefore reducing operational capacity. He added that estimated costs for further necessary work would require 800k - 1m, and take some considerable time to complete. The Chief Executive Officer confirmed alternative options for intermediate care capacity were being explored with Salford CCG and Salford City Council. In response to the Senior Independent Director seeking clarification regarding responsibility for provision of alternative accommodation, the Chief Executive Officer confirmed maintenance of The Limes building was the responsibility of Salford City Council, with joint responsibility (Salford City Council and SRFT) to provide capacity to meet the needs of the population of Salford. The Salford Care Organisation Chief Officer provided further clarity regarding remedial works, confirming that estimated costs would rise to 2m to increase the provision of nursing care, therefore sourcing an alternative and speedier solution was deemed sensible. A Non-Executive Director suggested that it would be of value to better understand surrounding context and future strategy for intermediate care. The Salford Care Organisation Chief Officer confirmed that an Intermediate Care Review was being undertaken by the ICO to determine the requirement for Oldham CO Chief Officer 4/13 6/112

7 No. Item Action residential and nursing care to support reduction in hospital admissions. In response to a Non-Executive Director seeking further information regarding the position of residential and nursing home provision in the Group s localities, the Chief Executive Officer offered that, as Pennine Acute Hospitals NHS Trust (PAT) did not have the same responsibility as SRFT, there was less clarity in this regard, however noting a general fragility in the nursing and care home market. The Chief Executive Officer confirmed that further intelligence on the Nursing/Care Home position across the PAT localities would be gathered to better understand fragility in the system. 7.3 North East Sector Care Organisations CQC Inspection The Chief Executive Officer provided an update regarding the detailed preparations underway for the expected CQC Inspection of North East Sector Care Organisations. The Chief Executive Officer confirmed the focal point of the CQC Inspection would be the acknowledged fragile services and, as part of the Well-Led domain, understanding how the Group Committees in Common had a line of sight, and supported, the North East Sector Care Organisations via revised governance arrangements. With respect to the Well- Led domain, the Chief Nursing Officer highlighted that the transition of PAT to separate Care Organisations continued, and that discussion had taken place to ensure the CQC had knowledge of the baseline from which improvement had taken place over the last 12 months. 7.4 Introduction of the Northern Care Alliance The Chief Executive Officer announced that an agreement had been reached, subject to the Group Committees in Common approval, to name the Group the Northern Care Alliance NHS Group. He drew the Group Committees in Common attention to the briefing note prepared to communicate arrangements to staff, stakeholders and partners. In addition, the Chief Executive Officer confirmed progress had been made to produce a simplified set of priorities for the Group Committees in Common and Care Organisations, and stated that consideration, and agreement, of the Group priorities would take place later in the meeting. A Non-Executive Director acknowledged the timely communication for staff in light of the forthcoming CQC Inspection, and the importance of staff understanding the vision and values of the Northern Care Alliance and a simple set of priorities. Group Committees in Common approved the proposed name, the Northern Care Alliance NHS Group. 7.5 Group Service Strategy and North East Sector Clinical Service Strategy The Chief Executive Officer reported that much work had taken place to develop the Group Service Strategy and North East Sector Clinical Service Strategy, including a clinical engagement event with Care Organisation leaders to discuss the organisation, transformation and provision of reliable care and services across the Northern Care Alliance, fully cognisant of the Single Hospital Service development. 7.6 Financial Position The Chief Executive Officer reported that the Group financial position was a net deficit of 12.0m, marginally better than planned. He commented that the Chief Finance Officer would provide further detailed information regarding the Care Organisation position, including run-rate, in Part 2 of the meeting. Chief Delivery Officer 5/13 7/112

8 No. Item Action 7.7 Nurse Recruitment The Chief Executive Officer provided a comprehensive update regarding the ongoing implementation of nurse recruitment and retention plans, including the forthcoming international recruitment campaign in India. The Senior Independent Director acknowledged the recruitment work undertaken, and mindful of current retention data, urged further reflection on retention initiatives including induction and staff engagement. The Chief Executive Officer wholly acknowledged this comment, and iterated the intention to present the Group Recruitment and Retention Strategy to the Group Committees in Common in September In response to a Non-Executive Director seeking further information regarding local recruitment and training initiatives, such as career progression for Care Workers and part-time nursing roles, the Chief Nursing Officer described discussion underway with Higher Education Institutions regarding a Virtual School of Nursing. She highlighted that all new nursing students, from September 2017, would be employed by the Northern Care Alliance as Healthcare Assistants, and should students pass all clinical placements, would only be required to transfer to their new position as a Registered Nurse on a ward. The Chief Nursing Officer commented that a number of successful Care Organisation recruitment events had taken place during July, with candidates being interviewed and job offers made on the day. In addition, the Chief Nursing Officer highlighted continued discussion with Further Education providers regarding the Nurse Associate top-up programme, and commencement of the Healthcare Cadet programme exclusively for local populations. 7.8 Fire Safety: Cladding Review The Chief Executive Officer stated that, following the tragic events at Grenfell Tower, NHS Improvement had asked each Trust in England to undertake an assessment of cladding used on NHS premises. He confirmed that following the assessment of all buildings (including buildings owned by other agencies where Trust staff are based) met the required fire safety standards. He added that as part of work to provide the necessary returns to NHS Improvement a small number of issues had been identified relating to fire doors, levels of specific fire related training provided for the managers who supervise the Fire Officers, and the timing of annual updates for some of the Fire Officers. He confirmed these matters were being addressed by the Director of Estates and Facilities. In response to the Vice-Chairman requesting confirmation that assurance had been received in writing from the Salford PFI partner, the Chief Executive Officer stated that this had been a requirement of the NHS Improvement return, and confirmed via the Group Director of Estates and Facilities. 7.9 Care Organisation Reports In response to a request from Non-Executive Directors, the Care Organisation Chief Officers provided a progress report regarding key Care Organisation operational and strategic matters Salford The Salford Care Organisation Chief Officer confirmed the financial position for the end of Quarter 1 was a deficit of 3.1m, 0.1 better than planned. He highlighted that the favourable income position was offset by worse than planned Better Care at Lower Cost (BCLC) performance. He confirmed that increased frequency of meetings with the Salford Director Team and the Division/Corporate Departments had been established to increase control on the BCLC programme. In response to the Senior Independent Director seeking Chief Strategy & OD Officer 6/13 8/112

9 No. Item Action further assurance with respect to HSMR and SHMI performance, the Chief Nursing Officer confirmed that HSMR and SHMI remained statistically lower (lower is better) than expected for the Salford Care Organisation and provided additional context regarding the baseline reset for data. The Vice-Chairman requested an Integrated Care Organisation Progress Report to an upcoming meeting of the Group Committees in Common Oldham The Oldham Care Organisation Chief Officer confirmed that the Oldham Care Organisation Leadership Team was fully established with a Communications and Engagement Plan in place to communicate key management and governance information to staff. She highlighted fragile services including General Surgery and Gastroenterology and confirmed the direction of travel to introduce Quality Improvement workstreams to facilitate improvement. In addition, the Oldham Care Organisation Chief Officer explained that the financial position was being impacted by BCLC underperformance and agency spend pressures. A Non-Executive Director sought further information regarding the issues contributing to fragility in General Surgery. The Oldham Care Organisation Chief Officer offered that the key issue related to effective team working and decision making, alongside a small number of Consultant gaps. She highlighted the wrap around support for General Surgery provided by Group. The Chief Medical Officer highlighted the notable improvement in clinical engagement and leadership at Oldham and commented that he had attended a meeting with colleagues in General Surgery to catalyse new ways of working based on fundamental standards and collaboration. In response to the Vice-Chairman seeking further information regarding the IM&T landscape in Oldham, the Oldham Care Organisation Chief Officer highlighted the challenge with respect to basic IM&T infrastructure and noted the proposed investment in unified business communications to address this matter. She confirmed data quality required further refinement; highlighting however that the availability of data was not currently hindering progress Bury and Rochdale The Bury & Rochdale Finance Director confirmed the Senior Leadership Team was fully established and that governance structures were in development. She highlighted that the financial position for June was slightly better than plan largely due to income, however expenditure continued to be worse than plan driven by agency spend and underperformance against BCLC. The Bury & Rochdale Finance Director confirmed service line reporting had been introduced to support and improve BCLC performance. In response to the Vice-Chairman seeking further information regarding relationships with key stakeholders, the Bury & Rochdale Finance Director confirmed that positive relationships were well established with key stakeholders in Rochdale, including the CCG and Local Authority, and that such relationships were emerging in Bury with the development of Cardiology and Community pathways North Manchester The North Manchester Medical Officer highlighted the necessary reconfiguration of wards and opening of additional ANU beds in the forthcoming week to support improved performance in Urgent Care. He added that further work was underway to address quality and safety matters including a renewed focus on infection control, hand hygiene and antibiotic stewardship. With respect to workforce matters, the North Manchester Medical Officer Salford CO Chief Officer 7/13 9/112

10 No. Item Action commented that a positive shift in staff engagement scores had been noted via the Staff Friends and Family Test (FFT), and highlighted that PAT had the highest rates of medical appraisals during 2016/17. In response to the Senior Independent Director querying the quality of the appraisals completed, the North Manchester Medical Director confirmed the high standard of appraisals and added that any concerns identified were addressed. Recognising the areas of positive progress, the Senior Independent Director queried further if the uncertain nature of North Manchester was impacting on recruitment. The North Manchester Medical Director expressed his view that the development of the Single Hospital Service presented an opportunity for recruitment; however the uncertainty was adversely impacting on staff retention. The North Manchester Medical Officer referred to the development of clinical pathways, including Urgent Care, Surgery, Women s and Childrens and Complex Care at North Manchester. A Non-Executive Director cautioned that clinical pathways must be developed and standardised across the Group. The Chief Medical Officer expressed the priority to establish reliable fundamentals of care within the North East Sector Care Organisations, acting as the catalyst to develop specific care pathways for disease profiles. The Chief Executive Officer confirmed that during the clinical engagement event, attended by Clinical Directors from all Care Organisations, discussion had taken place regarding the establishment of Clinical Reliability Groups to ensure a single methodology, and care pathways across the Group footprint. A Non-Executive Director acknowledged the proposed transfer of North Manchester Adult Community Services from PAT and noted further discussion would take place regarding this matter Staffing The Chief Nursing Officer provided an update regarding the implementation of Trendcare, confirming that the Salford Care Organisation had roster reengineered 8 wards, commencing in September The Vice-Chairman referred to the different staffing ratios at the Salford and the North East Sector Care Organisations and queried if they would be aligned in the future. The Chief Nursing Officer confirmed that ratios at Salford would shift based on Trendcare data. She described the outcome of the ward by ward staffing review conducted at PAT during 2016, and the significant investment that would be required to wholly implement the standard staffing model currently embedded at Salford. She further described initial investment agreed to increase nurse staffing levels in the North East Sector Care Organisations, mindful of current national recruitment challenges. In response to the Vice- Chairman querying the proposal for implementation of Trendcare across the Group, the Chief Nursing Officer confirmed that initial discussion had taken place with the Chief Finance Officer to ratify the required procurement process and further scope the Trendcare offer. A Non-Executive Director sought assurance that systems were in place to identify if adverse events were linked to areas with significant agency staff usage. The Chief Nursing Officer confirmed that staff on duty was reviewed as part of all patient safety incidents. In addition, she provided an example of action taken on a ward as a result of triangulated data including staff vacancy levels, sickness absence and incidents, this included negotiation with NHS Professionals of temporary staff on a 3 month contract, and physical relocation of the ward. In response to a Non-Executive Director seeking assurance that risk associated with diagnostic capacity was being managed appropriately, the Chief Medical Officer confirmed that, as approved by the Group Committees in Common in June, the PAT Clinical Effectiveness Committee would continue to 8/13 10/112

11 No. Item Action meet and that Diagnostic Review was a standing item of this committee at which he sought assurance from Care Organisation Medical Directors that appropriate review and action was in place on this matter. 8. Pennine Acute Hospitals NHS Trust (PAT) Improvement Plan The Chief Delivery Officer presented progress made towards the delivery of the PAT Improvement Plan and sustained improvements. In addition, the Chief Delivery Officer highlighted workforce availability continued as a significant risk, and a new risk relating to available funding to support the improvement plan following the inability to reach the desired settlement with NHS Improvement. In response to a Non-Executive Director seeking further information as to how the aforementioned risks were to be managed and mitigated, the Chief Delivery Officer confirmed that discussion concerning the potential impact on stabilisation had taken place with the Pennine Improvement Board, and whilst accepted was recognised to be sub-optimal. She added that CCG Quality Leads had agreed that monitoring the quality and performance impact of the revised plan would be undertaken by the Clinical Quality Leads. Furthermore, the Chief Delivery Officer confirmed a detailed and expert review of recruitment plans and strategy had been completed, with a number of areas for improvement identified and an implementation plan developed to be delivered by April The Chief Nursing Officer provided detailed information regarding the process for the follow up inspection at PAT, confirming that the Patient Information Request (PIR) had been submitted to the CQC on 10 th July. She added that as part of the PIR submission the Trust had been asked to identify areas of significant improvement, weaker areas and areas of biggest challenge. The Senior Independent Director referred to the number of projects within the PAT Improvement Plan currently rated as amber, and queried the potential consequence of this for the forthcoming CQC Inspection. The Chief Nursing Officer acknowledged the 17 projects rated as amber, and expressed her view that the position was accurate and reflected the implementation of an Improvement Plan against a backdrop of serious workforce constraints. The Vice-Chairman referred to the optimism bias evident in the self-assessments within CQC Corporate Assurance Programme Reports presented to Audit Committee, and sought assurance that this had been fully considered in the current assessment. The Chief Nursing Officer confirmed that the Executive Team had reviewed each Care Organisation Self-Assessment and, her belief that the self-assessments presented a correct reflection of current position. The Chief Medical officer alerted the Group Committees in Common to the emerging risk with respect to the fragility of maintaining the Critical Care Unit consultant cover at the Fairfield General Hospital and confirmed that he had been charged with identifying a solution to ensure patient safety was maintained in the immediate term and a long term plan. The Group Committees in Common reviewed and confirmed the progress and key risks to the delivery of the CQC and SRFT CQC Diagnostic Improvement Plan. 9. Patient and Service User Experience Report The Chief Nursing Officer presented the Patient and Service User Experience 9/13 11/112

12 No. Item Action Report and provided the Group Committees in Common with an update on the progress and effectiveness of systems and processes for the collection, analysis and learning from patient and service user feedback including: Annual Care Quality Commission (CQC) Inpatient Survey 2016 Family and Friends Test (FFT) Near Real Time and Real Time feedback Nursing Accreditation and Assessment Scheme (NAAS) Community Assessment and Accreditation Scheme(CAAS) She highlighted results from the national CQC Inpatient Survey 2016 confirming that SRFT had ranked joint 3 rd for Overall Patient Experience and Care & Treatment, and ranked 1 st for Operations & Procedures, declining in one area compared to 2015, From the time you arrived in hospital, did you feel that you had to wait long to get a bed on a ward?. With respect to PAT, the Chief Nursing Officer confirmed that results indicated About the Same on all section scores when compared to all other Trusts. The Chief Nursing Officer highlighted the variation in current systems and processes across the 4 Care Organisations for the collection, analysis and presentation of patient experience data, and reported that potential solutions and timeframes to provide comparable and meaningful data to assist with performance monitoring in the future was in scope. The Chief Nursing Officer highlighted the fantastic improvements made to improve End of Life Care and Bereavement Services in the North East Sector Care Organisations following the identification of common themes from real time feedback. In response to the Senior Independent Director querying if themes identified in a Care Organisation were addressed across the Group, where pertinent, the Chief Nursing Officer confirmed that identified themes were considered Groupwide, with identification of where best practice existed and sharing of expertise across the Group. Furthermore, the Senior Independent Director emphasised the importance of standardisation and reliably deploying methodology. The Chief Nursing Officer fully acknowledged this comment, further explaining the current review of real-time patient feedback, and opportunity to standardise and ensure questions were fit for the case mix of patients. 10. Learning From Experiences Report The Chief Nursing Officer presented the first Learning from Experiences Report, providing insight into incident reporting, coronial activity, litigation and complaint management for the period 1 st April th June The Chief Nursing Officer highlighted lesson learning from each category, together with key areas of improvement and areas of risk and how the risk was being managed. The Chief Nursing Officer highlighted an increase in incident reporting in the North East Sector Care Organisations (without an increase in harms) associated with a changing positive culture of being open, and staff confidence in learning. In response to a Non-Executive Director seeking further information as to how learning from incidents had been shared across Care Organisations during the previous year, the Chief Nursing Officer stated that the focus during this period 10/13 12/112

13 No. Item Action had been the embedding of reliable systems of care. She confirmed that the Learning from Experiences Report had previously been presented to the PAT Quality and People Experience Committee with attendance from all Care Organisations, noting further development of a Group Learning Framework. Further discussion took place regarding the theme of communication evident within both incidents and complaints across the Care Organisations and how clinicians were held accountable for their communication and behaviours. The Chief Nursing Officer acknowledged the improvements required in this regard, and expressed her view that firstly the fundamental processes for communication with patients must be visible and reliably deployed, enabling clinicians to be held to account. The Chief Nursing Officer described tests of change taking place as part of the Deteriorating Patient collaborative to improve communication. The Chief Medical Officer echoed these comments and stressed the importance of a stable leadership providing consistent messaging with respect to patient-centred care. In response to a Non-Executive Director requesting that the Group Committees in Common be sighted on deaths by neglect at the earliest opportunity, the Chief Nursing Officer confirmed that this information would be made available within the monthly Group Risk and Assurance Committee Summary Report. Group Committees in Common confirmed progress in the monitoring and management of governance assurance systems. 11. Staff Engagement Progress Report The Chief Strategy and Organisational Development Officer provided progress to date regarding the following staff engagement programmes; 1000 Voices Events, Pioneer Programme Rollout and Q1 Pulse Check Survey Results for the North East Sector Care Organisations. In response to the Senior Independent Director seeking further information regarding the number of staff participating in the 1000 Voices Events, the Chief Strategy and Organisational Development Officer offered that, in addition to the 150 staff members attending the 1000 Voices Event, many more had been involved in various staff engagement projects and that the events must not be viewed in isolation. The Chief Nursing Officer described the fantastic engagement, and considerable number of staff attending the Steve Head Sessions and recently launched Quality Improvement Collaboratives. The North Manchester Medical Director emphasised the importance of acting on, and delivering, outcomes from the staff engagement sessions. The Chief Executive concurred, further highlighting the importance of communicating a simple set of actions on which staff can act. The Group Committees in Common reviewed and confirmed the progress to date and supported actions to address challenges faced. 12. Memorandum of Understanding: SRFT and Centre for Healthcare Innovation, Singapore The Chief Strategy and Organisational Development Officer informed the Group Committees in Common that SRFT and Haelo had been invited to join a co-learning network with global thought leaders in improvement and 11/13 13/112

14 No. Item Action innovation, led by the Centre for Healthcare Innovation (CHI) in Singapore. He confirmed that the proposed areas of collaboration were linked to the Group strategic agenda and provide opportunity for significant learning. The Chief Strategy and Organisational Development Officer presented the proposed Memorandum of Understanding exploring the benefits and associated risks. Group Committees in Common approved the proposed Memorandum of Understanding, to be signed in November, covering a period of three years, effective from 8 November 2017 and confirmed that the Chief Strategy and Organisational Development Officer, supported by the Haelo Associate Director would lead the partnership. 13. SRFT: SCAPE Recommendation The Group Committees in Common reviewed the recommendation of the SCAPE Panel held on 13 th July 2017 and: Approved SCAPE status for the Bladder and Bowel Service Approved deferral of SCAPE for the Community Intermediate Rehabilitation and Supportive Discharge service The Chief Nursing Officer and Senior Independent Director recognised the deferral of 2 community services to date, and offered that additional support would be provided to Community based teams to allow them to demonstrate innovation and continuous improvement. 13. Reports from Standing Committees: Group Audit Committee Meeting held on 29 th June 2017 The Vice-Chairman provided overview of the key matters and decisions made at the meeting on 29 th June Group Executive Committees: Risk and Assurance Committee Meeting held on 17 th July 2017 The Chief Executive Officer provided overview of the key matters and decisions made at the meeting on 17 th July Any Other Business (Part 1) No other business 15. Date and Time of the Next Meeting The Chairman confirmed that the next meeting would take place on Monday, 25 th September 2017 from am at Humphrey Booth Lecture Theatre, Mayo Building. Closure of Part 1 of the Group Committees in Common Meeting 16. Exclusion of the Public The Group Committees in Common resolved to exclude the press and 12/13 14/112

15 No. Item Action public from the meeting at this point on the grounds that publicity of the matters being reviewed would be inappropriate, by reason of the sensitive and confidential nature of business. Members of the public were requested to leave the meeting room at this point. 13/13 15/112

16 Committee in Common Scorecard Saving Lives, Improving Lives by delivering highly reliable services at scale, which are trusted, connected and pioneering Highly Reliable & Trusted Harms Salford HSMR Rolling 12 Month HSMR is statistically below the national position. However, Salford CO's HSMR has increased incrementally for the last four rolling periods. Fairfield: HSMR is statistically as expected as a result of improvements in documentation and coding as well as a reduction in in-hospital deaths. Rochdale has seen an increase in mortality indicators as a result of increased in hospital deaths. Casenote reviews are being undertaken to determine any underlying cause Fairfield HSMR Rolling 12 Month 14/15 Q1 14/15 Q2 14/15 Q3 14/15 Q4 15/16 Q1 15/16 Q2 15/16 Q3 15/16 Q4 16/17 Q1 16/17 Q2 16/17 Q3 16/17 Q Rochdale HSMR Rolling 12 Month 60 Actual Av UCL LCL +1 Sigma -1 Sigma +2 Sigma -2 Sigma HSMR is a ratio of the observed number of in-hospital deaths to the expected number of inhospital deaths for 56 specific Clinical Classification System (CCS) groups. HSMR is risk adjusted to take into account key risk factors associated with mortality /15 Q1 14/15 Q2 14/15 Q3 14/15 Q4 15/16 Q1 15/16 Q2 15/16 Q3 15/16 Q4 16/17 Q1 16/17 Q2 16/17 Q3 16/17 Q4 HSMR for Pennine as a Trust has reduced mortality to statistically within expected levels compared to national. Salford remain statistically below expected. 120 North Manchester HSMR Rolling 12 Month HSMR is updated quarterly and the latest data is presented here. 120 Oldham HSMR Rolling 12 Month Actual Av UCL LCL +1 Sigma -1 Sigma +2 Sigma -2 Sigma HSMR for North Manchester is statistically above expected. This increase is not reflected in an increase in hospital deaths but more as a result of a change in casemix, according to the data. Further deep dive analysis is being undertaken to support the CO to focus their action plans. HSMR for Oldham CO remains within statistically expected levels Actual Av UCL LCL +1 Sigma -1 Sigma +2 Sigma -2 Sigma HSMR - Rolling 12 months Salford Royal Foundation Trust Pennine Acute Hospitals Trust 14/15 Q1 14/15 Q2 14/15 Q3 14/15 Q4 15/16 Q1 15/16 Q2 15/16 Q3 15/16 Q4 16/17 Q1 16/17 Q2 16/17 Q3 16/17 Q /19 16/112

17 Committee in Common Scorecard Saving Lives, Improving Lives by delivering highly reliable services at scale, which are trusted, connected and pioneering Highly Reliable & Trusted Harms Salford SHMI Quarterly SHMI for the Salford Care Organisation is statistically lower than the expected level. SHMI for Fairfield is above the expected range and is the subject of more detailed review. SHMI at Rochdale remains below expected levels Fairfield SHMI Quarterly 14/15 Q1 14/15 Q2 14/15 Q3 14/15 Q4 15/16 Q1 15/16 Q2 15/16 Q3 15/16 Q4 16/17 Q1 16/17 Q2 16/17 Q Rochdale SHMI Quarterly 80 Actual Av UCL LCL +1 Sigma -1 Sigma +2 Sigma -2 Sigma SHMI is the ratio between the actual number of patients who die following hospitalisation and the number that would be expected to die on the basis of average England rates and then risk adjusted to take into account key risk factors associated with mortality /15 Q1 14/15 Q2 14/15 Q3 14/15 Q4 15/16 Q1 15/16 Q2 15/16 Q3 15/16 Q4 16/17 Q1 16/17 Q2 16/17 Q3 Salford's SHMI remains statistically lower than expected, although there has been an increase in quarter. Pennine as a Trust has a SHMI which is statistically higher than expected (against 95% Confidence Intervals). SHMI is updated quarterly. North Manchester SHMI Quarterly Oldham SHMI Rolling 12 Month SHMI for the North Manchester Care Organisation continues to be above expected levels but has reduced over the last quarter. SHMI for the Oldham Care Organisation remains above expected levels Actual Av UCL LCL +1 Sigma -1 Sigma +2 Sigma -2 Sigma Actual Av UCL LCL +1 Sigma -1 Sigma +2 Sigma -2 Sigma SHMI - Quarterly Salford Royal Foundation Trust Pennine Acute Hospitals Trust 14/15 Q1 14/15 Q2 14/15 Q3 14/15 Q4 15/16 Q1 15/16 Q2 15/16 Q3 15/16 Q4 16/17 Q1 16/17 Q2 16/17 Q /19 17/112

18 Apr-16 May-16 Jun-16 Jul-16 Aug-16 Sep-16 Oct-16 Nov-16 Dec-16 Jan-17 Feb-17 Mar-17 Apr-17 May-17 Jun-17 Jul-17 Aug-17 Sep-17 Oct-17 Nov-17 Dec-17 Jan-18 Feb-18 Mar-18 Apr-16 May-16 Jun-16 Jul-16 Aug-16 Sep-16 Oct-16 Nov-16 Dec-16 Jan-17 Feb-17 Mar-17 Apr-17 May-17 Jun-17 Jul-17 Aug-17 Sep-17 Oct-17 Nov-17 Dec-17 Jan-18 Feb-18 Mar-18 Apr-16 May-16 Jun-16 Jul-16 Aug-16 Sep-16 Oct-16 Nov-16 Dec-16 Jan-17 Feb-17 Mar-17 Apr-17 May-17 Jun-17 Jul-17 Aug-17 Sep-17 Oct-17 Nov-17 Dec-17 Jan-18 Feb-18 Mar-18 Apr-16 May-16 Jun-16 Jul-16 Aug-16 Sep-16 Oct-16 Nov-16 Dec-16 Jan-17 Feb-17 Mar-17 Apr-17 May-17 Jun-17 Jul-17 Aug-17 Sep-17 Oct-17 Nov-17 Dec-17 Jan-18 Feb-18 Mar-18 Monthly Cumulative Monthly Cumulative Committee in Common Scorecard Saving Lives, Improving Lives by delivering highly reliable services at scale, which are trusted, connected and pioneering Highly Reliable & Trusted Clostridium Difficile Salford C.Dif The Salford Care Organisation is within trajectory for C.Dif. The Bury & Rochdale Care Organisation is within trajectory for C.Dif Bury & Rochdale C.Dif C-Diff Actual Trajectory C-Diff Actual Trajectory Cumulative Trajectory Cumulative Actual Cumulative Actual Cumulative Trajectory Trajectories for Clostridium Difficile have been set for each Care Organisation. This metric forms part of the Single Oversight Framework. 20 North Manchester C.Dif Oldham C.Dif C-Diff Actual Trajectory Cumulative Actual Cumulative Trajectory 5 0 The North Manchester Care Organisation remains below trajectory for C.Dif. The Oldham Care Organisation is beyond its cumulative trajectory for August after 1 occurence within the month. 5 0 C-Diff Actual Trajectory Cumulative Actual Cumulative Trajectory 5 0 3/19 18/112

19 Apr-16 May-16 Jun-16 Jul-16 Aug-16 Sep-16 Oct-16 Nov-16 Dec-16 Jan-17 Feb-17 Mar-17 Apr-17 May-17 Jun-17 Jul-17 Aug-17 Sep-17 Oct-17 Nov-17 Dec-17 Jan-18 Feb-18 Mar-18 Apr-16 May-16 Jun-16 Jul-16 Aug-16 Sep-16 Oct-16 Nov-16 Dec-16 Jan-17 Feb-17 Mar-17 Apr-17 May-17 Jun-17 Jul-17 Aug-17 Sep-17 Oct-17 Nov-17 Dec-17 Jan-18 Feb-18 Mar-18 Apr-16 May-16 Jun-16 Jul-16 Aug-16 Sep-16 Oct-16 Nov-16 Dec-16 Jan-17 Feb-17 Mar-17 Apr-17 May-17 Jun-17 Jul-17 Aug-17 Sep-17 Oct-17 Nov-17 Dec-17 Jan-18 Feb-18 Mar-18 Apr-16 May-16 Jun-16 Jul-16 Aug-16 Sep-16 Oct-16 Nov-16 Dec-16 Jan-17 Feb-17 Mar-17 Apr-17 May-17 Jun-17 Jul-17 Aug-17 Sep-17 Oct-17 Nov-17 Dec-17 Jan-18 Feb-18 Mar-18 Committee in Common Scorecard Saving Lives, Improving Lives by delivering highly reliable services at scale, which are trusted, connected and pioneering Highly Reliable & Trusted Falls Salford Falls Falls have decreased for the Salford Care Organisation in August'17. The Bury & Rochdale Care Organisation have had an increased in reported falls for August'17 and have had 3 reportable falls in the month Bury & Rochdale Falls Actual Falls Actual Falls This metric measures falls resulting in moderate harm and above. Improvement trajectories are to be set to further reduce occurrences once improvement initiatives begin in the care organisiations. 25 North Manchester Falls 25 Oldham Falls The North Manchester Care Organisation have had an increase in reported falls for August '17. The CO reported 4 falls in the month. The Oldham Care Organisation has seen 3 falls in August '17, which is an increase on July Actual Falls Actual Falls 4/19 19/112

20 Apr-16 May-16 Jun-16 Jul-16 Aug-16 Sep-16 Oct-16 Nov-16 Dec-16 Jan-17 Feb-17 Mar-17 Apr-17 May-17 Jun-17 Jul-17 Aug-17 Sep-17 Oct-17 Nov-17 Dec-17 Jan-18 Feb-18 Mar-18 Apr-16 May-16 Jun-16 Jul-16 Aug-16 Sep-16 Oct-16 Nov-16 Dec-16 Jan-17 Feb-17 Mar-17 Apr-17 May-17 Jun-17 Jul-17 Aug-17 Sep-17 Oct-17 Nov-17 Dec-17 Jan-18 Feb-18 Mar-18 Apr-16 May-16 Jun-16 Jul-16 Aug-16 Sep-16 Oct-16 Nov-16 Dec-16 Jan-17 Feb-17 Mar-17 Apr-17 May-17 Jun-17 Jul-17 Aug-17 Sep-17 Oct-17 Nov-17 Dec-17 Jan-18 Feb-18 Mar-18 Apr-16 May-16 Jun-16 Jul-16 Aug-16 Sep-16 Oct-16 Nov-16 Dec-16 Jan-17 Feb-17 Mar-17 Apr-17 May-17 Jun-17 Jul-17 Aug-17 Sep-17 Oct-17 Nov-17 Dec-17 Jan-18 Feb-18 Mar-18 Committee in Common Scorecard Saving Lives, Improving Lives by delivering highly reliable services at scale, which are trusted, connected and pioneering Highly Reliable & Trusted Harms Salford Pressure Ulcers The Salford Care Organisation has seen a decrease in Pressure Ulcers for August '17 and has an improvement trajectory of no more than five per month, which has been met. Pressure Ulcers decreased in August'17 for the Bury & Rochdale Care Organisation, reporting 5 PUs in the month. An improvement trajectory of no more than four per month has been set Bury & Rochdale Pressure Ulcers Actual Pressure Ulcers Trajectory This metric monitors pressure ulcers at Grade 2 and above, including ungraded. Actual Pressure Ulcers Trajectory Improvement trajectories have been set with each Care Organisation expected to deliver a 30% reduction in Pressure Ulcers based on the first quarter of 2017/18, as per the Care Organisation Operational Plans. Data is provided by Tissue Viability Teams. 25 North Manchester Pressure Ulcers 25 Oldham Pressure Ulcers Actual Pressure Ulcers Trajectory The North Manchester Care Organisation has had 11 pressure ulcers during August. This is an increase on July and over double the amount set in the improvement trajectory. The Oldham Care Organisation has seen a decrease in Pressure Ulcers with 13 reported in month. The improvement trajectory is no more than four Actual Pressure Ulcers Trajectory 5/19 20/112

21 Apr-16 May-16 Jun-16 Jul-16 Aug-16 Sep-16 Oct-16 Nov-16 Dec-16 Jan-17 Feb-17 Mar-17 Apr-17 May-17 Jun-17 Jul-17 Aug-17 Sep-17 Oct-17 Nov-17 Dec-17 Jan-18 Feb-18 Mar-18 Apr-16 May-16 Jun-16 Jul-16 Aug-16 Sep-16 Oct-16 Nov-16 Dec-16 Jan-17 Feb-17 Mar-17 Apr-17 May-17 Jun-17 Jul-17 Aug-17 Sep-17 Oct-17 Nov-17 Dec-17 Jan-18 Feb-18 Mar-18 Apr-16 May-16 Jun-16 Jul-16 Aug-16 Sep-16 Oct-16 Nov-16 Dec-16 Jan-17 Feb-17 Mar-17 Apr-17 May-17 Jun-17 Jul-17 Aug-17 Sep-17 Oct-17 Nov-17 Dec-17 Jan-18 Feb-18 Mar-18 Apr-16 May-16 Jun-16 Jul-16 Aug-16 Sep-16 Oct-16 Nov-16 Dec-16 Jan-17 Feb-17 Mar-17 Apr-17 May-17 Jun-17 Jul-17 Aug-17 Sep-17 Oct-17 Nov-17 Dec-17 Jan-18 Feb-18 Mar-18 Committee in Common Scorecard Saving Lives, Improving Lives by delivering highly reliable services at scale, which are trusted, connected and pioneering Highly Reliable & Connected Care Urgent Care 100% 95% 90% 85% 80% 75% 70% 65% 60% 55% 50% Salford A&E 4 Hour Performance The Salford Care Organisation is above it's improvement trajectory and has seen improvement in month. The Bury & Rochdale Care Organisation continues to deliver it's improvement trajectory and is above expected performance for August' % 95% 90% 85% 80% 75% 70% 65% 60% 55% 50% Bury & Rochdale A&E 4 Hour Performance Actual Trajectory Waiting times in A&E from arrival to admission, transfer or discharge should be a maximum of 4hrs for 95% of patients. Improvemnt trajectories have been set for Care Organisations to ensure deliver of 95% at a Trust level by March '18. Actual Trajectory 100% 95% 90% 85% 80% 75% 70% 65% 60% 55% 50% North Manchester A&E 4 Hour Performance Actual Trajectory The North Manchester Care Organisation is above it's improvement trajectory however has seen a deterioration in month. As a Trust, Pennine has failed to achieve it's trajectory for August '17 with an overall performance of 85.01%. Salford has achieved it's trajectory for August'17. Oldham Care Organisation performance has improved in month but is still below it's improvement trajetory. Detailed analysis has been completed and an improvement programme is 100% 95% 90% 85% 80% 75% 70% 65% 60% 55% 50% Oldham A&E 4 Hour Performance Actual Trajectory A&E 4 Hour Performance Salford Royal Foundation Trust Pennine Acute Hospitals Trust Jul-16 Aug-16 Sep-16 Oct-16 Nov-16 Dec-16 Jan-17 Feb-17 Mar-17 Apr-17 May-17 Jun-17 Jul-17 Aug % 90.1% 92.0% 87.6% 80.2% 83.7% 76.7% 77.3% 84.8% 89.9% 82.1% 83.6% 91.6% 93.0% 81.6% 87.1% 84.7% 81.6% 79.6% 77.8% 76.7% 78.1% 81.3% 80.9% 86.4% 83.5% 84.5% 85.0% 6/19 21/112

22 Apr-16 May-16 Jun-16 Jul-16 Aug-16 Sep-16 Oct-16 Nov-16 Dec-16 Jan-17 Feb-17 Mar-17 Apr-17 May-17 Jun-17 Jul-17 Aug-17 Sep-17 Oct-17 Nov-17 Dec-17 Jan-18 Feb-18 Mar-18 Apr-16 May-16 Jun-16 Jul-16 Aug-16 Sep-16 Oct-16 Nov-16 Dec-16 Jan-17 Feb-17 Mar-17 Apr-17 May-17 Jun-17 Jul-17 Aug-17 Sep-17 Oct-17 Nov-17 Dec-17 Jan-18 Feb-18 Mar-18 Apr-16 May-16 Jun-16 Jul-16 Aug-16 Sep-16 Oct-16 Nov-16 Dec-16 Jan-17 Feb-17 Mar-17 Apr-17 May-17 Jun-17 Jul-17 Aug-17 Sep-17 Oct-17 Nov-17 Dec-17 Jan-18 Feb-18 Mar-18 Apr-16 May-16 Jun-16 Jul-16 Aug-16 Sep-16 Oct-16 Nov-16 Dec-16 Jan-17 Feb-17 Mar-17 Apr-17 May-17 Jun-17 Jul-17 Aug-17 Sep-17 Oct-17 Nov-17 Dec-17 Jan-18 Feb-18 Mar-18 Committee in Common Scorecard Saving Lives, Improving Lives by delivering highly reliable services at scale, which are trusted, connected and pioneering Highly Reliable & Trusted Elective Access 96% 94% 92% 90% 88% 86% 84% 82% 80% Salford RTT Open Performance The Salford Care Organisation continues to meet the 92% standard. In August there were 2 Open 52 week breaches, and 2 Non-Admitted 52 week breaches. The Bury & Rochdale Care Organisation has failed to meet the 92% standard with performance of 91.86%. 100% 98% 96% 94% 92% 90% 88% 86% 84% 82% 80% Bury & Rochdale RTT Open Performance Actual Target Actual Target Stretch Target Referral to Treatment waiting times for open pathways should not exceed 18 weeks for 92% of patients. North Manchester RTT Open Performance Oldham RTT Open Performance 100% 98% 96% 94% 92% 90% 88% 86% 84% 82% 80% The North Manchester Care Organisation has deteriorated in performance in August'17 and is still below the 92% standard with a performance of 90.44%. Oldham Care Organisation has seen a deterioration in performance in August'17 and is still below the 92% standard with a performance of 87.48%. 100% 98% 96% 94% 92% 90% 88% 86% 84% 82% 80% Actual Target Actual Target RTT Open Performance Salford Royal Foundation Trust Pennine Acute Hospitals Trust Aug-16 Sep-16 Oct-16 Nov-16 Dec-16 Jan-17 Feb-17 Mar-17 Apr-17 May-17 Jun-17 Jul-17 Aug % 92.8% 92.9% 92.6% 92.0% 92.7% 92.5% 92.7% 92.4% 93.0% 93.0% 92.4% 92.2% 92.0% 92.1% 92.7% 92.3% 93.1% 92.1% 92.1% 92.2% 92.0% 92.1% 92.2% 90.9% 89.8% 7/19 22/112

23 Apr-16 May-16 Jun-16 Jul-16 Aug-16 Sep-16 Oct-16 Nov-16 Dec-16 Jan-17 Feb-17 Mar-17 Apr-17 May-17 Jun-17 Jul-17 Aug-17 Sep-17 Oct-17 Nov-17 Dec-17 Jan-18 Feb-18 Mar-18 Apr-16 May-16 Jun-16 Jul-16 Aug-16 Sep-16 Oct-16 Nov-16 Dec-16 Jan-17 Feb-17 Mar-17 Apr-17 May-17 Jun-17 Jul-17 Aug-17 Sep-17 Oct-17 Nov-17 Dec-17 Jan-18 Feb-18 Mar-18 Apr-16 May-16 Jun-16 Jul-16 Aug-16 Sep-16 Oct-16 Nov-16 Dec-16 Jan-17 Feb-17 Mar-17 Apr-17 May-17 Jun-17 Jul-17 Aug-17 Sep-17 Oct-17 Nov-17 Dec-17 Jan-18 Feb-18 Mar-18 Apr-16 May-16 Jun-16 Jul-16 Aug-16 Sep-16 Oct-16 Nov-16 Dec-16 Jan-17 Feb-17 Mar-17 Apr-17 May-17 Jun-17 Jul-17 Aug-17 Sep-17 Oct-17 Nov-17 Dec-17 Jan-18 Feb-18 Mar-18 Committee in Common Scorecard Saving Lives, Improving Lives by delivering highly reliable services at scale, which are trusted, connected and pioneering Highly Reliable & Trusted Cancer Pathways 100% 95% 90% 85% 80% 75% 70% 65% 60% Salford 62 Day Performance Salford continues to meet the 85% standard. The Gynaecological, Haematological, Lung and UGI tumour groups fell below the national standard. Performance for Pennine has improved in July. Achievement of the standard is expected in Quarter Two. All tumour groups with the exception of Breast, Head & Neck, Lung, Sarcoma and Other fell below the national standard. 100% 95% 90% 85% 80% 75% 70% 65% 60% Pennine 62 Day Performance National GM Target Salford 2 Week Wait Performance 100% 98% 96% 94% 92% 90% 88% 86% 84% 82% 80% Actual Target All patients should receive an inital appointment within 14 days of urgent referral for suspected cancer. Those referred urgently and diagnosed with cancer should begin their first definitive treatment within 62 days of referral. Salford continues to deliver the standard and has improved in month. Cancer performance is currently reported at Trust level and is two months retrospective. Greater Manchester (GM) Trusts have a repatriation agreement which may mean performance against this standard differs to Pennine's two week wait performance saw a slight improvement in month however the standard has not been achieved. This may lead to challenges for the 62 days standard in coming National GM Target Pennine 2 Week Wait Performance 100% 98% 96% 94% 92% 90% 88% 86% 84% 82% 80% Actual Target 62 Day National Salford Royal Foundation Trust Pennine Acute Hospitals Trust 62 Day GM Salford Royal Foundation Trust Pennine Acute Hospitals Trust TWW Salford Royal Foundation Trust Pennine Acute Hospitals Trust Jul-16 Aug-16 Sep-16 Oct-16 Nov-16 Dec-16 Jan-17 Feb-17 Mar-17 Apr-17 May-17 Jun-17 Jul % 88.4% 86.0% 97.3% 93.2% 88.9% 89.9% 89.3% 89.8% 88.9% 90.2% 86.9% 89.1% 83.6% 87.7% 84.2% 81.9% 89.0% 87.6% 85.6% 82.4% 76.1% 77.1% 79.9% 73.9% 82.7% Jul-16 Aug-16 Sep-16 Oct-16 Nov-16 Dec-16 Jan-17 Feb-17 Mar-17 Apr-17 May-17 Jun-17 Jul % 87.0% 81.3% 97.3% 90.4% 86.8% 85.0% 88.5% 88.5% 85.4% 87.5% 85.0% 87.1% 79.7% 83.6% 80.1% 77.9% 85.3% 82.9% 82.2% 74.6% 69.1% 72.1% 72.8% 69.4% 77.8% Jul-16 Aug-16 Sep-16 Oct-16 Nov-16 Dec-16 Jan-17 Feb-17 Mar-17 Apr-17 May-17 Jun-17 Jul % 93.0% 96.7% 97.8% 96.4% 96.1% 93.0% 96.9% 92.8% 93.2% 97.0% 95.2% 96.1% 93.5% 93.5% 94.8% 95.8% 97.3% 93.6% 89.4% 94.8% 93.5% 87.4% 95.6% 85.1% 85.7% 8/19 23/112

24 Apr-16 May-16 Jun-16 Jul-16 Aug-16 Sep-16 Oct-16 Nov-16 Dec-16 Jan-17 Feb-17 Mar-17 Apr-17 May-17 Jun-17 Jul-17 Aug-17 Sep-17 Oct-17 Nov-17 Dec-17 Jan-18 Feb-18 Mar-18 Apr-16 May-16 Jun-16 Jul-16 Aug-16 Sep-16 Oct-16 Nov-16 Dec-16 Jan-17 Feb-17 Mar-17 Apr-17 May-17 Jun-17 Jul-17 Aug-17 Sep-17 Oct-17 Nov-17 Dec-17 Jan-18 Feb-18 Mar-18 Apr-16 May-16 Jun-16 Jul-16 Aug-16 Sep-16 Oct-16 Nov-16 Dec-16 Jan-17 Feb-17 Mar-17 Apr-17 May-17 Jun-17 Jul-17 Aug-17 Sep-17 Oct-17 Nov-17 Dec-17 Jan-18 Feb-18 Mar-18 Apr-16 May-16 Jun-16 Jul-16 Aug-16 Sep-16 Oct-16 Nov-16 Dec-16 Jan-17 Feb-17 Mar-17 Apr-17 May-17 Jun-17 Jul-17 Aug-17 Sep-17 Oct-17 Nov-17 Dec-17 Jan-18 Feb-18 Mar-18 Committee in Common Scorecard Saving Lives, Improving Lives by delivering highly reliable services at scale, which are trusted, connected and pioneering Highly Reliable & Trusted Diagnostic Access 100% 98% 96% 94% 92% 90% 88% 86% 84% 82% 80% Salford Diagnostic 6 Week Performance Performance for the Salford Care Orgnisation in August '17 was 95.36% however remains subject to final validation. The Bury &Rochdale Care Organisation continues to maintain 100% compliance with the standard. In terms of diagnostics, this Care Organisation provides ECGs only. 100% 98% 96% 94% 92% 90% 88% 86% 84% 82% 80% Bury & Rochdale Diagnostic 6 Week Performance Actual Target Key diagnostic tests should to be carried out within 6 weeks of the request for the test being made for 99% of patients. Actual Target The Salford Care Organisation is expected to recover performance by Q4. 100% 98% 96% 94% 92% 90% 88% 86% 84% 82% 80% North Manchester Diagnostic 6 Week Performance Actual Target The North Manchester Care Organisation has failed to acheive the standard for August with a performance of 89.01%. In terms of diagnostics, this covers Cystoscopy (4), Audiology (0), Sleep Studies (66) and Neurophysiology (0). Breaches in brackets. The Oldham Care Organisation has failed to acheive the 99% standard with performance of 97.92% for August. This metric relates to Radiology, Urodynamics,Gastroscopy, Colonoscopy & Flexi Sigmoidoscopy. 100% 98% 96% 94% 92% 90% 88% 86% 84% 82% 80% Oldham Diagnostic 6 Week Performance Actual Target 6 Wk Diagnostic Performance Salford Royal Foundation Trust Pennine Acute Hospitals Trust Aug-16 Sep-16 Oct-16 Nov-16 Dec-16 Jan-17 Feb-17 Mar-17 Apr-17 May-17 Jun-17 Jul-17 Aug % 99.4% 99.4% 99.4% 99.1% 99.2% 99.0% 99.0% 99.1% 99.0% 99.1% 98.1% 95.4% 90.8% 94.6% 99.2% 99.3% 99.0% 99.1% 99.6% 99.4% 99.2% 99.1% 97.5% 97.6% 97.5% 9/19 24/112

25 Committee in Common Scorecard Saving Lives, Improving Lives by delivering highly reliable services at scale, which are trusted, connected and pioneering Connected & At Scale Workforce 6.00% 5.00% Salford - Sickness Absence The Salford Care Organisation has seen an decrease in sickness absence rates in month and remains below target. The Bury & Rochdale Care Organisation has seen a slight decrease in sickness absence rates in month but remains above target. 6.00% 5.00% Bury & Rochdale - Sickness Absence 4.00% 4.00% 3.00% 3.00% 2.00% 2.00% 1.00% 1.00% 0.00% 0.00% Salford Stretch Target Target Bury & Rochdale Target Sickness absence is the percentage of sickness in terms of WTEs. This includes both short-term and long-term sickness over a rolling 12 month period. Sickness absence data for Pennine Care Organisations excludes Corporate, Clinical Support Services and Estates. North Manchester - Sickness Absence Oldham- Sickness Absence 6.00% 6.00% 5.00% 5.00% 4.00% 4.00% 3.00% 3.00% 2.00% 2.00% 1.00% 0.00% North Manchester Target The North Manchester Care Organisation has seen an decrease in sickness absence rates in month however remains above target. The Oldham Care Organisation has seen a slight decrease in sickness absence rates in month and remains below target. 1.00% 0.00% Oldham Target 10/19 25/112

26 Committee in Common Scorecard Saving Lives, Improving Lives by delivering highly reliable services at scale, which are trusted, connected and pioneering Highly Reliable & Trusted Safe Staffing 150% 140% 130% 120% 110% 100% 90% 80% 70% 60% Salford Safe Staffing Performance The Salford Care Organisation has met the standard for Care Staff Day/Night but is below the standard for Nurse shift types. The Bury & Rochdale Care Organisation has met the standard for Care Staff Night but is below the standard for all other shift types 120% 110% 100% 90% 80% 70% 60% Bury & Rochdale Safe Staffing Performance Nurses % - Day Nurses % - Night Care Staff % - Day Care Staff % - Night Target The Safe Staffing metric compared the actual number of ward shifts filled compared to the number of expected to be filled. This is split be nursing and care staff and day and night shifts. All wards should achieve 95% compliance. Nurses % - Day Nurses % - Night Care Staff % - Day Care Staff % - Night Target North Manchester Safe Staffing Performance Oldham Safe Staffing Performance 150% 140% 130% 120% 110% 100% 90% 80% 70% 60% North Manchester Care Organisation achieved he standard for Care Staff and Nurse Night but is below the 95% target for Nurse Day shifts The Oldham Care Organisation has met the standard for Care Staff Day/Night but is below the standard for Nurse shift types. 130% 120% 110% 100% 90% 80% 70% 60% Nurses % - Day Nurses % - Night Care Staff % - Day Care Staff % - Night Target Nurses % - Day Nurses % - Night Care Staff % - Day Care Staff % - Night Target 11/19 26/112

27 Committee in Common Scorecard Saving Lives, Improving Lives by delivering highly reliable services at scale, which are trusted, connected and pioneering Highly Reliable & Trusted Safe Staffing Salford North Manchester Day Night Day Night Average fill rate - Average fill rate - Average fill rate - Average fill rate - Average fill rate - Average fill rate - Average fill rate - Average fill rate - Ward Ward registered nurses care staff registered nurses care staff registered nurses care staff registered nurses care staff ANU 62.04% 83.97% 76.70% 99.00% AnteNatal Ward 89.13% 82.26% 76.14% 90.32% ASU 72.18% 78.51% 67.74% 98.13% Childrens % 52.50% % % B % 95.02% 75.00% % Critical Care 89.06% % 96.17% % B % 94.24% 69.07% % Labour Ward 92.34% 78.86% 91.43% 50.75% B % 82.35% 92.65% 96.00% Neonatal Unit 77.37% 45.16% 76.97% - B % 96.68% 84.86% % PostNatal Ward 86.78% 87.50% 84.55% % B % 87.77% 95.79% % Ward C3 & C % 98.27% % % B % 71.52% 73.12% 96.67% Ward C % 87.66% 95.16% % C % 90.61% 74.70% 95.11% Ward C % 85.28% 98.41% % CCU 90.82% 97.41% 92.52% % Ward CCU G % 95.16% % % CPIU 90.32% 70.70% 88.24% % Ward D % 90.32% % % EAU 76.52% % 88.26% % Ward D % % % % HAEM 85.33% % % % Ward E % % 98.92% % HB % % 69.89% % Ward E % % % % HB % % 68.69% % Ward F % % % % HCU 81.65% % 76.61% % Ward F % % % % HH1M 92.20% % 92.74% % Ward F % % % % H % 94.65% 82.95% % Ward H % 95.08% 85.92% % H % 97.85% 77.59% % Ward I % 89.69% 96.40% % H % 88.17% 74.19% % Ward I % 92.75% % % H % % 64.52% % Ward J3J % 99.47% 97.42% % H % 81.92% 76.92% 87.50% Ward J % % % % H % % 78.92% % Ward STU 68.63% 95.61% 77.22% % L % 94.12% 62.37% % L % % 67.82% % L % % 68.13% % L % % 73.56% % L % % 68.04% % M % % 83.33% % MA % % % % MAPL 67.03% 92.34% 82.43% % SRU 68.48% 82.51% 98.39% % 12/19 27/112

28 Committee in Common Scorecard Saving Lives, Improving Lives by delivering highly reliable services at scale, which are trusted, connected and pioneering Highly Reliable & Trusted Safe Staffing Bury & Rochdale Oldham Day Night Day Night Average fill rate - Average fill rate - Average fill rate - Average fill rate - Average fill rate - Average fill rate - Average fill rate - Average fill rate - Ward Hospital Ward registered nurses care staff registered nurses care staff registered nurses care staff registered nurses care staff Fairfield Ward 10 (ITU/HDU) 95.31% 74.19% 94.19% 48.39% A&E Observation Ward % 95.16% % 90.32% Fairfield Ward 11a 84.41% 94.55% 88.17% % Antenatal Ward % % 94.62% % Fairfield Ward 11b (Stroke) 87.17% 78.37% 89.25% % Childrens Unit 94.19% 77.69% 96.27% 62.86% Fairfield Ward % 72.30% % 89.23% Critical Care 87.47% 73.17% 94.89% 93.55% Fairfield Ward % 79.34% % % Labour Ward 93.01% 94.35% 92.83% 88.71% Fairfield Ward 2 CCU 89.11% 66.46% 85.48% 74.51% Neonatal Unit 83.86% 47.58% 81.08% - Fairfield Ward % 96.79% 88.17% % Postnatal Ward 90.69% 95.43% 96.77% 80.65% Fairfield Ward % 79.29% 97.85% 98.78% Ward AMU 84.11% % 88.17% % Fairfield Ward % 98.84% 87.10% % Ward CCU 94.35% 92.86% 93.44% % Fairfield Ward % 96.07% 91.60% % Ward F % 91.34% 87.69% 98.39% Fairfield Ward % 87.50% 92.71% 98.53% Ward F % % 92.47% % Fairfield Ward % 52.15% 72.83% 68.85% Ward F % % 92.47% % Birch Hill Floyd Unit 89.52% 84.72% 96.77% % Ward F % % % % Rochdale Clinical Admissions Unit 95.69% 87.72% % % Ward F % % 91.94% 96.97% Rochdale Oasis Unit - RI % % % 97.30% Ward F % 93.05% 90.32% % Rochdale Wolstenholme Unit - RI 94.62% % 79.49% % Ward G % % 97.85% 98.39% Ward G % % 90.32% 98.39% Ward T % % 92.13% % Ward T4 STU 81.47% % 95.79% % Ward T % 94.09% 83.87% % Ward T % 89.81% 83.33% % Ward T % % 93.01% % 13/19 28/112

29 m m m m Committee in Common Scorecard Saving Lives, Improving Lives by delivering highly reliable services at scale, which are trusted, connected and pioneering Highly Reliable & Trusted Finance Apr-17 May-17 Salford Finance Performance Nov-17 Oct-17 Sep-17 Aug-17 Jul-17 Jun-17 Performance vs. Control Total Dec-17 Jan-18 Feb-18 Mar-18 The Salford Care Organisation financial position is 0.24m better than the control total. The Bury & Rochdale Care Organisation financial position is 0.0m better than the control total Apr-17 May-17 Bury & Rochdale Finance Performance Dec-17 Nov-17 Oct-17 Sep-17 Aug-17 Jul-17 Jun-17 Performance vs. Control Total Jan-18 Feb-18 Mar-18 Financial performance for care organisation is monitored in terms of alignment with budgetary control totals.. Corporate and Support Services for Pennine care organisations are managed centrally and are not included in individual care organisation performance. Salford hosted services are also excluded from the Salford Care Organisation position. North Manchester Finance Performance Oldham Finance Performance Apr-17 May-17 Jun-17 Jul-17 Aug-17 Sep-17 Oct-17 Nov-17 Dec-17 Jan-18 Feb-18 Mar Apr-17 May-17 Jun-17 Jul-17 Aug-17 Sep-17 Oct-17 Nov-17 Dec-17 Jan-18 Feb-18 Mar North Manchester Care Organisation financial position is 5.39m worse than the the control total. The Oldham Care Organisation financial position is 3.03m worse than the control total Performance vs. Control Total Performance vs. Control Total 14/19 29/112

30 Site Risk Name Principal Risk Risk Lead Action Plan Summary Risk Score SRFT Clinical Staffing Levels IF established Trust-wide clinical staffing levels cannot be achieved, THEN the Trust will remain heavily reliant on non-contracted staff which may in turn compromise patient care and service delivery Chief Strategy and Organisational Development Officer Monthly Workforce Strategy Board in place and focussing on effectively addressing this risk Focus on delivery of divisional workforce strategies Working with Universities to ensure the Salford Royal job offer is fully understood and we recruit as many newly qualified nurses as possible Full implementation of Trendcare in progress Fair and equitable bank rates for all general wards 13 SRFT Delivering Better Lower Cost IF the Trust fails to deliver Better Care at Lower Cost target of 28.7m in 2017/18 THEN the Trust may not achieve the forecast outturn financial position for 2017/18 Chief Finance Officer Work streams continue to develop for 2017/ SRFT A&E 4 Hour Target IF demand for emergency admission exceeds non-elective capacity or specialist teams/diagnostic services do not respond in a timely manner THEN more than 5% of patients will wait longer than four hours in A&E, and elective flow and patient care may be compromised Chief Delivery Officer Please see Clinical Staffing Risk Revising Urgent Care Action Plan Review of escalation / divert processes across Greater Manchester in progress 13 SRFT Radiology Turn- Around Times IF there are insufficient suitably qualified doctors and radiographers to report images in a timely manner THEN it increases the risk of delayed diagnosis resulting in higher morbidity and mortality with resultant increased cost and potential damage to Trust reputation Chief Strategy and Organisational Development Officer Update job plans following completion of capacity and demand calculation. MSK Radiologist appointments being considered 13 SRFT Vascular Intervention IF there is no provision for vascular intervention on site THEN patients are at increased risk of delays which may lead to higher rates of mortality and morbidity (In particular this is in relation to GI bleeds or bleeds as a result of renal biopsy. SRFT does not have vascular services on site, but is still required to provide vascular radiology support) Chief Medical Officer The risk has been escalated to CEO s in both organisations which has opened up channels for further discussion. CMFT are still in discussions around non trauma related vascular radiology at SRFT. Final word required from Ian Lurcock and Jane Eddlestone at CMFT and a response has been chased. SLA produced to cover trauma agreed SLA for non-trauma outstanding and awaits feedback 6.5 PA's suggested to be paid for this cover but CMFT have failed to recruit into vacant positions to support this service 12 SRFT Neuro Rehabilitation Pathways IF the issues of fragmentation, lack of co-ordination, lack of standard framework for clinical practice, and delays to securing complex packages of care for neuro-rehabilitation are not resolved across Greater Manchester, THEN the upstream backlog in terms of pressure in acute care capacity and hence cost will continue to be carried by Salford Royal Chief Medical Officer As part of Trauma Programme of Care SRFT would see itself becoming the lead provider for neurorehabilitation in Greater Manchester which would assist in facilitating standards of care across the rehab pathway and co-ordination of care and patient flow /19 30/112

31 Site Risk Name Principal Risk Risk Lead Action Plan Summary Risk Score SRFT Increased Number of Trauma Admissions IF the number of trauma admissions continues to increase THEN there will be a delay to patients accessing theatre/surgery within an appropriate clinical time period therefore patient outcomes maybe be adversely affected Chief Delivery Officer Action plan underway. 12 SRFT Paediatric Provision and Support IF there is not sufficient paediatric provision & support onsite THEN paediatrics are at increased risk of harm & may lead to increased mortality and morbidity (In particular SRFT is a designated Paediatric Trauma Unit and as such will receive Paediatric Trauma and Paediatric emergencies. These will require anaesthetic support from the consultant anaesthetists at SRFT and potentially emergency surgery should there be life threatening trauma. Further detail included in Datix) Chief Medical Officer Clinical Effectiveness Committee to oversee the following actions Service review as part of NW sector plans SOP being developed Meetings planned with NWAS 12 SRFT Capital Requirements for Major Trauma and Healthier Together IF the Trust fails to secure agreement around capital requirement for Major Trauma and Healthier Together in a timely manner THEN there is a significant risk to the implementation timetable for these important strategic developments Chief Strategy and Organisational Development Officer Development of Major Trauma and Healthier Together mobilisation plans, pending capital approval. 12 SRFT Transformation Funding IF the Trust fails to secure the appropriate transformation funding for PAHT THEN SRFT will withdraw its offer to incorporate PAHT in the SRFT Group Chief Strategy and Organisational Development Officer SRFT to prepare exit strategy in preparedness of system failure Further submission to GM HSCP for additional transformation funding Ongoing talks with national bodies 12 SRFT Activity and Income Levels IF the planned activity and income levels are not achieved and/or expenditure controls are exceeded leading to a NHSI Use of Resources Rating lower than planned in 2017/18, THEN this will increase regulatory investigation and intervention Chief Finance Officer Financial Plan for 2017/18 approved by Board of Directors December SRFT Capacity Plans for Increasing Demand IF specialities do not have robust capacity plans in place to meet demand / increasing demand and standardised systems in place to effectively manage the open/incomplete referral to treatment time standard THEN more than 8% of patients will not receive their treatment within 18 weeks Chief Delivery Officer Task and Finish Group ongoing to review the systems and processes in place to ensure standardisation across the organisation and systemize patient activity recording processes. Revised Recovery Plan in place. 12 SRFT Compliance with the Capped Agency Rate IF the Trust does not comply with the capped agency rates (from Nov 16) and cannot provide adequate explanation for breaches, THEN this may adversely affect the Trust s Single Oversight Framework rating Chief Strategy and Organisational Development Officer Director of OD and Medical Director to meet with counterparts at CMFT to reach agreement on compliance. 12 SRFT Operational Estate Capacity IF the Trust cannot secure sufficient and operational estate capacity THEN future service developments may be at risk Chief Strategy and Organisational Development Officer Better Care at Lower Cost Programme underway to improve bed capacity and utilisation. Stage 1 works to provide additional beds are underway. Review of future service requirements underway in conjunction with HT and MTC /19 31/112

32 Site Risk Name Principal Risk Risk Lead Action Plan Summary Risk Score Engagement plan 2017/18 presented to Board in May 2017 PAHT Omni recruitment review complete and implementation plan being developed IF evidenced based budgeted establishment levels are not Chief Nursing Officer Recruiting to New Care Organisation Management Teams in place maintained THEN the quality of care will be compromised and cost and Chief Medical Establishment OD plan phase 1 mobilised reduction targets not met Officer Corporate Services Review to report in June Re-engineering Workforce Directorate implemented in Q2 13 PAHT PAHT Stabilising the Workforce in ED and AMU Achieving the 62 Day National Cancer Target IF the Trust is unable to stabilise and sustain the medical and nursing workforce to support ED and AMU THEN there is a risk that the Trust could not provide high quality, timely 24/7 emergency care IF Capacity and Demand is not matched for challenged specialities THEN patients may not be treated within required timescales resulting in potential harm to patients, poor experience and failure of Cancer 62 day National Standards Chief Nursing Officer and Chief Medical Officer Chief Delivery Officer Continue to implement Improvement Plan (timelines outlined within plan) Recruitment against approved funding for consultants appointment within 17/18 financial plan (Dec 2017) Appoint to existing gaps in NMGH new Divisional and Directorate structures Work with UHSM to strengthen acute physician input into AMU Deliver against plan to expand AMU Beds Transition to NHSP and recruit to nursing workforce gaps Review Consultant leave Policies Training in place for bowel screening Continue Private sector capacity Gastro and recruit to business plan Pathway review with CMFT for urology Review colorectal / General surgical pathways and capacity Procure Capacity / demand tool and training and standardise model Transition plan to be progressed Re-establishment of Divisional Performance and Assurance systems PAHT IF lessons learnt are not acted upon following the Diagnostic review Learning Lessons THEN system failures could affect the quality of patient care from the delivered and regulatory involvement and reputational damage could Diagnostic Review occur Chief Nursing Officer and Chief Medical Officer Missed diagnosis e-learning programme launched December 2016 Radiology Reporting Policy Protocols and Procedures policy reviewed and updated. Draft considered at Diagnostic Review Group in Feb 2017 reported to the Audit Committee by Chief Medical Officer May 2017 and agenda item at Clinical Effectiveness Committee in My 2017 EPR system to control and manage diagnostic requests to be implemented April 2017 CRIS Communicator pilots to be commenced on all four sites 13 PAHT National Referral To Treatment standards IF Capacity and Demand is not matched for challenged specialities THEN patients may not be treated within required timescales resulting in potential harm to patients, poor experience and failure of National Referral to Treatment standards Chief Delivery Officer Capacity and demand analysis to be completed for all specialities Improvement plans outlined and delivered On-going Resolve process for inclusion of AHP activity Implement new CO performance and assurance structures and processes Recruit to workforce gaps Deliver final PTL and validation work Transition plan to be progressed Re-establishment of Divisional Performance and Assurance systems 13 PAHT Caring for the Deteriorating Patient IF processes are not in place and/or followed to reliably recognise a deteriorating patient, THEN patient care may be compromised Chief Nursing Officer and Chief Medical Officer 2nd learning session took place 01/03/2017- good attendance by both medics and nursing E-Obs project planned rollout planned for mid-may 2017 Third learning session to take place in Q2 NEWS audit process to commence in July 2017 Full implementation of NAAS 12 17/19 32/112

33 Site Risk Name Principal Risk Risk Lead Action Plan Summary Risk Score PAHT Learning Lessons IF lessons learnt are not effectively identified and acted upon THEN system failures could affect the quality of patient care delivered and regulatory involvement and reputational damage could occur Chief Nursing Officer and Chief Medical Officer DATIX system implementation from June 2017 Development of risk registers and BAFs at NE Sector CO level in SRFT format BAFs to be reviewed at PRAGS, and presented to GRAC in June. Quality Control of process for Serious Incident Investigations. (High level review of completed investigations). Improve communication and feedback process between Group and HM Coroners Learning Framework Report to be presented to Group CiC 12 PAHT Caring for Patients with Sepsis IF processes are not in place and/or followed when caring for patients with Sepsis, THEN patient care may be compromised Chief Nursing Officer and Chief Medical Officer Policy and procedure to be reviewed and refreshed Develop metrics aligned to SRFT To achieve quarterly CQUIN targets notes reviewed retrospectively until 50 patients with potential sepsis are found Development of measurements/proxy measurements - completed Roll out of NEWS chart Sepsis steering group now established Sepsis clinical leadership now in place for each Care Organisation Sepsis Toolkit finalised at Sepsis steering group 12 PAHT Delivering an Effective Quality Improvement Strategy IF the Trust fails to deliver an effective Quality Improvement Strategy THEN the Trust may fail to save and improve lives through reliable care Chief Nursing Officer Final version of Quality Improvement Strategy to be approved by Group CiC. 12 PAHT Delivering the Cost Improvement Programme Target IF the Trust fails to deliver its Cost Improvement Programme target in 17/18 THEN the Trust may not achieve the forecast outturn financial positon for 2017/18 Chief Finance Officer GROUP Productivity strategy to be developed via executive development and delivery committee Establishment of QPID across group to ensure opportunities for quality and productivity improvements are identified and delivered in Care Organisations 12 PAHT Putting Clinical Leadership in Place IF effective, clinical leadership is not in place across the Trust THEN Clinical variation may continue potentially leading to patient harm Chief Strategy and Organisational Development Officer Work being undertaken to develop a Leadership model for CDs to include the development of assurance mechanisms. 12 PAHT Regaining JAG Accreditation IF the Trust fails to regain JAG Endoscopy accreditation THEN this could lead to financial contract penalties and reputational issues Chief Delivery Officer On-going recruitment to permanent consultant posts (on-going) Deliver on action plan to meet JAG standards Complete estates, equipment and training risk assessments 12 PAHT Achieving Planned Activity and Income Levels IF the planned activity and income levels are not achieved and or expenditure controls are exceeded leading to NHSI use of resources rating lower than planned in 2017/18 THEN this will increase regulatory investigation and intervention Chief Finance Officer 2017/18 financial plan forecast to be achieved. 12 PAHT Retrieving Clinical Notes Electronically (Evolve) IF the system for digitisation of clinical notes (Evolve) does not deliver timely accessible and reliable retrieval of clinical notes THEN care and communications with partners will be compromised Chief Delivery Officer Agreed, robust staff training plan to strengthen and standardise records management and retrieval practice/skills across all areas of the Trust and regular provision of assurance against plan provided into PAT EARC. 12 PAHT IM&T Clinical Systems IF the Trust fails to achieve a coherent range of IM&T clinical systems THEN there will be a lack of interoperability and sub optimal support for clinical decision making and recording Chief Strategy and Organisational Development Officer SOC incl high level IM&T plan shared with NHSI 12/12/2016, identifying 25m for EPR / PAS / healthview. Clarify and establish the JEPR Board or similar Maintain current direction of travel and all controls as we work closely with Salford and GM 12 18/19 33/112

34 Site Risk Name Principal Risk Risk Lead Action Plan Summary Risk Score PAHT Cyber Security Threat IF the available cyber security expert advice or the Trust preventative measures do not prevent emerging threats THEN this may lead to the unavailability of key ICT systems/ infrastructure/records which would significantly impact the Trust's ability to deliver safe patient care and its ability to function as a care organisation Chief Strategy and Organisational Development Officer 1.Review roles and responsibilities to ensure to address current and future cyber security threats 2. Increase Trust staff awareness of cyber security 3. Establish a task and finish group to implement recommendations from recent audits 4. Established a internal processes to review and maintain security controls and procedure 5. Plan further external reviews for assurance 12 PAHT PAHT PAHT PAHT Improving Patient Flow Patient Tracking and Booking System Completing Staff Personal Development Reviews The Estate at NMGH IF the Trust is unable to improve patient flow and ensure capacity to meet demand through all sites with emergency departments THEN the national standards for access will not be met and patient care will be compromised IF effective systems and process are not in place to assure patient tracking, booking and to ensure data quality THEN patient treatments may be delayed, data submissions, and data used for assurance and governance processes may be compromised IF staff do not participate in a good quality PDR THEN staff retention may reduce and the workforce capabilities of Trust to deliver high performance and improvement may be compromised IF lack if investment in NMGH estate continues due to national shortage of public dividend capital or business case not approved at Greater Manchester or treasury levels THEN temporary work to allow patient care in current facilities will need to continue Chief Delivery Officer Chief Delivery Officer Chief Strategy and Organisational Development Officer Chief Strategy and Organisational Development Officer Delivery of PAHT improvement plan projects (timelines outlined within plan) plan to support acute assess / ambulatory expansion at NMGH Trusted assessor and single line management of all IDT Agree ambulatory codes, counting and recurrent financial investment to enable recruitment and expansion all sites Complete final validation of PTLs Develop robust BI tools and systems to ensure data is viable, timely and accurate for operational teams July 2017 Symphony upgrade PAS upgrade Deliver against actions in B&S improvement plan Establish new Divisional performance and assurance systems Review of cancer tracking and performance management arrangements Develop and implement a PDR quality monitoring system with which to improve the effectiveness of the conversation. Site based reporting being developed Divisional Directors and Divisional HR BP have been requested to submit assurance plans to confirm required target will be met Plans submitted and monitored weekly Review underway of first elements of site investment of NM and TROH Developing Capital programme to bring forward some infrastructure and demolition Expectation of approval of infrastructure works Full premises assurance model survey for all sites within next 12 months Full Trust participation in regular meetings with CCG and GM on site redesign PAHT IM&T Clinical Systems IF the Trust fails to achieve a coherent range of IM&T clinical systems THEN there will be a lack of interoperability and sub optimal support for clinical decision making and recording Chief Strategy and Organisational Development Officer SOC incl high level IM&T plan shared with NHSI 12/12/2016, identifying 25m for EPR / PAS / healthview Clarify and establish the JEPR Board or similar Maintain current direction of travel and all controls as we work closely with Salford and GM 12 19/19 34/112

35 Pennine 1/5 35/112

36 Fairfield 2/5 36/112

37 Rochdale 3/5 37/112

38 North Manchester 4/5 38/112

39 Oldham 5/5 39/112

40 Spells In-Hosptial Deaths Relative Risk Crude Rate Relative Risk Crude Rate Dr Foster Mortality Dashboard Benchmark: 10 years to Feb-2017 Diagnosis Groups (Top 8 - Lower Confidence Interval) Diagnosis Group CUSUM Obs Exp Intestinal infection Short gestation, low birth weight, and fetal growth retardation Coma, stupour, and brain damage Heart valve disorders Conduction disorders * Intestinal obstruction without hernia Regional enteritis and ulcerative colitis * Pneumonia Nutritional deficiencies Meningitis Period Diagnosis Group (CUSUM Alert Only) CUSUM Obs Exp RR LCI Trend RR LCI Jun-16 - May-17 8 Trend Pennine Acute Hospitals NHS Trust 12 Month Rolling Trends HSMR: Rolling 12 Month Trend Relative Risk 4.00% 3.90% 3.80% 3.70% 3.60% 3.50% Jun-16 Jul-16 Aug-16 Sep-16 Oct-16 Nov-16 Dec-16 Jan-17 Feb-17 Mar-17 Apr-17 May month rolling period Deaths in Low Risk Diagnosis Groups Deaths after Surgery Patients Safety Indicators Obs Exp RR LCI SMR: Rolling 12 Month Trend Relative Risk 1.52% 12 Month Rolling Trend in Spells and In-Hospital Deaths Spells In Hospital Deaths K 177K 176K 175K 174K 173K Jun-16 Jul-16 Aug-16 Sep-16 Oct-16 Nov-16 Dec-16 Jan-17 Feb-17 Mar-17 Apr-17 May Jun-16 Jul-16 Aug-16 Sep-16 Oct-16 Nov-16 Dec-16 Jan-17 Feb-17 Mar-17 Apr-17 May month rolling period 1.48% 1.44% 1.40% Saturday (HSMR) Sunday (HSMR) Weekend (HSMR) Elective (HSMR) Non-Elective (HSMR) Performance HSMR Influencers Trust Peer National Coding \ Casemix Trust Peer National % Non-Elective Spells Palliative Care 2.82% 3.75% 3.95% % Non-Elective Deaths with Palliative Care 18.41% 25.75% 28.28% % Spells Charlson Comorbidity Score Zero 48.9% 47.8% 49.9% % Spells Charlson Comorbidity Score % 8.1% 8.1% % of Spells in Risk Decile (0-10%) 88.0% 88.8% 88.9% % Spells in Signs and Symptoms Chapter 5.1% 4.0% 5.4% % Spells in HSMR basket (non-elective) 37.9% 44.5% 36.9% % Spells in HSMR basket (elective) 27.5% 24.8% 28.6% Key Statistically below expected Crude Rate Statistically As Expected Statistically Above Expected Salford Royal NHS Foundation Trust Doncaster and Bassetlaw Teaching Hospitals NHS Foundation Trust Tameside and Glossop Integrated Care NHS Foundation Trust Wirral University Teaching Hospital NHS Foundation Trust University Hospital Of South Manchester NHS Foundation Trust University Hospitals Of North Midlands NHS Trust Central Manchester University Hospitals NHS Foundation Trust Shrewsbury and Telford Hospital NHS Trust Pennine Acute Hospitals NHS Trust South Tees Hospitals NHS Foundation Trust Peer Group Barnsley Hospital NHS Foundation Trust Warrington and Halton Hospitals NHS Foundation Trust St Helens and Knowsley Hospital Services NHS Trust Hull and East Yorkshire Hospitals NHS Trust Sherwood Forest Hospitals NHS Foundation Trust North Tees and Hartlepool NHS Foundation Trust Mid Yorkshire Hospitals NHS Trust City Hospitals Sunderland NHS Foundation Trust The Rotherham NHS Foundation Trust Wrightington, Wigan and Leigh NHS Foundation Trust Peer Comparison (HSMR) /2 40/112

41 Definitions Date: 25/8/2017 Created By: David Chapman, Head of Business Analytics Indicator Numerator Denominator Description HSMR Observed Deaths within the 56 diagnosis groups Expected Deaths within the 56 diagnosis groups National indicator for risk adjusted mortality. 56 diagnosis groups account for 80%+ in-hospital deaths SMR Observed Deaths - All in-hospital Expected Deaths - All in-hospital Indicator for risk adjusted mortality, including all in-hospital activity Crude Mortality In-hospital deaths Spells Non-risk adjusted mortality indicator Saturday (HSMR) Observed Deaths Expected Deaths Risk adjusted mortality indicator for patients admitted on a Saturday Sunday (HSMR) Observed Deaths Expected Deaths Risk adjusted mortality indicator for patients admitted on a Sunday Weekend (HSMR) Observed Deaths Expected Deaths Risk adjusted mortality indicator for patients admitted on a Saturday or Sunday Elective (HSMR) Observed Deaths Expected Deaths Risk adjusted mortality indicator for patients admitted Electively Non-Elective (HSMR) Observed Deaths Expected Deaths Risk adjusted mortality indicator for patients admitted Non- Electively % Non-Elective Spells Palliative Care Palliative care Spells Non-Elective Spells Crude indicator for the rate in which non-elective patients receive palliative care % Non-Elective Deaths with Palliative Care Palliative care Deaths In-hospital Deaths Crude indicator for the rate in which non-elective patients who die in hospital receive palliative care % Spells Charlson Comorbidity Score Zero Spells with Charlson Comorbidity Score of 0 Spells Percentage of spells who do not have any charlson comorbidities recorded within the spell % Spells Charlson Comorbidity Score 20+ Spells with Charlson Comorbidity Score of 20+ Spells Percentage of spells who have a charlson comorbidities score of 20 or more % of Spells in Risk Decile (0-10%) Spells with a Risk of Mortality 10% or less Spells Percentage of patients who fall within the lowest risk decile, using their standardisaed mortality ratio % Spells in Signs and Symptoms Chapter Spells that fall within the Signs and Symptoms Diagnosis Chapter % Spells in HSMR basket (non-elective) Spells that fall within one of the 56 HSMR diagnosis groups % Spells in HSMR basket (elective) Spells that fall within one of the 56 HSMR diagnosis groups Spells Spells Spells Percentage of spells who do not have a defined diagnosis in their 1st or 2nd FCE Percentage of non-elective spells which fall within the basket of 56 HSMR diagnosis groups Percentage of elective spells which fall within the basket of 56 HSMR diagnosis groups 2/2 41/112

42 Spells In-Hosptial Deaths Relative Risk Crude Rate Relative Risk Crude Rate Dr Foster Mortality Dashboard Benchmark: 10 years to Feb-2017 Period Diagnosis Groups (Top 8 - Lower Confidence Interval) Diagnosis Group CUSUM Obs Exp * Intestinal obstruction without hernia * Other lower respiratory disease Regional enteritis and ulcerative colitis * Chronic obstructive pulmonary disease and bronchiectasis * Liver disease, alcohol-related Other connective tissue disease * Pneumonia * Skin and subcutaneous tissue infections * Chronic ulcer of skin Conditions associated with dizziness or vertigo Nutritional deficiencies RR Jun-16 - May-17 Diagnosis Group (CUSUM Alert Only) CUSUM Obs Exp RR LCI Trend LCI 8 Trend Month Rolling Trends HSMR: Rolling 12 Month Trend Relative Risk Fairfield General Hospital (RW601) Jun-16 Jul-16 Aug-16 Sep-16 Oct-16 Nov-16 Dec-16 Jan-17 Feb-17 Mar-17 Apr-17 May month rolling period 5.90% 5.80% 5.70% 5.60% 5.50% 5.40% 5.30% 5.20% 5.10% 5.00% 4.90% Deaths in Low Risk Diagnosis Groups Deaths after Surgery Patients Safety Indicators Obs Exp RR LCI Month Rolling Trend in Spells and In-Hospital Deaths Spells In Hospital Deaths 32K 31K 30K Jun-16 Jul-16 Aug-16 Sep-16 Oct-16 Nov-16 Dec-16 Jan-17 Feb-17 Mar-17 Apr-17 May SMR: Rolling 12 Month Trend Relative Risk Jun-16 Jul-16 Aug-16 Sep-16 Oct-16 Nov-16 Dec-16 Jan-17 Feb-17 Mar-17 Apr-17 May month rolling period 2.84% 2.80% 2.76% 2.72% 2.68% 2.64% 2.60% 2.56% Performance Saturday (HSMR) Sunday (HSMR) Weekend (HSMR) Elective (HSMR) Non-Elective (HSMR) HSMR Influencers Site Trust Peer National Coding \ Casemix Site Trust Peer National % Non-Elective Spells Palliative Care 4.65% 2.82% 3.75% 3.95% % Non-Elective Deaths with Palliative Care 21.14% 18.41% 25.75% 28.28% % Spells Charlson Comorbidity Score Zero 38.6% 48.9% 47.8% 49.9% % Spells Charlson Comorbidity Score % 9.0% 8.1% 8.1% % of Spells in Risk Decile (0-10%) 82.3% 88.0% 88.8% 88.9% % Spells in Signs and Symptoms Chapter 7.4% 5.1% 4.0% 5.4% % Spells in HSMR basket (non-elective) 56.2% 37.9% 44.5% 36.9% % Spells in HSMR basket (elective) 34.4% 27.5% 24.8% 28.6% Key Statistically below expected Crude Rate Statistically As Expected Statistically Above Expected Salford Royal NHS Foundation Trust Doncaster and Bassetlaw Teaching Hospitals NHS Foundation Trust Tameside and Glossop Integrated Care NHS Foundation Trust Wirral University Teaching Hospital NHS Foundation Trust University Hospital Of South Manchester NHS Foundation Trust University Hospitals Of North Midlands NHS Trust Central Manchester University Hospitals NHS Foundation Trust Fairfield General Hospital (RW601) Shrewsbury and Telford Hospital NHS Trust Pennine Acute Hospitals NHS Trust South Tees Hospitals NHS Foundation Trust Peer Group Barnsley Hospital NHS Foundation Trust Warrington and Halton Hospitals NHS Foundation Trust St Helens and Knowsley Hospital Services NHS Trust Hull and East Yorkshire Hospitals NHS Trust Sherwood Forest Hospitals NHS Foundation Trust North Tees and Hartlepool NHS Foundation Trust Mid Yorkshire Hospitals NHS Trust City Hospitals Sunderland NHS Foundation Trust The Rotherham NHS Foundation Trust Wrightington, Wigan and Leigh NHS Foundation Trust Peer Comparison (HSMR) /2 42/112

43 Definitions Date: 25/8/2017 Created By: David Chapman, Head of Business Analytics Indicator Numerator Denominator Description HSMR Observed Deaths within the 56 diagnosis groups Expected Deaths within the 56 diagnosis groups National indicator for risk adjusted mortality. 56 diagnosis groups account for 80%+ in-hospital deaths SMR Observed Deaths - All in-hospital Expected Deaths - All in-hospital Indicator for risk adjusted mortality, including all in-hospital activity Crude Mortality In-hospital deaths Spells Non-risk adjusted mortality indicator Saturday (HSMR) Observed Deaths Expected Deaths Risk adjusted mortality indicator for patients admitted on a Saturday Sunday (HSMR) Observed Deaths Expected Deaths Risk adjusted mortality indicator for patients admitted on a Sunday Weekend (HSMR) Observed Deaths Expected Deaths Risk adjusted mortality indicator for patients admitted on a Saturday or Sunday Elective (HSMR) Observed Deaths Expected Deaths Risk adjusted mortality indicator for patients admitted Electively Non-Elective (HSMR) Observed Deaths Expected Deaths Risk adjusted mortality indicator for patients admitted Non- Electively % Non-Elective Spells Palliative Care Palliative care Spells Non-Elective Spells Crude indicator for the rate in which non-elective patients receive palliative care % Non-Elective Deaths with Palliative Care Palliative care Deaths In-hospital Deaths Crude indicator for the rate in which non-elective patients who die in hospital receive palliative care % Spells Charlson Comorbidity Score Zero Spells with Charlson Comorbidity Score of 0 Spells Percentage of spells who do not have any charlson comorbidities recorded within the spell % Spells Charlson Comorbidity Score 20+ Spells with Charlson Comorbidity Score of 20+ Spells Percentage of spells who have a charlson comorbidities score of 20 or more % of Spells in Risk Decile (0-10%) Spells with a Risk of Mortality 10% or less Spells Percentage of patients who fall within the lowest risk decile, using their standardisaed mortality ratio % Spells in Signs and Symptoms Chapter Spells that fall within the Signs and Symptoms Diagnosis Chapter % Spells in HSMR basket (non-elective) Spells that fall within one of the 56 HSMR diagnosis groups % Spells in HSMR basket (elective) Spells that fall within one of the 56 HSMR diagnosis groups Spells Spells Spells Percentage of spells who do not have a defined diagnosis in their 1st or 2nd FCE Percentage of non-elective spells which fall within the basket of 56 HSMR diagnosis groups Percentage of elective spells which fall within the basket of 56 HSMR diagnosis groups 2/2 43/112

44 Spells In-Hosptial Deaths Relative Risk Crude Rate Relative Risk Crude Rate Dr Foster Mortality Dashboard Benchmark: 10 years to Feb-2017 Period Diagnosis Groups (Top 8 - Lower Confidence Interval) Diagnosis Group CUSUM Obs Exp Diseases of mouth, excluding dental , Intestinal infection Heart valve disorders Intrauterine hypoxia and birth asphyxia * Pneumonia Coma, stupour, and brain damage * Acute cerebrovascular disease * Urinary tract infections * Chronic renal failure RR Jun-16 - May-17 Diagnosis Group (CUSUM Alert Only) CUSUM Obs Exp RR LCI Trend LCI 8 Trend North Manchester General Hospital (RW602) 12 Month Rolling Trends HSMR: Rolling 12 Month Trend Relative Risk 4.10% 4.00% 3.90% 3.80% 3.70% 3.60% 3.50% Jun-16 Jul-16 Aug-16 Sep-16 Oct-16 Nov-16 Dec-16 Jan-17 Feb-17 Mar-17 Apr-17 May month rolling period Deaths in Low Risk Diagnosis Groups Deaths after Surgery Patients Safety Indicators Obs Exp RR LCI Month Rolling Trend in Spells and In-Hospital Deaths Spells In Hospital Deaths 56K 55K 54K Jun-16 Jul-16 Aug-16 Sep-16 Oct-16 Nov-16 Dec-16 Jan-17 Feb-17 Mar-17 Apr-17 May SMR: Rolling 12 Month Trend Relative Risk Jun-16 Jul-16 Aug-16 Sep-16 Oct-16 Nov-16 Dec-16 Jan-17 Feb-17 Mar-17 Apr-17 May month rolling period 1.44% 1.40% 1.36% 1.32% Performance Saturday (HSMR) Sunday (HSMR) Weekend (HSMR) Elective (HSMR) Non-Elective (HSMR) HSMR Influencers Site Trust Peer National Coding \ Casemix Site Trust Peer National % Non-Elective Spells Palliative Care 2.06% 2.82% 3.75% 3.95% % Non-Elective Deaths with Palliative Care 19.45% 18.41% 25.75% 28.28% % Spells Charlson Comorbidity Score Zero 51.9% 48.9% 47.8% 49.9% % Spells Charlson Comorbidity Score % 9.0% 8.1% 8.1% % of Spells in Risk Decile (0-10%) 89.1% 88.0% 88.8% 88.9% % Spells in Signs and Symptoms Chapter 4.8% 5.1% 4.0% 5.4% % Spells in HSMR basket (non-elective) 33.3% 37.9% 44.5% 36.9% % Spells in HSMR basket (elective) 26.6% 27.5% 24.8% 28.6% Key Statistically below expected Crude Rate Statistically As Expected Statistically Above Expected Salford Royal NHS Foundation Trust Doncaster and Bassetlaw Teaching Hospitals NHS Foundation Trust Tameside and Glossop Integrated Care NHS Foundation Trust Wirral University Teaching Hospital NHS Foundation Trust University Hospital Of South Manchester NHS Foundation Trust University Hospitals Of North Midlands NHS Trust Central Manchester University Hospitals NHS Foundation Trust Shrewsbury and Telford Hospital NHS Trust Pennine Acute Hospitals NHS Trust South Tees Hospitals NHS Foundation Trust Peer Group Barnsley Hospital NHS Foundation Trust Warrington and Halton Hospitals NHS Foundation Trust St Helens and Knowsley Hospital Services NHS Trust Hull and East Yorkshire Hospitals NHS Trust Sherwood Forest Hospitals NHS Foundation Trust North Tees and Hartlepool NHS Foundation Trust North Manchester General Hospital (RW602) Mid Yorkshire Hospitals NHS Trust City Hospitals Sunderland NHS Foundation Trust The Rotherham NHS Foundation Trust Wrightington, Wigan and Leigh NHS Foundation Trust Peer Comparison (HSMR) /2 44/112

45 Definitions Date: 25/8/2017 Created By: David Chapman, Head of Business Analytics Indicator Numerator Denominator Description HSMR Observed Deaths within the 56 diagnosis groups Expected Deaths within the 56 diagnosis groups National indicator for risk adjusted mortality. 56 diagnosis groups account for 80%+ in-hospital deaths SMR Observed Deaths - All in-hospital Expected Deaths - All in-hospital Indicator for risk adjusted mortality, including all in-hospital activity Crude Mortality In-hospital deaths Spells Non-risk adjusted mortality indicator Saturday (HSMR) Observed Deaths Expected Deaths Risk adjusted mortality indicator for patients admitted on a Saturday Sunday (HSMR) Observed Deaths Expected Deaths Risk adjusted mortality indicator for patients admitted on a Sunday Weekend (HSMR) Observed Deaths Expected Deaths Risk adjusted mortality indicator for patients admitted on a Saturday or Sunday Elective (HSMR) Observed Deaths Expected Deaths Risk adjusted mortality indicator for patients admitted Electively Non-Elective (HSMR) Observed Deaths Expected Deaths Risk adjusted mortality indicator for patients admitted Non- Electively % Non-Elective Spells Palliative Care Palliative care Spells Non-Elective Spells Crude indicator for the rate in which non-elective patients receive palliative care % Non-Elective Deaths with Palliative Care Palliative care Deaths In-hospital Deaths Crude indicator for the rate in which non-elective patients who die in hospital receive palliative care % Spells Charlson Comorbidity Score Zero Spells with Charlson Comorbidity Score of 0 Spells Percentage of spells who do not have any charlson comorbidities recorded within the spell % Spells Charlson Comorbidity Score 20+ Spells with Charlson Comorbidity Score of 20+ Spells Percentage of spells who have a charlson comorbidities score of 20 or more % of Spells in Risk Decile (0-10%) Spells with a Risk of Mortality 10% or less Spells Percentage of patients who fall within the lowest risk decile, using their standardisaed mortality ratio % Spells in Signs and Symptoms Chapter Spells that fall within the Signs and Symptoms Diagnosis Chapter % Spells in HSMR basket (non-elective) Spells that fall within one of the 56 HSMR diagnosis groups % Spells in HSMR basket (elective) Spells that fall within one of the 56 HSMR diagnosis groups Spells Spells Spells Percentage of spells who do not have a defined diagnosis in their 1st or 2nd FCE Percentage of non-elective spells which fall within the basket of 56 HSMR diagnosis groups Percentage of elective spells which fall within the basket of 56 HSMR diagnosis groups 2/2 45/112

46 Spells In-Hosptial Deaths Relative Risk Crude Rate Relative Risk Crude Rate Dr Foster Mortality Dashboard Benchmark: 10 years to Feb-2017 Diagnosis Groups (Top 8 - Lower Confidence Interval) Diagnosis Group CUSUM Obs Exp * Acute myocardial infarction Short gestation, low birth weight, and fetal growth retardation Other inflammatory condition of skin * Complication of device, implant or graft * Skin and subcutaneous tissue infections * Other perinatal conditions * Acute cerebrovascular disease * Congestive heart failure, nonhypertensive Gout and other crystal arthropathies Period Diagnosis Group (CUSUM Alert Only) CUSUM Obs Exp RR LCI Trend RR LCI Jun-16 - May-17 8 Trend Royal Oldham Hospital (RW603) 12 Month Rolling Trends HSMR: Rolling 12 Month Trend Relative Risk 3.80% 3.70% 3.60% 3.50% 3.40% 3.30% 3.20% Jun-16 Jul-16 Aug-16 Sep-16 Oct-16 Nov-16 Dec-16 Jan-17 Feb-17 Mar-17 Apr-17 May month rolling period Deaths in Low Risk Diagnosis Groups Deaths after Surgery Patients Safety Indicators Obs Exp RR LCI Month Rolling Trend in Spells and In-Hospital Deaths Spells In Hospital Deaths 62K 61K 60K Jun-16 Jul-16 Aug-16 Sep-16 Oct-16 Nov-16 Dec-16 Jan-17 Feb-17 Mar-17 Apr-17 May SMR: Rolling 12 Month Trend Relative Risk Jun-16 Jul-16 Aug-16 Sep-16 Oct-16 Nov-16 Dec-16 Jan-17 Feb-17 Mar-17 Apr-17 May month rolling period 1.64% 1.60% 1.56% 1.52% 1.48% 1.44% 1.40% 1.36% Saturday (HSMR) Sunday (HSMR) Weekend (HSMR) Elective (HSMR) Non-Elective (HSMR) Performance HSMR Influencers Site Trust Peer National Coding \ Casemix Site Trust Peer National % Non-Elective Spells Palliative Care 2.56% 2.82% 3.75% 3.95% % Non-Elective Deaths with Palliative Care 15.30% 18.41% 25.75% 28.28% % Spells Charlson Comorbidity Score Zero 52.6% 48.9% 47.8% 49.9% % Spells Charlson Comorbidity Score % 9.0% 8.1% 8.1% % of Spells in Risk Decile (0-10%) 89.2% 88.0% 88.8% 88.9% % Spells in Signs and Symptoms Chapter 5.2% 5.1% 4.0% 5.4% % Spells in HSMR basket (non-elective) 33.9% 37.9% 44.5% 36.9% % Spells in HSMR basket (elective) 39.7% 27.5% 24.8% 28.6% Key Statistically below expected Crude Rate Statistically As Expected Statistically Above Expected Salford Royal NHS Foundation Trust Doncaster and Bassetlaw Teaching Hospitals NHS Foundation Trust Tameside and Glossop Integrated Care NHS Foundation Trust Wirral University Teaching Hospital NHS Foundation Trust University Hospital Of South Manchester NHS Foundation Trust University Hospitals Of North Midlands NHS Trust Royal Oldham Hospital (RW603) Central Manchester University Hospitals NHS Foundation Trust Shrewsbury and Telford Hospital NHS Trust Pennine Acute Hospitals NHS Trust South Tees Hospitals NHS Foundation Trust Peer Group Barnsley Hospital NHS Foundation Trust Warrington and Halton Hospitals NHS Foundation Trust St Helens and Knowsley Hospital Services NHS Trust Hull and East Yorkshire Hospitals NHS Trust Sherwood Forest Hospitals NHS Foundation Trust North Tees and Hartlepool NHS Foundation Trust Mid Yorkshire Hospitals NHS Trust City Hospitals Sunderland NHS Foundation Trust The Rotherham NHS Foundation Trust Wrightington, Wigan and Leigh NHS Foundation Trust Peer Comparison (HSMR) /2 46/112

47 Definitions Date: 25/8/2017 Created By: David Chapman, Head of Business Analytics Indicator Numerator Denominator Description HSMR Observed Deaths within the 56 diagnosis groups Expected Deaths within the 56 diagnosis groups National indicator for risk adjusted mortality. 56 diagnosis groups account for 80%+ in-hospital deaths SMR Observed Deaths - All in-hospital Expected Deaths - All in-hospital Indicator for risk adjusted mortality, including all in-hospital activity Crude Mortality In-hospital deaths Spells Non-risk adjusted mortality indicator Saturday (HSMR) Observed Deaths Expected Deaths Risk adjusted mortality indicator for patients admitted on a Saturday Sunday (HSMR) Observed Deaths Expected Deaths Risk adjusted mortality indicator for patients admitted on a Sunday Weekend (HSMR) Observed Deaths Expected Deaths Risk adjusted mortality indicator for patients admitted on a Saturday or Sunday Elective (HSMR) Observed Deaths Expected Deaths Risk adjusted mortality indicator for patients admitted Electively Non-Elective (HSMR) Observed Deaths Expected Deaths Risk adjusted mortality indicator for patients admitted Non- Electively % Non-Elective Spells Palliative Care Palliative care Spells Non-Elective Spells Crude indicator for the rate in which non-elective patients receive palliative care % Non-Elective Deaths with Palliative Care Palliative care Deaths In-hospital Deaths Crude indicator for the rate in which non-elective patients who die in hospital receive palliative care % Spells Charlson Comorbidity Score Zero Spells with Charlson Comorbidity Score of 0 Spells Percentage of spells who do not have any charlson comorbidities recorded within the spell % Spells Charlson Comorbidity Score 20+ Spells with Charlson Comorbidity Score of 20+ Spells Percentage of spells who have a charlson comorbidities score of 20 or more % of Spells in Risk Decile (0-10%) Spells with a Risk of Mortality 10% or less Spells Percentage of patients who fall within the lowest risk decile, using their standardisaed mortality ratio % Spells in Signs and Symptoms Chapter Spells that fall within the Signs and Symptoms Diagnosis Chapter % Spells in HSMR basket (non-elective) Spells that fall within one of the 56 HSMR diagnosis groups % Spells in HSMR basket (elective) Spells that fall within one of the 56 HSMR diagnosis groups Spells Spells Spells Percentage of spells who do not have a defined diagnosis in their 1st or 2nd FCE Percentage of non-elective spells which fall within the basket of 56 HSMR diagnosis groups Percentage of elective spells which fall within the basket of 56 HSMR diagnosis groups 2/2 47/112

48 Spells In-Hosptial Deaths Relative Risk Crude Rate Relative Risk Crude Rate Dr Foster Mortality Dashboard Benchmark: 10 years to Feb-2017 Period Diagnosis Groups (Top 8 - Lower Confidence Interval) Diagnosis Group CUSUM Obs Exp Thyroid disorders , * Pneumonia * Intestinal obstruction without hernia * Cancer of bronchus, lung * Syncope , Nausea and vomiting , Conduction disorders , * Liver disease, alcohol-related Epilepsy, convulsions RR Jun-16 - May-17 Diagnosis Group (CUSUM Alert Only) CUSUM Obs Exp RR LCI Trend LCI 8 Trend Month Rolling Trends HSMR: Rolling 12 Month Trend Relative Risk Rochdale Infirmary (RW604) Jun-16 Jul-16 Aug-16 Sep-16 Oct-16 Nov-16 Dec-16 Jan-17 Feb-17 Mar-17 Apr-17 May month rolling period 1.20% 1.10% 1.00% 0.90% 0.80% 0.70% 0.60% 0.50% 0.40% 0.30% 0.20% 0.10% 0.00% Deaths in Low Risk Diagnosis Groups Deaths after Surgery Patients Safety Indicators Obs Exp RR LCI SMR: Rolling 12 Month Trend Relative Risk 0.24% 12 Month Rolling Trend in Spells and In-Hospital Deaths Spells In Hospital Deaths % 29K 28K 27K Jun-16 Jul-16 Aug-16 Sep-16 Oct-16 Nov-16 Dec-16 Jan-17 Feb-17 Mar-17 Apr-17 May Jun-16 Jul-16 Aug-16 Sep-16 Oct-16 Nov-16 Dec-16 Jan-17 Feb-17 Mar-17 Apr-17 May month rolling period 0.16% 0.12% 0.08% 0.04% 0.00% Performance Saturday (HSMR) Sunday (HSMR) Weekend (HSMR) Elective (HSMR) Non-Elective (HSMR) HSMR Influencers Site Trust Peer National Coding \ Casemix Site Trust Peer National % Non-Elective Spells Palliative Care 0.44% 2.82% 3.75% 3.95% % Non-Elective Deaths with Palliative Care 9.80% 18.41% 25.75% 28.28% % Spells Charlson Comorbidity Score Zero 52.5% 48.9% 47.8% 49.9% % Spells Charlson Comorbidity Score % 9.0% 8.1% 8.1% % of Spells in Risk Decile (0-10%) 95.7% 88.0% 88.8% 88.9% % Spells in Signs and Symptoms Chapter 3.0% 5.1% 4.0% 5.4% % Spells in HSMR basket (non-elective) 49.9% 37.9% 44.5% 36.9% % Spells in HSMR basket (elective) 14.3% 27.5% 24.8% 28.6% Key Statistically below expected Crude Rate Statistically As Expected Statistically Above Expected Rochdale Infirmary (RW604) Salford Royal NHS Foundation Trust Doncaster and Bassetlaw Teaching Hospitals NHS Foundation Trust Tameside and Glossop Integrated Care NHS Foundation Trust Wirral University Teaching Hospital NHS Foundation Trust University Hospital Of South Manchester NHS Foundation Trust University Hospitals Of North Midlands NHS Trust Central Manchester University Hospitals NHS Foundation Trust Shrewsbury and Telford Hospital NHS Trust Pennine Acute Hospitals NHS Trust South Tees Hospitals NHS Foundation Trust Peer Group Barnsley Hospital NHS Foundation Trust Warrington and Halton Hospitals NHS Foundation Trust St Helens and Knowsley Hospital Services NHS Trust Hull and East Yorkshire Hospitals NHS Trust Sherwood Forest Hospitals NHS Foundation Trust North Tees and Hartlepool NHS Foundation Trust Mid Yorkshire Hospitals NHS Trust City Hospitals Sunderland NHS Foundation Trust The Rotherham NHS Foundation Trust Wrightington, Wigan and Leigh NHS Foundation Trust Peer Comparison (HSMR) /2 48/112

49 Definitions Date: 25/8/2017 Created By: David Chapman, Head of Business Analytics Indicator Numerator Denominator Description HSMR Observed Deaths within the 56 diagnosis groups Expected Deaths within the 56 diagnosis groups National indicator for risk adjusted mortality. 56 diagnosis groups account for 80%+ in-hospital deaths SMR Observed Deaths - All in-hospital Expected Deaths - All in-hospital Indicator for risk adjusted mortality, including all in-hospital activity Crude Mortality In-hospital deaths Spells Non-risk adjusted mortality indicator Saturday (HSMR) Observed Deaths Expected Deaths Risk adjusted mortality indicator for patients admitted on a Saturday Sunday (HSMR) Observed Deaths Expected Deaths Risk adjusted mortality indicator for patients admitted on a Sunday Weekend (HSMR) Observed Deaths Expected Deaths Risk adjusted mortality indicator for patients admitted on a Saturday or Sunday Elective (HSMR) Observed Deaths Expected Deaths Risk adjusted mortality indicator for patients admitted Electively Non-Elective (HSMR) Observed Deaths Expected Deaths Risk adjusted mortality indicator for patients admitted Non- Electively % Non-Elective Spells Palliative Care Palliative care Spells Non-Elective Spells Crude indicator for the rate in which non-elective patients receive palliative care % Non-Elective Deaths with Palliative Care Palliative care Deaths In-hospital Deaths Crude indicator for the rate in which non-elective patients who die in hospital receive palliative care % Spells Charlson Comorbidity Score Zero Spells with Charlson Comorbidity Score of 0 Spells Percentage of spells who do not have any charlson comorbidities recorded within the spell % Spells Charlson Comorbidity Score 20+ Spells with Charlson Comorbidity Score of 20+ Spells Percentage of spells who have a charlson comorbidities score of 20 or more % of Spells in Risk Decile (0-10%) Spells with a Risk of Mortality 10% or less Spells Percentage of patients who fall within the lowest risk decile, using their standardisaed mortality ratio % Spells in Signs and Symptoms Chapter Spells that fall within the Signs and Symptoms Diagnosis Chapter % Spells in HSMR basket (non-elective) Spells that fall within one of the 56 HSMR diagnosis groups % Spells in HSMR basket (elective) Spells that fall within one of the 56 HSMR diagnosis groups Spells Spells Spells Percentage of spells who do not have a defined diagnosis in their 1st or 2nd FCE Percentage of non-elective spells which fall within the basket of 56 HSMR diagnosis groups Percentage of elective spells which fall within the basket of 56 HSMR diagnosis groups 2/2 49/112

50 Spells In-Hosptial Deaths Relative Risk Crude Rate Relative Risk Crude Rate Dr Foster Mortality Dashboard Benchmark: 10 years to Feb-2017 Period Diagnosis Groups (Top 8 - Lower Confidence Interval) Diagnosis Group CUSUM Obs Exp Other complications of pregnancy , * Fluid and electrolyte disorders * Intracranial injury * Septicemia (except in labour) * Pneumonia * Skin and subcutaneous tissue infections Nausea and vomiting * Acute cerebrovascular disease Nutritional deficiencies Crushing injury or internal injury RR Jun-16 - May-17 Diagnosis Group (CUSUM Alert Only) CUSUM Obs Exp RR LCI Trend LCI 8 Trend Salford Royal NHS Foundation Trust 12 Month Rolling Trends HSMR: Rolling 12 Month Trend Relative Risk 4.50% 4.40% 4.30% 4.20% 4.10% 4.00% 3.90% Jun-16 Jul-16 Aug-16 Sep-16 Oct-16 Nov-16 Dec-16 Jan-17 Feb-17 Mar-17 Apr-17 May month rolling period Deaths in Low Risk Diagnosis Groups Deaths after Surgery Patients Safety Indicators Obs Exp RR LCI Month Rolling Trend in Spells and In-Hospital Deaths Spells In Hospital Deaths 90K 89K 88K 87K 86K Jun-16 Jul-16 Aug-16 Sep-16 Oct-16 Nov-16 Dec-16 Jan-17 Feb-17 Mar-17 Apr-17 May SMR: Rolling 12 Month Trend Relative Risk Jun-16 Jul-16 Aug-16 Sep-16 Oct-16 Nov-16 Dec-16 Jan-17 Feb-17 Mar-17 Apr-17 May month rolling period 1.72% 1.68% 1.64% 1.60% 1.56% 1.52% Performance Saturday (HSMR) Sunday (HSMR) Weekend (HSMR) Elective (HSMR) Non-Elective (HSMR) HSMR Influencers Trust Peer National Coding \ Casemix Trust Peer National % Non-Elective Spells Palliative Care 5.36% 3.75% 3.95% % Non-Elective Deaths with Palliative Care 34.83% 25.75% 28.28% % Spells Charlson Comorbidity Score Zero 46.7% 47.8% 49.9% % Spells Charlson Comorbidity Score % 8.1% 8.1% % of Spells in Risk Decile (0-10%) 84.8% 88.8% 88.9% % Spells in Signs and Symptoms Chapter 6.7% 4.0% 5.4% % Spells in HSMR basket (non-elective) 46.4% 44.5% 36.9% % Spells in HSMR basket (elective) 22.4% 24.8% 28.6% Key Statistically below expected Crude Rate Statistically As Expected Statistically Above Expected Salford Royal NHS Foundation Trust Doncaster and Bassetlaw Teaching Hospitals NHS Foundation Trust Tameside and Glossop Integrated Care NHS Foundation Trust Wirral University Teaching Hospital NHS Foundation Trust University Hospital Of South Manchester NHS Foundation Trust University Hospitals Of North Midlands NHS Trust Central Manchester University Hospitals NHS Foundation Trust Shrewsbury and Telford Hospital NHS Trust Pennine Acute Hospitals NHS Trust South Tees Hospitals NHS Foundation Trust Peer Group Barnsley Hospital NHS Foundation Trust Warrington and Halton Hospitals NHS Foundation Trust St Helens and Knowsley Hospital Services NHS Trust Hull and East Yorkshire Hospitals NHS Trust Sherwood Forest Hospitals NHS Foundation Trust North Tees and Hartlepool NHS Foundation Trust Mid Yorkshire Hospitals NHS Trust City Hospitals Sunderland NHS Foundation Trust The Rotherham NHS Foundation Trust Wrightington, Wigan and Leigh NHS Foundation Trust Peer Comparison (HSMR) /2 50/112

51 Definitions Date: 25/8/2017 Created By: David Chapman, Head of Business Analytics Indicator Numerator Denominator Description HSMR Observed Deaths within the 56 diagnosis groups Expected Deaths within the 56 diagnosis groups National indicator for risk adjusted mortality. 56 diagnosis groups account for 80%+ in-hospital deaths SMR Observed Deaths - All in-hospital Expected Deaths - All in-hospital Indicator for risk adjusted mortality, including all in-hospital activity Crude Mortality In-hospital deaths Spells Non-risk adjusted mortality indicator Saturday (HSMR) Observed Deaths Expected Deaths Risk adjusted mortality indicator for patients admitted on a Saturday Sunday (HSMR) Observed Deaths Expected Deaths Risk adjusted mortality indicator for patients admitted on a Sunday Weekend (HSMR) Observed Deaths Expected Deaths Risk adjusted mortality indicator for patients admitted on a Saturday or Sunday Elective (HSMR) Observed Deaths Expected Deaths Risk adjusted mortality indicator for patients admitted Electively Non-Elective (HSMR) Observed Deaths Expected Deaths Risk adjusted mortality indicator for patients admitted Non- Electively % Non-Elective Spells Palliative Care Palliative care Spells Non-Elective Spells Crude indicator for the rate in which non-elective patients receive palliative care % Non-Elective Deaths with Palliative Care Palliative care Deaths In-hospital Deaths Crude indicator for the rate in which non-elective patients who die in hospital receive palliative care % Spells Charlson Comorbidity Score Zero Spells with Charlson Comorbidity Score of 0 Spells Percentage of spells who do not have any charlson comorbidities recorded within the spell % Spells Charlson Comorbidity Score 20+ Spells with Charlson Comorbidity Score of 20+ Spells Percentage of spells who have a charlson comorbidities score of 20 or more % of Spells in Risk Decile (0-10%) Spells with a Risk of Mortality 10% or less Spells Percentage of patients who fall within the lowest risk decile, using their standardisaed mortality ratio % Spells in Signs and Symptoms Chapter Spells that fall within the Signs and Symptoms Diagnosis Chapter % Spells in HSMR basket (non-elective) Spells that fall within one of the 56 HSMR diagnosis groups % Spells in HSMR basket (elective) Spells that fall within one of the 56 HSMR diagnosis groups Spells Spells Spells Percentage of spells who do not have a defined diagnosis in their 1st or 2nd FCE Percentage of non-elective spells which fall within the basket of 56 HSMR diagnosis groups Percentage of elective spells which fall within the basket of 56 HSMR diagnosis groups 2/2 51/112

52 Summary of the CQC and SRFT Diagnostic Improvement Plan BLUE GREEN AMBER/GREEN AMBER AMBER/RED RED Milestone successfully achieved Successful delivery of the project is on track and seems highly likely to remain so, and there are no major outstanding issues that appear to threaten delivery significantly. Successful delivery appears probable however constant attention will be needed to ensure risks do not materialise into issues threatening delivery. Successful delivery appears feasible but significant issues already exist requiring management attention. These appear resolvable at this stage and if addressed promptly, should not cause the project to overrun. Successful delivery is in doubt with major risks or issues apparent in a number of key areas. Urgent action is needed to ensure these are addressed, and to determine whether resolution is feasible. Successful delivery appears to be unachievable. There are major issues on project definition, with project delivery and its associated benefits appearing highly unlikely, which at this stage do not appear to be resolvable. Version Version 7.8 Date 31/8/17 1/32 52/112

53 PENNINE ACUTE HOSPITALS TRUST SAVING LIVES, IMPROVING LIVES OUR IMPROVEMENT PLAN AND OUR PROGRESS What and why we need to improve During February 2016 the CQC inspected services at PAHT. On 1 st March 2016 Ms. Ann Ford, Head of Hospitals Inspection CQC, wrote to confirm immediate patient safety concerns that had been discovered as a result of the inspection. The concerns that required decisive immediate actions to stabilise services and assure patient safety were across 4 main service areas Maternity, Children, Urgent Care and Critical Care. In April, following the interim appointment of Sir David Dalton as CEO, a team of senior health executives, supplemented by external support constructed and conducted a diagnostic review of the causes of risk to patient safety and care sustainability. The diagnostic focus was to identify areas for improvement that impacted on patient safety. It was not a full investigation into all aspects of operations of the trust. Nor was it a full due diligence of the trust. The diagnostic was informed by the immediate concerns raised by the CQC. The key areas for improvement identified in addition to the fragile services were: Patient safety, harm and outcomes Systems of assurance and governance arrangements Operational management and data quality Workforce capacity and capability Leadership and external relations 2 e0vyv2n1.vtx 2/32 53/112

54 3 e0vyv2n1.vtx PENNINE ACUTE HOSPITALS TRUST SAVING LIVES, IMPROVING LIVES OUR IMPROVEMENT PLAN AND OUR PROGRESS The CQC report has now been published (August 2016). The CQC identified 77 Must Dos and 144 Should Dos to ensure sustainable improvement to care delivered across the Pennine Trust services. The full report corroborates the findings of SRFT s diagnostic. The full CQC report has established evidence that PAHT, overall, is rated Inadequate. All of the CQC must dos and should dos have been mapped across to the themes for improvement identified in the SRFT Diagnostic. This improvement plan sets out the immediate (first 9 months) improvement actions this is to ensure we are getting the basics right, stabilising services and creating the right conditions upon which we can continue to improve and ultimately transform care delivery across Pennine. Our quality improvement strategy Saving Lives, Improving Lives, aims to go beyond the immediate concerns raised by the CQC report, we will engage our staff in a quality improvement strategy that will result in our services to be rated good or outstanding by regulators, that our staff would rate as a good place to work and a good place for their relatives to be cared for. Who is responsible? NHS Improvement (NHSi), in conjunction with GM Health & Social Care Partnership (coordinating the response of Bury, Oldham, HMR and North Manchester CCGs), invited Salford Royal NHS Foundation Trust (SRFT), to provide interim leadership support to PAHT from 1st April 2016 the Chair, Mr. Jim Potter and the CEO, Sir David Dalton, were appointed to interim positions of Chair and CEO of PAHT. 3/32 54/112

55 PENNINE ACUTE HOSPITALS TRUST SAVING LIVES, IMPROVING LIVES OUR IMPROVEMENT PLAN AND OUR PROGRESS The Trust Chief Executive Sir David Dalton is ultimately responsible for implementing the actions in this document, the Trust executive team will provide the leadership to ensure we identify the right improvement actions that will tackle some of the long standing issues the Trust has faced and create the right conditions to deliver the changes required. Our site leadership teams, divisional triumvirates and clinical leaders across the Trust will be key to delivering the actions that will ensure service sustainability and transformation. The high level deliverables articulated in this plan are underpinned by weekly improvement actions that clinical and management teams have developed and own. These weekly actions and evidence of delivery will be managed via an integration management office; teams will be supported to deliver changes at scale and pace with access to the SRFT standard operating model. The GM Improvement Board will bring together parts of the local health and care economies to ensure there is a shared understanding and collective commitment to the delivery of the improvement plan, including resources that need to be made available to enable the changes to happen. It is evident that the Trust has many thousands of staff trying to deliver good standards of care to patients. However, we need to create a culture of continuous improvement supported by robust governance and accountability arrangements from Board to ward which ensures leaders are focused on the key risks to the delivery of excellent care. 4 e0vyv2n1.vtx 4/32 55/112

56 PENNINE ACUTE HOSPITALS TRUST SAVING LIVES, IMPROVING LIVES OUR IMPROVEMENT PLAN AND OUR PROGRESS How will we measure our improvement? Measurement of our improvements will be fundamental to ensuring sustainability and the reliability of our care. We will develop a high level assurance dashboard against our key themes that measures our progress. We need to ensure that our improvement actions and activities are translating to improvement in outcomes for patients using a small number of key performance indicators. We will assure our improvement plan through our Trust board and Executive assurance committees How will we communicate progress? Internal Communication to staff within the Trust will utilise the full range of existing communication channels and our new leadership arrangements to listen, update and engage staff in the delivery of the improvement plan. We will utilise a weekly message circulated to all staff, site notice boards; monthly face to face Team Talk sessions led by an Executive Director; regular briefings with the staff side representatives and direct engagement sessions between the Executive team and senior managers with a particular focus on meeting with the Clinical Directors. Briefing of key issues through the line management structure; use of dedicated pages on the Trust intranet and articles on our improvement journey will feature in the monthly Pennine News magazine. Any matters which require immediate communication will be sent through an all user . 5 e0vyv2n1.vtx 5/32 56/112

57 PENNINE ACUTE HOSPITALS TRUST SAVING LIVES, IMPROVING LIVES OUR IMPROVEMENT PLAN AND OUR PROGRESS There are multiple routes for staff to feed-back comments including the dedicated address; raising issues at face to face sessions with their line managers or at Team Talk sessions; contributing through the staff engagement programme; if necessary using the Speak in Confidence system to raise matters anonymously directly with senior managers. Working in partnership with the multi-agency communications group we will: Ensure the clear, consistent and integrated delivery of all internal and external communications including staff, patients, families and carers, commissioners, GPs; Ensure the public/patients are informed and reassured that services are safe; Ensure that all key partners and stakeholders are kept up to date and informed about developments, decisions and any service changes that are required and their impact; Ensure all related media enquiries are co-ordinated and managed effectively, to ensure clear and consistent messages and to ensure media coverage is accurate; Work together to manage and protect the reputation of the NHS and social care in Greater Manchester and the services provided across the local healthcare economy; Ensure any subsequent operational or service changes are communicated effectively across PAT and the local healthcare system to staff, GPs, the public and externally. 6 e0vyv2n1.vtx 6/32 57/112

58 PENNINE ACUTE HOSPITALS TRUST SAVING LIVES, IMPROVING LIVES OUR IMPROVEMENT PLAN AND OUR PROGRESS Improvement Theme Summary of actions required Agreed timescale Assurance and external support RAG Status Executive and Operational Leadership Revised deadline if required BAF Urgent Care Establish clear leadership for the urgent care services and EDs in line with site based leadership model External GM Improvement Board CCGs GM providers All appointments made and commence in post June Sept GREEN Chris Brookes Chief Medical Officer June for Division Improving fragile services Ensure adequate stabilisation of consultant and middle grade cover in ED at NMGH to meet the agreed service model requirements Internal Care Board and Quality Assurance Committee Stability of consultant cover. Middle grade to be kept under review until permanent appointments made AMBER for review Revised Assess the options for the Urgent Care service model for North Manchester Options assessed and recommendation made to GMHSCP. COMPLETE e0vyv2n1.vtx 7/32 58/112

59 PENNINE ACUTE HOSPITALS TRUST SAVING LIVES, IMPROVING LIVES OUR IMPROVEMENT PLAN AND OUR PROGRESS Have in place a nursing, ENP, ANP workforce to meet the demand of patients across EDs ROH vacancies = no vacancies from Sept NMGH vacancies = 14 current, none from Sept AMBER GREEN Chief Nurse ongoing Have in place a nursing, ANP, AHP workforce to meet the demand of patients across AMU s Develop and deliver primary care offer within ED at NMGH (including streaming) Develop integrated ambulatory pathways and frailty model at NMG ROH= 14 RN vacancies from Sept post new recruits NMGH =3 RNs current but 28RNs post expansion, 11 in pipeline AMBER Goes live October. Capital bid approved by NHSi AMBER GREEN Model agreed, see above re: capital bid against Frailty offer will be included within phase 2 of the AMU expansion. Workforce recruitment remains risk to expansion AMBER Chief Medical Officer Chief Delivery Officer Chief Medical Ongoing e0vyv2n1.vtx 8/32 59/112

60 PENNINE ACUTE HOSPITALS TRUST SAVING LIVES, IMPROVING LIVES OUR IMPROVEMENT PLAN AND OUR PROGRESS Ensure best practice patient pathways within the ED and time to assessment, treatment and transfers are well understood and delivered in order to manage risks to patient safety and improve care Ensure the pathways/escalation response for medical, surgical and paediatrics and the speciality services capacity to respond to urgent and emergency care is developed in place. Have in place an extended crisis response service for North Manchester, 8am 10pm, 7 days Improvement actions underway at all CO with weekly tests of change. Workforce & bed capacity remains key risk. Indicators stabilised or improving. ROH delivery risk increased. AMBER Speciality solution not yet reliable but improving. DTAs at NMGH significantly improved. ROH delivery risk increased AMBER COMPLETED Officer Chief Delivery Officer ongoing Go live Feb 17 9 e0vyv2n1.vtx 9/32 60/112

61 PENNINE ACUTE HOSPITALS TRUST SAVING LIVES, IMPROVING LIVES OUR IMPROVEMENT PLAN AND OUR PROGRESS Maternity Care Put in place the senior management and clinical leadership to develop and drive forward the maternity improvement plan Have in place robust workforce plans and available staff to deliver maternity services, including medical, nursing and support posts External GM Improvement Board CCGs CMFT/RBH Internal Care Board and Quality Assurance Committee COMPLETE Midwife to births ratio improving. New recruits Sept. Interview dates for ROH consultant appointments made NMGH 5 posts advertised after RCOG approval, interviews Sept 6th GREEN Chief Nurse/ Chief Medical Officer Chief Nurse/Chief Medical Officer Phase appoints In post Establish comprehensive risk and governance arrangements which includes learning from incidents, complaints, auditing practice and improving incident and risk management systems and processes. Embed learning culture Systems and processes in place. COMPLETED Ongoing On- 10 e0vyv2n1.vtx 10/32 61/112

62 PENNINE ACUTE HOSPITALS TRUST SAVING LIVES, IMPROVING LIVES OUR IMPROVEMENT PLAN AND OUR PROGRESS going Ensure all staff are trained and developed specific to their job roles Ensure the engagement of all staff in the improvement plan, developing a culture of continuous quality improvement Indicators improving with CTG training at 93%. 200 midwives on advanced NHSi programme GREEN Continuous engagement on-going GREEN Ongoing Paediatric Care Ensure adequate numbers of trained paediatric nurses are in place to meet the demand and ensure safe care Develop and deliver on the new model to stabilise paediatric urgent care for FGH External GM Improvement Board CCGs CMFT/RBH Internal Care Board and Quality Assurance Committee HDU beds reliably staffed (discussions with NHSE re funding). Beds flexed to daily staffing to maintain safe ratios and business case under review for expansion. Recruitment ongoing. Reduction in transfer out remains stable at reduced rate AMBER COMPLETED Chief Nurse Chief Delivery Officer Chief Nurse e0vyv2n1.vtx 11/32 62/112

63 PENNINE ACUTE HOSPITALS TRUST SAVING LIVES, IMPROVING LIVES OUR IMPROVEMENT PLAN AND OUR PROGRESS Ensure all staff are trained and competent to manage the critically ill child and have in place a 24hr/7 day rota for APLS/PLS trained staff. Ensure the capacity to treat and care for children requiring elective treatment is in place sustainably Develop and deliver on the new models of care to receive, assess and treat paediatrics at all sites COMPLETED Oral surgery wait list reopened with agreement from NHSI. Daily elective lists in place with some weekend capacity GREEN 23Hr unit in place at NMGH. Gaps in workforce cap/demand at ROH and ANP role introduced AMBER/GREEN Chief Delivery Officer Chief Delivery officer Critical Care Ensure sufficient consultant and middle grade cover to the HDU at ROH External GM Improvement Board CCGs CMFT/RBH Internal Care Board and Quality Assurance Committee HDU cover maintained at agreed levels and middle grade recruitment progressed. Risks to sustainability due to emerging consultant gaps at FGH and ROH cover required. AMBER Chris Brookes Chief Officer Chief Nurse e0vyv2n1.vtx 12/32 63/112

64 PENNINE ACUTE HOSPITALS TRUST SAVING LIVES, IMPROVING LIVES OUR IMPROVEMENT PLAN AND OUR PROGRESS Ensure that the required nursing/ahp workforce across the critical care units is determined and in place Determine the requirements for critical care outreach and safe response at night and weekends Develop and Ignite our QI Strategy Develop PAHT QI strategy External GM Improvement Board CCGs Nursing gap closing to enable delivery against agreed plan. AHP plan to be reviewed in line with benchmark and funding revision AMBER Review post QI- Deteriorating patient COMPLETED Chief Nurse Engagement and launch of Strategy with CO staff COMPLETED ongoing Improving Quality Improving Safety QI Collaborative on deteriorating patients and managing sepsis Engagement of staff Internal Care Board and Quality Assurance Committee COMPLETED Chief nurse/chief Medical Officer 13 e0vyv2n1.vtx 13/32 64/112

65 PENNINE ACUTE HOSPITALS TRUST SAVING LIVES, IMPROVING LIVES OUR IMPROVEMENT PLAN AND OUR PROGRESS Development of QI faculty COMPLETED Commence collaborative COMPLETED Test of change being undertaken and QI learning being embedded Underway GREEN Develop change package and scale up and spread Improving Safety 90 day improvement cycles for pressure ulcers, falls, CAUTI Have in place reliable data (Mar-Jun17) Internal Care Board and Quality Assurance Committee To be develop following completion of collaborative Pressure Ulcer data correct, falls data correct, CAUTI under review but using ST GREEN Chief Nurse/Chief Medical Officer ongoing Develop ward improvement goals Falls continues to improve, and P Ulcer collaborative launched GREEN e0vyv2n1.vtx 14/32 65/112

66 PENNINE ACUTE HOSPITALS TRUST SAVING LIVES, IMPROVING LIVES OUR IMPROVEMENT PLAN AND OUR PROGRESS Improving Safety 90 day improvement cycle reducing hospital acquired C.Diff Have in place reliable data (Oct-Dec) Internal Care Board and Quality Assurance Committee COMPLETED-local action plans developed Chief Medical Officer Dec-Feb Develop ward improvement goals and plans COMPLETED Mar 17 Review and improve the Trust antibiotic polices and antimicrobial stewardship Policies reviewed by IP&C. Fundamentals of care programme led by CMO GREEN Review and improve hand hygiene practices CO medical directors assuring compliance but system not yet reliable. AMBER Improving Safety Implement NAAS System to ensure core nursing standards are met Mobilise team and engage senior Internal Care Board and Quality Assurance Committee COMPLETED Chief Nurse 15 e0vyv2n1.vtx 15/32 66/112

67 nurse leaders in NAAS model PENNINE ACUTE HOSPITALS TRUST SAVING LIVES, IMPROVING LIVES OUR IMPROVEMENT PLAN AND OUR PROGRESS Undertake desktop assessment COMPLETED Identify data collections methods and priority areas (pilot wards) Baseline assessment of all priority wards and improvement plans developed COMPLETED COMPLETED Completion of all wards On track 7 wards outstanding will complete in next 3 weeks GREEN 50% of all wards to achieve Green status Improving Safety Implement patient support system Deploy a support system to support vulnerable patients and Commence Complete Internal Care Board and Quality Assurance Committee 33%, 19 amber = 44% and 10 green = 23%. Clear action plans agreed with ward managers and new corporate matrons for reassessments AMBER COMPLETED Chief Nurse e0vyv2n1.vtx 16/32 67/112

68 PENNINE ACUTE HOSPITALS TRUST SAVING LIVES, IMPROVING LIVES OUR IMPROVEMENT PLAN AND OUR PROGRESS families Evaluation of support system Improving Effectiveness Reducing mortality External GM Improvement Board CCGs Chief Medical Officer Outline methodology Undertake Trust wide mortality review Internal Care Board and Quality Assurance Committee COMPLETED COMPLETED Determine CO/Service level improvement actions using review data and Dr Foster intelligence Ensure reliable system for M&M reviews and learning from avoidable factors COMPLETED Maturity of system seen at FGH. Roll out to other CO under MD leadership AMBER GREEN Improving patient experience Improving End of Life Care 17 e0vyv2n1.vtx External GM Improvement Board CCGs Elaine Inglesby- Burke Site Nurse 17/32 68/112

69 PENNINE ACUTE HOSPITALS TRUST SAVING LIVES, IMPROVING LIVES OUR IMPROVEMENT PLAN AND OUR PROGRESS Undertake a baseline assessment of bereavement care Work with wards and departments to agree the plan Internal Care Board and Quality Assurance Committee COMPLETED COMPLETED Directors and Medical Directors Roll out the Royals Alliance bereavement model COMPLETED Improving patient experience Implement what matters most to me Commence Complete Project to form part of last 1000 days Chief Nurse Undertake baseline assessment of Patient Experience and determine other key improvement actions Ongoing improvement actions relating to FFT continue GREEN ongoing Develop QI Collaborative on last 1000 days and PJ Paralysis Commence June 17. Conclude COMPLETED 18 e0vyv2n1.vtx 18/32 69/112

70 PENNINE ACUTE HOSPITALS TRUST SAVING LIVES, IMPROVING LIVES OUR IMPROVEMENT PLAN AND OUR PROGRESS Undertake tests of change July-Nov Commenced GREEN Develop change package and spread Nov-Dec Ensure safe medicines management Develop plans derived from core standards and audits COMPLETED Chief Medical Officer Deliver on improvements to: - CD/RD checks - Fridge ambient temps - Crossing out/signatories Improvements in Duthie audits. Clear action plans at ward level assured by DONs AMBER Revise Medicines Safety Group New TOR agreed and membership, Medical Director appointed to chair, schedule of dates agreed AMBER-RED 19 e0vyv2n1.vtx 19/32 70/112

71 PENNINE ACUTE HOSPITALS TRUST SAVING LIVES, IMPROVING LIVES OUR IMPROVEMENT PLAN AND OUR PROGRESS Complete MIAA audit actions Plans in place to address actions AMBER Improving Risk and Governance Implement new risks and governance arrangement across the Trust Undertake comprehensive assessment of governance arrangements and develop work plan focussing initially on 4 priority areas: complaints, claims, serious incidents and coroners inquests External GM Improvement Board CCGs Internal Care Board Executive Risk Assurance Committee Assessment and early improvement actions determined COMPLETED. Month on month improvements continue Complaints backlog trajectory agreed real time response to be in place by November 17 GREEN Chief Nurse Implement new risk and governance framework COMPLETED Put in place new Board Assurance Framework Ensure risk and governance arrangements during Transition COMPLETED New Transition Board established. Clear project plan 20 e0vyv2n1.vtx 20/32 71/112

72 PENNINE ACUTE HOSPITALS TRUST SAVING LIVES, IMPROVING LIVES OUR IMPROVEMENT PLAN AND OUR PROGRESS to new CO and once new CO are established remain robust Roll out risk training for all staff AMBER- GREEN COMPLETED for phase 1. Phase 2 training to be delivered for new Divisional leaders once established Commence July Additional training procured and underway GREEN Implement new Datix system Implementation underway track mobilisation issues AMBER GREEN 21 e0vyv2n1.vtx 21/32 72/112

73 PENNINE ACUTE HOSPITALS TRUST SAVING LIVES, IMPROVING LIVES OUR IMPROVEMENT PLAN AND OUR PROGRESS Review all safeguarding Deliver on level 3 children s safeguarding training to agreed standard External GM Improvement Board CCGs Local Authorities New Head of Safeguarding in post, training compliance maintained for high risk areas GREEN Chief Nurse Ongoing Undertake gap analysis for MCA DOLs and deliver on agreed action plan Internal Executive Quality Assurance Committee Gap analysis completed. Plans in place to develop staff knowledge and application AMBER/GREEN Ongoing Improving Operations and Performance Ensure improvement to patient flow Implement SAFER model across all wards Improving reliability of SAFER External GM Improvement Board CCGs Local Authorities Community providers COMPLETED See refresh below Tests on 2-3 wards per CO to identify bottlenecks Chief Delivery Officer Commence QI project on Reliable ward rounds Commence QI project on standard work for bed managers Start Start Internal Executive Operations and Performance Committee PID approved 90 day improvement cycle underway. AMBER PID approved 90 day improvement plan underway AMBER 22 e0vyv2n1.vtx 22/32 73/112

74 PENNINE ACUTE HOSPITALS TRUST SAVING LIVES, IMPROVING LIVES OUR IMPROVEMENT PLAN AND OUR PROGRESS Ensure flow/bed requirements are driven by agreed clinical pathways of care, are modelled and delivered AMU/ambulatory pathways modelled. GREEN Workforce risks to AMU/Ambulatory expansion. Acute bed capacity limited and optimum occupancy reliant on OOH improvements AMBER/RED Revised date Have in place systems and processes for the management and escalation of patient flow across the acute sites to ensure patients are care for in the right place Put in place and deliver against agreed standards which ensure medically optimised patients are transferred safely and appropriately Ensure data quality systems and processes are robust to deliver on operational performance Reduce PAS open registrations by External GM Improvement Board CCGs Trust escalation systems revised to include OPEL. COMPLETE IDT teams in place. Needs agreed timeliness standards across NES & TA. Agreed DTOC levels not achieved AMBER Chief Delivery Officer e0vyv2n1.vtx 23/32 74/112

75 PENNINE ACUTE HOSPITALS TRUST SAVING LIVES, IMPROVING LIVES OUR IMPROVEMENT PLAN AND OUR PROGRESS completing data cleanse exercise and put in place systems and process for access control Create business intelligent patient tracking list and tools to support operational staff in managing stages of treatment for patients Internal Care Board and Executive Operations and Performance Committee Open registration closure commenced AMBERGREEN RTT and FU PTLs live in July/Aug AMBER GREEN Ensure all identified staff groups have access to and are trained and assessed on referral to treatment rules and PAS functionality Core systems trainers appointed. Training ongoing GREEN Ongoing Ensure booking and scheduling functions and resources are in place to meet the standards required and are structured to support operational delivery and the best patient experience. Put in place systems and processes to ensure clinical input into validation of ED breaches Engagement sessions delivered, plan developed AMBER COMPLETED e0vyv2n1.vtx 24/32 75/112

76 PENNINE ACUTE HOSPITALS TRUST SAVING LIVES, IMPROVING LIVES OUR IMPROVEMENT PLAN AND OUR PROGRESS and non breaches Ensure ED symphony system is utilised and optimised in patient tracking and clinical pathway management Continued delays with technical solution AMBER RED (TBR) Ensure ED patient tracker roles are developed and supported across all EDs Undertake self-assessment against audit commission standards on DQ, develop action plans to address gaps COMPLETED DQ and assurance processes underway as BI functions aligned and CO s develop AMBER ongoing Workforce and safe staffing Undertake baseline safe staffing review of nursing Assess all wards and departments against Salford Nursing Standards commencing with high risks areas External GM Improvement Board CCGs COMPLETED Chief Nurse Agree and develop workforce plan to address shortfalls Internal Care Board and Strategic work underway with HEIs and e0vyv2n1.vtx 25/32 76/112

77 PENNINE ACUTE HOSPITALS TRUST SAVING LIVES, IMPROVING LIVES OUR IMPROVEMENT PLAN AND OUR PROGRESS Executive Quality Assurance Committee international recruitment partner procured. AMBER RED Ongoing Have in place systems and processes to report and close workforce gaps to achieve safe reliable staffing (90% standard) Fill rates achieved with reliance on temporary staff due to recruitment challenges. NHSP gone live. New graduates start Sept AMBER RED Ongoing Undertake baseline safe staffing assessment for medical staff Understand vacancies against funded establishment Assess fragile services against national standards and clinical service need. Develop plans for resolution of gaps External GM Improvement Board CCGs, GMTU Internal Care Board and Executive Workforce Assurance Committee COMPLETED Assessment COMPLETE Agreed initial investment 12.5 WTE Consultants across the three CO s to support general internal medicine Chief Medical Officer 26 e0vyv2n1.vtx 26/32 77/112

78 PENNINE ACUTE HOSPITALS TRUST SAVING LIVES, IMPROVING LIVES OUR IMPROVEMENT PLAN AND OUR PROGRESS COMPLETED Close all critical medical workforce gaps on sustainable base Progress on stabilisation. Sustainable solution at risk timescale and cost Overseas recruitment underway with circa MGs in pipeline RED Implement new model for recruitment Identify hard to recruit groups COMPLETED Outline model and strategy for recruitment for fragile services COMPLETED plan revised following exec discussion Evaluation of strategy COMPLETED revised action plan developed Deliver on staff Happy Health Here programme Promote and improve the health, 27 e0vyv2n1.vtx External GM Improvement Board CCGs Sickness absence static 27/32 78/112

79 PENNINE ACUTE HOSPITALS TRUST SAVING LIVES, IMPROVING LIVES OUR IMPROVEMENT PLAN AND OUR PROGRESS wellbeing and engagement of the workforce Improve availability of the workforce and reduce reliance on temporary staffing Internal Care Board and Executive Workforce Assurance Committee Engagement strategy approved and underway with launch of 1000 voices AMBER GREEN Temporary staffing spend remains high. Staff appointments in pipeline for Sept starts. Group wide approach developed for management of temp staffing (nursing and medical) AMBER/RED Chief of Strategy and Organisational Development On-going On-going Develop new PDR offer and ensure staff have opportunity to engage in performance development discussions New offer developed. COMPLETED On-going Meet 90% PDR standard PDRs at 71% DQ issues being addressed. AMBER On-going Ensure all staff have access to Current performance marginally below target at 86% against 90% standard 28 e0vyv2n1.vtx 28/32 79/112

80 PENNINE ACUTE HOSPITALS TRUST SAVING LIVES, IMPROVING LIVES OUR IMPROVEMENT PLAN AND OUR PROGRESS and complete mandatory training Meet 90% standard AMBER-GREEN On-going Improving Leadership and strategic relations Development of Group Transition from interim executive Chair and CEO arrangement to permanent solution External NHSi, NHSE, GM Improvement Board CCGs COMPLETED Chief Executive Finalise group structure and governance arrangements COMPLETED Implement Site Leadership model Agree model and for site leadership and management of services External GM Improvement Board CCGs COMPLETED Jon Lenney Executive Director of HR &OD Recruit to site leadership teams Develop site improvement plans and accountability framework Commence Conclude Internal Care Board and Executive Workforce Assurance Committee COMPLETED COMPLETED e0vyv2n1.vtx 29/32 80/112

81 PENNINE ACUTE HOSPITALS TRUST SAVING LIVES, IMPROVING LIVES OUR IMPROVEMENT PLAN AND OUR PROGRESS Develop and deliver on clinical leadership programmes Design, commission and deliver joint clinical leadership programmes with Chief Nurse, PAHT MD and Salford Head of Leadership (post TFL programme) Design Delivery commence QI and Leadership programmes developed and delivery underway. GREEN Chief of Strategy and Organisational Development Ongoing delivery Develop and deliver a range of leadership workshops for nonclinical leaders with SRFT Head of Leadership and Executive Sponsor(s) Develop Delivery commence Plans developed with CO and underway GREEN Ongoing 30 e0vyv2n1.vtx 30/32 81/112

82 PENNINE ACUTE HOSPITALS TRUST SAVING LIVES, IMPROVING LIVES OUR IMPROVEMENT PLAN AND OUR PROGRESS Requirements to support improvement action Timescale for implementation Owner Progress against timescale Revised deadline if required Agreement of management contract with SRFT Raj Jain Financial settlement agreed to support improvement plans and delivery on LTFM in 16/17 and projections for 17/ Damien Finn/CCGs Agreed specification and plans from commissioners on model of care for primary care front end Engagement with and support from CCGs and LA to deliver on site and locality clinical service strategies CCG/LAs Engagement and contribution to system wide UC improvement & safety workshop led respectively by ECIP and Charles Vincent Review of clinical quality and performance arrangements with commissioners to ensure robust assurance and safety systems in place 31 e0vyv2n1.vtx Complete Complete CCGs Requires finalisation in all localities CCG/LAs and PAHT CCGs and PAHT Establishment of IMO to manage integration and co-ordinate improvement activities/synergies with SRFT Jude Adams Support from GM transformation unit and GM providers to develop and contribute where appropriate to new models of care for frail GMTU services Joint Transformation Board in place. LCO plans in various stages of development Commenced Contributions to CQC inspections by Commissioners In place In place Requires revised deadline 31/32 82/112

83 PENNINE ACUTE HOSPITALS TRUST SAVING LIVES, IMPROVING LIVES OUR IMPROVEMENT PLAN AND OUR PROGRESS SALFORD STANDARD OPERATING MODEL 32 e0vyv2n1.vtx 32/32 83/112

84 The Northern Care Alliance NHS Group Salford Royal NHS Foundation Trust (SRFT) & Pennine Acute Hospitals NHS Trust (PAT) Title of Report Urgent Care: Winter Planning Meeting Author Presented by Group Committees in Common Care Organisation Chief Officers Chief Delivery Officer Jude Adams Chief Delivery Officer Date 25 th September 2017 Executive Summary The high level actions for each Care Organisation, which are being pursued to deliver our urgent care trajectories over the winter months, are attached for Group Committees in Commons information. A confirm and challenge workshop is taking place on Friday, 22 nd September 2017, where the Care Organisations will relay their individual plans and consider key data analytics. Leaders will be gauging when winter surge periods will manifest and agree what the local responses to those surges will be. Proposals for mutual aid will be identified and agreed. Presentation about the outcome of the confirm and challenge workshop will be provided at Group Committee in Common s meeting on Monday, and detailed plans will be provided to the October meeting of Group Committees in Common. Annual Plan Objective Principal Associated Risks Recommendations To assure safe, reliable and compassionate care Delivery of Mandatory Standards Saving lives, reducing harm Delivery of A&E Standard The Group Committees in Common is asked to review and confirm progress as presented. Public and/or Patient Involvement (Including equality related impacts) Communication Freedom of Information Please indicate appropriate box below A This document is for full publication x B This document contains FoIA exempt information C This whole document is exempt under the FoIA. 1/6 84/112

85 Salford - Winter Plan Summary point plan key themes GP/Specialty Streaming ED Surge Response Bed Occupancy / Flow Bed Escalation Capacity/Minimise outliers Stranded Patients Intermediate Care Community/Social Care Capacity Mental Health Access Primary Care 2017/ 2018 Approved Winter Resilience Scheme GP Streaming - Capital scheme and new service mode Escalation Beds identified Control centre phase 1 - Model Wards Control centre phase 2 - Improved site management Integration of Hospital at night team Integrated DiscHome safe / Rapid Response Out of Hospital Assessment risis team - NWAS Green/Amber pathfinder diversion Reopening of Limes beds Take up and Tuck up expansion Engagement with the voluntary sector risis team - NWAS Green/Amber pathfinder diversion RAG Q1 Q2 Q3 Q4 Key Theme(s) &3 3 5 & 7 5& RAG Performance %age of all patients who spend four hours or less in A&E Reportable delayed transfers of care (acute and non-acute beds) 12hr trolley waits in A&E Bed Occupancy Rate First Contact GP Streaming - Capital scheme and new service model, Crisis Team - NWAS Green and Amber pathfinder diversions, Acute patient assessment service (APAS) 24/7 Month A&E Performance Monthly Trajectory Cumulative Performance Cumulative Trajectory Month DTOCs MOATs Urgent Primary Care Extended GP Access Swinton Neighborhoods, Acute Patient Assessment Service (APAS)24/7 Urgent Community Care Home Safe/Rapid Response, Crisis team - NWAS Green and Amber pathfinder diversions Risks Increase in unplanned activity Bed capacity (in patient) Out of Hospital capacity Workforce Specialist ED Surge Specialist response, Surgical Triage, Hospital Escalation Capacity A&E 4Hr Performance and Trajectories Apr-17 May-17 Jun-17 Jul-17 Aug-17 Sep-17 Oct-17 Nov-17 Dec-17 Jan-18 Feb-18 Mar % 82.08% 83.73% 91.56% 93.03% 87.50% 90.00% 92.50% 90.00% 90.00% 90.00% 90.00% 90.00% 90.00% 90.00% 90.00% 95.00% 89.93% 85.90% 85.18% 86.78% 87.99% 90.00% 90.00% 90.00% 90.00% 90.00% 90.00% 90.00% 90.00% 90.00% 90.00% 90.00% 95.00% Delayed Transfers of Care (DTOCs) and Medically Optimised (MOAT) Patients Apr-17 May-17 Jun-17 Jul-17 Aug-17 Sep-17 Oct-17 Nov-17 Dec-17 Jan-18 Feb-18 Mar hr A&E throughput - achieve 95% by March hour trolley waits - no waits recorded in ED by March 2018 Ambulance turnaround - no longer than 60 minutes by March 2018 Bed occupancy - not exceeding 89% by March /18 Urgent Care Performance Targets DTOC - reduce bed days lost to DTOC by 20% by March 2018 Reduce A&E referrals in line with GP Streaming and ICO plans ED 4hr Performance RAG Rating Below STF Target Above STF, below national Above national standard (95%) Month Attendances Admissions from A&E Apr May Jun Jul Aug Sep-17 Oct-17 Nov-17 Dec-17 Jan-18 Feb-18 Mar-18 Total Mean /6 85/112

86 Bury - Winter Plan Summary point plan key themes Front door clinical streaming Demand Diversion: Ambulances Urgent Treatment Centres Demand Diversion: 111 Support to Care Homes Mental Health in A&E Bed Capacity Patient Flow GP Extended Access 2017/ 2018 Approved Winter Resilience Scheme Ambulatory Care Discharge Lounge Escalation Beds Additional OT support Navigators Integrated Discharge Team Over-night Breach Tracker Additional AMU consultation A&E Streaming* Re-ablement service Winter Transport Scheme RAG Q1 Q2 Q3 Q4 Key Theme(s) 8 8 7, , ,8 8 RAG Performance % of all patients who spend four hours or less in A&E Reportable delayed transfers of care (acute and non-acute beds) 12hr trolley waits in A&E Bed Occupancy Rate Primary Care Alternative to Transfer and Clinical Hub (Bury Out of Hours provider providing clinical assessment to reduce ambulance conveyance) Bury Green Car GP Streaming Monday to Friday 6.oo pm to p.m. Saturday and Sunday 4.00 p.m. to p.m. Month A&E Performance Monthly Trajectory Cumulative Performance Cumulative Trajectory Month DTOCs MOATs Flow Extended opening hours in ACU With an expanded medical and nursing workforce. Reduction of DTOC Roll out of SAFER and FOCUS improvement plan Expanded ANP workforce in A&E Integrated Services Risks Increase in unplanned activity Bed capacity (in patient) Out of Hospital capacity Workforce Integrated Discharge Team working collaboratively with ward teams and site management team. Development of on site discharge lounge with the flexibility to accept patients who require beds. Reallocation of junior and consultant medical staff to discharging wards Increase in number of IMC beds in Tudor Court Flexibility within existing IMC facilities to accept Bury registered patients A&E 4Hr Performance and Trajectories Apr-17 May-17 Jun-17 Jul-17 Aug-17 Sep-17 Oct-17 Nov-17 Dec-17 Jan-18 Feb-18 Mar % 89.34% 87.58% 93.29% 90.79% 82.80% 84.30% 86.40% 88.10% 88.10% 90.00% 90.50% 90.89% 91.20% 90.70% 91.70% 92.00% 84.51% 87.01% 87.20% 88.81% 89.19% 82.80% 83.55% 84.50% 85.40% 85.94% 86.62% 87.17% 87.64% 88.03% 88.30% 88.61% 88.89% Delayed Transfers of Care (DTOCs) and Medically Optimised (MOAT) Patients Apr-17 May-17 Jun-17 Jul-17 Aug-17 Sep-17 Oct-17 Nov-17 Dec-17 Jan-18 Feb-18 Mar ED 4hr Performance RAG Rating Below STF Target Above STF, below national Above national standard (95%) A&E Attendances Attendances Average UCL LCL Attendances Average UCL LCL 2017/18 Urgent Care Performance Targets 4hr A&E throughput - achieve 92% by March hour trolley waits - no waits recorded in ED by March 2018 Ambulance turnaround - no longer than 60 minutes by March 2018 Bed occupancy - not exceeding 89% by March Admissions via A&E Admissions Mean UCL LCL DTOC - maximum 60 bed days lost to DTOC by March calls referred to ED - maximum 180 referred by March 2018 Attendances at A&E - not to exceed 5,000 by March 2018 # Month Attendances Admissions from A&E Apr May Jun Jul Aug Sep-17 Oct-17 Nov-17 Dec-17 Jan-18 Feb-18 Mar-18 Total Mean /6 86/112

87 HMR - Winter Plan Summary point plan key themes Front door clinical streaming Demand Diversion: Ambulances Urgent Treatment Centres Demand Diversion: 111 Support to Care Homes Mental Health in A&E Bed Capacity Patient Flow GP Extended Access 2017/ 2018 Proposed Resilience/Transformation Scheme Ambulatory Care Expansion Primary Care streaming Paediatric streaming in Urgent Care ITS expansion - increased demand via SPOA Enhanced flow - expanded D2A Mental health Urgent Care streaming HEATT Service expansion UCC 111 triage Patient Choice advocate - reduce MOATs/DTOCs Enhanced support to Care Homes Enhanced workforce support to enhanced IMC RAG Q1 Q2 Q3 Q4 Key Theme(s) ,2,7,8 7, ,4 7,8 5 7,8,1 RAG Key Performance Priorities Urgent Care Performance - 4hr Target Delayed Transers of Care %age of HMR activity managed at Rochdale Infirmary Reductions in ED attendances and NEL admissions Primary care -Primary Care Streaming -Development of UTC -Increase in demand into SPOA and ITS provision Month A&E Performance Monthly Trajectory Cumulative Performance Cumulative Trajectory Month DTOCs MOATs Admission Avoidance - Increase ambulance attendances at RI site by 5% - Decrease care home admissions and NWAS calls to care homes by 10% -Reduced admissions for IV antibiotics Flow - 50% reduction in DTOCs and MOATs - SAFER outcomes - 80% of supported discharged via D2A - Expanded ambulatory caacity at RI Risks Workforce Flow Ambulance activity out of Borough Pathfinder Specialist - Mental Health Care in Urgent Care -Paediatric streaming in Urgent Care A&E 4Hr Performance and Trajectories Apr-17 May-17 Jun-17 Jul-17 Aug-17 Sep-17 Oct-17 Nov-17 Dec-17 Jan-18 Feb-18 Mar % 97.01% 95.73% 96.56% 97.90% 95.30% 95.60% 96.40% 97.00% 96.60% 96.30% 97.20% 97.50% 97.80% 96.80% 98.40% 98.70% 95.65% 96.36% 96.16% 96.26% 96.60% 95.30% 95.45% 95.77% 96.08% 96.18% 96.20% 96.34% 96.49% 96.63% 96.65% 96.81% 96.97% Delayed Transfers of Care (DTOCs) and Medically Optimised (MOAT) Patients Apr-17 May-17 Jun-17 Jul-17 Aug-17 Sep-17 Oct-17 Nov-17 Dec-17 Jan-18 Feb-18 Mar ED 4Hr Performance RAG Rating Below STF Target Above STF, below national Above national standard (95%) RI Attendances Attendances Average UCL LCL Admissions via ED Admissions Average UCL LCL Month RI Attendances NEL Admissions Apr May Jun Jul Aug Sep-17 Oct-17 Nov-17 Dec-17 Jan-18 Feb-18 Mar-18 Total Mean Attenda Apr May Jun Jul Aug Sep-17 Oct-17 Nov-17 Dec-17 Jan-18 Feb-18 Mar-18 4/6 87/112

88 North Manchester - Winter Plan Summary 5/6 88/112

89 Oldham - Winter Plan Summary point plan key themes Front door clinical streaming Demand Diversion: Ambulances Urgent Treatment Centres Demand Diversion: 111 Support to Care Homes Mental Health in A&E Bed Capacity Patient Flow GP Extended Access 2017/ 2018 Approved Winter Resilience Scheme Oldham Rapid Community Assessment Team (ORCAT) Therapists, Nursing ORCAT RAID worker ORCAT Social Worker ORCAT PIP Worker Medical Services Transport Discharge Co-ordinators Patient Flow Trackers A&E Therapy Team Community Crisis Step Up Promoting Independence Worker - ORCAT Integrated Discharge Team Lead Medical Consultant in A&E 7 days Hospital 2 Home A&E 2 Home Under 5s Attendees Community Support Programme Ambulance Liaison Officer Frequent Caller Paramedic Healthy Homes Paediatrics End to End Tracking Resilience Ad Hoc Funding RAG Q1 Q2 Q3 Q4 Key Theme(s) 8 6, ,8 7, RAG Performance %age of all patients who spend four hours or less in A&E Reportable delayed transfers of care (acute and non-acute beds) 12hr trolley waits in A&E Bed Occupancy Rate First Contact Pilot Ambulance Liaison Officers and Frequent Callers Scheme Avhieve single site management including HMR staff Continue to pilot two models of B7 nurse streaming Implement end-to-end tracking to identify system pressures Month A&E Performance Monthly Trajectory Cumulative Performance Cumulative Trajectory Month DTOCs MOATs 2017/18 Urgent Care Performance Targets Urgent Primary Care Primary care clusters focus on supporting patients outside the hospital environment Urgent Community Care Review Oldham Rapid Communbity Assessment Team Healthcare at Home undertaking scoping into how patients can be managed better at home and how the resilience of care homes can be improved Additional transitional beds identified with further work underway to provide additional support from ORCAT A&E 4Hr Performance and Trajectories (incl. WiC) Apr-17 May-17 Jun-17 Jul-17 Aug-17 Sep-17 Oct-17 Nov-17 Dec-17 Jan-18 Feb-18 Mar % 90.90% 88.80% 84.40% 87.30% 75.00% 78.50% 78.50% 87.00% 87.00% 87.00% 92.00% 92.00% 92.00% 92.00% 92.00% 92.00% Delayed Transfers of Care (DTOCs) and Medically Optimised (MOAT) Patients Risks Increased in unplanned activity Bed capacity (in patient) Out of Hospital capacity Workforce Ambulatory Care Phase 1 - extension of access from 8am - 11pm (Mon-Fri) Phase 2 - extension of access to seven days a week from November 2017 Apr-17 May-17 Jun-17 Jul-17 Aug-17 Sep-17 Oct-17 Nov-17 Dec-17 Jan-18 Feb-18 Mar hr A&E throughput - achieve 92% by March hour trolley waits - no waits recorded in ED by March 2018 Ambulance turnaround - no longer than 60 minutes by March 2018 Bed occupancy - not exceeding 89% by March 2018 DTOC - maximum 60 bed days lost to DTOC by March calls referred to ED - maximum 180 referred by March 2018 Attendances at A&E - not to exceed 8,600 by March 2018 ED 4hr Performance RAG Rating Below STF Target Above STF, below national Above national standard (95%) A&E Attendances Attendances Average UCL LCL Attendances Average UCL LCL Admissions via A&E Admissions Mean UCL LCL Month A&E Attendances Admissions from A&E Apr May Jun Jul Aug Sep-17 Oct-17 Nov-17 Dec-17 Jan-18 Feb-18 Mar-18 Total Mean /6 89/112

90 The Northern Care Alliance NHS Group Salford Royal NHS Foundation Trust (SRFT) & Pennine Acute Hospitals NHS Trust (PAT) Title of Report Northern Care Alliance Transforming Recruitment Meeting Author Presented by Group Committees in Common Amy Goodale, Lead for Resourcing Raj Jain, Chief Strategy and Organisational Development Officer Raj Jain, Chief Strategy and Organisational Development Officer Date 25 th September 2017 Executive Summary Annual Plan Objective Principal Associated Risks Recommendations This paper recommends a recruitment model which enables us to become World Class and support care organisations in being able to effectively recruit and retain the best talent to enable the delivery of highly reliable care. Support our staff to deliver high performance and improvement Assure safe, reliable and compassionate care Deliver Financial Plan to assure sustainability Recruitment and retention of our workforce The Group Committees in Common is asked to support the resourcing strategy including the establishment of an EVP for the Alliance, a multi-channel approach to sourcing candidates and a new approach to candidate and hiring manager experience. Freedom of Information Please indicate appropriate box below A This document is for full publication x B This document contains FoIA exempt information C This whole document is exempt under the FoIA If you have chosen B above, highlight the information that is to be redacted within the document for subsequent removal. Confirm to the Group Secretary which applicable exemptions apply to the whole document or to highlighte sections. 1/9 90/112

91 Resourcing 1.0 Background The Committee in Common have prioritised the need to act to more effectively recruit and retain the best talent to enable the delivery of highly reliable care. One of the key assets that drove the ambition to create a group was the belief that a larger organisation will be able to create an employment that provides a distinct competitive advantage in the hugely competitive labour market. This proposal summarises how the Alliance s assets will be leveraged to produce additionality. 2.0 Diagnostic of current approach The necessity to change is borne out of the current difficulties experienced trying to attract talent into the organisation to fill the significant number of vacancies across the Alliance. Our latest data (August) shows that we have an approximate 10% vacancy rate across nursing and medical staff, with critical shortages in many areas. Part of the solution to this issue is improved retention (to reduce turnover from the current 11.5%). Additionally, the history and situation of the Northeast Sector Care Organisations are such that a significant competitive disadvantage in the labour market is present. i.e. it is much harder to recruit than it is to SRFT. It is our belief that our current recruitment model (used in SRFT & PAHT, and now acting as a single entity) is not fit for purpose. It has not kept up with developments in the market place. The necessity to change has been validated by an external assessment undertaken by Omni Resource Management Solutions. Omni Resource Management Solutions were commissioned to undertake a Recruitment Effectiveness Assessment to determine whether our current recruitment systems are fit for purpose and to make recommendations around our recruitment model with a view to us becoming world class. To do so, OMNI utilised their best practice Recruitment Maturity Matrix which utilises 9 elements of organisational recruitment to benchmark practice. These are: 2/9 91/112

92 Each of the 9 elements were assessed against a formal measure to ascertain a level of maturity. Scores range from 1 (Risk) to 4 (Strategic) with each level aligned to the four stages of the transformation pyramid: This review revealed that our sourcing practices were substandard/inadequate. The ratings given to our current recruitment practice were: 3/9 92/112

93 It elicited a set of findings that included the following: No strategic direction or fit with business need Engagement with only 20% of potential candidates when recruiting No employer brand awareness in a crowded market place No clear value add to potential staff Scattergun approach to candidate attraction and minimal future pipelining of talent Traditional channels, with only recent adoption of other media A recruitment service which is impersonal, driven with systems and mindsets that are transactional Inconsistent or poor candidate experience Low conversion rate Poor line manager experience and value added Inconsistent selection methodology Inconsistent with core trust strategies (values) Potential for poor decision making Inconsistent levels of training & competence of line managers The review highlighted recommendations to transform the current recruitment model with the overall ambition to establish and promote the Alliance employer brand as a destination employer of choice, decrease the current deficit of nurse and medical hires (in particular), improve the volume and quality of candidates especially within the nursing community, improve the candidate and hiring manager experience and deliver best value now and in the future. What follows is a summary of prioritised actions that have catalysed and evidenced by the OMNI review and with their professional support. 3.0 Priority One Creating and Establishing a Strong Employee Value Proposition A strong and differentiated Employee Value Proposition is key to the Alliance s ability to attract, recruit and retain the best talent: An employee value proposition (EVP) is the unique set of benefits which an employee receives in return for the skills, capabilities and experience they bring to a company. An EVP is about defining the essence of your company - how it is unique and what it stands for. The benefits of defining an EVP fall not just in the areas of sourcing and attraction but also provide an additional framework for assessment and selection of candidates and ongoing engagement of talent across the organisation. Organisations who have invested in the development of an EVP report lower cost per hire figures, lower attrition rates and successful recruitment of talent. The large scale of group brings positive opportunities and we are working to build these into an Employee Value Proposition which will help us to compete effectively in the labour market and drive staff loyalty through effective recruitment, engagement and retention practices. The EVP will drive the branding of the Alliance s recruitment activities. The delivery of the EVP will not only produce excellent external branding, but will drive all recruitment and onboarding activities so that success is maintained. 4/9 93/112

94 We have gathered data from surveys, existing engagement events and focus groups to understand why staff (and potential recruits) like working at their Care Organisation, what drives engagement and why staff leave. This supplements the professional and academic evidence base, allowing us to develop understandings that are context rich and timely. We have also assessed our competitors offers, and that of other companies that are seen to be best in class at recruitment. From this we are building the Alliance EVP ensuring that it is inspirational, realistic, aligned, differentiated and simple. The following is work in progress, but gives a good indication of the elements of the Alliance s EVP. We are also ensuring that there is coherence with our strategy for engagement (the Go Engage model). Below are some examples of EVP s from World Class Employers and links to their careers websites to show what we are aiming to achieve. a) L OREAL A thrilling experience An environment that will inspire you A school of excellence b) DELL BUILD YOUR FUTURE, CHANGE AN INDUSTRY'S Every great story has a beginning. This is ours - and it could be yours. If you're ready to fast forward your career, greatness begins here. LIFE AT DELL We pride ourselves on being a great place to work. We think of our team members as an extended family and work to foster an environment that benefits our workforce and generates personal and professional innovation. See what our employees have to say about working at Dell. 5/9 94/112

95 c) MARRIOTT HERE S TO THE JOURNEY To making your own way To endless possibilities To exploring new opportunities To never settling To wandering the world d) UNILEVER A job at Unilever is a career made by you, with development opportunities, benefits and a working culture that embraces diversity. So whether you re looking for an internship, apprenticeship, graduate opportunities, or a job opening to progress your professional career, at Unilever you can shape your own path as you work with the brands and people that drive our sustainable business growth Priority Two - Sourcing Strategy The Alliance will leverage its Employee Value Proposition to access the widest possible and best talent pool through new and innovative sourcing initiatives. An effective multi-channel sourcing plan has been developed to ensure that we can keep ahead of other NHS organisations, stand out and ensure the high levels of hires required can be reached in what is a crowded market place. The sourcing plan identifies a range of options which focus on both active and passive candidates to improve the breadth of the talent pool available. Active candidates (i.e. people actively looking for a new job) represent around 20% of the UK workforce. 70% are considered passive and whilst would not be actively looking for work through job boards/advertisements, but may be receptive to a direct approach or social media. Passive candidate targeting will be crucial to ensure the Alliance can supply the volume of candidates required to meet needs. Multi-Channel Sourcing Strategy - On-line channels A social media strategy has been developed to support our overall multi-channel sourcing plan. Facebook and twitter are being utilised to promote job opportunities across the Alliance and is proving to be a cost effective and targeted approach to sourcing talent. This needs to be further developed to ensure that we utilise social media to cultivate two-way relationships with potential talent and promote our offer to them and tell them about what it is really like to work for us. The strength of our presence on social media is reliant on our content and engagement. Further work and investment is required to develop this across the Alliance along with consideration of other opportunities through the use of Instagram, You Tube, Snapchat and Linked In. The use of social media also drives traffic to an organisations career website to create a funnel of candidates and support the employer brand. We plan to develop a dynamic careers site which is fundamental to the candidate experience and is different to our competitors. Building on our desire to become world class we have researched ideas from proven digital resourcing models based on successful models such as Autotrader, Spotify, Virgin Money, Automobile Association, 6/9 95/112

96 Rightmove, Twitter, Air BNB to create a platform which gives us a competitive edge. Whilst the social media strategy is important to initially attract candidates, a careers website that isn t functional and engaging will cause candidates to lose interest. The careers site is effectively the anchor holding together the pieces of our sourcing strategy. The development of a creative, memorable and on brand site is therefore crucial. We will create our capability that keeps people that have expressed an interest and that look like suitable candidates, but have not been successful in securing a job yet, engaged with the organisation. This will reduce cost and time to hire. Multi-Channel Sourcing Strategy - Off line channels Our multi-channel sourcing plan also builds on initiatives already in place including establishing a clear strategy around university engagement building on the strong established links with Salford University to recruit pre-registration nurses along with promotion of our EVP and job opportunities to a widened geographical spread of universities. International recruitment will feature. A planned trip to India in October is hoped to source 150 nurses across the Alliance in the first 12 months. We plan to continue participation in the MCH programme in India to recruit doctors and expand on the work with organisations such as Inpatria. The implementation of the Clinical Fellow rotational programme at Salford has already started to see impact in terms of interest and is seen as a positive way forward to fill the current doctor gap at a junior level. This programme now needs to be fully implemented and widened across the Alliance. A business case is being developed to formalise and align Return to Practice opportunities across group and a business case has been written to pilot an international nurse adaptation programme for 20 applicants who have expressed interest. Of significant importance in each Care Organisation locality will be the focus on supporting local people in their pursuit of meaningful employment. We will target local people, working alongside local authority and other local agencies to support each localities strategies for health & well being, and supporting disadvantaged groups. In this way we will leverage the health dividend that derives from employment and be seen as a positive contributor to the objectives and targets of local authorities. Multi-Channel Sourcing Strategy - Internal mobility The opportunities presented by the scale of the Alliance will be taken advantage of. We will support employees through rotational programmes, staff transfers and careers days building on an idea for an itchy feet programme. For those that we have been unable to retain in the organisation, exit interviews will be undertaken and action plans developed in response. Goodbye postcards have been developed and plans are in place to establish an alumni database with regular contact including asking them whether they wish to return. As our talent management programme is developed and matures, we will develop career ladders and development programmes that support succession planning. Staff will be identified for development into senior clinical and leadership posts. Staff will also be able to plan their careers over the long term, so that they can be more assured that their personal needs, eg flexible working as retirement is approached, will be met. These programmes will become significant attractors in the labour market, and will enable us to capture the best of clinical and leadership talent. 7/9 96/112

97 5.0 Priority Three - Candidate and Hiring Manager Experience Improving the candidate and hiring manager experience will subsequently improve conversion rates and time to hire. In addition candidates that have a good experience in our recruitment process will market that experience to other potential candidates. Improved candidate and hiring manager experience will requires upskilling of both the recruitment team in terms of delivering great customer focus but also of hiring managers to ensure that they have the necessary skills to recruit and select the right people. Development programmes are being developed. Additionally, we will set standards for things like job descriptions, advertisements, and other communications so that they are consistent with the EVP and brand. This will be digitised and controlled so that it supports workforce cost controls and minimises rework that currently happens every time we go out for a job. Hiring managers will be much more supported through this standardised and digitised approach. Controls on costs (i.e. to prevent grade drift through inappropriate job specifications and/or consistency with change programmes) will be enhanced. Experience will be measured to improve and inform recruitment strategy, process and activity across the Trust. 6.0 Priority Four - Assessment Good assessment and selection criteria and procedures should ensure that we recruit the right talent into the organisation. Assessment and selection criteria also enable fair and nondiscriminatory recruitment practices to be enforced ensuring all recruitment decisions are fair. Work will be undertaken to improve the consistency and suitability of the assessment and selection framework by defining Trust wide competency or values framework that maps both the technical and behavioural competencies aligned to each role or job family. To support this a programme of in-depth training of those employees responsible for assessment & selection will be delivered. 7.0 Priority Five - Onboarding Onboarding is a focus of the recruitment team and is a well-documented and understood process however the current emphasis is on compliance rather than candidate engagement/delight and relationship building. This must change to enable improvement in our conversion and retention rates. This position is reflective of other NHS organisations therefore there is a considerable opportunity for the Alliance to be different and leading in this area. There is a strong business case to support this change, evidenced by the number of candidates who withdraw following offer. We need to look at how we better utilise technology to deliver a personalised onboarding experience. This will help embed a candidate into the culture of the organisation, its vision and values but ensure that they understand their roles and responsibilities and opportunity s to develop. There are a number of new platforms on the market which offer responsive portals which put candidates in touch with their line manager and peers. We are also reviewing how we can further utilise innovative technology for ID checking to improve the candidate experience and reduce the number of withdrawals which can occur due to delays in the administrative process. 8/9 97/112

98 8.0 Measurement Measures have been put in place to monitor the success of our plans and include: increasing number of actual hires (reducing vacancy rate) Reduced agency costs to increase student nurse conversion rates for Band 5 to over 70% reduce time to hire from authorisation to offer to 40 days Improved candidate and hiring manager feedback on both recruitment administrative process and interview experience. online candidate activity and registrations/applications along with candidate engagement (number of revisits), increasing number of Facebook and twitter followers and number of re-tweets and shares, Increasing number of returners to the organisation 9.0 Mobilisation Alliance Corporate Review A new centralised recruitment structure with a consistent and standardised process has been planned and is being consulted on. The resourcing team will change from being focussed on administration to one that is a partner in the need to have wards, departments etc. fully staffed with high calibre people. The current team will need to fundamentally change its operating model. We are on to this and will implement development and change that delivers a team of highly skilled well motivated people that see success through the eyes of candidates and managers. There is a need for one off and recurrent investment in the Service. At a time when the Alliance is struggling to deliver its finances, it must be that the business case is strong. It is. The business case will be examined by the CIC Executive. 10. Recommendations The CIC is asked to support: a) Establishment of an EVP for the Alliance b) The multi-channel approach to sourcing candidates c) The new approach to candidate and hiring manager experience. Parts of the plan require investment. The business case and mobilisation plan will be scrutinised by the CIC Executive. 9/9 98/112

99 The Northern Care Alliance NHS Group Salford Royal NHS Foundation Trust (SRFT) & Pennine Acute Hospitals NHS Trust (PAHT) Title of Report Meeting Author Presented by SCAPE Panel Recommendations Group Committees in Common Fiona Morris, Lead Nurse for Corporate Services at Salford Royal James Sumner, Chief Officer Salford Care Organisation Date 25 th September 2017 Executive Summary Annual Plan Objective Principal Associated Risks Recommendations This paper is to provide recommendations to the Trust Board regarding two wards attending SCAPE Panel on the 14th September 2017 Pursuing Quality Improvement to assure safe, reliable and compassionate care Saving Lives, Reducing Harm The Group Committees in Common is asked to review and approve the recommendation to award SCAPE status to the following wards at Salford Royal: Ward B4 Ward B5 Public and/or Patient Involvement (Including equality related impacts) N/A Communication Outcome to be conveyed to ward staff. Freedom of Information Please indicate appropriate box below A This document is for full publication x B This document contains FoIA exempt information C This whole document is exempt under the FoIA If you have chosen B above, highlight the information that is to be redacted within the document for subsequent removal. Confirm to the Group Secretary which applicable exemptions apply to the whole document or to highlighted sections. 1/2 99/112

100 1. Introduction 1.1 The NAAS (Nursing Assessment and Accreditation System) is used on all ward areas to highlight best practices as well as deficiencies in practice, patient safety, education and management. 1.2 The aim is for all wards to achieve SCAPE (safe clean and personal every time) status. Once wards are consistently assessed as green they may apply for SCAPE and further rigorous assessments continue. 1.3 SCAPE goes beyond nursing care; wards being considered must demonstrate multidisciplinary working on improvement and safety. SCAPE is a reward for achievement of quality standards as well as being a Trust leader in patient safety. 2. SCAPE Panel 2.1 On the 14 th September 2017 the Panel sat to review SCAPE applications from B5 a 17 bedded Trauma Admissions Ward and B4 a 22 bedded Trauma and Neuro Rehabilitation Ward. 2.2 The Panel consisted of the Director of Nursing, the Medical Director, a Divisional Managing Director, a Non-Executive Director, a Divisional Nurse Director, two Assistant Directors of Nursing, a patient representative and a research observer from Kings College (who is researching the patient s experience). 2.3 The Panel process involved reviewing background information supplied by the areas, attending both wards in the morning of Panel: reviewing the environment whilst speaking to staff, including student nurses and patients. In the afternoon the Panel then listened to both team presentations and engagement in a question and answer sessions. 3. Recommendations 3.1 The Board is recommended to approve SCAPE status for the following wards: B4 and B5 3.2 The Panel felt that both teams were led by enthusiastic, motivated leaders with their full teams support. All data was thoroughly interrogated by the Panel. Both wards had the full support and commendation of the ADNS for Infection Control who was a Panel member. 3.3 Panel recommended that both teams review their approach to patient centeredness and family involvement in a more consistent way with all team members. For B5 the further recommendation was for the Ward Manager to be supported by a mentor and that she undertakes a Leadership programme to support and develop her skills. For B4 a further recommendation was to maximise the physiotherapy sessions and review equipment required to improve the rehabilitation process. 3.4 If both wards approved, the total number of SCAPE wards in the Trust will stand at 35. There will be one further SCAPE Panel for this year in November /2 100/112 2

101 Salford Royal NHS Foundation Trust (SRFT) & Pennine Acute Hospitals NHS Trust (PAT) Title of Report Report from Group Audit Committee 8 th September 2017 Meeting Author Presented by Group Committees in Common Rebecca McCarthy, Deputy Trust Secretary John Willis, Chairman of Audit Committee Date 25 th September 2017 Executive Summary Annual Plan Objective Principal Associated Risks Recommendations A summary is provided for the Group Committees in Common of the key matters and decisions from the Group Audit Committee meeting on 8 th September N/A The Group Committees in Common is asked to review the summary of the meeting and the agreed actions. Public and/or Patient Involvement (Including equality related impacts) N/A Communication N/A Freedom of Information Please indicate appropriate box below A This document is for full publication X B This document contains FoIA exempt information C This whole document is exempt under the FoIA If you have chosen B above, highlight the information that is to be redacted within the document for subsequent removal. Confirm to the Group Secretary which applicable exemptions apply to the whole document or to highlighted sections. 1/2 101/112

102 1. Chief Nursing Officer Report: CQC Corporate Assurance Review Programme Reviewed and confirmed outcomes from the Salford Care Organisation CQC Corporate Assurance Review Programme: Obstetrics and Gynaecology Ultrasound Ward H7 Emergency Assessment Unit (EAU) 2. Chief Finance Officer Report Reviewed and approved including approval of the Losses and Special payments covering the period 1 st June 2017 to 31 st July 2017 (PAT) and 1 st April to 31 st July 2017 (SRFT). Further discussion took place regarding the PAT control total negotiations. 3. Group Governance Framework Manual Review and confirmed, noting further review in November Group Procurement Work Plan Reviewed and confirmed progress on the Procurement Department s delivery of the Procurement theme as part of the BCLC programme and the joint working across Group. 5. Group Internal Audit Progress Report including escalated Care Organisation high risks Reviewed and confirmed update of internal audit findings and reports issued to the Group since April 2017 as per below table. Received progress report against the following Limited Assurance Reports: Clinical Audit (noting further update to be provided in November 17), Mobile Devices, Personal Files. 6. Group Anti-Fraud Progress Report Reviewed and confirmed. 7. Group External Audit Progress Report Reviewed and confirmed including Independent Auditor Report to Governors on the Quality Report and External Annual Audit Letter 2016/17. 2/2 102/112