Special Measures Improvement
Plan Update
Norfolk and Suffolk NHS
Foundation Trust
April 2016
KEY
Delivered
On Track to deliver
Some issues – narrative disclosure
Not on track to deliver
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Norfolk and Suffolk NHS Foundation Trust - Our improvement plan & our progress
Background & Summary
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The Trust entered the special measures programme following a Care Quality Commission (CQC) inspection which took place in October 2014
the Trust was rated as ‘inadequate’ overall in February 2015 and as a result was placed into special measures by our regulator, Monitor, the
same month.
•
The Trust has been given a variety of recommendations for the areas that were rated as “inadequate”,(safe and well led) or “requires
improvement” (effective and responsive). Although the Trust was rated as “good “ for caring, the Trust ‘Quality improvement plan’ (QIP)
includes further actions to improve the caring rating. All of the urgent actions that were identified by the CQC have been completed. These
predominantly related to ligature issues and these have either been removed or the risk mitigated. The QIP was developed following receipt of
the CQC inspection reports and includes the 39 recommendations made in the reports as well as additional actions to raise quality across the
Trust.
•
The published CQC report can be found on the CQC website: www.cqc.org.uk
•
The Trust agreed an implementation plan to deal with these 39 recommendations, maintain progress and ensure actions lead to measurable
improvements in the quality and safety of care for patients . We recognised all of the recommendations and are addressing them to improve the
quality of services.
•
This document provides a summary of Trust progress against our published Improvement Plan www.nsft.nhs.uk/aboutus - which provides
further detail. While we take forward our plans to address the CQC’s 39 recommendations, the Trust is in ‘special measures’.
•
Oversight and improvement arrangements have been put in place to support changes required . The Quality Improvement Plan was approved
by the Board of Directors on the 26th February 2015 . The Board is responsible for ensuring that the required changes are made. We have also
set up a dedicated team called a Programme Management Office (PMO) to support our staff in making the changes quickly and efficiently. The
PMO sponsor is Michael Scott, Chief Executive, who reports on progress monthly to the Board of Directors . Our governors are also monitoring
the progress of the QIP and have set up a sub-group which reviews progress against the plan every month and then reports to the full council of
governors each quarter. The Trust publishes its board papers at www.nsft.nhs.uk Our Chief Executive, Michael Scott chairs the fortnightly PMO
meeting and ensures that the specific actions are undertaken. The PMO meeting includes all of the executive directors and there is a named
member of the executive team who takes responsibility for each action.
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Norfolk and Suffolk NHS Foundation Trust - Our improvement plan & our progress
Who is responsible?
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Our actions to address the Quality Improvement Plan (QIP) recommendations have been agreed by the Trust Board.
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Our Chief Executive, Michael Scott is ultimately responsible for implementing actions in this document. Other key staff are Dr Bohdan Solomka medical
director and Dr Jane Sayer, Director of Nursing, as they provide the executive leadership for quality, patient safety and patient experience.
•
The Improvement Director assigned to Norfolk and Suffolk NHS Foundation Trust is Alan Yates, who will be acting on behalf of Monitor and in concert with
the relevant Regional Team of Monitor to support delivery of the improvements and oversee the implementation of the action plan overleaf. Should you
require any further information on this role please contact specialmeasures@monitor.gov.uk
•
Ultimately, our success in implementing the recommendations of the Quality Improvement Plan (QIP) will be assessed by the Chief Inspector of Hospitals,
upon re-inspection of our Trust. This is now planned for July 2016.
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If you have any questions about how we’re doing, contact Stuart Clifton, stuart.clifton@nsft.nhs.uk, 01603 421421
How we will communicate our progress to you
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We will update this progress report every month while we are in special measures. Please access our Improvement Plan should further detail be required
www.nsft.nhs.uk/aboutus
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The Trust communicates with external stakeholders through the monthly Stakeholder assurance meeting and with commissioners at monthly clinical quality
review groups.
Chair / Chief Executive Approval (on behalf of the Board):
Chair Name: Gary Page
Signature:
Date:12/04/16
Chief Executive Name: Michael Scott
Signature:
Date:12/04/16
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Norfolk and Suffolk NHS Foundation Trust– Summary of progress against improvement plan
CQC Key Question
Agreed timescale for implementation
Progress (i.e. successes/outcomes) against
original timescale
Comments / Current main concerns
What has been achieved?
Safe
CQC rating ‘Inadequate’
Environmental risks (March 2016)
“5% reduction in ward incidents from
baseline by March 16”
Where ligatures cannot be removed,
mitigating actions will be put in place
This indicator has not met the target set. Interrogation of the data
however has demonstrated that the incidents are no longer attributable to
ligature points which have either been removed or mitigating actions are
in place. It is also identified that the incidents are frequently attributed to a
small number of patients who are very unwell. A new indicator detailing
the work being undertaken will be included in the new plan for May
Mixed sex accommodation
Female lounges to be available on Poppy
The building work has now commenced and is due for completion in June
and Avocet wards
Seclusion and restraint (March 2016)
“Use of restrictive interventions to be
below national average by March 16”
Monthly reporting and analysis of seclusion
data
Monthly reporting and analysis of restraint
data
Whilst the national data is not yet available, the trust target to achieve a
reduction of 10% by end of March 2016 has not been achieved and the
monthly mean for the total number of restraints has increased from 219 to
222. Prone restraint has however achieved the target 10% reduction and
the monthly mean has reduced from 76 to 64. Seclusion has also met the
10% reduction target with the monthly mean reducing from 61 to 52
seclusions.
Work is ongoing to improve seclusion environments and detail will be
added to the new plan for May.
Community policies and procedures
(September 2015)
Revised date December 2015
Revised date: March 2016
All teams will adhere to the lone worker
policy.
Team leaders to ensure that they act on the
results of the mock inspection and ensure
everyone is aware of the policy.
The mock inspection held in November 2015 showed that the overall
compliance was only 75% but this figure included ward data. Ongoing
mock inspections are highlighting much greater compliance with
community teams. This action is rated green and will be taken forward to
the new plan for ongoing monitoring
Learning from incidents
“Locality governance groups will be
able to demonstrate that learning has
led to changes in practice”
(March 2016)
Pilot project in Suffolk implemented
Whilst a review of the locality governance minutes has demonstrated that
learning from incidents is shared and this information is disseminated to
team level through the use of a standard agenda, staff can still be better
informed. This action will carry over to the new plan. The action is rated
blue as it has been delivered but there are still improvements that can be
made
Standardised agenda implemented in locality
governance groups
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CQC Key Question
Agreed timescale for implementation
Safe
Medication management (October 2015)
Revised date December 2015
CQC rating ‘Inadequate’
Due December 2015
Progress (i.e. successes/outcomes) against original
timescale
What has been achieved?
Competency assessments completed for all relevant
staff
Introduce ‘heat-map’ to identify areas of non
compliance
Due For completion March 2016
Effective
CQC rating ‘requires
improvement’
Ensure that all risk assessments and care plans are up to date in
line with multi-disciplinary reviews (May 2016)
Following the implementation of the new electronic
system, Lorenzo, audits demonstrate that the there is
improved availability of care plans. This is a clinical
priority for the Trust
Clinical strategy to be in place (April 2016)
Clinical strategy being developed with stakeholder
involvement
Comments / Current main concerns
The heat-map has now been introduced and will
be reported monthly. This will roll over to the
new plan. The heatmap and mock inspections
are demonstrating much improvement in
medicines management particularly in inpatient
areas.. The focus will now move to ensure
community teams are compliant with guidance.
This action is green and will roll over to the new
plan for ongoing monitoring
A number of initiatives are in place to ensure
compliance with this target. The Lorenzo team is
working hard to deal with issues but this remains
a risk
The clinical strategy will be agreed at the April
board meeting.
Proper procedures for detention under the mental Health Act will
be implemented
Revised date: March 2016
Mental health act requirements
•
CQC information posters available
(Complete)
•
MHA quality reporting system in place
(complete)
•
Additional guidance on recording capacity
issued (November)
•
Heatmap of compliance compiled monthly
following audit and presented to law forum.
This indicator is blue as all actions have been
delivered. Heatmap shows improvement and
local accountability will be reinforced to ensure
further improvements are made.
Recent MHA report demonstrates improvement.
This will roll over into the next plan for ongoing
monitoring
Physical healthcare needs will be identified, managed and
monitored.
Revised date: December 2015
Revised date: March 2016
Physical health
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Physiological workbook training introduced
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Implementation of physical health strategy
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Physical health strategy group in place
An audit completed in February 2016 has
demonstrated that 90.3% of people admitted to
the ward have had physical health assessments.
This remains below the trust target of 95%.
Quality reviews of the care plans have
demonstrated that only 50% of those people
who have a physical health issue, had this
documented in their care plan. It should be
acknowledged that the data is drawn from all
data sources including paper records so the
results may differ from data produced solely
from Lorenzo. This will form a new action in the
updated action plan.
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CQC Key Question
Agreed timescale for implementation
Progress (i.e. successes/outcomes) against
original timescale
Comments / Current main concerns
What has been achieved?
Caring
CQC rating ‘Good’
Implement service user and carer strategy, structure
to be in place by March 2016
Overall strategy full implementation by 2018
resource mapping to create process map,
timescales to be defined at meeting on
11/11/15
The strategy work is on track and new milestones will be
included in the rewritten plan available in May.
Structure for implementation to be agreed at
March board
Improvement plan for secure services (March 2016)
Team training on positive behaviour planning
Options appraisal for environmental changes
Following a request for some changes to the original
plan, the final strategy will now be agreed at the April
board meeting.
Secure services strategy approved
This action will be removed as duplicated in the separate
‘forensic inpatient services’ section
Responsive
CQC rating ‘Requires
improvement’
Well led
CQC rating ‘Inadequate’
Community caseload management. (Sept 2016)
WAVES Pilot in place
Pilot evaluation is underway and will report in September
Review inpatient and community provision to ensure
local people have access to the services they need
(Autumn 2016)
Discussions with commissioners are ongoing
Building work scheduled for completion end August with
service commencing Autumn 2016 based on the original
bed numbers. Ongoing discussions with commissioners
to fund the additional 5 beds
Ensure staff understand and own the refreshed
vision and values (March 2016)
Putting people first programme
implemented
Plans to provide additional Tier 4 beds are on
track
Vision and values approved by to Trust
board in October 2015
Training continues and individual teams are rolling out
their values based on the overall trust values. A total of
1550 staff have now been involved in the development
and roll out.
Roll out of vision and values through events
and publicity
Check and review internal control systems through
the implementation of the new operating model
(Dec 15)
Appointment of lead clinicians complete.
All lead clinicians now appointed
Board oversight of quality (December 2015)
Foresight Governance re-assessment :
positive report on progress. Board
development plan in place.
The Foresight report identifies clear improvements and a
further plan is in place.
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Norfolk and Suffolk NHS Foundation Trust– Summary of progress against improvement plan
Specific service (i.e.
cutting across CQC
Key Questions)
Forensic In patient
services
Agreed timescale for
implementation
Improvements to the clinical
environment
(March 2016)
Progress (i.e. successes/outcomes) against original timescale
What has been achieved?
Norvic capital design first approval
Due to changes in the detail of the plans and delays in financial approval, work has not yet
commenced
CQC Rating
‘inadequate’
Improved staff wellbeing and morale
(August 2016)
Following a request for additional proposals, the
final strategy will now be approved at the April
board meeting. This indicator is therefore overdue
and red.
Additional milestones will be provided in the
rewritten plan available in May
Recruitment and retention plan in place
Staff survey results show improved morale
Embedding an open and supportive
culture that values diversity
Comments / Current main concerns
Initial results from the 2015 staff survey show
improved morale. On track for 2016
Team training on positive behaviour plans
Equality and diversity strategy approved
Cultural change programme in place
Three workshops have been delivered and a culture of
care barometer introduced which is reported 6
monthly. New milestones will be reported in the new
plan available in May.
Other (e.g. concerns arising after CQC re-inspection; awaiting CQC report from re-inspection etc.)
This document was originally written in February 2015 and has been updated monthly. As many of the target dates for completion identified at that time were March 2016, this update will
report our progress and then the plan will be reviewed with new actions and new target dates to reflect the position of the trust moving in to the new financial year and the work underway
prior to the next inspection.
Whilst the issues identified in the original plan will remain the same, many actions have been completed and outcomes achieved. In some areas however the outcomes have changed in
response to the emerging landscape within the NHS and the new action plan to be reported next month will reflect those changes
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