Special Measures Action Plan. Norfolk and Suffolk NHS Foundation Trust

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1 Special Measures Action Plan Norfolk and Suffolk NHS Foundation Trust June 2015 KEY Delivered On Track to deliver Some issues narrative disclosure Not on track to deliver 1

2 Norfolk and Suffolk NHS Foundation Trust - Our improvement plan & our progress Background and summary of actions Norfolk and Suffolk NHS Foundation Trust provides mental health services across the two counties. We also provide services people with learning disabilities in Suffolk and services people with substance misuse problems in Norfolk, We employ c.4000 staff and provide services from over 40 sites. Following a 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. Of the five areas that the CQC assessed, the Trust was rated as inadequate safe and well-led. The Trust also commissioned an independent board permance review in 2014 which highlighted important development areas and these m part of our action plan under the well-led domain. The Trust was rated by CQC as requiring improvement in the areas of responsive and effective and was rated as good caring. Following the initial inspection feedback, the Trust immediately addressed the urgent actions. These included concerns about the safety of some of our inpatient areas where the inspection identified risks of points where ligatures could be attached. These have all been addressed by physical changes to the wards or by changing nursing practice. When we received the inspection report in February 2015 we developed a Quality Improvement Plan (QIP). This plan addresses all of the 39 recommendations from the CQC inspection report, but we recognised that our approach to quality needed to go further and to raise standards across the whole Trust not only in those areas that were inspected. The Trust also needs to provide services on a sound and sustainable financial footing and so the QIP work is integrated with the Trust s financial recovery plan. The QIP is supported by over 40 work plans. In the next section of this progress report you can read more about the changes we are making. We recognise that we need support to implement the QIP. As part of being in special measures we have the support of an Improvement Director (Alan Yates) and a Buddy Trust, Nottinghamshire NHS Foundation Trust, who we will work with to incorporate learning and share best practice. 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 to the Board of Directors at each meeting. 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 We intend to make the changes required to improve quality and to be out of special measures in The decision will be made by Monitor based on a further CQC inspection, the date of which is not yet decided. 2

3 Who is responsible? Norfolk and Suffolk NHS Foundation Trust - Our improvement plan & our progress The Quality Improvement Plan was approved by the Board of Directors at its February 2015 meeting. The Board is responsible ensuring that the required changes are made. Our Chief Executive, Michael Scott chairs the weekly 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 leads on each action. 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 ensure delivery of the improvements and oversee the of the action plan overleaf. Should you require any further inmation on this role please contact specialmeasures@monitor.gov.uk Ultimately, our success in implementing the recommendations of the Quality Improvement Plan will be assessed by the Chief Inspector of Hospitals, upon re-inspection of our Trust. If you have any questions about how we re doing, contact richard.ellis@nsft.nhs.uk How we will communicate our progress to you We will update this progress report every month while we are in special measures. There will be regular updates on NHS Choices and subsequent longer term actions may be included as part of a continuous process of improvement. More detailed reports will also be published as part of our board of directors and board of governors reports at Chair / Chief Executive Approval (on behalf of the Board): Chair Name: Gary Page Signature: Date:11/6/15 Chief Executive Name: Michael Scott cc Andrew Hopkins Signature: Date:11/6/15 3

4 Norfolk and Suffolk NHS Foundation Trust - Our improvement plan (1) Urgent Actions Environment (1) Urgent action needed to ensure that the physical environment is safe including removing ligature risks and mitigating the risks where there are poor lines of sight. March 2016 Where it has been possible to undertake Immediate remedies, these have taken place. Other changes to the Trust estate require considerable investment or building changes and this work is planned to be complete by March 2016 and the risk is managed by increased monitoring / or changing the use of the building. Environment (2) Changes to mixed sex accommodation to promote privacy and dignity including access to female only communal spaces. March 2016 Immediate actions have been completed. Other areas that will require building work and investment are ongoing. The timescale has theree been changed to reflect that work. Restrictive Interventions Improve seclusion facilities and use of restraint. Buddy Trust to be asked to provide support on best practice in use of restrictive interventions. The seclusion policy has been ratified and implemented. It is monitored weekly, with monthly data reports to the permance review group. The new Preventing and Managing Aggression syllabus has commenced which will be targeted at high risk areas and in place by September 15 4

5 Norfolk and Suffolk NHS Foundation Trust - Our improvement plan (2) Urgent Actions Staffing Ensure that there are sufficient staff at all times to meet patient needs. Additional work on community caseload management to be completed by Sept This includes introduction of the Flexible Assertive Community Treatment model. This model ensures that service users are assertively managed to promote recovery and avoid dropping out of services. While the action plan is on track, recruitment challenges impact on the ability to recruit substantive staff. Medication Processes Medication to be stored, administered, recorded and disposed of safely. While the processes are in place, there are still areas of concern with the outcomes, particularly with community teams or where teams are waiting new equipment. It is still however planned evidence to show compliance with policy by Sept 15 Well-Led Staff Engagemen t (1) Ensure that staff understand and own the refreshed vision and values of the Trust. October 2015 External consultancy engaged from February 2015 The Putting people First programme of listening events /workshops staff and service users commenced on the 18 th May. All staff and service users to be encouraged to attend and contribute to this process Revised vision and values to board in October 15 5

6 Norfolk and Suffolk NHS Foundation Trust - Our improvement plan (3) Urgent Actions Well-Led Staff Engagement (2) Improved visibility board in Trust / engagement. In place and ongoing Buddy Trust support on sharing best practice in staff engagement Director programme of team visits in place Regular staff presentations to the board on what it is like to work NSFT. Well-Led Governance Ensure that the arrangements holding the organisation to account the delivery of strategy function effectively with clear and reliable systems of control and assurance. May 2015 Operating model to be approved by the Board of Directors on Delivered and evidence in board minutes Check and review internal control systems Following agreement of the model, further actions are planned to ensure that control systems are functioning Well-Led Board Oversight of Quality Committee structure and reporting arrangements to be streamlined with clarity on non-executive / executive roles. April 2015 Buddy Trust support on sharing best practice in board governance Board structure approved by the Board of Directors on The workplan will be discussed and agreed by the end of June to agree workplan is June outcomes to be monitored prior to external reassessment in December 2015 December 2015 Non executive directors who chair committees will report outcomes to board Responsive Access to Services (1) Review inpatient and crisis provision to ensure that local people have access to the services they need. -Review of Tier 4 beds young people -Contractual negotiations to review services March 2016 Discussions with commissioners are ongoing. Plans to provide additional tier 4 beds are on track. 6

7 Norfolk and Suffolk NHS Foundation Trust - Our improvement plan (4) Urgent Actions Responsive Access to Services (2) Review unallocated community cases and ensure there is a care coordinator. increase in staffing Increase in community staffing from June 2015 is planned but there remain some recruitment difficulties although the Trust is working extremely hard to attract new staff. The unallocated cases May has shown a decrease and all of the MAY milestones have been met. Implementation of the Flexible Assertive Community Treatment Model in West Norfolk has yet to be complete because of recruitment challenges. This may affect the scheduled delivery by sept15. Responsive Inmation about Services Ensure that people have access to inmation about services in the right mat. May 2015 An inmation leaflet and poster in local languages and easy-read has now been printed but distribution has not yet taken place. This will now be in place by the end of June. Monitoring the use of interpreters and translation services August 2015 A analysis of take up will go to the Equality and Diversity Group which will monitor the usage of interpreters and translation services by locality / service and provide feedback to localities. Effective Risk Assessment and Care Planning Ensure that all risk assessments and care plans are up to date in line with multi-disciplinary reviews. Monitoring compliance with the standard via Lorenzo reporting May 2015 Documentation process is now complete. Following the completion of process, monthly audits of compliance will be reported. These audits will commence in July 2015 following the delay in Lorenzo 7

8 Norfolk and Suffolk NHS Foundation Trust - Our improvement plan (5) Urgent Actions Effective Accurate Clinical Records Effective Mental Health Act records Improve arrangements maintaining, storing, and accessing records out of hours. Was April 2015 Supported via national agreement Lorenzo has now been implemented and read only access is available to legacy systems. Support staff to embed the system In place and ongoing On site floorwalking Webex sessions Intranet site containing supporting material Ensure proper procedures followed detention under the MHA and S.17 leave. and Ongoing monitoring Process of reporting bi-monthly to the Law Forum. Effective Training, Supervision and Appraisal Ensure that staff receive regular supervision, appraisals and training. Training templates have been simplified and launched from April Appraisals now at 75%. Practice educators to be appointed in teams from June Supervision and appraisal meetings to identify specialist training needs by. Caring Recovery Strengthen involvement of service users and carers in their care and in service development. Implementation plan to be launched in May 2015 Buddy Trust assistance in devising plans. The launch of the strategy and plan has been delayed. This is now planned the end of June. launch, June 2015 Revised date June

9 Norfolk and Suffolk NHS Foundation Trust - How our progress is being monitored and supported Oversight and improvement action Agreed Timescale Implementation Action owner Progress An Improvement Director has been appointed by Monitor, Alan Yates. Appointed February 2015 Monitor Completed and evidenced A Buddy Trust has been approached with a view to taking on this role from May Nottinghamshire NHS Foundation Trust has been appointed from 1 st May May 2015 Monitor Completed and evidenced Project Management Office team appointed. April 2015 NSFT Completed and evidenced Weekly PMO meetings to track progress. April 2015 onwards NSFT COMPLETE Monthly progress reports to the Board of Directors. April 2015 onwards NSFT COMPLETE Monthly stakeholder progress review meetings dates set to December March 2015 onwards NSFT COMPLETE Monthly updates of this improvement plan published on NHS Choices website. April 2015 onwards NSFT COMPLETE 9