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SOMERSET PARTNERSHIP NHS FOUNDATION TRUST
BUSINESS ACTION PLAN
PROGRESS REPORT FOR 1 APRIL 2015 TO 31 DECEMBER 2015
Sponsoring Director:
Director of Finance and Business Development.
Author:
Associate Director – Strategic Planning and Performance.
Purpose of the report:
The Trust’s Business Action Plan for 2015/16 sets out the key
priorities for the Trust, together with the actions to be
undertaken and the timescales for their achievement.
The quarterly Business Action Plan progress report provides
an update regarding progress made in relation to the
achievement of the six objectives which form the Trust’s
Annual Plan Action Plan for 2015/16.
Key Issues and
Recommendations:
The Business Action Plan for 2015/16 sets out the Trust’s key
business objectives for the year. These objectives and
associated actions relate to the Trust’s six strategic themes:

Quality and Safety;

Service Delivery;

Culture and People;

Integration;

Innovation;

Viability and Growth.
The key priorities set out in the Plan are drawn from:

the Trust’s Monitor Annual Plan for 2015/16;

the Trust’s Monitor Strategic Plan for 2014/15 to 2018/19;

priorities identified by the Council of Governors during the
annual business planning cycle;

priorities identified by staff and professional groups
across the Trust as part of the annual business planning
cycle.
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A new action included in the Business Action Plan from
Quarter 3 is:

Action 6.11: Prepare and submit the Trust’s draft
operational plan for 2016/17, in line with Monitor
requirements.
Progress against the 63 actions contained within the plan was
as follows:
Achieved:
Ongoing:
Unlikely to be met:
Not met:
23
31
6
3
The actions which are assessed as ‘Not met’ are:

Action 1.11: Achieve all standards relating to the
framework for commissioning for quality and innovation
(CQUIN). As at 31 December 2015, the Trust had
achieved all of its CQUIN standards, with the exception
of the requirement relating to the incidence of pressure
ulcers occurring on the district nursing caseload and in a
community hospital setting. A series of additional actions
has been put in place across the Trust following
appointment of a new Tissue Viability lead;

Action 1.12: Meet all compliance requirements of the
Care Quality Commission and other regulatory and
statutory bodies. Reports received from the Care Quality
Commission has identified areas for improvement in the
Trust’s core services and some more significant
concerns regarding learning disability services. An
action plan has been developed to address the concerns
raised, and its implementation is being overseen by a
learning disabilities improvement board;

Action 3.8: Review the findings regarding the potential to
extend incentives for employers who provide effective
NICE recommended workplace health programmes for
employees. The recommendations of the NICE
‘Workforce Health Management Practices’ document
published in June2015 will inform a review of
occupational health provision ahead of the
commencement of the tendering process. It is proposed
that the timescale for this action be amended to 31 July
2016.
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The actions which are assessed as ‘unlikely to be met’ are:

Action 1.3: Extend the use of the ‘Triangle of Care’ by
implementing the approach in all community mental
health services: 50% of staff in identified services to have
‘Triangle of Care’ awareness training. A significant
amount of training is due to take place during the fourth
quarter of 2015/16. If all staff currently booked onto the
training attend, a total 47% of community health staff will
have undertaken the training by 31 March 2016. The
resource allocated to this training is being reviewed
alongside the aspiration to deliver the ‘Open Dialogue’
model;

Action 3.3: Develop an organisational development
strategy to support the wider Trust strategy and its values
and commitment to empower and engage with staff at all
levels. It is planned that feedback from staff survey
engagement events and the leadership diagnostic will
inform the development of the draft organisational
development strategy, which will then be subject to
discussion and presentation to the Trust Board for
approval. It is proposed that the timescale for this action
be amended to 31 May 2016;

Action 3.6: To develop a talent management and
succession planning strategy and plan to ensure the
Trust maximises the potential of staff and understands
the ‘talent pipeline’ within the organisation. Work will be
undertaken to produce a strategy informed by the
direction of travel in respect of Leadership Development
and discussions at a system level. It is proposed that the
timescale for this action be amended to 31 July 2016;

Action 4.7: Integration - Achieve productivity and
efficiency savings of £5.5million. As at 31 December
2015 the IP2 project was £514,000 behind its financial
target. Pay savings are in line with target, but savings in
respect of reduced cost of travel and additional income
are falling short of plan;

Action 6.1: Deliver an operational surplus of £0.25
million. As at 31 December 2015, the Trust’s overall
financial position showed an adverse variance of
£1,199,000. It is unlikely that the Trust will achieve a
break-even position by the end of the year, but is acting
to minimise the deficit;
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
Actions required by
the Board:
Action 6.2: Deliver the Trust Cost Improvement Plan and
release savings of £7.4 million. As at 31 December 2015
the Trust’s cost improvement plan showed an adverse
variance of £604,000 against the original plan of
£7.4million. During the year the cost improvement
programme was increased by £0.2m in order to fund
changes to inpatient establishments. The variance
against the revised target is £709,000. The Trust is
considering a range of options to support those elements
of the plan that are falling short of target.
The Board is asked to:

note the Business Action Plan Quarter 3 progress
report;

agree the proposals to revise the timescales
associated with Actions 3.3, 3.6 and 3.8.
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BUSINESS ACTION PLAN 2015/16
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Introduction
This Business Action Plan for 2015/16 spans the period from 1 April 2015 to 30 June 2016 and sets out the Trust’s key business objectives in a
framework which enables the Trust Board to receive reports on progress throughout the year. The Plan comprises six objectives and 63 actions,
drawn from:




priorities set out in the Trust’s Monitor Annual Plan (AP) for 2015/16
priorities set out in the Trust’s Monitor Strategic Plan (SP) for 2014/15 to 2018/19
priorities identified by the Council of Governors during the annual business planning cycle
priorities identified by staff and professional groups across the Trust as part of the annual business planning cycle
The Business Action Plan also encompasses the strategic and annual objectives, outlined in the Trust’s Assurance Framework (AF).
Progress with the achievement of the objectives and targets set out in the Business Action Plan will be reported quarterly to the Trust Board, and
to the Council of Governors via the Strategy and Planning Group.
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MISSION AND VISION
The Mission and Vision of Somerset Partnership NHS Foundation Trust is underpinned by the values and commitments enshrined in the NHS
Constitution.
The Mission of the Trust is:
Caring for you in the heart of the community
The Trust’s Vision is:
We will be the leading provider of community-based health and social care
The views of staff and the Council of Governors, were sought in developing the Trust’s Mission and Vision.
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STRATEGIC THEMES
A series of Strategic Themes for the Trust were also developed, in consultation with staff, as part of the Trust’s annual business planning
process, and with the Council of Governors. These Strategic Themes support the achievement of the Trust’s Mission, Vision and Values. The
six Strategic Themes are as follows:
1. Quality and Safety
2. Service Delivery
3. Culture and People
4. Integration
5. Innovation
6. Viability and Growth
VALUES
The values of the Trust are consistent with those of the wider NHS:

Working together for patients

Respect and Dignity

Commitment to quality of care

Compassion

Improving lives

Everyone counts
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Key to initials:
CE
Chief Executive
DNPS
Director of Nursing and Patient Safety
COO
Chief Operating Officer
DFBD
Director of Finance and Business Development
MD
Medical Director
DG
Director of Governance and Corporate Development
DW
Director of Workforce and Organisational Development
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Somerset Partnership NHS Foundation Trust has adopted a double Red / Amber / Green (RAG) rating system for monitoring progress against all
actions associated with the achievement of Business Action Plan objectives. Actions related to objectives are assessed as follows:
RATING
DEFINITION
Green
Green
Completed.
Green
Amber
Work is in progress, in line with the target date.
Amber
Amber
Initial work has commenced, appropriate to the target date.
Amber
Red
Work has commenced but the target date is unlikely to be
met.
Red
Red
Not completed by the target date.
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STRATEGIC THEME
1. QUALITY AND SAFETY
OBJECTIVE
Continuously reduce levels of avoidable harm, deliver best clinical outcomes and improve patient experience.
LINKS
AF, QS, AP, SP
ANNUAL OBJECTIVE
Maintain and improve compliance with safer staffing rates on inpatient wards and prepare for implementation
of safer staffing in community services.
REF
1. 1.1
ACTIONS
Undertake six-monthly
reviews of nursing
establishment levels.
TARGET
DATE
31 August
2015 and 28
February 2016
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LEAD
DNPS
PROGRESS COMMENTARY
AS AT 30 SEPTEMBER 2015
Monthly reports to the Trust
Board continue. A full
consultative safer staffing review
has been conducted with all
inpatient wards. The next sixmonthly formal report on the
review of nurse staffing levels is
scheduled to be presented to the
Trust Board on 24 November
2015.
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PROGRESS COMMENTARY
AS AT
31 DECEMBER 2015
A full review was completed
during the quarter and the
resultant report was presented to
the meeting of the Trust Board
on 24 November 2015. The Trust
Board approved the report’s
recommendations.
A workshop took place regarding
the national mental health safer
staffing toolkit and plans are
being implemented to pilot the
toolkit on three wards.
Preparatory work has
commenced on the safer care
tool for community inpatient
wards, and a workshop was held
during the quarter.
RAG RATING
Green
Green
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ANNUAL OBJECTIVE
REF
1.2
Implement the targets in our Quality Improvement Plan for 2015/16, reducing avoidable harm and improving
patient experience.
ACTIONS
TARGET
DATE
Strengthen the Trust’s
arrangements for engaging
patients, carers and
communities in quality
improvement
31 March 2016
LEAD
DG
PROGRESS COMMENTARY
AS AT 30 SEPTEMBER 2015
The revised and updated
strategy for communications and
patient and public involvement
was agreed by the Trust Board in
July 2015.
An engagement workshop was
held in July 2015, to gather views
from patients and carers about
the development of the new
mental health crisis service.
Action plans to deliver the aims
of the communications and
patient and public involvement
strategy have been developed
and will be monitored by the
Trust’s patient and public
involvement group on a quarterly
basis.
PROGRESS COMMENTARY
AS AT
31 DECEMBER 2015
Progress against the actions
included in the Communications
and Patient and Public
Involvement action plans are on
target and will be discussed at
the Trust’s Patient and Public
Involvement Group meeting on
21 January 2016.
Notable areas of progress
include:




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RAG RATING
Ash Ward held its first
evening event specifically for
carers in September 2015
the Acute Care Forum for
mental health inpatients has
been relaunched
the Voluntary Sector Forum
met in October 2015 and
discussed outcomes based
commissioning and working
together
Healthwatch has carried out
lay visits to two mental health
inpatient wards and will be
visiting others in the next
quarter.
Green
Amber
J
REF
1.3
2. 1.4
ACTIONS
TARGET
DATE
Extend the use of the
‘Triangle of Care’ by
implementing the approach
in all community mental
health services: 50% of
staff in identified services
to have ‘Triangle of Care’
awareness training
31 March 2016
Play an active part in the
local Patient Safety
Collaborative, embedding
the five ‘Sign Up to Safety’
pledges, with the aim of
delivering harm-free care
for every patient, every
time, everywhere.
31 March 2016
2015/16 Business Action Plan Quarter Three Progress Report
January 2016 Public Board
LEAD
COO
DNPS
PROGRESS COMMENTARY
AS AT 30 SEPTEMBER 2015
As at 30 September 2015, a total
of 52 staff, out of a total of 346
staff in identified services (15%),
had been trained in the ‘Triangle
of Care’ approach. A further five
training courses are scheduled to
be held before 31 March 2016, in
order to meet the 50% standard
The ‘Sign Up to Safety’
campaign continues, with regular
reporting on harm free care and
with the pledges supported by
Quality Improvement Plans.
The pledges have been posted
on the Trust’s public website and
will feature at a Trust-wide
patient safety event, which is
planned to be held in January
2016.
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PROGRESS COMMENTARY
AS AT
31 DECEMBER 2015
The percentage of staff trained in
the Triangle of Care, as at 12
January 2016 was 20%. A
significant amount of training is
due to take place during the
fourth quarter of 2015/16. If all
staff currently booked onto the
training attend, a total 47% of
community health staff will have
undertaken the training by
31 March 2016. The resource
allocated to this training is being
reviewed alongside the
aspiration to deliver the ‘Open
Dialogue’ model, and e-learning
is being developed to enable a
more sustained approach.
As part of the Sign Up to Safety
work stream we have secured
another five places on the next
Institute for Healthcare
Improvement / Academic Health
Science Networks patient safety
officer training course in May
2016. Work is being undertaken
to assess where these roles
would be of most benefit.
A conference day is planned for
April 2016, to improve
organisational awareness and
launch improvement
RAG RATING
Amber
Red
Green
Amber
J
REF
3. 1.5
ACTIONS
TARGET
DATE
Implement the Mental
Health Crisis Care
Concordat to ensure that
the Trust fully meets the
requirements in relation to
access standards, quality of
treatment and prevention
31 March 2016
LEAD
COO
PROGRESS COMMENTARY
AS AT 30 SEPTEMBER 2015
PROGRESS COMMENTARY
AS AT
31 DECEMBER 2015
methodology to front line teams.
A pilot being developed for the
use of the Early Warning Trigger
Tool within the District Nursing
service. Representatives from
the Trust attended the Mental
Health Collaborative in
December 2015.
The staff consultation on the
management restructure for the
countywide crisis service has
been completed and an
implementation plan has been
produced.
Recruitment has continued and
interviews have been held for
Band 6 crisis, crisis/ward
rotational posts and Band 3
Support Time Recovery workers.
Offers of appointment have been
made. Additional actions
implemented during the quarter
include:
A new crisis service manager
and deputy head of division/crisis
and inpatient manager have
been appointed.
Work has been undertaken to
review the impact of recruitment
on inpatient services. Job
descriptions have been
developed for joint posts and
advertisements for these posts
have been produced.



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additional staff have been
provided to support 7-night,
night assessor cover to
Yeovil District Hospital NHS
Foundation Trust
an Approved Mental Health
Professional hub has been
established at the Trust’s
Wellsprings site
a review of the Section 136
health-based place of safety
protocol has been
undertaken with the police,
RAG RATING
Green
Amber
J
REF
4. 1.6
5. 1.7
ACTIONS
Enhance leadership
engagement, promote
Board level and senior
management engagement
with patient safety and the
Sign Up to Safety’
programme
Achieve a 10% reduction,
compared to 2014/15, in
unplanned transfer where
physical deterioration was
not recognised, escalated
or treated appropriately for
three hours or more,
TARGET
DATE
31 March 2016
LEAD
DNPS
PROGRESS COMMENTARY
AS AT 30 SEPTEMBER 2015
The programme of Patient Safety
walk rounds continues as
scheduled and action plans for
wards, arising from the visits, are
being produced.
Given the success of the
programme an experimental
Patient Safety ‘Talk round’, with
a community team is planned to
be tested over the next quarter.
31 March 2016
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January 2016 Public Board
COO
In 2014/15 there were 56
unplanned transfers across the
Trust’s mental health wards and
community hospital inpatient
wards, where physical
deterioration was found not to
have been recognised, escalated
or treated appropriately for three
hours or more.
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PROGRESS COMMENTARY
AS AT
31 DECEMBER 2015
ambulance and accident &
emergency departments, to
include revised protocols for
CAMHs patients
 a review of Section 136
control room based triage
within multi-agency crisis
concordat meeting.
Patient Safety walk rounds have
continued as scheduled. All
actions from these are shared
with the relevant heads of
division who then monitor the
completion of the action plan.
Results of the walk round visits
are also shared at the Clinical
Governance group.
Pilot ‘talk rounds’ are being built
into the schedule for community
services and will commence in
2016/17.
During the period from 1 April to
30 September 2015, the latest
date for which fully validated data
is available, there were 20
unplanned transfers across the
Trust’s mental health wards and
community hospital inpatient
wards, where physical
deterioration was found not to
have been recognised, escalated
RAG RATING
Green
Amber
Green
Amber
J
REF
ACTIONS
TARGET
DATE
LEAD
PROGRESS COMMENTARY
AS AT 30 SEPTEMBER 2015
During the period from 1 April to
30 September 2015, there have
been 14 such cases confirmed,
with a further 22 cases currently
subject to investigation.
6. 1.8
Reduce levels of harm,
compared to 2014/15, from
catheter associated urinary
tract infections by
assessment and timely
removal of non-clinically
indicated devices
31 March 2016
2015/16 Business Action Plan Quarter Three Progress Report
January 2016 Public Board
DNPS
Work is being undertaken with
the Trust’s Incident Review
Group and the Heads of Division
to improve and speed up the
current investigation process,
which relies upon the retrieval
and review of paper-based
documentation, including
patients’ observation
charts. Work is also being taken
forward to capture the relevant
information on RiO, in order to
improve the investigation
process.
All hospitals have now
commenced the ‘catheter free’
initiative. The Trust’s Infection
Prevention and Control team has
audited the Trust’s community
hospitals over a 12 week period.
The audit showed that 86
patients met the criteria for trial
without catheter and of these
79% of catheters were
successfully removed.
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PROGRESS COMMENTARY
AS AT
31 DECEMBER 2015
or treated appropriately for three
hours or more, equating to a rate
of 0.311 transfers per 1000 beds
days.
RAG RATING
This compares to a total of 56
unplanned transfers matching
these criteria was during the
whole of 2014/15 (a rate of 0.426
transfers per 1000 bed days),
equating to a reduction in
2015/16 of 27%. Data prior to
2014/15 was not routinely
collected on a comparable basis.
‘Catheter free’ care is now
established across the
community hospitals.
Prior to commencement of the
workstream specific data was not
collected to measure the
development of urinary tract
infections in patients with
indwelling urinary catheters
meaning baseline data is not
available. This work stream was
Green
Amber
J
REF
7. 1.9
ACTIONS
Reduce the levels of harm
from incidents of violence
and aggression per 1,000
bed days by 10%,
compared to 2014/15
TARGET
DATE
31 March 2016
LEAD
COO
PROGRESS COMMENTARY
AS AT 30 SEPTEMBER 2015
Between 1 April and
30 September 2015, a total of 69
incidents of violence and
aggression by patients to
patients were recorded, equating
to a rate of 1.07 incidents per
1000 bed days.
This compares to a total of 96
incidents recorded during the
corresponding period in the
previous year (1.47 incidents per
1000 bed days). This represents
a reduction of 26.9% in the rate
per 1000 bed days during the
first six months.
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PROGRESS COMMENTARY
AS AT
31 DECEMBER 2015
developed as an improvement
programme. The project has
successfully resulted in 79% of
patients successfully being
managed without a urinary
catheter, which entirely
eliminates the risk of developing
a catheter related infection.
RAG RATING
The Infection Prevention and
Control team is involved with
catheterisation training and is
working to develop aseptic
technique training to improve
standards and practice further.
During the 12 months from
1 January to 31 December 2015,
a total of 141 incidents of
violence and aggression by
patients to patients were
recorded (3.15 incidents per
1000 bed days).
This compares to a total of 231
incidents recorded during the
corresponding period in the
previous year (4.85 incidents per
1000 bed days), equating to a
reduction of 35.2% in the rate per
1000 bed days.
Green
Green
J
REF
8. 1.10
ACTIONS
TARGET
DATE
Reduce the use of restraint
incidents per 1,000 bed
days by 10%, compared to
2014/15
31 March 2016
LEAD
COO
PROGRESS COMMENTARY
AS AT 30 SEPTEMBER 2015
Between 1 April and
30 September 2015, a total of
114 incidents of restraint were
recorded, equating to a rate of
5.70 incidents per 1000 bed
days.
This compares to a total of 131
incidents recorded during the
corresponding period in the
previous year (5.92 incidents per
1000 bed days). This represents
a reduction of 10.4% in the rate
per 1000 bed days during the
first six months.
1.11
Achieve all standards
relating to the framework
for commissioning for
quality and innovation
(CQUIN).
31 March 2016
DFBD
These figures exclude Wessex
House, on a like-for-like basis,
due to the ward being
temporarily closed between April
and December 2014.
As at 30 September 2015, the
Trust had achieved all of its
CQUIN standards, with the
exception of the requirement for
reductions in the incidence of
pressure ulcers on the district
nursing caseload.
Between 1 April and
30 September 2015, there were
20 incidents of ‘avoidable’
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PROGRESS COMMENTARY
AS AT
31 DECEMBER 2015
During the 12 months from
1 January to 31 December 2015,
a total of 240 incidents of
restraint were recorded (5.36
incidents per 1000 bed days).
This compares to a total of 340
incidents recorded during the
corresponding period in the
previous year (7.14 incidents per
1000 bed days), equating to a
reduction of 25.0% in the rate per
1000 bed days.
As at 31 December 2015, the
Trust had achieved all of its
CQUIN standards, with the
exception of the requirement
relating to the incidence of
pressure ulcers occurring on the
district nursing caseload and in a
community hospital setting.
Between 1 April and
30 November 2015, the latest
RAG RATING
Green
Green
Red
Red
J
REF
ACTIONS
TARGET
DATE
LEAD
PROGRESS COMMENTARY
AS AT 30 SEPTEMBER 2015
pressure ulcer damage, equating
to a rate of 0.1169 cases per
1,000 contacts, against a
required CQUIN standard of
0.1064 cases per 1,000 contacts.
Final assessment of
achievement of this measure will
be based upon the rate for the
period 1 April 2015 to 31 March
2016.
PROGRESS COMMENTARY
AS AT
31 DECEMBER 2015
validated data available, there
were 31 incidents of ‘avoidable’
pressure ulcer damage, equating
to a rate of 0.1360 cases per
1,000 contacts, against a
required CQUIN standard of
0.1064 cases per 1,000 contacts.
This is 28% above the rate
reported in 2014/15, against a
CQUIN requirement that there
should be no increase.
During the same period, seven
‘avoidable’ pressure ulcers were
reported in community hospitals.
During the whole of 2014/15 a
total of four ‘avoidable’ pressure
ulcers were reported in
community hospitals. Again, the
CQUIN requirement for 2015/16
is that there should be no
increase.
A series of additional actions has
been put in place across the
Trust following appointment of a
new
Tissue
Viability
lead
including:
 a review of all Trust systems
and processes in relation to
pressure prevention;
 a move to local team-based
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RAG RATING
J
REF
1.12
ACTIONS
Meet all compliance
requirements of the Care
Quality Commission and
other regulatory and
statutory bodies
TARGET
DATE
31 March 2016
LEAD
DG
PROGRESS COMMENTARY
AS AT 30 SEPTEMBER 2015
The comprehensive inspection of
the Trust was undertaken by the
Care Quality Commission, during
the week commencing
7 September 2015 and further
visits took place up to 25
September 2015.
Initial feedback from the Care
Quality Commission indicated
areas for improvement and some
more significant concerns
regarding learning disability
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PROGRESS COMMENTARY
AS AT
31 DECEMBER 2015
action plans for pressure
prevention;
 peer review is planned for 24
February 2016;
 two multi-disciplinary
pressure ulcer summit days
to be held in March and
October 2016. These include
legal perspectives and
record keeping;
 a monthly rolling programme
of education has been
formulated for 2016/17
around the common themes
identified during the
validation of all pressure
damage incidents. This
includes a focus on
prevention of heel damage.
The report of the Care Quality
Commission inspection was
published on 17 December 2015,
following the Quality Summit held
on 11 December 2015.
RAG RATING
The Care Quality Commission
and issued 17 reports for all core
services as well as an overall
provider report, with an overall
judgement that the Trust
“Requires Improvement”. A
schedule of areas of non-
Red
Red
J
REF
ACTIONS
TARGET
DATE
LEAD
PROGRESS COMMENTARY
AS AT 30 SEPTEMBER 2015
services, details of which have
been provided to the Trust. An
action plan has been developed
to address the concerns raised,
overseen by a learning
disabilities improvement board.
In August 2015 healthcare
services at HM prison Ashfield
were inspected by the Care
Quality Commission and the
Trust received notice of some
areas of improvement required
for which an action plan has also
been developed.
1.13
Implement actions arising
from feedback received
following the visit of the
Care Quality Commission
31 March 2016
COO
Following the comprehensive
inspection of the Trust by the
Care Quality Commission, the
Trust has planned a range of
actions to be undertaken within
six weeks in respect of learning
disabilities services, including:

2015/16 Business Action Plan Quarter Three Progress Report
January 2016 Public Board
establishing a learning
disabilities improvement
board, with membership
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PROGRESS COMMENTARY
AS AT
31 DECEMBER 2015
compliance was published with
the report and the Trust will
produce an action plan to
address these, for submission to
Care Quality Commission by
26 January 2015.
RAG RATING
Results of the Care Quality
Commission inspection have
been shared with a full range of
stakeholders, including the local
media, and press statements and
interviews have been given.
Plans are being developed to
publicise the results via the Care
Quality Commission widget on
the Trust website and via posters
at service locations as required
under Care Quality Commission
guidance.
Further actions were taken in
relation to learning disabilities
services during Quarter 3,
including:


update health leads in
relation to safeguarding
processes, including
escalation of safeguarding
concerns
ensuring all staff have
Green
Amber
J
REF
ACTIONS
TARGET
DATE
LEAD
PROGRESS COMMENTARY
AS AT 30 SEPTEMBER 2015





2015/16 Business Action Plan Quarter Three Progress Report
January 2016 Public Board
drawn from management
and clinical staff, the local
authority and Somerset
Clinical Commissioning
Group
holding a learning disabilities
service away day, to engage
senior clinical and
management staff in
identifying and agreeing
areas for review and actions
to improve the service
undertaking face to face
review of open learning
disabilities cases, including
risk stratification,
identification of risks and
ensuring safety plans are in
place
reviewing the Trust’s Clinical
Risk Assessment and
Management training and its
applicability to learning
disabilities services
assessing and managing
risks in relation to pathways,
specifically where care is
shared or transferred
writing to existing service
users and carers about the
concerns raised and actions
being taken
- 22 -
PROGRESS COMMENTARY
AS AT
31 DECEMBER 2015
access to training in relation
to the Mental Capacity Act
and Deprivation of Liberty
 developing a Trust-wide tool
for recording capacity,
including supporting
evidence and triggers for
completion of a Mental
Capacity Act assessment
 the development and
implementation of new
information and performance
management arrangements,
at the level of service, team
and individual practitioner
 undertaking an audit of
clinical supervision for
nurses and allied healthcare
professionals
 implementing new systems
for monitoring and following
up non-attendance of
appointments
 holding meetings with
consultant psychiatrists to
discuss performance and
current practice regarding
the prescribing and review of
antipsychotic medication
 introducing the caseload
zoning approach to
managing the levels of risk
RAG RATING
J
REF
ACTIONS
TARGET
DATE
LEAD
PROGRESS COMMENTARY
AS AT 30 SEPTEMBER 2015


establishing external support
arrangements and sharing
examples of good practice
confirming that appropriate
Safeguarding arrangements
are in place and immediately
addressing any identified
issues.
Further actions are planned, to
follow the initial six-week period.
2015/16 Business Action Plan Quarter Three Progress Report
January 2016 Public Board
- 23 -
PROGRESS COMMENTARY
AS AT
31 DECEMBER 2015
and complexity of the
caseload
A comprehensive action plan will
be produced, based on the
issues identified by the Care
Quality Commission in the
Trust’s provider report and in the
17 core services reports,
addressing the actions that the
Trust is required and
recommended to take.
RAG RATING
J
STRATEGIC THEME
2. SERVICE DELIVERY
OBJECTIVE
Achieve a reduction in inpatient based care and an increase in the delivery of care in a community-based
setting.
LINKS
AF, SD, AP, SP
Reduce the aggregate average length of stay in community hospitals to 21 days and achieve 85% bed
ANNUAL OBJECTIVE occupancy, to preserve annual levels of inpatient admissions to the Trust’s community hospitals between
2015/16 and 2018/19.
REF
2.1
ACTIONS
TARGET
DATE
Reduce the aggregate
average length of stay in
community hospitals to 21
days and achieve 85% bed
occupancy, to preserve
annual levels of inpatient
discharges from the Trust’s
community hospitals.
31 March 2016
LEAD
COO
PROGRESS COMMENTARY
AS AT 30 SEPTEMBER 2015
As at 30 September 2015, the
cumulative average length of
stay in the Trust’s community
hospitals in 2015/16 was 22.1
days and the cumulative bed
occupancy rate was 89.0%.
PROGRESS COMMENTARY
AS AT
31 DECEMBER 2015
As at 31 December 2015, the
cumulative average length of
stay in the Trust’s community
hospitals in 2015/16 was 22.7
days and the cumulative bed
occupancy rate was 89.4%.
A total of 1,727 patients had
been discharged from the Trust’s
community hospitals during that
time, against a plan for the year
to date of 1,837 patients.
A total of 2,672 patients had
been discharged from the Trust’s
community hospitals during that
time, against a plan for the year
to date of 2,820 patients.
Bed days lost due to delayed
discharges continues to affect
the length of patient stays in
community hospitals, although
the position has improved
2015/16 Business Action Plan Quarter Three Progress Report
January 2016 Public Board
- 24 -
RAG RATING
Amber
Amber
J
REF
2.2
2.3
ACTIONS
TARGET
DATE
Reduce the percentage of
available bed days lost due
to delayed discharges,
compared to 2014/15
31 March 2016
In partnership with
Somerset Clinical
Commissioning Group and
other key stakeholders,
review the role and
capacity requirements for
community hospitals and
mental health inpatient
wards.
31 March 2016
LEAD
COO
COO
PROGRESS COMMENTARY
AS AT 30 SEPTEMBER 2015
Between 1 April and
30 September 2015, 5.5% of
community hospital bed days
were lost due to delayed
discharges. This represents an
improvement on the rate of 8.9%
recorded in the corresponding
period in 2014.
For adult mental health, the Trust
continues to engage with
Somerset Clinical
Commissioning Group regarding
the provision of beds for the
Mendip area and reviewing
options for the Priory Health
Care site, and the impact on
wider services. The Trust’s
Transformation Implementation
Manager has commenced in post
and is leading this review.
Refurbishment has been
completed on Rowan ward,
which includes the Section 136
place of safety. Rowan ward
now has 18 en-suite bedrooms.
2015/16 Business Action Plan Quarter Three Progress Report
January 2016 Public Board
- 25 -
PROGRESS COMMENTARY
AS AT
31 DECEMBER 2015
compared to last year. Work
remains ongoing with partner
organisations including the local
authority, to improve the position
further.
Between 1 April and
31 December 2015, 5.1% of
community hospital bed days
were lost due to delayed
discharges.
RAG RATING
Green
Amber
Green
Amber
This represents a reduction on
the rate of 9.3% recorded in the
corresponding period in 2014.
The St Andrew’s Steering Group
is actively engaging with internal
and external stakeholders to
assess the optimal use for the St.
Andrew’s unit and the Priory site
in general.
A market assessment is currently
being undertaken with the
expectation that this will inform
an options appraisal and
decision making process by the
Trust Board in March / April
2016, prior a formal consultation
(if required) thereafter.
J
REF
2.4
ACTIONS
Expand ambulatory care in
community hospital
settings, compared to
2014/15
TARGET
DATE
31 March 2016
LEAD
COO
PROGRESS COMMENTARY
AS AT 30 SEPTEMBER 2015
Consultation on the proposals
outlined in ‘Making the Most of
Community Services’ is being
undertaken with patients, carers
and the public. A final
recommendation remains on
schedule to be taken to the
meeting of the Clinical
Commissioning Group’s
Governing Body by November
2015.
For the period from 1 April to
30 September 2015, the Trust
undertook 3721 ambulatory care
appointments.
During the period from 1 April
2014 to 31 March 2015, the
number of appointments
undertaken was 1631.
2.5
Implement arrangements
for the opening of eight
beds at South Petherton
community hospital
30 November
2015
COO
The reopening of the eight beds
at South Petherton community
hospital remains on schedule to
be undertaken on a phased
basis, as follows:


2015/16 Business Action Plan Quarter Three Progress Report
January 2016 Public Board
Week commencing
26 October 2015: two beds
Week commencing
2 November 2015: two beds
- 26 -
PROGRESS COMMENTARY
AS AT
31 DECEMBER 2015
For the period from 1 April to
31 December 2015, the Trust
undertook 6,165 ambulatory care
appointments in community
hospital settings, an increase on
the 1,712 appointments
undertaken during the same
period in 2014.
RAG RATING
Green
Amber
Green
Green
Completed.
J
REF
ACTIONS
TARGET
DATE
LEAD
PROGRESS COMMENTARY
AS AT 30 SEPTEMBER 2015


ANNUAL OBJECTIVE
REF
2.6
2.7
PROGRESS COMMENTARY
AS AT
31 DECEMBER 2015
RAG RATING
Week commencing
11 November 2015: two
beds
Week commencing
18 November 2015: two
beds
Minimise the length of time that patients have to wait to be seen by our services, meeting waiting time targets
for all services during 2015/16.
ACTIONS
Implement ‘Caseload
Zoning’ to ensure that the
needs of patients on
community caseloads are
met most effectively
Meet all Monitor Risk
Assessment Framework
standards.
TARGET
DATE
31 March 2016
31 March 2016
2015/16 Business Action Plan Quarter Three Progress Report
January 2016 Public Board
LEAD
COO
DFBD
PROGRESS COMMENTARY
AS AT 30 SEPTEMBER 2015
A caseload zoning model has
been developed, based upon
levels of complexity and risk,
supported by a bespoke tool for
services to complete and adopt
for their own service line.
Following consultation with key
service leads, dates have been
set for the initial roll out. The
expectation is that caseload
zoning will be fully implemented
across the Trust ahead of the
target date.
Completed.
The Trust met all applicable
- 27 -
PROGRESS COMMENTARY
AS AT
31 DECEMBER 2015
The majority of services have
developed a draft caseload
zoning tool specific to their
service and these are now being
trialled within teams. The
feedback from teams has been
very positive.
RAG RATING
Green
Amber
Green
Green
The project remains on schedule
for full implementation by
31 March 2016.
Completed.
The Trust met all applicable
J
REF
ACTIONS
TARGET
DATE
LEAD
PROGRESS COMMENTARY
AS AT 30 SEPTEMBER 2015
Monitor standards, during the
period 1 July to 30 September
2015.
PROGRESS COMMENTARY
AS AT
31 DECEMBER 2015
Monitor standards, during the
period 1 October to
31 December 2015.
RAG RATING
PROGRESS COMMENTARY
AS AT
31 DECEMBER 2015
Completed. We were fully
involved in developing systemwide plans for winter escalation,
in line with the agreed
timescales.
RAG RATING
OTHER KEY ACTIONS
REF
2.8
ACTIONS
Work with local partner
organisations to ensure that
robust arrangements are in
place for winter escalation
TARGET
DATE
30 November
2015
LEAD
COO
PROGRESS COMMENTARY
AS AT 30 SEPTEMBER 2015
Representatives from the Trust
have attended a series of winter
planning workshops. The Trust
has been working with the local
authority to develop solutions to
help with the shortage of
domiciliary care provision and it
has been agreed that the local
authority will fund the Trust to
provide domiciliary care,
delivered by health care
assistants and rehabilitation
assistants.
It has been agreed that Taunton
and Somerset NHS Foundation
Trust and Yeovil District Hospital
NHS Foundation Trust will
second health care assistants to
Somerset Partnership, to support
the delivery of the home care
service over a 24 hour period.
2015/16 Business Action Plan Quarter Three Progress Report
January 2016 Public Board
- 28 -
We worked with partner
organisations over the summer
and autumn period to develop a
model for the provision of home
care, funded by the local
authority. That model was
implemented, designed to
provide care to people with newly
increased rehabilitation needs,
for a period of two weeks,
following initial assessment by
the local authority. The
outcomes for people discharged
from the service have been
good, resulting in people having
either reduced or no ongoing
Green
Green
J
The acute Trusts were also
aware that Somerset Partnership
had not been allocated any
designated funding to manage
winter pressures so have offered
to fund additional in-reach
support from their funding
allocation.
care needs. Escalation
arrangements over the
Christmas period resulted in
patients with more complex
needs being referred, with a
requirement for care lasting up to
four weeks, which has affected
capacity accordingly.
In agreement with Somerset
Clinical Commissioning Group,
17 escalation beds were opened
in community hospitals, to
accommodate patients who were
medically fit for discharge. This
has since been increased to 25
beds, with the aim of easing
pressures on the acute hospital
bed position.
2015/16 Business Action Plan Quarter Three Progress Report
January 2016 Public Board
- 29 -
J
STRATEGIC THEME
3. CULTURE AND PEOPLE
OBJECTIVE
Continuously improve staff confidence and pride in the Trust and its services.
LINKS
AF, CP, AP, SP
ANNUAL OBJECTIVE
Support managers and staff at all levels to monitor, evaluate and drive continuous improvement of
organisational culture, improving staff engagement levels.
REF
3.1
3.2
ACTIONS
TARGET
DATE
LEAD
Support managers and staff
at all levels to monitor,
evaluate and drive through
continuous improvement of
staff engagement and
empowerment and the
organisational culture
31 March 2016
CE / DW
Roll out the ‘Leading the
Health and Wellbeing of My
Team’ leadership module, to
31 March 2016
2015/16 Business Action Plan Quarter Three Progress Report
January 2016 Public Board
DW
PROGRESS COMMENTARY
AS AT 30 SEPTEMBER 2015
PROGRESS COMMENTARY
AS AT
31 DECEMBER 2015
Three staff engagement sessions The planned engagement
are planned for late August/early sessions did not occur as a
September 2015, as the start of
consequence of limited take up.
a new way of engaging directly
Improving engagement at all
with staff. The overall strategy
levels will be a focal point of the
for staff engagement will be
Organisational Development
taken forward by the Director of
strategy currently being
Human Resources and
developed.
Workforce Development, once
appointed, as part of the Trust’s
A range of initiatives helped to
Organisational Development
secure a significantly enhanced
strategy. The training and
level of response to this year’s
support of managers will be an
staff survey. A series of
important component of this
divisionally-based engagement
work.
events have been organised
across the Trust, the feedback
from which will help inform the
Organisational Development
strategy.
This module continues to be
A key component of the
delivered, in addition to resilience Organisational Development
training for staff. The module is
strategy will be health and
- 30 -
RAG RATING
Green
Amber
Green
Amber
J
REF
ACTIONS
TARGET
DATE
LEAD
help reduce levels of stress
and anxiety.
3.3
Develop an organisational
development strategy to
support the wider Trust
strategy and its values and
commitment to empower
and engage with staff at all
levels.
31 March 2016
2015/16 Business Action Plan Quarter Three Progress Report
January 2016 Public Board
DW
PROGRESS COMMENTARY
AS AT 30 SEPTEMBER 2015
PROGRESS COMMENTARY
AS AT
31 DECEMBER 2015
wellbeing, an integral element of
which will be measures to reduce
the evidence of stress-related
absence building on those
currently being delivered.
to be expanded to incorporate a
section on delivering the line
management responsibilities of
the Trust’s Absence Policy.
A Human Resources Business
Partner has been assigned to
provide additional support to
The work being undertaken by
managers in addressing sickness the aligned human resources
absence.
business partners, to provide
dedicated support to managers
in respect of addressing sickness
absence management issues
continues and has been well
received. Well@Work took over
the running of these workshops
in August 2015, since when four
workshops have been held.
Workshops are now being held
on a monthly basis.
The 2015 staff survey includes
In addition to the update outlined
questions about values,
in 3.1 above, a specific piece of
leadership and patient
work has been commissioned to
experience. This full census
explore the experiences of
survey will provide crucial
leaders within the organisation to
information around culture and
help inform development of the
will support the Director of
Leadership and wider
Workforce and Organisational
Organisational Development
Development in developing an
strategies. It is planned that
Organisational Development
feedback from the staff survey
strategy.
engagement events and the
leadership diagnostic will inform
the development of the draft
- 31 -
RAG RATING
Amber
Red
J
REF
3.4
3.5
ACTIONS
Focus on the development
of staff in bands 1 to 4
Develop an appropriate
means to measure
organisational culture as
part of the Organisation
Development Strategy
TARGET
DATE
31 March 2016
31 March 2016
2015/16 Business Action Plan Quarter Three Progress Report
January 2016 Public Board
LEAD
DW
DW
PROGRESS COMMENTARY
AS AT 30 SEPTEMBER 2015
A fifth cohort Level 5 Assistant
Practitioner Programme is due to
commence in October 2015 for
school nurses and staff working
in stroke services. New starters
in clinical roles are now
undertaking the care certificate.
Members of the Trust’s Learning
and Development team are
participating in local careers
events.
The action was previously
worded as follows:
“Develop a cultural barometer to
measure staff morale across the
Trust”
- 32 -
PROGRESS COMMENTARY
AS AT
31 DECEMBER 2015
organisational development
strategy, which will then be
subject to discussion and
presentation to the Trust Board
for approval.
It is proposed that the timescale
for this action be amended to
31 May 2016.
The Trust continues to work with
Health Education England (South
West) and local academic
institutions to promote
opportunities for apprenticeships
and other school leavers within
the Trust. The Care Certificate is
now fully embedded as the
foundation point for the
development of all new starters
in clinical roles. The roll out of
the Assistant Practitioner
programme continues with new
cohorts commencing in District
Nursing and Mental Health
services.
A range of key performance
indicators will be identified as
part of the development of the
Organisational Development
strategy. It is intended that these
will be monitored by a new
Workforce / Engagement
RAG RATING
Green
Amber
Green
Amber
J
REF
ACTIONS
TARGET
DATE
LEAD
PROGRESS COMMENTARY
AS AT 30 SEPTEMBER 2015
It is proposed that this action be
reworded as follows:
PROGRESS COMMENTARY
AS AT
31 DECEMBER 2015
Committee, reporting to the
Quality Assurance Committee.
RAG RATING
Develop an appropriate means to
measure organisational culture
as part of the Organisation
Development Strategy, with a
timescale for completion of
31 March 2016.
3.6
To develop a talent
management and
succession planning
strategy and plan to ensure
the Trust maximises the
potential of staff and
understands the ‘talent
pipeline’ within the
organisation
31 March 2016
DW
The Chief Executive has initiated
talent mapping work with the
Executive team. The Director of
Workforce and Organisational
Development will hold
discussions with the South West
Leadership Academy.
This work remains outstanding.
Work will be undertaken to
produce a strategy informed by
the direction of travel in respect
of Leadership Development and
discussions at a system level
where the potential benefits of
closer working in respect of such
issues are being explored.
Amber
Red
It is proposed that the timescale
for this action be amended to
31 July 2016.
ANNUAL OBJECTIVE
REF
3.7
Improve the physical and mental health and wellbeing of staff, reducing stress and stress related sickness
absence during 2015/16.
ACTIONS
Undertake action to improve
the physical and mental
TARGET
DATE
31 March 2016
2015/16 Business Action Plan Quarter Three Progress Report
January 2016 Public Board
LEAD
DW
PROGRESS COMMENTARY AS AT 31 DECEMBER 2015
The Trust has participated in
health checks for staff aged over
- 33 -
In addition to the update in 3.2
above, the Well@Work Service
RAG RATING
Green
Amber
J
REF
ACTIONS
TARGET
DATE
health and wellbeing of staff
LEAD
PROGRESS COMMENTARY AS AT 31 DECEMBER 2015
40, provided by Somerset County
Council. The Trust has launched
its ‘flu campaign and will offer
staff vouchers to take to local
providers to improve access to
the ‘flu vaccination.
The Well@work service
continues to provide support to
staff and access to counselling
and physiotherapy is also
available.
With the extension of the Optima
Occupational Health contract, the
Employee Assistance
Programme provider has
changed to Right Management.
The service offers confidential
advice and support to staff and
managers on a wide range of
work and personal issues and will
be promoted via the Trust’s staff
communication routes
2015/16 Business Action Plan Quarter Three Progress Report
January 2016 Public Board
- 34 -
continues to offer a range of
initiatives to support Health and
Wellbeing across the Trust.
Communications have been
issued to promote the services
currently available via Right
Management and additional
resources have been made
available to the team to help
facilitate the preventative activity
with which they are engaged,
such as the HSE Stress Audit.
Take up of the staff ‘flu
vaccinations was lower this year
than last, at 45.6%, but this
decline is in line with national
figures. Work will be undertaken
internally and with partners to
explore the rationael for this and
how participation may be
improved in the future.
The occupational health contract
is due for renewal in September
2016 and this provides an
opportunity to review current
occupational health support, the
associated work of the
Well@Work team and the links
between them.
RAG RATING
J
REF
3.8
3.9
ACTIONS
Review the findings
regarding the potential to
extend incentives for
employers who provide
effective NICE
recommended workplace
health programmes for
employees
Maintain and strengthen
flexible working
arrangements and support
for staff with unpaid caring
responsibilities
TARGET
DATE
31 December
2015
31 March 2016
2015/16 Business Action Plan Quarter Three Progress Report
January 2016 Public Board
LEAD
DW
DW
PROGRESS COMMENTARY AS AT 31 DECEMBER 2015
This will be undertaken by the
Director of Workforce and
Organisational Development,
following the release of the
findings.
Work to review and develop the
Trust’s existing arrangements will
be taken forward by the Director
of Workforce and Organisational
Development.
- 35 -
The recommendations of the
NICE ‘Workforce Health
Management Practices’
document published in June2015
will inform a review of
occupational health provision
ahead of the commencement of
the tendering process.
It is proposed that the timescale
for this action be amended to
31 July 2016.
This work is ongoing. A key part
of any recruitment and retention
initiatives will be maximising the
flexibility of staff rotas / patterns
to facilitate flexible working and
the employment of those with
dependent care responsibilities.
Although this work needs to be
balanced with the need to ensure
that we remain able to deliver
services cost effectively. In order
to offer greater flexibility to staff,
managers now have the
opportunity to offer 12 hour
shifts, where acceptable
operationally and where
personally requested.
RAG RATING
Red
Red
Green
Amber
J
OTHER KEY ACTIONS
REF
ACTIONS
3.10
Equality and Diversity:
Establish a Staff Forum of
Equality Champions to carry
out equality work across the
Trust
3.11
3.12
TARGET
DATE
30 June 2015
Equality and Diversity: Raise 30 September
awareness of the Trust
2015
Carer’s Charter and
translate into the top five
languages used by patients
and with easy read versions
made available
Equality and Diversity:
Implement the NHS
Workforce Race Equality
Standard
30 September
2015
LEAD
PROGRESS COMMENTARY
AS AT 30 SEPTEMBER 2015
DG
Completed.
DG
The forum is scheduled to have
its second meeting in October
2015 and will develop a mission
statement to be considered by
the Trust Board.
Completed.
DW
The PALS and Complaints
leaflets have also been
translated into these languages.
Completed.
The Trust reported against the
Workforce Race Equality
Standard on 1 July 2015 as
required, and will continue to do
so.
- 36 -
RAG RATING
Green
Green
Green
Green
Green
Green
Completed.
The Carers’ Charter has been
translated into five languages
and is available on the Trust
website.
Findings in respect of this
standard will be discussed at the
Trust’s Workforce Governance
2015/16 Business Action Plan Quarter Three Progress Report
January 2016 Public Board
PROGRESS COMMENTARY
AS AT
31 DECEMBER 2015
Completed.
Completed.
J
REF
3.13
3.14
3.15
3.16
ACTIONS
Equality and Diversity:
Implement the Accessible
Information Standard
Equality and Diversity:
Establish a database of
umbrella/third sector
agencies for each protected
characteristic and build
relationships with main
groups via the Voluntary
Sector Forum
Equality and Diversity:
Include protected
characteristics in core
assessment process in RiO
Undertake work to prepare
for the introduction of
nursing revalidation in April
2016
TARGET
DATE
31 March 2016
31 December
2015
31 March 2016
31 March 2016
2015/16 Business Action Plan Quarter Three Progress Report
January 2016 Public Board
LEAD
DG
DG
DFBD
DW /
DNPS
PROGRESS COMMENTARY
AS AT 30 SEPTEMBER 2015
Group, which will monitor any
necessary action plans.
RiO has been developed to
identify all protected
characteristics that can be used
to identify accessibility needs.
This work has commenced and
is being taken forward by the
Patient Advice and Liaison
service.
The functionality has been built
in the RiO test system.
Discussions were held at the
Trust’s Caldicott and Information
Governance Group on
4 September 2015. Work is
scheduled to be undertaken to
implement this onto the live RiO
system in October 2015.
The Nursing and Midwifery
Council has formally approved
revalidation arrangements, which
will commence from April 2016.
The workshop support
programme continues. A
- 37 -
PROGRESS COMMENTARY
AS AT
31 DECEMBER 2015
Information is being produced to
inform staff of the requirements
of the new duty. Work to include
all protected characteristics in
the core assessment process in
RiO remains on schedule to be
completed by 31 January 2016.
Completed.
This work has been completed
by the PALS service and will be
updated regularly.
Work to include all protected
characteristics in the core
assessment process in RiO
remains on schedule to be
completed by 31 January 2016.
The electronic portfolio has been
purchased, as planned, and is in
the process of being added to
the Learning Management
System.
RAG RATING
Green
Amber
Green
Green
Green
Amber
Green
Amber
J
REF
ACTIONS
TARGET
DATE
LEAD
PROGRESS COMMENTARY
AS AT 30 SEPTEMBER 2015
proposal to purchase an
electronic portfolio has been
approved by the Trust’s
Executive Team and a range of
providers will demonstrate their
programmes prior to a final
purchase being made. The
revalidation toolkit and templates
will be loaded onto the Trust’s
intranet site for staff to access
Progress on Nurse revalidation is
monitored by the Trust’s
Workforce Governance Group.
2015/16 Business Action Plan Quarter Three Progress Report
January 2016 Public Board
- 38 -
PROGRESS COMMENTARY
AS AT
31 DECEMBER 2015
Workshops have been arranged
for the first tranche of nursing
who need to revalidate. Further
workshops will be held until all
registered nurses have been
through the new process.
Workshops are also being
arranged for staff who will be
confirmers.
RAG RATING
J
STRATEGIC THEME
4. INTEGRATION
OBJECTIVE
Deliver the planned further integration of community health, mental health, learning disability, and social care
services to support better patient care and achieve identified financial efficiencies.
LINKS
AF, Int, AP, SP
ANNUAL OBJECTIVE Deliver the implementation plan for Phase II Integration by 31 March 2016.
REF
4.1
4.2
4.3
4.4
ACTIONS
Conclusion of IP2
consultation relating to
management restructuring,
with all key stakeholders
including staff, staff side
representatives, and Heads
of Division
Completion of the
consideration of the IP2
consultation on
management restructuring
Conclusion of IP2
consultation relating to
service redesign, with all
key stakeholders
Implementation of new
models of care and working
practices arising from IP2.
TARGET
DATE
8 May 2015
1 June 2015
1 July 2015
31 March 2016
2015/16 Business Action Plan Quarter Three Progress Report
January 2016 Public Board
LEAD
COO
COO
COO
COO
PROGRESS COMMENTARY
AS AT 30 SEPTEMBER 2015
Completed.
Completed.
PROGRESS COMMENTARY
AS AT
31 DECEMBER 2015
Completed.
RAG RATING
Green
Green
Green
Green
Green
Green
Green
Amber
Completed.
Completed.
Completed.
The implementation period is on
schedule to complete all of the
changes resulting from IP2, with
the exception of the 0-25 service
which has a longer development
- 39 -
The final sign off for the 0-25
service model is scheduled to be
completed by 31 January 2016,
with recruitment, selection and
appointment to be completed
J
REF
ACTIONS
TARGET
DATE
LEAD
PROGRESS COMMENTARY
AS AT 30 SEPTEMBER 2015
period and for which
implementation is scheduled for
April 2016.
4.5
As part of IP2, review skill
mix, efficiency and wider
integration cross the health
and social care community
31 March 2016
2015/16 Business Action Plan Quarter Three Progress Report
January 2016 Public Board
COO
The first of a series of skills mix
events took place in June 2015,
to plan the process of assessing
the workforce requirements of
the new teams and services.
Further events with the Heads of
Division are scheduled for July
2015 to take this work forward.
- 40 -
PROGRESS COMMENTARY
AS AT
31 DECEMBER 2015
during February and March
2016, ready for implementation
in April 2016.
RAG RATING
Risks remain in relation to the
strategic intentions of the local
authority, around the future of
integrated services and their
effects on child and adolescent
mental health service and
community mental health teams,
and we will continue to work with
the local authority to manage
these risks.
All skill mix review processes are
now complete for existing and
new services.
An assessment will be
undertaken of the impact on the
child and adolescent mental
health service and community
mental health teams, of the
establishment of the 0-25
service. This work will be
completed during the staff
identification and selection
process during February and
March 2016, and will encompass
a review of the impact of any
actions implemented by the local
authority actions in relation to
Green
Amber
J
REF
ACTIONS
TARGET
DATE
4.6
Front-line community-based
staff to spend 40% of their
time with patients
31 March 2016
4.7
Achieve productivity and
efficiency savings of
£5.5million
31 March 2016
2015/16 Business Action Plan Quarter Three Progress Report
January 2016 Public Board
LEAD
COO
COO
PROGRESS COMMENTARY
AS AT 30 SEPTEMBER 2015
The ‘Releasing Time to Care’
group has completed a pilot
project and is assessing the data
produced. The work of this
group has been identified as an
organisational priority and
additional executive and project
management support are now
committed. The Chief Operating
officer and Director of Nursing
and Patient Safety will attend the
group to drive forward the work
to free up the time of frontline
staff.
PROGRESS COMMENTARY
AS AT
31 DECEMBER 2015
integrated services.
The ‘Releasing Time to Care’
programme remains ongoing
and is very active.
Activities include:




caseload zoning
clinical review of RiO
Question Everything
review of the administration
function
Each of these initiatives is set to
have significant impact on
Releasing Time to Care, and a
repeat of the frontline
assessments is planned for early
in 2016/17, to assess the effect
of the improvements which have
been made. Thereafter, a culture
of continuous improvement will
need to be embedded within the
Trust to sustain these
improvements.
As at 30 September 2015 the IP2 As at 31 December 2015 the IP2
project was £90,000 ahead of its project was £514,000 behind its
financial target.
financial target. Pay savings are
in line with target, but savings in
respect of reduced cost of travel
and additional income are falling
short of plan.
- 41 -
RAG RATING
Green
Amber
Amber
Red
J
ANNUAL OBJECTIVE
REF
4.8
Work with partners to develop a sustainable health and social care system, delivering the Test and Learn
project milestones by 31 March 2016.
ACTIONS
Actively participate in Test
and Learn initiatives
TARGET
DATE
31 March 2016
LEAD
COO
PROGRESS COMMENTARY
AS AT 30 SEPTEMBER 2015
Achieved and ongoing.
The Trust is actively participating
in the three Local Implementation
Groups which are implementing
Test and Learn pilots. Work will
continue with partner
organisations to develop new
services.
PROGRESS COMMENTARY
AS AT
31 DECEMBER 2015
Achieved and ongoing.
We continue to participate in the
three Local Implementation
Groups. Examples of
developments in the Taunton
area include:



developing a ‘team around
the patient’, including
wellbeing advisors, Long
term condition practice
nurses, and care coordinators
all 14 general practices
participating, hosting staff
and referring patients
348 patients invited onto the
caseload, with 143 having
accepted, and 69 of whom
now have an escalation plan
The model is strongly supported
by stakeholders and plans are in
place to recruit a complex care
GP and a pharmacist, and for a
further 100 patients per month to
join the caseload.
2015/16 Business Action Plan Quarter Three Progress Report
January 2016 Public Board
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RAG RATING
Green
Green
J
STRATEGIC THEME
5. INNOVATION
OBJECTIVE
Implement the Information Management and Technology strategy to deliver effective mobile working and an
integrated patient record for all services.
LINKS
AF, SD, Inn, AP, SP
ANNUAL OBJECTIVE
Deliver the Information Management and Technology Strategy and achieve the milestones for enabling better
mobile working and integrated technology during 2015/16.
REF
5.1
ACTIONS
Implement agile working
across all of the Trust’s
locations
TARGET
DATE
31 March 2016
LEAD
DFBD
PROGRESS COMMENTARY
AS AT 30 SEPTEMBER 2015
A further 62 staff have been
identified for Phase 3 of the roll
out of devices. Around
1500 devices have been
purchased to date.
Firewalls, to enable video
conferencing to be used across
the network, are being installed.
This work is scheduled to be
completed by 31 December
2015.
PROGRESS COMMENTARY
AS AT
31 DECEMBER 2015
An Office Accommodation
project group has been
established and meetings have
been held. Actions have been
agreed with managers at a local
level and progress has been
made in releasing the
accommodation agreements for
Woodlands in Bridgwater and
Charter House in Yeovil. A desk
usage audit has been completed,
to inform future provision.
Improved car parking
arrangements are in place for
Mallard Court.
Firewalls, to enable video
conferencing to be used across
the network, have been installed
in 45 sites across the Trust.
2015/16 Business Action Plan Quarter Three Progress Report
January 2016 Public Board
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RAG RATING
Green
Amber
J
REF
5.2
ACTIONS
TARGET
DATE
Use Document Management 31 August
Systems such as
2015
SharePoint, to automate
workflow.
LEAD
DFBD
PROGRESS COMMENTARY
AS AT 30 SEPTEMBER 2015
This project has been delayed
due to an unfilled vacancy in the
Application Development team,
which is currently being
advertised.
It is proposed that the timescale
for this action be amended to
28 February 2016.
5.3
Implement E-messaging
within the district nursing
service
30 September
2015
DFBD
The Trust completed the
development of electronic
messaging for the district nursing
service, but full implementation
across general practices was
delayed, pending the receipt of
authorisation from the Local
Medical Committee and
Somerset Clinical
Commissioning Group, which
was received on 28 September
2015.
It is proposed that the timescale
2015/16 Business Action Plan Quarter Three Progress Report
January 2016 Public Board
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PROGRESS COMMENTARY
AS AT
31 DECEMBER 2015
Further sites in Bridgwater, and
Foundation House in Taunton, at
which the installations are more
complex, are scheduled to be
completed by 28 February 2016.
The Trust’s Application
Development Team is currently
piloting the Sensenet electronic
Document Management System,
to assess its effectiveness.
Work to take forward the
automation of workflow for the
Workforce and Organisational
Development directorate will
follow a review of the
arrangements which are in place
in other Trusts locally.
Completed.
E-messaging arrangements have
been implemented within the
District Nursing service to enable
discharge summaries which have
been written by nurses to be sent
automatically.
RAG RATING
Green
Amber
Green
Green
J
REF
ACTIONS
TARGET
DATE
LEAD
PROGRESS COMMENTARY
AS AT 30 SEPTEMBER 2015
PROGRESS COMMENTARY
AS AT
31 DECEMBER 2015
RAG RATING
for this action be amended to
30 November 2015.
ANNUAL OBJECTIVE Identify, invest in and promote good practice and innovation from within our Trust.
REF
5.4
ACTIONS
TARGET
DATE
Proactively seek out and
embed innovation and good
practice, from within and
outside the organisation.
31 March 2016
LEAD
All
PROGRESS COMMENTARY
AS AT 30 SEPTEMBER 2015
The contract with NHS
Innovation South West has been
signed. A Trust Innovation
Steering Group has been
established and two schemes
have been identified for support.
The Trust has requested support
from South West Directors of
Human Resources to benchmark
instances of bullying and
harassment. The Trust is also
involved in a pan-Somerset
group looking at developing coordinated approaches to
recruitment.
5.5
Continue to develop the
Trust’s arrangements for
research and strengthen
31 March 2016
2015/16 Business Action Plan Quarter Three Progress Report
January 2016 Public Board
DNPS
The Trust recruited 119
participants to National Institute
for Health Research portfolio
- 45 -
PROGRESS COMMENTARY
AS AT
31 DECEMBER 2015
During the quarter, the Trust’s
Innovations Board has been
relaunched, with the involvement
of NHS Innovations, and closer
links to the Academic Health
Sciences Network. Other
examples of the implementation
of good practice and innovation
during the quarter include:

work to develop ‘Open
Dialogue’ arrangements in
the South Somerset area, as
part of the 0-25 years care
pathway
 participation in a pilot centred
on raising awareness of
mental health in schools in
Somerset.
The Trust recruited 168
participants to National Institute
for Health Research portfolio
RAG RATING
Green
Amber
Green
Amber
J
REF
ACTIONS
TARGET
DATE
LEAD
academic links.
PROGRESS COMMENTARY
AS AT 30 SEPTEMBER 2015
studies in Quarters 1 and 2.
The Trust’s Head of Research
and Clinical Effectiveness has
been invited to be part of the
Strategic Executive Group of the
South West Peninsula
Collaboration for Leadership in
Applied Health Research and
Care (PenCLAHRC).
5.6
Commission a review of the
30 June 2015
2015/16 Business Action Plan Quarter Three Progress Report
January 2016 Public Board
DNPS
The Trust recently entered into
an agreement with Taunton and
Somerset NHS Foundation Trust
and Yeovil District Hospital NHS
Foundation Trust to work
collaboratively on dementia
research (and other specialty
areas in due course), which will
increase the likelihood of
Somerset being chosen as a site
for Clinical Trials Involving
Investigational Medicinal
Products (CTIMPs) and
dementia studies that span the
patient pathway. The CRN: SWP
is supporting this collaborative
approach by funding an Assistant
Psychologist (Band 4) post for 12
months to work across all three
Trusts.
Completed.
- 46 -
PROGRESS COMMENTARY
AS AT
31 DECEMBER 2015
studies in Quarters 1, 2 and 3.
RAG RATING
A Consultant Physiotherapist and
a Clinical Specialist
Physiotherapist, sponsored by
the Trust, have been awarded a
research project grant of £50,000
by the Physiotherapy Research
Foundation, to conduct a
qualitative study into “What
matters most to clients in
physiotherapy consultations?”
The Trust’s Research Seminar,
held in October 2015, was
attended by 47 delegates, taking
the combined total number of
delegates attending the two
Research Seminars held in
2015/16 to 90. This compares to
a total of 74 delegates in
2014/15.
Completed.
Green
Green
J
REF
ACTIONS
TARGET
DATE
LEAD
Trust’s arrangements for
identifying and promoting
innovation
5.7
Lead in developing a culture
which engages staff at all
levels in playing a full role in
the service redesign and
transformation across the
Trust and in their immediate
working environment
31 March 2016
2015/16 Business Action Plan Quarter Three Progress Report
January 2016 Public Board
COO
PROGRESS COMMENTARY
AS AT 30 SEPTEMBER 2015
NHS Innovation South West has
been commissioned to support
the Trust. A Trust Innovation
Steering Group has been
established and two initial
schemes have been identified for
support. Links have been
established with the Academic
Health Sciences Network
Innovation Lead.
The management restructure for
the Trust’s IP2 project has been
completed, following extensive
engagement with staff. Staff at
all levels of the organisation have
been involved in the identification
of initiatives to redesign
processes across services in
order to release time to care.
Staff have also been engaged in
the design team for the new
integrated teams being
established across the Trust.
Further redesign of services,
including the 24-hour crisis
service, is being undertaken,
again involving staff at all levels.
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PROGRESS COMMENTARY
AS AT
31 DECEMBER 2015
Building on the work undertaken
during the Phase II Integration
process, staff are actively being
engaged in a range of initiatives
to redesign services and improve
the working environment
including the design,
development and implementation
of caseload zoning
arrangements, identifying
opportunities to release time to
care, and implementing agile
working arrangements across the
Trust.
RAG RATING
Green
Amber
J
STRATEGIC THEME
6. VIABILITY AND GROWTH
OBJECTIVE
Increase the Trust's operating income by £30 million.
LINKS
AF, VG, AP, SP
ANNUAL OBJECTIVE Deliver an operational surplus of £0.25 million.
REF
6.1
6.2
ACTIONS
Deliver an operational
surplus of £0.25 million.
Deliver the Trust Cost
Improvement Plan and
release savings of
£7.4 million.
TARGET
DATE
31 March 2016
31 March 2016
2015/16 Business Action Plan Quarter Three Progress Report
January 2016 Public Board
LEAD
DFBD
DFBD
PROGRESS COMMENTARY
AS AT 30 SEPTEMBER 2015
As at 30 September 2015, the
Trust’s overall financial position
showed an adverse variance of
£549,000. The Trust has been
developing a recovery plan with
a view to achieving a break-even
position for the year.
As at 30 September 2015 the
Trust’s cost improvement plan
showed an adverse variance of
£258,000 against the original
plan of £7.4million. During the
year the cost improvement
programme was increased by
£0.2m in order to fund changes
to inpatient establishments. The
variance against the revised
target is £310,000. Discussions
in respect of this shortfall are
integral to the financial recovery
- 48 -
PROGRESS COMMENTARY
AS AT
31 DECEMBER 2015
As at 31 December 2015, the
Trust’s overall financial position
showed an adverse variance of
£1,199,000. It is unlikely that the
Trust will achieve a break-even
position by the end of the year,
but is acting to minimise the
deficit.
As at 31 December 2015 the
Trust’s cost improvement plan
showed an adverse variance of
£604,000 against the original
plan of £7.4million. During the
year the cost improvement
programme was increased by
£0.2m in order to fund changes
to inpatient establishments. The
variance against the revised
target is £709,000.
The Trust is considering a range
RAG RATING
Amber
Red
Amber
Red
J
REF
ACTIONS
TARGET
DATE
LEAD
PROGRESS COMMENTARY
AS AT 30 SEPTEMBER 2015
plan.
PROGRESS COMMENTARY
AS AT
31 DECEMBER 2015
of options to support those
elements of the plan that are
falling short of target.
RAG RATING
ANNUAL OBJECTIVE Increase the Trust’s income from newly commissioned business by £2 million.
REF
6.3
ACTIONS
TARGET
DATE
Increase the Trust’s income
from newly commissioned
business by £2 million.
31 March 2016
LEAD
DFBD
PROGRESS COMMENTARY
AS AT 30 SEPTEMBER 2015
The Trust has been successful
with a number of opportunities
which include newly
commissioned services or
expansions of existing services.
This has provided approximately
£200,000 of additional new
income for the Trust, delivering a
year to date total for new and
expanded commissioned
business of around £1.5 million.
PROGRESS COMMENTARY
AS AT
31 DECEMBER 2015
The Trust has been successful in
respect of further opportunities,
comprising newly commissioned
services or expansions to the
services.
These include:


These include:


2015/16 Business Action Plan Quarter Three Progress Report
January 2016 Public Board

Healthy Weight and Physical
Activity for Somerset, for
Somerset County Council
Position of Any Qualified
Provider for the provision of
intermediate oral surgery for
NHS England (Wessex)
- 49 -
RAG RATING
Community Health
Improvement Services
(Dynamic Purchasing
System)
Somerset Sexual Health and
Contraceptive Services
Provision of an all-age oral
health promotion service for
children and young people
and adults at increased risk
of poor oral health
This has provided an additional
£1.9 million of new business,
Green
Green
J
REF
ACTIONS
TARGET
DATE
LEAD
PROGRESS COMMENTARY
AS AT 30 SEPTEMBER 2015

6.4
Develop a marketing
strategy for the Trust to
support the future
development of the Trust in
response to changes in the
NHS and changing
demands of patients, the
wider community and
commissioners.
31 July 2015
2015/16 Business Action Plan Quarter Three Progress Report
January 2016 Public Board
DFBD
Child and Adolescent Mental
Health Services and Schools
Link programme
PROGRESS COMMENTARY
AS AT
31 DECEMBER 2015
which brings the year to date
total to £3.26 million.
The Trust is also awaiting the
outcome of a number of further
opportunities which include
newly commissioned and
expanded services.
Completed. The outline strategy The move towards Outcomes
was presented to the Trust Board Based Commissioning requires
in July 2015.
us to continue to develop our
strategy in line with the emerging
requirements for this process.
In view of the announcement by
Somerset Clinical
It is unlikely that further
Commissioning Group of the
developments will change the
intention to proceed with
fundamental strategy of the Trust
Outcomes Based
Commissioning, the strategy has to remain as a countywide
leading provider of community
focused on how this will impact
and mental health services.
the future development of the
Updates will be presented to the
Trust. An updated strategy
Trust Board at future meetings.
document reflecting this has
been developed and will be
presented to a future meeting of
the Trust Board.
- 50 -
RAG RATING
Green
Green
J
OTHER KEY ACTIONS
REF
6.5
6.6
6.7
6.8
6.9
6.10
ACTIONS
Agreement of contracts for
2015/16 with Somerset
Clinical Commissioning
Group, NHS England,
Somerset County Council
and other commissioning
organisations.
Prepare and submit the
Trust’s plans for 2015/16, in
line with Monitor
requirements.
Submission of the Trust’s
final accounts for 2014/15.
Publication of the Trust’s
annual review for 2014/15.
Publication of the Trust’s
quality account for 2014/15.
TARGET
DATE
31 May 2015
30 June 2015
LEAD
DFBD
DFBD
PROGRESS COMMENTARY
AS AT 30 SEPTEMBER 2015
Completed.
Completed.
PROGRESS COMMENTARY
AS AT
31 DECEMBER 2015
Completed.
DFBD
Completed.
Completed.
31 October
2015
DG
Completed.
Completed.
DG
Copies of the annual review for
2014/15 have been shared with
key stakeholders and staff and
have been made available to
attendees of the Trust’s Annual
Members’ Meeting.
Completed.
Work with local partner
31 March 2016
organisations to develop
arrangements for the local
implementation of Outcomes
Based Commissioning
2015/16 Business Action Plan Quarter Three Progress Report
January 2016 Public Board
DFBD
Green
Green
Green
Green
Green
Green
Green
Green
Green
Green
Green
Amber
Completed.
31 May 2015
30 June 2015
RAG RATING
Discussions have been held with
key local provider and
commissioning organisations in
relation to the plan for Outcomes
Based Commissioning. Meetings
- 51 -
Completed.
The Trust continues to play an
active role in the development of
local arrangements to move
towards Outcomes Based
Commissioning.
J
REF
6.11
ACTIONS
Prepare and submit the
Trust’s draft operational plan
for 2016/17, in line with
Monitor requirements.
TARGET
DATE
8 February
2016
2015/16 Business Action Plan Quarter Three Progress Report
January 2016 Public Board
LEAD
DFBD
PROGRESS COMMENTARY
AS AT 30 SEPTEMBER 2015
have also been held with third
sector organisations to examine
the potential for working in
partnership within the Outcomes
Based Commissioning context
across Somerset
New action for Quarter 3
- 52 -
PROGRESS COMMENTARY
AS AT
31 DECEMBER 2015
A ‘Somerset Together’
Collaborative Working Workshop
is due to be held in February
2016.
Work has commenced on the
production of the Trust’s
operational plan for 2016/17,
informed by the outputs of
engagement events held as part
of the Trust’s planning cycle.
Guidance on the development of
operational plans was issued by
Monitor on 13 January 2016.
RAG RATING
Green
Amber
J
Links to Strategic
Themes:
Links to the
Assurance
Framework:
Links to the NHS
Constitution and Trust
Values:
Links to CQC
Domains:
Quality and Safety
X
Innovation
X
Viability and Growth
X
Integration
X
Service Delivery
X
Culture and
People
X
Relates to the following risks on the Trust’s Assurance
Framework:

relates to all risks on the Assurance Framework.
Working together for
patients
Respect and dignity
X
Compassion
X
X
Improving lives
X
Commitment to quality
of care
X
Everyone
counts
X
Is it safe?
X
Is it caring?
X
Is it well-led?
X
Is it effective?
X
Is it responsive to people’s needs?
Public/Staff
Involvement History:
X
The Annual Plan is developed followed extensive involvement
of staff, partnership organisations and Governors.
The quarterly action plan is monitored by the Strategy and
Planning Group of the Council of Governors.
Legal or statutory
implications/
No additional legal or statutory implications/requirements
have been identified.
requirements:
Previous
Consideration:
The progress report is presented to the Board on a quarterly
basis.
2015/16 Business Action Plan Quarter Three Progress Report
January 2016 Public Board
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