Dear day and being

[HS Tameside and Glossop Integrated Care NHS Foundation Trust the sequence of events above, the referral to District Nurses for Mr Beard was a delayed referral, as the Ward staff would have continued to re-send the referral t0 District Nurses as planned, and that telephone call from District Nurses occured before this took place: As above; we do apologise for any confusion on this point at the Inquest Our witness who gave evidence in this respect was simply recounting their experience of the transaction between District Nurses and Acute staff and was not attempting t0 mislead the Coroner is any way: Notwithstanding the above, due to your concern, the Trust has made enquiries into whether missed referrals are 'common' as was suggested to you at the Inquest Firstly, would Iike to respectfully outline the difference between a missed referral and a missed visit as missed referral does not necessarily mean patient has not received a visit they should have had. As tha Trust operates triage system for all referrals to District Nurses, it may be appropriate that & patient may not been seen by a District Nurse for several days after receipt of a referral, if thelr need does not require it; Secondly, would Iike to share information regarding what practices the Trust has that ensure patient care Is handed over smoothly between District Nurses and Acute Services. The District Nurses have clear process when patient is transferred to Acute services, which includes preparing a Transfer of Care document, which provides the Acute service with all the necessary detail of their involvement: This document helps District Nurses track their patienls and update their cases. Further, District Nurses discuss patients who have been admitted t0 hospital in their daily Safety Huddles and there is board or book used by the different teams in which they also keep track of patients who are admitted to hospital. The tracking of patients helps District Nurses to ensure patients are successfully handed over: Additionally, when a patient is discharged from hospital, if require further care by District Nurses, a referral is completed and submitted to District Nurses by Acute services. This communication between District Nurses and Acute services helps to ensure patient care is handed over smoothly and no care is missed. As mentioned above, we have made enquiries to assist you in understanding more fully if missed referrals are 'common' A meeting took place at the beginning of June with the Trust's entire group of District Nursing Team Leads and their Matron at which a discussion was had regarding the regularity of missed referrals: The consensus was much that this was not 'common' Or regular occurrence from their professional experience A review of all incidents detailing missed referral from March 2018 to March 2019 was completed_ This review found that a total of eight missed referrals were identified in this twelve month period. A rate of 0.67 missed referrals per month is not considered t0 be 'common' by the Trust: Enquiries were also made with the Trusts Single Point of Contact [SPOC]; which is a Trust service that receives and triages all referrals to District Nurses trust- wide. Missed referrals were not deemed to be 'common' by this service either: Whilst we hope we can provide you with assurance that missed referrals are not 'common' between Trust services, we would also Iike to assure you that we are aware that they do occur and take these incidents very seriously when they do, to learn and prevent reoccurrence: The first course of action when a missed referral is identified is for SPOC to determine what the referral was for and who it was from. They then triage the referral to ensure that any urgent care is provided. The Trust's priority is to ensure that patients receive the care they need as quickly as possible: Further, whenever a missed referral is identified by member of staff, they have a responsibility to raise clinical incident report SO that the matter can be investigated_ District Nurses have continuously reinforced the importance of a robust incident-reporting culture so as to ensure further incidents can be prevented and appropriate learning and training can take place to keep patients safe. disability Everyoneters confident chief Executlve Karen James EMPLOYER Chalr ~ Jane McCall in the they very any

NHS Tameside and Glossop Integrated Care NHS Foundation Trust In addition to reviewing individual incidents, which are raised when missed referral is identified, these incidents are tracked by relevant services and any trends or themes are looked for to ensure these are quickly identified and addressed. Any trends or themes that are identified are highlighted to the relevant divisions in their regular divisional meetings so that appropriate can be taken to address them in a timely manner As part of our investigation into your concern, discussions have been held with the Head of Nursing Community Adults, Service Director and Lead Nurse of the Trust's Intermediate Tier Services, and the Team Lead for SPOC in relation to ongoing improvements in the District Nursing referral process: am happy to inform you that we will be moving onto an electronic portal for all referrals to District Nurses made within the Trust. Once this has been running for a while, we will investigate the potential for non-Trust agencies to also use this portal for referrals, as we receive a high number of referrals from care homes. Given we are still working towards moving onto the electronic system , we have taken steps to tighten our processes in the meantime and are currently working through our strategy for the removal of all fax machines and the migration to electronic communication systems We hope to have provided you with assurances that missed referrals between the Acute services and the District Nursing Service are not in fact 'common' ad that when missed referrals do occur; the Trust pro-actively addresses any learning that can be drawn from it Concern 2: The Ward Manager of Ward 31 confirmed in her evidence that; at the time of the care provided to Mr Beard, there was only one permanent substantive registered nurse working on the ward, with the vast majority of shifts being fulfilled by agency workers: Whilst the Ward Manager gave evidence of significant improvements t0 recruitment and retention of nursing staff on the ward; and of additional actions her ad her team have introduced to promote consistency amongst agency staff, it is a matter of concern that there is still significant reliance on agency nurses (with the financial and continuity of care implications which can arise that) within the Trust: In order to address your concern above, the Trust wishes t0 offer you information and assurances around our recruitment processes and why it is necessary at times to use Agency and Bank nursing staff, Recruitment and employee retention are high priorities for the Trust, reflecting the National position and priorities for Nursing: We understand the importance of having an adequate level of substantive staff to ensure patient safety, continuity of care and to avoid the financial burden Ihat can be caused by being under-staffed. am happy to be able to assure you that (he Trust is very proactive when it comes to employee recruitment;, including the recruitment of registered nursing staff;, whose numbers were the cause of your concern in this Inquest: The Trust is a active partner in the Greater Manchester-wide Nursing Leadership Workforce and Recruitment work: We run 'Recruitment Open Days' , which have increased in frequency and are now occurring each quarter: To prepare for these and to ensure high attendance numbers, the Trust advertises these events on Social Media and websites such as NHSJobs, Linkedln, Indeed, and the Trust's recruitment website, TRAC , which is system that is used by close to 9% of all Trusts_ During these Open prospective employees meet with teams are interested in joining and have a tour of the site to see what the working environment is like. We make effort to engage them and support them from the start on what is hopefully a long career with the Trust. am happy to disability Everyone confident Chlef Exccutive Karen James Matters EMPLOYER Chalr - Jane McCall steps the from days Days they every

[HS] Tameside and Glossop Integrated Care NHS Foundation Trust report that our most recent Open which took place in June 2019, saw registered nursing posts filled with another two candidates awaiting interviews: In addition to open days, we work with other Trusts across Greater Manchester and advertise job opportunities on recruitment websites and through NHSJobs and our own TRAC system: We also use Social Media on occasions where we are trying to fill a particularly difficult job posting: These methods have been successful for the Trust t0 date, and we will continue to use them: We are also attending college job fairs and university open days in the Greater Manchester area to discuss employment opportunities with the Trust: am also able to assure you that we do a lot of work to recruit newly qualified staff Our recruitment team works in connection with our Preceptorship Team, who are responsible for the training and education of our trainee nurses, to ensure the transition from trainee to qualified is smooth process and involves securing permanent post with Trust Since September 2018 we have retained 39 newly qualified nurses, which is an improvement from our position in September 2017 when we retained 32 newly qualified nurses. We expect (hese figures to continue to rise given the work being done by our teams: In addition, since 2016 the Trust has been working to improve our registered nurse retention rate. At that time, the Trust was contacted by NHS Improvement who offered targeted support to improve our retention rate for registered nurses, as the Trust was in the lower quartile of performance. Since then, the Trust has managed this issue via a Recruitment and Retention Action Plan, with outcomes being reviewed by the Executive Management Team and the Workforce Committee. Although our involvement in this support programme has now finished, we continue to measure performance and associated outcomes. The Trust focused specifically o improving retention within Nursing and Midwifery services, which included taking the following steps: Strengthening the Exit Interview process, with earlier notificationlintervention; Offering career development conversations with a Senior Nurse or Midwife; Launching an Internal Transfer process to enable sideward moves; Reducing time for fill for vacancies, aided by TRAC recruitment database; Improving e-roster forecasting of future rosters, so staff can plan ahead better; Starting on-boarding sessions, t0 engage with staff who have joined the Trust; Strengthening staff recognition with '"Who's Your Hero' scheme; Introducing the e-card system scheme to aid recognition and gratitude amongst staff; Mapping training opportunities to clinical roles via a Clinical Skills Matrix; Designing and delivering a Preceptorship programme for newly qualified Nurses; Trialing of alternative roles such as the Registered Nurse Associate; Acclimatisation programme developed for Assistant Practitioners new to role. can confirm that over the last 12 months there been an overall trend of improvement noted in the registered nurse profession within the Trust The tumover target was achieved in 2019 and our overall picture for staff turnover, including nursing staff; is now in the best quartile, which indicates our retention efforts have been successful; Although we have seen success in the past 12 months, we will continue to closely monitor retention performance and take pro-active steps to ensure future success in this area. hope to have assured you of the ongoing efforts made by the Trust to recruit and retain registered nursing staff:. disability] Everyoriters confident chlet Executlve Karen James EMPLOYER Chalr Jane McCall in Day; five nursing the has

NHS Tameside and Glossop Integrated Care NHS Foundation Trust would like to also assure you that the Trust's use of Agency registered staff has seen a downward trend August 2018 t May 2019. We hope to see this continue given the improvements made so far in our recruitment efforts_ And whilst we appreciate that it is preferable to employ substantive registered nurses, s0 that patients have continuity of care and stability in the Trusts finances, we are acutely aware of the need to use Bank and Agency staff at times, to ensure our patients' safety is secure. As you may know, Bank staff are employees of the Trust who take o shifts in other areas of the Trust, when the need arises These employees are familiar with Trust policies and procedures ad can therefore facilitate a consistent treatment environment for patients, even if are not always on their usual Ward. Further; efforts are made to ensure that when Agency staff are used, the same individuals are used consistently in the same areas. Again, this is to ensure continulty of care and to ensure that these individuals are familiar with the way the Trust operates_ We acknowledge that ideally: the Trust would not have cause to use Bank and Agency staff to fill vacancies that arise, however we also recognise that at present the use of these individuals is essential to the effective and safe running Of the Trust And as such, we ensure that there are processes in place to ensure any Bank or Agency staff member completes a full local induction and the Trust's expectations of their performance are communicated to them; Although the need to use Bank ad Agency staff still exists for the Trust;, can assure you that we are making effort to improve ad develop our recruitment and retention processes to ensure as many registered nurses are employed by the Trust as possible. hope to have addressed the concems and should you have any queries arising from the content of this letter or require further information or clarification, please do not hesitate to contact me;