CENTRAL MANCHESTER UNIVERSITY HOSPITALS NHS FOUNDATION TRUST

CENTRAL MANCHESTER UNIVERSITY HOSPITALS NHS FOUNDATION TRUST Report of: Chief Nurse - Cheryl Lenney Paper prepared by: Debra Armstrong, Deputy Director of Nursing (Quality) Janice Streets. Head of Quality Improvement Date of paper: April 2017 Subject: Annual Ward Accreditation Report Indicate which by Information to note Purpose of Report: Support Resolution Approval Consideration of Risk against Key Priorities: Recommendations: Patient & Staff Experience Note the content of the report and the progress of the expansion and development of the Ward Accreditation programme. Contact: Name: Debra Armstrong Deputy Director of Nursing (Quality) Tel: 0161 276 5061 Page 1 of 39

1. Executive Summary 1.1 The purpose of this paper is to provide the Board of Directors with an overview of the Accreditation process, detailed analysis of the Accreditation process, annual results from 2016/7 and intended changes and expansion to the programme in 2017/18. 1.2 Currently Accreditations are undertaken within Inpatient Wards, Day-Case areas, Critical Care areas, Dialysis Units and Emergency Departments (adult and paediatric) and in the Accreditation Programme has been expanded to include all Emergency Department areas, Clinical Research Units and Theatre areas. 1.3 In total 81 areas were accredited in with plans to accredit over 100 areas in 2017/18. 1.4 In and in collaboration with the Transformation Team a modified Outpatient Accreditation has been developed and a pilot exercise was successfully undertaken in the Manchester Royal Eye Hospital (MREH) OPD, in February 2017. 1.5 A working group, comprising of staff from both Adult and Children s community services, have developed a specifically designed Community Accreditation Assessment, to align with the diversity of services provided within community settings. Two Community Accreditation pilots were undertaken during March 2017, one in Adults and one in Children s Community Services. 1.6 The process for each Accreditation has been designed to provide consistency of assessment whilst allowing flexibility to adjust the visit based on the differences within areas. 1.7 An Accreditation Portfolio was developed in 2016. The Portfolio is an electronic resource file. The Portfolio is designed to enable teams to collect and display evidence against each of the Accreditation standards and provides an overview of achievements over a sustained period of time, allowing areas the opportunity to demonstrate their improvement journey. 1.8 In 2016/7 there has been an overall positive increase in the number of areas achieving Gold status (36%) compared to 24% in. There have been no areas assessed as White in 2016/7. Areas scoring Bronze remains comparatively the same to previous years. 1.9 Analysis of the results achieved since 2011, highlights that 11 wards/ departments are demonstrating consistently high standards and sustaining improvements achieving 3 or more consecutive Gold Awards, including one area, Tameside Dialysis Unit, who has achieved Gold status, every year since the Accreditation Programme was developed 6 years ago. 1.10 In, 24 areas have demonstrated improvement since their Accreditation in. This supports a step change in sustained improvement. Page 2 of 39

1.11 In, 31 areas have remained the same at either bronze or silver standard or scored lower than the previous year/s. 1.12 For the first time, any area that has deteriorated has reported their plans for 2017/18 to the Chief Nurse and had a clinical follow up visit from the Chief Nurse and those areas that achieved the same result, demonstrating no progression, have reported their plans for 2017/18 to the Directors of Nursing and similarly these areas have either undergone a clinical follow-up visit or a clinical follow-up visit is planned. 1.13 An Annual Review of the Ward Accreditation Process has been undertaken and identified changes for the 2017/18 Accreditation Programme has been agreed. These changes will be incorporated into an Accreditation Standard Operating Procedure that is currently under development. 1.14 The Accreditation Process in Outpatient Departments (OPD) will continue to be rolled out during 2017/18. Accreditations are routinely unannounced; however as part of the pilot 48 hours notice has been provided for the forthcoming Accreditation visits for OPD and Community Services. Due to the complexities and wider team engagement this will continue for all OPDs and Community Services in 2017/18. This will be reviewed as part of the next annual review of the Accreditation process. 1.15 The Accreditation Process within Community Services will be developed further to ensure the process is aligned to match the specific service being accredited. The diversity of services provided within community settings is recognised and alongside the changes in the delivery of healthcare systems, the standards and indicators need to be further developed prior to roll out. 1.16 During 2017/18 the Accreditation Process for areas that have achieved Gold for at least two consecutive years with no changes in senior leadership will continue with the presentation of their Accreditation Portfolio. 1.17 As part of the model of continuous improvement, the Accreditation Portfolio will become mandatory for all areas for 2017/18, with an appraisal of each portfolio being introduced as a mandatory element of the pre-accreditation data review undertaken as part of the Accreditation Process. 1.18 As the Accreditation Process continues to expand and the number of areas increases, it is recognised that it is no longer possible for all Accreditations to be led solely by Directors/Deputy Directors of Nursing. During 2017/18, the Heads of Nursing will start to lead Accreditations. This will be a phased approach with quarter one being used as the transition period to ensure that Heads of Nursing have the support to lead the whole process, including validation and providing feedback to the ward/departmental teams. 1.19 The Accreditation Team will continue to be inclusive of core members, but for specific nominated areas staff with expertise in that clinical service and wider members of the MDT (for example members of the Transformation Team or, Anaesthetists) to ensure the assessment reflects the multi-disciplinary nature of the service. Page 3 of 39

1.20 The Accreditation process is well embedded, drives continuous improvement and recognises excellence. The developments, detailed within the report are intended to increase the focus on effective leadership and accountability across the entire multidisciplinary team to build further on the culture of continuous improvement. The proposed developments reflect this culture and will enhance the process by introducing opportunities for areas to shine and be rewarded for their achievement. 1.21 Despite a period of significant change, including a focus on turnaround and transformation; the process of accreditation is valued by the clinical teams and provides an opportunity to focus on what matters to patients and service users and what matters to staff. 1.22 The Board of Directors are asked to note the content of the annual Accreditation Report and the on-going work to expand the Accreditation process providing the Board of Directors with a high level of assurance in regards to the quality of patient care. 2. Introduction 2.1 This paper provides the Board of Directors with a review of the activity undertaken during and planned future developments for the ward accreditation process. 2.2 The annual Ward Accreditation process was launched in 2011, as part of the Trust s assurance mechanisms for ensuring the delivery of high quality care and demonstrating how the best patient experience could be evidenced. The process, which is underpinned by the Trust s values and behaviours framework, the Nursing and Midwifery Strategy and the quality strategy, currently includes Inpatient Wards, Day- Case areas, Critical Care areas, Dialysis Units and Emergency Departments (adult and paediatric). In the Accreditation Programme has been expanded to include all Emergency Department areas, Clinical Research Units and Theatre areas. 2.3 This paper provides a summary of the background to the development of the current Accreditation process, highlights changes in, and advises on the future plans to extend and enhance the process in 2017/18. 3. Background 3.1 The Ward Accreditation process was developed building on the 2008, Productive Ward Programme. 1 The Accreditation Programme provides an assessment across four main categories, Culture of Continuous Improvement, including leadership, of Care, about and with Patients and Nursing Processes: including medication management and the delivery of nutrition and hydration requirements. 1 NHS Improvement and Innovation (2008) Releasing Time to Care: The Productive Ward. Available From: http://webarchive.nationalarchives.gov.uk/20081112122528/http://www.institute.nhs.uk/quality_and_value/product ivity_series/productive_ward.html [Accessed 23 April 2017]. Page 4 of 39

3.2 Informed by analysis of previous National Inpatient Surveys, ward metrics were developed to focus on What Mattered to Patients. Six key areas were initially identified: management of infections, clean hospitals, feeling safe, food and nutrition, privacy and dignity and pain management. 3.3 The resulting series of indicators, including nurse sensitive indicators relating to the incidence of falls, healthcare associated infections and pressure ulcers form the basis of the Quality of Care Round (QCR) process. The principle of the QCR is that Ward/Departmental Managers and Matrons, on a monthly basis, assess their ward/department against these indicators through a process of observation, questioning and review of nursing documentation records. 3.4 Patient feedback against the same metrics is captured and presented alongside the QCR data on a monthly basis on a Quality Dashboard. This is displayed in wards and clinical areas to visually demonstrate the performance of that area to staff and patients. 3.5 Ward/Departmental Managers are required to review their information with their teams, on a monthly basis, to identify areas falling below the minimum standard of 85% and develop plans to target these areas for improvement. This process forms the Improving Quality Programme (IQP) and is supported by the Trust s Improving Quality methodology to promote a culture of continuous improvement. 3.6 Assessment of the understanding and use of data generated through this process by Ward/Departmental Managers and their teams forms one element of the Accreditation process. 4. Overview of the Accreditation Process 4.1 The Accreditation Process aims to provide a level of assurance for the Board of Directors, that wards and departments are consistently delivering high quality care across four main categories. The categories have previously remained constant since 2011, but the standards required within each category are reviewed annually to ensure that they remain current and relevant. The categories are as follows: Culture of Continuous Improvement: including leadership, team culture and use of evidence based practice, safer staffing of Care: including infection control, accessibility and safety standards about and with Patients: including team communication, documentation and patient perceptions Nursing Processes: including medication management and provision of nutrition and hydration. Page 5 of 39

4.2 Annual unannounced Accreditations have been conducted across wards and departments by teams comprised of a Director or Deputy Director of Nursing/ Head of Midwifery, a Head of Nursing and a member of the Quality Improvement Team. Dependent upon the area being accredited Lead Nurses have also been part of the team. The Accreditation team undertake an observational visit to the clinical area, informed by analysis of clinical data relating to the area, including the Quality Dashboard, complaints, incidents, compliments, patient track information and student feedback. If data bespoke to a particular area, such as ORMIS scheduling data for Theatre areas is available, this also informs the overall analysis. Discussion with patients and staff are a key element of the process. 4.3 The process for each Accreditation has been designed to provide consistency of assessment whilst allowing flexibility to adjust the visit based on the different services and case mix within areas. 4.4 On the day Ward/Department Managers are given high level feedback of the Accreditation visit. The feedback focuses on three areas of success and three areas for improvement. When prompt action is required to address an issue identified during the process, an action plan is developed and re-assessment is undertaken within seven to ten days to seek assurance that issues raised have been addressed. An example of a prompt action would include: If it is identified that fridge temperatures are not being checked daily as they must be, the team would be expected to put a process in place immediately to ensure daily checks are undertaken. Another example of a prompt action: If it is identified that the nursing team are not signing, dating and printing their names against documentation entries. The Ward Manager would be expected to discuss the professional responsibility of accurate documentation and immediately put a process in place to monitor and address any non-compliance of documentation standards. In the event of any urgent actions these are addressed immediately. An example of immediate action would include: if a hand gel dispenser was empty, a member of the team would be expected to replace the empty container immediately. 4.5 Findings are initially mapped against agreed criteria for each standard and scored as gold, silver, bronze or white. The collated result across all categories provides the overall result for the area. All results are validated weekly by the Directors and Deputy Directors of Nursing/ Head of Midwifery to ensure consistency in approach. The criteria for each of the scores are as follows: Gold: Excellent, achieving highest standards with evidence in the data that success sustained for at least six months. Silver: Very good, achieving minimum standards or above with evidence of improvement in relevant data. Bronze: Good, achieving minimum standards or below but with evidence of active improvement work. White: Not achieving minimum standards and no evidence of active improvement work. Page 6 of 39

4.6 If a ward/department is assessed as White, this indicates that there are elements of the assessment where the Trust standards have not been fully met. The Chief Nurse is informed immediately and provided with an overview of the assessment. Whilst White status does not necessarily indicate that the area is necessarily unsafe, it does demonstrate that additional support is required. In these circumstances, notwithstanding any immediate actions required, a support package is agreed, which includes: Additional support from the Head of Nursing/ Midwifery and the divisional senior nursing/management team. Mentoring for the Ward/Department Manager. Bespoke Organisation, Development and Training (OD&T) support for all ward/departmental staff. Six bespoke improvement sessions from the Quality Improvement Team to ensure IQP methodology is understood and utilised effectively to drive improvement. A follow up meeting 6-8 weeks after the Accreditation by the Accreditation Lead. 4.7 The Head of Nursing/ Midwifery is accountable for delivery of the plan to support the clinical area to achieve the appropriate standard. Areas that score White are reaccredited within the year to seek assurance that improvement has taken place. The highest achievable score at this point is bronze. Progress is monitored through 1-2-1 Meetings with the Directors of Nursing. 4.8 All areas are supported to continuously improve and when wards/ departments achieve gold, this success is formally recognised by the Chief Executive, Chief Nurse and senior divisional staff who attend the area to present the certificate. In addition, a small team is invited to the annual We re Proud of You Gala Dinner where the results are celebrated and a wall plaque is presented to the team by the Chairman. 5. Developments of the Process Introduced in 2016/7 5.1 Following annual Accreditation review during the Accreditation process has been developed further with the introduction of Accreditation assessments to the Clinical Research Units (children s and adults CRF) and all Theatre areas, which are now included in the Accreditation schedule. 5.2 The development of the Theatre Accreditation and expansion to other areas such as Outpatients and Community Services has identified the need to develop modified Accreditation Assessment for these areas and whilst the core principles and assessment areas remain the same, adaptations in terms of processes have been required and developed in recognition of the diversity of the services provided by these areas. Page 7 of 39

5.3 Outpatient Department (OPD): A modified Outpatient Accreditation has been developed and a pilot exercise was successfully undertaken in the Manchester Royal Eye Hospital (MREH) OPD, in February 2017. The process was developed in collaboration with the Trust Outpatient Transformation Group to ensure the Accreditation was aligned to the Trust Outpatient Standards and the overall Outpatient Transformation Work stream. To support the Outpatient Accreditation process the Quality Improvement Team has undertaken engagement sessions with multidisciplinary teams who work in outpatient settings across all divisions. 5.4 Community Services: A working group, comprising of staff from both acute and community services, have met to review the current accreditation process and the documentation to develop an appropriate Community Accreditation Assessment. Two Community Accreditation pilots were undertaken during March 2017, one in Adults and one in Children s Community Services. Following the pilot there will be an opportunity to reflect and review the process to make any further adjustments prior to agreeing the next steps. 5.5 It was recognised that community services have had limited exposure to the Improving Quality Programme and the Accreditation Process. As such, support from the Quality Improvement Team and the senior nurses/service leads has been provided and they are working together to provide the necessary information and training to ensure the teams are fully knowledgeable and briefed in terms of expectations. 5.6 Accreditation Portfolio: The Accreditation Portfolio was developed in 2016. The Portfolio is an electronic resource file designed to enable teams to collect and display evidence against each of the Accreditation standards on an on-going basis and provides an overview of achievements over a sustained period of time, allowing areas the opportunity to demonstrate their improvement journey. 5.7 In all previously Gold accredited areas were asked to utilise the Portfolio, as this would form part of their subsequent Accreditations. Other areas could utilise the portfolio but this was optional. 5.8 For areas that have previously achieved Gold status the Portfolio has been reviewed by the Accreditation team prior to the annual Accreditation visit and at additional points during the year. This process provides a further tier of assurance within the Accreditation process. Whilst some areas have updated their portfolios regularly there have been inconsistencies across divisions with teams keeping their portfolios up to date. 5.9 Gold Wards: In previous years, areas that achieve Gold status for two consecutive years currently retain their gold status in the third year without undergoing the full Accreditation assessment. This was based on the provision that there were no significant changes such as a change of Ward/Departmental Manager, no significant increase in the number high level incidents or complaints or data from QCR and/or PET did not show a deteriorating trend. Page 8 of 39

5.10 During areas who had previously achieved Gold status with no change in leadership presented their portfolio using a PowerPoint presentation template. This was followed by a short observational visit to the clinical area in place of the full visit. Positive feedback has been received and this process will continue in 2017/18. 6. Results 2011 6.1 All of the planned Accreditations have been completed from commencement of the process in July 2011 to March 2017. The total number of areas accredited each year has varied between 56 and 81 due to operational changes and the addition of clinical areas to the schedule. The overall results, compared to previous years are provided in Appendix 1. 6.2 Table 1, provides the number and proportion of Wards/Departments achieving each level of Accreditation since the commencement of the assessments. In 2016/7 there has been an overall positive increase in the number of areas achieving Gold status (36%) compared to 24% in. There have been no areas assessed as White in 2016/7. The number of areas scoring Bronze is similar to previous years. There is some correlation of outcomes with changes in patient cohort and changes in ward leadership and similarly areas who have not previously been accredited. Table 1: Number and proportion of wards/departments achieving each level of accreditation 2011 2012 2013 2014 2016/7* No % No % No % No % No % No % Gold 12 21% 23 41% 10 16% 22 35% 15 24% 29 36% Silver 27 47% 20 36% 34 55% 28 44% 36 58% 35 44% Bronze 12 21% 9 16% 18 29% 12 19% 11 18% 16 20% White 6 11% 4 7% 0 0% 1 2% 0 0% 0 0% Total 57 56 62 63 62 80 *During as of Thursday 20 th Accreditations for will equal 81. April 2017 one area is yet to be validated. Total completed 6.3 Analysis of the results achieved since 2011, highlights that some wards/ departments are demonstrating consistently high standards and sustaining improvements. Table 2 provides details of those areas that have achieved Gold for at least the last three consecutive years and Table 3 presents the areas that have demonstrated improvement since their Accreditation in. This supports a step change in sustained improvement. Page 9 of 39

Table 2: High achieving wards/departments presenting annual overall score Agenda Item 9.6 Ward/Department Division 2011 2012 2013 2014 2016 AKU (Ward 37a) Specialist Medicine Altrincham Dialysis Specialist Medicine AM2 ACU (CCU/35) CICU DMACS Specialist Medicine Specialist Medicine Day Case/Eye J REH White Adult ICU NICU (Ward 68) CSS SMH Surgical Daycase Trafford Specialist Tameside Dialysis Medicine Ward 32 DMACS Table 3: Areas demonstrating improvement in 2016/7 Ward/Department Division 2011 2012 2013 2014 2016 AM1 DMACS Specialist AM3 Medicine AMU DMACS AMU Trafford NA NA ETC SS/DC Surgery Galaxy House RMCH White Haematology DC Specialist Medicine INRU Trafford Ward 1 Trafford NA NA Ward 12 MOC Trafford NA NA Ward 15 DMACS NA NA NA White Ward 2 Trafford Ward 30 DMACS White Ward 31 DMACS White Ward 36 Specialist Page 10 of 39

Medicine Specialist Ward 37 Medicine Specialist Ward 44 Medicine Ward 46 DMACS Ward 47b SMH White Ward 5 DMACS Ward 64 SMH Ward 66 SMH Ward 8 Surgery NA NA NA Ward 85 RMCH 6.4 Analysis of the Accreditation results demonstrates that whilst most areas are demonstrating sustained and continuous improvement, some areas have not progressed successively and have remained at either bronze or silver standard or scored lower than the previous year/s. Table 4 presents the areas that have not demonstrated progression in compared to. It is noted that some of the areas have undergone considerable changes in leadership, workforce or operationally, which may have had an impact on their scores. Table 4: Areas not demonstrating progression Ward/Department Division 2011 2012 2013 2014 2016 A&E RMCH Adult A&E DMACS NA NA NA NA AM4 Specialist Medicine ESTU Surgery White HDU CSS MRI Dialysis Specialist Medicine North Manchester Dialysis Specialist Medicine OMU/ACU DMACS PHDU RMCH PICU RMCH Vascular Head and Neck Surgery NA NA NA NA Wards 11&12 Surgery Ward 14 Surgery Wards 3&4 Specialist Medicine Ward 4 Trafford NA NA Ward 45 DMACS Ward 47a SMH White Ward 55 RMEH Ward 6 TGH Trafford NA NA Ward 62 SMH White Page 11 of 39

Ward 65 SMH Ward 75 RMCH Ward 76 SS/DC RMCH Ward 77 RMCH Ward 78 RMCH Ward 83 RMCH White Ward 83 (TCU) RMCH White Ward 84 RMCH White Ward 84 (BMTU) RMCH Ward 81 (Burns) RMCH Wards 9&10 Surgery White 6.5 A detailed comparative analysis (Appendix 2) of the results from compared to for all Wards/ Departments, broken down by each assessment category, has been undertaken to understand in more detail areas of improvement, areas that have deteriorated and areas that have not demonstrated year on year progression. This information has been shared with the divisional teams to support targeted intervention to deliver improvement. 6.6 In addition, this year for the first time, any area that has deteriorated has reported their plans for 2017/18 to the Chief Nurse and had a clinical follow up visit from the Chief Nurse and those areas that achieved the same result, demonstrating no progression, have reported their plans for 2017/18 to the Directors of Nursing and similarly these areas have either undergone a clinical follow-up visit or a clinical follow-up visit is planned. 6.7 In, to support innovation, prizes of 10K and 5k to fund improvements to enhance patient experience, were introduced in recognition of areas that demonstrated the most improvement in the quality of their patient s experience. The aim of the initiative was to engage clinical teams to demonstrate and sustain success. The winning teams in 2016 were presented with their awards by the Chief Nurse at the Annual Nursing and Midwifery Conference, these were: First place: Central Delivery Unit (CDU), SMH Runner Up: Ward 30, DMACS Runner Up: Galaxy House, RMCH 7. Future Developments 7.1 An Annual Review of the Accreditation Process has been undertaken and identified changes for the 2017/18 Accreditation programme has been agreed. These changes will be incorporated into an Accreditation Standard Operating Procedure that is currently under development. 7.2 The Accreditation Process in OPD Departments will continue to be rolled out during 2017/8 to other OPD Departments. Accreditations are routinely unannounced; however Page 12 of 39

as part of the pilot the first OPD and Community Services 48 hours notice has been provided for the forthcoming Accreditation visit. Due to the complexities and wider team engagement this will continue for all OPDs and Community Services in 2017/18. This will be reviewed as part of the next annual review of the Accreditation process. 7.3 The Accreditation Process within Community Services will be developed further to ensure the process is aligned to match the specific service being accredited. It is recognised that many services are bespoke and with the evolving changes of the healthcare systems, the standards and indicators need to be further developed prior to roll out. 7.4 Accreditation Portfolio: During 2017/18 the Accreditation Process for areas that have achieved Gold for at least two consecutive years with no changes in senior leadership will continue with the presentation of their Accreditation Portfolio. 7.5 The Accreditation Portfolio will become mandatory for all areas for 2017/18 with an appraisal of each portfolio being introduced as a mandatory element of the preaccreditation data review undertaken as part of the accreditation process 7.6 Accreditation Team: As the Accreditation Process continues to expand and the number of areas increases, it is recognised that it is no longer possible for all Accreditations to be led solely by Directors/Deputy Directors of Nursing. 7.7 During 2017/18 Heads of Nursing will start to lead Accreditations. This will be staged approach with quarter one being used as the transition period to ensure that Heads of Nursing have the support to lead the whole process, including validation and providing feedback to the ward/departmental teams. 7.8 Furthermore Lead Nurses will undertake more Accreditations and Matrons will also join the rota as part of the Accreditation team. To support this development bespoke training sessions will be provided. 7.9 The Accreditation Team will continue to be inclusive of core members but for specific nominated areas will also include staff representation with experience in the area being accredited and wider members of the MDT i.e. members of the Transformation Team, Anaesthetists. 7.10 Support Package: Areas that have demonstrated a deterioration or achieved the same result as the previous year will have a designated member of the Quality Improvement Team to support delivery of actions as agreed with the Chief Nurse or Directors of Nursing. 7.11 Work is being undertaken with UHSM to compare the process with the process in place at UHSM. 8. Conclusion Page 13 of 39

8.1 The Accreditation process is a key component of the Trust s Improving Quality Programme and provides a high level of transparency to the Board of Directors, Council of Governors and to patients and families regarding the standards of patient experience achieved at ward and department level. 8.2 The Accreditation process is supported with data and evidence including patient experience feedback, is well embedded, drives continuous improvement and recognises excellence. The developments, detailed above are set out to increase the focus on effective leadership and accountability for continuous improvement, as well as enhancing the process by introducing opportunities for areas to shine and be rewarded for their achievements. Page 14 of 39

Appendix 1: Overview of Overall Results, compared to Previous Years ETC Short Stay/Day Case Ward 9 & 10 ESTU Surgery 2011 2012 2013 2014 2016 White White Ward 14 Ward 8 HBP New Ward 8 (HPB) Ward 11&12 Vascular/Head and Neck MRI Theatres Ward 55 Royal Eye Hospital 2011 2012 2013 2014 2016 Day Case White Retained gold REH Theatres EED MREH OPD Ward 66 Ward 65 Saint Mary's 2011 2012 2013 2014 2016 Includes ERP Page 15 of 39

Ward 64 - CDU Ward 47a Ward 47b Ward 62 NICU SMH Theatres EGU White White White Includes triage ACU (Ward 35 / CCU) Ward 3 & 4 Ward 37 Ward 36 Ward 44 AM3 AM4 CICU PIU Haematology Day Case AKU (Ward 37a) MRI dialysis Tameside dialysis North Dialysis Altrincham dialysis Division of Specialist Medicine 2011 2012 2013 2014 2016 Retained gold Retained gold Retained gold Page 16 of 39

Ward 5 (now ward 7) Division of Acute Medicine and Community Services 2011 2012 2013 2014 2016 Ward 31 White Ward 32 ACU AMU Ward 15 White AM1 AM2 Ward 45 Ward 46 Ward 30 (now Ward 5) White Adult A&E Adult Community Children's Community TBC 76 SS/Day Case Ward 77 Ward 78 Ward 84 BMTU Ward 85 83 - TCU White Galaxy House White Ward 75 Royal Manchester Children's Hospital 2011 2012 2013 2014 2016 White Page 17 of 39

Burns (Ward 81) PICU PHDU PED Theatres Children's Resource Centre ICU HDU High Care Unit (TGH) Division of Clinical Support Services 2011 2012 2013 2014 2016 AMU MOC (Ward 12) Ward 6 Ward 1 Ward 3 (INRU) Ward 4 Ward 2 Day Surgery Unit TGH Theatres Urgent Care Centre Minor Injuries Unit Trafford 2011 2012 2013 2014 2016 Page 18 of 39

Adults Clinical Research Children's Clinical Research R&I 2011 2012 2013 2014 2016 Page 19 of 39

Appendix 2: Accreditation Results for Each Area and 2016/7 Detail by Category Division of Acute Medicine Ward 5 (now ward 7) 2014 Ward 31 2014 Ward 32 2014 ACU (previous OMU) 2014 Page 20 of 39

AMU 2014 Ward 15 2014 White White White White AM1 2014 AM2 2014 Page 21 of 39

Ward 45 2014 Ward 46 2014 Ward 30 (now Ward 5) 2014 MRI A+E 2014 Key Standards Key Standards Page 22 of 39

Division of Specialist Medicine ACU (Ward 35 / CCU) 2014 Results from 2013 not accredited 2014 double gold Ward 3 & 4 2014 Ward 37 2014 Ward 36 2014 Page 23 of 39

Ward 44 2014 AM3 2014 AM4 2014 CICU 2014 Retained Gold No Ward Accreditation in Page 24 of 39

Haematology D/C 2014 AKU (Ward 37a) 2014 MRI Dialysis 2014 Tameside Dialysis 2014 Page 25 of 39

NMGH Dialysis 2014 Altrincham Dialysis 2014 ETC Short Stay / Day Case DIVISION OF SURGERY 2014 Ward 9 & 10 2014 Page 26 of 39

ESTU 2014 Ward 14 2014 Ward 8 HBP 2014 Ward 11&12 2014 Key Standards Key Standards Page 27 of 39

Vascular / Head and Neck 2014 Ward 7 MRI Theatres 2014 Anaesthetic room Theatre Recovery Key Standards DIVISION OF CLINICAL SUPPORT SERVICES HDU 2014 ICU 2014 Page 28 of 39

High Care Unit (TGH) 2014 NA Ward 55 Manchester Royal Eye Hospital 2014/15 /16 Day Case 2014 Retained Gold No Ward Accreditation in Out Patient Dept 2014 Key Standards Page 29 of 39

MREH Theatres 2014 Anaesthetic room Theatre Recovery Key Standards Emergency Eye Dept (EED) Ward 66 Ward 65 2014 2014 Saint Mary's Key Standards 2014 Page 30 of 39

Ward 64 - CDU Ward 47a Ward 47b Ward 62 2014 2014 2014 2014 Page 31 of 39

NICU 2014 SMH Theatres Anaesthetic room Theatre Recovery 2014 Key Standards Emergency Gynaecology Unit 2014 Key Standards Page 32 of 39

Royal Manchester Children's Hospital 76 SS/Day Case 2014 Ward 77 2014 bronze Ward 78 2014 Ward 84 2014 Page 33 of 39

Ward 84 - BMTU 2014 Ward 85 2014 Ward 83 - TCU 2014 Galaxy House 2014 Page 34 of 39

Ward 75 2014 Burns 2014 PICU 2014 PHDU 2014 Page 35 of 39

RMCH Theatres 2014 Anaesthetic room Theatre Recovery Key Standards Paediatric Emergency Dept 2014 Key Standards Key Standards TRAFFORD DIVISION AMU 2014 MOC (Ward 12) 2014 Page 36 of 39

Ward 6 2014 Ward 1 2014 Ward 3 (INRU) 2014 Ward 4 2014 Page 37 of 39

Day Surgical Unit 2014 Ward 2 2014 TGH Theatres 2014 Anaesthetic room Theatre Recovery Key Standards Altrincham MIU 2014 Key Standards Page 38 of 39

TGH Urgent Care 2014 Key Standards Adult's Clinical Research 2014 R&I Key Standards Children's Clinical Research 2014 Key Standards Page 39 of 39