SOMERSET PARTNERSHIP NHS FOUNDATION TRUST BUSINESS ACTION PLAN 2015/16 AND PROGRESS REPORT FOR 1 APRIL 2015 TO 30 JUNE PDF Free Download

SOMERSET PARTNERSHIP NHS FOUNDATION TRUST BUSINESS ACTION PLAN 2015/16 AND PROGRESS REPORT FOR 1 APRIL 2015 TO 30 JUNE 2015 Sponsoring Director: Author: Purpose of the report: Key Issues and Recommendations: Director of Finance and Business Development. Associate Director Strategic Planning and Performance. 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. 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; 2015/16 Business Action Plan July 2015 Public Board - 1 -

priorities identified by staff and professional groups across the Trust as part of the annual business planning cycle. The Plan also reflects the strategic and annual objectives, outlined in the Trust s Assurance Framework. The draft Business Action Plan for 2015/16 was presented to the Trust Board at its away day on 16 June 2015 and has subsequently been updated as follows: the strategic and annual objectives have been aligned with those set out in the Trust s Assurance Framework; as requested by the Board, Action number 3.7 has been added in relation to talent management and succession planning. Progress against the 60 actions contained within the plan was as follows: Achieved: 8 Ongoing: 51 Unlikely to be met: 1 The action which is assessed as unlikely to be met is: action 1.3: Extend the use of the Triangle of Care by implementing the approach in all community mental health services: 70% of staff in identified services to have Triangle of Care awareness training. Triangle of Care training has commenced but has recently been paused, to help enable staff to be fully engaged in the Trust s Phase II Integration process. Training will recommence in full as the new models of care are embedded. It is proposed that the compliance rate associated with this action be revised to 50% by 31 March, and subsequently to 90% by 31 March 2017. Actions required by the Board: The Board is asked to: approve the Business Action Plan for 2015/16; note the Business Action Plan quarter 1 progress report; agree the proposal to revise the compliance standard to be achieved in relation to Triangle of Care training. 2015/16 Business Action Plan July 2015 Public Board - 2 -

BUSINESS ACTION PLAN 2015/16 2015/16 Business Action Plan July 2015 Public Board - 3 -

Introduction This Business Action Plan for 2015/16 spans the period from 1 April 2015 to 30 June 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 60 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. 2015/16 Business Action Plan July 2015 Public Board - 4 -

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. 2015/16 Business Action Plan July 2015 Public Board - 5 -

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 The values of the Trust are consistent with those of the wider NHS: VALUES Working together for patients Respect and Dignity Commitment to quality of care Compassion Improving lives Everyone counts 2015/16 Business Action Plan July 2015 Public Board - 6 -

Key to initials: CE DNPS COO DFBD MD DG DHR Chief Executive Director of Nursing and Patient Safety Chief Operating Officer Director of Finance and Business Development Medical Director Director of Governance and Corporate Development Director of Human Resources and Workforce Development 2015/16 Business Action Plan July 2015 Public Board - 7 -

Somerset Partnership NHS Foundation Trust has adopted a double Red / / (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 Achieved. Work is in progress, in line with the target date. Initial work has commenced, appropriate to the target date. Red Work has commenced but the target date is unlikely to be met. Red Red Not achieved by the target date. 2015/16 Business Action Plan July 2015 Public Board - 8 -

STRATEGIC THEME OBJECTIVE LINKS 1. QUALITY AND SAFETY Continuously reduce levels of avoidable harm, deliver best clinical outcomes and improve patient experience. 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 ACTIONS TARGET 1.1 Undertake six-monthly reviews of nursing establishment levels. 31 August 2015 and 28 February LEAD DNPS ANNUAL OBJECTIVE Implement the targets in our Quality Improvement Plan for 2015/16, reducing avoidable harm and improving patient experience. REF ACTIONS TARGET LEAD 1.2 Strengthen the Trust s arrangements for engaging patients, carers and communities in quality improvement 31 March DG 1.3 Extend the use of the Triangle of Care by implementing the approach in all community mental health services: 70% of staff in identified services to have Triangle of Care awareness training 1.4 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 COO 31 March DNPS 2015/16 Business Action Plan July 2015 Public Board - 9 -

REF ACTIONS TARGET LEAD 1.5 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 COO 1.6 Enhance leadership engagement, promote Board level and senior management engagement with patient safety and the Sign Up to Safety programme 1.7 Achieve a 10% reduction in unplanned transfer where physical deterioration was not recognised, escalated or treated appropriately for three hours or more 1.8 Reduce harm from catheter associated urinary tract infections by assessment and timely removal of non-clinically indicated devices 31 March DNPS 31 March COO 31 March DNPS 1.9 Reduce the levels of harm from incidents of violence and aggression per 1,000 bed days by 10% 31 March COO 1.10 Reduce the use of restraint incidents per 1,000 bed days by 10% 31 March COO 1.11 Achieve all standards relating to the framework for commissioning for quality and innovation (CQUIN). 31 March DFBD 1.12 Meet all compliance requirements of the Care Quality Commission and other regulatory and statutory bodies 31 March DG 2015/16 Business Action Plan July 2015 Public Board - 10 -

ANNUAL OBJECTIVE 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. REF ACTIONS TARGET 2.5 Implement Caseload Zoning to ensure that the needs of patients on community caseloads are met most effectively 31 March 2.6 Meet all Monitor Risk Assessment Framework standards. 31 March LEAD COO DFBD 2015/16 Business Action Plan July 2015 Public Board - 12 -

STRATEGIC THEME OBJECTIVE LINKS 3. CULTURE AND PEOPLE Continuously improve staff confidence and pride in the Trust and its services. 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 ACTIONS TARGET 3.1 Support managers and staff at all levels to monitor, evaluate and drive through continuous improvement of staff 31 March engagement and empowerment and the organisational culture 3.2 Roll out the Leading the Health and Wellbeing of My Team leadership module, to help reduce levels of stress and anxiety 31 March 3.3 Hold engagement events to respond to issues identified in the national staff survey for 2014 30 September 2015 3.4 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 3.5 Focus on the development of staff in bands 1 to 4 31 March 3.6 Develop a cultural barometer to measure staff morale across the Trust 30 September 2015 3.7 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 LEAD CE / DHR DHR DHR DHR DHR DHR DHR 2015/16 Business Action Plan July 2015 Public Board - 13 -

ANNUAL OBJECTIVE Improve the physical and mental health and wellbeing of staff, reducing stress and stress related sickness absence during 2015/16. REF ACTIONS TARGET 3.8 Undertake action to improve the physical and mental health and wellbeing of staff 31 March LEAD DHR 3.9 Review the findings regarding the potential to extend incentives for employers who provide effective NICE recommended workplace health programmes for employees 31 December 2015 DHR 3.10 Maintain and strengthen flexible working arrangements and support for staff with unpaid caring responsibilities 31 March DHR OTHER KEY ACTIONS REF ACTIONS TARGET LEAD 3.11 Equality and Diversity: Establish a Staff Forum of Equality Champions to carry out equality work across the Trust 30 June 2015 DG 3.12 Equality and Diversity: Raise awareness of the Trust Carer s Charter and translate into the top five languages used by patients and with easy read versions made available 30 September 2015 3.13 Equality and Diversity: Implement the NHS Workforce Race Equality Standard 30 September 2015 DG DHR 2015/16 Business Action Plan July 2015 Public Board - 14 -

REF ACTIONS TARGET 3.14 Equality and Diversity: Implement the Accessible Information Standard 31 March LEAD DG 3.15 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 31 December 2015 DG 3.16 Equality and Diversity: Include protected characteristics in core assessment process in RiO 31 March 3.17 Undertake work to prepare for the introduction of nursing revalidation in April 31 March DFBD DHR / DNPS 2015/16 Business Action Plan July 2015 Public Board - 15 -

STRATEGIC THEME STRATEGIC OBJECTIVE LINKS 4. INTEGRATION 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. AF, Int, AP, SP ANNUAL OBJECTIVE Deliver the implementation plan for Phase II Integration by 31 March. REF ACTIONS TARGET LEAD 4.1 Conclusion of IP2 consultation with all key stakeholders including staff, staff side representatives, and Heads of Division 1 June 2015 COO 4.2 Completion of the consideration of the IP2 consultation on management restructuring 1 July 2015 COO 4.3 Conclusion of IP2 consultation relating to service redesign, with all key stakeholders 31 July 2015 COO 4.4 Completion of the consideration of the IP2 consultation on service redesign 31 August 2015 4.5 Implementation of new models of care and working practices arising from IP2. 31 December 2015 4.6 As part of IP2, review skill mix, efficiency and wider integration cross the health and social care community 31 March 4.7 Front-line staff to spend 40% of their time with patients 31 March COO COO COO COO 2015/16 Business Action Plan July 2015 Public Board - 16 -

REF ACTIONS TARGET 4.8 Achieve productivity and efficiency savings of 5.5million 31 March LEAD COO ANNUAL OBJECTIVE Work with partners to develop a sustainable health and social care system, delivering the Test and Learn project milestones by 31 March. REF ACTIONS TARGET 4.9 Actively participate in Test and Learn initiatives 31 March LEAD COO 2015/16 Business Action Plan July 2015 Public Board - 17 -

REF ACTIONS TARGET 5.5 Continue to develop the Trust s arrangements for research and strengthen academic links. 31 March LEAD DNPS 5.6 Commission a review of the Trust s arrangements for identifying and promoting innovation 30 June 2015 DNPS 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 COO 2015/16 Business Action Plan July 2015 Public Board - 19 -

STRATEGIC THEME OBJECTIVE LINKS 6. VIABILITY AND GROWTH Increase the Trust's operating income by 30 million. AF, VG, AP, SP ANNUAL OBJECTIVE Deliver an operational surplus of 0.25 million. REF ACTIONS TARGET 6.1 Deliver an operational surplus of 0.25 million. 31 March 6.2 Deliver the Trust Cost Improvement Plan and release savings of 7.4 million. 31 March LEAD DFBD DFBD ANNUAL OBJECTIVE Increase the Trust s income from newly commissioned business by 2 million. REF ACTIONS TARGET 6.3 Increase the Trust s income from newly commissioned business by 2 million. 31 March LEAD DFBD 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 DFBD 2015/16 Business Action Plan July 2015 Public Board - 20 -

OTHER KEY ACTIONS REF ACTIONS TARGET 6.5 Agreement of contracts for 2015/16 with Somerset Clinical Commissioning Group, NHS England, Somerset County Council and other commissioning organisations. LEAD 31 May 2015 DFBD 6.6 Prepare and submit the Trust s plans for 2015/16, in line with Monitor requirements. 30 June 2015 DFBD 6.7 Submission of the Trust s final accounts for 2014/15. 31 May 2015 DFBD 6.8 Publication of the Trust s annual review for 2014/15. 31 October 2015 DG 6.9 Publication of the Trust s quality account for 2014/15. 30 June 2015 DG 2015/16 Business Action Plan July 2015 Public Board - 21 -

BUSINESS ACTION PLAN 2015/16 PROGRESS REPORT FOR 1 APRIL TO 30 JUNE 2015 July 2015 Public Board - 1 -

STRATEGIC THEME OBJECTIVE LINKS 1. QUALITY AND SAFETY Continuously reduce levels of avoidable harm, deliver best clinical outcomes and improve patient experience. 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 ACTIONS TARGET 1.1 Undertake six-monthly 31 August reviews of nursing 2015 and 28 establishment levels. February LEAD PROGRESS COMMENTARY AS AT 30 JUNE 2015 RAG RATING DNPS Reports on nursing establishment levels are provided monthly to the Trust Board. The Trust Board received and approved the first sixmonthly formal review of nurse staffing levels in May 2015. ANNUAL OBJECTIVE Implement the targets in our Quality Improvement Plan for 2015/16, reducing avoidable harm and improving patient experience. REF ACTIONS TARGET LEAD PROGRESS COMMENTARY AS AT 30 JUNE 2015 RAG RATING 1.2 Strengthen the Trust s arrangements for engaging patients, carers and 31 March DG Workshop sessions were held as part of the Trust s Service and Team Managers Away Day on 22 June 2015, on the theme of Patient and Carer Involvement, in order to support managers with for a service user co-ordinator, based within the Trust s Operational directorate, to support volunteers and develop arrangements relating to patient engagement. A revised and up-dated strategy for communities in quality the engagement of patients, carers and communities in quality improvement improvement. Work is being undertaken to develop a job description July 2015 Public Board - 7 -

REF ACTIONS TARGET 1.3 Extend the use of the Triangle of Care by implementing the approach in all community mental health services: 70% of staff in identified services to have Triangle of Care awareness training K LEAD PROGRESS COMMENTARY AS AT 30 JUNE 2015 RAG RATING communications and patient and public involvement is scheduled to be presented to the Trust Board in July 2015. 31 March COO Triangle of Care training began to be being rolled out to teams across the Trust during the first quarter of 2015/16. Triangle of Care Training has recently been paused, to help enable staff to be fully engaged in the Trust s Phase II Integration process. The training programme will recommence in full as the new models of care are embedded. It is proposed that the compliance rate associated with this action be revised to 50% by 31 March, and subsequently to 90% by 31 March 2017. Red 1.4 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 DNPS Somerset Partnership is actively engaged with the Mental Health learning sets of the Patient Safety Collaborative programme. Quality Improvement Plans and Driver Diagrams relating to the five pledges have been produced, approved by the Trust s Clinical Governance Group, and submitted to the national Sign up to Safety programme team. 1.5 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 COO The Trust continues to contribute actively, and to support the development of the countywide multi-agency Crisis Care Concordat action plan, particularly in relation to access to 24hr crisis and home treatment services and the reduction of admissions to the healthbased Place of Safety under Section 136 of the Mental Health Act. July 2015 Public Board - 8 -

REF ACTIONS TARGET 1.6 Enhance leadership engagement, promote Board level and senior management engagement with patient safety and the Sign Up to Safety programme 1.7 Achieve a 10% reduction in unplanned transfer where physical deterioration was not recognised, escalated or treated appropriately for three hours or more 1.8 Reduce harm from catheter associated urinary tract infections by assessment and timely removal of nonclinically indicated devices 1.9 Reduce the levels of harm from incidents of violence and aggression per 1,000 bed days by 10% 1.10 Reduce the use of restraint incidents per 1,000 bed days by 10% July 2015 Public Board - 9 - K LEAD PROGRESS COMMENTARY AS AT 30 JUNE 2015 RAG RATING 31 March DNPS The Trust s programme of Patient Safety walk rounds, with Boardlevel representation, continues in all of the Trust s inpatient areas, in accordance with the planned schedule. Resulting action plans are produced and submitted to Heads of Division for implementation and monitoring. 31 March COO Baseline data has been collected during the first quarter of 2015/16 and is being validated. Following validation, a trajectory will be set, culminating in a 10% reduction in the rate, to be achieved by 31 March. 31 March DNPS Following a successful pilot at Burnham on Sea community hospital, the urinary catheter free hospital pilot has now been rolled out to ten of the remaining community hospitals managed by the Trust. Bridgwater and Dene Barton community hospitals commenced the pilot during Quarter 1 and are being supported by the Trust s Infection Prevention and Control team. 31 March COO During the period from 1 April to 30 June 2015, a total of 27 incidents of violence and aggression by patients to patients were recorded, equating to a rate of 0.82 incidents per 1000 bed days. This compares to a total of 59 incidents recorded during the corresponding period in the previous year (1.75 incidents per 1000 bed days). This represents a reduction of 53% in the rate per 1000 bed days during the first quarter. 31 March COO During the period from 1 April to 30 June 2015, a total of 72 incidents of restraint were recorded, equating to a rate of 2.82 incidents per 1000 bed days. This compares to a total of 95 incidents recorded during the corresponding period in the previous year (2.18 incidents per 1000

REF ACTIONS TARGET LEAD PROGRESS COMMENTARY AS AT 30 JUNE 2015 RAG RATING bed days). This represents a reduction of 23% in the rate per 1000 bed days during the first quarter. 1.11 Achieve all standards relating to the framework for commissioning for quality and innovation (CQUIN). 1.12 Meet all compliance requirements of the Care Quality Commission and other regulatory and statutory bodies 31 March DFBD As at 30 June 2015, the Trust had achieved all of its CQUIN standards, with the exception of the requirement for reductions in the incidence of pressure ulcers relating to community hospital inpatients, for which the latest data available was as at 31 May 2015. The Trust s Tissue Viability team is offering bespoke support and education to all relevant teams. The rate of avoidable pressure ulcer incidence improved in the Trust s community hospital inpatient settings between April and May 2015. 31 March DG Achieved as at 30 June 2015. The Trust has no areas of non-compliance. The Care Quality Commission s Intelligent Monitoring Report for June 2015 shows that there were no areas of elevated risk for the Trust. Two areas of risk identified within the report related to: potential under-reporting of patient safety incidents patients who die following injury or self-harm within three days of being admitted to acute hospital beds. The Trust will be subject to a planned full Care Quality Commission inspection, which is scheduled to take place in September 2015. The Trust continues to maintain its Governance rating with Monitor. July 2015 Public Board - 10 -

STRATEGIC THEME OBJECTIVE LINKS 2. SERVICE DELIVERY Achieve a reduction in inpatient based care and an increase in the delivery of care in a community-based setting. AF, SD, AP, SP ANNUAL OBJECTIVE Reduce the aggregate average length of stay in community hospitals to 21 days and achieve 85% bed occupancy, to preserve annual levels of inpatient admissions to the Trust s community hospitals between 2015/16 and 2018/19. REF ACTIONS TARGET 2.1 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. 2.2 Reduce the percentage of community hospital bed days lost due to delayed discharges 2.3 In partnership with Somerset Clinical Commissioning Group and other key stakeholders, review the role and capacity July 2015 Public Board - 11 - LEAD PROGRESS COMMENTARY AS AT 30 JUNE 2015 RAG RATING 31 March COO As at 30 June 2015, the cumulative average length of stay in the Trust s community hospitals in 2015/16 was 21.7 days and the cumulative bed occupancy rate was 88.9%. A total of 921 patients had been discharged from the Trust s community hospitals during that time, against a plan for the year to date of 925 patients. 31 March COO During the period 1 April to 30 June 2015, 5.0% of community hospital bed days were lost due to delayed discharges. This represents an improvement on the rate of 8.4% in the corresponding period in 2014. 31 March COO The Trust remains actively engaged in the Somerset Clinical Commissioning Group-led review, Making the Most of Community Services. Following the presentation to the Governing Body of Somerset Clinical Commissioning Group on 19 November 2014, the Clinical Commissioning Group recommended that Local Implementation Groups in Somerset consider, between December

REF ACTIONS TARGET requirements for community hospitals and mental health inpatient wards. 2.4 Expand ambulatory care in community hospital settings K LEAD PROGRESS COMMENTARY AS AT 30 JUNE 2015 RAG RATING 2014 and July 2015, how the proposed service model could be implemented most effectively within their areas. Patients, carers and the public will be formally consulted on the proposals from July to October 2015, with a final recommendation to be taken to the meeting of the Clinical Commissioning Group s Governing Body by November 2015. 31 March COO The Trust s Ambulatory Care Service has clinics established in Bridgwater, Burnham on Sea, Crewkerne, Frome, Minehead and Taunton, providing a service to patients in community hospitals and also in their own homes. Activity currently stands at around 400 appointments per month. ANNUAL OBJECTIVE 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. REF ACTIONS TARGET LEAD PROGRESS COMMENTARY AS AT 30 JUNE 2015 RAG RATING 2.5 Implement Caseload Zoning to ensure that the needs of patients on 31 March COO The implementation of Caseload Zoning is being taken forward through the Phase II Integration programme and forms part of the work of the Time to Care Task and Finish Group. The group will community caseloads are consider different approaches to caseload zoning and will assess a met most effectively range of tools for implementation. 2.6 Meet all Monitor Risk Assessment Framework standards. Project capacity is being identified, to support the implementation process through to 31 March. 31 March DFBD Achieved. The Trust met all applicable Monitor standards, during the period 1 April to 30 June 2015. July 2015 Public Board - 12 -

STRATEGIC THEME OBJECTIVE LINKS 3. CULTURE AND PEOPLE Continuously improve staff confidence and pride in the Trust and its services. 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 ACTIONS TARGET 3.1 Support managers and staff at all levels to monitor, evaluate and drive through continuous improvement of staff engagement and empowerment and the organisational culture 3.2 Roll out the Leading the Health and Wellbeing of My Team leadership module, to help reduce levels of stress and anxiety 3.3 Hold engagement events to respond to issues identified in the national staff survey for 2014 31 March CE / DHR LEAD PROGRESS COMMENTARY AS AT 30 JUNE 2015 RAG RATING Three staff engagement sessions are planned for late August/early September 2015, as the start of a new way of engaging directly with staff. The overall strategy for staff engagement will be taken forward by the Director of Human Resources and Workforce Development, once appointed, as part of the Trust s Organisational Development strategy. The training and support of managers will be an important component of this work. 31 March DHR This module is being delivered and is ongoing. The Workforce and Human Resources directorate is undertaking a further review of teams which continue to have high rates of sickness/absence. Work is also being undertaken with operational managers to develop plans, tailored to meet individual needs to ensure a return to work, to minimise and remove avoidable delays, and to review different ways to help people to cope with stress. 30 September 2015 DHR Three engagement events are planned to be held across the county, in Bridgwater, Yeovil, and in the Mendip area. July 2015 Public Board - 13 -

REF ACTIONS TARGET 3.4 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. 3.5 Focus on the development of staff in bands 1 to 4 3.6 Develop a cultural barometer to measure staff morale across the Trust 3.7 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 July 2015 Public Board - 14 - K LEAD PROGRESS COMMENTARY AS AT 30 JUNE 2015 RAG RATING 31 March DHR Initial work has been undertaken and will be taken forward by the Director of Human Resources and Workforce Development, once appointed. 31 March DHR The Trust has a number of apprentices in non-clinical roles and supports the development of existing clinical and non-clinical staff through the Qualifications and Credit Framework, levels 2 and 3. The Trust is developing Assistant Practitioners through a level 5 Qualifications and Credit Framework Apprenticeship and is working with Health Education South West to spread best practice. 30 September 2015 DHR The Trust is also working with local education providers to encourage school and college learners to consider careers in the NHS and to access workplace experience. The Trust s Chief Executive has signed the Talent for Care pledge, supporting the development of staff in Bands 1-4 and encouraging staff to progress to professional registration. The Care Certificate is now a mandatory requirement for all newly appointed clinical staff in support roles. The Trust will use a cultural barometer for staff within services commissioned by NHS England, and has discussed the use of the King s Fund survey with JMSCC. 31 March DHR The Trust s Interim Director of Human Resources and Workforce Development will meet with the South West Leadership Academy to commence this work.

ANNUAL OBJECTIVE Improve the physical and mental health and wellbeing of staff, reducing stress and stress related sickness absence during 2015/16. REF ACTIONS TARGET LEAD PROGRESS COMMENTARY AS AT 30 JUNE 2015 RAG RATING 3.8 Undertake action to improve the physical and mental 31 March DHR The Trust has launched health checks, for staff aged over 40. The Trust will undertake a review of its Well@work service and its health and wellbeing of staff Occupational Health provision. This will be taken forward by the Director of Human Resources and Workforce Development, once 3.9 Review the findings regarding the potential to extend incentives for employers who provide effective NICE recommended workplace health programmes for employees 3.10 Maintain and strengthen flexible working arrangements and support for staff with unpaid caring responsibilities 31 December 2015 DHR appointed. This will be undertaken by the Director of Human Resources and Workforce Development, once appointed. 31 March DHR Work to review and develop the Trust s existing arrangements will be taken forward by the Director of Human Resources and Workforce Development, once appointed. July 2015 Public Board - 15 -

OTHER KEY ACTIONS REF ACTIONS TARGET LEAD PROGRESS COMMENTARY AS AT 30 JUNE 2015 RAG RATING 3.11 Equality and Diversity: Establish a Staff Forum of 30 June 2015 DG Achieved. Equality Champions to carry out equality work across the Trust The forum has been established and is scheduled to meet on 16 July 2015. 3.12 Equality and Diversity: Raise awareness of the Trust Carer s Charter and 30 September 2015 DG This remains on schedule. The Carers Charter will be publicised at the annual carers conference in July 2015. A list of corporate leaflets and top five languages has been drafted. translate into the top five languages used by patients and with easy read versions made available 3.13 Equality and Diversity: Implement the NHS Workforce Race Equality Standard 3.14 Equality and Diversity: Implement the Accessible Information Standard 3.15 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 3.16 Equality and Diversity: Include protected characteristics in core 30 September 2015 DHR July 2015 Public Board - 16 - The Trust remains on course to report against this standard as required on 1 July 2015, and will continue to do so as it moves towards full implementation by 30 September 2015. 31 March DG RiO development work is ongoing. A subgroup of the RiO Development Group will meet in July 2015 to progress this further. 31 December 2015 DG The project is scheduled to begin in August/September 2015, following the commencement in post of the Trust s new PALS officer. 31 March DFBD All protected characteristics are on RiO, except for transgender, in respect of which work is ongoing. The Trust s Clinical Systems team is developing the new RiO 7 functionality to provide a privacy tab on

REF ACTIONS TARGET assessment process in RiO 3.17 Undertake work to prepare for the introduction of nursing revalidation in April 31 March DHR / DNPS K LEAD PROGRESS COMMENTARY AS AT 30 JUNE 2015 RAG RATING the system for each client record, showing protected characteristics and staff access to the record. The Trust s Nurse Validation group continues to meet on a regular basis to progress the preparatory arrangements. A workshop has taken place for the first cohort of nurses who will undertake the new validation process. Plans are being taken forward, to have a pilot revalidation cohort later in the year. Work is also being taken forward, exploring how the new Learning Management System could support staff with the collection of evidence. July 2015 Public Board - 17 -

STRATEGIC THEME OBJECTIVE LINKS 4. INTEGRATION 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. AF, Int, AP, SP ANNUAL OBJECTIVE Deliver the implementation plan for Phase II Integration by 31 March. REF ACTIONS TARGET LEAD PROGRESS COMMENTARY AS AT 30 JUNE 2015 RAG RATING 4.1 Conclusion of IP2 consultation relating to management restructuring, 1 June 2015 COO Achieved. The consultation relating to management restructuring was with all key stakeholders including staff, staff side representatives, and Heads of Division completed successfully and on schedule. The Trust was commended by staff-side representatives for its inclusive approach to engagement and consultation. 4.2 Completion of the 1 July 2015 COO Achieved. consideration of the IP2 consultation on management restructuring 4.3 Conclusion of IP2 31 July 2015 COO The consultation process in respect of service redesign has consultation relating to commenced and remains on schedule to conclude by 31 July 2015. service redesign, with all key stakeholders 4.4 Completion of the consideration of the IP2 consultation on service redesign 4.5 Implementation of new models of care and working 31 August 2015 31 December 2015 COO COO July 2015 Public Board - 18 - This remains on schedule. The consideration of findings relating to service redesign will commence following the conclusion of the consultation period. This remains on schedule for implementation, following the conclusion of the consultation process and the consideration of

REF ACTIONS TARGET practices arising from IP2. 4.6 As part of IP2, review skill mix, efficiency and wider integration cross the health and social care community 4.7 Front-line staff to spend 40% of their time with patients 4.8 Achieve productivity and efficiency savings of 5.5million K LEAD PROGRESS COMMENTARY AS AT 30 JUNE 2015 RAG RATING feedback. The implementation process will run from 1 September to 31 December 2015. 31 March 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. 31 March COO Work is progressing through the Time to Care Task and Finish Group. A project support post has been agreed to help teams implement the productive community series approach and to begin identifying areas of duplication and reducing the burden of bureaucracy. 31 March COO The achievement of productivity and efficiency savings remains on target. Projected savings are to be monitored by IP2 Project Director and Finance Director. ANNUAL OBJECTIVE Work with partners to develop a sustainable health and social care system, delivering the Test and Learn project milestones by 31 March. REF ACTIONS TARGET LEAD PROGRESS COMMENTARY AS AT 30 JUNE 2015 RAG RATING 4.9 Actively participate in Test and Learn initiatives 31 March COO The Trust continues to be actively engaged in the work of the four Local Implementation Groups in Somerset. The Local Implementation Groups are focused on the delivery of Test and Learn pilots, delivering more patient-centred, joined-up care for people with long term conditions, facilitating closer working within organisations involved at all stages of the patient care pathway. July 2015 Public Board - 19 -

STRATEGIC THEME OBJECTIVE LINKS 5. INNOVATION Implement the Information Management and Technology strategy to deliver effective mobile working and an integrated patient record for all services. 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 ACTIONS TARGET LEAD PROGRESS COMMENTARY AS AT 30 JUNE 2015 RAG RATING 5.1 Implement agile working across all of the Trust s locations 31 March DFBD The Trust s Information Technology team is progressing agile working arrangements, as part of the Phase II Integration programme. A total of 1300 devices had been distributed by 31 May 2015, and work continues, to replace older laptops systematically during 2015/16. 5.2 Use Document Management Systems such as SharePoint, to automate workflow. 5.3 Implement E-messaging within the district nursing service 31 August 2015 30 September 2015 DFBD DFBD The new Follow Me printing system was implemented in June 2015. New firewalls, to be installed during 2015, will enable video conferencing to be used across the network. Pilot arrangements are being taken forward in the Trust s Information Management and Technology department. The Decisions product is being used with SenseNet to develop an electronic Document Management System in August 2015. The Trust has completed the development of electronic messaging, in relation to the District Nursing caseload. Somerset Clinical Commissioning Group has informed the Trust that the EMIS system is unable to receive e-messages. Further work is temporarily on hold, pending a solution being found for EMIS. July 2015 Public Board - 20 -

ANNUAL OBJECTIVE Identify, invest in and promote good practice and innovation from within our Trust. REF ACTIONS TARGET LEAD PROGRESS COMMENTARY AS AT 30 JUNE 2015 RAG RATING 5.4 Proactively seek out and embed innovation and good practice, from within and outside the organisation. 31 March All A workshop involving the chairs of all of the Trust s Best Practice Groups, developed improved arrangements for monitoring and reporting, and established arrangements for two annual meetings to be held, to identify key priorities and share best practice. These revised arrangements have been approved by the Trust s Clinical Governance Group. A draft contract with NHS Innovation South West is currently under consideration, with a view to providing a specialist support programme. The IP2 Task and Finish Groups have all considered national and international models of care in their service redesign recommendations. These are due for implementation from September 2015 and will represent innovative new ways of working across a range of service areas. 5.5 Continue to develop the Trust s arrangements for research and strengthen academic links. The Interim Director of Human Resources and Workforce Development has developed performance dashboards for Divisions with key workforce metrics and is undertaking a workforce analysis. The Interim Director of Human Resources and Workforce Development is also attending the South West and NHS Provider networks to support the introduction of good practice in Human Resources. 31 March DNPS The Trust had a positive annual review for 2014/15 with the National Institute for Health Research Clinical Research Network: South West Peninsula, as well as successful negotiation of network funding for 2015/16. Continuation of funding for the Stroke Research Nurse has been agreed with the League of Friends of South Petherton Hospital. The Trust held a productive research seminar in April 2015, with key note speaker Jos Latour, Professor of Nursing at Plymouth July 2015 Public Board - 21 -

REF ACTIONS TARGET 5.6 Commission a review of the 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 K LEAD PROGRESS COMMENTARY AS AT 30 JUNE 2015 RAG RATING University. STEPWISE, a healthy lifestyle interventional study for patients on antipsychotic medication has commenced in Taunton. 30 June 2015 DNPS The Trust is currently reviewing options for identifying and promoting innovation, and has held discussions around the scope to develop areas identified through the Trust s Compendium of Good Practice and other examples of innovation put forward by teams from across the Trust. A draft contract with NHS Innovation South West is currently under consideration, with a view to providing a specialist support programme. 31 March COO An ongoing series of staff listening events is planned, with directorlevel attendance and leadership. Proposals are being developed for all managers to undertake a 360-degree appraisal process, with a view to strengthening all aspects of management skills, including staff engagement. Arrangements are also being taken forward, to develop a new, facilitated Managers Club, as part of developing a new leadership culture within operational services. The Trust s Phase II Integration processes are based upon principles of staff engagement, and proposals have been modified and improved in response to staff advice and feedback. July 2015 Public Board - 22 -

STRATEGIC THEME OBJECTIVE LINKS 6. VIABILITY AND GROWTH Increase the Trust's operating income by 30 million. AF, VG, AP, SP ANNUAL OBJECTIVE Deliver an operational surplus of 0.25 million. REF ACTIONS TARGET LEAD PROGRESS COMMENTARY AS AT 30 JUNE 2015 RAG RATING 6.1 Deliver an operational surplus of 0.25 million. 31 March DFBD As at 30 June 2015, the Trust s overall financial position showed an adverse variance of 128,000 compared to plan. Meetings have been held with all Directors and Heads of Division to review the position and to agree actions to be implemented in order to redress the variance. The forecast outturn position for the year remains a 6.2 Deliver the Trust Cost Improvement Plan and release savings of 7.4 million. surplus of 0.25 million. 31 March DFBD As at 30 June 2015 the Trust s cost improvement plan showed an adverse variance of 127,000 compared to plan. This issue has been subject to discussion as part of reviewing the wider financial position, and the Trust expects to achieve the overall planned level of savings of 7.4 million by 31 March. ANNUAL OBJECTIVE Increase the Trust s income from newly commissioned business by 2 million. REF ACTIONS TARGET LEAD PROGRESS COMMENTARY AS AT 30 JUNE 2015 RAG RATING 6.3 Increase the Trust s income 31 March DFBD The Trust has been successful in winning the following newly from newly commissioned commissioned business since 1 April 2015, which provides business by 2 million. approximately 1.3 million worth of additional income: July 2015 Public Board - 23 -