Agenda Item: 08 Pam Fenner NHS Norwich CCG Governing Body Tuesday 22 March 2016

Agenda Item: 08 Pam Fenner NHS Norwich CCG Governing Body Tuesday 22 March 2016 Subject Presented By Submitted To Purpose of Paper Quality and Patient Safety Committee Executive Harvest Summary Pam Fenner Quality and Safety Committee Chair and Lay Member (Registered Nurse) NHS Norwich CCG Governing Body Tuesday 22 nd March 2016 For Information Summary The purpose of this paper is to provide a summary of the key highlights of clinical quality and patient safety relating to our NHS provider services. Further information and performance data can be found within the accompanying dashboard. CT / March 2016 / Executive Harvest Summary / FINAL

NCH&C Serious Incidents (SI) There were 53 SI reported in February 2016 which is comparable with the 6 previous months. The majority, 48, relate to grade 3 pressure ulcers which were acquired within patient s own homes, including residential care, 11 of which relate to Norwich CCG patients. Other SI include two grade 4 pressure ulcers, two falls and on information governance breach, none of which relate to Norwich CCG patients. Pressure Ulcers (PU) The Trust PU policy has been reviewed, however the launch of the policy has been delayed until March 2016 to allow commissioners the opportunity to comment and make recommendations. Norwich CCG has provided feedback on the draft policy and made a number of recommendations. Following the launch of the updated policy, the Trust will commence reporting PU in line with the Serious Incidents Framework (2015), where RCA for avoidable PUs will be completed, with a monthly audit of unavoidable PUs to provide assurance that PU have been appropriately classified. The RCA reports will continue to be presented at the PU Validation Meeting to support and facilitate learning from avoidable PUs. CT / March 2016 / Executive Harvest Summary / FINAL Page 2

Falls The number of falls reported in January 2016 reduced to 46. This is the lowest number of falls reported over the last 12-month period. There was one severe harm fall reported in January 2016 categorised by the Trust as severe harm, relating to a Norwich CCG patient who had sustained a fracture following a fall. The number of falls per month remains comparable with previous months, with the exception of the spike in August 2015. Medications Incidents There were 42 medication incidents reported in January 2016, this is comparable with previous months, although all categories of harm have reduced this month. One moderate incident was reported in January 2016 which was due to a lack of availability of diamorphine (national shortage) delaying the replenishment of a syringe driver. There had been an increase in the number of Controlled Incidents (CDs), culminating in a peak (12) in September 2015. These figures have now reduced and plateaued with 6 incidents reported in January 2016. The Trust reported a 40% increase in CDs incidents over the last three years. Findings suggest this may be as a result of an increase in the number of patients requiring complex clinical care, for example End of Life care. This will be discussed at CQRM. Infection Prevention and Control (IP&C) There were no cases of C.Diff reported in January 2016 and to date the Trust have a total of 6 cases year to date against a trajectory of 7. There are 2 further cases currently awaiting appeal which may see the Trust breach their trajectory. The Trust IP&C team have been undertaking a series of commode audits. The audits demonstrated poor compliance with IP&C standards, with the percentage of clean commodes within inpatient settings ranging from 21% to 83%. Areas identified as noncompliant are being re-audited on a weekly or fortnightly basis until compliance with cleaning schedule is achieved. The audit identified a number of commodes that need replacing this should be achieved by the beginning of the financial year April 2016. The IP&C team will continue to undertake monthly audits for at least the next 3 months as a minimum until they are assured of consistent compliance with cleanliness standards. Safety Thermometer The number of patients receiving harm free care over the last 3 months has continued to improve: January 2016 92.6% December 2015 90.7% November 2015 88.2% There were no new VTEs reported in January 2016, however an RCA is underway regarding the VTE reported in December 2015. The CAUTI project remains ongoing with an aim to reduce the number of CAUTI s reported across the organisation. Catheter passports have now been printed and are available within all clinical teams for completion and dissemination. There is a strategic piece of work being undertaken by a Public Health Consultant who will be liaising with local Directors of Nursing to encourage wider collaboration in the use of catheter passports. Mortality The Mortality Review Group convened in February 2016 and agreed the revisions to the mortality review process. As from the beginning of February 2016 Ward Managers and CT / March 2016 / Executive Harvest Summary / FINAL Page 3

Doctors will record all inpatient deaths on a dedicated form, highlighting any sub-optimal care and classifying all deaths according to a nationally recognised mortality scale. For patients where anything untoward has been recognised, those with a Learning Disability and a random sample of other patients will be subject to a more detailed review. These revisions are in line with the recommendations within the Mazars Report. The Mortality Review Group will meet in April 2016 to review stages one and two documentation to identify any subsequent trends and learning and consider the need for remedial action plans where appropriate. NCHC s mortality data has been reviewed for January 16 and there are no significant areas of concern noted. Complaints 21 complaints were received during January 2016, compared to 16 in November 2015. The numbers of complaints received over the past 6 months have remained comparable. There were three complaints received regarding specialist services, two of which specifically related to difficulties in contacting the Trust s podiatry department at Norwich Community Hospital and lack of communication when cancelling appointments. This will continue to be monitored to see if this becomes a reoccurring issue. There has been a further complaint regarding the poor quality of continence products being provided. As problems with continence products are identified by patients, a reassessment of their continence needs is undertaken. Patients with more complex needs may require more than one assessment to determine the most appropriate product to meet their needs. Some patients take 3 6 months to work through their new continence products and this may be why this issue appears to be a reoccurring theme. Friends and Family Test (FFT) The overall Trust FFT score for January 2016 is 99 with year-to-date at 98, demonstrating a slight improvement from November and December 2015. All categories received less than 10 negative comments during January 2015, with estates and facilities receiving the most negative comments. This is consistent with the previous month. A new category (survey/questions) is being collated and has recorded the second highest number of negative comments (8) during January 2016. Looked After Children (LAC) The LAC Project Steering Group met for the second time on 2 March 2016 and is currently completing the Project Initiation Document. Four work-streams have been established: Commissioning, Adoption, IM&T and Workforce. NCH&C is still exploring opportunities to work with secondary provider(s) to reduce the backlog. Fortnightly operational meetings continue to take place between the LAC Designated Nurse and Dr, Providers and NCC to ensure any process blockages are highlighted and resolved. Lymphoedema The current service model is in the process of being reviewed to ensure that this can be delivered within the cost envelope available. There are currently staffing shortfalls within the service which will impact on the Trust s ability to assess and follow up patients on the caseload. The Trust is actively trying to recruit to increase capacity within the service, despite any formal agreement regarding a new service model. IC24 Serious Incidents (SI) and Quality Issue Reporting (QIR). There were 2 new SI reported during February 2016, both of which relate to treatment CT / March 2016 / Executive Harvest Summary / FINAL Page 4

delays. Neither of these incidents relate to Norwich CCG patients. There were 8 QIR reported in February 2016, with 4 of these relating to a delay/difficulty in obtaining clinical assistance, this has almost halved when compared to the previous month. Performance The final copy of the CCG s report following unannounced visits have been shared with CQC and Monitor. An improvement plan was developed in October 2015 and this has now been superseded with a remedial action plan. This has been agreed with the provider, the coordinating commissioner and NHS England. Bi-monthly operational meetings between the provider and local CCGs continue to monitor and review the remedial action plan. 111 Service The main area of the CCG s focus is on the number of calls answered in 60 seconds and the percentage of abandoned calls. The workforce is not running at full capacity due to attrition and high levels of sickness which reflects on the current level of performance. Active recruitment of call handlers is taking place to achieve over establishment to support timely call taking. Recruitment via a specialist agency remains ongoing to ensure the most appropriate staff are appointed to these posts. Activity within the service remains consistently higher than anticipated and IC24 are remodelling their workforce to meet the current level of demand. Ratios of call handlers to clinicians are closely monitored to ensure patient safety. A graduation bay with a separate coach is in place to provide additional support for newly trained and trained staff. A Norwich-centric dispatch is in place to support local knowledge, although this will not be at full capacity until the recruitment process has been completed. A DOS review is ongoing to ensure providers are listed with work progressing regarding local amendment to include SWIFT service for falls. OOH Service There is a Contract Query Notice raised regarding performance against speak to a GP within 1, 2 and 6 hour, PPC and home visit standards. Recruitment to GP vacancies is improving with 10 GPs recruited over the last few months. The introduction of a remote GP service has been implemented to support the service at times of high activity. There is active recruitment to other roles including Urgent Care Practitioners and Advanced Practitioner Nurses remains in progress. IC24 have reviewed and adapted a number processes to make improvements following trends highlighted within QIR relating to treatment delays for palliative care patients. This has included the pilot of a rapid response vehicle to improve the response times and provision of a stock box supply for clinicians to access. IT systems and processes have been amended to improve the identification of Palliative patients that are End of Life to improve the timeliness of access to care and treatment. Improvements have been evidenced through a reduction in QIR submissions. We are more assured of progress made within the OOH service following implementation of the oversight GP, home triage and local dispatch, including the booking of urgent base visits to address performance. Workforce IC24 have now recruited a substantive Chief Executive Officer. There are a number of strategies in place to improve communication within the organisation. This includes the development of a monthly newsletter which is shared with operational staff. There are regular meetings between executive and operational teams with an open door approach being promoted. IC24 have developed an action plan to address current compliance with CT / March 2016 / Executive Harvest Summary / FINAL Page 5

safeguarding training and policy update. They are working closely with Adult Safeguarding Lead for Norfolk CCGs and NNCCG. Commissioners continue to work with the new provider to monitor and manage progress against the RAP to plan and mitigate the risks wherever possible to ensure safe provision of service. NSFT Serious Incidents (SI) and Quality Issue Reporting (QIR) There were 6 SI reported in February 2016, two of which occurred in January 2016 and refer to unexpected deaths. One incident following initial investigation appears to relate to a physical cause with an inpatient requiring resuscitation, there is no evidence to suggest that the patient received any sub-optimal treatment at this stage. RCA submission date 27.04.16. Of the remaining four incidents, two relate to falls resulting in injury, one was an unexpected death of an ex service user and one was an expected death of a client under a Deprivation of Liberty Safeguards. The Trust completed an internal review of unexpected deaths to support this work a further external review of unexpected deaths has been commissioned. Quality Improvement Plan (QIP) There are currently 23 active QIPs and 5 new QIPs are currently being scoped in support of the 2016/17 Quality Plan: Two are Red Nine are Amber Twelve are Green The two red QIPs, Physical health Monitoring and Mandatory Training, are being monitored via CQRM. It is expected that once the results of the internal mock CQC audit have been reviewed further work will be required in redefining/revisiting existing QIPs and/or creation of new. This is to be orchestrated at the bi-weekly CQC Preparedness Meeting (CPM) led by their Director of Nursing. Performance Central Norfolk Contract A Remedial Action Plan (RAP) remains in place in relation to the non-achievement of the AAT 28-day target. A 95% target has been proposed by July 2016. The Trust is confident that restructuring their Central Norfolk Community Adult services will support the achievement of this. The Trust has highlighted a significant number of 4-hour referrals received within AAT service that are inappropriate. To address this from April 2016, Primary Care Liaison Workers within secondary care will be in place to provide greater support and education in referral management. The long term aim of the Trust is to eliminate the use of prone restraint. The Trust continues to make good progress in decreasing the use of prone restraint with only two breaches of the standard reported in July & October 2015. Seclusion numbers are also below the internal Trust target for December 2015. Waiting list analysis undertaken in February 2016 has raised some concerns. A detailed review has been requested of the number of patients waiting to be seen by patient group. CT / March 2016 / Executive Harvest Summary / FINAL Page 6

The Trust will present a report to March 2016, CQRM and SPRG. Out of Trust Placements Out of Trust placements remain a significant feature. Eleven patients were reported as out of placement 18 February 2016. Four patients were placed at Mundesley hospital with a joint visit agreed to be undertaken for assurance purposes within the next two months. Of the remaining seven patients two relate to older age service users. The co-ordinating commissioner is working on a repatriation template to be included within the 2016/17 contract. Workforce The Trust has an 11.35% vacancy rate. Recruitment continues to be an issue for Band 5 nurses (25% vacancy rate) and consultants (12.4%); however these positions have shown some improvement compared to Q2. benchmarking data that indicates in comparison other Trusts have higher vacancy rates than NSFT. Workforce analysis indicates an improvement across all localities within Norfolk. Voluntary Turnover rate within the Trust at end of Q3 was 8.80%; with work-life balance and relocation continue to be the highest voluntary reasons for leaving. National Benchmarking for turnover amongst all Mental Health Trusts and Learning Disability Trusts is 13.50% (September 2015). Central Norfolk = 7.13% (up) at end of Q3. Absence rate within the Trust at end of Q3 was 4.82%, the lowest rate in 2015 with an improving trend over the last 12 months. The Trust is assured that it is on target to reach 4.5% by March 2016. Current UK average for absence in mental health Trusts is 4.70% (September 2015). Central Norfolk Locality 4.91% at end of Q3. Incidents related to staffing concerns continue to reduce in number, after reaching a peak of 272 incidents in August 2015. Feedback suggests that where teams have been booking long term regular agency staff, the temporary staff have become part of the team and ward staff are no longer report staffing concerns. Appraisal rate within the Trust at end of November 2015 was 87.10%. System issues prevented appraisal reporting at end Dec 2015. There is an improving trend during Q1 and Q2, continuing into Q3 with an average increase of 1% per month. Central Norfolk Compliance is 83.90%. The number of reported assaults on staff with harm were at their lowest level in December 2015. NNUH HSMR (Hospital Standardised Mortality Rate) The Trust HSMR figure for September and October 2015 was 96.1 and 98.0 respectively. This remains below the annual target of 100, however HSMR has predominantly remained above this threshold for majority of 2015/16 financial year to date. Mortality rates are monitored through governance structures at the Trust for example mortality group, CQRM and benchmarks HSMR against national rates. NCCG gains assurance of this process through Quality and Patient Safety Committee. Maternity Services Serious Incidents (SI) A number of SI has been reported within Maternity Services the Directorate is undertaking Root Cause Analyses (RCA) to identify any learning outcomes and or recommendations that may be required. The Local Supervisory Authority (LSA) has undertaken an RCA of one of the incidents and has identified some recommendations that will be followed up through the CT / March 2016 / Executive Harvest Summary / FINAL Page 7

Trust internal Directorate and Corporate clinical governance processes. The scanning for small for gestational age (SFGA) has been identified as a 16+ risk by the Trust as they are non-compliant with Royal College of Obstetricians and Gynaecology guidance. This relates to a skills gap within the workforce, the Trust has trained a midwife to undertake the scanning process with a further midwife due to commence their training in March 2016. Harm Free Care CAUTIs Catheter care The Trust has confirmed that their ambition is to treat the insertion of catheters as if they were a prescribing and administering a drug with the same rigor of reviewing a drug chart. The appropriateness of catheter use, regularity of review and possible removal before discharge has been discussed at CQRM. It is recommended that revisiting this topic at CQRM is considered based on the data provided in the NNUH Integrated Report. Medication Incidents Three medication incidents resulting in possible harm or death were reported in Jan 2016, outcome of RCA waited. Falls Seven inpatient falls were reported in January 2015. A further three falls was reported as falls relating to moderate/severe harm in February 2016. It is not possible to comment at the time of this report RCAs are awaited. Boarders 18 per cent of Patient Advisory Liaison Services contacts for January 2016 relate to patients boarded into the Day Procedure Unit (DPU) overnight at times of internal escalation. Norwich CCG is seeking assurance regarding the process for patients boarded to DPU and other areas that their needs can be met by staff caring for them out of specialty. Performance The Trust continues to breach the Emergency Department (ED) 4 hour standard reporting 12 hour trolley waits RCA awaited. The predominate reasons for non-compliance relates to: Bed Availability DTOC & complex discharge issues severely impacting upon the flow out of ED, Acute Medical Unit Actions by Trust Internal and external focus on delayed discharges. Twice weekly exec review of patients requiring complex discharge with escalation to system partners including Clinical Commissioning Groups. Rapid Action Plan. Cancer Targets Cancer 62-day GP referral performance remains a priority for recovery. Failure to meet the agreed backlog reduction in December 2015 related to delays in accessing CT CT / March 2016 / Executive Harvest Summary / FINAL Page 8

Colonography driven by unprecedented levels of demand. This has been resolved and good progress is being made. It is anticipated that a sustainable backlog (20 patients) will be achieved by February 2016 with the associated delivery of this critical performance target in March 2016. Performance data provided by the Trust indicates that overall backlog for Cancer 62 day remains above trajectory of 20 for actual backlog and below trajectory for rollovers. A remedial action plan has been agreed with commissioners. RTT admitted backlog trajectory is not being met and has led to increasing number of cancellations due to bed pressures impacting on elective activity. Care Homes Gryphon Place A routine announced quality visit was carried out on 8 February 2016. The provider is a small care home providing specialist care. There was evidence of good person centred care. The manager was advised to address the staff s training compliance rate and the Clinical Quality and Patient Safety (CQPS) manager will follow up with the care home on any recommendations made at the time of the visit. The Hawthorns A routine announced quality visit was carried out on 11 February 2016. There were no issues or concerns noted at this visit and some good practice was noted. The Infection Prevention and Control (IPAC) officer Norfolk County Council (NCC) had previously carried out an audit and identified areas for improvement. The provider has developed an action plan that has been updated following an inspection by the IPAC to reflect improvements made. Ivy Court The provider was visited by a Safeguarding practitioner and Quality officer NCC in December 2015. The visit identified concerns with poor documentation and recommendations not being acted upon. Although improvements were observed the assessors do not have full confidence that the changes are sustainable a further CQPS visit is planned. Any requests for placing of CHC patients must firstly be discussed with the CQPS team or Safeguarding. Cavell Court Requirements required relating to documentation; care plans, audit of plans and medicines management. A Safeguarding Practitioner and Quality Assurance Officer, Norfolk County Council visited on 29 January 2016 to undertake a joint visit to gain assurance of progress with required improvements. The assessors identified there still remained some significant gaps in documentation and the provider needed to demonstrate the auditing of the care plans. Medicines management team visit identified some improvements on previous findings of medications omissions and errors. GP surgeries will contact medicines management team if they have any concerns. Current restrictions on CHC placements are to continue and will be reviewed following the next CQPS manager. Larchwood CT / March 2016 / Executive Harvest Summary / FINAL Page 9

Unannounced visit by the CQPS was undertaken on 14 January 2016, a slight improvement was noted with leadership becoming more visible. A more comprehensive shift handover has been implemented with work ongoing to improve documentation. Funding has been agreed for a refurbishment programme and a schedule being developed to address actions from the previous Infection Prevention and Control (IPAC) audit. The CQPS team plan a further visit. Current restrictions, no CHC admissions until the improvements can be embedded. CT / March 2016 / Executive Harvest Summary / FINAL Page 10

Norfolk Community Health & Care NHS Trust (RY3) Patient Safety Org Stnd Apr15 May15 Jun15 Jul15 Aug15 Sep15 Oct15 Nov15 Dec15 Jan16 Feb16 Mar-16 Trend line Serious incidents reported NCHC 0 49 32 49 42 37 53 55 53 47 45 52 514 Serious incidents reported NCHC (N) 0 9 12 7 7 9 13 10 5 3 8 11 94 Never events reported NCHC 0 0 0 0 0 0 0 0 0 0 0 0 0 Pressure ulcers - Grade 2 NCHC 0 7 12 18 20 4 8 7 15 10 3 104 Pressure ulcers - Grade 3 NCHC 0 40 25 44 38 29 45 44 47 41 34 48 435 Pressure ulcers - Grade 3 NCHC (N) 0 5 8 7 6 7 10 9 5 3 7 11 78 Pressure ulcers - Grade 4 NCHC 0 4 6 5 3 6 8 8 5 2 2 2 51 Pressure ulcers - Grade 4 NCHC (N) 0 2 4 0 1 2 3 1 0 0 0 0 13 Quality issue reporting (QIR) NCHC 0 18 16 17 21 11 6 14 15 11 14 18 161 Quality issue reporting (QIR) NCHC (N) 0 0 1 0 0 0 1 0 0 0 1 0 3 Injurious falls by occupied bed days NCHC 4 2.8 2.6 2.8 3.4 4.4 4.2 1.9 3.2 3.9 2.5 31.7 Total falls NCHC 0 50 55 65 64 80 62 54 58 65 46 599 No harm falls NCHC 0 31 37 47 41 50 35 41 37 40 29 388 Low harm falls NCHC 0 13 13 17 22 29 27 10 21 21 15 188 Moderate harm falls NCHC 0 5 4 1 1 1 0 3 0 4 1 20 Severe harm falls NCHC 0 0 0 0 0 0 0 0 0 0 1 1 Total Medication incidents NCHC 0 36 51 38 44 44 44 43 24 45 42 411 Medication Incidents - no harm NCHC 0 25 41 34 33 38 37 35 18 36 38 335 Medication Incidents - low harm NCHC 0 11 8 4 9 5 7 7 6 7 3 67 Medication Incidents - moderate harm NCHC 0 0 2 0 2 1 0 1 0 2 1 9 Medication Incidents - severe harm NCHC 0 0 0 0 0 0 0 0 0 0 0 0 Clostridium difficile cases NCHC 0 0 0 0 2 0 1 0 2 2 4 11 MRSA bacteraemia NCHC 0 0 0 0 0 0 0 0 0 0 0 0 Mortality - Discharges (exc. PBC & Pall) NCHC 219 205 N/A 202 190 N/A 183 N/A N/A 163 1162 Mortality - Deaths (exc. PBC & Pall) NCHC 8 1 N/A 3 4 N/A 1 N/A N/A 0 17 Mortality -% Deaths (exc. PBC & Pall) NCHC 3.7 0.5 N/A 1.5 2.1 N/A 0.5 N/A N/A 0 8.3 Workforce Org Stnd Apr15 May15 Jun15 Jul15 Aug15 Sep15 Oct15 Nov15 Dec15 Jan16 Feb16 Mar-16 Trend line Sickness absence rate NCHC 4.4 4.0 3.5 3.8 3.4 3.9 4.4 6.1 4.3 4.3 5.7 43.4 Staff turnover rate NCHC 12 12.1 12.7 13.0 13.1 13.1 13.3 14.6 14.6 12.1 12.7 131.3 Vacancy rate NCHC info -6.6-9.0-7.4-12.0-7.0-10.0-7.7-8.7-10.0-9.0-87.4 Appraisal rate NCHC 80.3 76 65 50 41 42 45 53 52.90 67.3 71 563.2 Mandatory training compliance NCHC 87 87.1 87.3 87.8 89.6 89.2 88.6 88.9 88.9 89.4 89 885.8 Patient Experience Org Stnd Apr15 May15 Jun15 Jul15 Aug15 Sep15 Oct15 Nov15 Dec15 Jan16 Feb16 Mar-16 Trend line Friends and family score NCHC 98 99 98 98 98 97 99 98 98 99 982 Compliments NCHC 0 81 95 95 196 73 53 75 78 76 822 Compliments NCHC (N) 0 4 10 10 18 3 7 6 12 8 78 Complaints NCHC 0 20 21 20 15 13 24 27 21 16 21 198 Complaints NCHC (N) 0 2 4 3 5 0 1 3 4 3 2 27 CT / March 2016 / Executive Harvest Summary / FINAL Page 11

Integrated Care 24 (IC24) - 111 Patient Safety Org Stnd Sep15 Oct15 Nov15 Dec15 Jan16 Feb16 Mar16 Trend Line Serious incidents IC24 0 1 2 1 0 0 Quality Issue Reporting (QIR) IC24 0 7 13 17 9 15 8 Quality Issue Reporting (QIR) IC24 (N) 0 0 1 1 0 3 1 Performance Org Stnd Sep15 Oct15 Nov15 Dec15 Jan16 Feb16 Mar16 Trend Line % calls answered within 60 seconds at the end of the introductory message IC24 95 94.09 90.33 88.65 81.16 69.58 % calls referred to ambulance service with 3 minutes which are life threatening IC24 100 100.0 100.0 100.0 100.0 100 % answered calls triaged IC24 60 % abandoned calls IC24 5 0.46 0.80 1.67 5.56 7.43 % answered calls passed for call back IC24 28 25.61 25.63 25.58 27.22 28.3 % call backs within 10 minutes IC24 65 75.00 70.16 67.04 61.04 60.16 % calls warm transferred as percentage of calls eligible to go to a clinician IC24 72 51.48 57.82 52.30 56.43 58.65 Patient Experience Org Stnd Sep15 Oct15 Nov15 Dec15 Jan16 Feb16 Mar16 Trend Line Friends & Family IC24 68 37 34 Complaints IC24 5 19 11 Compliments IC24 0 23 14 Workforce Org Stnd Sep15 Oct15 Nov15 Dec15 Jan16 Feb16 Mar16 Trend Line Sickness IC24 4 8.36 15.41 15.95 15.81 18.81 Turnover IC24 0.8 2.82 1.62 5.21 CT / March 2016 / Executive Harvest Summary / FINAL Page 12

Norfolk & Suffolk NHS Foundation Trust (RMY) Patient Safety Org Apr15 May15 Jun15 Jul15 Aug15 Sep15 Oct15 Nov15 Dec15 Jan16 Feb16 Mar16 Trend Line Serious incidents reported NSFT 8 4 7 11 3 7 1 4 6 0 8 Serious incidents reported NSFT(N) 2 1 3 3 0 2 3 3 3 0 6 Never events reported NSFT 0 0 0 0 0 0 0 0 0 0 0 Pressure ulcers - Grade 2 NSFT 0 1 1 1 1 6 1 1 1 1 Pressure ulcers - Grade 3 NSFT 0 0 0 0 0 0 0 0 0 0 0 Pressure ulcers - Grade 3 NSFT(N) 0 0 0 0 0 0 0 0 0 0 0 Pressure ulcers - Grade 4 NSFT 0 0 0 0 0 0 0 0 0 0 0 Pressure ulcers - Grade 4 NSFT(N) 0 0 0 0 0 0 0 0 0 0 0 Catheter-associated UTIs reported NSFT 9 2 1 4 4 5 8 5 3 5 Falls NSFT 0 0 0 0 0 0 0 0 0 0 0 Falls NSFT (N) 0 0 0 0 0 0 0 0 0 0 0 Unexpected Deaths NSFT 6 3 7 8 3 6 2 10 7 0 4 Unexpected Deaths NSFT (N) 0 0 3 2 1 1 1 4 4 0 3 Quality issue Reporting (QIR) NSFT(N) 3 14 9 18 13 19 11 11 9 5 2 Patient Experience Org Apr15 May15 Jun15 Jul15 Aug15 Sep15 Oct15 Nov15 Dec15 Jan16 Feb16 Mar16 Friends & Family (% recommended) NSFT 84 64 82 93 90 79 87 85 69 Complaints NSFT 52 51 61 60 45 40 63 56 31 39 Complaints (Central) NSFT 20 19 18 15 19 14 20 17 8 13 Compliments NSFT Performance (Central) Apr15 May15 Jun15 Jul15 Aug15 Sep15 Oct15 Nov15 Dec15 Jan16 Feb16 Mar16 Trend Line Patient safety thermometer NSFT 98 95 98 96 98 88 94 96 98 96 Number of inpatients reported to have self-harmed NSFT 15 21 4 3 18 6 30 17 16 37 Medication incidents with harm reported for inpatients NSFT 0 0 0 0 0 1 0 0 0 0 Number of occasions where restraint was used (target) NSFT 58.5 58 57.5 57 56.5 56.1 55.6 55.1 54.6 54.1 53.6 53.1 Number of occasions where restraint was used (actual) NSFT 68 80 41 64 52 53 102 64 61 103 Number of occasions when prone restraint was used (target) NSFT 11.9 11.8 11.7 11.6 11.5 11.4 11.3 11.2 11.1 11 10.9 10.8 Number of occasions when prone restraint was used (actual) NSFT 9 7 5 12 11 10 29 9 10 31 Number of seclusion incidents in month (target) NSFT 7.9 7.9 7.8 7.7 7.7 7.6 7.5 7.5 7.4 7.3 7.3 7.2 Number of seclusion incidents in month (actual) NSFT 4 2 3 9 8 9 19 8 5 20 Number of people secluded in month NSFT 3 2 2 8 5 5 9 6 5 10 Number of episodes of long term segregation (June 2015 onwards) NSFT 0 0 0 0 0 0 0 0 3 0 Number of physical assaults on service users with harm NSFT 7 8 3 9 13 6 9 9 10 14 Number of physical assaults on staff with harm NSFT 32 33 26 49 27 43 56 30 27 25 Number of working age adults placed in out of area bed in month NSFT 16 10 10 4 9 11 0 7 13 8 Number of older people placed in out of area bed in month NSFT 1 2 1 0 3 1 1 0 2 0 % Bed Occupancy monthly NSFT 103 101 99 102 101 100 Number of people under 18 admitted to adult wards NSFT 1 0 0 0 0 0 0 0 0 0 % long term inpatients (>12m) with an annual health check NSFT x x x x x 42 30 73 100 100 % of qualifying patients with a MHCT cluster NSFT x x x x x 78 92 91 91 93 % Care Plans assessed as being complete (Trustwide only) NSFT x x 95 x x x x x x x CPA patients having formal reviews within 12m NSFT x x x x x 53 47 55 55 50 % inpatient finished episodes during the periods with an ICD10 code NSFT x x x x x x x x x x Service users followed up in 7 days post discharge NSFT x x x x x 79 92 90 94 98 IAPT patients who complete treatment and move to recovery in month NSFT 48 48 47 47 48 41 43 44 63 46 Control Panel (Central) Org Apr15 May15 Jun15 Jul15 Aug15 Sep15 Oct15 Nov15 Dec15 Jan16 Feb16 Mar16 Trend Line % of patients on CPA who were followed up within 7 days after discharge from psychiatric inpatient care NSFT 80.3 78.5 74.6 86.4 77.6 81.7 93.4 91.9 96.9 98.1 % of admissions to adult care acute wards gate-kept by CRHT teams (denominator the total number of admissions to the trust's acute wards) NSFT 63.8 45.8 40 54.7 57.9 46.9 57.8 67.4 72.9 74.6 % of patients whose transfer of care was delayed NSFT 3 1 0 0 1 1 1.1 1 0.9 2.4 % of long-term (over 12 months) inpatients that have received an annual health check NSFT 100 100 50 50 36 42 30 72.7 100 100 % of CAMHS patients have been seen within 8 weeks of referral received date (completed pathways) NSFT 79.4 71.1 78.9 65.7 59.7 51.7 69.9 76.7 75 62.5 % of patients having at least two face to face attended contacts with a valid MHCT assessment and a care cluster NSFT 98.3 94.7 92.9 91.5 90.4 90.9 91.9 90.9 91.6 93.2 AAT/CRHT Org Apr15 May15 Jun15 Jul15 Aug15 Sep15 Oct15 Nov15 Dec15 Jan16 Feb16 Mar16 Trend Line Patients seen within 4 hours (Lorenzo) NSFT x x x x x x x x 50 34.8 Patients seen within 4 hours (Service reported data) NSFT x x x x x 16 95.1 96 96.9 Patients seen within 120 hours (Lorenzo) NSFT x x x x x x 60.3 61.7 73.9 62.7 Patients seen within 120 hours (Service reported data) NSFT x x x x x 79.7 87 99.2 90.1 92.7 Patients seen within 28 days (Lorenzo) NSFT x x x x x x 58.6 36.4 43.3 16 Patients seen within 28 days (Service reported data) NSFT x x x x x 77.8 77.6 46.6 64.9 58 MH Liasion Org Apr15 May15 Jun15 Jul15 Aug15 Sep15 Oct15 Nov15 Dec15 Jan16 Feb16 Mar16 Trend Line Patients seen within 4 hours NSFT 82.9 94.7 78.1 75.5 88.9 66 75.5 83.3 92.6 97.8 Patients seen within 24 hours NSFT 33.3 91.9 85.5 92.3 93.2 95.8 92.6 96.1 100 Patients seen within 3 days NSFT 100 98.9 98.6 98.8 96.7 98.4 97.5 91.9 92.7 99.1 Section 136 Org Apr15 May15 Jun15 Jul15 Aug15 Sep15 Oct15 Nov15 Dec15 Jan16 Feb16 Mar16 Trend Line % NSFT S136 dedicated staff available in S136 suite within maximum one hour of police arrival in the S136 suite NSFT 100 100 100 Adult ADHD Service Org Apr15 May15 Jun15 Jul15 Aug15 Sep15 Oct15 Nov15 Dec15 Jan16 Feb16 Mar16 Trend Line % patients treated in month who have waited less than 18 weeks NSFT 100 100 Workforce Org Apr15 May15 Jun15 Jul15 Aug15 Sep15 Oct15 Nov15 Dec15 Jan16 Feb16 Mar16 Trend Line Vacancies (Central) NSFT 12.34 11.50 11.07 11.03 9.99 9.21 Appraisals (Central) NSFT 78.57 80.48 79.22 82.89 83.90 N/A Turnover (Central) NSFT 14.77 7.38 6.58 7.15 8.09 8.17 Sickness (Central) NSFT 5.01 5.17 5.05 5.10 5.04 4.91 Mandatory Training (Central) NSFT 68.28 68.7 69.47 68.74 68.95 71.57 CT / March 2016 / Executive Harvest Summary / FINAL Page 13

Norfolk & Norwich University Hospital NHS Foundation Trust (RM1) Patient Safety Org Stnd Apr15 May15 Jun15 Jul15 Aug15 Sep15 Oct15 Nov15 Dec15 Jan16 Feb16 Mar16 Trend line Serious incidents reported NNUH 0 10 7 15 9 15 17 11 12 10 22 12 Serious incidents reported NNUH (N) 0 3 0 6 5 6 6 5 4 5 8 3 Never events reported NNUH 0 0 0 0 1 0 0 0 1 0 0 0 Pressure ulcers - Grade 2 NNUH 0 7 7 5 10 7 7 6 3 5 5 Pressure ulcers - Grade 3 NNUH 0 4 3 7 3 7 10 2 4 5 3 4 Pressure ulcers - Grade 3 NNUH (N) 0 2 0 3 1 3 3 1 1 3 0 1 Pressure ulcers - Grade 4 NNUH 0 0 0 1 0 0 0 1 0 0 0 0 Pressure ulcers - Grade 4 NNUH (N) 0 0 0 0 0 0 0 1 0 0 0 0 Quality issue reporting (QIR) NNUH info 19 25 22 40 30 20 27 29 31 32 40 Quality issue reporting (QIR) NNUH (N) info 2 4 2 3 4 4 4 3 3 4 7 Catheter-associated UTIs reported NNUH 0 62 61 42 66 53 83 60 69 68 81 Mortality HSMR NNUH 100 99.4 112.4 111.2 110.9 110.2 96.1 98 MRSA bacteraemia NNUH 0 0 0 0 0 0 0 0 0 0 0 Clostridium difficile cases NNUH 4 3 0 3 3 1 4 5 9 0 4 Early Warning Score (EWS) NNUH Workforce Org Stnd Apr15 May15 Jun15 Jul15 Aug15 Sep15 Oct15 Nov15 Dec15 Jan16 Feb16 Mar16 Trend line Sickness absence rate NNUH 3.5 4 3.8 3.5 3.8 3.9 4 4.5 5.1 4.9 N/A Staff turnover rate NNUH 10 10.5 10.8 10.9 10.9 10.6 10.5 10.6 10.4 10.6 10.5 Vacancy rate NNUH 10 N/A N/A 3.84 N/A N/A N/A 4.9 N/A 7.7 7.8 Appraisal rate NNUH 90 70.2 69 66.7 N/A N/A 43.8 50.8 53.3 56.8 58.8 Mandatory training compliance NNUH 90 69.6 69.7 70.8 72.8 73.6 74.1 76.7 76.8 77.5 76.5 Patient Experience Org Stnd Apr15 May15 Jun15 Jul15 Aug15 Sep15 Oct15 Nov15 Dec15 Jan16 Feb16 Mar16 Trend line Complaints NNUH 68 64 72 73 Friends & Family A&E NNUH 89 78 93 95 90 93 93 91 89 Friends & Family A&E response rate NNUH 7.5 8.1 7.9 8.1 6 6.9 3.9 6.3 6.9 ` Friends & Family Inpatients NNUH 95 97 96 96 96 96 96 96 97 Friends & Family Inpatients response rate NNUH 8.4 8.9 9.7 7.1 6.8 6.7 6.1 7.1 6.3 Friends & Family Maternity - Q1 Antenatal Care NNUH 100 N/A 97 94 97 95 100 N/A N/A Friends & Family Maternity - Q2 Birth NNUH 100 97 100 100 95 98 100 100 100 Friends & Family Maternity - Q3 Postnatal ward NNUH 100 98 98 100 99 100 100 93 92 Friends & Family Maternity - Q4 Postnatal Community Provision NNUH N/A 100 100 100 100 100 100 100 97 Cancer Org Stnd Apr15 May15 Jun15 Jul15 Aug15 Sep15 Oct15 Nov15 Dec15 Jan16 Feb16 Mar16 Trend line Percentage of patients seen within two weeks of an urgent GP referral NNUH 93 88.0 94.6 98.8 98.2 96.3 94.4 98.3 97.8 78.2 75.5 Percentage of patients receiving subsequent treatment for cancer within 31-d NNUH 94 91.4 87.3 88.8 83.7 93.0 94.0 93.5 94.1 96.2 95.0 Stroke Org Stnd Apr15 May15 Jun15 Jul15 Aug15 Sep15 Oct15 Nov15 Dec15 Jan16 Feb16 Mar16 Trend line % length of stay on the stroke unit NNUH 79.1 69.8 75.9 86.3 92.9 85.2 80.8 80.3 % of patients with a primary diagnosis of stroke admitted to a HASU within 4 NNUH 76.9 80.9 71.4 68.4 68.3 77 91.0 78.8 73.2 76.2 % of urgent scans performed on eligible patients within 60 minutes of arrival annuh 85.2 88.1 86.1 76.7 87.5 94.3 88.2 64.7 84.4 92.7 A&E Org Stnd Apr15 May15 Jun15 Jul15 Aug15 Sep15 Oct15 Nov15 Dec15 Jan16 Feb16 Mar16 Trend line Percentage of patients who spent 4 hours or less in A&E NNUH 95.0 90.1 93.7 90.3 90.0 90.5 88.4 87.0 81.0 85.0 75.9 Maternity Org Stnd Apr15 May15 Jun15 Jul15 Aug15 Sep15 Oct15 Nov15 Dec15 Jan16 Feb16 Mar16 Trend line Born Before Arrival (BBA) NNUH 9 5 10 10 4 5 8 6 5 6 Closure to admission NNUH 0 0 3 4 2 2 2 2 3 0 0 CT / March 2016 / Executive Harvest Summary / FINAL Page 14