Annual Report

Transcription

1 Annual Report Saving Lives, Improving Lives

2 Contents Performance Report....1 About the Trust Chairman s Report... 4 Chief Executive s Report Statement of the purposeand activities of the Trust Performance analysis Clinical Safety, Risk and Governance Operational Performance Review Sustainable Development Accountability Report Corporate governance report Statement of the Chief Executive s responsibilities as the Accountable Officer of the Trust Statement of Directors responsibilities in respect of the accounts Annual Governance Statement 2016/ Remuneration and Staff Report Remuneration Committee Independent Auditor s Report to the Board of Directors of Pennine Acute Hospitals NHS Trust Quality Accounts Report PART 1 - Statements on Quality PART 2 - Priorities for and Statements of Assurance from the Board PART 3 - Review of Quality Performance Annual Accounts 2016/ Financial overview Notes to the accounts Finance Glossary Charitable Funds Membership Contacting the Trust

3 PAGE 1 Performance Report Annual Report

4 PAGE 2 About the Trust The Pennine Acute Hospitals NHS Trust is one of the biggest in the North West of England and has some of the largest services by volume in the whole of England. During 2016/17 the Trust has worked increasingly closely with and under the strategic leadership of Salford Royal FT who were asked by NHS to provide support to the Trust following the CQC Inspection in February / March The Trust operates from four main sites in North Manchester, Bury, Oldham and Rochdale, together with the Floyd Unit at Birch Hill Hospital. We have an annual operating budget of over 600 million. We employ over 9,000 staff and provide a wide range of acute, specialist and community services to 820,000 people across the north east of Greater Manchester in Bury, Prestwich, North Manchester, Middleton, Heywood, Oldham and Rochdale and parts of East Lancashire. From 1 April 2015 we took over responsibility for managing adult social care services in the north of the city, from Manchester City Council. From 1 October 2016 we took responsibility for a range of community and integrated services in Heywood, Middleton and Rochdale. We work with our local Clinical Commissioning Groups (CCGs) in Manchester, Bury, Oldham and Heywood, Middleton and Rochdale and also with East Lancashire to plan, develop and commission healthcare services for local people. We also work closely with our local authority partners to develop ever more integrated services across our communities. The communities we serve The health of the population we serve is by many measures some of the worst in England. Our communities are geographically and culturally diverse in their makeup, but remain largely characterised by their industrial past. They range from high density inner city areas with significantly higher than average deprivation and social exclusion to pockets of affluence in country villages. This has contributed to significant health inequalities among the residents with more densely populated areas, in particular, having poorer access to healthcare Although there is a high level of diversity, common themes emerge:- Our communities are generally less healthy when compared with the rest of England. There is a higher proportion of people who have a long term illness. There is a significant gap between the poorest and most affluent communities. Where there are high rates of unemployment and deprivation, there is poorer health and greater demands on health and social care services. Rates of obesity, smoking, cancer and heart disease related to poor general health and poor nutrition are significantly higher than the national average. Life expectancy at birth in some of the areas the Trust serves is one of the lowest in England. Common themes of ill health and death include vascular and circulatory diseases, i.e. coronary heart disease and stroke, diabetes, cancer and respiratory diseases i.e. pneumonia, asthma, bronchitis and emphysema. Our communities include proportionally larger numbers of younger and older people than average. Both of these age groups have specific and distinct healthcare needs.

5 PAGE 3 Many of our communities have large and growing ethnic minority populations whose health and access to healthcare have been poor requiring the development of specific health strategies. The health of children and young people is generally worse than the England average, including obesity in reception year children and high levels of teenage pregnancy. However, the percentage of children who are physically active is significantly better than the England average. Ten facts about the Trust In 2016/17 the Trust: 1. Spent over 600 million (about 1.6 million a day) on providing health care services for local people 2. Invested 6.5 million on capital programme and in maintain and improving the physical estate of our hospitals to develop frontline clinical services 3. Spent 8.8 million on vital medical and scientific equipment 4. Spent 2.3 million on information technology to support frontline clinical services 5. Employed over 9,500 staff 6. Saw 319,177 A&E urgent cases, 675,524 outpatients, 105,956 in patients, 72,342 day cases 7. Delivered 9,593 babies 8. Made 151,952 visits to patients in their own homes to provide treatment and care 9. Issued over 1 million items from pharmacy to inpatients, outpatients, patient discharges and ward stocks 10. Achieved 97% in patient catering satisfaction survey Annual Report

6 PAGE 4 Chairman s Report I am delighted to introduce this annual report which reflects on the first year of leadership support provided to The Pennine Acute Hospitals NHS Trust by the leadership team from Salford Royal Foundation Trust. At the outset I would like to pay tribute to and thank the staff in Pennine for welcoming the leaders from Salford into the Trust and for working with them in such a positive manner throughout the year. Equally I would like to thank Board member and managerial colleagues from Salford Royal, both those who have taken up formal roles within Pennine and those who have contributed of their time and talents while maintaining their day jobs at Salford. The joint and increasing close working between the two organisations as we move towards the creation of a Group model has been an example of good practice. The reasons that Salford Royal was asked, in the first part of 2016, to provide leadership support to Pennine Acute are well documented in the Chief Executive s report, and elsewhere in this Annual Report. The CQC Inspection has provided a catalyst for many underlying issues in Pennine to be addressed and staff from both Pennine and Salford have worked unstintingly throughout the year to make improvements in a wide range of services. Inevitably this first year has involved stabilising the services currently in place and laying the ground work for the wider transformation work which will follow over the coming years. I have also been impressed with the level of support that we have received throughout the year from our partners in the health and social care services across Greater Manchester, from the GM Health and Social Care Partnership Board and from wider regional and national bodies. It is clear that every agency and partner recognises the importance of improving the services to local people. Other sections of this annual report focus on details of our performance and provide an honest assessment of how much more there remains to be done, but I would like in my comments to focus on what has become the highlight of the year for staff within the Trust. The Annual Staff Awards, now in its seventh year, draws together nominees from across the Trust to celebrate and recognise the good and often innovative work undertaken day after day in our hospitals and community services. I was pleased to be able to host these awards alongside our Chief Executive and to spend time with so many of our inspiring staff. We presented a variety of awards on the night with the Chairman s Award for Living our Values being presented to Kara Ogden, District Nurse, North Manchester Community Services. Kara is an experienced district nurse who has a special interest in delivering end of life care at home, with a reputation for tirelessly acting as the patient s advocate, to ensure their preferences in end of life care are met where achievable. Our End of Life Services were rated as outstanding in the Care Quality Commission Inspection. I would also like to recognise the hard work undertaken by our hundreds of volunteers and also those who take time to raise money to support the Trust s charity. Thank you to everyone who has supported the Trust over the last year. As we move into a new era, one of the ways in which local hospitals and local healthcare providers can enable a better, more co-ordinated way of providing safe and sustainable local health services, consistent with the concepts of standardisation of best practice delivered at scale, is by creating a Group or chain of local NHS organisations around a large population catchment area. 2017/18 will see the bringing together

7 PAGE 5 We have achieved and delivered much in 2016/17, with much more to come in 2017/18. of over 17,000 staff across Pennine Acute and Salford Royal Trusts who will work as a Group of Care Organisations (hospitals and associated community services), in sharing resources, expertise, and learning as we aim to standardise our care to be the best that the NHS can offer. Our Group, comprising our four Care Organisations - Oldham, Bury/Rochdale, North Manchester and Salford - will be one of the largest NHS organisations in the country. Together, we will serve a population of over 1 million people across our local communities. We will manage over 2,000 beds across our hospitals, manage an operating budget of 1.3bn to spend on services, and work with our CCGs, local authorities and other healthcare partners in supporting the developments in primary and community care. As a Group, we will be able to pull our resources together to invest and develop new models of care and new ways of working that will ensure patients receive reliable, high standards of care. Public and staff who are registered as members of the Trust will have the opportunity to stand for election to a shadow council of governors across our new Group later in We have achieved and delivered much in 2016/17, with much more to come in 2017/18. Jim Potter Chairman 26 May 2017 Annual Report

8 PAGE 6 Chief Executive s Report The Salford Royal leadership team were pleased to be asked last year to support The Pennine Acute Hospitals NHS Trust to deliver better outcomes for patients and to enable a more co-ordinated way of providing local health services, consistent with the concepts of standardisation of best practice delivered at scale and the potential of creating a Group of NHS organisations. As a leadership team we have set out to engage with staff and stakeholders to ensure that we pursued changes consistent with the plans in each locality to secure safe and reliable services for the populations served by the Trust. We recognise the need to work collaboratively and progressively with local commissioners and health and social care partners across Greater Manchester to improve services in each locality. April 2016 marked the start of a new journey for everyone in the Trust; a journey that I believe will result in our hospitals and community services becoming safe and reliable and in time, being amongst the best in the country. The significant changes required within the Trust were set against the background of the Care Quality Commission inspection undertaken in February / March 2016, the report of which when published in August of that year rated the Trust as inadequate. The CQC s report did not make comfortable reading but staff across the Trust, while feeling very disappointed and somewhat bruised with the overall findings of the CQC s inspection, welcomed the report as a fair assessment of the issues facing the Trust. Staff recognised that the CQC report held up a mirror to the Trust and reflected very much what they had been saying for some time on issues related to staffing pressures, inadequate systems, culture, leadership and resources. Staff felt relieved that the report exposed the real challenges and difficulties they had been working under. While we have rightly focused on the negative and what needs to improve, it is also important to record that several of our services were rated as good, particularly those at Rochdale Infirmary and in the community and overall the Trust was rated as Good for caring for patients. Despite the issues identified in the CQC report, from my very earliest visits to wards and departments, and throughout the year, I know we have staff who care deeply about the service they want to provide to their patients. From the outset I committed to work with them, together with the leadership team, to steadily make the necessary improvements so that patients can receive reliable, high quality care, whatever the day of the week and whatever the hour of the day. As the Chief Executive of Salford Royal, one of only five Trusts in the country to be rated outstanding by the CQC, I set out to listen to staff and where appropriate, deploy Salford s systems and experience to help support staff in Bury, Rochdale, Oldham and North Manchester to deliver the high standards of service which are desired by all. A significant factor to enable improvement has been money and early on in the year I was delighted to be able to confirm that we had secured an additional 9m to invest in service improvement. Later on in the year we were able to confirm further allocations of 5m for The Royal Oldham Hospital and 5m for North Manchester General Hospital to start on some necessary immediate enabling and improvement works on those sites. Looking forward to 2017/18 we have secured a further 20m to support our improvement plans. From taking up post in April 2016 we did not wait for the publication of the CQC report to put an improvement plan in place to support staff and patients.

9 PAGE 7 Our first priority was to keep our services running safely to ensure patients receive good safe treatment in a timely manner, and then to make sustained and sustainable improvements across all of our services but particularly our key fragile areas, including urgent care, maternity, paediatrics and critical care. We developed a Pennine Plan which is overseen by the Pennine Board, chaired by Jon Rouse, Chief Officer of Greater Manchester Health and Social Care Partnership, and comprising senior directors of CCGs, local authorities, CQC and NHS. April 2016 marked the start of a new journey for everyone in the Trust... We should take pride in the achievements across the Trust as part of our Plan over the last 12 months. These include: New site-based leadership teams in place more responsive to local issues; An additional 303 (net) members of staff have been recruited; 122 registered nurses have been offered jobs to start in September 2017; plus a further 65 nurses that have been recruited in March and April 2017; Agreement for continued support from SRFT and CMFT consultants in NMGH A&E - over 200 hours of consultant cover in ED compared with c.50 hours previously; 16% reduction in cardiac arrest calls; improvement in identifying deteriorating patients; 15% reduction in the number of hospital patient falls; Positive roll-out of the Nursing Assessment and Accreditation System (NASS) to 40 wards; Our successful series of Igniting Pride in Pennine staff motivational sessions attended by all staff groups; The patient helpline installed in 78 wards; Over 1000 patients previously waiting over 50 weeks for admission - now meeting the RTT standard; Roll-out of the new SWAN end of life care model across all sites; Patient experience process improving with now no outdated complaints; The number of Coroner inquests have more than halved. These improvements cannot and have not been achieved in isolation; we are already working with our health and social care organisations across Greater Manchester to support us in our efforts, such as improvements in our emergency and maternity departments, and this is great evidence of how our new devolution arrangements are working for the benefit of patients. Despite these significant improvements during the year there remain a number of areas where we need to do much more. The results of the annual NHS staff satisfaction surveys show that we still have some way to go to raise morale and to become a Trust where staff would recommend their friends or family to be treated or cared for. Along with many other Trusts New bereavement service with bereavement suites/ resource rooms across all sites; Annual Report

10 PAGE 8 across the country we have faced increasing pressures due to the inability to discharge patients to appropriate accommodation when they are ready to leave hospital and this in turn has impacted on flow through the hospital and our ability to meet the four hour target for treatment, admission, transfer or discharge in our A&E departments. Despite the significant additional funding provided to support our improvement plan, our underlying financial position remains in deficit. Looking to the future the implementation of our new site-based leadership teams for our three Care Organisations (Oldham, North Manchester and Bury / Rochdale) is critical to our improvement journey where operational decisions, ownership and accountability for managing our services will be strengthened through this new structure. The additional leadership of a medical, nursing, finance and managing director at Care Organisation level will drive quality improvement on a local site basis at a more impactful pace. Our Care Organisations will be supported by clinical leadership and management capacity who will be able to more easily listen to and involve staff in the planning and decision making. We want staff in each Care Organisation to help us find solutions to problems which will work in their wards and departments. Work is also underway to design how corporate functions (finance, HR, etc) support and interface with our Care Organisations. The shared corporate services review across Salford Royal and Pennine Acute is part of this work. The development of Care Organisations forms part of the wider move towards a Group arrangement encompassing Pennine Acute Trust and Salford Royal described in the Chairman s report.. Looking more widely across Greater Manchester we continue to support the development of the Single Hospital Service for the city of Manchester. At the time of writing the Competition and Markets Authority is reviewing the case for the merger of University Hospitals of South Manchester and Central Manchester Foundation Trust in order to formally create a new NHS

11 PAGE 9 Foundation Trust in September The plan remains that North Manchester General Hospital will then be transferred into the new Trust during the year 2018/19. For community, primary care and social care services in the city of Manchester the Trust continues to work with other providers of health and social care to develop an Local Care Organisation to provide and transform social care, physical and mental health services, and deliver them in a consistent way across the city, to help people stay well in their own home and treat them promptly when they need further care. We remain in close contact with our partners in the CCGS and local authorities in Heywood, Middleton and Rochdale, in Oldham and in Bury as they also develop their plans for the future integration of health and social care services. We are implementing Healthier Together which sees the creation of a high acuity site at The Royal Oldham Hospital, one of four across Greater Manchester. We are working with our CCGS and local authorities to describe the clinical services strategy for our services, aligned to the wider Greater Manchester plans and strategies. The key success this year has been to bring stability to clinical services and to start the programme of improvement and investment which will transform those services over the coming years. We have successfully embarked on this journey, with the support of our staff, our commissioners, local authority and Greater Manchester partners and the national regulatory bodies. While we have made a good start there remains much more to do as we work towards our aim of being amongst the best in the country. Sir David Dalton Chief Executive 26 May 2017 Annual Report

12 PAGE 10 Statement of the purpose and activities of the Trust Vision and Values With an overall purpose of Saving lives, Improving Lives, the Trust s vision is to Improve the health and wellbeing of the people and communities that we serve. The method of achieving this is embodied in the Trust Values which are: WE ARE: Quality driven Responsible Compassionate We promise: To provide excellent quality safe, evidence based patient care that exceeds national standards. To push the boundaries of care delivery and efficiency by adopting best practice and building on our clinical and technical knowledge. To individually be the best we can in our actions and interactions. To work as one team with both our colleagues and partners to deliver the best care both in and out of hospital. We promise: To be honest, open and transparent in all our commitments, actions and results. To be personally accountable for the things we do, our services and the Trust s reputation. To be alert to the potential for errors and always strive to correct things that go wrong. To acknowledge and celebrate success. To be resourceful and open to new, innovative, evidence-based ideas. We promise: To treat you with empathy, professionalism and a positive, friendly attitude. To act with integrity and respect at all times. To listen to you, understand your perspective, value differences and be approachable, sensitive and considerate. To organise our services around the individual need of our patients and their carers, creating the best patient experience possible. Trust Strategic Goals The Trust s Strategic goals were updated for 2016/17 to refocus on excellent care, working in partnership, nurturing and developing staff, promoting valuesbased leadership, achieving high reliability and performance and delivering strong productivity and financial sustainability. The Strategic Goals are: To provide excellent care to our patients in our hospitals and the community services. To work with our partners and local people to build resilient and sustainable local services for the communities we serve To support staff to provide the best care by developing their skills and nurturing their talent To support values-based leadership which role models the behaviours we expect from everyone. To achieve high reliability and high performance across all of our services. To deliver strong productivity and assure financial sustainability.

13 PAGE 11 The key priorities for 2016/17 were expressed through our Trust Priorities for the year. In order to build on and leverage the experience and leadership support provided from Salford Royal FT the priorities for Pennine Acute were aligned to those for Salford Royal FT, taking account of any necessary differences in emphasis as required. The Trust Priorities for Pennine Acute for 2016/17 were: 1 Pursue quality improvement to assure safe, reliable and compassionate care 2 Deliver financial plan to assure sustainability 3 Support our staff to deliver high performance and improvement 4 Improve care and services through integration and collaboration 5 Demonstrate compliance with mandatory standards. The Priorities were underpinned by a series of specific targets which are included in the Trust Priorities map shown on the next page. Progress against the targets is reported in the Performance Analysis. Annual Report

14 Our Trust s Priorities 2016/ Our strategic goals: To provide excellent care to our patients in our hospitals and community services. To work with our partners and local people to build resilient and sustainable local services for the communities we serve. To support our staff to provide the best care by developing their skills and nurturing their talent. To support values-based leadership which role models the behaviours we expect from everyone. To achieve high reliability and high performance across all of our services. To deliver strong productivity which will assure financial sustainability. Priorities 1. Pursue quality improvement to assure safe, reliable and compassionate care 2016/17 Targe Save lives Assure a year on year reduction in standardised mortality rate to wit 2. Deliver financial plan to assure sustainability Meet Care Quality Commission (CQC) requirements Deliver improvements within time scales Reduce harm Assure safety thermometer target so that at least 95% of patien Improve patient experience Demonstrate improvements so that patients would recommend as a place for treatment on NHS patient survey Drive efficiency & productivity to financial improvement including cost imp at least 25m Reduce spend on agency staff is reco Improve staff con Implement the new st ensure that staff re Bury Heywood, Middleton and Rochdale 3. Support our staff to deliver high performance & improvement Reduce s Imple w Oldham North

15 2017 ts hin the top 10% of acute Trusts nationally ts receive harm free care deliver substantial rovements of Saving lives, Improving lives Improving the health and wellbeing of the people and communities that we serve. Improve staff engagement score Use NHS staff survey staff engagement score and Friends and Family test to demonstrate improvement, so that the Trust mmended as a place to work tribution to goals & values aff contribution assessment framework to ceive an effective and quality appraisal taff sickness absence to 4.6% ment Healthy, Happy, Here orkforce plan Support development of Local Care Organisations in Oldham, Bury, Rochdale and Manchester Describe the Trust s contribution to improvements in locality plans. Agree at least one key aim per locality with stakeholders Progress Single Hospital Service in Manchester Develop and implement an action plan for North Manchester General Hospital to form part of a Single Hospital Service for the City of Manchester and assure safe and effective services are supported at Oldham, Bury and Rochdale Improve the Urgent Care Service at North Manchester in line with Care Quality Commission (CQC) and NHS requirements Implement urgent care improvement plan. Deliver on A&E 4 hour standard in line with stretch trajectory Assure developments of high acuity services at The Royal Oldham as part of Healthier Together Implement Healthier Together standards for general surgery by April 2017 Improve services through standardisation at scale in association with Salford Royal NHS Foundation Trust 4. Improve care and services through integration and collaboration Infections C.Diff = <55 cases MRSA = 0 cases Set targets for each site to achieve above Achieve Access standards: A&E 4 hour standard Referral To Treatment (RTT) 18 week standard Cancer 62 day standard Diagnostics 6 week standard Deliver endoscopy improvement plan 5. Demonstrate compliance with mandatory standards

16 PAGE 14 Going Concern Where a Trust is aware of material uncertainties in respect of events or conditions that cast significant doubt upon the going concern ability of the entity, these uncertainties should be disclosed. This may include for example where continuing operational stability depends on finance or income that has not yet been approved. Should a Trust have concerns about its going concern status (and this will only be the case if there is a prospect of services ceasing altogether) it should raise the issue with its sponsor division or relevant national body as soon as possible i.e. NHSi. The Trust is receiving management support from SRFT, financial support from NHSi and commissioners. Plans are being prepared to improve the financial position of the trust including support from GMH&SC Partnership. At this stage, there is no reason to suggest that the trust is not a going concern. This will be kept under review as part of discussions and negotiations. Wider Strategic Framework Clinical Services Strategy GM Devolution and the development of local strategic plans provides the opportunity to create a Clinical Service Strategy for the Trust, including the development of service portfolios for each of the sites. This work is being undertaken with NHS commissioners and Local Authorities to enhance local care provision. It also includes developing a positive vision for the future role of North Manchester General Hospital, connected with its local community to improve care of people with multiple conditions and frailty. The process will also determine a plan for the improvement of accommodation on the hospital site. Likewise, we are in the process of implementing the decisions of the Healthier Together process to ensure that The Royal Oldham site can operate as one of four high acuity centres in Greater Manchester, serving the needs of the wider locality. Out Clinical Services Strategy will also include proposals to better utilize the estate of the two other sites: Fairfield Hospital at Bury and Rochdale Infirmary. This clinical service strategy, together with the Investment Plan, will describe how the Trust can move from a position of stabilising services to one of transforming services and becoming clinically and financially sustainable in the longer term. It has become evident, that in addition to stabilising the current services, the long term sustainable solutions to stability lie in working through a clinical service strategy for each site, closely aligned to the development of the Locality Care Organisations (LCOs). This emergent strategy is being co-designed with the Trust s four local CCGs and Local Authorities through a Programme Board. It will link to locality plans and locality care design in each area in Oldham, Bury, Rochdale borough and North Manchester, including a Single Hospital Service (SHS) for Manchester, Healthier Together, and Local Care Organisations (LCOs) in the NE sector. Single Hospital Service (SHS) The benefits case for the creation of a single Trust merging UHSM and CMFT was been submitted to the Competition and Markets Authority in the first quarter of 2017 and it is anticipated the CMA approvals process will be completed in June NHS will work in tandem to start an extensive approvals process. Following the completion of the external approval processes, it is intended that UHSM and CMFT will formally create a new NHS Foundation Trust in September Once the new Foundation Trust has been established, the plan is for North Manchester General Hospital to be transferred into the new Trust some months after. During this time the three Trusts, programme team and key stakeholders,

17 PAGE 15 including staff across all three Trusts, will continue to work together on the planning and implementation of the SHS programme. To support this work, a proposal has been submitted for investment from the GM Transformation Fund to enable the SHS implementation and this forms part of an integrated set of proposals from the Manchester system. Manchester Local Care Organisation (LCO) The prospectus for the establishment of a Local Care Organisation, approved by the Manchester Health and Wellbeing Board, details the commissioners ambition for the delivery of community based out of hospital care through a LCO. Recognising the complexity surrounding the scale of the services to be commissioned, in the first instance it is the intention of commissioners to put in place, an Alliance Agreement during 2017/18, with the overall aim of awarding a full contract to operate from April The Manchester Provider Board which involves the Trusts covering the city (including Pennine Acute), local authority and primary care providers, will bid to run and deliver the services through the Local Care Organisation. The Manchester Provider Board has been meeting regularly for the past 18 months to look at how the providers of health and social care can work together to transform services across Greater Manchester. The vision is therefore to bring social care services together with physical and mental health services, and deliver them in a consistent way across the city, to help people stay well in their own home and treat them promptly when they need further care. All current community health services delivered by UHSM, CMFT and Pennine Acute (in North Manchester), Adult social care teams, some aspects of Primary Care and walk in hospital services (not A&E) at Manchester Royal Infirmary and Wythenshawe Hospital, will be included in the LCO. In 2018/19 mental health services, Children s services, GP out of hours services and some scheduled care services currently provided in a hospital setting e.g. outpatient appointments will be added to the LCO. The Manchester Provider Board is confident that current provider organisations are the best placed group of organisations to deliver this, and as above, the provider board organisations have all been working together to establish an integrated partnership capable of delivering joined up services. At the moment, there has been no decision on who will run the LCO. This is because the commissioners will be required to run a formal procurement exercise. The Manchester Provider Board bid will, however, recommend one leadership team for the LCO, working with one service delivery team for the population and delivering as one system across Manchester communities. Any implications for staff will be the subject of consultation in due course. Annual Report

18 PAGE 16 Performance analysis This section sets out the most important performance measures and also provides longer term trend analysis where appropriate. Identification of Key Performance Metrics and Measuring Performance The Trust has identified key performance metrics which are aligned to the Trust Priorities and reflect the key national, regional and local standards against which the Trust is held to account. These priorities are monitored through a variety of reports presented to management and assurance groups throughout the Trust each month. They key line of sight for monitoring performance is through the Directorate and Divisional management teams (and the emerging Care Organisation management teams from quarter 4 of the financial year). The Divisional management Teams provide assurance on performance to a number of Executive Governance Committees, who in turn provide assurance to the Executive Risk and Assurance Committee which is chaired by the Chief Executive. The Chief Executive reports to the Trsut Board each month on the assurances received and considered by the Executive Risk and Assurance Committee and the Board itself receives and reviews the detailed Integrated performance report. In addition a range of further reports are submitted to the Board on specific targets as required. Executive Directors in attendenace at the Board are held accountable for performance. Analysis and Explanation of the development and performance of the Trust during the year. CQC Inspection Report The report of the CQ Inspection carried out in February / March 2016 was published in August The full ratings provided by CQC are noted below The overall rating for the trust was inadequate: Safe Effective Caring Responsive Well-led Overall Inadequate Good Inadequate Inadequate

19 PAGE 17 The summary ratings by site were as follows: North Manchester General Hospital Service Safe Effective Caring Responsive Well-led Overall Urgent and emergency services Medical care Surgery Inadequate Inadequate Good Inadequate Inadequate Inadequate Good Good Critical care Good Good Good Maternity and gynaecology Services for children and young people End of life care - Hospital Outpatients and diagnostic imaging Overall Inadequate Inadequate Good Good Good Inadequate Good Inadequate Inadequate Inadequate Good Inadequate Inadequate Good Good Good Good Good Not rated Good Good Good Good Inadequate Good Inadequate Inadequate Royal Oldham Hospital Service Safe Effective Caring Responsive Well-led Overall Urgent and emergency services Medical care Surgery Critical care Maternity and gynaecology Services for children and young people End of life care - Hospital Outpatients and diagnostic imaging Overall Inadequate Inadequate Inadequate Good Inadequate Good Good Good Good Good Good Good Good Good Good Good Inadequate Inadequate Inadequate Inadequate Inadequate Inadequate Not rated Good Good Good Good Good Inadequate Inadequate Annual Report

20 PAGE 18 Rochdale Infirmary Service Safe Effective Caring Responsive Well-led Overall Urgent and emergency services Good Good Good Medical care Good Good Good Good Good Good Surgery Good Good Good Good Good Good Outpatients and diagnostic imaging Good Not rated Good Good Good Good Overall Good Good Good Good Good Good Fairfield General Hospital Service Safe Effective Caring Responsive Well-led Overall Urgent and emergency services Medical care Surgery Critical care End of life care - Hospital Outpatients and diagnostic imaging Overall Good Good Good Good Good Good Good Good Good Good Good Good Good Not rated Good Good Good Good Good Community services Service Safe Effective Caring Responsive Well-led Overall End of life care Good Good Children, young people and families ««Outstanding Good Good Good Good Good Good Good Good Good Community adults Good Good Good Good Good Good Community inpatients Good Good Good Good Good Good

21 PAGE 19 The CQC has not taken enforcement action against the Trust, though alongside the publication of the report, the CQC announced in a press statement that such is the level of concern that we have around quality and safety that in line with normal policy we would have considered recommending the trust should go into special measures However, the statement acknowledged the leadership of the Trust by a team from Salford Royal FT immediately following the inspection and the improvement plans this had generated. The Trust reviewed the published reports and noted all the mandated actions ( must do ) and advisory actions ( should do ). These were circulated to the divisional leads, and mapped to executive assurance groups to monitor progress of assurance from the divisions. They were also incorporated within the improvement plans and integrated into the themes of: Fragile Services: immediate actions to stabilise Urgent Care at NMGH, Maternity, Paediatric, Critical Care Clinical Safety: large scale quality improvement collaboratives focusing on key clinical areas & patient care Risk & Governance: implementation of new risk and governance arrangements to protect patients Operations & Performance: focus on improving data quality, patient pathway management, models of care Workforce: focus on safe staffing levels. Greater emphasis on staff engagement, recruitment and retention Key elements of progress against these themes have included: Fragile Services Urgent Care - Additional temporary A&E consultant cover from senior clinicians from across PAT and from other neighbouring Trusts and joint recruitment campaigns with neighbouring Trusts to design innovative and attractive consultant job plans. Enhanced GP and primary care input directly into the North Manchester A&E department from Manchester GPs, enhanced community services, and increased physiotherapy and pharmacy staff in A&E. Development of reliable pathways for high acuity patients so that they are taken directly to high acuity sites at The Royal Oldham, Salford Royal and CMFT for specialist treatment. Maternity Services - Recruitment of additional midwives and a focus on clinical leadership continues to be the Trust s priority for maternity services. In addition to 58 new midwives, Central Manchester NHS FT are provding supplementary clinical leadership support in order to stabilise and strengthen services on the North Manchester site. Paediatric services - six patient pathway coordinators have been engaged, a new matron is in post and additional paediatric nurses have been recruited. We have also recruited six new consultant paediatricians. Critical Care Services additional middle grade doctors appointed, recruitment of supernumerary shift coordinators and continued efforts to recruit additional consultants. Leadership: consistent leadership within executive team and clinical leadership development. Strengthen local site operational management with triumvirate structure for each site with lead doctor, nurse, manager. Annual Report

22 PAGE 20 Clinical Safety, Risk and Governance Core nursing standards and ward improvement goals and plans have been developed for all wards and departments, supported by the implementation of a standardised Nursing Assessment and Accreditation System (NASS). This performance assessment framework (adopted from Salford Royal) is based on the safe, clean, personal approach to service delivery and provides evidence for the CQC s essential standards of quality and safety. The NAAS is designed to support nurses in practice to understand how they deliver care, identify what works well and where further improvements are needed. A major part of the Plan is the involvement of staff in large-scale improvement learning collaboratives. This approach, adopted by Salford Royal, will save lives. The first learning collaborative is addressing the identification, observation, timely escalation and care management of deterioration in patients, particularly elderly frail patients, and what care and treatment these patients need. The Deteriorating Patient Collaborative aims to reduce the rate of cardiac arrests per (1000 admissions). Further work is supporting the phased roll-out of the Sepsis screening tool and education package. There is focused work on a programme of work to improve mortality surveillance at PAT through a combination of independent mortality case reviews, mortality and morbidity (M&M) meetings, review of clinical documentation and coding, and speciality mortality reviews. A programme of staff education and training is being developed including use of Dr Foster data, training for reviewers, and clinical documentation and coding. Significant work on improving complaints handling, processes to support inquests, recording and investigation of serious incidents and implementing the duty of candour. Roll out of SAFER (a programme of care on improving patient flow on the wards including daily board rounds, senior decision making and ensuring that key areas of patient care are brought forward in the day) is now focused on two key activities engaging clinicians in board rounds and meeting Royal College of Physician standards and implementing standards for the bed management teams. Workforce An additional 303 (net) members of staff have been recruited and a further 122 registered nurses have been offered jobs to start in September 2017; plus a further 65 nurses that have been recruited in March and April The Trust has allocated 10m to increase the number of nursing staff across our wards, Leadership A number of key appointments have been made to strengthen the corporate support within the Trust and to begin the development of the site-based leadership model. The Care Organisations for Oldham, North Manchester and Bury/Rochdale have now been established with their own Medical, Nursing, Managing and Finance Directors. Good progress is being made on the theme of leadership and strategic relations with a QI programme developed in conjunction with AQuA to commence in June for the CiC Executive Directors and Care Organisation leadership teams. A system wide QI programme on Making Safety Visible will commence in May, which will involve leaders from partner organisations.

23 PAGE 21 Key issues and risks that could affect the Trust in delivering its objectives The Trust has a clear process through the Board Assurance Framework and Corporate Risk Register through which risks to the achievement of objectives are identified, with controls and mitigation put in place. Assurances are sought and provided against the operation of those controls with actions identified to further mitigate the risk. There is a clear structured process through which Executive Directors are assigned responsibility for each risk. The risk score determines the level at which the risk is reviewed Division, Executive Governance Committee, Executive Risk and Assurance Committee or the Trust Board. The full Board Assurance Framework is reviewed by the Trust Board every month and is placed in the public domain as part of the Board papers. This section of the report summarises the Trust Board level risks against the Trust priorities and outlines the actions required to mitigate the risks. Risks of 12 and above (Maximum score 15) Priority Annual Plan Objective Principal Risks and Actions Score 1. Pursue Quality improvement to assure safe, reliable and compassionate care Save Lives, assure HSMR within the top 10% of acute Trusts nationally Risk - IF processes are not in place and / or followed when caring for patients with Sepsis THEN patient care may be compromised. Actions - Develop metrics aligned to SRFT; Achieve quarterly CQUIN targets notes for retrospective notes review; Roll out of NEWS chart; Sepsis Toolkit finalised at Sepsis steering group; Sepsis Drive week commencing 03/04/17 Risk - IF effective, supportive, challenging clinical leadership is not in place across the Trust THEN Clinical variation will continue unchecked thus potentially leading to patient harm. Actions - Leadership model for CDs and Nurses being developed Risk - If lessons learnt are not acted upon following the Diagnostic Review Then system failures could affect the quality of patient care delivered and regulatory involvement and reputational damage could occur Actions - Diagnostic Review Group improvement plan; 6 month look back exercise completed; E-learning programme launched December 2016; Policy Protocols and Procedures to be updated; EPR system to control / manage diagnostic requests to be implemented; CRIS Communicator pilots to be commenced Risk - IF the Trust fails to provide safe staffing levels in all clinical areas 24/7 THEN this could lead to reduction in patient safety and quality of care along with poor staff and patient experience. Specific focus to be made to the fragile services: 1. Fragile Services 2. Hard to recruit areas 3 Clinical areas with significant staff shortages Actions - Arrangements for Acute Physicians at NMGH to be reviewed; Maternity Achieve transition to St Mary s at NMGH by October 2017; Paeds, Gynae and Neonatology to follow October 2017 transition; NHS Professionals contract Meet CQC requirements - deliver improvements within timescales 12 Annual Report

24 PAGE 22 Risks of 12 and above (Maximum score 15) Priority Annual Plan Objective Principal Risks and Actions Score 1. Pursue Improve Patient Risk - IF the timeliness of identifying and retrieving all relevant patient 12 Quality improvement to assure safe, reliable and compassionate care cont d Experience information within Evolve at the point of care is not assured THEN excessive time to retrieve the required information will reduce workflow efficiency and the confidence of clinicians, eroding their confidence and engagement with the solution and resulting in clinical decisions that omit information and reduce the quality of the administrated care. Actions - 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 the board with the appropriate authority to support the improvements Risk - IF a Maternity Handover of Care solution (for nursing staff) is not deployed THEN there is risk to patient (mother and baby/ies) care through poor communication at shift handover Deliver financial plans to assure sustainability Reduce spend on Agency staff from 38m to 29.9m Actions - Introduction of robust mechanism for recording result requests - standardising the process for all staff; Regularly undertaking audit and assessment of the process and the data until delivery of an EPR system; Clearly define roles and responsibilities around record management; Standardise record management process; Rolling audit programme. Risk - IF the supplier support and licenses for the (known) end of life Clinisys lab system is completely withdrawn THEN the Trust will lose its results reporting capability which will severely affect patient care and lead to adverse clinical incidents, slower patient flows, additional expense for results reporting, patient complaints and reputational. Actions - Agree a strategy for replacing the existing Lab centre solution that recognises the greater Manchester pathology service redesign work. Risk - 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. Actions - Review roles and responsibilities to ensure ability to address current and future cyber security threats; Increase Trust staff awareness of cyber security; Establish a task and finish group to implement recommendations from recent audits; Established a scheduled to review security controls and procedures are being followed; Plan further external reviews for assurance Risk - IF recruitment does not reach staffing establishment levels THEN the quality of care will be compromised, morale / sickness issues will rise and services will become financially unsustainable. Actions - Focus recruitment innovative joint working and advertising posts with neighbouring Trusts; International Nurse recruitment tender to be agreed; Review of NHSi targets for 2017/18 for agency spend; action required for IR35 issues

25 PAGE 23 Risks of 12 and above (Maximum score 15) Priority Annual Plan Objective Principal Risks and Actions Score 2. Deliver financial plans to assure Reduce Vacancy Gap to 6% Risk IF staff vacancies do not reduce in line with plan THEN the quality of care will not improve and financial sustainability will not be delivered. 12 sustainability Actions - Focus recruitment on innovative joint working and advertising cont d posts with neighbouring Trusts; Immediate focus on recruitment to medical positions within the fragile services and closing vacancy gap for qualified nurses; Work though options for role substitutes as part of the Workforce Development plans; International Nurse recruitment tender to be agreed; Review of NHSi targets for 2017/18 for agency spend. 3: Support High Performance and 4: Improve Care and Services through Integration and Collaboration Improve Staff Contribution to Goals and Values Progress Single Hospital Service in Manchester Improve the Urgent Care service in line with Q1 aims and deliverables Risk - IF staff do not participate in a good quality PDR the staff retention may reduce and the workforce capabilities of Trust to deliver high performance and improvement may be compromised. Actions - Develop and implement a PDR quality monitoring system with which to improve the effectiveness of the conversation; Site based reporting being developed; Introduction of 360 degree feedback for managers Risk 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. Actions - 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. Risk - IF the Trust is unable to stabilise and sustain the medical workforce to support ED and AMU THEN there is a risk that the Trust on the NMGH site could not provide 24/7 emergency care. Actions - Recruit Acute Physicians; Expansion AMU Beds. Risk IF the Trust is unable to improve patient flow and reduce UC demand through all sites with emergency departments THEN the national standards for access will not be met and patient care will be compromised. Actions - Estates plan to support acute assess / ambulatory expansion at NMGH; Bury LA to reduce LOS; MOATS to deliver bed capacity at NMGH; Agree ambulatory tariff and model at TROH; Increase Out of Hospital OoH) capacity Bury / TROH LA; NES Urgent Care Board needs to develop a systematic escalation plan; Ask Local Authorities to bring to NES Urgent Care Group their plans for use of social care council tax precept and what impact that will have on flow through hospitals Annual Report

26 PAGE 24 Risks of 12 and above (Maximum score 15) Priority Annual Plan Objective Principal Risks and Actions Score 5: Demonstrate Achieve the Cancer 62 day target RISK IF Capacity and Demand is not matched for challenged specialities THEN patients may not be treated within required timescales 13 Compliance resulting in potential harm to patients, poor experience and failure of Achieve the RTT Open 12 with national diagnostic standard, RTT standard and standards for planned pathway target Mandatory patients. Standards Actions (Cancer) - Review Consultant leave Policies; Training in place for screening; Continue Private sector capacity Gastro; Work with CMFT on urology pathway; Review colorectal / General surgical pathways and capacity; Procure Capacity / demand tool and training Actions (RTT) - Secure additional paed capacity; Deliver T&O arthroplasty unit; Develop Gastro business case; Capacity and demand analysis to be completed; B&S review Infections: C,Diff & MRSA Risk - IF the Trust fails to meet mandatory standards for infection control THEN this could lead to patient harm and / or the quality of patient care could be affected which could lead to regulatory involvement and reputational damage. Actions - Review of number of hand wash basins; Review antimicrobial prescribing; Infection control team undertaking 90 day improvement on patient hand hygiene; Microbiology team undertaking 90 day improvement on improving diagnostics for UTI s; Infection prevention team undertakinweekly diarrhoea ward rounds; Business case for FGH antimicrobial pharmacist being developed; Action week being developed; In future the whole team will need to present RCAs to emphasise collective accountability. There are a number of other sub-board level risks details of which can be found on the Board Assurance Framework. 13

27 PAGE 25 Operational Performance Review There are 23 individual measures aligned to the five priorities which are being tracked and reported in the Integrated Scorecard. Their successful delivery will enable the Trust to assess and demonstrate the extent to which it is meeting its key organisational objectives and also provide an opportunity to cross-reference against the risks identified in the BAF. The performance exceptions at the year-end for each priority area are noted below. Performance across the last three years can be identified from the trend lines on the Integrated Scorecard. 1. Pursue quality improvement to assure safe, reliable and compassionate care For HSMR, against an overall target to be within the top 10% performing trusts (87 or below) nationally, the Trust is reporting a score of (Jan-16 to Dec-16). Work to review and improve mortality will be reported back to the Trust Board through governance structures. The latest site level information shows that HSMR at FGH remains above 100, but it is no longer categorised as a high outlier. For the Friends and Family Test (FFT) the response from patients treated at our Trust - the Trust has set itself a target to achieve a score for recommendation as a place for treatment that is, at or better than the national average. The Trust is below average for: (1) Maternity antenatal care and (2) Maternity postnatal ward, and in the lower quintile (20%) for (3) A&E care (4) Inpatient care, (5) Outpatient care, (6) Community care, (7) Maternity postnatal community, and (8) Maternity birth For the Summary Hospital-level Mortality Indicator (SHMI), which includes patients that die within 30 days of discharge from hospital, the Trust is reporting 1.13 (Oct-15 to Sep-16), placing it in the higher than expected banding in the quarterly national update for the third time. For never events the Trust has a zero tolerance. For the year the Trust has reported 8 never events. Every never event undergoes a root cause analysis (RCA), with the outcome reported to Trust Board through governance structures. Three of the never events occurred at ROH (all July), two occurred at NMGH (April, and June,), and three occurred at FGH (1 in May and 2 in January). For the Friends and Family Test (FFT) the response from our own staff - the Trust has set itself a target to achieve a score for recommendation as a place for care that is, at or better than the national average. The FFT score for the latest period (Quarter ) is below target being in the lower quintile (lowest 20%). A pulse check monitoring system is being implemented which allows a more detailed analysis. For single sex accommodation breaches the Trust has a zero tolerance. For the year 273 patients have experienced breaches of this standard, with 65 breaches reported in March. The year to date breaches occurred at NMGH (249), FGH (21), and ROH (3). Year to date all of the breaches have been delays in transfer from higher dependency units to acute wards following step down. For Ward Safe Staffing levels, the Trust is meeting the internal standard for 90% or more of planned ward nursing and midwife hours to be filled, with an aggregate March fill rate of 97.1% and a year to date rate of 97.5%. The ward staffing level fill rates vary by shift and staff group. The average fill rate is detailed by ward within site in the Ward Level Scorecard section. 2. Deliver financial plan to assure sustainability The 2016/17 financial position for the Trust at Month 12 is a deficit of 2.4m. For Agency, the Trust has set a target to spend no more than 29.9m for the year. The year spend was 40.1m, which is 10.2m higher than the planned spend. Annual Report

28 PAGE Support our staff to deliver high performance and improvement For Sickness and Absence the Trust has set itself a target to reach 4.6% by March. The Trust is worse than target, with a reported performance of 5.14% for March For Personal Development Reviews the Trust has set itself an improvement trajectory to reach 90% by March. The Trust is below its trajectory of 90% for March 2017, with reported performance of 75%. The Director for Workforce and Organisational Development is leading work to improve the quality of appraisals, as well as ensuring that the completion increases through the development and implementation of detailed Care Organisation level plans. For the staff Friends and Family Test (FFT), the Trust has set itself a target to achieve a score for recommendation as a place to work that is, at or better than the national average. The FFT score for the latest period (Quarter /17) is below target being in the lower quintile (lowest 20%). The Director for Workforce and Organisation Development is leading the implementation of the Healthy Happy Here Plan to improve workforce satisfaction and has commissioned a staff pulse check reporting system to track progress at Care Organisation level. 4. Improve care and service through integration and collaboration NMGH performed worse than the 95% priority trajectory for March, with a reported performance of 73.4%. As identified in the BAF, medical staffing pressures at NMGH are a particular difficulty and are being closely managed. Work is also underway on Urgent Care pathway flow improvement that is focused on the primary drivers and is supported by the PMO, NHSI and CCGs. 5. Demonstrate compliance with mandatory standards For infection prevention and control, the Trust has not achieved the annual limit of no more than 55 C-diffcile cases. 58 cases were reported for the year. The in-month trajectory of 4 was achieved. At site level year to date 20 cases occurred at FGH, 16 at NMGH, 21 at ROH and 1 at RI. FGH has the highest rate of C-Difficile cases per bed day. Proactive management of cleaning is being undertaken and additional actions have been agreed following receipt of an internal audit report on cleaning. For MRSA the Trust has had one case for the year (which occurred Sep-16) the previous case occurred 7 months earlier and there has not been another case in the 5 months afterwards. The case occurred at NMGH and was reviewed by the nursing team. For A&E, the trajectory is for 95% to be achieved across all sites by year end. The externally agreed trajectory of 95% was missed for March with reported performance of 81.3%. At a site level all 4 sites performed worse than their internal stretch trajectories and worse than their externally agreed trajectories submitted in May-16. For the Cancer 62 day GP standard time from GP referral to treatment - the target is for 85% of patients to be treated within the 62 days, with the latest (February) period being reported as below the required local GM reallocated standard at 74.6%, and also worse than the national shared accountability standard with reported performance of 82.4%. For 12 hour trolley wait breaches the Trust has a zero tolerance. For the year the Trust has reported 786 breaches, with 73 reported in March. For the year to date the breaches have occurred at NMGH (570), ROH (135), and FGH (81).

29 PAGE Pursue quality improvement to assure safe, reliable & compassionate care Trust Priority Current Key Performance Indicator Lead Target Level 0 HSMR versus Dr Foster banding (rolling year - The 56 diagnostic groups) HSMR - Ranked in lop 10% of non-specialist trusts (Rolling year - The 56 diagnostic groups) Target Type Current Period MM LCL <=100 R Dec-16 MM <=87 I Dec-16 SHMI versus national HSCIC banding (rolling year) MM 1.12 LCL<1.00 R 1.13 Sep-16 Current Key Performance Indicator Lead Target Level Target Type Current Period 0 FFT patient feedback recommended targets met EI-B 6 8 I 0 Jan-17 1 Single sex accommodation breaches EI-B 58 0 R 65 Mar Staff FFT Recommend as a place for care JL 69.1% >=79.4% I 52% Oct-Dec 55% Current Key Performance Indicator Lead Target Level Target Type Current Period YTD YTD YTD 3 % Harm Free Care - New Harms EI-B 97.8% >=95% I 98.6% Mar % Never Events EI-B 1 0 R 0 Mar-17 8 Handover of care communication (IP <24hr) JA 95.6% >=95% C 95.0% Feb % Handover of care communication (OP <10 days) JA 91.0% >=95% C 97.4% Feb % Ward Safe Staffing Levels EI-B 97.2% >=90% I 97.1% Mar % Pressure Ulcer - Unstageable (Safeguard) EI-B tbc I 10 Feb Pressure Ulcer - Grade 2 (Safeguard) EI-B 188 tbc I 27 Feb Pressure Ulcer - Grade 3 and above (Safeguard) EI-B 4 0 I 1 Feb Current level measures performance against the Trust Priorities Above Target On Target Below target Unacceptable Unknown full year performance RAG rated against the targets 2. Integrated Scorecard Effective *** denotes a target that shows a trajectory which is phased across the year Caring Safe Target Type R - Regulatory I - Internal C - Contractual RAG Trend RAG Trend RAG Trend RAG Trend Key Target missed Target passed RAG Trend RAG Trend RAG Trend Height of RAG trend indicates direction of pass RAG Trend RAG Trend RAG Trend Year Trend 2 Year Trend 2 Year Trend 5. Demonstrate compliance with mandatory standards Current Key Performance Indicator Lead Target Level Target Type Current Period 1 C Difficile (<=55 by Mar-17) EI-B 56 <=55*** R 4 Mar MRSA (>48 hours) EI-B 5 0 R 0 Mar MRSA & C-Diff met at site level EI-B New 4 sites I & R 4 Mar-17 1 Current Key Performance Indicator Lead Target Level Integrated Scorecard Safe Target Type Current Period 6 Week Diagnostic wait vs national target JA 3.0% <1% R 0.4% Feb % YTD YTD RAG Trend RAG Trend RAG Trend RAG Trend RAG Trend RAG Trend Year Trend 2 Year Trend 2 6 Week Diagnostic wait vs trajectory JA 3.0% <1%*** R & I 0.4% Feb % See above 12 Hour Trolley Waits JA R 73 Mar hour urgent care standard vs national target JA 85.3% >=95% R 81.3% Mar % 1 Responsive RTT Open Pathways vs national target JA 96.4% >=92% R 92.1% Feb % 62 day GP Cancer Re-allocated vs GM target JA 79.1% >=85% R 74.6% Feb % 62 day GP Cancer vs national target JA 84.8% >=85% R 82.4% Feb % 62 day Screening Cancer vs national target JA 85.3% >=90% R 100.0% Feb % 62 day Upgrade Cancer vs internal target JA 88.8% >=85% I 63.9% Feb % 31 day First Treatment Cancer vs national target JA 99.7% >=96% R 99.3% Feb % 31 day Subsequent Drug Cancer vs national target JA 100.0% >=98% R 100.0% Feb % 31 day Subsequent Surgery Cancer vs national target JA 99.2% >=94% R 100.0% Feb % 2 week Cancer vs national target JA 94.2% >=93% R 94.8% Feb % 2 week Breast Symptomatic vs national target JA 89.1% >=93% R 95.0% Feb % Annual Report

30 PAGE Deliver financial plan to assure sustainability Current Key Performance Indicator Lead Target Level Integrated Scorecard Finance Target Type Current Period YTD 0 Agency spend of 29.9m or better JL 38 Cuml<= 29.9m*** R 3.13 Mar Surplus / Deficit vs Plan ( m) DF 0.0 >=0 R 6.1 Mar Income vs Plan ( m) DF -1.2 >=0 R 5.2 Mar Expenditure vs Plan ( m) DF -0.1 >=0 R 0.9 Mar CIP Achievement - vs Plan DF -8.2 >=0 R 0.7 Mar Cash Balance vs Plan ( m) DF 7.4 >=0 R 10.3 Mar Capital Resource Limit vs Plan ( m) DF 3.8 >=0 R 1.6 Mar Use of Resources (versus plan) DF n/a <=3 R 3 Mar-17 3 RAG Trend RAG Trend RAG Trend Year Trend 3. Support our staff to deliver high performance & improvement Current Key Performance Indicator Lead Target Level Well Led Target Type Current Period 0 FFT Staff - Recommend as a place to work JL 60.9% >=64.4% I 48% Oct-Dec 48% 2 Staff contribution framework implemented JL New Yes I Yes Sep-16 Yes 0 PDR completion (90% by Mar-17) JL 69% >=90%*** R 75% Mar-17 n/a YTD 1 Sickness & Absence (4.6% by Mar-17) JL 5.79% <=4.6%*** R 5.14% Mar % Mandatory Training JL 91% >=90% R 89% Mar-17 n/a Vacancy Rate (6% by Mar-17) JL 7.74% <=6.0*** R 6.63% Mar-17 n/a RAG Trend RAG Trend RAG Trend Year Trend 4. Improve care & services through integration & collaboration Current Key Performance Indicator Lead Target Level Target Type Current Period tbc Contribution to locality plans SG New tbc I Sep-16 tbc Single hospital service in Manchester SG New tbc I Sep-16 tbc Implement Healthier Together for Geneal Surgery MM New tbc I Sep YTD 0 Improve Urgent Care service at Trust vs trajectory JA New >=95.6%*** I 81.30% Mar % 0 Improve Urgent Care service at NMGH vs trajectory JA New >=95%*** I 73.40% Mar % 0 Improve Urgent Care service at FGH vs trajectory JA New >=95%*** I 87.97% Mar % 0 Improve Urgent Care service at ROH vs trajectory JA New >=95%*** I 76.38% Mar % 1 Improve Urgent Care service at RI vs trajectory JA New >=98.5%*** I 97.77% Mar % RAG Trend RAG Trend RAG Trend Year Trend

31 PAGE 29 Sustainable Development The Trust continues to be committed to supporting the carbon reduction and sustainable development agenda of the NHS and in reducing the Trust s carbon footprint. The initial target of the Carbon Reduction Strategy is to achieve a 10% reduction from the 2007 carbon footprint of the NHS by Each Trust has a similar target. The replacement of the ageing coal-fired steam boiler plant with a new modern lower carbon emitting gas hot water & CHP system at Fairfield General Hospital has helped the Trust contribute to the national carbon saving target. The Trust continues to use the good corporate citizenship toolkit for reviewing our carbon footprint and sustainability. This toolkit enables the Trust to evaluate its progress in improving its sustainability and informing stakeholders. The Sustainable Development Management Plan shows that of the 83 carbon reduction initiatives identified, 40 have been completed. These are programmed to deliver a minimum saving of 2,800 tonnes of carbon in each full year. Further schemes are now being programmed for delivery this year. Other initiatives including energy and carbon saving advice on the Trust s intranet have resulted in positive feedback from staff. By improving the awareness of staff on sustainable issues, we aim to encourage their support with energy and carbon reduction measures. The Trust s estate has increased in size over the last few years as developments have been made to provide improved patient care facilities. To maintain the drive to reduce our energy and carbon activity, the Trust needs to offset these additions by pursuing corresponding reductions by decommissioning underutilised buildings wherever possible. Annual Report

32 PAGE 30 Energy Costs Reducing the amount of energy used in our organisation contributes to achieving the NHS Carbon Reduction targets for England. There is also a financial benefit which comes from reducing our energy consumption Cost /8 2008/9 2009/ / / / / / / /17 Year Energy Consumption Our total energy consumption has fallen during the year from 118,128 to 117,694 MWh. This is due to the energy saving measures put in place by the Trust and the decreased heating requirement created by the milder weather during 2016/17. MWh Elec Steam Coal Gas Oil /9 2009/ / / / / / / /17 Year

33 PAGE 31 tonnes carbon 40,000 30,000 20,000 10,000 0 Elec Steam Coal Gas Oil 2008/9 2009/ / / / / / / /17 Year Carbon Emissions We have put plans in place to reduce carbon emissions and improve our environmental sustainability. Over the next two years we expect to save 800,000 as a result of these measures. Our measured carbon emissions have decreased by 199 tonnes this year; this represents a reduction of 0.75 % of our total emissions from the energy used in our premises. This is mainly due to the operation of the new CHP plant at FGH for generating our own electricity which has a high carbon emission factor. We do not currently collect data on our annual Scope 3 emissions which cover indirect emissions from non-energy activity such as the purchasing of goods and services. Energy Efficiency Schemes During 2015/16 our gross expenditure on the CRC Energy Efficiency Scheme was 297,000 for Carbon Emission Allowances. This is a mandatory scheme aimed at improving energy efficiency and cutting emissions in large public and private sector organisations. Renewable Energy We generate 12% of our electricity on site. This is due to the CHP plant recently installed at Fairfield Hospital & the existing plant at Rochdale Infirmary, the heat produced from the engines also helps to heat these hospitals also reducing our Gas costs. Water Consumption Our annual water consumption has decreased by cubic metres which is a reduction of 2.5 % on the previous year. In 2016/17 we spent 1,475814on water. Waste Cubic Meters /9 2009/ / / / / / / /17 Year Annual Report

34 PAGE 32 Clinical Waste Other Waste Confidential Waste Domestic Waste Waste / / / / / /17 Waste Recovery & Recycling In 2016/17 we recovered almost 2714 tonnes of waste (clinical & domestic) across the sites a small increase on the 2677 tonnes produced on the previous years. Only very small amounts of waste e.g. residue form general skips, goes to landfill. Sustainable Development Management Plan The Trust has an up to date Sustainable Development Management Plan. This enables us to ensure that as an NHS organisation we are fully committed to conducting all aspects of our activities with due consideration to sustainability, whilst providing high quality patient care. The NHS Carbon Reduction Strategy asks for the boards of all NHS organisations to approve such a plan. We consider the potential need to adapt the organisation s buildings and estates as a result of climate change, but not the potential need to adapt the organisation s activities. Adaptation to climate change will pose a challenge to both service delivery and infrastructure in the future. It is therefore appropriate that we consider it when planning how we will best serve patients in the future. Sustainability issues are included in our analysis of risk facing the Trust. NHS organisations have a statutory duty to assess the risks posed by climate change. Risk assessment, including the quantification and prioritisation of risk, is an important part of managing complex organisations. In addition to our focus on carbon, we are also committed to reducing wider environmental and social impacts associated with the procurement of goods and services. This is set out within our policies on sustainable procurement. We have started work on calculating the carbon emissions associated with the goods and services we procure. We also have a Sustainable Transport Plan. The NHS places a substantial burden on the transport infrastructure, whether through patient, clinician or other business activity. This generates an impact on air quality and greenhouse gas emissions. It is therefore important that we consider what steps are appropriate to reduce or change travel patterns. Sir David Dalton Chief Executive 26 May 2017

35 PAGE 33 Accountability Report Annual Report

36 PAGE 34 Corporate governance report The purpose of the corporate governance report is to explain the composition and organisation of the Trust s governance structures and how they support the achievement of the entity s objectives. The directors report Governance framework of the Trust Appropriate leadership arrangements have remained in place throughout the year. There is a clear division of responsibilities at the head of the Trust between the running of the Board and the executive responsibility for the Trust s business. The Chairman leads the Board while the Chief Executive manages the Trust. Board members self-declared during the year that they subscribed to the Codes of Conduct and Accountability and where necessary underwent a Fit and Proper Persons Test and completed Declarations of Interest. Board of Directors The Board of Directors comprising Non-Executive and Executive Directors is collectively responsible for setting out the values, strategy, direction and policy of the Trust and holding the executive to account for delivering against these and that the necessary financial and human resources are in place In line with the arrangements agreed with NHS through which Salford Royal FT has provided leadership support to the Trust during the year there have been a number of changes in Board membership. Mr Jim Potter took up post as Chairman on 1 April 2016 in addition to his role as Chairman of Salford Royal FT. Sir David Dalton took up post as Chief Executive on 1 April 2016 in addition to his role as Chief Executive of Salford Royal FT. Other changes in Board membership are outlined beliow. Non- Executive Directors Jim Potter, Chairman. Mr Potter is also Chairman of Salford Royal FT Chris Mayer, Non-Executive Director Riaz Ahmad, Non-Executive Director and Chair of Audit Committee (to 31 July 2016) John Willis, Non-Executive Director and Chair of Audit Committee (from 1 August 2016). Mr Willis is also a Non-Executive Director of Salford Royal FT Wendy Cardiff, Non-Executive Director (to 30 September 2016) Diane Brown, Non-Executive Director (from 1 October 2016). Mrs Brown is also a Non-Executive Director of Salford Royal FT Shauna Dixon, Non-Executive Director (to 28 February 2017) Camilla Guereca, Non-Executive Director (to 30 November 2016) Margaret Ollerenshaw, Non-Executive Director Executive Directors Sir David Dalton, Chief Executive. Sir David is also Chief Executive of Salford Royal FT Damien Finn, Director of Finance and IM&T Jon Lenney, Director of Workforce and Organisational Development Professor Mathew Makin Medical Director Gill Harris, Chief Nurse (to 31 July 2016) Elaine Inglesby-Burke, Chief Nurse (from 1 August 2016). Mrs Inglesby-Burke is also Chief Nurse of Salford Royal FT The Trust Board had 10 meetings in 2016/17 with attendance as noted below:

37 PAGE 35 Non- Executive Directors Attendance at Trust Board Meetings Jim Potter Chris Mayer Riaz Ahmad John Willis Wendy Cardiff Diane Brown Shauna Dixon Camilla Guereca Margaret Ollerenshaw 10/10 10/10 3/4 6/6 4/4 6/6 7/9 6/7 8/10 Executive Directors Attendance at Trust Board Meetings Sir David Dalton Damien Finn Jon Lenney Matthew Makin Gill Harris Elaine Inglesby-Burke 10/10 10/10 10/10 9/10 3/4 6/6 Audit Committee The Audit Committee is required to review the establishment and maintenance of an effective system of integrated governance, risk management and internal control. Reviews reports from internal and external audit. Reviews compliance with Secretary of State directives for countering fraud and bribery. Reviews the system of integrated risk, governance and internal control. Monitors compliance with standing orders and Standing Financial Instructions (SFIs). Receives and approves annual accounts. Following a review of assurance and Committee arrangements during the year the membership of the audit committee was extended to include all Non- Executive Directors. The Committee also refocused its agenda to so that progress in implementing the Pennine Plan was reviewed in detail at each meeting. Executive directors have also been asked to attend the Audit Committee to present on actions being taken to mitigate any limited assurance reports. The Audit Committee has also reviewed the Board Assurance Framework and Risk Register at each meeting, placing a particular focus at each meeting on one or two of the sub-board level risks where Executive Directors have been asked to attend the Committee to present on and be scrutinised on these risks and mitigating actions. Membership Riaz Ahmad (Chair to 31 July 2016) John Willis (Chair from 1 August 2016) Wendy Cardiff (to 30 September 2016) Diane Brown, Non-Executive Director (from 1 October 2016). Camilla Guereca (to 30 November 2016) Shauna Dixon, Non-Executive Director (from 19 July 2016 to 28 February 2017) Margaret Ollerenshaw, Non-Executive Director (from 19 July 2016 The Audit Committee had 6 meetings in 2016/17 with attendance as noted below: Riaz Ahmad John Willis Wendy Cardiff Diane Brown 2/3 3/3 2/3 2/3 Camilla Guereca Shanua Dixon Margaret Ollerenshaw Chris Mayer 4/4 2/4 2/4 3/4 Annual Report

38 PAGE 36 Executive Assurance and Risk Committee The Committee ensures: Serious risks to the Trust s principal objectives are managed effectively and efficiently; Adequate assurance mechanisms exist and are appropriately monitored to enable self-certifications and declarations of compliance with national standards and guidance to be confidently given. Membership Chief Executive (Chairman) All other Executive Directors Divisional Directors Divisional Nurse Directors Divisional Medical Directors The Assistant Chief Executive / Board Secretary, Director of Governance, Director of Patient Safety and the Associate Director of IM&T attend the Committee. The Committee met 10 times during the year with average attendance being 70%. Remuneration and Terms of Service Committee To be responsible for identifying and appointing candidates to fill all the Executive Director positions on the Board and for determining their remuneration and other conditions of service. To determine the appropriate remuneration and other conditions of service for other senior employees (Non Agenda for Change / non medical grades.) To approve redundancy, other special payments and extra contractual agreements over relevant thresholds. To approve allowances for management aspects of Board, Divisional and Directorate senior medical staff roles Jim Potter, Chairman. Chris Mayer, Non-Executive Director Riaz Ahmad, Non-Executive Director (to 31 July 2016) John Willis, Non-Executive Director (from 1 August 2016). Wendy Cardiff, Non-Executive Director (to 30 September 2016) Diane Brown, Non-Executive Director (from 1 October 2016). Shauna Dixon, Non-Executive Director (to 28 February 2017) Camilla Guereca, Non-Executive Director (to 30 November 2016) Margaret Ollerenshaw, Non-Executive Director The Remuneration Committee had 6 meetings in 2016/17 with attendance as noted below: Jim Potter Chris Mayer Riaz Ahmad John Willis Wendy Cardiff 6/6 6/6 1/1 3*/5 1/1 Diane Brown Shauna Dixon Camilla Guereca Margaret Ollerenshaw 5/5 4/5 2/3 4*/6 *Excused from one meeting due to the nature of the item discussed.

39 PAGE 37 Charitable Funds Committee The Board of Directors is the corporate trustee of The Pennine Acute Hospitals NHS Trust Charity, Charity Registration Number The Charitable Funds Committee discharges the duties of the trustees of the Charity. The Charitable Funds Committee Ensures operation of the charity within the terms of its governing documents Reviews and approves charitable funds and accounts for the year. Membership: Shauna Dixon (Chair up to 28 February 2017) Subcommittee reporting arrangements The Board sub committees have specific governance responsibilities for monitoring and reporting on key aspects of the Trust s business. The Trust Board receives a report on the work of each subcommittee after each meeting. A clear reporting cycle for the Board, its sub committees and the executive governance committees ensures an appropriate range of matters are considered at each meeting. The risk register process ensures that relevant matters are raised through the governance and assurance structure in a timely manner and are reported to the Board. Damien Finn Riaz Ahmad (Up to 30 July 2016) Prof Mathew Makin John Willis (from 1 August 2016) Jim Potter (from 1 March 2017) Two other senior managers are also members of the Committee. The Charitable Funds Committee had 4 meetings in 2016/17 with attendance as noted below: Shauna Dixon Mathew Makin Damien Finn 3/3 1/4 3/4 Riaz Ahmad John Willis Jim Potter 0/1 2/3 1/1 Annual Report

40 PAGE 38 Register of Declared Interests A register of declared interests is maintained by the Trust and is available for inspection on application to the Assistant Chief Executive / Board Secretary. There are no company directorships held by directors of the Trust with companies who are likely to, or are seeking to, conduct business directly with the Trust. Declarations as at 31 March 2017 for Board members. Board Member Position Interest Date Declared James Potter Chairman Chairman Salford Royal Foundation Trust.... Director and Shareholder of Harland Systems Group Ltd... Director of Harland Machine Systems Ltd.... Executive Vice President of Harland America.... Executive Director of Harland China (Shanghai).... Director and Shareholder in Cobalt AS IG Ltd Chris Mayer John Willis Diane Brown Non-Executive Director Non-Executive Director Non-Executive Director Self Employed Consultant.... Associate, Fiona Macneill Associates, Consultancy coaching and Facilitation.... Consultancy, The Slynn Foundation.... Managing Director, C & D Mayer Consultancy Limited.... Trustee, Royal Armouries.... Non-Executive Director Salford Royal Foundation Trust.... Trustee and Distributor of the Booth Charities.... Non-Executive Director, Salford Royal Foundation Trust... Shareholder Astra Zeneca... Sir David Dalton Chief Executive Chief Executive Salford Royal Foundation Trust... Vice Chair, GM AHSN.... Governor of Health Foundation.... Professor Matthew Makin Damien Finn Elaine Inglesby- Burke Medical Director Director of Finance Nurse Director Honorary Professor Bangor University Declared no interests Trustee of the Willowbrook Hospice NED Advancing Quality Alliance (AQuA)... NED National Institute for Health and Clinical Excellence (NICE).... Exec Nurse Governing Body of St Helens and Knowsley CCG.... Director of Nursing SRFT All Board members confirmed on appointment, or reconfirmed annually that they subscribed to the Codes of Conduct and accountability. All Board members were subject to the Fit and Proper Persons Test with the outcome reported to the Remuneration Committee on appointment and to the Board through an annual statememt.

41 PAGE 39 Personal Data IG SIRI Incidents within the Period: 01 April Mar 2017 Date of Incident IG SIRI Level Status Reported to the ICO Summary of Incident Number of people affected 28-Mar-17 1 Open No Marketing letter sent to Doctors. less than Mar-17 1 Open No Patient details disclosed in error in bundle set of 2 documents. 01-Mar-17 1 Open No Detail of one patient appointment letter able to be 1 viewed via a window type envelope. 27-Feb-17 1 Closed No 9 patient letters sent to wrong G.P Feb-17 1 Open No Confidential data viewable in a window type envelope Nov-16 1 Open No Trust solicitors sent patient data using password 1 protection but unencrypted. 01-Nov-16 1 Open Yes Did not meet required timeframe for a Subject Access 1 Request. 22-Sep-16 1 Closed No Complainants information inappropriately disclosed Aug-16 2 Closed Yes Patient details sent to GP in error 1 07-Jul-16 1 Closed No Boxes of records were sent for disposal to a local Tip Not Known 19-May-16 1 Open Yes Did not meet required timeframe for a Subject Access 1 Request. 10-May-16 2 Closed Yes Information in addition to that known by trusted partner organisation Faxed in error. 1 There were twelve serious untoward data security breaches which required investigating in the year: Two incidents related to non-compliance with a subject access request. Eight related to disclosure in error incidents. One related to non-secure disposal of paperwork. One related to non-secure transfer of patient data by . Two of the incidents, one relating to patient details sent to a GP in error and one relating to information faxed externally in error, were registered as Level 2 incidents. Four of the incidents were reported to the Information Commissioner s Office (ICO). The ICO has not requested that the Trust take any further action on the two closed incidents and is awaiting ICO feedback on the two open incidents. Statement Regarding Information Relevant to External Audit As at 8 May 2017 each Executive and Non-Executive member of the Pennine Acute Hospitals NHS Trust Board has confirmed that they know of no information which would be relevant to the auditors for the purposes of their audit report, and of which the auditors are not aware, and; have taken all the steps that he or she ought to have taken to make himself / herself aware of any such information and to establish that the auditors are aware of it. Annual Report

42 PAGE 40 Modern Slavery Act 2015 Transparency in Supply Chains The Pennine Acute Hospitals NHS Trust is committed to maintaining and improving systems, processes and policies to avoid complicity in human rights violation. We realise that slavery and human trafficking can occur in many forms, such as forced labour, domestic servitude, sex trafficking and workplace abuse. The Trust is fully aware of the responsibilities it bears towards patients, employees and the local community and as such, we have a strict set of values that we use as guidance with regard to our activities. We therefore would expect that all suppliers to the Trust adhere to the same principles. As part of our commitment the Trust we have review our supply chains and have introduced a Supplier Code of Conduct and have requested all existing and new suppliers to confirm that they are compliant with the Act. Where we use contracts awarded centrally, this is covered by the contract body placing the supplier on their contract / framework agreement. The Trust s Procurement Procedures have been updated and we use the NHS standard terms and conditions of contract which take account of the Act.

43 PAGE 41 Statement of the Chief Executive s responsibilities as the Accountable Officer of the Trust The Chief Executive of the NHS Trust Development Authority has designated that the Chief Executive should be the Accountable Officer to the trust. The relevant responsibilities of Accountable Officers are set out in the Accountable Officers Memorandum issued by the Chief Executive of the NHS Trust Development Authority. These include ensuring that: there are effective management systems in place to safeguard public funds and assets and assist in the implementation of corporate governance; value for money is achieved from the resources available to the trust; annual statutory accounts are prepared in a format directed by the Secretary of State with the approval of the Treasury to give a true and fair view of the state of affairs as at the end of the financial year and the income and expenditure, recognised gains and losses and cash flows for the year. To the best of my knowledge and belief, I have properly discharged the responsibilities set out in my letter of appointment as an Accountable Officer. I confirm that, as far as I am aware, there is no relevant audit information of which the trust s auditors are unaware, and I have taken all the steps that I ought to have taken to make myself aware of any relevant audit information and to establish that the trust s auditors are aware of that information. I confirm that the annual report and accounts as a whole is fair, balanced and understandable and that I take personal responsibility for the annual report and accounts and the judgments required for determining that it is fair, balanced and understandable. the expenditure and income of the trust has been applied to the purposes intended by Parliament and conform to the authorities which govern them; effective and sound financial management systems are in place; and Chief Executive 26 May 2017 Annual Report

44 PAGE 42 Statement of Directors responsibilities in respect of the accounts The directors are required under the National Health Service Act 2006 to prepare accounts for each financial year. The Secretary of State, with the approval of the Treasury, directs that these accounts give a true and fair view of the state of affairs of the trust and of the income and expenditure, recognised gains and losses and cash flows for the year. In preparing those accounts, directors are required to: apply on a consistent basis accounting policies laid down by the Secretary of State with the approval of the Treasury; By order of the Board Chief Executive 26 May 2017 Finance Director 26 May 2017 make judgements and estimates which are reasonable and prudent; state whether applicable accounting standards have been followed, subject to any material departures disclosed and explained in the accounts. The directors are responsible for keeping proper accounting records which disclose with reasonable accuracy at any time the financial position of the trust and to enable them to ensure that the accounts comply with requirements outlined in the above mentioned direction of the Secretary of State. They are also responsible for safeguarding the assets of the trust and hence for taking reasonable steps for the prevention and detection of fraud and other irregularities. The directors confirm to the best of their knowledge and belief they have complied with the above requirements in preparing the accounts.

45 PAGE 43 Annual Governance Statement 2016/17 This annual governance statement covers the year 2016/17 during which Sir David Dalton was Chief Executive and Accountable Officer. Scope of responsibility The Board is accountable for internal control. As Accountable Officer, and Chief Executive of this Board, I have responsibility for maintaining a sound system of internal control that supports the achievement of the Trust s policies, aims and objectives whilst safeguarding quality standards and public funds and the Trust s assets for which I am personally responsible. These responsibilities are contained in the Accountable Officer Memorandum which sets out propriety and accountability issues. This Annual Governance Statement draws together position statements and evidence in relation to corporate and quality governance, risk management and control. Governance Framework of the Trust Following the Care Quality Commission (CQC) inspection of the Trust in February 2016 and in discussion with NHS, the Trust entered into arrangements with Salford Royal FT to provide leadership and management support to the Trust from 1 April At Board level, NHS appointed Mr James Potter as Chair of the Trust in addition to his role at Salford Royal FT and I was appointed as Chief Executive and Accountable Officer from that date in addition to my role as Chief Executive of Salford Royal FT. Elaine Inglesby Burke was appointed as Chief Nurse from 1 August 2016 in addition to her role as Chief Nurse of Salford Royal FT. Mr Hugh Mullen, Director of Operations, was seconded to Stockport FT during the year. Five non-executive directors came to the end of their terms of office during the year. Mr John Willis and Mrs Diane Brown were appointed as non-executive directors by NHS in addition to their nonexecutive director roles at Salford Royal FT. Mr Willis became Chair of the Audit Committee, a role which he has carried out a Salford Royal FT for a number of years. Appropriate leadership arrangements have therefore remained in place throughout the year. There is a clear division of responsibilities at the head of the Trust between the running of the Board and the executive responsibility for the Trust s business. The Chairman leads the Board while the Chief Executive manages the Trust. Board members self-declared during the year that they subscribed to the codes of conduct and accountability and where necessary, underwent or reconfirmed the Fit and Proper Persons test and completed declarations of interest. A number of other Executive Directors and senior managers from Salford Royal FT have provided leadership and management support to the Trust throughout the year. Significant amongst these were the director of patient safety and the associate chief information officer. A new Interim Director focused on operational performance and a new director of governance were also appointed. During the year there has been a clear focus on re-orientating the leadership and management arrangements within the Trust from a horizontal model of a number of clinical divisions (Anaesthetics and Surgery, Medicine etc) operating across the Trust to three Care Organisations which are responsible for all services on their site and in their locality (North Manchester, Oldham and Bury / Rochdale). Annual Report

46 PAGE 44 Implementation of this new model has proceeded incrementally throughout the year as new senior leaders have been appointed and as the supporting Divisional and Directorate structures have been realigned. The Care Organisations assumed responsibility for Medical Division services from 1 January The new structures will be fully embedded during the first half of 2017/18. Throughout the re-orientation of the management arrangements, we have maintained clear lines of accountability and assurance by ensuring that we do not dismantle any of the existing Trust arrangements until the new structures are in place. Board of Directors and Committee Structure The Board of Directors meet regularly to set the Trust s strategic aims and to ensure that the necessary financial and human resources are in place to meet its objectives, and to review performance. The key focus for the Board during the year has been to stabilise services across the Trust and to commence the process of service improvement arising from the inadequate rating determined by the CQC. During the first quarter of the year, as an initial step in providing leadership and management support to the Trust, Salford Royal FT undertook a diagnostic of the Board and Trust. This has been used as the selfassessment of Board effectiveness during the year. In May 2016 the Trust Board approved a revised control framework (described later in this document), part of which included a revised Board committee structure. The basis of this structure was to refocus the Board, and in particular the Non-Executive cohort, on their strategic leadership and assurance role. The formal Board subcommittees were reviwed and revised.. All Non-Executive Directors (with the exception of the Trust Chair) were appointed as members of the Audit Committee. The Audit Committee is required to review the establishment and maintenance of an effective system of integrated governance, risk management and internal control across the whole of the Trust s activities (both clinical and non-clinical) that support the achievement of the Trust s objectives. The Audit Committee agenda was refocused so that progress in implementing the Pennine Plan was reviewed in detail at each meeting. Executive directors have also been asked to attend the Audit Committee to present on actions being taken to mitigate any limited assurance reports. The Audit Committee has also reviewed the Board Assurance Framework and Risk Register at each meeting, placing a particular focus at each meeting on one or two of the sub-board level risks where Executive Directors have been asked to attend the Committee to present on and be scrutinised on these risks and mitigating actions. The Board reconfirmed the roles of the Remuneration and Terms of Service Committee and the Charitable Funds Committee. The Remuneration and Terms of Service Committee covers all aspects of the remuneration of the Chief Executive and Executive Directors and the management aspects of senior medical roles. The Board of Directors is the corporate trustee of the Pennine Acute Hospitals NHS Trust Charity, Charity Registration number: The Charitable Funds Committee discharges the duties of the trustees of the charity. The Executive Assurance and Risk Committee was established as a standing committee of the Board with responsibility for the control of risk and provision of assurance to the Board with respect to the overall performance of the Trust. The Committee meets on a monthly basis and, subsequently, provides a monthly summary report to the Trust Board. The Executive Assurance and Risk Committee is chaired by the Chief Executive. Membership includes all Executive Directors, senior members of Divisional / Care Organisation Management Teams and key corporate leaders. Although Non-Executive Directors are not formal members of the Committee they are welcome to

47 PAGE 45 attend meetings. At the Executive Assurance and Risk Committee the Chief Executive holds the Executive Directors to account for the delivery of the principal objectives through receiving and reviewing reports from each of the Executive Governance Committees which are chaired by one of the Executive Directors. Executive Governance Committees have been established for Quality and Patient Experience, Finance, Clinical Effectiveness, Operations, Workforce, and Education and Research. The Committee also reviews and reviews assurance on the Board Assurance Framework and reviews the key risks identified in the Divisions. These risks and the associated action plans, are incorporated within the reporting schedules of the relevant Executive Governance Committees, which ensure effective oversight and report-back to the Executive Assurance and Risk Committee. The key strategic programmes (Single Hospital Service, Healthier Together and the Trust s Clinical Services Strategy) have been overseen by the Clinical Service Transformation Programme Board chaired by the Chief Executive. There has been good attendance at meetings throughout the year details of attendance at the main Committees are included in the Annual Report. Sub Committee reporting arrangements The Board sub committees have specific governance responsibilities for monitoring and reporting on key aspects of the Trust s business. The Trust Board receives a report on the work of each subcommittee after each meeting. A clear reporting cycle for the Board, its sub committees and the executive governance committees ensures an appropriate range of matters are considered at each meeting. The risk register process ensures that relevant matters are raised through the governance and assurance structure in a timely manner and are reported to the Board. UK Corporate Governance Code and Best Practice The UK Corporate Governance Code builds on Cadbury and Nolan principles and has five sections relating to leadership, effectiveness, accountability, remuneration and relationships with stakeholders. The UK Corporate Governance Code which applies to all private and public sector bodies (but not to NHS Trusts) maps to the CQC Well Led framework for the NHS. This was also a significant focus of the diagnostic review undertaken by Salford Royal FT in the first quarter of 2016/17. The matters identified in these reviews led to the revised Board membership, the amendments to the committee and governance assurance arrangements, the revised risk and assurance arrangements implemented throughout the Trust and the new Care Organisation leadership and management arrangements which are in the course of being implemented. These arrangements mirror those in place at Salford Royal FT which has been rated outstanding by the Care Quality Commission. The Trust has remained compliant with requirements to discharge its statutory financial functions as evidenced through the external audit opinion on the annual accounts and annual report. Quality Governance Quality governance arrangements were comprehensively reviewed during the year. A new Director of Governance was appointed and a Director of Patient Safety from Salford Royal FT was seconded to the Trust. Revised and improved arrangements have been put in place in relation to clinical audit, declaration and review of serious incidents, never events, complaints and incident management, relations with the Coroner and preparation for inquests and follow up on actions arising from incidents. There has been an increase in the number of incidents reported during the year, which Annual Report

48 PAGE 46 is a positive sign of a more open culture. The number of incidents graded as high risk has reduced indicating that the quality improvement work is beginning to have some positive effect. The Chief Nurse is responsible for the Quality Account which the Trust has chosen to fully integrate into the annual report. The Executive Quality and Patient Experience Governance Committee approved the outline content of the Quality Account, the Trust Board considered and reviewed the final draft and the Audit Committee approved the final version of the Quality Account. Data quality is assured through the Trust s data quality governance structures. Significant work has been undertaken during the year to improve data quality, although further work is required to ensure complete validity of data. Quality and Data Accuracy of Elective Waiting Time Data The Trust has implemented an improvement project this year to assure the quality and accuracy of elective waiting time data, and the risks to the quality and accuracy of this data. The quality of performance information was assessed as part of the Salford Royal diagnostic and audit support from an external body was commissioned. From the findings of this audit a data quality project was commenced and included in the Pennine Plan. Significant progress has been made in year to deliver against the aims of the project and assure the data quality of elective waiting times data and data submissions. Further work will be taken forward in 2017/18 to embed the new systems and processes across the Divisions in all Pennine Acute Trust Care Organisations to ensure data quality is robust and a reliable system is in operation. Pensions As an employer with staff entitled to membership of the NHS Pension Scheme, control measures are in place to ensure all employer obligations contained within the scheme regulations are complied with. This includes ensuring that deductions from salary, employers contributions and payments into the scheme are in accordance with scheme rules, and that member pension scheme records are accurately updated in accordance with the timescales detailed in the regulations. Risk Assessment Risk Assessment and Management Process. The risk assessment, management and assurance process was reviewed early in the year following the introduction of leadership and management support from Salford Royal FT. Revised arrangements were introduced aligning the systems with those in place at Salford Royal. These included a combined Board Assurance Framework and Corporate Risk Register, review and scrutiny arrangements by the Executive Assurance and Risk Committee, a revised risk scoring mechanism to more clearly identify and align risks to appropriate levels of scrutiny within the Trust (Directorate, Division, Executive or Board) and to enable escalation and de-escalation of risks. The revised Board Assurance Framework was approved by the Trust Board in July 2016 and has been reviewed at each Board meeting. The Board has considered risks, risk scoring and mitigation. The Board has been assisted in its scrutiny by the Audit Committee which has reviewed a number of risks in detail. The Board agenda is now closely aligned to the Board Assurance Framework demonstrating that the Board attention is focused on the key risks facing the Trust. The key risks facing the Trust are closely aligned to those identified in the CQC inspection and the Salford diagnostic. The top risk relates to the sustainability of the urgent care service at North Manchester General

49 PAGE 47 Hospital. The next highest risks relate to urgent care demand and flow, cancer pathways and infection control. There are also key board level risks relating to the deteriorating patient, clinical leadership, lessons learned, safe staffing levels, the evolve patient records system, the maternity handover of care system, the laboratory IT system, cyber security, recruitment and retention of staff, staff vacancies, performance and development reviews, referral to treatment standards and the estate at North Manchester General Hospital. The Trust achieved its financial targets and CIP target in 2016/17 with the exception of achieving at least a breakeven position on income and expenditure (the Trust delivered a 2.4m deficit). The Trust continued to have a sigificant underlying deficit. While the previous Board Assurance Framework in place for 2015/16 had noted the generality of some of these risks, due to the comprehensive review of the Board Assurance Framework and Corporate Risk Register in 2016, all of these risks can be considered to have been identified in year. There is clear mitigation and tracking of actions reflected in the Board Assurance Framework against each risk. The key risks for 2017/18 remain those currently identified. During the year considerable work has been undertaken to realign the Divisional Risk Registers to reflect the more robust method of expressing risks and the new scoring framework. This has been supported by dedicated training sessions for key managers. Work continues into 2016/17 to realign the risk registers to reflect the new Care Organisations, Divisions and Directorates. Risks to data security are managed through policies and procedures and mandatory training. Arrangements are in place to protect confidential information, whilst ensuring that information is released to those who have a right to access. These arrangements include policies on information governance, information security, data protection and freedom of information. The Director of Finance is the Senior Information Risk Officer. The Deputy Medical Director is the Caldicott Guardian. The Trust has a dedicated Information Governance Team. There were four serious untoward data security breaches reported to the Information Commissioner s Office (ICO). The ICO has not requested that the Trust take any further action on the two closed incidents and is awaiting ICO feedback on the two open incidents. The Risk and Control Framework The Risk and Control Framework is made up of the following key elements : The governance structure outlined above which has been fully reviewed during the year and of which risk management is an integral part. The Trust s risk management and assurance framework aligns to the Trust s strategic objectives and priorities for the year and ensures that risk is managed as part of the operational management of the Trust. The process is assured through the Executive Assurance and Risk Committee. The Board assurance framework has been reviewed during year. The BAF is used by the Board and reflects the risks discussed by the Board. The BAF brings together all of the evidence required to support the annual governance statement. The BAF has been reviewed by internal audit for 2016/17 and the internal audit opinion confirmed that the Trust meets the NHS requirements. Clear counter fraud and prevention of bribery arrangements, support for national initiatives and publicity of successful prosecutions as a deterrent effect. The Audit Committee receives a regular report from the local counter fraud specialist. Regular reports from internal audit and external audit to the Audit Committee including any external audit review of the risk of management override of Annual Report

50 PAGE 48 control. These elements taken together identify and provide mitigation for the key risks facing the Trust and provide a level of external assurance on the management and mitigation of these risks. Training has been provided to key managers during the year on the operation of the risk register. Review of the Effectiveness of Risk Management and Internal Control As Accountable Officer, I have responsibility for reviewing the effectiveness of the system of internal control. My review is informed through the risk and control framework described above. The Executive Assurance and Risk Committee, which I chair, draws together assurance from each of the Executive Governance Committees and undertakes comprehensive reviews and scrutiny of the Board Assurance Framework. The risk management arrangements and board assurance framework have been completely revised during the year and are more effective than those previously in place within the Trust. The design and operation of the new arrangements have been rated green by internal audit and compliant with NHS requirements. The head of internal audit also provides me with an opinion on the overall arrangements for gaining assurance through the Board Assurance Framework and on the controls reviewed as part of internal audit s work. The head of internal audit opinion for 2016/17 gave significant assurance on the system of internal control in place during the year. Where Internal audit issue a limited assurance report the relevant Executive Director attended the Audit Committee to discuss the report an actions taken. The report by the Care Quality Commission issued in August 2016 following the review of the Trust carried out in February and March 2016 rated the Trust as inadequate. CQC rated the Trust as Inadequate in the Safe and Well Led Domains; of Effectiveness and responsiveness and Good for Caring. Rochdale Infirmary and Community Services were rated as Good; Fairfield general Hospital was rated as, North Manchester General Hospital and The Royal Oldham Hospital were rated as Inadequate. A major improvement plan has been put in place with external assurance and review undertaken by the Pennine Board which is chaired by the Chief Officer of Greater Manchester Health and Social Care Partnership. Significant Issues This annual governance statement requires me to consider whether there are any significant issues facing the Trust. The following factors have been considered when determining whether an issue is significant: Prejudice the achievement of the priorities Undermine the integrity or reputation of the NHS Review of the Audit Committee Advice provided by internal and external audit Place delivery of the standards expected of the accountable officer at risk Make it harder to resist fraud or other misuse of resources Divert resources from another significant aspect of the Trust s business Have a material impact on the accounts Put national or data security or integrity at risk. The Trust faces significant issues in relation to: Quality improvement being mitigated through actions on sepsis, clinical leadership, lessons learned, staffing levels and improved information systems; Financial sustainability being mitigated through additional support funding, action to reduce agency

51 PAGE 49 spend and action to reduce the vacancy gap; Delivering performance and improvement being mitigated through work on staff PDRs, reducing sickness absence and improving engagement with staff; Improving services through integration and collaboration being mitigated through work on the single hospital service, stabilisation of services, improving patient flow and a focus on fragile services. Compliance with mandatory standards being mitigated through actions on capacity and demand and to reduce infections. I have concluded that these are significant issues facing the Trust in 2017/18. Continued focused management attention within the Trust and discussion and cooperation with commissioners, GM Health and Social Care Partnership and NHS are in place in order to mitigate these risks. Sir David Dalton Chief Executive and Accountable Officer Sir David Dalton Chief Executive 26 May 2017 Annual Report

52 PAGE 50 Remuneration and Staff Report

53 PAGE 51 Remuneration Committee Remuneration and staff reportthe membership of the Trust s Remuneration Committee comprises the chairman and non-executive directors with the chief executive attending as required. The committee determines on behalf of the Board the remuneration and terms of service arrangements of the chief executive, executive directors and a small number of other senior employees, ensuring they are fairly rewarded for their contribution to the Trust. The executive directors are employed on permanent contracts. The executive directors are required to give three months notice of termination of employment. There are no special guaranteed termination payments or compensation payments for early termination of executives. Executives are subject only to the same redundancy rights as all other employees of the Trust. Remuneration of key staff (board members) Details of remuneration of Board members being those individuals who are key to accountability and having authority or responsibility for directing or controlling major activities within the Trust are noted below. These have been determined as the Board members as they influence the decisions of the Trust as a whole rather than the decisions of individual directorates or departments. Annual Report

54 PAGE 52 Salary and Pension entitlements of senior managers A) Remuneration Name and Title (a) (b) (c) (d) (e) (f) (a) (b) (c) (d) (e) (f) Salary Taxable Performance Long term All pen- TOTAL (a Salary Taxable Performance Long term All pen- TOTAL (a expense performance sion-related to e ) expense pay and performance sion-related to e ) payments & taxable benefits total nearest 100 pay and bonuses pay and bonuses benefits payments & taxable benefits total nearest 100 bonuses pay and bonuses benefits (bands of 5000) (bands of 5000) 000 (bands of 5000) 000 (bands of 2500) 000 (bands of 5000) 000 (bands of 5000) Sir D Dalton, Interim Chief Executive (from 1 April 2016) , D Finn, Director of Finance (started 28 Sep 2015), Acting Chief Exec (1 Mar to 31 Mar 2016) Prof M Makin, Medical Director (started 1 Mar 2016) , G Harris, Chief Nurse (started 1 Apr 2015, left 31 July 2016) E Inglesby-Burke CBE, Chief Nurse (from 1 August 2016) , J Lenney, Director of Workforce & OD (started 1 Feb 2015) , , H Mullen, Director of Operations (until 24 January 2017) J Potter, Chairman (from 1 April 2016) R Ahmad, Non Executive (until 31 July 2016) W Cardiff, Non Executive (until 30 September 2016) C Mayer, Non Executive Director (Acting Chair from 1 March to March 2016) C Guereca, Non Executive Director (until 30 November 2016) M Ollerenshaw, Non Executive Director (until 31 March 2017) S Dixon, Non Executive Director (until 28 February 2017) J Willis CBE, Non Executive Director (from 1 August 2016) D Brown, Non Executive Director (from 1 October 2016) leavers/changes Dr GE Fairfield, Chief Executive (until 29 Feb 2016) RB Steven, Deputy Chief Executive/ Director of Finance (retired 30 Jun 2015) Dr A Sinniah, Acting Medical Director (until 29 Feb 2016) J Jesky, Chairman (until 29 Feb 2016) Column (e) is pension related benefits - this is the increase in year of the annual pension and lump sum that the individual would be entitled to from the NHS Pension scheme at 31 March or retirement less any employee contributions. In the case of Dr Fairfield, this is the payment in lieu of pension contributions. Sir David Dalton is represented in this statement for the proportion of time attributable to Pennine Acute. Sir David Dalton also holds the role of Chief Executive for Salford Royal NHS Foundation Trust and is represented in their accounts accordingly. Mrs E Inglesby-Burke CBE is represented in this statement for the proportion of time and term of office attributable to Pennine Acute. Mrs E Inglesby-Burke CBE also holds the role of Executive Nurse Director for Salford Royal NHS Foundation Trust and is represented in their accounts accordingly. Dr Fairfield opted out of the NHS Pension Scheme in 2010/11 and is a deferred member. In 2015/16 the Trust made payments to Dr Fairfield in lieu of employer pension contributions (shown in column e above) as part of her overall remuneration package. Dr Fairfield served as a Non Executive Member for the National Youth Justice Board for England and Wales from October Remuneration for this role was paid directly to the Trust in 2015/16 and she received no personal benefit. D Tkacyzk was Interim Director of Finance from 1 July to 27 September information is not available as not directly employed by the Trust. D Tomlinson was Interim Director of Finance from 15 March to 31 March information not available as not directly employed by the Trust. Prof Makin has opted out of the NHS pension scheme. Taxable benefits relate to lease cars provided as part of a salary sacrifice scheme and/or mileage rates paid in excess of HMRC rates. (bands of 5000) 000 (bands of 5000) 000 (bands of 2500) 000 (bands of 5000) 000

55 PAGE 53 B) Pension Benefits Name and title Sir D Dalton, Interim Chief Executive (from 1 April 2016) D Finn, Director of Finance (started 28 Sep 2015), Acting Chief Exec (1 Mar to 31 Mar 2016) Real increase in pension at pension age (bands of 2500) 000 Real increase in lump sum at pension age (bands of 2500) 000 Total accrued pension at pension age at 31 March 2016 (bands of 5000) 000 Lump sum at pension age related to accrued pension at 31 March 2016 Cash Equivalent Transfer Value at 31 March 2016 Cash Equivalent Transfer Value at 31 March 2015 Real Increase in Cash Equivalent Transfer Value (bands of 5000) ,058 1, G Harris, Chief Nurse (left 31 July 2016) ,370 1, E Inglesby-Burke, Chief Nurse (from 1 August 2016) J Lenney, Director of Workforce & OD (started 1 Feb 2015) H Mullen, Director of Operations (until 24 January 2017) ,534 1, ,286 1, As Non-Executive members do not receive pensionable remuneration, there will be no entries in respect of pensions for Non-Executive members. A Cash Equivalent Transfer Value (CETV) is the actuarially assessed capital value of the pension scheme benefits accrued by a member at a particular point in time. The benefits valued are the member s accrued benefits and any contingent spouse s pension payable from the scheme. A CETV is a payment made by a pension scheme, or arrangement to secure pension benefits in another pension scheme or arrangement when the member leaves a scheme and chooses to transfer the benefits accrued in their former scheme. The pension figures shown relate to the benefits that the individual has accrued as a consequence of their total membership of the pension scheme, not just their service in a senior capacity to which the disclosure applies. The CETV figures, and the other pension details, include the value of any pension benefits in another scheme or arrangement which the individual has transferred to the NHS pension scheme. They also include any additional pension benefit accrued to the member as a result of their purchasing additional years of pension service in the scheme at their own cost. CETVs are calculated within the guidelines and framework prescribed by the Institute and Faculty of Actuaries. Real Increase in CETV - This reflects the increase in CETV effectively funded by the employer. It takes account of the increase in accrued pension due to inflation, contributions paid by the employee (including the value of any benefits transferred from another pension scheme or arrangement) and uses common market valuation factors for the start and end of the period. Relationship between the remuneration report and exit packages, severance payments and off-payroll engagements disclosures None Annual Report

56 PAGE 54 Fair Pay Disclosure Pay Multiples Reporting bodies are required to disclose the relationship between the remuneration of the highest-paid director in their organisation and the median remuneration of the organisation s workforce. The mid-point of the banded remuneration of the highest paid director in the trust (Chief Executive) in the financial year was 222,500 ( , 252,500). This was 9.3 times ( , 10.5 times) the median remuneration of the workforce, which was 23,912 ( , 24,063). Sir David Dalton became Chief Executive of the Trust from 1 April 2016 in addition to his responsibilities as Chief Executive at Salford Royal FT. His remuneration is apportioned between the Pennine Acute Hospitals NHS Trust and Salford Royal FT. It is the remuneration rate rather than the actual cost which is used for the comparison purposes noted above. In there were no employees whose remuneration was in excess of the highest-paid director (none in ). Total remuneration includes salary, non-consolidated performance-related pay (eg clinical excellence awards), benefits-in-kind as well as severance payments. For the purposes of reporting pay multiples remuneration does not include variable aspects of pay such as overtime, enhancements or additional waiting list payments. Remuneration does not include employer pension contributions and the cash equivalent transfer value of pensions. The median remuneration for the workforce as a whole has been derived from permanent employees only and annualised for the year for the effect of starters and part time staff.

57 PAGE 55 Staff report Details of the number of permanently employed staff and costs and agency staff and costs. Staff Groups Total Number Permanently Employed Number Employed Cost 000 Other Number Agency Cost /17 Cost 000 Medical and dental , , ,578 Ambulance staff Administration and estates 1,999 1,936 61, ,824 63,041 Healthcare assistants and other , ,942 support staff Nursing, midwifery and health 4,383 4, , , ,132 visiting staff Nursing, midwifery and health visiting learners Scientific, therapeutic and , ,574 38,541 technical staff Social Care Staff Healthcare Science Staff , ,940 Other (staff costs transferred to non-pay) Non-NHS staff / Vacancy Factor (NO WTE associated) TOTAL 9,330 8, , , Staff composition At 31 December 2016 the staff composition profile was: Sex FTE FTE % Headcount Female % 7188 Male % 1864 Grand Total % 9052 Sickness absence data The Trust target for was to reduce the sickness and absence rate from 5.87% to 4.6% - this required a reduction of 1.27%, or a relative performance improvement of 22%. The Trust sickness and absence rate in March 2017 was 5.14%. This was a reduction of 0.73%, or a relative performance improvement of 12% While falling short of the target, this still represents a significant improvement over the course of the year. Staff Composition of Directors in post at 31 March 2017 Male Female Chairman and Non-Executive Directors 2 3 Executive Directors 4 1 Total 6 4 Annual Report

58 PAGE 56 Equality, Diversity and Human Rights The Trust is committed to ensuring that its staff and service users enjoy the benefits of an organisation that respects and upholds individuals rights and freedoms. The Trust has an equality and diversity strategy, identifying how staff and patients from different equality groups are supported and included in the Trust priorities and activities. The Trust has extensive policies and procedures in place that support all staff to access training and development and provide equal opportunity within the workplace. A specific equal opportunity policy is in place in the Trust to support and inform staff of their rights and action to take should they feel discrimination has occurred. All current policy and practices are developed and reviewed in line with the Equality Act The Trust recognises the value of a diverse workforce and is committed to implementing policies and procedures that will assist in eliminating discrimination and encouraging diversity amongst its workforce. By creating opportunities for all staff to reach their full potential, and ensuring that there is a fair and equitable organisational structure and accountability. We are committed to ensure that our approach to our staff is the same as our approach to our service users being open and transparent, focussed and valuing. The Trust s aim is that its workforce is fully representative of all sections of society and that each member of staff feels respected. We strive to ensure that individuals are treated equally and fairly and that decisions on recruitment, selection, training, promotion, career management and provision of other benefits are based solely on objective and job related criteria. The Trust is committed to ensure that the talents and resources of employees are utilised to the full and that no applicant or employee receives less favourable treatment on the grounds of sex, marital status, sexual orientation, pregnancy, ethnicity, religion, disability, age, gender reassignment, caring responsibilities or any other defining characteristic. Achievements during the year: The Trust s Recruitment Code of Practice which reinforces our commitment to value diversity and remove unlawful discrimination, and sets out effective and equitable processes has been widely disseminated across the Trust; A recruitment training course was made available for all managers and has been designed to ensure managers understand the recruitment process and how to implement staff policies and procedures in a fair and equitable manner; As part of the Improving Working Lives Strategy, the Trust offers a comprehensive adult and child care advice and information service to current and prospective members of staff. Employees have direct access to the adult and child care co-ordinator who will act as advisor, advocate and source of expertise, providing support in all adult or child care requirements; The Trust has been successful in transferring over to Disability confident which replaced the previous Two Ticks scheme. Disability confident has 3 levels of achievement which demonstrate the organisations commitment to employing and supporting disabled people whether that be staff or patients / carers. The Trust has effectively demonstrated this and has been awarded a level 2 and we are in the process to progress to level 3 by The Trust is continuing to raise disability awareness and provide information to existing staff and new candidates to encourage them to feel comfortable in declaring their disability. The Trust has also introduced a Communication and information needs passport for all patients who have communication needs. We developed a Pennine Stakeholder Partnership including all other public sector organisation to develop the communication

59 PAGE 57 passport. The communication passport is in operation across all the partnership organisations thus providing a consistent and standardised approach. This was initially a pilot for six months in all main outpatient area, due to the success of this we are now rolling this out throughout the Trust. This will also help to ensure that applicants and existing staff are aware of the support available from the Trust s occupational health department and how to obtain an assessment for reasonable adjustments if necessary; The Trust extended the statutory and mandatory training policy to include equality and diversity awareness training for all staff; the Trust has also developed comprehensive training packages that cover Cultural awareness, Sexual orientation and transgender and Dignity at work sessions for staff which provides them with insight in how to meet the needs of the diverse communities we serve across our footprint and all sites. To ensure a consistent and fair approach to implementing workforce procedures, the Trust works closely with its trade unions to develop its human resources policies. The Trust also provides managers with guidelines on implementing the main policies, as well as golden rules, a simple overview of the main points of the policy; The Trust has implemented the draft Workforce Disability standard and developed guidelines for managers on raising awareness and managing reasonable adjustments. The Trust has developed support networks for staff ( BAME, Disability and LGBT)to provide another avenue to enable them to voice their opinions and work together to offer support, advice and share experiences. The Trust held Equality Delivery System 2 ( EDS2) grading events with the local panel ( local panel consists of members of health watch and other local community groups covering all 9 protected groups) and with staff which were well attended and we have actually made progress from the previous grading session. The Trust overall is at developing level but with significant improvements made in goals 3 and 4 where some outcomes have been graded achieving by the panel. We have developed a Patient Participation Group in order to meet the requirements of the Healthier Together programme and this group monitors and reviews the equality implementation conditions for the Trust. This groups consists of representatives from the local Health watch organisations and various community groups and members representing the diverse groups surrounding our hospital sites. The Trust has been working very closely with its local Faith communities to meet their particular needs around End of Life care. We have been successful in developing a Multi-faith community group and we have together implemented many changes which has in turn impacted on a positive experience for the patients and their families. We have organised open days to the Jewish, Muslim and Christian mortuary s for staff and public to raise awareness and held health fairs with local mosques and community organisations. We continue to work with all our community and voluntary groups surrounding our sites in all four boroughs. We recognise the fact that there is a lot of experience and expertise within our third sector groups and view them as a valuable source. During this year we have made new relationships with some of our new emerging communities and have continued to strengthen and work in partnership with our existing groups. The BME Heath Forum in Rochdale is a wellattended forum which allows community and voluntary groups all gather in a forum with Public sector organisations and share their achievements, experiences and highlight any issues which they Annual Report

60 PAGE 58 have encountered. This forum covers all the minority groups in Rochdale and works collaboratively with the Trust and social services, CCG, Rochdale local authority it has allowed the Trust to open a two way communication channel and another means to enable us to engage and consult with this growing community Local engagement activity in the Muslim and Jewish community at North Manchester General Hospital has been undertaken during the last year, with meetings and events organised to support increased communication and partnership working. Regular meetings between the Trust and representatives from the Jewish Community, take place as and when needed to raise any issues and concerns. Expenditure on consultancy The Trust spent 0.3m on consultancy in 2016/17 this was a reduction of 2.3m from 2015/16. A key area of expenditure was on a review of Corporate Services functions to identify how the Trust can work with Salford Royal NHS Foundation Trust to develop shared corporate services. By modernising, integrating and consolidating corporate services across organisations the Trusts are taking the opportunity to drive greater efficiency, whilst delivering both increased resilience and improved quality. The Trust also engaged external consultants to carry out due diligence on financial plans plus consultancy support focused on quality improvement.

61 PAGE 59 Off-payroll engagements Table 1: Off-payroll engagements longer than 6 months For all off-payroll engagements as of 31 March 2017, for more than 220 per day and that last longer than six months: Number of existing engagements as of 31 March Of which, the number that have existed: for less than one year at the time of reporting 1 for between one and two years at the time of reporting for between 3 and 4 years at the time of reporting for 4 or more years at the time of reporting Number Table 2: New Off-payroll engagements For all new off-payroll engagements between 1 April 2016 and 31 March 2017, for more than 220 per day and that last longer than six months: Number Number of new engagements, or those that reached six months in duration, between 1 April 2016 and 31 March 2017 Number of new engagements which include contractual clauses giving the [entity name] the right to request assurance in relation to income tax and National Insurance obligations 2 2 Number for whom assurance has been requested 2 Of which: assurance has been received 2 assurance has not been received - engagements terminated as a result of assurance not being received - Table 3: Off-payroll board member/senior official engagements For any off-payroll engagements of board members, and/or, senior officials with significant financial responsibility, between 1 April 2016 and 31 March 2017 Number of off-payroll engagements of board members, and/or senior officers with significant financial responsibility, during the financial year (1) Total no. of individuals on payroll and off-payroll that have been deemed board members, and/or, senior officials with significant financial responsibility, during the financial year. This figure should include both on payroll and off-payroll engagements.(2) 0 16 The Trust can confirm that all existing off-payroll engagements outlined above have at some point been subject to a risk based assessment as to whether assurance is required that the individual is paying the right amount of tax and where necessary, that assurance has been sought. Annual Report

62 PAGE 60 Exit packages Exit Packages - other departures analysis 2016/ /16 Agreements Number Total value of Agreements 000s Agreements Number Total value of Agreements 000s Voluntary redundancies including early retirement contractual costs Mutually agreed resignations (MARS) or local Voluntary severance scheme (VSS) contractual costs Early retirements in the efficiency of the service contractual costs Contractual payments in lieu of notice Exit payments following Employment Tribunals or court orders Non contractual payments requiring HMT approval Total Exit package cost band (including any special payment element) *Number of compulsory redundancies *Cost of compulsory redundancies Number of other departures agreed Cost of other departures agreed Total number of exit packages Total cost of exit packages Number of departures where special payments have been made Cost of special payment element included in exit packages WHOLE NUMBERS ONLY s WHOLE NUMBERS ONLY s WHOLE NUMBERS ONLY s WHOLE NUMBERS ONLY Less than 10, , , ,000-25, , , ,001-50, , , , , , , , , , > 200, Total 1 37, , , s

63 PAGE 61 Site Award Winners and Finalists 2016 The seventh Trust staff awards were held in November Over 200 nominations were received from wards and departments across the Trust and from patients and relatives. The nominations and winners were: Leading by Example Award Julia Riley, lead nurse for medicine, The Royal Oldham Hospital Sue Petterson, interim directorate manager for medicine, North Manchester General Hospital Deborah Bancroft, advanced physiotherapy practitioner, Physiotherapy, Fairfield General Hospital (Winner) Deborah Lyon, head of service transformation, Rochdale Infirmary North Manchester Leg Circulation Service (Martin Fox, Lisa Smith and Sue Matthews), NM Community Services Doctor of the Year Award Dr Georges Ng Man Kwong, consultant chest physician and clinical director for long term conditions, The Royal Oldham Hospital Dr Isha Malik, consultant, Diabetes/endocrine, North Manchester General Hospital Dr Andrea Abbas, consultant, Acute Medical Unit, Fairfield General Hospital Mr Tanveer Hashmi, consultant ophthalmologist, Rochdale Infirmary (Winner) GP Care Services, Heywood, Middleton and Rochdale (HMR) Community Services Allied Health Professional / Technical / Scientific Worker of the Year Award Rebecca Chadwick, clinical specialist physiotherapist, Physiotherapy, The Royal Oldham Hospital (Winner) Nicola Heath, Occupational Therapy, North Manchester General Hospital Catherine Strong, lead pharmacist, Pharmacy, Fairfield General Hospital Halima Begum, food and nutrition advisor, Rochdale Infirmary Hannah Harrison and Beverley Clare, Crisis Response Service, North Manchester Community Services Chief Executive s Award for Service Aseptic Services and Haematology Day Unit Teams, The Royal Oldham Hospital Dr Mark Longshaw, consultant, Critical Care, North Manchester General Hospital (Winner) Physiotherapy team, Fairfield General Hospital June Hadley, service project manager, clinical admin team, elective access, Rochdale Infirmary North Manchester Macmillan Palliative Care Support Service (NMMPCSS), North Manchester Community Support Team of the Year Award The Discharge Co-ordinator and Tracker Team, The Royal Oldham Hospital (Winner) Children s Unit Pharmacy Discharge Team, North Manchester General Hospital Pharmacy discharge team, Fairfield General Hospital Clinical Administration Team, Elective Access, Rochdale Infirmary Community Assessment and Support Service (CASS), North Manchester Community Services Administration / Managerial Worker of the Year Award Rebecca Taylor, Macmillan end of life care administrator, The Royal Oldham Hospital Joanne McAllister, Volunteer Service, North Manchester General Hospital (Winner) Annual Report

64 PAGE 62 Annette Wray, clerk, Cardio-respiratory Laboratory, Fairfield General Hospital Anthony Szylak, divisional administrator, Rochdale Infirmary Julie Bowes, admin team leader, North Manchester Community Services Rising Star Award Victoria Ogden, acting ward manager, Ward F8, The Royal Oldham Hospital Kelly Dewhurst, midwife, Antenatal Clinic, North Manchester General Hospital (Winner) Chris Lomax, assistant directorate manager medicine, Fairfield General Hospital Heidi Tombling, centre manager or occupational health, Tudor Court, HMR Kara Ogden, district nurse, North Manchester Community Services Nurse or Midwife of the Year Award Anne Sharrocks, heart failure lead specialist nurse, The Royal Oldham Hospital (Winner) Marjorie Quinn, Ward F4, medicine, North Manchester General Hospital Jannine Todkill, A&E, Fairfield General Hospital Karen Jacques, community midwife, Rochdale Infirmary Samantha Reece, nurse practitioner, Rochdale Urgent Care Centre Outstanding Contribution to the Quality of Care Award Claire Doggett, Michelle Eachus, Katherine Robertson, Toby Garrity and Bethan Taylor, Simulation and Clinical Skills Team, Infection Prevention Team and Tissue Viability Team, The Royal Oldham Hospital

65 PAGE 63 Ann Slade, staff nurse, Ward F4, North Manchester General Hospital Ann Mcllwraith, ward manager, Ward 6, Fairfield General Hospital (Winner) Intermediate Tier Services (ITS), Rochdale Infirmary Community Active Case Management Team, North Manchester Community Services Clinical Team of the Year Award Occupational Therapy Department, The Royal Oldham Hospital Head and Neck Theatre Team, North Manchester General Hospital Pharmacy acute medicine team, Fairfield General Hospital Alcohol Liaison Service, Rochdale Infirmary Home Intravenous Therapy Team (HITT), North Manchester Community Services (Winner) Support Worker of the Year Award Tracy Fitchett and Clare Lamb, occupational health technicians, Occupational Health, The Royal Oldham Joanna Lonska, healthcare assistant, Ward J3/J4, North Manchester General Hospital Tyrone Supatan, housekeeper, Physiotherapy, Fairfield General Hospital (Winner) Juliet Smith, support worker/therapy assistant, Pulmonary and Palliative Rehabilitation Service, Rochdale Tracy Hall, community assistant practitioner, North Manchester Community Services Patients Choice Award High Dependency Unit, Fairfield General Hospital (Winner) Kathryn Lewis, midwife, Labour Ward, The Royal Oldham Hospital Dr S Kouta and the high risk podiatry team Volunteer of the Year Reception Desk, North Manchester General Hospital End of Life Care Volunteers Val Lee, North Manchester General Hospital (Winner) Chairman s Award for Living Our Values Kara Ogden, District Nurse, North Manchester Community Services (Winner). Sir David Dalton Chief Executive 26 May 2017 Annual Report

66 PAGE 64 Independent Auditor s Report to the Board of Directors of Pennine Acute Hospitals NHS Trust We have audited the financial statements of Pennine Acute Hospitals Trust for the year ended 31 March 2017 under the Local Audit and Accountability Act These financial statements have been prepared under applicable law and the accounting policies directed by the Secretary of State with the consent of the Treasury as relevant to NHS Trusts in England. We have also audited the information in the Remuneration and Staff Report that is subject to audit. This report is made solely to the Board of Directors of Pennine Acute Hospitals NHS Trust, as a body, in accordance with Part 5 of the Local Audit and Accountability Act Our audit work has been undertaken so that we might state to the Board of the Trust, as a body, those matters we are required to state to them in an auditor s report and for no other purpose. To the fullest extent permitted by law, we do not accept or assume responsibility to anyone other than the Board of the Trust, as a body, for our audit work, for this report or for the opinions we have formed. Respective responsibilities of Directors, the Accountable Officer and auditor As explained more fully in the Statement of Directors Responsibilities, the Directors are responsible for the preparation of financial statements which give a true and fair view. Our responsibility is to audit, and express an opinion on, the financial statements in accordance with applicable law and International Standards on Auditing (UK and Ireland). Those standards require us to comply with the Auditing Practices Board s Ethical Standards for Auditors. As explained in the statement of the Chief Executive s responsibilities, as the Accountable Officer of the Trust, the Accountable Officer is responsible for the arrangements to secure economy, efficiency and effectiveness in the use of the Trust s resources. We are required under section 21(3)(c), as amended by schedule 13 paragraph 10(a), of the Local Audit and Accountability Act 2014 to be satisfied that the Trust has made proper arrangements for securing economy, efficiency and effectiveness in its use of resources. Section 21 (5)(b) of the Local Audit and Accountability Act 2014 requires that our report must not contain our opinion if we are satisfied that proper arrangements are in place. We are not required to consider, nor have we considered, whether all aspects of the Trust s arrangements for securing economy, efficiency and effectiveness in its use of resources are operating effectively. Scope of the audit of the financial statements An audit involves obtaining evidence about the amounts and disclosures in the financial statements sufficient to give reasonable assurance that the financial statements are free from material misstatement, whether caused by fraud or error. This includes an assessment of: whether the accounting policies are appropriate to the Trust s circumstances and have been consistently applied and adequately disclosed; the reasonableness of significant accounting estimates made by the Directors; and the overall presentation of the financial statements. In addition we read all the financial and non-financial

67 PAGE 65 information in the annual report and accounts to identify material inconsistencies with the audited financial statements and to identify any information that is apparently materially incorrect based on, or materially inconsistent with, the knowledge acquired by us in the course of performing the audit. If we become aware of any apparent material misstatements or inconsistencies we consider the implications for our report. Scope of the review of arrangements for securing economy, efficiency and effectiveness in the use of resources We have undertaken our review in accordance with the Code of Audit Practice, having regard to the guidance on the specified criterion issued by the Comptroller and Auditor General in November 2016, as to whether the Trust had proper arrangements to ensure it took properly informed decisions and deployed resources to achieve planned and sustainable outcomes for taxpayers and local people. The Comptroller and Auditor General determined this criterion as that necessary for us to consider under the Code of Audit Practice in satisfying ourselves whether the Trust put in place proper arrangements for securing economy, efficiency and effectiveness in its use of resources for the year ended 31 March We planned our work in accordance with the Code of Audit Practice. Based on our risk assessment, we undertook such work as we considered necessary to form a view on whether, in all significant respects, the Trust had put in place proper arrangements to secure economy, efficiency and effectiveness in its use of resources. Opinion on financial statements In our opinion the financial statements: give a true and fair view of the financial position of the Trust as at 31 March 2017 and of the Trust s expenditure and income for the year then ended; and have been properly prepared in accordance with the accounting policies directed by the Secretary of State with the consent of the Treasury as relevant to NHS Trusts in England. Opinion on other matters In our opinion: the parts of the Remuneration and Staff Report subject to audit have been properly prepared in accordance with the accounting policies directed by the Secretary of State with the consent of the Treasury as relevant to NHS Trusts in England; and the other information published together with the audited financial statements in the Annual Report and Accounts is consistent with the financial statements. Matters on which we are required to report by exception We are required to report to you if: in our opinion the governance statement does not comply with the Department of Health Group Accounting Manual 2016/17; or we refer a matter to the Secretary of State under section 30 of the Local Audit and Accountability Act 2014 because we have reason to believe that the Trust, or an officer of the Trust, is about to make, or has made, a decision which involves or would involve the body incurring unlawful expenditure, or is about to take, or has begun to take a course of action which, if followed to its conclusion, would be unlawful and likely to cause a loss or deficiency; or Annual Report

68 PAGE 66 we issue a report in the public interest under section 24 of the Local Audit and Accountability Act 2014; or we make a written recommendation to the Trust under section 24 of the Local Audit and Accountability Act We have nothing to report in respect of the above responsibilities. Other matters on which we report by exception - adequacy of arrangements to secure value for money Basis for qualified conclusion We are required to report by exception if we conclude that we are not satisfied that the Trust has made proper arrangements to secure economy, efficiency and effectiveness in the use of resources for the year ended 31 March In considering the Trust s arrangements for securing sustainable resource deployment, we identified the following matters: the Trust was rated Inadequate by the Care Quality Commission in a report issued in August 2016, based on an inspection visit conducted in February/ March 2016; the Trust incurred a deficit of 2.4 million in 2016/17 against a planned deficit of 15.2 million. This resulted in a cumulative deficit of 15.6 million as at 31 March 2017; the Trust incurred agency expenditure of 40.1 million in 2016/17 against planned expenditure of 29.9 million. This represented an increase on the prior year figure ( 36.4 million) and exceeded the agency ceiling set by NHS of 23.1 million; the Trust did not meet all of its core performance targets, most notably the Accident and Emergency Wait target, for which annual performance was 82.2% against a national average of 89.1 %, with 12-hour waits increasing to 787 from 202 in the prior year; and the Trust s two year operational plan includes a challenging efficiency programme of 21 million per year and a requirement for interim revenue support to support cashflow of 25 million per year during 2017/18 and 2018/19. On the basis of our work, with the exception of the matters reported above, we are satisfied that, in all material respects, Pennine Acute Hospitals NHS Trust put in place proper arrangements for securing economy, efficiency and effectiveness in its use of resources for the year ending 31 March Certificate We certify that we have completed the audit of the accounts of Pennine Acute Hospitals NHS Trust in accordance with the requirements of the Local Audit and Accountability Act 2014 and the Code of Audit Practice. Robert Jones for and on behalf of KPMG LLP, Statutory Auditor Chartered Accountants 1 St Peter s Square Manchester M2 3AE 30 May 2017

69 PAGE 67 Quality Accounts Report Annual Report

70 PAGE 68 PART Statement on Quality on behalf of the Board Welcome to our Quality Account Report which describes the progress the Trust has made during the year This report is a public document. It summarises how the Trust has performed in relation to a number of important national and local clinical performance standards and key quality and patient safety indicators over the last year. These standards include key areas around patient experience that are important to patients and their families who choose to be treated and cared for across the four hospitals run by the Trust and by our staff who work out in the community and in people s homes. The report also describes the developments and progress that has been made against key quality indicators, and outlines the proposed next steps for improvement and priorities in 2017/18. Where possible, we have made comparisons with other Trusts, and/or our own performance in previous years in order to monitor progress. Part 1 introduces the Quality Account and the Trust. Part 2 identifies the Trust s quality priorities for next year, three in each of the three domains of quality: patient safety; clinical effectiveness; and patient experience. It also includes the statutory statements of assurance from the Board of Directors. Part 3 reports the Trust s progress in relation to the nine quality priorities that were described in last year s Quality Account. It then reports the Trust s performance in relation to NHS England s core quality indicators. Although it has not been specifically requested, we have also reported on the following national quality standards: Referral To Treatment (RTT) times Diagnostic waiting times A&E waiting times Cancer waits 2/52; 31/7; 62/7; Mixed-sex breaches Cancelled operations CQC Rating In August 2016, the Care Quality Commission (CQC) published its report and findings following its inspection of the Trust in February and March The Chief Inspector of Hospitals for England gave the Trust an overall rating as Inadequate. Although the CQC inspectors mostly saw Trust staff treating patients in a compassionate and sensitive way, they reported concerns about the systems and procedures that are in place to keep people safe and free from harm. The CQC can give one of four ratings to Trusts and its services: Outstanding, Good,, or Inadequate. A team of CQC inspectors found the Trust provided services that were Good for Caring, but were deemed overall Inadequate for being Safe and Well-Led, and to be Effective and Responsive.

71 PAGE 69 The CQC inspected all four of PAHT s hospitals and community services and rated them as: Rochdale Infirmary rated Good Fairfield General Hospital in Bury rated North Manchester General and The Royal Oldham Hospitals rated Inadequate All community services rated Good across all CQC domains Outstanding rating given for Caring in the community End of Life Service Outpatients, x-ray and diagnostic services rated Good across all hospital sites Our priority has been to keep key services running safely and to ensure patients receive good safe treatment in a timely manner. We have been very open and honest since the CQC published its report. We believe the report held up a mirror for us to see what was happening and reflected what many staff across the organisation had been saying for some time: that there were issues relating to staffing pressures, systems which didn t allow the Board of Directors to understand risks experienced on a ward or department, and a culture which began to tolerate inappropriate standards or behaviours. The issues identified here at Pennine could occur in any organisation if allowed to go un-checked. Evidence shows that staff are best placed to know what needs to be done to improve their ward or department. As Chief Executive of Salford Royal Hospital, one of only seven Trusts in the country to be rated outstanding by the CQC, since joining Pennine I, together with my senior team, have been listening to staff and using Salford s systems, experience and learning to help support staff across this Trust to drive the improvements and changes that are necessary to ensure services are of high standard and are safer, more reliable and sustainable for the future. Journey We did not wait for the publication of the CQC s report in August 2016 to put an improvement plan in place to support staff and patients. Our priority has been to keep key services running safely and to ensure patients receive good safe treatment in a timely manner. Since April 2016, real improvements and encouraging progress have been made. A comprehensive improvement plan is being implemented in response to both the CQC report and the diagnostic review and assessment undertaken by Salford Royal NHS Foundation Trust. The Pennine Acute Trust s Plan was approved by the CQC and endorsed by the Pennine Board, chaired by Jon Rouse, Chief Officer of Greater Manchester Health and Social Care Partnership, and PAHT s Board of Directors on 17 October The plan aims to deliver improvements across a range of services and areas to ensure services run by the Trust are safer, more reliable, efficient and effective. The plan sets out the immediate improvement actions that have needed to be taken to stabilise services and to create the right conditions upon which the Trust can continue to improve. Annual Report

72 PAGE 70 The CQC s 77 Must Do and 144 Should Do actions in its report have been mapped to the themes and deliverables contained within our Plan. The impact of the actions on patient care, outcomes and staff are being monitored and assessed through measurement dashboards. These 15 high level metrics are linked under the five CQC domains of: Safe, Effective, Caring, Responsive and Well-Led. The high level indicators that are being measured include national performance standards of care and performance at each hospital site, for example, mortality rates, number of cardiac arrests, reported pressure ulcers, Serious Incidents & Postpartum Haemorrhage, length of stay for elective patients, readmissions, formal complaints, staffing levels and staff absence, cancelled appointments, and median time from A&E arrival to admission and also to treatment. All actions in the Plan are integrated into these six main improvement themes: Improving Fragile Services: stabilising staffing across Urgent Care at NMGH, Maternity Care, Paediatric, Critical Care; new models of care where needed Improving Quality: Improving Safety, Effectiveness, Patient Experience; large-scale improvement learning collaboratives focusing on key clinical areas and patient care Improving Risk & Governance: implementation of new risk and governance arrangements to protect patients; review of all safeguarding systems and processes Improving Operations & Performance: focus on improving data quality, patient flow systems, pathway management, models of care Improving Workforce and Safe Staffing: focus on safe staffing levels. Greater emphasis on staff engagement, recruitment and retention Improving Leadership & Strategic Relations: clinical leadership development and strengthening local hospital operational management with triumvirate structure for each site with lead doctor, nurse, manager underpinned by a governance accountability framework. Stabilising fragile services It is recognised that these improvements cannot be done in isolation; we are working closely and positively with our health and social care partners across Greater Manchester to look at ways to strengthen medical and nurse staffing, strengthen models of care, and support frontline staff. Effort to support improvements in our emergency and maternity departments is great evidence of how our new devolution arrangements across GM are working for the benefit of patients. During 2016/17 the Trust has focused on stabilising key fragile services and strengthening areas that need attention, but also to build on some of Pennine s specific strengths and examples of best clinical service models and delivery. This includes the integrated care and Oasis medical dementia unit at Rochdale, integrated and community services at North Manchester, Community End of Life Care, and the specialist Stroke Service at Fairfield General Hospital. The Trust improvements are part of wider North East Manchester and City of Manchester sector development that includes out of hospital care, community and primary care, and the way that services are commissioned. Strengthening Leadership A number of key appointments have been made at the Trust since April 2016 to strengthen senior leadership at Board and Executive Director level and to support the development of a site-based leadership model for each hospital and our community services.

73 PAGE 71 The implementation of our new site-based leadership teams for our hospitals and locality areas is critical to our improvement journey where operational decisions, ownership and accountability for managing our services will be strengthened through this new structure. The additional leadership of a medical, nursing, finance and managing director at a local level will drive quality improvement on a local site basis at a more impactful pace. The priority is for all of the Trust s services to meet the high standards that patients expect and deserve. With the commitment and involvement of staff and close working with partner agencies across each locality, and through the delivery of the Pennine Plan and Quality Strategy, the Trust is determined that it can achieve great things so that PAHT, like Salford Royal, becomes one of the best and safest NHS Trusts in the country. I am convinced and optimistic that we will become stronger as a result of the CQC report. I am delighted to have been asked to lead the Pennine Acute Trust on this improvement journey, uniting it with colleagues at Salford Royal, and look forward to reporting the improvements that our staff will have made in next year s Quality Account report. The quality priorities and key indicators set out in this report have been measured using our internal information systems and processes, including information that we have submitted externally, as well as information from participation in national NHS surveys. Our governance and assurance structure ensures that all such information is reviewed and monitored throughout the year To the best of my knowledge, the information in this document is accurate. Sir David Dalton Chief Executive 1.2 Introduction Quality Accounts are annual reports to the public from providers of NHS healthcare services about the quality and standard of services they provide. They are required by Government to help NHS Trusts, including providers of hospital acute services, community health services and mental health services, maintain focus and improve the quality of care for patients. 1.3 Purpose of a Quality Account Quality Accounts have become an important tool for strengthening accountability for quality within NHS Trusts and for ensuring effective engagement of Trusts Boards of Directors in the quality improvement agenda. By producing a Quality Account, Trusts are able to demonstrate their commitment to continuous evidence-based quality improvement and to explain their progress to patients and their families, the public and those who have an interest in the services that the Trust provides. This report is the eighth Quality Account published by The Pennine Acute Hospitals NHS Trust. 1.4 How the Quality Account was produced We have welcomed comments from staff, our external partners and patient representatives on what information should be included in this year s Quality Account report in addition to the mandated content as set by the Department of Health. Production of the report has been overseen by our Chief Nurse, Director of Governance, and other senior staff. The outline content was approved by the Executive Quality and Patient Experience Governance Committee in February The final version of the Quality Account report was approved and ratified by the Audit Committee, on behalf of the Board of Directors on 24 May Annual Report

74 PAGE About the Trust As one of the largest Trusts in the country, it is our responsibility to develop and deliver high quality healthcare services around the needs of our patients, their families and the communities we serve. Our patients come primarily from the communities of Bury, Prestwich, North Manchester, Oldham, Heywood, Middleton, Rochdale and parts of East Lancashire. Our population of approximately 820,000 is demographically diverse and is spread across both urban and rural landscapes including some significant areas of deprivation. Some of our patients face health inequalities, and chronic disease. Our staff are highly committed, skilled and professional. We employ around 9000 staff. Our services include hospital services at North Manchester General Hospital in Crumpsall, Fairfield General Hospital in Bury, The Royal Oldham Hospital, and Rochdale Infirmary. We also run the Floyd Unit (neurological rehabilitation) at Birch Hill Hospital in Rochdale. We also provide a range of community and integrated healthcare services across the north part of the city of Manchester, and integrated healthcare and intermediate tier services across Heywood, Middleton and Rochdale. We have three NHS contracts for acute, community and specialist services, which detail commissioning requirements in terms of finance, activity, performance and quality. In addition, a number of specialist services previously included in the acute contract continue to be migrated into the Trust s contract with the North West of England Specialised Commissioning Group. Our Vision Saving Lives, Improving Lives improving the health and wellbeing of the people and communities that we serve. This is delivered by working with our partner agencies and particularly our local clinical commissioning groups (CCGs). These are NHS Oldham, NHS Heywood, Middleton and Rochdale, NHS Bury and NHS Manchester. Our CCGs are led by local family doctors (General Practitioners) and they commission (purchase) services from the Trust and other healthcare providers for their local populations. They are responsible for deciding what services are commissioned and how local taxpayers money is spent on healthcare services. Our Values guide every action we take. They determine how we work and the promise we make to our patients, their families, the public and each other as colleagues. Our vision is driven by three key Trust values. We are: Quality Driven, Responsible, Compassionate. Our Strategic Goals.support our vision. We have developed Strategic Goals along six domains: 1. Our services - to provide excellent care to our patients in our hospitals and community services; 2. Partnerships - to work with our partners and local people to build resilient and sustainable local services for the communities we serve; 3. People to support our staff to provide the best care by developing their skills and nurturing their talent; 4. Leadership - to support values-based leadership which role models the behaviours we expect from everyone; 5. Quality, governance and performance to achieve high reliability and high performance across all of our services; 6. Sustainability - to deliver strong productivity which will ensure financial sustainability

75 PAGE 73 Our Corporate Priorities set the overall direction for the Trust, both in terms of how our services are delivered and the expectations on our staff. Quality of care and patient safety is the cornerstone of everything we do and everything our staff believe in. Our Trust priorities for are rolled from previous years, as set out below: Pursue quality improvement to assure safe, reliable and compassionate care To deliver financial plan to assure sustainability To support our staff to deliver high performance and improvement To improve care and services through integration and collaboration To demonstrate compliance with mandatory standards Annual Report

76 PAGE 74 PART Priorities for In August 2016, the Care Quality Commission rated our clinical services as inadequate. This is a significant challenge to us all but Pennine has some of the most talented staff in the NHS and the new Quality Strategy aims to provide a framework for which these dedicated staff can band together and improve broken systems and processes of care that are letting us and our patients down. In March 2016 a new era dawned at Pennine Acute Hospitals NHS Trust, with the opportunity to join a new collaboration with Salford Royal NHS Foundation Trust. This move opened new opportunities for collaboration and improvement and coupled with robustly executed service development, organizational cultural development and governance plans, the Pennine staff will turn promises of improvement into results. Several comprehensive diagnostics have taken place in the last two years and these have informed the creation of a new QI strategy for Pennine. This includes the CQC report that incorporated the views of patients and other stakeholders. The priorities for 17/18 are the main aims of the Quality (QI) strategy, which is currently in consultation with frontline staff. After they have had a chance to shape the detail of the strategy, we ll be ready to publish and move ahead with implementation. Here, we present the aims of the strategy, which will also be our priorities for the reporting period. This strategy has been designed to harness the expertise of frontline staff and will be focused on building QI capability to staff and leadership both medical and non-medical. It is built on the knowledge that our staff are the best asset we have and we aim to provide the tools and space for learning, collaboration and improvement that will see our staff transform this Trust from inadequate to good. What we aim to Improve Aim: NO AVOIDABLE DEATHS As measured by: HSMR, SHMI (these are standardised measures of mortality that show the number of actual deaths against the number of expected deaths - based on certain criteria. For more information please see section 3.3.1) of reliability in recognising deterioration of first 48 hour care standards We will aim specifically to improve recognition and treatment of the deteriorating patient. This will include increasing reliability to existing deterioration detection systems to reduce cardiac arrests and increase early treatment of patients with sepsis. The first 48 hours of an emergency admission are crucial, and by redesigning our emergency pathways in the first 48 hours, we will ensure patients receive systematic review by the right clinicians during this critical timeframe. In addition, we aim to ensure that pathways are in place to address the unique needs of the frail elderly population.

77 PAGE 75 Aim: As measured by: REDUCE HARM TO PATIENTS Patient safety thermometer and locally created measures for: pressure ulcers, venous thromboembolism, catheter associated urinary tract infections, falls Harm is suboptimal care which reaches the patient either because of something we shouldn t have done or something we didn t do that we should have done. Hospital acquired infections, pressure ulcers, catheter related UTI s and inpatient falls are examples of harm which are commonplace. Despite the extraordinary hard work of healthcare professionals patients are harmed in hospitals every day. Fortunately catastrophic events are rare but we must acknowledge that unintentionally a significant number of our patients experience some harm. Our first priority is being open about errors and adverse events with our patients and families. Shedding light on these problems will allow us to join together to build systems to avoid the unintended consequence of patient harm. We will focus on testing and implementing harm reduction strategies that have been successful elsewhere, including a focus on appropriate antibiotic prescription, as well as working with frontline staff to create harm reduction interventions fit for Pennine. Aim: As measured by: IMPROVE RELIABILITY TO KEY PATIENT PATHWAYS The measures of improvement will depend upon the specific areas of improvement chosen once the pathways are mapped, and will be identified at that point. It is widely acknowledged that aspects of health care do not perform as well as they should. Studies have shown that there is inconsistency in the delivery of high quality care and that patients often only receive a fraction of the care that is recommended. Reliability science can help health care providers redesign systems to make sure more patients receive all the elements of care they need. We will use the principles of reliability science to underpin our approach to reducing harm and avoidable mortality and in the following pathways in particular: maternity and frailty. Measurement, monitoring, and reporting All of our improvement projects follow a structure which monitors and measures performance using measurement for improvement principles and defined at the outset in a project initiation document. Progress is reported to the Executive Quality and Patient Experience Committee, chaired by the Executive Nurse Director. Annual Report

78 PAGE Statements of Assurance from the Board of Directors Review of Services In , The Pennine Acute Hospitals NHS Trust provided and/or subcontracted 58 NHS services, as shown in the table below. Division of Medicine Acute Medicine Cardiology (includes coronary care) Clinical Haematology Diabetes and Endocrinology Elderly Care-acute General Medicine Infectious diseases Oncology (includes tumour chemo for breast, gynaecology & colorectal) Respiratory Stroke ( inpatient & OPD) Urgent Care (A&E) Division of Surgery & Anaesthetics Anaesthetics Breast Colorectal Surgery Critical Care Ear, Nose and Throat Surgery Gastroenterology General Surgery (including acute surgery) Maxillofacial Specialist Dental (including orthodontics) Trauma and orthopaedics Urology Vascular Support Services Division Anticoagulant Services Chemotherapy Services Main Outpatients Neurophysiology Pathology Pharmacy Radiology Integrated and Community Services Division Community nursing Audiology, Diabetes, Urgent/Crisis Response (including IV therapy) Care of the Elderly Expert patient programme Falls prevention Specialist Palliative care, Intermediate Care and Re-ablement Neuro Rehabilitation and stroke Nutrition and Dietetics Dementia care Occupational Therapy Ophthalmology Orthoptics, Orthotics, Pain Medicine Respiratory Physiotherapy Podiatry Rheumatology Sexual health Speech and language therapy Urgent Care UCC and CAU Women s and Children s Division Midwifery Gynaecology & Obstetrics Neonatology Paediatrics.

79 PAGE 77 The Pennine Acute Hospitals NHS Trust has reviewed all the data available to them on the quality of care in all of these NHS services. The Trust acknowledges that the review of some services is varied, but has defined review of services as having participated in one of more of the following reviews: Clinical audit activity national and local Cancer Quality Assurance process (formerly Cancer peer review) may be internal validated or external. CQUIN schemes Review of clinical data e.g. outcomes, Dr Foster, external submissions, internal dashboards Staff or patient surveys CCG review Service Audit Cancer QA CQuIN Clinical data collection Surveys Acute Medicine Anaesthetics Anticoagulant Services Audiology Breast Cardiology (includes coronary care) Care of the Elderly Chemotherapy Services Clinical Haematology Colorectal Surgery Community nursing Critical Care Dementia care Diabetes and Endocrinology Diabetes (community) Ear, Nose and Throat Surgery Elderly Care-acute Expert patient programme Falls prevention Gastroenterology General Medicine General Surgery (including acute surgery) Gynaecology & Obstetrics Infectious diseases Intermediate Care and Re-ablement Main Outpatients Maxillofacial CCG review Annual Report

80 PAGE 78 Service Audit Cancer QA CQuIN Clinical data collection Surveys Midwifery Neonatology Neuro Rehabilitation and stroke Neurophysiology Nutrition and Dietetics Occupational Therapy Oncology (includes tumour chemo for breast, gynaecology & colorectal) Ophthalmology Orthoptics, Orthotics, Paediatrics Pain Medicine Pathology Pharmacy Physiotherapy Podiatry Radiology Respiratory Respiratory (community) Rheumatology Sexual health Specialist Dental (including orthodontics) Specialist Palliative care, Speech and language therapy Stroke ( inpatient & OPD) Trauma and orthopaedics Urgent Care UCC and CAU Urgent Care (A&E) Urgent/Crisis Response (including IV therapy) Urology Vascular CCG review The income generated by the NHS services reviewed in represents 100% of the total income generated from the provision of NHS services by The Pennine Acute Hospitals NHS Trust for

81 PAGE Participation in Clinical Audit National clinical audits are commissioned by the Healthcare Quality Partnership (HQIP) which manages the National Clinical Audit and Patients Outcome Programme (NCAPOP). Priorities for the NCAPOP are set by the Department of Health with advice from the National Clinical Audit Advisory Group (NCAAG). Audits are largely funded directly by the Department of Health, but some are funded from subscriptions paid by NHS provider organisations. National confidential enquiry is a form of national clinical audit and is a method of assessing the quality of care to help identify potentially avoidable factors that are known to be associated with adverse outcomes. Undertaking clinical audit and acting on findings is a way of improving the quality of care we provide to patients, and the Trust aims to participate in all relevant audits. During national clinical audits and four national confidential enquiries covered NHS services that the PAHT provides. During that period, the Trust participated in 100% of the national clinical audits and national confidential enquiries, of the national clinical audits and national confidential enquiries which it was eligible to participate in. The national clinical audits and national confidential enquiries that the PAHT was eligible to and did participate in, and for which data collection was completed during , are listed below alongside the number of cases submitted to each auditor enquiry as a percentage of the number of registered cases required by the terms of that audit or enquiry. Service Peri and Neo-natal Children Acute Long-term Conditions Name of audit / focus area % of cases submitted 1. Neonatal intensive and special care (NNAP) Maternal, New-born and Infant Clinical Outcome Review Programme (MBRRACE-UK) Child health clinical outcome review programme (NCEPOD) Paediatric Pneumonia (BTS)* 100 (to date) 5. ICNARC (Case Mix Programme) Medical and Surgical Clinical Outcome Review Programme (NCEPOD)* National Emergency Laparotomy Audit (NELA) National Joint Registry (NJR)* Stress Incontinence Audit* Diabetes (National Adult Diabetes Audit) Diabetes (National Paediatric Diabetes Audit) Inflammatory bowel disease (IBD) programme* National Chronic Obstructive Pulmonary Disease (COPD) Audit Programme* Rheumatoid and early inflammatory arthritis* Adult Asthma (BTS)* Learning Disability Mortality Review Programme (LeDeR)* 100 Annual Report

82 PAGE 80 Service Elective Procedures Cancer Cardiovascular Disease Name of audit / focus area % of cases submitted 17. Elective Surgery (National PROMs Programme)** National Ophthalmology Audit *** Nephrectomy Audit* Percutaneous Nephrolithotomy (PCNL)* Endocrine & Thyroid National Audit TBC **** 22. Bowel cancer (NBOCAP) ***** Head & Neck Audit* Lung cancer (NLCA) Oesophago-gastric cancer (National Audit O-G Cancer) National Prostate Cancer Audit (CEU-RCSE) Acute coronary syndrome or Acute myocardial infarction (MINAP) Cardiac Rhythm Management (CRM) Coronary angioplasty / National Audit of PCI (NICOR) National Cardiac Arrest Audit (ICNARC)* National Heart Failure Audit (NICOR)* National Vascular Registry 100 Blood 33. National Comparative Audit of Blood Transfusion programme Falls and Fragility Fractures Audit Programme (FFFAP) 100 Older People 35. Sentinel Stroke National Audit Programme (SSNAP) National Dementia Audit Major Trauma (Major Trauma and Research Network) 100 Trauma 38. Adult Asthma Care - Emergency Department (RCEM)* Severe Sepsis & Septic Shock (RCEM)* 100 * The Trust has registered to participate and is awaiting publication of the audit results. ** PROMs (Patient Reported Outcome Measures) is a project that measures a patient s health-related quality life following surgery using pre and post-operative surveys. As patients can choose whether to participate in PROMs, the percentage represents the take-up rate rather than the percentage of cases submitted by the Trust. In addition the information provided is from 1st April to 30th November 2016 (as no further data is available). *** The first report was published April 2016 and was based on historic data providing a mechanism for refinement of the methodology. Information included in this initial report is limited as the audit is in a developmental phase. Following the first prospective data collection period covering surgery undertaken from September 2015 to August 2016, full reporting will come into effect. This will include case complexity adjusted outcomes for surgical complications and visual acuity loss from cataract surgery for named consultant and independent surgeons, and for named surgical centres. This report is currently awaiting publication therefore case ascertainment will only be available at this point. **** Late registration and data submission awaiting confirmation from national team. ***** Percentage calculated against the number of expected cases based on historic HES data.

83 PAGE 81 NCEPOD Cases Submitted Cancer in young children, teens and young adults 100% Adolescent mental health 100% Chronic Neurodisablity 100% Non-invasive Ventilation 100% List of acronyms to the above tables BTS British Thoracic Society CEU Clinical Effectiveness Unit COPD Chronic Obstructive Pulmonary Disease CRM Cardiac Rhythm Management FFFAP Falls and Fragility Fracture Audit programme IBD Inflammatory bowel disease ICNARC Intensive Care National Audit & Research Centre MINAP Myocardial Ischaemia Audit & Research Centre MBRRACE Mothers and Babies: Reducing Risk through Audits and Confidential Enquiries in the UK NBOCAP National Bowel Cancer Audit Programme NCEPOD National Confidential Enquiry into Patient Outcome and Death NELA National Emergency laparotomy Audit NICOR National Institute for Cardiovascular Outcomes Research NJR National Joint Registry NLCA National Lung Cancer Audit NNAP National Neonatal Audit Programme O-G Oesophago-gastric PCNL Percutaneous Nephrolithotomy PROMs Patient Reported Outcome Measures RCEM Royal College of Emergency Medicine RCSE Royal College of Surgeons of England SSNAP Sentinel Stroke National Audit Programme National Clinical Audits with low percentage data submission Data submission to the inflammatory bowel disease audit has proven difficult during 2016 and the IBD Clinical Lead expressed concerns relating to the directorate s inability to provide sufficient data to this national audit. His concerns around this were highlighted to, and discussed with, the Clinical Director and Medical Director in December 2016 where potential solutions were explored to improve compliance and quality in These include: An MDT alongside Biologics clinic to safely manage the complex cohort and use the limited resources to their full potential. An investment in recruiting three IBD nurses. An IBD Registry (the Trust registered in March 2017). The above issues have subsequently been added to the directorate s risk register. Annual Report

84 PAGE 82 The data submission to the National Patient Reported Outcome Measures (PROMs) Programme has increased from 26% in 2015/16 to 63% in 2016/17, although this is not as expected there continues to be changes made across the Trust in the reduction of patients attending pre-operative assessments. The orthopaedic directorate is currently recruiting patients both at pre-operative assessment and on the day of surgery and the process will be monitored against expected case submission. Learning from National Clinical Audits The reports of 19 national clinical audits were received by the Trust in and have been reviewed. The Pennine Acute Hospitals NHS Trust has taken or intends to take the following actions to improve the quality of healthcare provided. Key findings NATIONAL BOWEL CANCER AUDIT The 2016 Annual Report is the seventh report produced and includes data on over 30,000 patients diagnosed with bowel cancer between 1st April 2014 and 31st March The Trust has submitted 101% of its cases to the national audit. Pre-treatment staging was documented in 88% of cases. Performance status was documented in 100% of cases. 100% were seen by clinical nurse specialist. Laparoscopic surgery was attempted in 75% of cases compared to 53% regionally and 61% nationally. The Trust s adjusted 90-day unplanned readmission rate was 9.9% compared to 10.3% regionally and 10.1% nationally. The Trust s adjusted 18 month stoma rate was 58% and this is comparable with the region and nationally, where the stoma reversal rate was 50%. The Trust s 90 day mortality rate was 7.8% compared to 4.7% regionally and 3.8% nationally. The Trust s 2 year mortality rate was 24.9% compared to 22.5% regionally and 20.9% nationally. 2011, the two year mortality rate has fluctuated between 33.9 and 22%. In comparison to the 2013/2014 period there has been a 2.9% increase against the national figure, which itself has shown a reduction of 1.1%. Response The audit was presented at the Upper & Lower GI Audit & Governance meeting in March 2017 and the final action plan was completed by 31st March This included: Review measures to admit patients on day of surgery potentially reducing LOS by 33% (as the Trust is currently an outlier in terms of local peers). s to be made on the documentation of permanent stoma to reduce the APER (abdomino-perineal excision of the rectum) rate. Reviews of historic practice in terms of neo-adjuvant treatments will be undertaken as the Trust has a higher rate than nationally reported (although 1/3 higher participation figures than its peers). Colleagues asked to look at practice and assess. Review of the deaths during will be undertaken. This is crucial to investigate this further; findings to be disseminated and shared to ensure continual improvement.

85 PAGE 83 Key findings NATIONAL OESOPHAGO-GASTRIC CANCER AUDIT The National Oesophago-Gastric Cancer Audit 2016 Annual Report describes the care received by patients diagnosed with High Grade Dysplasia (HGD) and Oesophago-Gastric (OG) cancer between 1st April 2013 and 31st March 2015, and their outcomes. The Trust submitted more than 90% of its cases to the audit. The proportion of patients with an initial staging CT scan recorded was 81% for the Trust compared to 87% nationally. The Trust provides initial treatment and those patients requiring surgical intervention are seen at Salford Royal Foundation NHS Trust. Response The results of the audit were published in November 2016 and have been reviewed by the multi-disciplinary team. They have developed an action plan set against the national recommendations. Regular updates against the plan will be provided at the MDT meetings. In addition, the Trust patients are submitted to the national database via Salford. NATIONAL LUNG CANCER AUDIT The Trust compared favourably nationally and against peers in the local network, particularly in relation to discussion at MDT, and being seen by a cancer nurse specialist. NATIONAL PROSTATE CANCER AUDIT Discrepancies in the published data for the Trust have resulted in a review of the national data set. The Trust is working with the national prostrate cancer audit team to identify why only 319 patients data, of the 525 submitted, have been uploaded to the national dataset. Public Health England s National Cancer Registration and Analysis Service (NCRAS) have identified that all 525 patients submitted by Pennine Acute Hospital NHS Trust for April 2014-March 2015 are in the NPCA dataset, and that all these men had RW6 as a provider coded in at least one their records. However, it was not always possible to recognise the Pennine Acute Hospitals as the diagnosing Trust due to the shared pathways (CMFT & Christie are radical care providers). The NCRAS team is working with the Trust to revise the means of defining the Trust where a patient was diagnosed, and the corresponding date of diagnosis, for the purpose of the NPCA. This approach will take account of all the records for each individual patient. The Trust continues to validate its data prior to submission, and is committed to continuing to make improvements against the national findings. In terms of actions at a local level, the clinical audit team is collating the audit results at a local level for the 300+ cases that did make it into the audit. These findings can assist in a provisional action plan and an early indicator for potential concern areas. The team are still in the process of reviewing the findings and are concentrating on any area that did not match to the national average. The team is also reviewing data recording at a local level, to identify any solutions, which include the possibility of data be overwritten. The Trust s urology cancer lead has contacted the NPCA lead with concerns that the wrong information depicts the Trust against peers incorrectly, and to enquire about a retraction from the public domain. The national lead has acknowledged the comments and is working to provide a solution. Annual Report

86 PAGE 84 Key findings NATIONAL DIABETES INPATIENT AUDIT The audit sets out to measure the quality of diabetes care provided to people with diabetes while they are admitted to hospital Prevalence People with diabetes occupied 16.1% of PAHT beds. 7.0% had Type 1 diabetes and 16.9% had insulin treated Type 2 diabetes. 90.7% of inpatients with diabetes had been admitted as an emergency. Patient contact 30.0% of inpatients with diabetes were seen by a member of the diabetes team, compared to 35.8% nationally. Of 30.0% of patients, 60.0% had been seen by the multidisciplinary diabetic foot team within 24 hours of admission compared to 58% nationally. Staffing 43.6% of diabetes consultants time was spent on the care of patients with diabetes 43.6% of diabetes specialist nursing time was spent on the care of patients with diabetes Medication errors and patient harm 31.7% of PAHT patients drug charts that were reviewed had at least one or more medication error; 14.9% had at least one prescription error; and 25.2% of patients with diabetes experienced at least one management error compared to 38.1% nationally. Of the patients who were on insulin, 16.7% experienced one or more insulin (prescription or management) error, compared to 22.6 nationally 7.4% of inpatients with diabetes had been on an insulin infusion in the last 7 days. 26.6% of inpatients had mild hypoglycaemic episodes, which is comparable nationally. 10.2% had severe hypoglycaemic episodes during the stay, compared to 9.9% nationally. Foot disease and foot risk assessment Of inpatients that were admitted specifically for the management of their diabetes or a diabetic complication, 23.5% were admitted with an active foot ulcer. 44.7% had a risk assessment received within 24 hours of admission to PAHT compared to 28.7% nationally. Response The team has been asked to develop an action plan which can be transposed to site based working. There is now a diabetic steering group who will be responsible for monitoring improvements in diabetes across the Trust. The Trust has recruited additional members of staff to the diabetes nursing team. Since the publication of this report 40.6% of patients are seen by a member of the diabetes team compared to 34.1% nationally.

87 PAGE 85 Key findings NATIONAL DIABETES IN PREGNANCY The results of the third annual report, which was published in October 2016, identified key findings in a number of areas for the Trust against national results, one being that few women were prepared for pregnancy in the ways recommended in the NICE guideline NG3: Nationally 15.5% of women with type1 diabetes had first trimester HbA1c <48mmol/mol recorded: as there were fewer than 10 patients for PAHT, no value is available. Response The results of the audit have been sent to the sites leads, and were presented at the Obstetrics & Gynaecology audit meeting on 15th March The team has requested site-based data to identify specific areas for improvement and to develop action plans. Nationally 35.8% of women with type 2 diabetes had first trimester HbA1c <48mmol/mol recorded the Trust had 26.4% recorded. The Trust results highlight that we are not meeting at least the national targets of 15.5% for type 1 and 35.8% for type 2 diabetes Nationally 40.3% of women with type1 diabetes had a 24 weeks plus HbA1c <48mmol/mol recorded: the Trust recorded 21.6%. Nationally 72.9% of women with type2 diabetes had a 24 weeks plus HbA1c <48mmol/mol recorded, the Trust had 60.6% recorded. The Trust results highlight that we are not meeting at least the national targets of 40.3% for type1 and 72.9% for type2 Nationally 52.7% of women with type1 diabetes had first contact with antenatal team; the Trust recorded 72.2%, performing well above the national level Nationally 36.5% of women with type2 diabetes had first contact with antenatal team; the Trust had 42.2% recorded, performing just above the national level Nationally 44.5% of women with type1 diabetes were taking 5mg folic acid prior to pregnancy, the Trust recorded 43.6% Nationally 23.1% of women with type2 diabetes were taking 5mg folic acid prior to pregnancy, the Trust recorded 25.3% Annual Report

88 PAGE 86 Key findings NATIONAL PAEDIATRIC DIABETES AUDIT 95.1% of the patients attending PDU at PAHT have type I diabetes 2.3% of the patients attending PDU at PAHT have type II diabetes In the remaining 2.6% cases they attended the PDU for other reasons or this data was incomplete. 80.8% of the patients attending PDU at PAHT are screened for thyroid disease Median HbA1c for patients attending PDU at PAHT is 69mmol/ mmol The 12th report demonstrates continued improvement in outcomes. It also highlights that current strategies in place are helping improve outcomes. NATIONAL HIP FRACTURE DATABASE 2015 In total the Trust has submitted 737 cases to the national database (358 cases from NMGH and 379 cases from TROH). Admitted to orthopaedic ward within 4 hours: NMGH 45.2%; TROH 40.3%; national 43.9% Mental test score completed on admission: NMGH 98.9%; TROH 98.4%; national 94.8% Perioperative medical assessment: NMGH 98%; TROH 93.9%; national 87.5%. Mobilised out of bed on the day after surgery: NMGH 64.5%; TROH 96.7%; national 76.1% Received falls assessment: Response The results have been discussed at the divisional quality & performance committee. The results to be benchmarked against practices of care where high levels of performance have been found. Continue to work with the network and quality assurance (peer review) to support achieving quality improvements across the service. As a result of this audit the sites have reviewed their individual reports and have developed action plans to improve where possible the areas that don t meet the expected BPT standards. This includes ensuring that patients are mobilised out of bed the day after surgery and review of the pathway to ensure patients are admitted to an orthopaedic ward to meet the 4 hour target. Regular reviews are undertaken on the data submitted to the national dataset. NMGH 100%; TROH 99.1%; national 97% Received bone health assessment: NMGH 99.1%; TROH 98%; national 97.2% Met all criteria for best practice tariff: NMGH 45.8%; TROH 55.1%; national 65.6%. The Trust hospitals are in the lowest quartile for meeting all criteria for best practice tariff. Royal Oldham Hospital is placed in the 3rd quartile for patients being admitted to an orthopaedic ward within 4 hours of admission and having a mental test score completed on admission, whereas North Manchester General Hospital is in the 2nd quartile for these two measures.

89 PAGE 87 Key findings NATIONAL JOINT REGISTRY 2015 The results of the audit have identified that the Trust is achieving the following (expected national target of >95%): FGH % of patients were consented NMGH % of patients were consented ROH % of patients were consented Response The directorate is continuing to review the data and improve the patient pathway. Work continues supporting the clinical teams to improve the data submission in a timely manner across the Trust. % of patients consented who had a valid NHS number (the expected target is 95% nationally): FGH % NMGH % ROH NEONATAL INTENSIVE AND SPECIAL CARE 2015 The audit data covered ten key areas of neonatal care. Nationally, three demand particular attention: Two-year follow-up there has been an improvement in the rate of follow-up of very preterm babies (54% in 2014, 60% in 2015). However, there is considerable variation between networks, with the best performing network achieving recorded followup on almost three times the number of babies than the lowest performing. The report has been sent to the Neonatal Directorate leads and all the neonatologist consultants, and will be presented at the neonatal and peri-neonatal mortality meeting in May Temperature on admission more than one in four babies who had their temperature recorded within an hour after birth were too cold, a major concern given the recognised association between hypothermia and increased mortality and morbidity. Recorded consultation with parents there has been little or no overall progress since 2012 with this basic, but essential, standard of parental partnership in care. This is very disappointing, meaning that one in ten parents still did not have a recorded consultation with a senior member of the neonatal team within 24 hours of their baby s admission to the unit. Annual Report

90 PAGE 88 Key findings Response MATERNAL, NEW-BORN AND INFANT CLINICAL OUTCOME REVIEW PROGRAMME The enquiry found that in some cases diagnosis of heart disease in young women was overlooked and for others, who knew they had heart disease, care was fragmented. Nationally, over a quarter of women who died during pregnancy or up to six weeks after pregnancy died from a cardiovascular cause; the leading cause of maternal death in the UK. Nationally, the report highlighted many instances when pregnant and postpartum women had clear symptoms and signs of cardiac disease, which were not recognised because the diagnosis was not considered in a young pregnant woman. There was evidence of excluding rather than making a diagnosis in women who presented repeatedly for care. Despite blood pressure problems, pre-eclampsia and related complications being very common in pregnancy, maternal deaths from these conditions are at their lowest rate ever. Now in the UK less than one woman in every million women dies from a blood pressure disorder of pregnancy, a great success of maternity care in the UK. The report also contains messages for the future care of women with early pregnancy conditions including ectopic pregnancy and those women in pregnancy or soon after who require critical care. The report was presented and discussed at the Obstetrics and Gynaecology audit meeting on 15th March Risk triggers are already in place for pregnant women when cardiovascular problems are identified at booking. The key action is that when any pregnant woman presents with chest pain in A&E then a cardiology consultation is sought. A new pathway has been approved and is to be developed in collaboration with A&E and obstetric directorates.

91 PAGE 89 Key findings Response NATIONAL BLOOD TRANSFUSION AUDIT PROGRAMME: USE OF RED CELLS AND PLATELETS The Trust audited 33 adult patients and 46 transfusion episodes with the following results: 1. Clinical staff should measure haemoglobin prior to transfusion of red cells in haematology patients (within 24 hours for inpatients and 72 hours for day patients); The Trust achieved 92.9% (nationally 91.4%) for day patients and 100% (nationally 98.7%) for inpatients. The Trust is performing within the top 80% of hospitals. 2. Clinical staff should only transfuse red cells in normovolaemic haematology inpatients without additional risk factors (cardiovascular disease or signs or symptoms of cardiovascular compromise, severe sepsis or acute cerebral ischaemia) if their pre-transfusion Hb is less than 70g/L.; The Trust achieved 10.0% (nationally 17.1%) performance for this standard and was outside of the top 5% of hospitals. 3. Clinical staff should only transfuse prophylactic platelets in patients with a reversible cause for bone marrow failure and no other risk factors for bleeding if their pre-transfusion platelet count is below /L (within 24 hours for inpatients and 48 hours for day patients); The Trust achieved 50.0% (nationally 61.0%). 4. Clinical staff should avoid routinely prescribing prophylactic platelet transfusions to patients with irreversible chronic bone marrow failure; The Trust achieved 62.5% (nationally 42.7%) showing a high level of achievement in this standard, within the top quarter of hospitals. This shows strong support for good transfusion practice in haematology patients. 5. For patients receiving prophylactic platelet transfusions, clinical staff should prescribe no more than one adult therapeutic dose; The Trust achieved 92.3% (nationally 92.6%) The results of the audit have been shared with the blood transfusion team and clinical teams across the Trust. The findings have identified that the Trust is meeting the national standards in a number of areas and the team have identified areas for improvement in standards 2, 3 and 4. Currently the Clinical Lead and the blood transfusion team are developing an action plan to support improvements against standards 2, 3 and 4 part of which will be through blood transfusion awareness training. Annual Report

92 PAGE 90 Key findings NATIONAL VASCULAR REGISTRY 2015 At present the Trust s case ascertainment for lower limb amputation is good at just over 70%, compared to the national average of 50%. In addition the Trust s outcomes for lower limb amputations are below the national average. Pennine Acute Hospitals performs the highest number of carotid operations per year in England. Results show we are performing above average in terms of outcomes for patients having a carotid endarterectomy (CEA). Outcomes in 2015 for abdominal aortic aneurism shows the Trust is achieving good clinical outcomes and performing within our expected range for major surgical procedures. The very low case ascertainment across the UK for endovascular procedures was disappointing and it prevented the NVR from making any firm statements about the national picture. However the data Pennine Acute Hospitals submitted shows care was being delivered safely. MINAP The eighth annual report was published in January In total 1053 nstemi patients were admitted across the Trust. The key findings for the Trust were: Response In January 2017 the Vascular unit major amputation pathway was launched. A CCG healthcare professional now attends the bimonthly vascular clinical governance meetings with a positive impact by assisting in improved patient pathways. More data is being collected prospectively for entry to the NVR. A joint meeting with the stroke team took place on 2nd March As an outcome of this meeting a draft CEA shared pathway policy has been developed and distributed for comment. Local audit results are to be presented in poster form at the next UK Stroke Forum at the request of the Stroke Clinical lead for Strategic network and senate across Greater Manchester. The vascular team will continue to monitor the clinical outcomes to ensure continued sustainability in performance. The vascular team are continuing to encourage a more active approach to submitting data on endovascular lower limb procedures to the NVR. The report has been sent to the cardiology leads to develop an action plan linked to the audit recommendations. 94.2% of nstemi patients were seen by a cardiologist; 0.9% less than the national average (95.1%). Only 15.8% of nstemi patients were admitted to a cardiac ward. However, of those patients admitted directly to the hospital that has angiography capability prior to discharge, this was 92.9%; 13.1% above the national average (79.0%). Secondary medication (which includes beta blocker, ACEI or ARB, statin, aspirin, aldosterone antagonist, thienopyridine inhibitor and ticagrelor), was given to 95.1% nstemi patients; which is the same as the national average.

93 PAGE 91 Key findings NATIONAL HEART FAILURE AUDIT 2015 The purpose of this audit is to drive up standards of care during the acute admission phase to achieve better patient outcomes. This can be accomplished by capturing data on clinical indicators that have a proven link to improved outcomes, encouraging the increased use of clinically recommended diagnostic tools, implementing use of disease-modifying treatments, and by robust referral pathways. During hospital admission: 74% of patients had an echo (91.7% nationally). 44% of patients were admitted to a cardiology ward (48.1% nationally). Input from a consultant cardiologist was 32% (58.6% nationally). The number of patients seen by heart failure specialists (i.e. nurses and doctors) has decreased to 44% this year from 51%. The prescription of key disease-modifying medicines for patients with heart failure and a reduced LVEF on discharge for those patients prescribed Response The audit findings have identified a reduction in heart failure nurse input and the lead nurse has undertaken a review of the service which has resulted in a business case being put forward for the recruitment of more heart failure nurses. The ambulatory care pathway has been amended and once agreed by the team the policy will disseminated across the Trust. The Heart Failure Nurse Lead has attended directorate meetings and presented the pathway at FY2 training sessions. In addition a separate validation of the data is being undertaken linking to a lack of robust internal processes. ACEI/ARB 70% (72.2% nationally), Beta blocker 66% (85.7% nationally) MRA 42% (52.6% nationally). The number of patients who received discharge planning was 61%, (national target 87%). Cardiology follow up referral was at 42%, (national target 52.2%). Referral for heart failure nurse follow-up is 67%, (national target 57.9%): for patients with LVSD the national referral rate is 69.7% and the Trust is achieving the target of 89%. Annual Report

94 PAGE 92 Key findings NATIONAL CARDIAC RHYTHM MANAGEMENT AUDIT The aim of the CRM Audit is to examine the implant rates and outcomes of all patients who undergo pacemaker, ICD and CRT implantation procedures in the UK, against national and international standards defined by NICE and other specialist organisations. The pacemaker implant rate is at 466, both new and replacement device implant procedures across PAHT, which includes Rochdale Infirmary, Fairfield General Hospital and North Manchester General Hospital sites. There is no national target for the number of submissions but the data does look at the number of implantation activity throughout the year for implanting hospitals Response The cardiology team has reviewed the audit results and are working to ensure that their unit meets the national targets. The service identified the need for a devices implanter for the TROH and this post has been recently recruited. Providing a similar service across the Trust will increase the number of referrals and increase the number of implantations. The percentage of atrial based pacing implants, as a proportion of all new implants for sick sinus syndrome, was at 80%, which is lower than the UK national average target. The percentage of ICD implants for primary prevention is at 47%, which is 3% lower than the national target. However, the secondary prevention is at 53% and this is above the national target by just over 1%. The percentage of CRT-D implants, for primary prevention is at 53%, which is much lower than the national target by 23.9%. The secondary prevention is at 47% and this is above the national target by 24%. NATIONAL PERCUTANEOUS CORONARY INTERVENTION (PCI) AUDIT The audit of PCI is a continuous audit that collects information about all percutaneous coronary intervention procedures undertaken in all NHS hospitals and the majority of private hospitals in the UK. The Trust achieved > 98% in data completeness in all but the following two areas: weight & height not recorded in 65% of cases creatinine levels not recorded in 77% of cases The number of eligible records for arterial access has decreased by from 473 to 438 (7.4%) 32% of nstemi patients were treated with PCI within 72 hours from admission, which is lower than the national average of 54.3%. 56.9% of procedures used right or left radial access, which is lower than the national target of 75%. The team has reviewed the results and have developed an audit sheet collecting weight, height and creatinine, and follows the patient through to the Silver Heart Unit. Discussion has taken place at the cardiology specialist nurse meetings highlighting the need to complete the audit sheet in order to improve data completeness. The document is also being used for the inpatient PCI procedures. The lead nurse is monitoring the completion of the audit sheet (ensuring that the areas to support data completion are being completed).

95 PAGE 93 Key findings SENTINEL STROKE NATIONAL AUDIT PROGRAMME (SSNAP) 2016 The data submitted for stroke patients demonstrates that the Trust has provided good quality care, with all indicators being above the national average. The data is published on a quarterly basis. The following figures represent the patient centred care from August to November 2016: Directly admitted to a stroke unit within 4 hours: 88.3% (58.5% nationally). Patients who spent at least 90% of their stay on unit: 98.3% (84.8% nationally). Proportion of eligible patients according to the Royal College of Physicians (RCP) guidelines given thrombolysis 96.7% (88.1% nationally). Proportion of patients who were thrombolysed within 1 hour: 85.3% (63% nationally). Assessed by a stroke specialist consultant physician within 24 hours 98.3% (81.9% nationally). Assessed by a nurse trained in stroke management within 24 hours 97.7% (90.1% nationally). Swallow screen given within 4 hours 98.5% (74% nationally). Formal swallow assessment given within 72 hours 100% (87.2% nationally). Assessed by an occupational therapist within 72 hours 100% (91.7% nationally). Assessed by a physiotherapist within 72 hours: 100% (95.1% nationally). Assessed by a speech and language therapist within 72 hours 99.5% (89% nationally). Screened for nutrition and seen by a dietician by discharge 85.7% (83.3% nationally). Continence plan drawn up within 3 weeks 86.2% (92.0% nationally) Mood and cognition screening by discharge 99% (91.9% nationally). Receiving joint health and social care plan on discharge 100% (90.6% nationally). Treated by a stroke skilled early supported discharge team 71.5% (34.5% nationally). Response The overall level of compliance with the quality of care measures provides assurance that the Stroke Unit is providing care consistent with good practice. The team reviews the data at the Stroke Directorate meetings for information provided from the national team each quarter, and continues to act on the findings as appropriate. Annual Report

96 PAGE 94 Key findings NATIONAL EMERGENCY LAPAROTOMY AUDIT 2016 The results of the second national report, which were published in July 2016, identified the Trust had performed well in a number of areas, though some site differences were observed. Case ascertainment was poor with the Trust only achieving an average of 45% - 42% (NMGH) and 48% (TROH). CT reported before surgery: 69% NMGH; 71% TROH (83% nationally). Risk was documented before surgery: 33% NMGH; 84% TROH (64% nationally). Arrival in theatre in timescale appropriate to urgency: 75% NMGH; 82% TROH (82% nationally). Preoperative review by a consultant surgeon and anaesthetist when risk of death is 5%: 67% NMGH; 85% TROH; (57% nationally). Response Since the publication of this report the teams have worked to improve the number of completed cases submitted; with currently 100% of cases submitted to the national database and 76% are fully completed. In addition all other areas (with the exception of specialist care of the elderly input) have improved; the teams on both sites are more engaged and have taken ownership of the audit and are monitoring their own data more proactively. The Trust submitted and validated 100% of cases and this will be reflected in the 2017 report due to be published in July Consultant surgeon and anaesthetist present in theatre when risk of death is 5%: 85% NMGH; 88% TROH; (74% nationally). Admission to critical care following surgery when risk of death is >10%: 79% NMGH; 92% TROH (85% nationally). Assessment by care of the elderly specialist in patients >70 years: 3% of cases for both sites (10% nationally). Local Clinical Audit The reports of 21 local clinical audits were reviewed by the Trust in and the Pennine Acute Hospitals NHS Trust intends to take the following actions to improve the quality of healthcare provided. Key findings Response COMPLIANCE WITH PATIENT SAFETY ALERT, STORAGE OF THICKENING AGENTS This audit showed that the Trust was storing all thickening agents Educate and remind all nursing staff of patient in the kitchen in all areas, and that if patients require thickening care alert (PCA) 19 in daily meetings agents, they are not always risk assessed appropriately (42.8%) Introduce nursing risk assessment tool Though the patients who are capable of doing so are encouraged template to those already in use for nursing to make their own drinks, they may not be able to determine what documentation the right quantity is and this can result in harm. All agents must be stored in the kitchen; this Where the thickening agent is stored on the drinks trolley, the drink will reduce risk and ensure best practice is is made for the patient. But there is a risk of accidental ingestion if followed it is within reach of patients. Any thickening agents that are used should be only given by the clinical staff on the wards

97 PAGE 95 Key findings LESSONS LEARNT AUDIT In total 13 serious incidents, 7 inquests, and 3 patient safety alerts were reviewed. The greatest numbers of actions related to training compliance, but this also had the lowest level of completion with 79% being amber or red. Actions related to developing or reviewing policy, protocols and documentation showed the highest level of completion (94%) although compliance with policies and protocols was only 56%. Response The results of the audit were presented at the Divisional Quality & Performance committees in July 2016 for information and to disseminate across the directorates. Since that time, the new Director of Patient Safety has been introducing Salford s Lessons Learned programme into Pennine. Communication to staff had the second highest numbers of related actions and (excluding those categories with very low numbers of actions) also showed the second highest rate of completion at 65.5%. The divisions with the greatest compliance are Integrated and Community, and Support Services, though the overall numbers of actions for these are low. Anaesthetics and Surgery had the most actions reviewed, and showed the lowest full compliance of the divisions with 40.5%. Women and Children s had compliance with 43%; and Medicine with 57% of their actions. Whilst reviewing the documents to identify auditable standards, a number of actions were not ed that were not amenable to audit, for example raising awareness. Although it is possible to demonstrate communication of outcomes and follow this up by obtaining records of handover, ward meetings and minutes of meetings, this does not provide assurance that staff have taken on board and embedded good practice into their everyday roles and responsibilities. REDUCING THE RISK OF CLOSTRIDIUM DIFFICILE INFECTION The purpose of the audit was to reduce the risk factors for C. difficile infection, and ultimately reduce the rates of CDAD (clostridium difficile associated disease) in the patients being treated with PPIs and antibiotics at the The Royal Oldham Hospital. Standard: All patients high-risk for CDAD, who take a PPI and are requiring antibiotics, should have their PPI reviewed and stopped if possible, or changed to ranitidine. In the 1st audit cycle compliance of the above standard was met in 65.3% of cases. The results of the audit have been discussed with the clinical director and presented, highlighting the responsibilities of usage of PPI and antibiotics. Discussion taking place with epma team to assess the feasibility of having a pop up alert requesting appropriateness of antibiotics on PPIs for this cohort of patients. In the 2nd audit cycle compliance of the above standard was met in 87.2% of cases. Annual Report

98 PAGE 96 Key findings COMPLETION OF DNACPR FORMS ON G2, ROH The purpose of this audit was to determine the practice on the completion of DNACPR forms and the associated discussions with patients and their families on ward G2 at The Royal Oldham Hospital. The standard for all criteria is 100%. Only 75% DNACPR forms were clearly visible at the front of the patients notes. Only 67% DNACPR forms were countersigned by a consultant within 24 hours of being completed. In 89% of cases, discussion with patients was documented on the DNACPR forms 75% of cases had a mental capacity assessment recorded in their clinical record and documented evidence that discussion with next of kin had taken place. Response The audit has been presented at the Trust gastroenterology clinical governance meeting, and discussed with both the clinical and managerial teams. The junior doctors ward induction document has been amended so that it now includes a section on DNACPR decisions and guidance. The audit results have been reported to the frontline medical staff as they are commonly involved with completing DNACPR forms at an early stage in a patient s hospital admission. Discussion with nursing staff and ward clerks on G2 and have asked that they check that the forms are filed in the correct place. 60% of DNACPR discussions were clearly documented in the patients clinical records. In the remaining 40%, the DNACPR decisions were carried over from the community and therefore it was not deemed necessary to re-discuss. FALLS AUDIT INTEGRATED AND COMMUNITY The purpose of this audit was to review the appropriateness and effectiveness of prevention and management of falls within community bed based units. The standard for all criteria is 100%. 49% of patients Trust-wide had a specialist physiotherapy assessment within 24 hours of being identified as a falls risk. 59% of patients Trust-wide had a golden leaf symbol displayed above their bed. 27% of patients Trust-wide had a cognitive assessment completed. 54% of patients Trust-wide had a forget me not symbol displayed if required. The results of the audit have provided the division with real-time data that has been used to develop a quality improvement plan which will benchmark implementation and improvements in a timely manner. The key recommendation was to develop a bespoke Fallsafe Bundle more relevant to the community setting linked to staff knowledge and skills training programme. This is now in use across the community beds and bespoke training is being delivered. 64% of patients Trust-wide had a risk assessment reviewed if they had fallen on the unit. 64% of patients Trust-wide had a post fall action plan completed if they had fallen on the unit.

99 PAGE 97 Key findings Response COMPLIANCE WITH COMMUNITY NURSE CONTROLLED DRUG POLICY The purpose of this audit was to assess compliance against Trust The audit highlighted eight recommendations; policies and NICE guidance regarding controlled drugs, highlighting each has named leads and the teams have areas of good practice and any gaps in compliance. developed a series of processes to ensure implementation of the plan. The standard for all criteria is 100%. The results have been discussed at team 94% of prescribers provided a dated handwritten authorisation, meetings and it has been stressed that clearly detailing the drug, dose and route of administration in compliance must be 100% in all cases. the patient record 69% of controlled drugs were counted, documented and Re-audits are planned for November 2017 to signed at each visit assess compliance against the policy following additional training sessions. 67% of clinicians documented their signature, name and job title on all controlled drugs documentation Only 11% of entries were contemporaneous Only 9% of community nurses discussed with patients and their carers the administration and expected effects of taking controlled drugs and document this within the patient record Only 3% of patients receiving drugs via a syringe driver were provided with a syringe driver information leaflet 86% of records showed that controlled drugs destroyed by clinicians, had documentation dated and signed by a registered member of staff and only 66% signed by a witness 63% of records had documented evidence of DOOP kits being used to destroy unused controlled drugs. 89% of team members could discuss points relevant to controlled drugs and administration in line with Trust policy Annual Report

100 PAGE 98 Key findings Response GLUCOSE TESTING IN PATIENTS ADMITTED WITH NECK OF FEMUR FRACTURE A major clinical incident three years ago involved a patient with The audit results were presented at the A&E undiagnosed diabetes, who was admitted with a fractured neck Audit meeting at NMGH on Friday 27th May of femur, and died due to complications from the diabetes Following this, a new protocol was introduced in which all patients No action was required as the results admitted with a diagnosis of a fractured neck of femur would demonstrated that current practice was at a have a laboratory glucose test prior to referral to the Trauma and satisfactory level. Orthopaedic team. The standard for all criteria is 100%. Out of 20 patients identified, 19 had a laboratory glucose checked on admission which was identifiable on the Pathology Lab centre system. All 20 patients had some form of glucose testing performed in the form of laboratory or capillary, checked on admission. The one patient who did not have a laboratory glucose checked on admission was a patient with known type 2 diabetes, which was tablet controlled, who was placed on a capillary blood glucose chart from admission. Further to the implementation of the new protocol, A&E staffs were successful in implementing this change and 95% of patients had laboratory glucose check done on admission. DELIRIUM: PREVENTION, DIAGNOSIS AND MANAGEMENT WITHIN THE INPATIENT ORTHOPAEDIC PHYSIOTHERAPY TEAM AT NMGH The aim of the audit was to establish how current practice Results have been shared with all compares to the NICE guidelines CG 103 and, where necessary, physiotherapists (who practice on the form and implement a relevant action plan to drive improvement as orthopaedic trauma wards) at their team appropriate. meeting. The standard for all criteria is 100%. It is standard practice for physiotherapy staff to encourage mobility, walking and exercises with patients admitted to an orthopaedic ward following their surgery; irrespective of their age and cognitive function. The results of the audit confirmed that this is taking place on a consistent basis. The audit demonstrated full adherence to the physiotherapy practice recommended in the NICE guideline for delirium for patients admitted to the orthopaedic trauma ward at NMGH. They have been encouraged to maintain good standards of practice in relation to this particular guideline. As the audit demonstrated 100% compliance against the standards the re-audit is planned to be undertaken in 2 years time (unless there is a decrease in practice and or the standards change).

101 PAGE 99 Key findings Response AUDIT OF UPPER LIMB PHYSIOTHERAPY ASSESSMENT AND TREATMENT The purpose of the audit is to improve the treatment provided to The results of the audit have been fedback to patients with regard to their upper limb physiotherapy assessment the physiotherapy team highlighting the new and treatment following a stroke. RCP guidelines for stroke. The standard for all criteria is 100%. 80% of patients had a problem list documented. 75% of patients had a treatment plan documented. 58% of patients had their treatment plan evaluated during subsequent therapy sessions. In addition all rotational staff have been made aware of documentation standards. A review is being undertaken on the upper limb checklists ensuring that they reflect the changes in the RCP guidance. 64% of patients were given the opportunity to practice activities within their capacity during therapy sessions and only 45% of patients were given opportunities to practice independently of therapy sessions. 37% of patients who did not have 45 minutes of therapy had a documented reason as to why not. ADHERENCE TO, AND EFFECTIVENESS OF BLOOD GLUCOSE MONITORING AT NMGH In the spring of 2015, a new blood glucose monitoring document The results of the audit have been presented was rolled out across the Trust in a bid to document patients blood and it was agreed that there was a need glucose levels more accurately. to assess the understanding of the nursing team on blood glucose monitoring and to The standard for all criteria is 100%. ascertain any barriers to the effective use of In the first 48 hours of admission, 42% of patients had their the required documentation. blood glucose measured appropriately. In addition it was agreed that the use of After the first 48 hours of admission, 62% of patients had their algorithms is easier to follow than lines of blood glucose measured appropriately. prose work is being undertaken to collate 50% of episodes of hypoglycaemia are accompanied by a algorithms to incorporate cut-off values in all sticker in the patient notes. the algorithms, e.g. at what level does low 50% of episodes of hypoglycaemia are escalated appropriately. blood glucose need to be escalated. In patients who have an episode of hypoglycaemia, 100% have their blood glucose rechecked appropriately. 60% of patients with two consecutive readings of blood glucose greater than 15mmol/L had their ketones checked. All patients who had a blood glucose reading of more than 15mmol/L on two consecutive occasions, and who were positive for ketones, were escalated appropriately. Annual Report

102 PAGE 100 Key findings URINALYSIS IN UTI Observations on the Acute Medical Unit at North Manchester General Hospital (NMGH) suggest that urinalysis is not routinely carried out where it is indicated. In addition, when urinalysis is performed, results are not always documented and the majority of clinicians agree that finding results in clinical notes can be very difficult. This audit was undertaken to identify the extent of these problems and guide an action plan to address the issues with a view to improving practice and patient care. The standard for all criteria is 100%. A urinalysis was performed to confirm diagnosis of a UTI in only 64% of cases. Urinalysis results were documented in only 44% of cases and were easily accessible / visible in only 20% of cases. Response Staff in AMU (nursing, healthcare assistants and doctors) have been made aware of the new documentation and the use of the sticker system that has been developed. The stickers are easily accessible across the unit e.g. in the sluice room The doctors have been made aware that it is their responsibility to clearly document these results in the notes where appropriate i.e. ward round entry. A re-audit is planned to take place in May Only 84% of MSUs (midstream urine samples) were sent for cultures and sensitivities and only 52% of sensitivities were available before discharge. Only 8% of patients had antibiotics changed/prescribed according to sensitivities. IDENTIFICATION OF NEONATES REQUIRING BCG VACCINATION Manchester s incidence of TB has recently dropped below 40/100,000 and so babies on the postnatal ward born to parents living in Central Manchester, Salford, M8, M9, and M40 are no longer automatically being given the BCG. This change from giving BCGs to all babies living in the areas listed, to targeting those who are now classified as high-risk, started on the 1st April This means that it is now even more important to make sure that all babies who should be vaccinated are identified, according to the screening questions e.g. country of birth of parents and grandparents and also family history of TB. The results of the audit have been discussed with the project lead and clinical audit lead regarding the national shortage of vaccination at the time of the audit, and which continues. The results of the audit were presented in January 2017 with further audits planned to monitor vaccination programme. The shortage of BCG vaccine is noted on the divisional risk register. The audit highlighted that only 68% of babies that require a BCG vaccination after birth on the postnatal ward were identified. It is not a local practice to identify babies eligible for a BCG vaccination before birth. At the time of the audit there was a national shortage of vaccination. This meant that babies were not always being vaccinated before discharge from hospital. (If there were not enough babies requiring BCGs it was felt a waste of resources to open a vaccine vial that could be used for 8-10 babies: they are invited back to clinics so that larger groups can be vaccinated together).

103 PAGE 101 Key findings Response APPROPRIATENESS OF ANTIBIOTIC PRESCRIBING IN A&E FOR ADULT OUTPATIENTS 115 antibiotics were prescribed for A&E patients between 16th and A meeting took place in August 2016 with the 29th November A&E prescribers to highlight the prescribing 80 were indicated for conditions within the antibiotic policy of antibiotics for chest infections, including 59% complied with the policy not prescribing when there are no signs 41% did not comply. of infection unless confirmed by tests; this included usage and doses for COPD patients. 35 were indicated for conditions that were not included in the antibiotic policy. Continuous monitoring of antibiotic usage in A&E has been on-going since July Areas of good practice: Antibiotic dose for UTI was appropriate on 96% of occasions where the choice was appropriate. Antibiotic choice for cellulitis was appropriate on 90% of occasions. Areas for improvement: Antibiotic choice for ear infections was inappropriate on 50% of occasions. Antibiotics prescribed for wounds or laceration injuries were inappropriate on 65% of occasions. Co-amoxiclav was prescribed inappropriately in 71% of occasions out of which eleven indications did not exist within the antibiotic policy. AUDIT OF PRE-OP NOTES IN GENERAL AND VASCULAR SURGERY Given the established importance of good record-keeping in clinical The results of the audit were presented at the practice, the aim of this audit was to assess current practice within vascular and surgical audit meetings. the surgical department at The Royal Oldham Hospital; with a The operation notes have been re-designed to fundamental aim of improving patient safety and maintaining a ensure that the Royal Colleges standards will high standard of patient care. be met. The standard for all criteria is 100%. The vascular team has liaised with the theatre 100% of post-operative notes had a documented named staff and informed colleagues of new op note surgeon; name of procedure and post-operative care now available in all vascular theatres. instructions. 93% of post-operative notes had a documented date; and just 16% a documented time. Blood loss was documented in 7% of post-operative notes. 34% of post-operative notes had documented antibiotic prophylaxis; and DVT prophylaxis was documented in 21%. Patient demographics were complete in 91% of the postoperative notes assessed. Annual Report

104 PAGE 102 Key findings VASCULAR SURGICAL SITE INFECTION (SSI) AUDIT The aim of this audit was to review the incidence of groin infections and the degree of correlation between infection and known risk factors. 14% of patients acquired a 30 day post-op SSI target is 3%. 87% of patients were administered prophylactic antibotics target is 100%. 97% of patients received appropriate first line prophylactic antibiotics target 100%. All seven patients had a number of risk factors that are known to increase the risk of SSIs. 100% of patients were given prophylactic antibotics within 60 minutes before skin incision 57% of patients with an aquired post op SSI had their operation in theatre 3 100% of patients received appropriate first line prophylactic antibiotics. GP REFERRAL PATHWAY FOR BRONCHIOLITIS The purpose of the audit was to assess GPs adherence to the bronchiolitis pathway when making the referral to the paediatric team. The standard for all criteria is 90%. Two thirds of the referrals were for mild cases of bronchiolitis. These cases could have been managed in the primary settings with a period of observation and CCNT follow up. This would greatly reduce the burden on the already limited hospital resources. The compliance for the ManchEWS observations (particularly the oxygen saturation) and feeding assessment in the primary settings were below the set key standards. The reasons could be due to time constraint for observing each patient, lack of equipment or untrained staff who may not be familiar with the use of the oxygen saturation monitor. Response The results of the audit to be presented to highlight the audit findings and action plan to support implementation of the audit recommendations. Develop a SSI risk assessment tool Doors leading into the hybrid area to be kept closed at all times Limit the number of personnel within theatres Adherence to the surgical theatres workwear policy. Prophylactic antibiotics to be added to the WHO pre-op checklist to act as a reminder to ensure all patients are administered the appropriate antibiotic and within the best practice timeframe. The team has devised a tiered action plan as follows: Trust to continue to arrange CPD sessions with GPs on bronchiolitis management and to revisit the referral pathway. This would be helpful in areas with high referral rates (postcodes M8 and M9). Education programme should be offered again for Bury GPs. New doctors to be aware of the referral pathway so that they can ask appropriate questions and offer appropriate advice when contacted by the GPs i.e. to be included as part of the induction programme for new doctors joining paediatrics.

105 PAGE 103 Key findings APPROPRIATE REQUESTING OF MRI Magnetic resonance imaging (MRI) should be used to reduce radiation in situations where multiple imaging is required. For diagnosis of inflammatory disease of the small bowel (Crohn s disease) there is no consensus regarding initial imaging. NICE guidance recommends ultrasound scan (US) or MRI in conjunction with endoscopy if inflammatory markers are raised. Other literature has indicated that US, computed tomography (CT) and MRI are comparable in imaging small bowel pathology. Magnetic resonance elastography (MRE) is frequently used as a first line investigation in suspected cases of small bowel inflammatory bowel disease (IBD) in PAHT. Response The results of the audit have been shared with the Trust Inflammatory Bowel Disease Lead and to date the following actions have been implemented: Referrals for dedicated US of the small bowel have been increased A review of a new patient pathway for low suspicion for IBD A re-audit will be undertaken in The clinical history of 495 cases was examined for evidence of known Crohn s disease and the results highlighted that: The clinical history of those with no known history of Crohn s (n=301, 60%) was further evaluated. Almost three quarters (72.4%) of those with no known Crohn s disease also did not have any past medical history of GI disease, other imaging findings or endoscopic findings. MRE diagnosed small bowel pathology in only a small proportion of cases referred. The likelihood of a positive finding is increased in specific subgroups, e.g. endoscopic or CT findings. MRE picks up a significant number of incidental findings including large bowel pathology these patients then require further investigation. Faecal calprotectin was only mentioned in one clinical history: this should be utilised more effectively. US small bowel does not require bowel preparation, costs around a third of MRE and is comparable in sensitivity and specificity. Annual Report

106 PAGE 104 Key findings DENTAL TRAUMA IN ANAESTHETICS The rationale for this audit came from a clinical incident in which a patient undergoing an elective procedure experienced an uneventful anaesthetic but was later found to have a broken tooth. A review of the local policy / guideline was initiated to assess the effectiveness of the Trust s compliance to recommended practice and assist the anaesthetists in case of accidental trauma and subsequent management. A retrospective audit reviewed incidents reported over a 12- year period ( ) alongside a spot check of consent audit undertaken at The Royal Oldham Hospital (TROH) in June Aims - to quantify the magnitude of the problem in the Trust and the Division of Anaesthetics, to improve documentation, to safeguard against medico legal claims and to form a guideline for the department. Retrospective Audit Response The results of the audit have been shared with the anaesthetic department at the audit and governance meeting. A comprehensive action plan was developed based on the audit findings including: Development of department / Trust guidance on the management of dental trauma, including guidance on what to do if a tooth cannot be found and when to complete a Trust incident form. This is now implemented and available via the Trust intranet. Use of new anaesthetic charts at TROH with prompt for consent. Re-audit (pre-op documentation) scheduled for August dental incidents were reviewed, of which 59 were found to be related to anaesthetic dental injuries. 61% were found to occur during intubation; in 33% of cases it was impossible to tell when the incident occurred due to poor documentation. There were two reported cases of damage to identified healthy teeth both, of which received intraoperative intervention from the maxillary-facial team. Spot Check Consent Audit 42 patients reviewed over two days. Documentation of current dentition was identified in 88% of cases but only 38% went on to document the risk of dental trauma.

107 PAGE 105 Key findings CAROTID ENDARTERECTOMY (CEA) PATHWAY In England and Wales alone, over 80,000 people are hospitalised with acute stroke each year; the risk of completed stroke is much lower in studies of emergency treatment in specialist stroke services compared to non-urgent settings. Patients with suspected TIA should have a full diagnostic assessment urgently without further risk stratification. The Trust must demonstrate compliance to audit against NICE Guidance CG68 - Stroke and transient ischaemic attack in over 16s: diagnosis and initial management (2008), and at local levels Trusts must ensure that vascular departments audit practice of the carotid endarterectomy pathway. PAHT does this annually to provide this assurance. A retrospective audit on data extracted from the National Vascular Registry for all patients who have undergone CEA over a 12 month period between 01/01/ /12/2015 at TROH. Total number of CEA procedures identified was 113. The results against NICE CG68 standards are depicted below - the standard is 100%: 66.6% of patients had surgery within 2 weeks from onset of stroke or TIA. 72.5% undergo surgery within 7 days of referral 62.7% assessed and referred within 1 week of onset of symptoms of stroke or TIA 69.6% operated on within 24hrs of admission 37.5% return to Stroke Unit for on-going rehabilitation within 24 hours of surgery Although limited assurance to standard was identified from the audit the PAHT figures are higher than the national averages for the same time period. Response The results of the audit were disseminated widely throughout the vascular team and the Trust, being presented at the Vascular MDT on 22/09/2016: minutes were submitted to audit and governance meetings to provide evidence. A comprehensive action plan was collated, and actions have been implemented: Action: Raise awareness by presenting audit findings at the Multidisciplinary Team Meeting on 22/09/2016. Outcome: Lead Clinician presented the audit findings and a copy of the presentation and attendance register has been submitted as evidence. Action: Raise awareness and present local and national outcomes via a banner format at the PAHT annual public meeting 6/10/2016. Outcome: A banner was designed for the public meeting. Evidence of the banner and attendance at the meeting has been submitted as evidence. Action: Clinical Audit Department to send copies of the carotid endarterectomy pathway report to the stroke team. Outcome: The carotid endarterectomy pathway report has been submitted (16/10/2016) to the clinical audit supervisor, auditor and clinical director for comment. Annual Report

108 PAGE 106 Key findings SEPSIS IN SURGICAL INPATIENTS Sepsis is a major cause of death in the UK and is consistently within the top three causes of death reported monthly at PAHT An audit and re-audit against NICE guidance NG51 outlining the management of Sepsis. The aim was to assess adherence to sepsis 6 guidelines amongst general surgical patients, (standard 100%) and concurrently assess the correlation with 30-day morbidity and mortality. IV Antibiotics (within 1 hour), adequate IV fluids, provide oxygen, monitor UO, take 2 blood cultures from 2 separate sites, check lactate level. This was a prospective audit performed over a week from 14th- 20th November The study population consisted of general surgical patients on Ward T5, The Royal Oldham Hospital, identified as septic during this period. Four patients were diagnosed with sepsis. All patients were managed in accordance with the Sepsis 6 guidelines and received treatment with antibiotics within one hour of diagnosis. All blood samples were taken for culture and lactate levels and intravenous fluids were prescribed. 75% were given oxygen however the fourth cases contained poor documentation therefore it was impossible to determine if this was omitted or simply not documented. Response The results of the audit were disseminated widely throughout the General Surgery Directorate and the Trust, being presented at the General Surgery Audit and Governance meeting 16/12/2016. Minutes were submitted to provide evidence. A comprehensive action plan was collated, containing the below elements. All actions have been implemented. Action - Production of presentation using NICE guidelines for recognition, diagnosis and management of sepsis Outcome Session delivered 16/12/16 Electronic version of presentation, feedback from teaching session and register of attendees obtained for evidence Action - Poster production using research on qsofa Outcome - Completed - Poster produced and used as part of teaching session on 16/12/16 The planned re-audit was undertaken in March 2017 and as a result it was agreed that the new cohort of SHOs need to continue delivering teaching sessions to the FY1s on this topic. 75% documented catheterisation. In this case failure to meet the standard set may be in part due to again lack of documentation No patients included within this audit had two sets of blood cultures; In all cases there was documented use of the SIRS criteria in clinical assessment. The 30-day mortality rate for patients included in this audit was 0% and no patients required a further operation. The audit demonstrated limited levels of assurance to Sepsis 6 guidelines.

109 PAGE 107 Key findings LUMBAR PUNCTURES BASED ON CRP RESULTS NICE Guidelines for Neonatal infection (early onset): antibiotics for prevention and treatment (CG149) states babies with any red flags or two or more non-red flags or clinical indicators indicates investigations and antibiotic therapy. Babies with no red flags or only one risk factor/clinical indicator should be monitored, using clinical judgement on whether to withhold antibiotics or not. As part of this protocol a CRP hours after the first indicates to consider performing an LP if: CRP of 10mg/litre or greater; or positive blood culture; or does not respond satisfactorily to antibiotics. This audit questioned if the threshold of CRP of 10mg/litre should be raised: each baby who requires an LP must be admitted, observed for four hours in the SCBU post-procedure, and have an admission and discharge Badger completed. The Badgers done for these patients are often of a much lesser quality. Response The results of the audit were presented at the audit meeting November Advice from the meeting; this audit is strongly recommended to include CSF cell count findings. CSF culture often shows no growth but cell counts can lead to indications for meningitis treatment. Raise the study group s threshold for lumbar punctures based on CRP to 20 mg/ litre Re-audit to include cell count of CSF in babies had a lumbar puncture: 51 of these babies met the criteria of: no clinical signs shown first CRP <10 mg/litres hours CRP >10 mg/litres The average hour CRP was (highest 147.6, lowest of 11.8). The average increase in CRP from the first reading was 38. Based on these findings, lumbar punctures are being overdone due to the interpretation of guidelines. Annual Report

110 PAGE Participation in Clinical Research The Trust is committed to research and transformation as a driver for improving the quality of care we provide to our patients. It enables our staff and the wider NHS, regionally and nationally, to improve the current and future health outcomes of the people we serve. Only by carrying out research into what works can we continually improve treatment for patients, and understand how to focus NHS resources where they will be most effective. We currently support 374 research studies, of which 124 are clinical trials involving medicinal products. Our engagement with clinical research demonstrates the Trust s commitment to testing and offering the latest medical treatments and techniques. During , we recruited patients to 117 National Institute for Health Research Clinical Research Network (NIHR CRN) clinical research studies. The number of patients receiving NHS services provided or sub-contracted by the Trust in that were recruited during that period to participate in research approved by a research ethics committee was This level of participation demonstrates the Trust s commitment to research. The Trust s reputation for attracting, initiating and delivering high quality industry trials has continued to grow this year, with the Trust currently supporting over 90 industry sponsored trials. Our excellent reputation with industry culminated in us being named as the NHS Clinical Research Site of the Year at this year s Pharma Times International Clinical Researcher of the Year awards. The annual International Clinical Researcher of the Year competition is designed to challenge, recognise and reward the talent and passion of industry and academic researchers from all over the globe. To be named NHS research site of the year is a fantastic achievement and an independent stamp of endorsement, highlighting our excellence in the field of clinical research. In addition to the above, the Trust had two finalists in the Clinical Research Nursing category at this year s Nursing Times awards. The entries entitled Improving access to NIHR CRN studies and Development of a research orientated high risk cardiovascular clinic were both selected for the final. Having two finalists in this prestigious event was a fantastic achievement and the judging panel commended us on the high quality of our entries. A new bespoke clinical research facility has opened on our Royal Oldham Site. This facility has dedicated clinical space that can accommodate up to eight adult research participants. There is also a separate unit specifically for paediatric research. Previously participants were quite often seen in outpatient clinics which sometimes lacked capacity in terms of space to carry out research activities. The new unit allows a number of participants to be seen simultaneously for screening, randomisation, study visits and procedures, and follow-up visits. A number of Pennine employees were recognised for their contributions in the Greater Manchester Clinical Research Awards at a ceremony held in November Denise McSorland was the winner of the Research Nurse of the Year category for her significant contribution to research over 20 years. The pharmacy research team were runners up in the outstanding contribution category Use of the CQUIN Payment Framework The CQUIN framework encourages quality improvement by financially rewarding organisations that achieve specific quality indicators that are agreed with their commissioners during contract discussions. A proportion of PAHT s income for was conditional on achieving quality improvement and innovation goals agreed between the Trust and any person or body we entered into a contract, agreement or arrangement with for the provision of NHS services, through the Commissioning for Quality and Innovation payment framework. Detailed CQUIN performance is discussed at each contract meeting with the local CCGs, the Clinical Quality Leads meeting,

111 PAGE 109 and the Divisional and Trust-wide Quality and Performance meetings. Information regarding CQUINs is available via the NHSE website: For there were contract CQUIN indicators, some of which were nationally defined, some regional and some local with an associated value of approximately 11m. As a result of participation in the CQUIN framework in , the Trust continues to make significant improvements to patient experience and outcomes, and estimate recovery to be in the region of 10.9m from Commissioners for the achievement of CQUIN schemes. The Trust has agreed a plan with its Commissioners for to recover 7.1m from CQUIN payments. Acute contract schemes are now nationally mandated whereas specialised commissioning schemes are agreed separately from the nationally mandated schemes. The reduction in the financials achievable for is as a result of amendments to the percentage share of the 2.5% CQUIN value available, with 1% being held in escrow in relation to Sustainability and Transformation Funding. These indicators, the percentage weighting assigned to each, and the approximate associated financial value is outlined in the table below. 17/18 CQUIN Schemes Type Name of Indicator CQUIN % Approx Value s Acute and Community NHS staff and wellbeing % 997,080 Acute Reducing the impact of serious infections 13.70% 973,144 Community Improving physical healthcare to reduce premature mortality in people with serious mental illness (PSMI) 0.34% 23,936 Acute Improving services for people with mental health needs who present in A&E % 973,145 Acute Offering advice and guidance 13.70% 973,145 Acute E-referrals (Y1) 13.70% 973,145 Acute Pro-active and safe discharge 13.70% 973,145 Community Supporting Proactive and Safe Discharge Community Providers 0.34% 23,935 Acute: Community: Preventing ill health by risky behaviours 0.34% 23,935 Community Wound Care 0.34% 23,935 Community Personalised care and support planning 0.34% 23,935 NHS England Improving HCV treatment pathways through ODNs 8.32% 591,029 NHS England Nationally standardised Dose banding for Adult Intravenous Anticancer Therapy (SACT) 0.70% 50,000 NHS England Activation System for Patients with Long Term Conditions 0.84% 60,000 NHS England Medicines optimisation 3.09% 219,523 NHS England LOCAL - Neonatal Community Outreach 2 Year CQUIN 2.82% 200,000 Annual Report

112 PAGE Statements relating to the CQC The Pennine Acute Hospitals NHS Trust is required to register with the Care Quality Commission and its current registration status is registered with conditions as a result of the inspection during February / March 2016 (see below). The CQC has not taken enforcement action against the Pennine Acute Hospitals NHS Trust during the period , though alongside the publication of the report, the CQC announced in a press statement that such is the level of concern that we have around quality and safety that in line with normal policy we would have considered recommending the Trust should go into special measures However, the statement acknowledged the additional investigations into the challenges faced by the Trust that was undertaken by the leadership team from Salford (that had assumed leadership of the Trust immediately following the inspection) and the improvement plans that this review had generated. The Pennine Acute Hospitals NHS Trust has not participated in special reviews or investigations by the CQC during the reporting period, though there has been close monitoring of progress of improvement actions following on from the CQC inspection in February / March The formal report of findings was published in August 2016, but improvement work had already begun following feedback from the CQC at the time of the inspection (see section 3.1.1). This was to take immediate action to support what the CQC identified as fragile services: urgent care; maternity; paediatrics; and critical care in Oldham. The overall rating for the Trust was inadequate: Safe Effective Caring Responsive Well-led Overall Inadequate Good Inadequate Inadequate The summary ratings by site were as follows: North Manchester General Hospital Service Safe Effective Caring Responsive Well-led Overall Urgent and emergency services Medical care Surgery Inadequate Inadequate Good Inadequate Inadequate Inadequate Good Good Critical care Good Good Good Maternity and gynaecology Services for children and young people End of life care - Hospital Inadequate Inadequate Good Good Good Inadequate Good Inadequate Inadequate Inadequate Good Inadequate Inadequate Good Good Good Good

113 PAGE 111 Service Safe Effective Caring Responsive Well-led Overall Outpatients and diagnostic imaging Overall Good Not rated Good Good Good Good Inadequate The Royal Oldham Hospital Good Inadequate Inadequate Service Safe Effective Caring Responsive Well-led Overall Urgent and emergency services Medical care Surgery Critical care Maternity and gynaecology Services for children and young people End of life care - Hospital Outpatients and diagnostic imaging Overall Rochdale Infirmary Inadequate Inadequate Inadequate Good Good Inadequate Good Good Good Good Good Good Good Good Good Inadequate Inadequate Inadequate Good Inadequate Inadequate Inadequate Not rated Good Good Good Good Good Inadequate Inadequate Service Safe Effective Caring Responsive Well-led Overall Urgent and emergency services Good Good Good Medical care Good Good Good Good Good Good Surgery Good Good Good Good Good Good Outpatients and diagnostic imaging Good Not rated Good Good Good Good Overall Good Good Good Good Good Good Annual Report

114 PAGE 112 Fairfield General Hospital Service Safe Effective Caring Responsive Well-led Overall Urgent and emergency services Medical care Surgery Critical care End of life care - Hospital Outpatients and diagnostic imaging Overall Good Good Good Good Good Good Good Good Good Good Good Good Good Not rated Good Good Good Good Good Community services Service Safe Effective Caring Responsive Well-led Overall End of life care Good Good ««Outstanding Good Good Good Children, young people and families Good Good Good Good Good Good Community adults Good Good Good Good Good Good Community inpatients Good Good Good Good Good Good The Trust reviewed the published reports and noted all the mandated actions ( must do ) and advisory actions ( should do ). These were circulated to the divisional leads, and mapped to executive assurance groups to monitor progress of assurance from the divisions. They were also incorporated within the improvement plans (see section 3.1.1). Most of the mandated and advisory actions have been considered as Trust-wide actions, even though they might have been directed at a specific service or site. This is to ensure that all areas are improving and learning from the findings of the inspections across all the sites. The Trust met with representatives and the Head of Inspection for the CQC in both December and February to review and update on progress against the agreed action plan and priorities following the February 2016 inspection. Focus was given to the fragile services of maternity, paediatrics, critical care and urgent care, reviewing the must dos that had been outlined in the final published report of August The CQC were supportive of the direction of travel and progress made to date, in particular the Quality strategy and plans for staff engagement and organisational development. The Trust is expecting a follow up visit and assessment during the course of 2017/18 which will comprise of a planned inspection, an unannounced inspection of a core service and a well led review.

115 PAGE 113 Statement of Purpose It is a statutory obligation of the Trust to notify the CQC of any changes in our premises or the type of services provided. The Statement of Purpose was comprehensively reviewed in July 2016 when a number of amendments were made including transferring the document to the template supplied by the CQC. Service leads were asked to review their information again in December 2016, and it is planned that this will be undertaken each quarter during the period of transition for the Trust s services. A new certificate of registration was issued by the CQC in January Nominated Individual Mrs Elaine Inglesby-Burke, Chief Nurse, is the Nominated Individual for the Trust s CQC registration since being appointed as Chief Nurse on 1st August Data Quality Good quality information underpins sound decision making within the Trust and contributes to the improvement of healthcare services. There is a dedicated Data Quality Department, part of Information Management and Technology (IM&T), which concentrates on the electronic systems in use at the Trust. It works to an annual programme of audits which is agreed by the IM&T Steering Group (ISG): this is a governing group for data quality at the Trust, chaired by the Director of Finance and represented at a senior level with executive members, Divisional Directors (clinical and non-clinical), Finance, Commissioning and IM&T senior managers. Annual Report

116 PAGE 114 There is an approved Data Quality Strategy and Data Quality Policy in place which are reviewed and approved by the Data Quality Assurance Group (DQAG) and ISG annually, or more frequent if required. Adherence to the policies is monitored via data quality audits and the findings are presented and recorded via the CQAG to the ISG that reports into the Executive Finance, Information & Capital Governance Committee. There is a structured approach to the department s work, both day-to-day work and the annual programme of audits which are supplemented by bespoke audits identified as requiring a focus and improvement linked to the following: Accuracy and timeliness of data collection for key datasets Baseline audits and reviews for Urgent Care Baseline audits and reviews for key patient pathways (Accident & Emergency, and Referral to Treatment times) Quality Account Data Quality improvement work-streams Service Reviews Information Governance Toolkit Contract KPIs Adverse variances in Trust activity recording However, it has been identified that the Trust has some data quality issues in relation to validating the grading of reported incidents. A new incident management system has been purchased and this will support more timely and accurate validation. It is planned to be implemented throughout the Trust during Q The Trust will be taking the following additional actions to improve data quality: 1. Improve the recording of Outpatient Procedures in the following specialties by training clinicians and staff and increase routine audits to maintain improvements: Trauma & Orthopaedics Urology Breast Surgery General Surgery Oral & Maxillofacial Surgery Ear Nose & Throat 2. Improve the recording of a patient s treatment information including co-morbidities for select specialties to support patient care and accurate reflection of the Trust s mortality ratio as follows: Cardiology - stroke Pneumonia Chronic Obstructive Pulmonary Disease (COPD) Urinary Tract Infections Acute Kidney Failure (AKI) Cardiac Pacing Upper GI Tract

117 PAGE Improve the recording of Accident and Emergency data to ensure that it is reflected in the systems used for our urgent care patients admitted by: Undertaking baseline audits to understand key issues with data quality System upgrades and changes to support accurate data capture of data Devising and delivering training for clinical staff in A&E Monitoring and reviewing data quality to maintain improvements NHS Number and General Medical Practice Code Validity The Pennine Acute Hospitals NHS Trust submitted records during to the Secondary Uses Service (SUS) for inclusion in the Hospital Episode Statistics which are included in the latest published data. The percentage of records in the published data submitted to the SUS which included the patient s valid NHS number was: 99.8% for admitted patient care; 99.8% for outpatient care; and 98.7 % for accident and emergency care. The percentage of records in the published data which included the patient s valid General Medical Practice Code was: 100% for admitted patient care; 99.9% for outpatient care; and 100% for accident and emergency care Information Governance Toolkit attainment levels Information Governance regulates how NHS and social care organisations handle information, particularly confidential or sensitive personal or corporate information. The Pennine Acute Hospitals NHS Trust s Information Governance Assessment report score overall for was 68%, and was graded green (satisfactory). Key areas for improvement are linked to cyber security and continuation of data flow mapping and aligning of contracts with associated information sharing agreements Clinical Coding Error Rate The PAHT was not subject to the Payment by Results clinical coding audit during by the Audit Commission / regulatory bodies that decide which NHS Trust is to be audited for clinical coding. This year the Trust has not been subject to a Clinical Coding Assurance Framework Audit. Following an annual clinical coding audit in line with the IG Toolkit requirement 505, the Trust achieved level 2 based on the error rates for diagnosis and treatment coding as detailed on the table. Audit Area Compliance Primary Diagnosis 92.50% Secondary Diagnosis 92.61% Primary Procedure 94.77% Secondary Procedure 94.81% Annual Report

118 PAGE 116 PART 3 REVIEW OF QUALITY PERFORMANCE 3.1 Quality s at PAHT High-level plan Since August 2016, the Trust has an overarching improvement plan in place, outlining immediate actions which would help the Trust stabilise its services and create the right conditions upon which to continue to improve and ultimately transform care delivery across Pennine. Progress against the plan is discussed at each public board meeting and delivery is monitored by the Pennine Board. This board includes external representatives from the local health and care economies, and is chaired by the Chief Officer of the GM Health and Social Care Partnership. This ensures there is a shared understanding and collective commitment to the delivery of the improvement plan, including the resources that need to be made available to enable the changes to happen. The plan was developed from two sources. First were the immediate patient safety concerns that the CQC raised with the Trust during their inspection in February/ March These related to four main service areas, referred to as the fragile services: Maternity; Children s services; Urgent Care; and Critical Care Secondly, were the key areas for improvement identified by the senior executives from Salford Royal NHS Foundation Trust, during their review into the causes of risk to patient safety and care sustainability. The other key areas for improvement identified by the SRFT review were: Patient safety, harm and outcomes; Systems of assurance and governance arrangements; Operational management and data quality; Workforce capacity and capability; and Leadership and external relations. A number of improvement projects have been developed within each of these areas, and together these form the Quality Programme coordinated by the Interim Director. Each project contains various work streams and these incorporate all the recommendations made by the CQC ( must-do and should do actions - see section 2.2.5) where relevant. The overarching Project Plan is being dis-aggregated into Care Organisation level improvement to enable a more focused, site-specific transformation strategy, in addition to providing clearer ownership and accountability for project tasks. The assurance framework will be adapted to reflect the new arrangements.

119 PAGE Quality Programmes A summary of the key work-streams of each project, and the progress, is shown in the tables below. Some of these projects incorporated or superseded some of the priorities for improvement for the forthcoming year, that were set out in the Quality Account. These are noted below where applicable. Project: Urgent Care improvement (including Ambulatory Care) Aim: stabilisation of service Work-stream Summary of actions completed Impact Staffing Medical consultant rota supported via Salford Royal FT and Central Manchester FT consultants resulting in additional 18 PAs per week. Consultant post from ROH moved to NMGH resulting in additional 5 PAs per week. Core of 5 consultant CCT Certificated (3 x PAHT substantive and long term locums). Introduction of 12 hours per day 7 day GP cover to support primary care presentations. Doctor recruitment programme. Directors of nursing have undertaken a review of ED nursing establishments, workforce paper has been agreed at Trust board. Total additional cover 24 PAs giving 90 hours per week senior consultant shop floor cover. Greater senior presence has increased clinical leadership and support for junior staff with decision-making. Additional workforce has supported the stabilisation of the department. On average 30 patients per day now seen by GP. Increase in Speciality Doctor at Rochdale from 0.75 to An increase in consultants from 4.80 wte at NMGH to 6 WTE At the end of March, an increase in qualified nurses at FGH ED from 41 wte to wte, and an increase in HCA in ED from to The Trust has 303 more staff across medicine and urgent care than this time last year, with 122 new nurses offered jobs to start in September. As part the preceptorship programme we also have 35 newly qualified nurses who joined the EDs in March and 13 other staff now on our programme. Additional workforce has supported the stabilisation of the department. Annual Report

120 PAGE 118 Work-stream Summary of actions completed Impact Staffing Ambulatory care Staff development Working differently An additional registered nurse has been in place since December 2016 on each shift in each ED. They are predominantly to support minor injuries, but can be utilised to support care of majors patients when required. A successful pilot scheme for a Tracker Role has been undertaken and a job description is being developed. The A&E Tracker role will trouble-shoot any issues arising to improve patient flow throughout all EDs. National innovative recruitment campaign focused around acute physicians but also encompassing other specialities. Ambulatory care process reviewed, PDSA cycles undertaken, work with NWAS in place on direct triage from ED to ambulatory care NMGH rollout of Trusted Assessor framework. An audit of the use of exclusion criteria for Ambulatory Care has been delivered in January to confirm the right patients are being progressed through the pathway. All newly qualified staff have a six-week supernumerary preceptorship, in excess of the period defined in the Trust policy. All newly qualified nurses have an identified mentor and preceptorship. Emergency Department Extended Wait Policy has been reviewed with clear escalation and reporting procedures defined, in line with Greater Manchester processes. It is too early to assess the full impact of these roles, but the median time in ED has stabilised. These roles will commence in April This commenced in February 2017, and there has been good initial levels of interest in the vacancies. Non-elective LOS reductions from 5.9 to 5.2 days over last 12 months. 30-day readmissions down by 0.7% to 5.6% Left without being seeing rates down from 6.8% to 4.9%. Attendance to admission rates improved and maintained below national average. This has led to better patient flow and patient experience throughout the ED dept. and helps free up time for clinicians to attend to more major injuries. A pilot at NMGH recently found that 15% of patients in ED are suitable for Ambulatory Care, and the Trust has set a target of 20% to achieve for coming months. Performance Development review (PDR) rates across all EDs have increased from 49% to 89% (nursing and medical staff combined). PDRs enable staff to improve their development and skills and which will lead to increased patient quality and care. This provides clear guidelines for clinicians which empowers them to make appropriate clinical decisions. The number of 4-12 hour target breaches had decreased since the introduction of the policy in December 2016: 621 in December to 459 in March 2017.

121 PAGE 119 Work-stream Summary of actions completed Impact Service development NMCCG have approved business case for the extended crisis response service for the remainder of Funds have been agreed for additional support workers and building improvements. The new discharge lounge at TROH has been completed and is now live and running. Two additional community support nurses are in post to support delivery of the service. This has helped alleviate unnecessary waits for patients to be discharged and has led to improvements in freeing up capacity throughout the department. The numbers of 12 hour breaches has improved from 85 in December 2016 (when the lounge was opened) to 54 in March Annual Report

122 PAGE 120 Work-stream Summary of actions completed Impact Patient flow Streaming to Primary Care Process has been developed and is now live in Rochdale. It enables patients requiring urgent specialist assessment to be streamed directly to an appropriate assessment unit. Identification and commissioning of interim beds in partnership with the local authority. A Trusted Assessor role has been developed and implemented so patients are assessed by just one healthcare professional, on behalf of all professional groups. This has improved the patient journey and efficiency and safety of the patients requiring specialist assessments at the Rochdale site. From Dec 2016 to end March 2017, there were no 4-hour breaches from 456 patients on the Primary Care Pilot. This facilitates timely discharges at Fairfield site, by having increased capacity for patients and by eliminating the need for separate assessments by different professional groups. Project: Maternity Care improvement Aim: stabilisation of service Work-stream Summary of actions completed Impact Safe midwifery staffing Safe medical staffing Appointments have been made to Director of Midwifery, Practice-based Educator, Deputy Head of Midwifery, Inpatient matron and labour ward matron. Recruitment of additional consultants for labour ward. Consultant job planning process undertaken. Strengthening of leadership, improved focus on training. Increase in staff development and education. Compliance with training targets. Implementation of 168 hour-week consultant resident cover on labour ward at the ROH being worked toward. Twilight shifts established. Strengthening of medical staffing rotas across all sites. Proposals for new rotas for both sites under development. All consultant job plans completed and on-call consultants meet the RCOG recommendations and non-resident consultants can attend labour ward within 30 minutes of call out.

123 PAGE 121 Work-stream Summary of actions completed Impact Managing risk Mortality and morbidity Communication QI Capacity and demand Single site preparation Implementation of risk assessment tool for use within Maternity including EWS for adults and neonates. Review the internal governance structure including Complaints, Risk and Project Management. in the management of Clinical Incidents, support development of culture in which lessons are learned - including feedback mechanisms. Addition of Midwives to the TOR for meetings, and for matrons to attend as a minimum. Administrative support provided to ensure support to meetings. Review of communication across the Division. Quality improvement methodology is being embedded into the review of services across W&C. Comprehensive capacity and demand work completed for all services in W&C. Significant infrastructure in place to support the early transfer of W&C services. Tools implemented and audits of effectiveness planned. Full review of governance and risk structures completed. Historic cases completed and moved into real time case management. Strengthened the process for management of incidents, including feedback to staff, establishment of comprehensive feedback mechanism. Focus on key themes with development of on key work streams to ensure repeated incidents are reduced. Comprehensive review of all cases provided at the M&M meetings. Focus on learning lessons and wide ranging attendance from across the Division achieved, alongside attendance monitoring. Implementation of core huddles. SBAR handovers in place. Newsletter for all staff. Strengthening of local meetings to improve communications Greater focus on understanding the data within individual services. Development of comprehensive dashboards to ensure attention on key areas is achieved. Variation in service delivery achieved across a number of metrics. Identification of areas requiring attention. Development of action plans, work programmes and a number of task and finish groups to drive improvement work through. Milestones established to monitor transfer. Annual Report

124 PAGE 122 Project: Paediatric Care improvement Aim: stabilisation of service Work-stream Summary of actions completed Impact Workforce Managing risk Governance Mortality and morbidity Training Appointment of Patient Flow Co-ordinators to review patients with length of stay of over 4 days, and introduce a system to capture and monitor patients needing higher levels of care. Paediatric escalation audit has been completed. Review of existing clinical guidelines. Implementation of risk assessment tool for use within Paediatrics including EWS at Oldham. Review the internal governance structure including Complaints, Risk and Project Management. in the management of Clinical Incidents, support development of culture in which lessons are learned - including feedback mechanisms. Review of ToR: it is now compulsory for matrons to attend. All nursing staff band 6 and over are invited to attend. Plan for medical and nursing staff to be trained in advanced paediatric life support and paediatric intermediate life support Weekly length of stay meetings established. Shortening of pathways and length of stay across a number of pathways e.g. asthma. LOS dashboard established to benchmark performance and used to drive further improvement. Development of paediatric capacity escalation guidelines to ensure prompt escalation and reduction in transfers of children out of the service. Work is in progress to complete the review. MANCHEWS assessment tool embedded into clinical practice. Full review of governance and risk structures completed. Historic cases completed and moved into real time case management. Strengthened the process for management of incidents, including feedback to staff, establishment of comprehensive feedback mechanism. Focus on key themes with development of on key work streams to ensure repeated incidents are reduced. Comprehensive review of all cases provided at the M&M meetings. Focus on learning lessons and wide ranging attendance from across the Division achieved, alongside attendance monitoring. Training needs assessment carried out to ensure that training in life support is appropriate to job role and skill level required. This is comprehensively in place alongside a sustainability plan.

125 PAGE 123 Work-stream Summary of actions completed Impact Communication Clinical practice Engagement sessions to ensure staff have the opportunity to contribute to service improvements. Tops and Pants initiative - Patients, Parents. Review of capacity and demand within Outpatient areas (NMGH) and inpatient / POAU areas (ROH) - making recommendations to improve service provision identifying benefits realisation. 23:59 paediatric assessment unit has been established at Oldham. Going for Gold staff involvement sessions have enable staff to drive services changes and undertake tests of change to implement new ideas and plans. RESPECT feedback boards established. National initiative which has been embraced in paediatrics encouraging families/carers and young people to give feedback on their experience. New services models and ward configuration being trialled to test effectiveness of proposed models. Significant reduction in length of stay in ED for children requiring an inpatient or observation bed. Reduction in transfers of children out of Pennine for secondary care bed needs. Ongoing monitoring and assessment to understand effectiveness of services. Annual Report

126 PAGE 124 Project: Critical Care improvement Aim: stabilisation of service Work-stream Summary of actions completed Impact Recruitment & Retention: Medical and Nursing Advanced Critical Care Practitioners (ACCP) Equipment/ Environment Governance A medical and nursing business case has been approved and is being implemented: 2.98 qualified nurse posts were approved for FGH, 5.01 for ROH and 3.14 for NMGH. 4 additional consultants and 7 speciality doctors were approved for ROH. Overseas recruitment of speciality doctors is on-going and to date one is in post in ROH with a further three to start June / July However, all overseas recruits need a sixmonth induction so won t be in the numbers on the rota independently until December Nursing recruitment is on-going with some appointments already made, and working within the numbers. A matron for ROH ICU has been recruited and is in post: this role has added a greater level of experience, and leadership to the team. Two ACCP trainees have been appointed and commenced a 2-year training programme in Feb A further two are to commence in Feb A funding case for a new 24-bedded Critical Care Unit at Oldham has been submitted to the Treasury and is awaiting final approval in August With support from the newly appointed ROH site lead, and a unit manager undertaking additional governance responsibilities, a biweekly mortality and morbidity meeting was established. This developed to becoming a joint site meeting over the ensuing months. Approval of the business case has enabled the service to work towards full staffing compliment and will lead to improved performance and patient safety over the next 6 to 12 months. At end March, there were 0.33 qualified nurse vacancies at FGH, 4.19 at ROH and 2.72 at NMGH. However, the position continues to fluctuate. There is still a shortfall of 8 consultants at ROH (including the additional posts from the business case), 1 at FGH from a recent resignation, and 1.5 at NMGH. 3 remaining speciality doctor posts at ROH, and 2 between FGH and ROH, are being actively recruited to. The vacancies pose an on-going risk/challenge for the service. These roles will enhance the staff cohort by stabilising the units reliance on agency staff and will lead to greater stability within the units participating in the resident layer of the rota. These developments will ensure that the service is safe and fit for purpose, and comply with the mandated requirements (NHS England s D16 standard contract for adult critical care, and the Department of Health s HBN guidance on planning and design of critical care units). The introduction of a designated site lead has led to more robust governance and clinical expertise at site level. There is a focus on the learning outcomes of these meetings. The new structure and processes need to become embedded.

127 PAGE 125 Work-stream Summary of actions completed Impact Education/ Training Work to improve compliance with mandatory training and PDR completion has been delivered in terms of addressing and identifying the gaps. There has been a significant increase in the number of staff appraisals completed and the directorate are on track. The nursing staff with personal development plans in place at 31st March 2017 was: FGH 100% TROH 89% NMGH 100% Project: Deteriorating patient (incorporating the quality priority to improve early identification and management of patients who are deteriorating ) Aim: To reduce the rate of cardiac arrests by 50% by 30th November 2017 Work-stream Summary of actions completed Impact National early warning score (NEWS) chart Sepsis drive Deteriorating Patient Collaborative Learning Session 2 NEWS observation chart pilot completed. The final version of the NEWS observation chart is being rolled out across the Trust from 7th April 2017 with aligned training. Sepsis e-learning module developed and has been made essential job training for all clinical staff in emergency departments and treatment units; training is to be completed by Q1 2017/18. The sepsis screening and action tool has been ratified by the sepsis steering group and will be rolled out across the Trust in April A Sepsis communication drive is planned for the week of 3rd April This was held on 1st March Each innovation ward updated on their tests of change. A focus was placed on udnarcpr in the latter half of the day. From pilot feedback, staff feel more confident in identifying and knowing when to escalate a deteriorating patient. Better training and education will enable staff to recognise and respond to sepsis in a more timely way to improve care. Overall, staff reported more confidence in 1) identifying, 2) escalating and 3) managing the deteriorating patient. Annual Report

128 PAGE 126 Project: Infection prevention Clostridium difficile infection reduction 90 day improvement cycle Aim: to improve hand hygiene compliance and antibiotic stewardship Work-stream Summary of actions completed Impact Antimicrobial stewardship Improving hand hygiene for patients using an innovative five moments of hand hygiene model. Urinary tract infection screening toolkit developed to support effective and accurate diagnosis of UTI with appropriate antibiotic prescribing. Staff engagement and training complete. Antimicrobial stewardship tests on ROH AMU commenced 28th February and impact of test to be reviewed week commencing 3rd April Staff education of patient hand hygiene moments (the occasions when patients should undertake hand hygiene) is completed. Patient awareness posters and leaflets have been developed. Hand hygiene wipes made available to all patients. Patient Hand Hygiene first cycle complete; test sites are ROH Ward T3 and FGH Ward 18. Pilot has also been extended to three other wards for additional reliability / validity. Initial audit results reviewed and areas for improvement have been identified. The next stage will be to monitor and review the use of the screening toolkit on AMU. At the half-way stage of the test period the average increase in patient hand hygiene compliance was: Ward 18 at FGH 74% Ward T3, ROH, 74% Project: Pressure ulcer reduction Aim: (proposed) 30% reduction in grade 2; and 50% reduction in grades 3 and 3 pressure ulcers by April 2018 Work-stream Summary of actions completed Impact Scoping Expert meeting was held 30th March. Driver diagram formulated. Ward involvement / project structure agreed. Project initiation document is in development and will be presented to May EQPE by Tyrone Roberts. Attendees introduced to the proposed methodology. This will prepare for the initial learning event to commence the programme at the end of June Project: NAAS ward accreditation (nursing assessment and accreditation

129 PAGE 127 system) (incorporating the quality priority to implement the accreditation programme for wards and departments across the Trust ) Aim: to conduct an initial assessment on all 59 wards by w/c 14th July 2017 Work-stream Summary of actions completed Impact NAAS: preparation and pilot. Implementation of NAAS Implementation of action plans Leadership Salford documentation reviewed to reflect PAHT needs and pilot completed on nine wards. To 31st March, 25 first assessments and three reassessments have been undertaken. 14 wards were graded red, 8 amber and 6 green. s made in the areas identified as required in the pilot ward. Action plan implementation is monitored by the relevant divisional senior nursing team. Three corporate matrons have been recruited to work with the NAAS team. A tested tailored methodology in place to roll out Trust-wide. Action plans have been developed by the relevant ward managers and improvements implemented. These improvements will be validated in the reinspections. Wards scoring red have two weeks to complete their action plan, and are then reassessed after eight weeks. If wards are graded red for a second time, the senior nursing team meets with the Director of Nursing to compile and agree the action plan. Targeted priority and support is given to these areas. These improvements have resulted in the NMGH pilot ward going from red to amber, and the FGH pilot ward going from red to green. These improvements reflect a direct improvement in patient experience and safety. They will commence in post in May Project: Help-line implementation Aim: To have a phone, manned 24/7 on each site by a senior member of staff, that patients and their families can use Annual Report

130 PAGE 128 to raise urgent concerns Work-stream Summary of actions completed Impact The helpline scheme provides a mechanism for patients or their families to contact a senior member of staff who has responsibility to respond to their call. Help line is now available across the Trust. During December 2016 and January 2017 the help line scheme was successfully piloted within the Trust. The implementation phase of the scheme was completed during February and March 2017: a total of 78 wards and departments across all four hospital sites and off-site premises such as the Trust s intermediate care homes and the rehabilitation unit. Each of the sites is responsible for managing an on-call rota 24/7. The helpline scheme is advertised by displaying posters in each of the bed/bay areas. In addition, each ward & department entrance has a larger A3 sized multi-lingual version of the poster. Information from the calls placed to the helpline contributes to identifying areas for safety or patient experience improvement within the Trust. Since the implementation of the scheme, there have been six calls made to the helplines; four of which were at NMGH, and two at TROH. All six calls were successfully managed without escalation to the executive for intervention, though one call was escalated for information. Project: Mortality reduction (incorporating the quality priority to review and improve the Trust s independent mortality review processes )

131 PAGE 129 Aim: year on year improvement in HSMR to be in top 10% of acute Trusts Work-stream Summary of actions completed Impact Analyse relevant information to gain a full understanding of the current position Maximise the effective use of available information systems Identification of the five clinical conditions showing most excess deaths: pneumonia; UTI; stroke; COPD; and renal failure. Agreement with Dr Foster that they will conduct the clinical review of excess deaths at FGH. Clinical documentation / coding review of case notes in the alerting conditions completed internally (doctor and coder working together). Internal review of low-risk deaths in April / May 2016 completed. Mortality time-lines have been created, mapping the timeframes of significant operational issues against changes in mortality rates. Processes and responsibilities for routine surveillance of Dr Foster, and for investigating alerts, have been agreed. Process flowchart developed. Training needs analysis for different staff groups has been completed. Training in Dr Foster system commenced. Further analysis is focusing on these areas. This will ensure independence and objectivity in the review. It is expected to report at the end of May Areas for improvement identified: accuracy of primary diagnosis coding accuracy of comorbidity coding It has been recognised that introduction of a summary of care document will make a significant impact. Review identified some deaths were not lowrisk and had been wrongly classified from documentation / coding. A quarterly review of the lowest risk deaths will now be undertaken routinely Initial review shows a rise in HSMR following implementation of the Evolve system, and following the reduction in coding deadline timescale. These timelines will be kept as routine work to support analysis of varying rates. This informed the training needs analysis. Training schedule agreed with Dr Foster. Staff able to use the system effectively to identify areas for further investigation. Annual Report

132 PAGE 130 Work-stream Summary of actions completed Impact Ensure accuracy of clinical documentation and coding Improving mortality surveillance with the development of a systematic and cohesive approach Acting on findings and making improvements Strengthening governance arrangements 60 sets of case notes have been reviewed for accuracy: doctor and coder working together. Review of coding processes for discharged and deceased patients completed. Routine monthly reviews continued, and backlog has been addressed. Requests to the new care organisations to nominate staff from other professional disciplines for the core review team. Review of each speciality s approach to mortality case reviews at clinical governance meetings. Development of standard templates for local investigation and reporting, including core agenda for governance meetings. The structure and processes for sharing findings from all mortality reviews, including approval and monitoring implementation of actions, has been agreed and standardised. Mortality Surveillance Group has been established - will receive reports relating to all mortality investigations, and monitor progress of improvements. The core standards and ToR for M&M meetings (or for the M&M component of clinical audit meetings) have been agreed and disseminated to the directorates. Site Medical Directors have been asked to nominate mortality leads for each site/ speciality. Key areas for improvement have been identified and communications prepared and sent to doctors. Findings to be incorporated into coding training sessions. Standard Operating Procedure agreed. Identified the requirement for a summary of care document for deceased patients, and this is being developed in association with the end of life care group and IT. Reports will now be circulated two months after the month of the deaths: this will facilitate timely actions and better links with speciality reviews. This will be required with the forthcoming new national methodology. Identification of best practice and agree the benchmark and core requirements for local mortality review. To provide clear guidance for the speciality leads in relation to their responsibilities and processes. This will facilitate sharing and learning from findings. All mortality information is now channelled through the same group to facilitate monitoring. To provide clear guidance for the speciality leads in relation to their responsibilities and processes. The mortality leads will lead mortality governance on behalf of the site medical directors.

133 PAGE 131 Project: End of Life and Bereavement Care Aim: Equitable care irrespective of place of dying - every patient - every time. Work-stream Summary of actions completed Impact End of Life Care Ward walks throughout Trust incorporating updates on: Individual plans of care and support for the dying person Rapid transfer pathway Recording time of death and reasons for this Recording care given at end of life, at death, after death Recording care given to relatives Guides / uniformed groups initiative for provision of comfort packs. Revised notification of death form. Revised mortuary deceased person bag form. Raise awareness of EOLC initiatives to staff and increase knowledge. Empower staff members. Annual Report

134 PAGE 132 Work-stream Summary of actions completed Impact Implementation of swan symbol to represent end of life and bereavement care End of Life Care and Bereavement For patients and relatives: Swan signs in A5 and A4 for all wards and departments. Swan magnets for patient boards. Swan patients property bags. For staff (to raise awareness / profile): posters the meaning of the swan. Various accessories, e.g. swan calendars, pens, post-its, notepads, A7 pocket cards. Swan pin badges for uniform lapel to be issued to staff as appropriate. End of life care resource files revised and fully updated with new initiatives, signposting to education, policies and webpage, swan model, spiritual care, and delivered back to the wards. End of life care storage boxes for all wards and departments containing: All swan merchandise Comfort packs Personal message cards Sympathy cards Lock of hair pouches Ring/treasure boxes Religious and spiritual aids such as The Bible, The Quran, rosary beads etc. Relevant information leaflets Increase standards of care within bereavement by staff relating a best practice model to care delivery provided to our patients and families. Increase in staff knowledge in relation to resources available for bereavement and EOLC, providing quick reference guides and resources at close hand. This will in turn increase the quality of care delivery and ensure we are providing choice and options as appropriate at the EOL.

135 PAGE 133 Work-stream Summary of actions completed Impact Education and Training End of Life Support Volunteers Link Professionals Bereavement Nurses Bereavement Offices Launch of monthly end of life care and bereavement care study days Trust-wide for all staff. Real time coaching provided on wards; Trustwide but with an initial focus on NMGH and ROH. Bereavement and all end of life care, incorporated into existing modules of palliative and end of life care education running four times a year Trust-wide. Bereavement, tissue donation and all end of life care incorporated into link professional meetings, running three full days a year Trustwide. Regular slots on NMGH ED mandatory training days aim to establish the same for each site. Focus on appropriate use of the individual plan of care and support for the dying person along with the communication diary. udnacpr audit, improvement, education throughout the Trust and launching three half-day conferences. Work on-going with patient experience team to ensure a safe effective service of volunteers Trustwide, who follow a structured role description with Trust governance and support mechanisms. Currently a revised title and contract being developed to incorporate the NAAS and individual appraisal systems. Job descriptions for dedicated bereavement nurses for each care organisation are finalised awaiting agreement prior to advertising. Dedicated bereavement swan suites for NMGH, ROH and FGH/RI. Areas identified. Agreed building plans. Furnishings ordered. Increase education, knowledge, confidence & competence of all staff groups across the organisation and provide them with ownership and engagement in relation to bereavement/eolc. Increased support and experience for patients and families at the EOL. Increased knowledge, confidence and competence of bereavement/eolc which will be cascaded back to clinical areas. Improved quality, experience and support to our bereaved families across the organisation. Improved quality, experience and support to our bereaved families across the organisation. Annual Report

136 PAGE 134 Work-stream Summary of actions completed Impact Swan Suites Multi Faith Group Work with Coroner and GMP Service review Work with mortuaries Work with Portering staff Data collection Collaboration with the theatre departments across the organisation to develop their own swan suites. Formation of a multi faith care after death group to ensure a quality service, meeting the faith communities needs and reviewing current guidelines. Partnership working. Specific joint initiative around patient identification by families. Service review undertaken of the Specialist Palliative & EOLC teams across the organisation. Review of mortuary services. Review of the environmental facilities for families. Review of historical working practices. Collection of key data following every death of every patient across the organisation. Improved quality, experience and support to our bereaved families across the organisation. Improved care after death for our faith communities. Appropriate access to a workforce meeting the SPC/EOLC needs of our patients and families 24/7. Improved experience for patients and families. Appropriate provision and access to mortuary services Trust-wide. Adherence to safe working practices. Ability to produce regular reporting of data so identification of gaps, compliance can be addressed appropriately. Project: Hospital at Night Aim: to review the night practitioner and night management teams to enhance patient flow and improve out-ofhours safety for patients. Work-stream Summary of actions completed Impact Activities of Hospital at Night team Audit results collated by night teams on each site using the data collection tool and presented to the hospital at night steering group. Highlighted the variation in practices between sites. This information will be used to develop the improvement plan for work to progress in

137 PAGE 135 Project: Safeguarding and medicines safety Aim: 12 month work plan for improvement Work-stream Summary of actions completed Impact MCA/DoLS Training Level 3 Safeguarding Adult Training Clinical Medical Champion has been identified for MCA/DoLS. Extra MCA/DoLS sessions have been delivered to key areas across the Trust since Q3 during reaching a total of 354 staff by end of Q4. Added to the other training in which MCA/DoLS is covered (Safeguarding, MCA/DoLS Master class, Dementia study day, Patient Safety training days) a total of 1772 staff have received MCA/DoLS training during NAAS returns will be used to identify hot spot wards which are offered extra drop in sessions to provide additional training for MCA/DoLS. First MCA/DoLS master class was held in November Additional classes will be held in May Mandatory Safeguarding Adult Level 3: although there is an annual decrease of 4% at Q4, there is a 2% increase since Q3 and a 9% increase since Q2. Overall percentage uptake of training is at 73% for Safeguarding Adults Level 3 against an internal target of 80%. It should be noted that the apparently slow rise in percentage uptake is largely due to the 22% rise in headcount. If we were to look at the percentage uptake at Q4 alongside the headcount given for Q4 last year we would see an uptake of 88% for Level 3 Safeguarding Adults training (15% increase). Training compliance figures disaggregated per Care Organisation by ward/dept to support local leadership accountability. Improved understanding of process for staff and improved care for patients and families. Improved understanding of process for staff and improved care for patients and families. Annual Report

138 PAGE 136 Work-stream Summary of actions completed Impact Level 3 Safeguarding Children Training Children Caring Responsibilities Dementia Falls Medicines Management Mandatory Safeguarding Children Level 3 is showing a sustained increase at 75% (against the 80% target), and is 12% higher at Q4 than the same period last year. This is particularly encouraging in light of the headcount, which has increased by 31%. If we were to look at the percentage uptake at Q4 alongside the headcount given for Q4 last year we would see an uptake of 98% uptake of Level 3 Safeguarding Children training (23% increase). Training compliance figures disaggregated per Care Organisation by ward/dept to support local leadership accountability. An additional question regarding caring responsibilities has been incorporated into the proforma when a child attends A&E. This has been uploaded to Symphony and available to all EDs and UCC. Successful implementation of a project to turn off paper in the children s area and have electronic patient records only. Dementia training video produced and used at all Trust inductions. Dementia screening process reviewed and the first two stages of the process have been incorporated into the nursing admission process. Training sessions provided on each site to ensure staff understand the assessment process. Falls management leaflets have been made available on wards for both patients and visitors to read. The Trust have adopted the Royal College of Physicians leaflet; Falls prevention in hospital: a guide for patients, their families and carers, and this was ratified at Safeguarding Committee in November 16. Internal audit review of medicines management completed. Outcome to be reported at improvement board, CEC and Audit committee. Clear reporting mechanisms provided through CEC for medicines management assurance. Themes identified through NAAS to support improvement via localised action plans. Improved understanding of process for staff and improved care for patients and families. Improved understanding of process for staff and improved care for patients and families. Improved understanding of process for staff and improved care for patients and families. Improved understanding of process for staff and improved care for patients and families. For additional information, please see section Identified areas for improvement. Improved care for patients.

139 PAGE 137 Project: Risk and Governance - systems and management of claims, complaints, inquests, and incidents (incorporating the quality priority to improve the Trust s responsiveness to complainants ) Aim: 12 month work plan for improvement Work-stream Summary of actions completed Impact Claims Complaints Inquests Incidents Draft policy developed and awaiting sign off. EL/PL claims are now in-house and recorded on the Safeguard system, along with clinical negligence claims. For all governance areas that use Safeguard preliminary works have been completed to create the modules on the new Datix Risk Management System and will commence testing of these modules in April Developed reports per Care Organisation which detail the number of outstanding complaints against trajectory. New Interim Head of Complaints, PALS and Legal Services commenced in post March KPIs agreed with CCGs for Additional support provided by all CCGs. No outstanding MP complaints. All inquest leads have now moved towards case management. The backlog in the system has been reduced and all inquest leads are now up to date with all cases. The inquest outcome backlog has been completed. All SOPs have been produced and formally ratified. Inquest Review Lead and Datix Project Manager have met to design the inquest modules. 8 inquest training sessions have been delivered across the Trust. All 2015 serious incidents have been signed off and completed by divisions. At the end of March, there were three Q serious incidents outstanding. Continued support provided by CCGs. Consistent approach to managing all aspects of claims and identification of themes across the organisation. Reduction in backlog and improved management of complaint responses. There were no complaints over 100 days at 31 March Improved relationships with coroners, improved information sharing with families. Clear local accountability with clinicians and support for attendance at coroners court. Reduction in backlog and improved learning and improved care delivery for patients. Improved support for families with senior manager identified for Duty of Candour (see section 3.4.1). Annual Report

140 PAGE 138 Project: Improve patient flow including bed management, implementation of the SAFER care bundle and system resilience (incorporating the quality priority to improve timely access for patients requiring urgent care ) Aims: Bed Management - Implement a robust bed management structure through the standardisation of bed management meetings, documentation and escalation procedures, to improve patient flow and A&E performance standards. SAFER - to implement the SAFER patient flow bundle across all wards by the 31st March 2017, in order to comply with national requirements. System resilience - to expedite patient discharges to reduce length of stay and delays in transfer of care. Work-stream Summary of actions completed Impact Bed Management Bed Management Bed Management Escalation Policy Bed Management Supporting Choice for Reluctant Leavers A baseline assessment of bed management meetings, engagement, checklists, processes, roles and responsibilities across three sites has been completed. This included testing of: standardising new roles and responsibilities bed meeting format and guidance. Amendments to the Sit Rep ensuring a clear set of daily core actions are agreed and documented. This includes introducing a SBAR safety huddle at weekends. This has been tested at FGH, and awaiting a date to be tested at ROH. Escalation triggers have been extracted from relevant policies and procedures and collated. Five letters have been produced which relate to different situations where patients are reluctant to leave the hospital. Areas for improvement were identified which informed the project. The trial of Sit Rep was a success, and the trial form is still in use as the everyday way of reporting. However, it is not always possible for the huddle to take place at weekends, depending upon site pressures. As an alternative, individual face-toface conversations take place with each areas consultants or representatives. This will inform the development of escalation policy and action cards. These will append to the Discharge Policy once reviewed, and will provide confidence for staff in managing patients who are reluctant to leave.

141 PAGE 139 Work-stream Summary of actions completed Impact SAFER SAFER rollout commenced on 26 July 2016, with the exemplar ward programme wards commencing implementation from September. The full roll-out was completed on 7th February 2017, with 55 wards and departments across the Trust being included. Outcome measures: Length of stay, Discharges/transfers before 12noon, Data for the measures identified shows very little improvement at 31 March 2017, from the June 2016 baseline (see table below). NAAS assessments across 23 areas showed that on just under half of these the staff were unaware of SAFER and didn t have robust board rounds or white boards in place. >6 day length of stay ( stranded patient metric ). Indicator FGH NMGH TROH RI Trust Date Jun 16 Jul 16 to Mar 17 Jun 16 Jul 16 to Mar 17 Jun 16 Jul 16 to Mar 17 Jun 16 Jul 16 to Mar 17 Jun 16 Jul 16 to Mar 17 Average LoS % discharged before LOS >6days Annual Report

142 PAGE 140 Work-stream Summary of actions completed Impact SAFER The Emergency Care programme team (part of NHS ) has supported the Trust with the review of the initial impact, and areas for improvement have been identified. System resilience: Trusted Assessor System resilience: Discharge To Assess (D2A) Future priorities include: Improving discharge lounge facilities. Site leadership teams to identify clinical, nursing and managerial site SAFER leads. Reviewing the measures in order to capture the actual impact. The site leadership teams will confirm actions and next steps for each site in relation to these. Trusted assessments for re-ablement Services for each NES locality are now completed by acute occupational therapists and physiotherapists at all sites for all patients requiring the service. A Trusted Assessment form has recently been created for Intermediate Care beds. This is currently being trialled at Fairfield General Hospital and North Manchester General Hospital. FGH and Rochdale Infirmary have commenced pilot of D2A using SRG funding for Rochdale patients. ROH has been piloting D2A for low level patients, and now wish to refresh their model in order to adopt a model similar to Rochdale. A reduction in average length of stay from the point of referral to discharge home has been achieved. Pre-project measure: 2.5 days (median). Range 1 7 day Post-project measure: 0.5 days (median). Range days Occupational therapists and physiotherapists are now able to complete assessments for patients that require Intermediate Care beds in Bury and North Manchester. The HMR D2A Pathway has had a positive impact on reducing delayed transfers of care for HMR patients at Fairfield General Hospital and Rochdale Infirmary. This has been done by discharging up to 80% of their medically-optimised patients who are awaiting assessments, and ensuring that these are completed outside of a hospital, regardless of their needs. The D2A project that was piloted at The Royal Oldham Hospital targeted patients with limited care needs only. To have a greater impact, the Oldham Urgent Care Alliance will be looking to expand this project to replicate the model in Rochdale in quarter 1,

143 PAGE 141 Project: Data quality (PAS upgrade, RTT and training, booking and scheduling review) Aim: To cleanse and improve data quality in PAS / RTT in line with the required standard. Work-stream Summary of actions completed Impact PAS data cleansing RTT Booking and scheduling improvement The master files on the system have been cleansed, and updated, e.g. in relation to consultant attribution, clinical specialities, and appointment type. An external elearning package has been rolled out to the booking and scheduling team, and all members have completed it. A permanent RTT trainer has been appointed commenced in post December Review of service looking at the systems and processes in place at Rochdale (centralised service). 12 staff engagement sessions have been held these included process mapping of clinical specialities individual pathways. A patient experience survey has been undertaken. Work to standardise OPA outcome forms has been commenced. KPIs for the booking and directorate teams are being developed. Accurate data is retained on PAS. Accurate up to date lists, e.g of current consultants, facilitates accurate completion of new entries. This work will be completed by August 2017, prior to the planned upgrade. The training has helped to ensure accuracy of data recorded, e.g. codes used for certain pathways etc. Classroom-based, role specific training will be provided, and updated accordingly. Differences in the clinical teams processes to short-notice cancellations have been identified and will inform actions to reduce these. Core improvements have been identified to inform future plans and actions. This has provided a baseline assessment of patients views of the booking processes and improvement actions identified. Awaited. Awaited. Project: Data quality in Emergency Department (ED systems, breach Annual Report

144 PAGE 142 analysis) Aim: Provide assurance regarding data quality in ED following MIAA review in Work-stream Summary of actions completed Impact Analysis of clock stops Breach analysis ED systems ED systems Data interrogation for patients attending ED with assault related issues An audit of clock stops between 3 hours 30 minutes and 4 hours was undertaken to verify the validity of the data. This showed an error rate of 1.5% with little variation between sites. The processes for breach validation have been standardised and documented. This is undertaken across all sites by a central team based at Oldham. Supporting data related to the implementation of the Extended Waits Policy, e.g. response by specialities within 1 hour, is provided to the directorates. Job descriptions for certain roles in ED, e.g. tracker roles, have been revised to provide clarity in relation to responsibilities for data quality. Worked alongside the Data Quality Engagement Officer at the Public Health Institute to understand how to improve compliance with the College Of Emergency Medicine s Trauma and Injury Intelligence Group (TIIG) data. An internal audit of data entry identified errors in the data being extracted by TIIG, which has been rectified. This provided assurance regarding live processing of patient data in the Emergency Departments. A quarterly point prevalence audit of clock stops before 4 hours will be undertaken to provide continues assurance. Improved quality and assurance regarding standards of breach validation for the Trust. Provided a feedback mechanism for quality improvements in ED care, for specialties and directorates to identify actions for improvement. Improved quality and assurance regarding standards for data quality in the Emergency Department. Across the data set range, Oldham has improved from % compliance in July 2016 to % in November Correct data will enable better identification of areas of risk to facilitate targeted improvements by Public Health to improve public safety. Project: Safe Staffing / Recruitment and Retention

145 PAGE 143 Aim: To ensure safe staffing in every department Work-stream Summary of actions completed Impact Recruitment marketing Recruitment events 19 staff videos and 4 case studies now on www. pat.nhs.uk/working-for-us/meet-the-team Trust fleet vehicles now displaying RECRUITING NOW magnetic signs, signposting to vacancies webpage/social media. RECRUITING NOW banners have been produced and will shortly be installed in each site. Joint recruitment banner stand for PAHT/SRFT produced for use at events. Intranet article developed to showcase recruitment marketing activity nhs.uk/corporate-departments/hr/nursingand-midwifery-recruitment.htm Radio adverts for Band 6 Nurse vacancies ran in January on Revolution Radio, Key 103 and Heart Radio. Attendance at RCN Manchester event communications made, all received personal s and offer of applying for role. Dedicated vacancy advert created for applications relating to this event. Newly qualified recruitment event 47 attended for interview (45 adult and 2 Paediatric). Will track number of people viewing pages that are being promoted. 55 applications received, 43 shortlisted (18 of which were external), 29 attended interview with 18 appointed (of which 7 were external). Two of those appointed applied as a direct result of hearing the radio adverts on Key 103 and Heart. Newly-qualified recruitment event: roles were offered to 39 (adult-trained) nurses and two paediatric students were passed for interview to the paediatric management team. Two further paediatric students were identified at shortlisting. Facebook/ Twitter six candidates attended as a result of seeing our campaign. Safer staffing A further 16 band 6 nurses appointed (7 external) through Trustwide campaign, resulting in 44 appointed in total against the 100 agreed. RCN Jobs Fair - eight candidates attended following their visit to our stand or due to a friend s referral. Annual Report

146 PAGE 144 Work-stream Summary of actions completed Impact Workforce transformation Staff engagement and retention The Trust was successful in its GM bid, being allocated 48 trainees - both internal and external candidates. They are either on secondment from their substantive post or on a two-year fixed-term contract. The two-year programme commenced in January The trainees will be supported by two Clinical Educator Facilitators who are funded by HENW (Health Education North West). New roles to support existing professions, e.g. physician associates, trainee nurse associates, and pharmacy technicians have been introduced. We have also expanded our approach to advanced practitioners across different professional groups nurses, physiotherapists, pharmacists and paramedics. Introduction of Go Engage staff engagement framework. A new improved exit questionnaire to has been launched. Trainees have been placed across both acute and community services and specialties. The aim is to have staff with the right skills and competencies to deliver excellent care. Ensure that staff we have trained and developed remain within the organisation. To have a better understanding of the reasons why staff have left the Trust, and to take action to address them.

147 PAGE 145 Project: Healthy, Happy, Here Aim: Improve the health and wellbeing of the workforce by raising awareness, promoting and embedding health and wellbeing into the Trust. Over time this will assist in reducing stress, increasing morale and improving the quality of care for patients. Work-stream Summary of actions completed Impact Healthy Happy Implementation of podiatry, physio and counselling services offered by Occupational Health Services. Staff Support Networks arranged. Implementation of a new Values Based Appraisal Framework. Launch of the Pioneer Programme and Pulse Survey. Improved health and wellbeing of staff. The BME and disabled staff networks have been implemented along with mentoring scheme for BME staff which has seen a positive impact on the individuals morale. Having a viable and engaged workforce is a key priority for the Trust, which is supported by staff being able to have regular discussions with their supervisor /manager. These are ongoing conversations to review the previous year and look forward and plan for the next so that relevant objectives are set. It is also an opportunity for an aspirational discussion about job role/future career to take place. Analyse staff engagement within the organisation which will help form improvement plans. Here Centralisation of the medical staffing function Implementation of the Trac recruitment system. Implementation of a new on-line exit questionnaire. Over recruitment of HCSWs to build up a pool. To improve efficiency and quality of service. To improve efficiency and quality of service. Reducing time to recruit resulting in reduced reliance on agency staff. To obtain better feedback from staff who are leaving the Trust, to support retention of staff. To reduce the reliance on agency staff resulting in improved quality of care for patients. Annual Report

148 PAGE 146 Project: Leadership Clinical Aim: To ensure that the Trust s leaders have the confidence and capability to be effective leaders Work-stream Summary of actions completed Impact Transforming leaders programme The Pennine Ward Managers Leadership Programme Programme was delivered to all senior divisional and directorate triumvirate leaders. Six days of training over a 14-month period. Programme combined individual and group work, with some external speakers. Feedback was obtained on final day of programme (Dec 16) from which a summary paper was drafted for the Workforce and Organisational Development Committee, which will inform development of future programmes. The programme, delivered to 70 band 7 ward managers, was completed in November: four cohorts participated in five days of experimental, action and simulation learning over one year. The programme was co-designed and co-delivered with the senior nurse leaders, clinical simulation team and Salford University. Scenarios with subject matter experts helped to maximise learning through solution focussed and guided reflection. Input was variable from internal senior nurse due to operational issues and organisational changes. The quality improvement component to the programme concluded with a Festival of Learning where the participants shared their projects with key stakeholders. Delegates valued the opportunity to take part, and felt that it improved self-knowledge as leaders. An opportunity to work in different ways with colleagues across the Trust. Attendance and level of participation was good overall. Leaders felt they d made changes to their leadership and communications styles. Leaders had a better understanding of the context they operate in. However, some of the group work was not as effective as it might have been. (This will be considered in developing future programmes). The Festival of Learning showcased a number of Innovative project ideas were apparent including: Reduction in falls in transferred patients. Reviewing discharge process. End to end process for improving quality of care for nephrostomy patients. Improving the response rates to call bells. Introduce improvements in treatment room processes following audit data. in detection and escalation of early warning score. Continued reduction of C.Difficile. The transferability of projects using learn & spread methodologies was explored, whilst the themes could be trended to particular groups such as deteriorating patient collaborative. It was felt that more work could be done with the projects as it is really important to acknowledge that the ward managers work has been listened to and appreciated by the Trust s senior nursing team and that this work continues.

149 PAGE 147 Work-stream Summary of actions completed Impact Executive Visibiblity Programmes of Executive work-with, Nurse Director Friday walk-rounds, and patient safety walk-rounds, have been introduced. Heightened visibility of the executives and senior management for clinical staff. Improved understanding of the key issues by senior leadership. Project: Leadership Site-based Aim: To support the formation and effectiveness of the Care Organisations leadership from April 2017 onwards Work-stream Summary of actions completed Impact Care Organisation leadership Discussion and consideration of options for the leadership structure for the new organisations. Programme in development - for delivery during next financial year. This will include programmes for: Care Organisation quartets (Managing Directors, Medical Directors, Directors of Nursing, and Finance Directors). The committee in common. Pennine Nurses Leadership Programme (from SRFT programme). Pennine Consultants programme (working in partnership with an external company). Annual Report

150 PAGE Review of Performance against Priorities for Nine priority areas for improving quality in the year were set out in the Quality Account. They each included outline plans for implementation and the proposed methodology for monitoring progress. Three priorities were identified for each of the domains of quality. They were: Patient Safety To report on harm occurring to patients, including instances of pressure ulcers, falls, infections and venous thromboembolisms To implement the safety standards for invasive procedures in all interventional areas across the Trust To improve early identification and management of patients who are deteriorating Clinical effectiveness To review and improve the Trust s independent mortality review processes To improve compliance with NICE guidelines To implement the Accreditation Programme for wards and departments across the Trust Patient experience To improve the Trust s responsiveness to complainants To improve timely access for patients requiring urgent care To review the Trust provision of access to interpreters The progress made in these priorities is summarised below. Some of them were superseded by, or incorporated within, projects of the post-cqc Quality programme and the progress and impact of these has already been reported (see section 3.1.2). Some of the projected timetables for implementation were adjusted in accordance with other work and developments, and a review of governance arrangements necessitated a change from the planned process for monitoring progress in some cases Patient Safety Priorities To report on harm occurring to patients, including instances of pressure ulcers, falls, infections and venous thromboembolisms (VTE) The rationale was to enhance the existing Patient Safety Thermometer data (point-prevalence audit) to give more information of the incidences of harm to help identify areas for improvement. The plan was to set up monthly reporting into the Corporate Performance Report on the internal harm-free care bundle, which is reported to the Board of Directors. This work was incorporated within the QI safety work-streams, which include objectives to have reliable data in place. It is acknowledged that falls data is correct, pressure ulcer data is improving, and that processes for data relating to catheter-associated urinary infections needs review. The information is incorporated into the performance report.

151 PAGE 149 To implement the safety standards for invasive procedures in all interventional areas across the Trust This was a national directive (LocSSIPS local safety standards for invasive procedures) from NHS England. It related to an area where there had been a number of patient safety incidents reported in the Trust, so was therefore included as a priority. The aim was that each clinical area undertaking interventional procedures would implement appropriate local patient safety procedures using a safety checklist based on the WHO surgical safety checklist, and that audits would show 95% compliance. A list of NatSSIPs (national standards) was provided as a template and Trusts were required first to identify all procedures undertaken across clinical settings that these would be applicable to. Following this, LocSSIPs were to be developed and implemented. The local standards were to be bespoke to the procedure, but similar procedures could be grouped where appropriate. A task and finish group of clinicians, supported by the clinical governance team, was formed to implement this programme. A scoping exercise was undertaken to identify relevant invasive procedures (and any standards and checklists already in place) was completed and a master list of these procedures was created. An overarching policy has been created, and was approved by the Executive Clinical Effectiveness Governance Committee in March. A staff guide summarising the principles for developing and using LocSSIPS has been written to accompany the policy: this is based on a document produced by Barts Trust, with their permission. The policy, staff guide and master list of invasive procedures was formally handed over to the Care Organisations after it was ratified. All Care Organisations have been tasked with reviewing areas for what is already in place, and revise their procedures accordingly where these don t already meet the minimum standards. Responsibility for auditing compliance, which will include implementation of the process and document review, lies with the relevant speciality. Capacity for this is incorporated in the clinical audit forward programmes. Annual Report

152 PAGE 150 To improve early identification and management of patients who are deteriorating This was identified as a priority when staff were consulted for their views on the proposed Quality Strategy, and it was a theme in reported incidents and complaints received. It was superseded by the Quality collaborative identifying and early intervention for the deteriorating patient, and has been reported in section Clinical Effectiveness Priorities To review and improve the Trust s independent mortality review processes The rationale for this being included as a priority was to build on the independent mortality review process that has commenced in August It was recognised that this was an area the Trust could enhance with further developments. It was incorporated into the wider mortality reduction project, with the aim to bring about year-onyear reduction in the Trust s HSMR (hospital standardised mortality rate). See section To improve compliance with NICE guidelines The rationale for selecting this as a priority was that during the preparations for the CQC inspection it had been identified that the process for assuring compliance with NICE guidance needed more rigour. A large number of baseline assessments had not been completed, and in some instances compliance with guidance was recorded though the completed assessments were not supported with sufficient evidence. The aim was to have all the baseline assessments completed with appropriate evidence stored, action plans in place to address gaps, and audits of guidance assessed as compliant being undertaken as part of the divisional audit programme. There was to be clear accountability and governance arrangements in relation to NICE guidance, led by clinical directors and speciality clinical leads, and monitored by the Trust Clinical Audit and Effectiveness Committee. Progress overall Significant progress has been made completing overdue baseline assessments and collating relevant evidence. To achieve this, the quality team has supported divisional leads and delivered a number of 1:1 workshops to clinicians. An e-learning package has been created which is available to all clinicians to use as a resource when completing the NICE baseline assessments. Robust reporting arrangements are now in place: the divisions are sent a weekly update of all the outstanding baseline assessments and action plans. This has enabled the divisions to embed a clear escalation process for the NICE guidance that is overdue, with the outstanding guidance being reviewed by the divisional management team. This has been particularly successful in the divisions of Surgery, Women s and Children s and Integrated Community Services. The plan for is to: complete the backlog of baseline assessments; undertake audits of the guidance stated to be compliant; and create and implement action plans for guidance stated to be non-compliant The new site-based leaders will be responsible for compliance with NICE guidance in their areas, and to take action in respect of the risks associated with being non-compliant. The Integrated Community Services division designated NICE champions which proved successful in progressing this work, and the sites will be encouraged to adopt this approach.

153 PAGE 151 Baseline assessments The table below shows the progress made during the year with NICE guidance completion. Guidance status Guidance under review April 2016 July 2016 October 2016 January 2017 end Mar 2017 Out of date 94 * Within timeframe # Compliant 318 * Partially compliant **category reassigned Non-compliant * These anomalies were due to it being identified that, in some cases, guidance had been stated as compliant without sufficient supporting documentation available. **Guidance that has previously been assessed as partially compliant has been reassessed as non-compliant, as it was difficult to quantify the extent of compliance, and some classifications were ambiguous. # received during March awaiting allocation to speciality Action Plans For guidance that is non-compliant, action plans to address areas of non-compliance are created and implemented in order to become compliant. As the Trust moves to its care organisation structure, actions plans will be in place at each organisation where the guidance is applicable: this means that each organisation will have to complete these in order for overall Trust compliance to be acknowledged. Audit programme From 2016 to present 18 audits have been completed that are linked to NICE guidance, with specific elements of the guidance selected for audit. These were reported in section 2.2.2; local clinical audit. Going forward, the care organisations will link the specific elements of guidance for audit with the action plans. To implement the Accreditation Programme for wards and departments across the Trust This priority was supported by the commissioning groups within the CQUIN framework. The scheme was devised as a framework to measure the quality of care and to strengthen professional leadership. It was superseded by the NAAS (nursing assessment and accreditation system) that had been implemented successfully at Salford Royal and was introduced by the new leadership team. See section Annual Report

154 PAGE Patient Experience Priorities To improve the Trust s responsiveness to complainants This rationale for this as a priority was to support the Trust s complaints improvement plan which focused on timeliness and quality of responses, and learning. A new policy and process was in place for , and performance metrics were agreed with the commissioners. This was incorporated into the Quality programme in the Risk and Governance project which also includes management of incidents, inquests and claims, and review of the governance systems. See section To improve timely access for patients requiring urgent care This was identified as a priority as it had become an area of increasing concern during , particularly during Q4 when performance in relation to the 4-hour access target was significantly deteriorating and an unprecedented number of 12-hour trolley waits were reported. The aim was to support the existing urgent care improvement plan to help the Trust achieve the national standards. Following the CQC inspection and the concerns that were raised relating to urgent care service a revised urgent care plan was approved as part of the Quality programme, which is being monitored by the Greater Manchester board. See section To review the Trust provision of access to interpreters The rationale to include this as a priority was that feedback from patients and their carers, and concerns raised internally by management, indicated that this was a key area for improvement. The aim was to implement a revised policy and procedures, which would increase the usage of interpreters within the Trust and reduce the number of complaints relating to availability of interpreters. Increased use of telephony interpreting results in improved patient experience, and decreased appointment cancellation due to interpreter not being available, and it is also more costefficient for the Trust, as there is no travel time for the interpreters. In July 2016 a programme of work was initiated by the Interpretation and Translation Service (ITS) and the Transformation Team. The main aims were: To amend the ITS policy to promote of the use of telephone interpreting for all types of appointments, where appropriate. To implement a new IT interpreter booking / management system to improve the allocation of internal and external interpreters; in addition to providing ITS activity Trust-wide. A revised Standard Operating Procedure has been approved and will be published in April This will complement the service and provide more detailed information regarding equipment, criteria for telephony use, and staff roles and responsibilities. Training and equipment requirements have been scoped for each clinical area; and the departments will review their IT requirement following the scoping exercise. The promotion of telephone interpretation commenced in the Outpatient G and Infectious Disease clinics in November 2016, following formal confirmation of a new service provider. Further roll out of the service across Outpatients at NMGH was agreed following a successful go live week (20th February 2017): any operational matters regarding service delivery such as the timeliness of connecting to telephone interpreting calls are responded to when they develop.

155 PAGE 153 The Interpretation and Translation Service (ITS) and the Transformation Team monitor the progress of the scheme biweekly, and report to the Patient Experience Committee. Next steps The transition to increased telephone interpreting is proving a gradual process with many staff still accustomed to utilising face to face interpreters. In order to assess the impact of the programme of work we will be consulting with patients and staff using ITS in the trial areas during April A series of communications to staff promoting the use of telephony is planned for mid-april, and will be supported by training on how best to utilise this option of interpreting. A patient experience survey will also be undertaken from late April to early May 2017 to benchmark patients current experience of interpretation services, as the service develops. Annual Report

156 PAGE NHS England Core Quality Account Indicators This section shows the Trust s progress and performance for each of NHS England s core set of indicators that all Trusts are required to report against in their Quality Accounts, where the indicator is applicable to them. For the PAHT these indicators are: SHMI Summary Hospital Mortality Indicator with regard to the Trust s summary SHMI the % of patient deaths with palliative care coded PROMS Patient-reported Outcome Measures Scores for Groin hernia surgery Varicose vein surgery Hip replacement surgery Knee replacement surgery Patients readmitted to the Trust within 28 days of discharge Responsiveness to patients personal needs Staff recommending the Trust as a care provider to family and friends Patients recommending the Trust s A&E service to family and friends Percentage of patients risk-assessed for venous thromboembolism Rate (per 100,000 bed-days) of C difficile infection in patients over two years old Number and rate of patient safety incidents reported in the Trust, with number and percentage resulting in severe harm or death Summary Hospital Mortality Indicator (SHMI) The SHMI is a ratio of the actual number of patients who die following hospitalisation, and the number that would be expected to die, given the characteristics of patients treated by that Trust. It is published each quarter and is based on 12 months data, 6-18 months previously. Data to produce the SHMI for the whole year will not be available nationally until October The data used to calculate the SHMI includes all deaths in hospital, plus those deaths occurring within 30 days after discharge from hospital, though it does not adjust for palliative (end of life) care because of the unreliability of coding. Some hospitals, therefore, may appear to have a higher death-rate if patients are admitted for care in the last days of life or if they are discharged home to die if that is their preference. The SHMI can be used by hospital Trusts to compare their mortality outcomes to the national baseline. The Trust, the Care Quality Commission, and local clinical commissioning groups use it as a smoke alarm to identify potential areas of concern for investigation into clinical outcomes. However, the SHMI should not be used to directly compare mortality outcomes between Trusts and it is inappropriate to rank Trusts according to their SHMI. It requires careful interpretation and should be used in conjunction with other indicators and information from other sources (e.g. patient feedback, staff surveys and other similar material) that together form a holistic view of Trust outcomes. The data made available to the Trust by the Health and Social Care Information Centre (HSCIC) with regard to: a) the value and banding of the summary hospital-level mortality indicator ( SHMI ) for the Trust for the reporting period is shown below:

157 PAGE 155 Time Period Pennine Acute National Baseline Highest Score Lowest Score Jul 14 - Jun Oct 14-Sep Jan 15-Dec Apr 15-Mar Jul 15-Jun Oct 15-Sep The Pennine Acute Hospitals NHS Trust Score has been higher than expected for SHMI since the publication in October 2016 (April 2015-March 2016 data). b) the % of patient deaths with palliative care coded at either diagnosis or speciality level for the Trust for the reporting period is shown below. Time Period Pennine Acute National Baseline Highest Score Lowest Score Jul 14 - Jun Oct 14-Sep Jan 15-Dec Apr 15-Mar Jul 15-Jun Oct 15-Sep The palliative care indicator is a contextual indicator: it does not contribute to the SHMI. The rate is fairly consistent each year however there has been a slight reduction in the last 12 months which is under review. In order for palliative care to be coded, the patient must have received input from a specialist palliative care clinician, and this must be documented accordingly in the clinical records. The Trust has vacancies in the specialist palliative care team. The Pennine Acute Hospitals NHS Trust considers that this data is as described for the following reasons: there are nationally regulated assurance processes in place to ensure the accuracy and validity of the data prior to publication. The Pennine Acute Hospitals NHS Trust has taken the following actions to improve this percentage and so the quality of its services, with the introduction of a mortality reduction plan as part of the overarching quality improvement programme. There are actions in six key areas: analyse relevant information to gain a full understanding of the current position; maximise the effective use of available information systems; ensure accuracy of clinical documentation and coding; improving mortality surveillance with the development of a systematic and cohesive approach; acting on findings and making improvements; and strengthening governance arrangements. (See section for additional information) Hospital Standardised Mortality Ratio (HSMR) is another means by which the Trust monitors its mortality rates. HSMR calculations enable the comparison of mortality rates between hospitals serving different communities by Annual Report

158 PAGE 156 including a variety of factors such as the age and sex of patients, their primary clinical diagnosis and complicating factors, and their length of stay in hospital. HSMR is based on the likelihood of a patient dying of the condition with which they were admitted to hospital. This means the methodology relies on accurate diagnosis and record-keeping by doctors, and appropriate data coding of patients records. If a Trust has an HSMR of 100, this means that the number of patients who died is exactly as would be expected. Values above 100 suggest a higher than expected mortality would therefore be a smoke alarm for further investigation to identify potential problems or where patient care can be improved. The latest year-to-date HSMR (April to February 2017) figures show the Trust s score is This is a continued increase from the reported last year, and the previous year, but is a reduction on the previous quarter s release which was The increase is partly due to a rebasing of Dr Foster data but there are a number of clinical conditions where the Trust is alerting, showing an increased number of excess deaths (higher number than expected). The Trust is investigating the possible causes for these as part of the mortality reduction plan, and this review is expected to report in May Its findings will identify specific actions to inform the next stages of the plan. (see section for additional information) Patient-reported Outcome Measures Scores (PROMS) NHS Trusts are required to report on patient-reported outcome measures (PROMs), short questionnaires given to patients to complete. The information is collected on NHS patients undergoing elective (planned) hip or knee replacements, groin hernia surgery and varicose vein procedures. PROMs are a means of gaining an insight into the way patients perceive their health, and the impact that treatments or adjustments to lifestyle have on their quality of life, by measuring their health status or health-related quality of life at a single point in time. The first questionnaire is given at the time of pre-operative assessment or on the day of admission to hospital. A second questionnaire is sent out three months after surgery for varicose vein and groin hernia procedures, and six months from date of surgery for hip or knee replacements. The data from the pre-operative questionnaire compared to the post-operative questionnaire links to a specific set of questions that nationally recognise the following: EQ-5D Health Status includes living arrangements, mobility, able to self-care, daily activities and mental status. EQ-VAS this is a visual analogue scale that asks the patient on the day they are completing the questionnaire to assess their own state of health ranging from 0 (worse imaginable health state) up to 100 (best possible imaginable health state). The Oxford Hip and Knee Replacement and the Aberdeen Varicose Vein scores are also used as an additional measure of assessing health and overall outcomes of surgery. Data for the year is available only up to 30th September 2016, as some follow-up questionnaires are not due to be sent out to patients. From 1st April 2016 to 30th September 2016, the Trust had 1,108 eligible hospital episodes, for which 696 preoperative questionnaires were returned; a participation rate of 62.8% compared to 76.2% nationally. 318 post-operative questionnaires were sent out, of which 104 have been returned; a response rate of 32.7% compared to 41.1% nationally. The table below compares the Trust with others in the region.

159 PAGE 157 Trust (to 30th September) Questionnaire % Pre-operative Post-operative Bolton NHS Foundation Trust Central Manchester University Hospitals NHS Foundation Trust Pennine Acute Hospitals NHS Trust Salford Royal NHS Foundation Trust Stockport NHS Foundation Trust Tameside Hospital NHS Foundation Trust University of South Manchester NHS Foundation Trust Wrightington, Wigan and Leigh NHS Foundation Trust England The following table demonstrates the numbers and % of all patients completing both questionnaires, comparing the Trust with other Trusts nationally (all procedures). The table below shows the percentage of patients who reported an improvement in their health following their procedure in (to date), compared to other local Trusts and nationally. The comparative figures for are shown in italics Trust Groin Hernia % Hip replacement % Knee replacement % Varicose vein % EQ-5D EQ VAS EQ-5D EQ VAS EQ-5D EQ VAS EQ-5D EQ VAS Pennine Acute Hospitals NHS Trust England Bolton NHS Foundation Trust Central Manchester University Hospitals NHS Foundation Trust Salford Royal NHS Foundation Trust Stockport NHS Foundation Trust Tameside Hospital NHS Foundation Trust Annual Report

160 PAGE 158 University of South Manchester NHS Foundation Trust Wrightington, Wigan and Leigh NHS Foundation Trust Pennine Acute Hospitals NHS Trust ( ) England ( ) The Pennine Acute Hospitals NHS Trust considers that this data is as described for the following reasons: there are nationally regulated assurance processes in place to ensure the accuracy and validity of the data. The Trust acknowledges there are difficulties in patients completing questionnaires. This might be due to lack of opportunity with the introduction of pre-operative telephone assessments, or unwillingness by some patients to participate because of an increase in other surveys and questionnaires. Patients who complete their pre-operative assessment by telephone are encouraged to complete the pre-operative questionnaire on the day of surgery, but this is not always feasible. During the Trust implemented the following: Patients attending pre-operative assessment have been asked to complete the pre-operative questionnaire Patients who complete their pre-operative assessment by telephone are asked to complete the pre-operative questionnaire on the day of surgery. This action has seen an increase in the number of completed questionnaire submitted. In feedback on the participation rates were produced on a quarterly basis. New posters were displayed in Pre-operative Assessment Areas and Day Surgery Units. Discussions with patients which includes expected outcome of surgery continues to improve. As a result of these actions: More patients are completing the questionnaires. There is an increased awareness of the programme amongst staff. Health gains have been achieved. Patients completing the questionnaires have a better understanding of PROMs. The Pennine Acute Hospitals NHS Trust intends to take the following actions to improve this percentage and so the quality of its services, by acting on the findings of a further review of how it recruits patients. The outcome of the review includes the same recommendations as in the previous year for the Trust, which were to: Ensure all patients are requested to complete the pre-operative questionnaire Continue to provide feedback on the outcome data and benchmark health gains against Trusts in the North West and national results. Update the posters within the pre-operative assessment areas Continue discussions with patients which includes expected outcome of surgery. Participation rates have improved since last year, and the Trust anticipates that there will be improvements in response rates and outcomes in the reporting by the HSCIC on the final completion of data. The Trust continues to work to improve participation and anticipates that there will be improvements in response rates and outcomes in the reporting by the HSCIC

161 PAGE Patients readmitted to the Trust within 28 days of discharge If patients are readmitted as an emergency following discharge from hospital, this can indicate that there have been difficulties or complications with their follow-up care and treatment. Monitoring the numbers of emergency readmissions, and comparing against other Trusts, helps us to identify areas for improvement to services and processes which can help to reduce and avoid emergency admissions wherever possible. The Trust monitors the number of readmissions and the rate using the Dr Foster Intelligence tool. It shows the % of patients aged 0 to 14, and 15 or over, who are readmitted to one of the Trust s hospitals within 28 days of being discharged from one of the Trust s hospitals during the reporting period. A lower percentage shows that fewer patients have been readmitted as an emergency following discharge. The data is six months in arrears as it is compared to others in the Trust s peer group. Dr Foster will publish the next set of data again in Sept Dr Foster 28 day Readmission Data; October 2015 to September 2016: Age range Pennine Acute All Acute Peers Higher than expected Lower than expected All patients 8.21% 8.10% 10.53% of Trusts 5.7% of Trusts 0-14 years 11.83% 9.11% 14.46% of Trusts 4.18% of Trusts 15+ years 7.55% 7.96% 10.83% of Trusts 6.30% of Trusts The Trust s overall comparisons with previous years is shown in the table below: Time Period Admissions Readmissions Readmission % October 2015 to September % October 2014 to September % October 2013 to September % October 2012 to September % The Pennine Acute Hospitals NHS Trust considers that this data is as described for the following reasons: there are nationally regulated assurance processes in place to ensure the accuracy and validity of the data. The Pennine Acute Hospitals NHS Trust has taken the following actions to improve this percentage and so the quality of its services, by responding to Dr Foster alerts, and to local data that shows the Trust as an outlier for particular procedures or treatment. Key procedures identified as being outliers in are as follows: Appendicectomy Catheterisation of heart Hysteroscopy Drainage of lesion of skin Laparoscopy Lower female reproductive organs Procedure on skin Therapeutic endoscopic operations on urethra Annual Report

162 PAGE 160 The Trust s overall readmission rate has reduced by 0.56% compared to last year and progress on any actions taken to improve the areas identified above is monitored via local Quality & Performance Committees to reduce readmission rates in the future. The data provided is reviewed by the services, and consideration given to review of care pathways or other relevant systems and processes Responsiveness to patients personal needs To improve the overall quality of patient experience and care, it is vital we collate, review and act on patient feedback. The national inpatient survey includes five specific questions which relate to the Trust s responsiveness to patient needs and perceptions, which enable us to assess and measure whether it has been consistently achieved. The results for the last 3 years are shown in the table below: Specific Questions National Average 2016 Q35. Were you involved as much as you wanted to be in decisions about your care and treatment? 45% 48% 49% 44% Q38+. Did you find someone on the hospital staff to talk to you about your worries and fears? 61% 65% 66% 62% Q40. Were you given enough privacy when discussing your condition or treatment? 27% 29% 26% 24% Q63+. Did a member of staff tell you about medication side-effects to watch for when you 68% 62% 71% 61% went home? Q69. Did hospital staff tell you who to contact if you were worried about your condition or 28% 25% 26% 20% treatment after you left hospital? External Benchmark: the Trust was within the bottom 50 hospitals. within the bottom 50 hospitals. within the top 30 hospitals. within the bottom 20 hospitals. within the bottom 40 hospitals. The Picker Institute, which administers the survey, presents the results in the form of problem scores, i.e. the percentage of patients who have indicated by their response that this particular aspect of their care could have been improved. Therefore, lower scores are better. The Pennine Acute Hospitals NHS Trust considers that this data is as described for the following reasons: there are nationally regulated assurance processes in place to ensure the accuracy and validity of the data. The Pennine Acute Hospitals NHS Trust intends to take / has taken the following actions to improve this percentage and so the quality of its services, by introducing over 2016/17 initiatives to drive through quality and consistency of care, such as Safer Start programme of work, which commenced in July 2016 to improve patient flow and discharge; this was introduced Trust wide in over 55 wards, with the focus on the traditional ward areas. It is envisaged that the initiative will address the underlying patients concerns relating to discharge; this will be supported, and improvements monitored through the Nursing Assessment and Accreditation System (NAAS). The Trust s transition to Care Organisations will assist the respective senior management teams to identify and respond to the themes emanating from their sites. The Care Organisations will be working with Picker and the Patient Experience Department in early May 2017 to analyse and develop improvement plans that will augment the current Quality Plans developed following the 2016 CQC Quality Report. The improvement plans will

163 PAGE 161 be monitored through the Patient Experience Committee and Executive Quality and Patient Experience Committee. The Trust will also review and where required update the Patient Experience Strategy in order to strengthen patient engagement and co-production of service improvement, with patients, carers and the public participation to ensure learning from their experiences enhance patient care. The Trust had overall not achieved a significant improvement on a specific question within the 2016 national inpatient survey; however, specific sites received better response rates than the Trust average in certain aspects of care. Fairfield General Hospital performed significantly better than the Trust average on five questions, as seen in the table below: Aspect of Care FGH Trust Q16. Hospital: bothered by noise at night from staff 11% 21% Q18+. Hospital: toilets not very or not at all clean 1% 6% Q22+ Hospital: food was fair or poor 26% 38% Q23 Hospital: not offered a choice of food 17% 27% Q26 Doctors: did not always have confidence and Trust 15% 24% Lower scores are better North Manchester General Hospital s results predominately mirrored the Trust s average percentage score: the few stronger scores are noted below: Aspect of Care NMGH Trust Q14+ Hospital: patients using bath or shower area who shared it with opposite sex. 5% 10% Q21+ Hospital: not always able to take own medication when needed to. 34% 41% Q48+. Surgery: questions beforehand not fully answered 23% 28% Royal Oldham Hospital results contained five questions that were higher than the Trust average: Aspect of Care ROH Trust Q38+ Care: could not always find staff member to discuss concerns with 61% 66% Q54 Discharge: not given notice about when discharge would be 37% 45% Q59+. Discharge: did always get enough support from health or social care professionals 41% 47% Q60+ Discharge: did not always know what would happen next with care after leaving hospital 52% 57% Q67+ Discharge: family or home situation not considered 40% 45% The Trust s results overall were significantly worse than average in 28 questions, compared to 20 in 2015 and 29 in Annual Report

164 PAGE These are shown below: Specific Questions National Average National Average 2016 Admission: had to wait long time to get to bed on ward 36% 41% 32% 43% 36% Hospital: not always able to take own medication when needed to - N/A N/A 41% 34% Hospital: not offered a choice of food 27% 26% 20% 27% 20% Doctors: did not always get clear answers to questions 35% 35% 30% 38% 30% Doctors: did not always have confidence and Trust 24% 23% 19% 24% 18% Nurses: sometimes, rarely or never enough on duty - 42% 38% 45 % 40 % Care: staff did not always work well together - 23% 21% 27% 22% Care: wanted to be more involved in decisions 45% 48% 41% 49% 44% Care: did not always have confidence in the decisions made 28% 32% 27% 33% 27% Care: not enough (or too much) information given on condition or treatment - 23% 20% 24% 19% Care: not always enough emotional support from hospital staff 50% 43% Care: staff did not do everything to help control pain 36% 35% 29% 37% 29% Surgery: risks and benefits not fully explained - 22% 19% 26% 17% Surgery: questions beforehand not fully answered - 26% 21% 28% 21% Surgery: results not explained in clear way - 33% 31% 38% 30% Discharge: did not always know what would happen next with care after leaving hospital - N/A N/A 57% 48% Discharge: not given any written/printed information about what they should or should not do after leaving hospital 37% 38% 33% 44% 36% Discharge: not fully told purpose of medications 31% 32% 25% 34% 25% Discharge: not fully told side-effects of medications - 62% 59% 71% 76% Discharge: not told how to take medication clearly - 26% 24% 32% 24% Discharge: not given completely clear written/printed information about medicines 33% 34% 27% 33% 28% Discharge: not fully told of danger signals to look for 62% 63% 56% 68% 57% Discharge: Family or home situation not considered 38% 45% 36% 45% 37% Discharge: not told who to contact if worried 28% 25% 20% 26% 20% Overall: not treated with respect or dignity 21% 16% Overall: rated experience as less than 7/10 16% 21% 15% 20% 15% Overall: not asked to give views on quality of care - 73% 69% 78% 70% Overall: Did not receive any information explaining how to complain 64% 68% 59% 67% 60% As mentioned earlier, the Care Organisations will be working with Picker and the Patient Experience Department in early May 2017 to analyse and develop improvement plans that will augment the current Quality plans to address the themes identified from the above responses. Triangulation of quality metrics information from sources

165 PAGE 163 such as PALS, complaints, friends and family test, and local patient surveys will support in the identification of areas in need of improvement Staff recommending the Trust as a care provider to family and friends In April 2014, NHS England introduced a staff Friends and Family Test (FFT) in all NHS Trusts providing acute, community, ambulance and mental health services in England. It is a quicker feedback mechanism than the existing NHS annual staff survey, and it was hoped that it would also promote a cultural shift in the NHS, where staff have opportunity and confidence to speak up, and where their views are increasingly heard and are acted upon to improve things for staff and patients. It consists simply of two questions (with options to give free text feedback for each) through which NHS Trusts can take a temperature check of how staff are feeling: better staff morale is known to correlate with improved patient outcomes. The Trust, using the support of the Picker Institute, has sent the staff FFT to hundreds of our staff for their feedback every three months since April The staff FFT in quarters 1, 2 and 4 is a separate survey, whereas the question for quarter 3 is asked as part of the staff survey and is phrased slightly differently. Picker Institute, who run both the staff survey and the staff FFT for the Trust, therefore advise against comparing Q3 results with the other quarters results. The table below shows the Trust s score - the percentage is based on the number of staff who answered very likely Annual Report

166 PAGE 164 or likely to each question. Staff FFT Question How likely are you to recommend <this organisation> to friends and family if they needed care or treatment? How likely are you to recommend <this organisation> to friends and family as a place to work? Q1 Q2 Q3 Q4 Q1 Q2 Q3 Q4 74% 70% 54% 69% 71.4% 61.5% 57% 59.8% 60% 57% 49% 61% 61.9% 55.8% 50% 49% National benchmarking is difficult due to the different ways Trusts conduct the survey and the number of staff who are asked. However, average scores are reported by NHS England at a national level. At quarter 2 the average percentage of staff who would recommend their organisation to friends and family in need of care and treatment was 82% compared with 62% for this Trust. The percentage of staff who would recommend their organisation to friends and family as a place to work was 66%, compared with 56% for this Trust. When the Trust is benchmarked with NHS England-Greater Manchester the average percentage of staff who would recommend their organisation to friends and family in need of care and treatment was 82% compared with 62% for this Trust. The percentage of staff who would recommend their organisation to friends and family as a place to work was 64%, compared with 56% for this Trust. The Pennine Acute Hospitals NHS Trust considers that this data is as described for the following reasons: there are nationally regulated assurance processes in place to ensure the accuracy and validity of the data. The Pennine Acute Hospitals NHS Trust has taken the following actions to improve this percentage and so the quality of its services, by directly engaging with staff to gain a better understanding of their issues and concerns to identify appropriate action. These actions have been incorporated into the Healthy Happy Here Plan (see section 3.1.2) and progress is reported to the Workforce and Leadership Programme Board. As the Trust progresses along its quality improvement journey and begins to implement changes that demonstrate tangible improvement, it is expected that the percentage of staff recommending the Trust to F&F for care and treatment will increase. However, the large scale organisational change the Trust is going through over the next two years has an impact on the staff perceptions and this is evident in the FFT scores Patients recommending the Trust s A&E service to family and friends The Trust continues to gather and act on patients feedback via the national Friends and Family Test (FFT): upon discharge patients are invited to offer their opinion as to whether they would recommend a friend or family member to be treated at the Trust. Different modes of FFT data collection are available; cards, SMS/Text messaging; and interactive voice messaging, and is guided by the staff for that particular area and patient feedback. The mode of collection should be influenced by the type of patient groups being served, for instance the Wolstenholme Intermediate Care Service is better suited to have cards as older patients are more comfortable with this than SMS; whilst A&E patient are found to respond better to SMS and automated calls. The mode of collection can be changed or added to if required. The Trust will be undertaking a programme of work with patients, staff and partner organisations, beginning in May

167 PAGE The aim is to improve the Trust s response rates to the best national quintile of 20% for A&E, and to 40% for inpatients, through ensuring FFT is adequately promoted and accessible to the widest range of patients possible. This will be supported by actions such as awareness sessions for staff, and awareness events for patients and their families, accessible current FFT information on how to participate including the use of response cards in the most frequently used languages for our communities, and age / ability appropriate. For example, bespoke cards using the Tops and Pants theme are being developed for children and young people. The progress of the refocus on FFT work will be reported to and monitored by the Patient Experience Committee and Executive Quality and Patient Experience Committee. Local managers are encouraged to display FFT patient themes, changes implemented due to feedback, and ratings on the ward-based Open and Honest boards, alongside information such as staffing profiles for that day, and the name of ward manager. The percentages of patients that would recommend the Trust s departments for 2016 are shown below: Patient FFT - area Q1 Q2 Q3 Q4 Q1 Q2 Q3 Q4 Q1 Q2 Q3 Q4 A&E N/A N/A N/A 50% 78% 74% 73% 72% 82% 82% 81% 82% Maternity N/A N/A N/A 0% N/A 96% 83% 84% 95% 96% 95% 95% Outpatients N/A N/A 19% 49% 65% 53% 67% 96% 88% 87% 89% 88% Inpatients N/A N/A N/A 0% N/A 98% 98% 98% 98% 96% 96% 97% Day case N/A N/A 9% 59% 76% 72% 74% 89% 90% 90% 89% 88% Community N/A N/A N/A 61% 74% 81% 86% 89% 93% 96% 90% 91% The Pennine Acute Hospitals NHS Trust considers that this data is as described for the following reasons: Response rates for maternity (births) is averaging at 95%, which remains high for Trusts of its size in relation to response rates but slightly below the current national average of 97%. Recommendation rates for A&E remain low at an average of 82%, with the national average standing at 87%. Inpatient recommendation rate is 97% above the national average at 96% placing this Trust in the top 30% of hospitals for its size. The Pennine Acute Hospitals NHS Trust intends to take / has taken the following actions to improve this percentage and so the quality of its services, as follows: As stated earlier, a programme of work has commenced to refocus and strengthen the use of FFT across the Trust through education and communication via various media to staff and patients. This is in addition to ensuring increasing the level of access for all patients as appropriate to have the ability to provide feedback on their care and for action to be taken to share learning and implement improvements where required Percentage of patients risk-assessed for venous thromboembolism Thrombosis is the term used to describe a blood clot forming inside a blood vessel. The most common form of thrombosis is a deep vein thrombosis (DVT) which occurs in the leg. If part of the clot breaks off it will travel through the circulation to the lungs: this is known as a pulmonary embolism which is serious and can be life-threatening. It is believed that many cases of thrombosis are potentially preventable if patients have appropriate prophylaxis Annual Report

168 PAGE 166 (preventative measures) to reduce the risk. These measures include having injections to thin the blood and wearing support stockings to assist circulation. In order to determine what is appropriate for each patient, a risk assessment must be completed. Goal: for 95% of patients to have VTE risk assessments within 24hrs admission to hospital Outcome: target achieved more than 95% of patients had VTE risk assessments undertaken Table showing VTE Assessments: April 2016 to March 2017 (patients aged 18+) Pennine Acute Hospitals NHS Trust England overall Month No of No of No of No of % assessed admissions assessments admissions assessments % assessed Apr % % May % % Jun % % Jul % % Aug % % Sep % % Oct % % Nov % % Dec % % Jan % % Feb % % Mar % % The Pennine Acute Hospitals NHS Trust considers that this data is as described for the following reasons: the data is scrutinised by external auditors who have confirmed the robustness of the process for data validation. The Pennine Acute Hospitals NHS Trust has taken the following actions to improve this percentage and so the quality of its services, by aiming to meet all the other requirements of NHS England s VTE Prevention Programme, as summarised in the table below: NHS England s requirement Pathways to be in place to identify hospital acquired VTEs (Defined as a VTE occurring either within 72 hours of admission or within 90 days of a hospital discharge). Process in Pennine Acute Trust The Trust s VTE team is alerted to cases of VTE via different routes. They are notified if patients are scanned for either a DVT or PE, and also by the bereavement service if DVT or PE is listed on a death certificate.

169 PAGE 167 NHS England s requirement A root cause analysis (RCA) investigation to be undertaken for all confirmed cases of hospital-acquired VTE, and that these are provided to the commissioners. Process in Pennine Acute Trust An RCA investigation is initiated by the VTE nurse to identify if appropriate medication was prescribed and administered during the patient s admission. Additional information is requested from the clinical team to complete the RCA, and once they are concluded the reports are shared with the commissioner quality leads. Most of the RCA investigations conclude that the VTE event was unavoidable, that is that all the necessary measures were taken. It was anticipated that the back log of RCAs would be resolved by distributing RCAs out for completion to the patients consultants. However, due to competing pressures, the timescales for completion of the RCAs overall remains poor, and the back-log that was reported last year still persists. Local audits to be undertaken to ascertain the percentage of patients receiving appropriate prophylaxis after being risk assessed. The system of completing the RCAs is still under review, and it remains a priority to improve their timely completion with an increased input from the clinical teams. One change being considered is to review, and where possible reduce, the amount of information that is required for completion of the form: this will reduce the length of time each takes. Audits of compliance have been undertaken in high risk areas on the use of anti-embolic stockings, risk assessment and re-assessment compliance, use of appropriate prophylaxis and provision of patient information. Additionally, over the year the following has also been completed: Completion of guidelines for the diagnosis and management of deep vein thrombosis and pulmonary embolism in adult inpatients and outpatients. Community partners in attendance at VTE Committee meetings, to ensure they are aware of the number of VTEs occurring within the community. Future goals to be achieved: Training for nursing staff to improve the use and ensure accurate documentation for anti-embolic stockings Trial of VTE electronic risk assessment which has been developed during the last year. Tri-annual update of the policy for the prevention of venous thromboembolism Undertake Trust-wide audits of compliance with VTE risk assessment and re-assessment, prescribing and administrating of prophylaxis when indicated by the risk assessment, and provision of information to patients/ carers. Finalise the pathway and process for fulfilling the duty of candour with VTE Committee and governance team, and implement this once it is agreed. Continue to increase mandatory training compliance. Although the percentage of staff trained has reduced slightly from last year, the overall numbers of staff trained has increased. This is because there is now a larger group of staff requiring training, with the target staff numbers having increased by 812 to Of these, 1866 staff members (71%) have completed the training, compared to 1348 of 1798 (75%) in Rate (per 100,000 bed-days) of C.difficile infection in Annual Report

170 PAGE 168 patients over two years old Our drive to reduce the numbers of patients with healthcare acquired infections (HAIs), such as methicillin resistant staphylococcus aureus (MRSA) and clostridium difficile infections (CDI), across our hospitals and community services is a top priority and is a key aim within our quality improvement programme. Our HAI performance, including reported cases of MRSA and CDI, are reported to our Trust Board of Directors, and the data is publically available and also reported back to our staff. Our national objective was to have fewer than 55 cases of CDI for : we reported 58. Although this is a slight increase from 56 in , it is a reduction of 84.2% on the 356 cases reported in , as shown in the chart below. Each case of Clostridium difficile is investigated to understand any lessons learnt so that risks are reduced; for example, by improving infection prevention strategies or antibiotic prescribing. The cases are individually reviewed with colleagues from neighbouring CCGs to ascertain and share mutual ideas for improvement. These clinical reviews have confirmed 54% of the CDI cases reported this year to be unavoidable, with no lapses in care identified. Areas for improvement have been identified, specifically in relation the knowledge and understanding by healthcare professionals of how to interpret symptoms of diarrhoea and link this to risks for CDI infection. To support this, a risk assessment tool to aid in the rapid clinical diagnosis for patients with diarrhoea has been introduced. This is audited and compliance will form part of each ward s performance metrics for 2017/18. Additionally, the Infection Prevention Team has introduced a pilot scheme of diarrhoea ward rounds to support ward teams with assessing patients with diarrhoea for risk of CDI. It is hoped that the pilot evaluation will identify weaknesses in knowledge which can be targeted for further training in The Trust s rate (per 100,000 bed days) cases of c.diff from April 2016 to March 2017 has been reported as Comparison with local peers and against the national average over the previous three years is shown in the table below: Rate (per 100,000 bed days) cases of Clostridium difficile April 2014 March 2015 April 2015 March 2016 April 2016 March 2017

171 PAGE 169 NW Trust average Best performing NW Trust (excluding specialist hospitals) Worst performing NW Trust (excluding specialist hospitals) Pennine Acute Hospitals NHS Trust The Pennine Acute Hospitals NHS Trust considers that this data is as described for the following reasons: The national benchmark for all acute hospitals for Clostridium difficile infections is reported as the rate per 100,000 bed days and this remains comparable to other hospitals of similar size across England, and within the top four Greater Manchester Trusts. The Pennine Acute Hospitals NHS Trust has taken the following actions to improve this percentage and so the quality of its services, by Improving our infection prevention and control practices to support clinical assessment and isolation of patients with diarrhoea by using a risk assessment tool. This is audited and compliance will be part of ward performance metrics for 2017/18. Additional hours of cleaning and disinfection of wards where patients are particularly vulnerable A change of disinfectant wipes to aid the cleaning of equipment after a review of the efficacy data has been completed. Additionally in , we will continue our focus on good practice to reduce healthcare acquired infections, working with staff to: Ensure rapid clinical assessment for patients with diarrhoea for risk of CDI, is part of routine clinical practice and share with other specialist colleagues for wider adoption. Sustain and continually improve antibiotic prescribing to enhance and support the national Start Smart, then Focus antibiotic stewardship programme. This will be achieved through audits of antibiotic prescribing and feedback to clinical teams. Evaluate an innovative programme of emphasis on improving facilities and support for patient hand hygiene as a quality improvement programme. Continue to promote high standards in hand hygiene through the expansion of a red/yellow /green card scheme to highlight missed opportunities or evidence of good practice. Review further innovative methods of evaluating environmental cleaning and surface contamination through the use of UV light decontamination. A closely-related indicator is to eliminate MRSA bacteraemias (blood stream infections): the national target for all acute hospitals in was zero. We reported one case. We continue work to reduce all bacteraemias including MRSA with: a programme of screening high-risk patients on admission provision of topical treatments for those at risk of MRSA infection, including an antiseptic body wash which is Annual Report

172 PAGE 170 continued for the duration of a patient s stay. An investigation involving the clinical and nursing team is undertaken for each MRSA and actions from lessons learnt are implemented with specified training in the area of clinical practice requiring improvement. During : A multi-disciplinary group will focus on improving the diagnosis and rapid treatment of severe sepsis. This forms part of the Trust s patient safety programme. The Department of Health review on Antimicrobial Resistance (AMR) was published in September 2016, with the expectation that we will continue to drive forward the UK AMR Strategy. These includes setting new ambitions to reduce infections and prescribing and introduce new quality indicators including a reduction in healthcare associated Gram-negative bloodstream infections in England by 50% and reduce inappropriate antibiotic prescribing by 50%, with the aim of being a world leader in reducing prescribing by To support this new initiative, we will implement improvement programmes to further enhance antimicrobial prescribing stewardship and improve the prevention and early diagnosis strategies for urinary tract infections which are the main risk factor for gram negative blood stream infections Number and rate of patient safety incidents reported in the Trust, with number and percentage resulting in severe harm or death NHS Trusts must submit the details of patient safety incidents to the National Reporting and Learning Service (NRLS) regularly. The NRLS provides comparative feedback to Trusts twice yearly; six months after the reporting period. Trusts can use this information to identify and address areas of low reporting, as high-reporting Trusts are considered to have a stronger safety culture. The information in the table below has been extracted from the NRLS system and shows the Trust s performance for the reporting periods October 2015 to March 2016 (published September 16) and April to September 2016 (published April 17). The table also compares the Trust s performance against its peer group - a cluster of the 11 North (Lancashire and Greater Manchester) regional Trusts. NRLS Measure Oct 15 Mar 16 PSIs total Apr 16 Sep 16 National average number Maximum number for peers PSIs Resulting in Severe Harm Oct 15 Mar (0.291%) 57 (0.479%) Apr 16 Sep (0.262%) 75 (0.634%) PSIs Resulting in death Oct 15 Mar 16 6 (0.125%) 37 (0.311%) Apr 16 Sep 16 5 (0.101%) 36 (0.304%) Minimum number for peers (0.25%) Pennine Acute number (0.809%) 72 (1.014%) 37 (0.525%) 26 (0.366%)

173 PAGE 171 per 1000 bed days Oct 15 Mar 16 PSIs total Apr 16 Sep 16 National average Maximum value for peers PSIs Resulting in Severe Harm Oct 15 Mar (0.758%) 1.4 (2.435.%) Apr 16 Sep (0.735%) 1.0 (1.650%) PSIs Resulting in death Oct 15 Mar (0.253%) 0.5 (0.870%) Apr 16 Sep (0.245%) 0.4 (0.660%) Minimum value for peers Pennine Acute value (2.66%) 1.0 (2.732%) 0.5 (1.416%) 0.4 (1.093%) The Trust has reported a small increase in the total number of incidents reported to the NRLS in each 6 month period. In October 15 to March 16, there was a 2.81% increase from the 6854 reported in April to September 15; and the number for April to September 16 showed a further 0.7% increase. The number of deaths reported has reduced in the April to September 2016 period. This is due to the figure for Oct 15 to Mar 16 being falsely elevated because of a number of historical incidents were reported in this period following a look-back exercise. The number of severe harm incidents has increased in the April to September 2016 period: this can be attributed to the high numbers of reports of patients waiting for admission for more than 12 hours in ED, which is shown in the chart on page 90. The Trust s rate of reporting (per 1000 bed days) has increased in both periods but remains below the national average and is the lowest overall in its peer group. Though there is no national target, we aim to be in the mid-range of the peer group, which would demonstrate a good open and honest reporting culture. Within the numbers reported overall, we would aim to have a higher rate of reports relating to near misses / no harm incidents, which provide opportunity to learn from these and from investigations of less serious incidents. For incidents resulting in death or severe harm the Trust is the highest in its peer group, and we aim to see a reduction in these grades of incidents. There are a number of quality improvement work-streams in progress (see section 3.1.2) that will contribute to the delivery of harm-free care as they are implemented. The Pennine Acute Hospitals NHS Trust considers that the number of incidents is as described, but has some concerns in relation to the accuracy of some of the grading. Although all reported incidents are reviewed by governance processes, it has been noted that there are sometimes delays in verifying the grading. This is due to the wish to obtain as much information as possible before assigning a grading, and the lack of resource to undertake initial reviews. However, in respect of the 12-hour breaches in ED, there has been scrutiny by the CCGs as the quality leads have worked with the governance team within the Trust to validate the high numbers of these incidents. The Trust has taken the following actions to improve the quality of its services. Since April 2016 the Safeguard Systems Manager has delivered training sessions in wards, departments and health centres to promote improvement in both the standard of incident reporting and the way managers respond on-line. From April 2016 to March 2017 there has been an 11% increase in the number of patient incidents reported. Divisional Governance Managers have supported staff in the departments when responding to incidents with root cause analysis investigations. The Trust will be introducing a new risk management system, Datix, during the coming months, which includes a module for incident reporting. The system offers features that will support the early review and verification of incidents. Annual Report

174 PAGE 172 Serious Untoward Incidents From 1 April 2016 to 31st March 2017, the Trust has reported 775 serious incidents (SIs): this is a significant increase from 275 reported in , and 102 in The main reason for this is that the Trust has reported a large number of incidents where patients have waited in ED for over 12 hours from the decision to admit them. In total there were 641 such incidents reported, accounting for almost 83 % of all SIs in This is illustrated in the chart below: Serious Incidents reported from Sept 2015 to March 2017: 12 hour breaches shown separately ED 12-hr breach All other S.Is No. of SIs Sep-15 Oct-15 Nov-15 Dec-15 Jan-16 Feb-16 Mar-16 Apr-16 May- Jun-16 Jul-16 Aug-16 Sep-16 Oct-16 Nov-16 Dec-16 Jan-17 Feb-17 Mar-17 s Throughout processes for identifying and responding to Serious Incidents have been improved. At the beginning of there were a large number of outstanding serious incident investigations which had breached the date for response, the Trust invested in a number of temporary governance managers to support the divisions in addressing them. Targets were set to address tranches of overdue incidents according to the original due dates given by commissioners. By December 2016 all serious incidents originating in 2015 had been investigated. Between April 2016 and December 2016, 478 incidents investigations were completed, 342 of which related to Emergency Department breaches. The CCGs have supported the Trust with the investigation and closure of these incidents. A further 154 serious incident investigations, including 129 emergency department breaches, were completed and forwarded to commissioners between January and February Since December 2016 potential serious incidents have been reviewed by Divisional Directors and escalated to Directors of Nursing/ Medical Directors for the Care Organisations to determine if a serious incident has occurred. Monitoring mechanisms have been set in place in which Divisional Directors of Nursing meet with the Director of Patient Safety to review open incidents and update on progress. A series of Serious Incident Review Panel meetings with Care Organisaton Directors of Nursing have been put in place and will review and improve the quality of investigations and action plans going forward.

175 PAGE 173 Never Events The Trust has reported eight never events in These were: three instances of wrong-site surgery; three instances of foreign objects retained post-operatively; and two cases of the wrong implant or prosthesis being used. This is a sharp increase from the one never event that was reported during , which related to a wrong implant/prosthesis. This is in part due to the retrospective nature in which some never events are identified: two of the eight never events reported in related to events outside that time period, for example one case of a retained foreign object post operatively related to an operation in 2012 but was not identified until further surgery in In order to reduce the number of never events, the Trust has undertaken some specific actions: An overarching policy for swab, needle and instruments for all departments where invasive procedures take place was approved at the Clinical Effectiveness Committee in March 2017 as part of the wider NatSIPPs work (see section 3.2.1) Following the never event with the wrong size implant, a second time out was introduced prior to any opening of prosthesis. The full team stop. The implant is confirmed against the expectation of the surgeon, the consent form and any other relevant documentation. The site is also verified with the consent. Sizes are then visibly displayed on the swab, needle and instrument board. Other work in progress: Bespoke procedural checklists, by directorate, are to be developed once agreed at the clinical effectiveness committee. Improved visual WHO communication to be displayed via a whiteboard in theatre. Launch of the overarching policy and NatSIPPs now this has been agreed. 3.4 Additional Core Information Requested by NHS England In addition, NHS England requested that, where possible Trusts also include information relating to: Implementation of the Duty of Candour Patient Safety Plan this is now incorporates within the Quality plans (section 3.1) NHS Staff Survey results indicators relating to bullying and harassment, and Workforce Race Equality Standard CQC ratings grid or, where not available, the Trust s self-assessment (see previous section 2.2.5) Implementation of the Duty of Candour In line with the Duty of Candour regulations that came into force on 27 November 2014, the Trust continues to work to ensure that we are open and transparent with patients who use our services, and specifically when things go wrong with their care and treatment. A number of changes have been implemented to improve compliance with this important requirement. In December 2016, the Trust implemented a process in which the allocation of a family liaison officer to discharge the Duty of Candour has been overseen by the site Directors of Nursing and Medicine. Annual Report

176 PAGE 174 The online form used by managers to respond to incident investigations has been modified to automatically display the Duty of Candour requirements where patient harm is reported as moderate, severe or death. A weekly Duty of Candour log is circulated automatically to clinical divisions via the Trust s risk management system to enable divisions to monitor outstanding Duty of Candour requirements. The Trust Welcome, delivered to all new starters, now includes information on Duty of Candour and the key actions required where it applies. Training slides for Duty of Candour have been provided by the Trust s solicitors and are accessible through the Clinical Governance intranet pages. A training video using examples and Trust staff has also been produced. From April 17, a series of half-day training sessions will be provided by Trust solicitors: Duty of Candour will be one of the areas covered alongside root cause analysis investigation and report writing training NHS Staff Survey results The NHS Staff Survey is an annual survey, first run in 2003, and is required by NHS England for all NHS Trusts in England. There is a significant body of evidence that demonstrates the link between high levels of staff satisfaction and engagement with better patient experience and outcomes. The quality of care that patients receive depends first and foremost on the skill and dedication of NHS staff. Engaged staff are more likely to have the emotional resources to show empathy and compassion, despite the pressures they work under. Individuals who are committed to their organisations and involved in their roles are more likely to bring their heart and soul to work, take the initiative, go the extra mile and collaborate effectively with others. (Kings Fund, Staff Engagement 2015). The importance of the staff survey results therefore links to a number of the Trust s strategic priorities. The Picker survey was sent to all staff across different divisions, directorates and professions throughout the Trust; 9103 in total. The survey was conducted from October to early December The response rate to this survey was 45% with 4068 staff completing the survey. This was a significant improvement from the 2015 response rate which was 21%. The results of the 2016 NHS England survey are summarised into 32 Key Findings grouped into nine themes: Appraisals & support for development Equality & diversity Errors & near misses Health and wellbeing Job satisfaction Managers Patient care & experience Violence, harassment & bullying Working patterns PAHT compares favourably against other Trusts in two areas; percentage of staff working extra hours, and percentage of staff experiencing discrimination at work, have both reported lower than average. The survey also reported a significant increase in satisfaction with staff having opportunities with flexible working. The key area of staff motivation at work has also increased marginally from last year s survey; we will be working to keep this momentum going.

177 PAGE 175 Staff reported a deterioration in the percentage of staff experiencing physical violence from patients, relatives or the public in the last twelve months and this will be an area of focus for 2017, as will strengthening clinical and site leadership and increasing frontline staffing numbers. Overall the staff engagement scores are stable having changed little from the 2015 survey. Encouragingly, the staff group engagement score for our adult general nursing workforce and HCAs/nursing assistants (which make up the largest proportion of the Trust s workforce) has increased significantly from 3.67 to This shows that in the face of the huge amount of pressures our nursing workforce are under, more of our frontline clinical staff have more confidence in the future, feel better engaged and can see they are being listened to and supported. Work continues against the milestones of the Healthy Happy Here plan (see section 3.1.2) which was introduced in 2015 and refreshed in The aims are to support recruitment and retention, and improve morale and attendance levels; both of which are key in the Trust s drive to become an employer of choice. Supplementary to those milestones, and following the results of the 2015 survey, a number of actions were implemented from April 2016 onwards. These were aimed at further improving staff engagement and included: Action Appointment of a Staff Engagement Lead and Advisor Outputs introduction of a quarterly pulse check staff engagement survey, which provides a regular sense check of how staff are feeling; establishment of a Staff Engagement Steering Group to oversee all matters related to staff engagement establishment of reward and recognition focus groups and resultant action plan adopting tactical measures to increase visibility and engagement with directors and senior managers introduction of staff engagement pioneers programme, working with teams to improve staff engagement and support service improvement Work will continue on the above and further actions agreed from this year s results throughout Additional Information requested by the Commissioners Reducing the risk around missed and delayed diagnosis s to systems and processes to reduce the incidence of missed and delayed diagnosis have continued through the year. This work is overseen by the Diagnostics Group (DIG) which reports to the Executive Clinical Effectiveness Governance Committee, chaired by the Chief Medical Officer. Some key developments during the year are: The CRIS communicator is being trialled as a means of ing consultants about urgent, unexpected results or results which have been amended. Acute Medicine at Fairfield General Hospital and Urology are the two potential chosen areas. An electronic tracker for all tests has been developed and is being trialled in Urology. This will assist consultants PAs in tracking tests and results. Unfortunately, this work has not progressed as quickly as hoped due to a number of competing priorities, and the removal of some agency staff who were supporting the project. Annual Report

178 PAGE 176 In addition, radiologists have been reminded of the need to ensure unexpected findings are referred to the Rapid Access Clinic. All clinicians have been reminded about the need to comply with the Your Request, Your Responsibility policy. In November 2016 an audit linked to your request; your responsibility was undertaken to assess compliance with requests for tests being documented and results being reviewed and acted upon in a timely manner. The audit reviewed the radiology, bloods, microbiology and histology/cytology tests of 51 patients: it identified a total of 117 tests were undertaken, of which 79 had abnormal results. The audits have been undertaken each month, and reported back to the Diagnostic Group. The latest audit from March 2017 identified the tests of 58 patients were reviewed: a total of 118 tests, of which 57 had abnormal results. The overall results (all metrics) of the November audit, compared with the March 2017 audit, are summarised in the table below: All tests All abnormal tests Tests November (n=117) March (n=118) November (n=79) March (n=57) Target Radiology 70% 92% 72% 95% 100% Blood 68% 78% 76% 82% 100% Microbiology 58% 52% 77% 50% 100% Histology/Cytology 50% 83% 70% 88% 100% The results of the audits have been sent to the participating directorates/specialities requesting that the results are discussed at their next Audit & Governance meeting and that if required an action plan is developed to improve timely reviews of tests and taking the appropriate steps to act on abnormal test results. Some IT-related issues, e.g. access to systems and tracking of the source of requests, have been highlighted and under review. Ultimately an Electronic Patient Record will help to provide a more robust solution for tracking of requests and results. Current timescales for this suggest it will be implemented during

179 PAGE Progress of the Falls Prevention Strategy The Trust employed a falls team of two registered nurses in May The team s remit was to reduce the number of patient falls, and to reduce the severity of injuries that patients sustain from falls. Prior to this, a project team led by the Orthopaedic Physician had introduced the Royal College of Physicians national initiative, Fallsafe. A complete bundle, which included a falls risk assessment, interventions and a post-fall action plan, was developed and implemented in February Following this, the falls figures began to reduce (see chart below). Number of falls reported April 2015 to March 2016; and April 2016 to March A baseline audit was undertaken in June 2016 in the five wards in each site reporting the highest numbers of falls. This showed that although all wards were using the Fallsafe bundle, there was varying compliance with the quality of completion. It was also identified that some basic nursing elements could be improved within the bundle to facilitate its completion. The bundle has been revised and a draft has been circulated for consultation at the time of this report. The audit also showed that there had been a lack of training on how to use the document to support patient care, and this will be incorporated with the launch of the new bundle. The results of the audit became the basis of how the training plan was developed. The falls team receives copies of all falls incidents: this enables a database to be maintained to monitor trends and build reports. If a patient has more than one fall, the team contact the ward to offer advice and support for that patient to prevent further falls. If a particular ward is reporting several falls the team carries out an audit of the ward and training to identify areas for improvement and reduce the incidence of falls. The team also encourage staff to report near misses so interventions can be put in place to prevent an actual fall. If a patient sustains a fall with harm, the falls team supports the governance team with the actions required, for example with completion of 72hr reviews for falls with severe harm. The team receives copies of completed root cause analysis investigation reports and contributes to the development of action plans to ensure they are pertinent to the area and that they address the lessons learned. Annual Report

180 PAGE 178 The falls team has also supported the Trust to prepare for inquests, with preparation of statements and providing evidence in the inquest with the work done so far to improve practice around falls. The team has made changes acting on the outcome of the inquests, for example introducing bay nursing and bay tagging, providing staff with an easy-read guide to completing the Fallsafe bundle, and providing supporting guidance on how to complete neurological observations and lying and standing blood pressure readings. The team has discussed the lessons learned at ward managers meetings, training sessions, and site safety meetings to cascade the information accordingly. The team identified a lack of training in falls prevention. An e-learning package was available for staff to complete, but it was not fully compatible with the IT systems in many areas. The team introduced face-to-face training whilst the issue was being resolved and since July 2016 over 700 staff have attended training sessions; either bespoke to their area or standard training sessions. These sessions have been accredited for mandatory training requirements. The team has also been involved in various staff training days to increase staff awareness about falls prevention. The issues with the e-learning package have not been rectified to date therefore the team has produced an in-house package for staff. In total, with staff that have been able to access the e-learning package a total of over 1600 staff have undertaken falls awareness training during In June 2016 a post-fall checklist was introduced, which is completed by the matron. It measures compliance with the Fallsafe bundle prior to the patient falling, and whether all the post-fall actions have been carried out, to ensure appropriate care is being provided. It enables the matrons to assess gaps in practice and support ward managers to improve practice in their areas. Compliance rates have improved from 22% at launch, to 61%. To improve this, from January 2017 the ward managers on some sites are completing their own checklists, and this is being rolled out to all areas. This also encourages local accountability for falls. Compliance with the Fallsafe bundle has improved since this process was implemented. For example, completion of the bundle within four hours of admission has improved from 36% in June 2016 to 88% in March 2017 average across all the sites. Informing families about a fall has improved from 56% to 96% (average) for the same period. The Trust audit showed lack of compliance with the Intentional Rounding and Enhanced Patient Observation policies for patients that were identified as being at risk of falling. The falls team contributed to the review and updating of these policies to improve practice. For example, intentional rounding of all patients will now take place every hour during the day; two-hourly at night. To support compliance with these policies, the falls team incorporate them into their training so staff have a practical understanding of the expectations of care they deliver to patients. The team also delivered four Patient Safety training days, based on the policies, to provide appropriate skills and knowledge for staff to incorporate into their practice. The training days incorporated content from all the speciality teams within the safeguarding team, and brought these together with case studies on the day. The findings from the national bedrail audit showed that the risk assessment in use did not adequately support the practice on the wards, and it was identified that a more appropriate risk assessment was required. This was done, in association with a revision of the bedrail policy. Bedrail magnets have also been ordered for bed boards so they indicate whether a patient has had bedrails recommended or not, to improve safety and practice. In September 2016, the Falls Champions group was set up: this was initially very well attended but unfortunately attendance has dwindled due to staff not being able to leave the wards for varying reasons. This was found to be an issue with many link nurse meetings, so the Safeguarding Team established the Vulnerable Adults Professional Leads. This group meeting is attended by the ward managers, matrons, and any other relevant staff to receive updates from all the specialities. The meetings are held on all sites, at the same time, to deliver the same messages, and are led by the Safeguarding Team.

181 PAGE 179 However, as falls is a high priority for the Trust, the falls champions group will continue by contact each month, and a quarterly meeting. An initial Falls Champions Expert day was held in March 2017, and another is planned for April. The aim of these days is to provide the falls champions with the knowledge and skills to act as ward resources for falls. Finally, an equipment amnesty has been held across the Trust to ascertain what falls sensors are in use, as previously wards were buying their own equipment. Falls Sensor Trials have been completed to identify the most appropriate equipment to use in the Trust: this will be managed via a virtual library supported by a full maintenance programme provided by the medical devices team. In the forthcoming year the team will provide intense support for wards that have high incidence of falls, bank and agency usage, or poor patient satisfaction feedback. The aim is to help ensure patients receive the appropriate medical and nursing care, reduce falls and reduce the length of stay in hospital. This will commence in April 2017 on a pilot ward. The team provides a month of intense support, based on the ward carrying out observations of care, providing support and advice. The team will also arrange relevant bespoke training to provide staff with a virtual tool bag of skills and knowledge, especially around cognitive impairment and how to manage the patients individual needs. Volunteers from the Patient Experience Team are being recruited to assist, in addition to a company that provides Reminiscence Screens that have interactive activities to use to engage patients. Annual Report

182 PAGE National Quality Standards Referral to Treatment National and local NHS standards require patients to be admitted for surgery or scheduled (elective) services within 18 weeks of referral by their GP. This standard is known as 18 weeks Referral to Treatment (RTT). The incomplete standard divides the number of open (untreated) patients waiting less than 18 weeks of referral to the hospital by the total number of open (untreated) patients waiting. The national operational target allows a tolerance for patient choice and clinical complexity and is set at 92% or over. The number of untreated patients waiting exceeding 18 weeks is called the backlog. The graph below describes the Trust s performance over time. The blue line shows the number of untreated (open) pathways exceeding 18 weeks (the backlog) over time. The green shaded area shows the operational tolerance described by the 92% standard, to account for patient choice of appointments and clinical complexity. The Trust has remained within the national tolerance (the green shaded area) and has therefore passed the target every month this year. RTT Open Pathways Backlog (+18 weeks) 92% Tolerance Backlog Actual 3,000 2,500 2,000 1,500 1, Apr-15 May-15 Jun-15 Jul-15 Aug-15 Sep-15 Oct-15 Nov-15 Dec-15 Jan-16 Feb-16 Mar-16 Apr-16 May-16 Jun-16 Jul-16 Aug-16 Sep-16 Oct-16 Nov-16 Dec-16 Jan-17 Feb-17 Mar-17 Like many other NHS Trusts across Greater Manchester and the country, we have experienced pressures during The chart reflects the pressures and shows a reduction in performance between Feb-16 and Jul-16, which has subsequently stabilised. Work is being undertaken at speciality level to improve performance and make reporting systems and processes better. Year / Comparison Incomplete: Target 92% Apr-15 to Mar-16 Pennine Acute Trust 96.4% National 92.2% Regional 93.4%

183 PAGE 181 Year / Comparison Incomplete: Target 92% Apr-15 to Mar-17 Pennine Acute Trust 92.7% National 90.4% Regional 91.7% England as a whole has missed the incomplete standard since and including December 2015 The most recently published information is shown in the table below Diagnostic wait times The Trust carries out on average 16,700 diagnostic tests/procedures each month relating to Imaging, Physiological Measurement and Endoscopy. There are approximately 11,000 patients on our waiting list each month, with 3.12% of patients waiting longer than six weeks for their test / procedure. This is a slight increase from last year (3.02%) The table and charts below show the number of patients waiting longer than 6 weeks each month and the type of tests / procedures. Area Apr 16 May 16 Jun 16 Jul 16 Aug 16 MRI CT Non-obs Ultrasound Barium Enema De XA Scan Audiology Cardiology -Echo Cardiology Electrophysiology Peripheral Neurophysiology Sleep Studies Urodynamics Colonoscopy Flexi Sigmoidoscopy Cystoscopy Gastroscopy Total Sep 16 Oct 16 Nov 16 Dec 16 Jan 17 Feb 17 Mar 17 Annual Report

184 PAGE 182 The chart below shows the number of patients waiting over six weeks for a diagnostic test or procedure, by month 500 Waits over six weeks at month end: MRI Cardiology - Echo Colonoscopy Flexi sigmoidoscopy Gastroscopy Apr-16 May-16 Jun-16 Jul-16 Aug-16 Sep-16 Oct-16 Nov-16 Dec-16 Jan-17 Feb-17 Mar-17 There was an increase in patients waiting longer than six weeks during the first half of 2016 which peaked in August 2016, although patients waiting for MRI and Echo were low compared to other tests. The number of patients waiting over 6 weeks was greatest for those having an endoscopy type procedure and may be attributed to the implementation of NICE GP cancer referral guidance, as part of the national cancer strategy, which aims to improve cancer survival rates by lowering the criteria for GPs to refer patients for endoscopy. Overall, the number of patients in the diagnostic part of an urgent pathway has increased considerably. The demand for colonoscopy has increased by 9.74% from the previous year, and this is compounded by a reduction in capacity due to staff availability and available slots. However, as the chart depicts, the number of 6 week breaches has reduced dramatically since the August rise which is due to improvements in the service as follows: Procuring additional capacity from the independent sector (Care UK) Recruitment of additional clinical staff to undertake endoscopy activity Additional lists from nurse endoscopists Additional lists for colorectal surgery to support straight to scope work to reduce sickness and absence Collaboration with the Trust s Project Management Office to improve in key areas Improving patient pathways to create capacity to meet demand

185 PAGE A&E waiting times The Department of Health s national 4-hour Emergency Care Access Standard requires at least 95% of patients to be seen, treated, admitted, transferred or discharged within four hours of attendance at an A&E department, urgent care centre or NHS walk-in centre. An additional standard is that no patient should wait more than 12 hours from the decision to admit. We understand how important these standards are for patients and their families, and work hard to ensure our patients are seen as quickly as possible across our three Accident & Emergency departments at North Manchester General Hospital, Fairfield General Hospital and The Royal Oldham Hospital, as well as our Urgent Care Centre (UCC) at Rochdale Infirmary. Like most Trusts across the country, we are finding this a challenge due to the flow of patients in and out of hospitals and the large numbers of admissions of patients, particularly those who are elderly and with complex and chronic health conditions. The Trust s monthly performance for each of our sites, across all A&E quality indicators, are available on our website under quality and performance at The table below shows the performance for the Trust by quarter and total for the year for , with comparison to Department / (%) (%) standard Q1 Q2 Q3 Q4 year Q1 Q2 Q3 Q4 year 4 hour FGH A&E hour ROH A&E hour NMGH A&E hour RI UCC hour Trust overall hour trolley wait (reportable) The Trust overall performance in the A&E 4 hour target for was significantly below the England average of 89.1%. However, this target has been challenging to achieve throughout the last year, in which over a third of a million patients requiring urgent care presented to our hospitals. October to January was a particular busy and difficult period for A&Es across our patch and nationally, and we reported a larger number of longer waits than usual for patients to be admitted to a hospital ward after being seen by an A&E doctor, particularly at our North Manchester site. The situation improved in the New Year but services have still been facing pressures due to patients not being discharged from our hospital wards back home or in the community and therefore not freeing up beds as quickly as required. Bed capacity has, however, been increased through resilience schemes and the deferral of routine elective inpatient work at various times throughout the year. Delayed discharges remain a significant pressure and non-elective length of stay has increased slightly when compared to last year. Industrial strike action has also had an impact within the last financial year. We are working hard to improve our performance, reduce waiting times and find ways to manage the demands on our services. Following a four day rapid improvement event supported by the TDA in January 2016, nine work-streams emerged from this and these all feed into the delivery of the Urgent Care Plan (see section 3.1.2). This Plan is high priority for the Trust in order to deliver the improvements identified by the Care Quality Commission. Annual Report

186 PAGE 184 We have recently introduced a new arrangement through our new Decision to Admit Policy (DTA) to speed up admission for those who need it and we have also been working closely with our colleagues in primary care, community care and social services to improve patient flow in and out of our hospitals and to speed up treatment and discharge for our patients. Patient safety remains our priority and our staff are working extremely hard to triage and treat those with serious conditions, those who require urgent attention, and critically ill patients brought in by ambulance as a priority. Any patient that is recognised as frail is immediately placed on a bed and measures put in place to ensure they suffer no harm from pressure damage etc. All patients who are expected to or have waited 6 hours in A&E are transferred onto a bed where all risk assessments are carried out (falls, pressure areas, VTE etc.) We continue to work closely as a local healthcare system with our NHS primary care, community care and social care colleagues to speed up treatment, admission and discharge times for our patients. For example, at our A&E department at North Manchester, a number of measures have been put in place to support staff in A&E to stabilise and strengthen the service. This involves enhanced GP and primary care input directly into the department from Manchester GPs, enhanced community services, and increased physiotherapy and pharmacy staff in A&E. Additional temporary A&E consultant cover from senior clinicians has also been offered from other neighbouring Trusts at the Manchester RoyaI Infirmary and Salford Royal. The Trust has made it a priority on abolishing 12 hour waits/breaches for patients brought to A&E needing to be admitted. Significant progress has been made since January 2017 in reducing the number of 12 hour breaches across all of our hospital sites Cancer waiting times The Trust provides cancer services for all of the main cancer tumour groups, including palliative care services. Each tumour group has an established multidisciplinary team (MDT), comprising doctors, specialist nurses and other health professionals from different health disciplines. Diagnosing cancer as early as possible and starting treatment quickly are key factors to improving survival for many cancers, and meeting the national targets is a priority for the Trust. The performance data for the year shows that the % national targets have been achieved for the two-week wait standard, 31-day first treatment standard, 31-day subsequent treatment standard (drug), and the 31-day subsequent treatment standard (surgery). Unfortunately the Trust has failed the remaining standards. The breast symptom non-achievement was due to failing Q1 and Q2. Q1 was predominantly due to patient choice delays: 68 breaches of which 58 were patient choice. Q2 failure was due to significant capacity issues caused by consultant sickness and absence of a locum consultant: 254 breaches of which 183 were capacity issues and 65 patient choice. Additional capacity has now been put in place resulting in compliance of the standard for both Q3 and Q4. The 62 day cancer GP referral standard was below the 85% target for Q1 and Q4. Q1 achieved 84.6% with 87 breaches of which 55 were due to late referrals to treating Trust; and Q4 achieved 80.3% with 92 breaches of which 49 were due to late referrals to treating Trust. The 62 day screening standard was below target for all quarters: as treatment numbers are low a small number of breaches can result in failing the target. The majority of the breaches have been cited as due to late referrals to treating Trust and capacity issues. The 62 day consultant upgrade standard was below target for Q4 only, with 23 breaches of which 17 were due to late referrals to treating Trust. Finally, for the 62 day GP referred local standard, non-achievement relates to patients breaching 62 days who have not been transferred to tertiary providers within Greater Manchester within locally agreed timescales: this results with the breach being fully reallocated to PAHT as opposed to shared between the two Trusts. This was a result of an

187 PAGE 185 unusually high number of breaches caused by a range of reasons such as patient choice, medical reasons, complex pathways, and capacity issues. National target % achievement % achievement standard target % Q1 Q2 Q3 Q4 Year Q1 Q2 Q3 (prov) Q4 Year two-week wait breast symptom /7 day first treatment 31 day subsequent - drug 31 day subsequent - surgery 62 day cancer GP Referral Standard 62 day Screening Referral Standard 62 day Consultant Upgrade Standard 62 day cancer GP referral local standard ** n/a TBC ** this is a local agreement between Manchester providers to repatriate breaches based on agreed timescales The Trust is continuing to work closely with other organisations within Greater Manchester on areas of service development to enable timely pathways and improved patient experience Single-sex accommodation breaches The Trust has seen a marked increase in the number of breaches of our Single Sex Accommodation Policy, particularly since July 2016, as seen in the charts below. Year Apr May Jun Jul Aug Sep Oct Nov Dec Jan Feb Mar Total Annual Report

188 PAGE Single-sex Accomodation Breaches to Apr May Jun Jul Aug Sep Oct Nov Dec Jan Feb Mar The breach figures include not only the patient who experienced the delay in step down, but also all other patients in that bay (e.g. a four bedded area with one patient delayed would register as four breaches). The breaches are all related to the timeliness of step down from critical care areas where mixed sex accommodation is permitted, to ward areas where it is not. Priority for available beds in wards was given to patients requiring admission from A & E. The greatest percentage of breaches (over 91%) occurred on the North Manchester site. The management teams continue to focus attention on this area. Revised single sex accommodation policy and processes were implemented from May 2016, along with an escalation policy to try to avoid potential breaches. The criteria that constitute a breach are clearly stipulated within this. An investigation into breaches is conducted and a template detailing the reasons completed within 72 hours, to be signed off within seven days by the division. Breaches are recorded on Safeguard and then validated internally before the information is submitted to NHS England Cancelled operations The Trust has treated elective inpatients during this year. It is sometimes necessary to defer routine non-urgent treatments in order to accommodate more urgent patients and, as reported nationally, urgent care demand has been particularly high this year. The Trust cancelled 1129 operations in the last 12 months; 1.3% of the total number of elective patients treated. This is a slight increase from 1.12 the previous year. The table below shows Pennine s performance by month, Month Elective Inpatients Cancelled Operations % Cancelled Operations 28 day breaches % 28 day Breaches Apr May June

189 PAGE 187 Month Elective Inpatients Cancelled Operations % Cancelled Operations 28 day breaches % 28 day Breaches July August September October November December January February March % Total % The Trust has worked hard to rearrange appointments and performs well against the 28 day standard compared to peers, as demonstrated in the table below which is based on published results. Of the 1129 cancellations there were only 59 patients who did not have their operation within 28 days of the cancellation Peer % patients treated within 28 days of cancelled operation Q1 Q2 Q3 Q4 Total Q1 Q2 Q3 Q4 Total Pennine North of England National Annual Report

190 PAGE Building a positive future The Trust has faced a very difficult and challenging chapter, particularly following the publication of the Care Quality Commission s (CQC) report and rating for the Trust in August The Trust s new leadership team under the direction of Chairman, Mr John Potter, and Chief Executive, Sir David Dalton, believe the CQC s findings mark the start of a new journey of improvement that will result in the hospitals and community services provided by the Trust becoming safer and more reliable and in time, being amongst the best in the country. The progress that has been made over the last year to make services safer and more reliable has been encouraging. Our staff recognise there is still a lot more work that needs to be done over the next year as part of the Trust s improvement journey. The information set out in this section highlights some of the key developments and progress that have been made for each of our hospital sites and community services, now what we are calling our locally-based care organisations NMGH Care Organisation New 5m Intermediate Care Unit The future of North Manchester General Hospital has a vitally important role to play in providing a range of local hospital services to a population with complex long-term chronic health needs. In September 2016, construction work started on the Trust s new 5m purpose-built 24 bed community Intermediate Care Unit situated in the grounds at North Manchester General Hospital. The unit is a joint partnership between the Trust, our local NHS commissioner

191 PAGE 189 North Manchester Clinical Commissioning Group (CCG), and Manchester City Council. The new unit, which is due to be completed and open by December 2017, will become part of the Trust s Community Assessment and Support Service (CASS), a new integrated service delivery model that aims to avoid admissions, reduce length of stay and improve patient and carer experiences by providing better access to the right intervention, at the right time, delivered by the right healthcare or social care worker. The majority of patients who access intermediate care services are over 75 years of age and the new unit will provide an enhanced service for community patients who require a period of rehabilitation. The unit will also support patients who do not require, or no longer need, specialist acute hospital care and treatment, but who do still need support within a community setting. The unit will offer patients support in the transition period between illness and recovery. Since November 2014 the Trust has been providing nine temporary intermediate care beds at North Manchester General Hospital on ward J5 in the main hospital building. These are in addition to 15 beds currently at Henesy House, a residential home in Collyhurst, Manchester. This new Intermediate Care Unit will replace all of these beds Improving Safety in Primary Care award In July 2016 staff within the Trust s Community Crisis Response Service in North Manchester won the Improving Safety in Primary Care award at the national 2016 Patient Safety Awards. The community Crisis Response Service aims to improve health and social care in patients that have reached a crisis point, that previously would have presented at Urgent Care or been placed in 24 hour care. The team support people in their own home environment wherever possible, and include staff such as nurses, Therapists, and Social Workers. Studies show that the function of older people is reduced significantly within 48 hours of being admitted to hospital, and in patients with any form of mental health need, there is evidence of increased mortality, increased length of stay, loss of independence and higher rates of admissions to care homes. An inter-disciplinary team was set up to provide a rapid response to referrals from any health or social care professional, for patients with a North Manchester GP, serving 36 practices and a growing population in excess of 189,000. The team is able to assess the patient in their own home within one to three hours. Our community services team at North Manchester are able to manage some very seriously ill people in their own homes, and over 90 per cent of patients would have otherwise been admitted to hospital. Crisis Response is now an essential service that provides a valued alternative for patients in the community preventing them attending hospital. New Needle-free vaccine An innovative public health initiative which has been launched at North Manchester General Hospital is not to be sniffed at in the fight against flu! As part of this year s national flu programme, pre-school children and older children in at risk groups who attend the paediatric emergency department at North Manchester General have been offered a needle-free flu vaccine. The pilot, organised by Dr Rachel Isba, consultant in paediatric public health medicine and who works in the Trust s emergency department, is believed to be the first of its kind in the country and is being organised in conjunction with colleagues in Greater Manchester Health and Social Care Partnership (GMHSCP). The nasal spray which is squirted up the children s nose will protect them from the flu virus. According to Public Health England, in flu vaccine pilot areas (2014/15) where primary school age children were given the nasal spray vaccine, the rates of hospital admissions due to confirmed influenza in that age group were down by 93%. Annual Report

192 PAGE 190 Specially trained nursing staff will be able to give the vaccination to children in the department as part of their routine work and the initial scheme will run from 9am to 5pm, Monday to Friday, throughout October, November and December. The North Manchester Macmillan Palliative Care Support Service In March 2017, staff who work within The North Manchester Macmillan Palliative Care Support Service (NMMPCSS) were recognised for their work with a top International Journal of Palliative Nursing award. The Service won the Multidisciplinary Teamwork Award. Based at the Cornerstones Centre in Beswick, the Service is regarded as an excellent model of integrated communitybased care for patients requiring end of life care and support. Since its launch in 2015 the service has: Increased the number of patients identified on Palliative Care Registers from 380 to 826 Helped 88 percent of patients achieve their preferred place of care Contacted all patients on the day of their referral ensuring timely access for all Increased the number of patients creating an Advance Care Plan stating wishes about their care from 30 percent in 2015 to 79 percent in 2016 Seen month on month increases in volunteer support for patients Been rated as Outstanding for caring at the Trust s CQC inspection in 2016.

193 PAGE 191 The Service was devised and implemented by The Macmillan Cancer Partnership (MCIP), a partnership between Macmillan, The Pennine Acute Hospitals NHS Trust, the Manchester CCGs, St Anne s Hospice, Manchester City Council, patients and carers. The Service, which operates every day of the week, is for any patient registered with a North Manchester GP with a life limiting illness who has palliative care needs. Patients, carers and professionals are able to refer into the Service making it more accessible for patients. NMMPCSS provides input to manage complex symptoms and needs, psychological, social and spiritual support. Staff can also signpost patients to a wide number of volunteer and advisory services. Half a million pounds investment in specialist radiology room Patients will benefit from better quality images and reduced radiation dose as a result of a 500,000 investment in a specialist radiology room at North Manchester General Hospital which opened this year. The fluoroscopy room has undergone a make-over and had 10 year old equipment replaced and updated to the latest models. A new Toshiba Ultimax-I fluoroscopy machine has been installed and the room has been redecorated and remodelled to provide an extra door into the room to avoid staff being irradiated. Fluoroscopy is the study of moving body structures, similar to an x-ray movie. A continuous beam is passed through the body part being examined with the beam then transmitted to a TV-like monitor so that the body part and its motion can be seen in detail. As an imaging tool, fluoroscopy allows physicians to look at many body structures including the skeletal, digestive, urinary, respiratory and reproductive systems. Our fluoroscopy service at North Manchester sees around 2,600 patients per year. It is used to diagnose and treat patients who have gastrointestinal problems, including problems with the stomach and throat, through to paediatric imaging and hysterosalpingograms which is an examination for ladies who are trying to get pregnant The Royal Oldham Hospital Care Organisation Maggie s Oldham Cancer Centre In June 2016, construction work started on site at The Royal Oldham site for a new Maggie s cancer centre. Maggie s is the national charity that provides free practical, emotional and social support for people with cancer and their family and friends. The new centre will be named Maggie s Oldham, The Sir Norman Stoller Centre and will be the charity s second facility in Greater Manchester. Maggie s Oldham has been designed by acclaimed architects drmm and was developed by Maggie s working in partnership with the Trust to enhance the cancer care and support already on offer. Every year 50,000 people in the North West are diagnosed with cancer. As the number of people living with cancer increases, support becomes even more important. Once open, Maggie s Oldham will give visitors access to Maggie s evidence based programme of support, including psychological support, benefits advice, nutrition workshops, relaxation and stress management, art therapy, tai chi and yoga. The Centre is due to open in summer 2017 and is predicted to receive 10,000 visits every year, many of whom will use it to relax before or after treatment and to share experiences with other cancer patients. The Trust already benefits from having The Christie at Oldham facility on the grounds of The Royal Oldham Hospital which provides high quality cancer services. Annual Report

194 PAGE 192 Trust leads the way with UK s first NHS use of hand held pain relief treatment The Trust has been helping patients trial a new pain reliving drug that can be self-administered via a hand held device. The Trust is the first NHS Trust in the UK to use the pioneering technique. Using a hand held device eliminates the risks associated with traditional intravenous pain relief. This year the Trust has been using one Zalviso device at The Royal Oldham Hospital as part of an evaluation process, where 40 patients will try out the device. Another Zalviso device will be introduced at North Manchester General Hospital soon for evaluation purposes. It is a novel technique that is currently used in Europe and we are proud to be the pioneers in this country. This technique is non-invasive and the analgesia provided does not require intravenous access thus reducing patient risks. Following the evaluation, the Trust will share its findings and experiences throughout this process with other NHS Trusts. The first NHS patient to use the device in the UK is local man Peter Fletcher, 81, who has used the device to ease postoperative pain following colorectal surgery.

195 PAGE 193 Baby Minnie makes history with new MRI scan Baby Minnie Macfarlane from Lees in Oldham made history when she was 11 days old. Born on 11 March 2016, she was the first baby at The Royal Oldham Hospital to undergo a landmark scan using new equipment which allows new born babies to have MRI scans. Previously new born babies would have had to have been transferred to another hospital Trust if they needed a MRI scan at such an early age, but thanks to the investment in the neonatal MRI compatible monitoring, babies can now be scanned in the radiology department at Oldham. As the hospital cares for high risk infants who are transferred to the level three neonatal unit, for therapeutic cooling to reduce the risk of brain injury, MRI scanning is helpful to assess the risk of any long term problems. MRI imaging of babies is a more complex procedure than the imaging performed in adults. The scanning parameters need to be optimised to enable detailed imaging of the small and newly developing brain and extra protection must also be provided to the infant to protect their developing organs. Baby Minnie paved the way and underwent a scan modelling the aptly named mini-muff ear protectors which protect the ears from the loud noise that the scanner makes. The new service for scanning neonatal patients will greatly improve our assessment of babies at high risk of brain injury, and allow more detailed imaging for early diagnosis of problems, without the need for a transfer to a different hospital. Investment in Maternity equipment As part of the Trust s improvement plan, 340,000 has been invested on new electronic fetal monitoring equipment to support staff across our maternity services. The new equipment is being installed into the labour wards and obstetric theatres at our two maternity units at North Manchester and The Royal Oldham hospitals where over 9,000 babies are born each year. Previously staff have used monitors at the bedside and a paper recording of the baby s heart rate traced. The new K2 system provides a central electronic monitoring and archiving solution for the fetal heart during labour. The equipment will improve patient care by having an electronic recording at the bedside, and it can also be used remotely and reviewed by other doctors and midwives, so that advice and support can be given if required. Misinterpretation of the fetal heart rate trace (CTG) is a common feature in labour care throughout the world. The aim of switching to a new electronic e-ctg monitoring and archiving system is to reduce harm by making it easier for staff to interpret CTGs using an approved electronic system. This will lead to appropriate and timely intervention by our doctors and midwives where necessary. In addition to the fetal monitoring equipment the Trust has also rolled out a new computerised system called the Antenatal Paediatric Alert system which was developed by the Trust. This system promotes appropriate sharing of information between midwives, obstetricians and paediatric staff at The Royal Oldham Hospital and Rochdale Infirmary. Staff have enthusiastically embraced the new system, which allows midwives and obstetricians to send alerts to staff in the paediatric and neonatology teams about information that may affect the care of the unborn child. The alert is used to document a postnatal care plan on the mother s electronic notes where it can be accessed by all clinicians who need to see this information. A live report also lists all women who have had an alert sent, and their up to date plan of care, for staff working on the labour ward, birthing centre and post-natal ward at The Royal Oldham Hospital. Annual Report

196 PAGE Fairfield General Hospital and Rochdale Infirmary Care Organisation New Rochdale Provider Partnership forms new multi-disciplinary neighbourhood teams In May 2016, over 200 community based care staff from a variety of backgrounds transferred to work for the Trust, based at Rochdale Infirmary, as part of a new integrated health and social care service for Rochdale borough. The new services have been commissioned by NHS Heywood, Middleton and Rochdale CCG through a new 9m contract to deliver a range of health and care services through integrated teams who work in the community. Integrated community health and care teams now provide community nursing and therapy services for adults, treatment room services, expert patient (health promotion) services, neurological-rehabilitation, amputee services, epilepsy services, stroke early supported discharge services and pulmonary rehabilitation. The teams also provide the out-of-hours adult community nursing service. Trust staff are working in the community as part of a unique partnership with local organisations including Age UK Rochdale, BARDOC (Bury and Rochdale Doctors on Call), GP Care Services Ltd, Greater Manchester Carers Trust, Link4life, Rochdale Borough Council, Rochdale Housing Initiative, and VIC (Veterans in Communities). Rochdale is leading the way in providing truly integrated health and social care services. Through this partnership approach, patients and local people are benefiting from greater joined-up working between the local NHS, social services and local care and community organisations. Radiology Services strengthened Radiology services at Rochdale Infirmary have been strengthened following the investment and creation of a third digital x-ray room on the hospital site. Over 220,000 has been invested in a new x-ray room which houses state-of-the-art equipment to produce images of the inside of the body to diagnose a range of conditions. The digital x-ray machine allows the equipment to be used much like a digital camera so that the acquired images can be viewed immediately and repeated if necessary without causing unnecessary distress to the patient. This will result in a faster radiology service with better image quality. The x-ray room has also been relocated from the outpatient department at Rochdale Infirmary to within the main x-ray department, allowing for improved team working. Productivity and patient throughput in the department are expected to increase as radiology staff do not have to leave the room now to process the images as they are available immediately on the machine in the room. Previously a computed radiography (CR) x-ray machine was used which involved the use of an x-ray cassette which needed processing after the image was taken in a different location. With this new equipment the Trust has massively improved the patient experience at Rochdale Infirmary by reducing waiting times, increased resolution of images, and lower radiation dose, all in a state of the art diagnostic facility. New Gastrointestinal Unit opened In October 2016, the Trust opened a new purpose-built gastro-intestinal (GI) physiology unit at Rochdale Infirmary for patients with gastrointestinal problems. Now housed in a larger purpose-built unit on level A in the Infirmary, the unit houses state-of-the-art equipment with separate rooms for undertaking upper and lower GI function tests, office accommodation and a patient consenting room.

197 PAGE 195 The unit offers a wide range of GI physiological studies for the assessment and investigation of patients with swallowing problems, gastro-oesophageal reflux disease and non-cardiac chest pain. The unit now enables doctors to undertake two separate procedures at the same time, thereby reducing waiting times. The GI physiology unit receives approximately 400 new referrals for upper and lower GI function tests per year, and provides biofeedback therapy to approximately 200 patients with ano-rectal dysfunction. New 23 hour day surgical beds This year our Day Surgery and Operating Theatre Department at Rochdale Infirmary opened eight new 23 hour postoperative beds. These new 23 hour beds mean that Rochdale patients will stay in one department from admission to discharge and will not need transferring to another hospital. The expansion of the unit is helping to relieve bed pressures and reduce cancelled operations at our other hospital sites. It is also helping reduce time and costs for the ambulance service, freeing up ambulance crews to attend local emergencies. The Day Surgery and Operating Theatre Department at Rochdale Infirmary opened in 2000, and was purpose built to accommodate a variety of surgical specialities for Inpatient, Day Case Elective and Emergency/Trauma procedures. The department has become a centre of excellence for day surgery procedures in General Surgery, Orthopaedics, Plastics, Oral, Pain, Vascular, Ophthalmology, Gynaecology and develop clinics for Urology and Lithotripsy. In 2016 the department cared for 11,069 patients undergoing surgical procedures. Annual Report

198 PAGE 196 New pilot helps people avoid Urgent Care Local patients from Rochdale borough are benefiting from a new pilot scheme, which started in November 2016, providing an emergency response vehicle manned by a multi-disciplinary team of healthcare professionals that goes out in the community to people s homes. Known as HEATT (Heywood Middleton Rochdale Emergency Assessment & Treatment Team) this consists of a senior paramedic and an advanced nurse practitioner from the local Urgent Community Care Team who have access to specialist services for patients i.e. pharmacy\medication support, social care, access to a local GP and enhanced diagnostics. The team respond to emergency calls and assess and treat people in their own home and where safe, maintain them in their own home in a virtual bed or community setting. HEATT calls are identified from IT systems following 999 calls to the ambulance service for appropriate patients aged 18 years or over who reside within the Heywood, Middleton and Rochdale area. The HEATT service aims to target calls where there is an opportunity to avoid an emergency admission or A&E attendance, and provide care for patients in their own home or community setting rather than an acute hospital. HEATT is a collaborative project between the community health and social care teams Rochdale, provided by the Trust and our partners including the North West Ambulance Service NHS Trust (NWAS), funded by HMR CCG. This rapid response team comprising of a senior paramedic and an advanced nurse practitioner ensures that care is brought to patients, and we have moved away from transporting patients to where care is traditionally provided, i.e. hospitals. Since the service commenced at the end of November 2016, the HEATT service has helped 88% of patients avoid the need to be taken to A&E or the Urgent Care Centre at Rochdale by providing care in their own home or community setting. New MRI scanner at Fairfield In January 2017 a new magnetic resonance imaging (MRI) unit at Fairfield General Hospital was officially opened. The Trust has invested over 2.2m on the new scanner and subsequent building work to house it. The unit contains a new state-of-the-art MR scanner which will provide images for around 6,000 patients a year. Housed in a brand new unit which is accessed via the radiology department at the front of the hospital, the new equipment scanned its first patient in mid-december. Manetic resonance (MR) scanning works by creating very strong magnetic fields and radio frequency waves to produce incredibly detailed images of inside the body without the use of ionising radiation or invasive procedures. The new installation also means that Bury residents will no longer have to travel to Rochdale Infirmary to be scanned. It will be used for all Trust inpatients and outpatients, and Bury GP patients. Investment in the new scanner supports the Trust s strategy for providing dedicated specialist stroke services at Fairfield General Hospital as it will allow clinicians to make a quicker stroke diagnosis. Getting it Right for people with a Learning Disability The year the Trust signed up to Mencap s Getting it right charter to show our commitment to improving healthcare and treatment for people with a learning disability. People with a learning disability experience poorer health and poorer healthcare than the general population, with research exposing how 1,200 people with a learning disability die avoidably every year in the NHS.

199 PAGE 197 Mencap worked in partnership with a number of organisations to produce a charter for healthcare professionals, to help them work towards better health, wellbeing and quality of life for people with a learning disability. The charter reminds us to see the person, not their disability, and to make any reasonable adjustments to care that they may need to ensure that their journey of care is person centred and the best that it can be. To show our commitment to getting it right the Trust has also this year employed a Learning Disability Liaison Nurse and has committed to fulfilling all nine points of the getting it right charter. Annual Report

200 PAGE What others say about the Trust North East Sector NHS Commissioner Response Thank you for asking us to comment in response to your Quality Account Saving Lives, Improving Lives. I am pleased that we had the opportunity to give feedback in February into the production of this report was a year of great change for PAHT, with the recognition by all stakeholders that the previous arrangements were failing local residents in the care and services they deserved. The Care Quality Commission (CQC) and the 100 day diagnostic evaluation led by a team from Salford Royal Foundation Trust provided clear focus of the quality issues and presented a new beginning for the Trust s stabilisation and quality improvement journey. The Board hosted by Greater Manchester Health and Social Care Partnership with key senior directors from the Trust, the North East Sector CCGs, NHS and the CQC has successfully provided direction and sought assurance on the progress of the Trust s CQC Quality Action Plan. The CQC Action Plan and the refreshed draft Quality Strategy Igniting Quality which you have developed and are building on have formed the platform for your quality improvement agenda. The improvements we would expect to see in that are of particular importance to us as commissioners are: Care and Treatment: Processes to eliminate long waits in your emergency departments Processes to ensure there are no Never Events across the organisation Computer IT solutions to reducing the risk around missed and delayed diagnosis particularly in chest radiology s to Maternity Services with all women describing positive experiences in care and treatment s in cleaning, hand hygiene and other infection control and prevention measures Building on the progress of the Falls Prevention Strategy Continuing the excellent programme of the Nursing Assessment and Accreditation System Staff recruitment and support Strategy for staff recruitment and retention; including flexible working and the plans to use the workforce in new and innovative ways, for example, Physician Assistant type roles and the Nursing Associate role. Promoting outstanding practice and recognising the dedication of the Trust s excellent staff. Engagement with local partners Plans for engaging with all stakeholders in the formation of Local Care Organisations; being open to change processes to enable working in new ways to deliver health care by the right person at the right time in the right place. The Quality Account details much of the improvement work seen over the previous year and it is a transparent and honest account of the organisation. Additionally we want to commend the front line staff for their dedication and resilience shown through the previous 12 months who are embracing change and are positively supporting the Trust s senior leaders.

201 PAGE Local Health Watch organisations Thank you for the draft copy of your quality accounts and the opportunity to comment. The document clearly outlines the challenges and opportunities facing Pennine Acute during the forthcoming year. We note the overall rating of the Care Quality Commission (CQC), following its inspection of the Trust in March A number of the issues were raised by Healthwatch, prior to the inspection, but no-one at that time seemed prepared to listen, so it came as no surprise to read that staff across the organisation had also expressed genuine concerns. Thankfully, the Chief Executive of Salford Royal has realised the need for a change of culture and, together with his senior team, has already been listening to staff and supporting them to bring about the changes which are necessary to ensure patients receive good safe treatment in a timely manner. We note the actions in the Plan and, in particular, the six main improvement themes and aims for the current year ( ). At this point in time, it would be inappropriate to comment on specific areas but there are some basic issues which appear within the report, that give cause for concern. 1. Inconsistencies across specialties 2. Poor communication 3. Lack of relevant training 4. Failure to complete forms/records, especially those relating to information regarding treatment given to patients 5. Lack of compliance with standard procedures/policies 6. Failure to provide patients (within the community) with relevant information/guidance 7. The significant increase in Serious Untoward Incidents 8. The number of 12-hour A & E breaches We are pleased to note the wide range of improvement projects that have been developed during the year and the huge recruitment programme which has taken place, in response to recommendations made by the CQC. Hopefully, better governance and a more positive culture within the organisation, will eradicate most of the concerns expressed above. Healthwatch Bury looks forward to working with the Trust, through the NE Sector Healthwatch/PAHT Forum, and monitoring the results of the many initiatives which are presently taking place. Healthwatch Bury May 2017 Healthwatch Rochdale have noted the contents of the report and have no further comments to make. Kate Jones; CEO Annual Report

202 PAGE Statement of Directors responsibilities in respect of the Quality Account The directors are required under the Health Act 2009, National Health Service (Quality Accounts) Regulations 2010 and National Health Service (Quality Account) Amendment Regulation 2011 to prepare Quality Accounts for each financial year. The Department of Health has issued guidance on the form and content of annual Quality Accounts, which incorporate these legal requirements. In preparing the Quality Account, directors are required to take steps to satisfy themselves that: the Quality Accounts presents a balanced picture of the Trust s performance over the period covered; the performance information reported in the Quality Account is reliable and accurate; there are proper internal controls over the collection and reporting of the measures of performance included in the Quality Account, and these controls are subject to review to confirm that they are working effectively in practice; the data underpinning the measures of performance reported in the Quality Account is robust and reliable, conforms to specified data quality standards and prescribed definitions, is subject to appropriate scrutiny and review; and the Quality Account has been prepared in accordance with Department of Health guidance. The directors confirm to the best of their knowledge and belief they have complied with the requirements in preparing the Quality Account. By order of the board Chairman and Chief Executive 26 May Independent auditors limited assurance report to the Directors of Pennine Acute Hospitals NHS Trust on the Annual Quality Account We are required to perform an independent assurance engagement in respect of Pennine Acute Hospitals NHS Trust s Quality Account for the year ended 31 March 2017 ( the Quality Account ) and certain performance indicators contained therein as part of our work. NHS Trusts are required by section 8 of the Health Act 2009 to publish a Quality Account which must include prescribed information set out in The National Health Service (Quality Account) Regulations 2010, the National Health Service (Quality Account) Amendment Regulations 2011 and the National Health Service (Quality Account) Amendment Regulations 2012 ( the Regulations ). Scope and subject matter The indicators for the year ended 31 March 2017 subject to limited assurance consist of the following indicators: Percentage of patient safety incidents resulting in severe harm or death FFT patient element score We refer to these two indicators collectively as the indicators.

203 PAGE 201 Respective responsibilities of the Directors and the auditor The Directors are required under the Health Act 2009 to prepare a Quality Account for each financial year. The Department of Health has issued guidance on the form and content of annual Quality Accounts (which incorporates the legal requirements in the Health Act 2009 and the Regulations). In preparing the Quality Account, the Directors are required to take steps to satisfy themselves that: the Quality Account presents a balanced picture of the Trust s performance over the period covered; the performance information reported in the Quality Account is reliable and accurate; there are proper internal controls over the collection and reporting of the measures of performance included in the Quality Account, and these controls are subject to review to confirm that they are working effectively in practice; the data underpinning the measures of performance reported in the Quality Account is robust and reliable, conforms to specified data quality standards and prescribed definitions, and is subject to appropriate scrutiny and review; and the Quality Account has been prepared in accordance with Department of Health guidance. The Directors are required to confirm compliance with these requirements in a statement of directors responsibilities within the Quality Account. Our responsibility is to form a conclusion, based on limited assurance procedures, on whether anything has come to our attention that causes us to believe that: the Quality Account is not prepared in all material respects in line with the criteria set out in the Regulations; the Quality Account is not consistent in all material respects with the sources specified in the NHS Quality Accounts Auditor Guidance ( the Guidance ); and the indicators in the Quality Account identified as having been the subject of limited assurance in the Quality Account are not reasonably stated in all material respects in accordance with the Regulations and the six dimensions of data quality set out in the Guidance. We read the Quality Account and conclude whether it is consistent with the requirements of the Regulations and to consider the implications for our report if we become aware of any material omissions. We read the other information contained in the Quality Account and consider whether it is materially inconsistent with: Board minutes for the period April 2016 to May 2017; papers relating to quality reported to the Board over the period April 2016 to May 2017; feedback from the Commissioners dated 23/05/2017; feedback from Local Healthwatch dated 25/04/2017 and 23/05/2017; the Trust s complaints report published under regulation 18 of the Local Authority, Social Services and NHS Complaints (England) Regulations 2009, dated 27/04/2017; the latest national patient survey dated February 2017; the 2016 national staff survey; the Head of Internal Audit s annual opinion over the Trust s control environment dated March 2017; the annual governance statement dated 26/05/2017; and the Care Quality Commission Inspection Report dated 12/08/2016. Annual Report

204 PAGE 202 We consider the implications for our report if we become aware of any apparent misstatements or material inconsistencies with these documents (collectively the documents ). Our responsibilities do not extend to any other information. This report, including the conclusion, is made solely to the Board of Directors of Pennine Acute Hospitals NHS Trust. We permit the disclosure of this report to enable the Board of Directors to demonstrate that they have discharged their governance responsibilities by commissioning an independent assurance report in connection with the indicators. To the fullest extent permissible by law, we do not accept or assume responsibility to anyone other than the Board of Directors as a body and Pennine Acute Hospitals Trust for our work or this report save where terms are expressly agreed and with our prior consent in writing. Assurance work performed We conducted this limited assurance engagement under the terms of the Guidance. Our limited assurance procedures included: evaluating the design and implementation of the key processes and controls for managing and reporting the indicators; making enquiries of management; testing key management controls; limited testing, on a selective basis, of the data used to calculate the indicator back to supporting documentation; comparing the content of the Quality Account to the requirements of the Regulations; and reading the documents. A limited assurance engagement is narrower in scope than a reasonable assurance engagement. The nature, timing and extent of procedures for gathering sufficient appropriate evidence are deliberately limited relative to a reasonable assurance engagement. Limitations Non-financial performance information is subject to more inherent limitations than financial information, given the characteristics of the subject matter and the methods used for determining such information. The absence of a significant body of established practice on which to draw allows for the selection of different but acceptable measurement techniques which can result in materially different measurements and can impact comparability. The precision of different measurement techniques may also vary. Furthermore, the nature and methods used to determine such information, as well as the measurement criteria and the precision thereof, may change over time. It is important to read the Quality Account in the context of the criteria set out in the Regulations. The nature, form and content required of Quality Accounts are determined by the Department of Health. This may result in the omission of information relevant to other users, for example for the purpose of comparing the results of different NHS organisations. In addition, the scope of our assurance work has not included governance over quality or non-mandated indicators which have been determined locally by Pennine Acute Hospitals NHS Trust.

205 PAGE 203 Basis for disclaimer conclusion As set out on page 105 of the Trust s Quality Report, the Trust currently has concerns with the accuracy of data on which the percentage of patient safety incidents resulting in severe harm or death is based. This is primarily due to delays in data being validated. We are also unable to comment on the timeliness and the validity of the data used to calculate the FFT patient element score as the responsibility lies with the service organisation who collate the data for the indicator and not Pennine Acute Hospitals NHS Trust. As a result of these issues, we are unable to give limited assurance on the percentage of patient safety incidents resulting in severe harm or death and the FFT patient element score indicators included in the Quality Report for the year ended 31 March Disclaimer qualified conclusion Based on the results of our procedures, with the exception of the effects of the matters reported in the Basis for disclaimer conclusion paragraphs above, nothing has come to our attention that causes us to believe that, for the year ended 31 March 2017: the Quality Account is not prepared in all material respects in line with the criteria set out in the Regulations; and the Quality Account is not consistent in all material respects with the sources specified in the Guidance. KPMG LLP Chartered Accountants 1 St Peter s Square Manchester M2 3AE 30 May 2017 Annual Report

206 PAGE 204 Annual Accounts 2016/17