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 1 Norfolk and Suffolk NHS Foundation Trust - Our improvement plan & our progress Background & Summary • 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. 2 Norfolk and Suffolk NHS Foundation Trust - Our improvement plan & our progress Who is responsible? • Our actions to address the Quality Improvement Plan (QIP) recommendations have been agreed by the Trust Board. • 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. • 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 • 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 • 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 3 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 4 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 • Physiological workbook training introduced • Implementation of physical health strategy • 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. 5 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. 6 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 7