Report to the Meeting of the Oxford Health NHS Foundation Trust

Board of Directors

29 November 2017

Progress report against the Quality Account Priorities and Objectives for 2017/18

Executive SummaryThe following report provides a 6 month summary of progress against each of the 23 quality objectives identified in the Quality Account for 2017/18. The report has been compiled with input from a wide range of staff across the trust.

The objectives are organised around four priorities; Quality priority 1: Improve staff retention and engagement Quality priority 2: Improve the experiences of patients and their families and carers Quality priority 3: Increase harm free care Quality priority 4: Promote health and wellbeing of patients

This 6 month position is being shared for discussion and information before being presented to the Trust Board in November 2017. In December 2017 the final version will be shared with external stakeholders.

Significant progress has been made against a number of the objectives. There are some objectives where there is a risk that the impact of the actions being taken will not be achieved in year, these are;

Quality priority 1: Improve staff retention and engagemento Seeing the impact of actions around retention on turnover/ vacancies (1.1)o Seeing the impact of work to better prevent and support staff to manage stress (1.2)

Quality priority 4: Promote health and wellbeing of patientso Seeing the impact of improving physical healthcare for mental health patients (4.1)o Developing diabetes care (4.2)

The full year end position will be published in May/ June 2018 following discussion and agreement by the Audit Committee, Quality Committee and Trust Board.

Governance Route/Approval ProcessThe information has been shared with the Extended Executive Team members before being presented to the committee.

Strategic ObjectivesThis report relates to or provides assurance and evidence against the following Strategic Objective(s) of the Trust;

1) Driving Quality Improvement(Goals: patients will be safe from harm; patients will achieve the clinical outcomes they want; and patients and carers will have an excellent experience)

3) Delivering Innovation, Learning and Teaching

1

BOD 147/2017(Agenda item:8)

(Goals: the impact of the AHSN, AHSC and CLAHRC will be maximised; we will collaborate in research and innovation; and we will deliver high quality teaching)

4) Developing Our Business through Collaboration and Partnerships(Goals: we will work in collaborative partnerships; we will maintain and grow our services where we add value; and we will have strong relationship with our stakeholders)

5) Developing Leadership, People and Culture(Goals: staff satisfaction will be in the top 20% of Trusts nationally; our staff and teams will be high-performing; and we will recruit and retain an excellent workforce)

6) Getting the most out of Technology(Goals: our patients and staff will have the right technology available; our workforce will have the necessary IT skills to do their jobs well; and an outstanding IT service will be delivered)

RecommendationMembers are asked to note the work carried out to date against the quality objectives, and areas of risk where objectives are unlikely to be completed by year end, 31st March 2017.

Author and Title: Jane Kershaw, Head of Quality GovernanceLead Executive Director: Ros Alstead, Director of Nursing and Clinical Standards

1. A risk assessment has been undertaken around the legal issues that this report presents and there are no issues that need to be referred to the Trust Solicitors.

2. This report satisfies or provides assurance and evidence against the requirements of the following Terms of Reference of the Committee (please delete as appropriate):

to oversee the effective development of the Trust’s corporate and clinical governance arrangements;

to ensure that there is an objective and systematic approach to the identification and assessment of risk and delivery of the organisation’s priorities in the context of all national standards;

to critically review and recommend to the board, and to receive annual progress reports where applicable on, the following strategies and programmes: risk management; workforce, training and education; patient and carer experience, including complaints and PALS; quality, including safety and harm reduction, incident reporting and management, clinical audit; leadership; quality improvement; safety of the physical estate; and compliance with national requirements and standards including CQC, NICE, NHSLA;

to ensure that workforce planning, education and training are fully integrated into the integrated governance framework, ensuring a workforce fit for purpose;

to agree and monitor the work of the quality sub-committees and review, through their annual reporting, their performance and effectiveness within the integrated governance framework;

2

Quality priority 1: Improve staff retention and engagement

Priority Objective Progress after 6 months Any delays or risks Key measures1.1 Focus on retention of existing staff

There are significant staff shortages across England, with demand for services and demands on staff increasing. Given this national situation and to address our own local context we are working with our system partners through workforce groups to develop shared strategies and areas of focus.

Recruitment and retention are identified as an extreme risk on the Trust wide risk register and Board assurance framework. The key risks identified are; i) pressures on staff having an adverse effect on morale with the possible impact of increased stress related sickness/ difficulties in retaining; ii) unable to achieve required recruitment of staff to substantive posts which may result in increased usage of agency staff and inability to fill emergency shifts; iii) not sufficiently promoting and supporting the well-being of staff which may lead to a reduction in staff morale, increase sickness and loss of reputation.

In November 2016 a leadership seminar was held with senior operational and clinical staff to gather their questions and ideas of how to address the retention and recruitment challenges. The Trust then developed and agreed our local priorities and objectives identified in a workforce strategy.

From July 2017 a fortnightly recruitment and retention working group was set up chaired by the Director of HR, and including the Chief Executive, Chief Operating Officer, Heads of Nursing and Service Directors to maintain a focus on actions. Below is detail of some of the initiatives which have been taken.

In addition a new Oxford School of Nursing and Midwifery was formally launched in June 2017 through a unique partnership between Oxford Brookes University, OUH and OH, under the umbrella of the Oxford Academic Health Science Centre. It has been developed in response to a unique period of change in the professions of nursing and midwifery including the changes to funding and bursaries related to nursing and midwifery education. Against this backdrop Oxford Brookes, along with healthcare partners in Oxfordshire responsible for educating and employing nurses and midwives, wanted to maximise the opportunity to increase collaborative working and change the model of nursing education and research in Oxford. The purpose of the School is to create a joint University and Trust environment, and by offering a model of education, research and clinical practice we hope to better attract and retain nurses and midwives.

The initiatives in recruitment include: Regular contact with the student qualifying in our area, this includes senior

staff going in to the university to teach and talk to student about their career choices. We also run a career day on the Whiteleaf centre for all students, where we run sessions on interviewing techniques and offer them interviews for our vacant post.

We run permanent adverts on NHS jobs, and have identified a careers office in the reception area of the hospital which will be operational at the end of the year; this will encourage local people in and give us the opportunity for an early face to face conversation with prospective employees.

We are about to commence a trial with a recruitment agency for them to assist us with finding substantive staff.

The trust has implemented a new initiative offering a financial incentive for agency workers to move from the agency to our internal bank, which

A number of actions have and are being taken and the situation is reviewed regularly. However the actions have not yet shown a reduction in turnover or vacancies.

i. Reduce turnover (workforce strategy target is reduce to 13.5% by Dec 2018)

ii. Coordinated plan to identify talent and support success planning (workforce strategy)

iii. Reduce vacancies (workforce strategy target is under 600 vacancies by June 2018)

VacancyThe vacancy rate has decreased slightly to 11.32% in September from 11.62% in August 2017. The long-term increase in the Trust vacancy rate is driven by the growing shortfall in registered nursing staff, most particularly bands 5 and 6.

TurnoverThe Turnover figure remains unchanged at 14.94% in September 2017. Slight declines in the Children and Young People and Adult directorates were offset by increases in Corporate and Older Peoples.

The Trust turnover rate is being driven by a long-term increase in turnover in the medical and registered nursing staff groups.

The main reasons for leaving are: Career development (40% of leavers in September) Not specified (40% of leavers in September)

3

Priority Objective Progress after 6 months Any delays or risks Key measuresprovides us with more assurance around quality and consistency.

‘Refer a friend’ initiative In November 2017 we are commencing a new programme for third year

students with Bedfordshire University, They will have a senior Nurse (8a and above) assigned as their mentor for the year, they will meet with them on a bi-monthly basis to discuss their experiences and career choices, on the alternative months we will put on a variety of talks and professional interest groups.

Looking at ways to reduce the hire time of candidates Better promote career pathways to enhance attraction

The initiatives in retention include: Improving the pay for staff employed through the internal bank We have an existing 1 year long preceptorship programme for newly qualified

staff of all professions, to support and encourage staff towards development within the Trust.

In response to the staff survey earlier this year, the directorates commenced a programme of open dialogue meetings with all staff teams, to understand the challenges and explore solutions to both local and trust-wide challenges. These meeting have been well attended and appreciated from staff.

NHS Improvement has asked the Trust to participate in a programme with several other NHS Trusts aimed at sharing best practice and examining new strategies to retain staff. This commences in October 2017.

1.2 Develop how we support staff to be able to manage stress

A new steering group is being established to develop how staff are supported to manage and prevent stress, the group has met twice. The group is using the HSE standards on stress management to identify actions to focus on prevention of stress and building staff resilience. The group is still at an early stage and has not yet identified specific areas for action.

A number of actions are being taken and the situation is reviewed regularly. However the actions have not yet shown a reduction in turnover or vacancies.

i. Reduction in sickness relating to stressii. Prevention work around stress management

iii. Staff feedback

1.3 To review and enhance the channels of communication across the Trust

The focus is to review and develop the internal communication methods for sharing learning with staff from incidents, deaths, complaints and patient feedback etc...

An analysis is being completed on what profession of staff, at what banding, from which services and geographies reads the weekly communication email, attends the linking leader/ senior conferences against staff experiences in the 2016 national survey. The outcome of this will be used to start looking at how to better target communications by considering the method to use, reason for the communication e.g. for information, action or discussion, and which staff group the communication is aimed at. Potential to use ‘Staff engage’ module offered as part of the e-rostering software.

There have been delays however the year end objective is still achievable.

i. Complete review and develop a communication plan initially focused on information from the N&CG department as a trial

4

Priority Objective Progress after 6 months Any delays or risks Key measures

1.4 Increase the number of apprenticeships, to upskill staff, particularly in pay bands 1-4 to enable career progression

The Trust’s Learning and Development Department successfully applied to be an employer provider of apprenticeships and so from June 2017 we will provide apprenticeships in healthcare, business and administration and customer service.

Three apprenticeship programmes are set to commence by the end of January 2018 which will ensure our apprenticeship numbers are greater than ever before.

No. i. Number of apprentices employed by month

1.5 Introduce nurse career pathways through piloting new roles, for example associate nurses, assistant practitioners, advanced practitioners and consultant practitioners (for pay bands 4 and above)

The trust has 25 associate nurse trainees; the trainees are currently on placement. Across the adult mental health wards and forensic wards the skill mix and establishment of staff is currently being reviewed to explore options of different roles within existing budgets.

Consultant nurse posts have been advertised and at least one successful candidate is being supported to undertake their professional doctorate.

No i. Number of new roles introduced and an evaluation of the impact of these roles

1.6 Introduce and evaluate the new development leadership pathways for staff at pay bands 6 and above

The first leadership programme commenced in January 2017 with 20 participants the maximum for a cohort at the present time due to the availability of mentors/ coaches. The next cohorts are due to start in January 2018 and May 2018.

No i. Start date for first cohort and number of staff in cohortii. Feedback from staff in first cohort

1.7 To refine and enhance existing functionality of the electronic patient record to support care delivery

The Trust has an EHR programme board and delivery plan by quarter. An extract from the Q2 report is below;

The top risks in the programme are;- Lack of current functionality in the system to enable the programme to realise

the planned benefits - the EHR team remain focussed on improving their system knowledge and ability to improve end user experience within their capabilities and to utilise existing functionality deployed to other Trusts, for example, electronic discharge via Docman, MIG.

- External System Interoperability - In keeping with the need to support pathways of care across multiple organisations there is a need to support systems interoperability. Differing approaches are emerging with timelines / deadlines fixed without involving the Trust. Therefore, there is a risk that the Trust’s systems will not be ready for interoperability to comply with the expectations of partners.

Alongside the EHR development work the Trust has developed a draft data quality strategy for 2017-2020 to improve how data is captured, used and reported internally

No Not applicable.

5

Priority Objective Progress after 6 months Any delays or risks Key measuresand externally.

Quality priority 2: Improve the experiences of patients and their families and carers

Priority Objective Progress after 6 months Any delays or risks Key measures2.1 Implement the second year of the Trust-wide patient experience and involvement strategy, with a focus on how patients and their families are involved in their care

The co-produced Patient Experience and Involvement (PEI) Strategy for April 2016-March 2019 identified 61 objectives. As of September 2017; 8 of those objectives have been fully completed, 31 are in progress and 22 have yet to be started.

The Taking Action on Patient Feedback group, which includes patients/ service users, oversees the implementation of the PEI strategy. Quarterly updates on progress are reported to the Trust Board and Quality Committee.

The PEI report for quarter 2 2017/18 provides a good summary of the work completed and the experiences of patients/ service users. It also reports on progress against the measures identified for the PEI strategy. The report can be accessed at https://www.oxfordhealth.nhs.uk/papers/27-september-2017/

The introduction of peer support workers, for people with lived experience working alongside clinicians to support patients and their families, being rolled out across the adult mental health services in 2017/18 will have a positive impact on the care provided and staff. The roles will be linked to the recovery colleges in both counties and the apprenticeship scheme in the trust.

Overwhelming the feedback we have received from patients, families and carers is very positive with patients reporting feeling cared for by staff and that as a result they highly value the service provided (see measures). However some people do not receive the positive experience we expect every person to have and therefore we have more work to do. The themes highlighted from complaints mirror the key areas for improvement identified from the feedback we receive, and are focused on communication and sharing information with patients and their families/carers to enable joint decision making and full involvement in care.

There was a delay in starting some of the objectives due to resources and funding, which is now mostly in place but meant many of the objectives for 2016/17 were not delivered and therefore the work plan for 2017/18 has been re-prioritised.

See the PEI report for quarter 2 2017/18 for full details. In summary;

6,541 responses received to an experience survey between January-September 2017

94% of people responded they were likely to recommend our care

Star rating for how involved our patients feel in their care: 4.7 out of 5

58/200c clinical teams are displaying ‘you said, we did’ feedback in their local area.

Most frequently used word in the open comments is care/ caring (used 1084 times), good (used 919 times) and then friendly (used 667 times).

2.2 Transfer the provision of the Oxfordshire community learning disability services and look at how to improve the service provided with patients and their families

The transition of specialist health services for adults with a learning disability within Oxfordshire happened as planned on the 1st July 2017.

The ‘first hundred days’ project plan has been completed with further actions identified and passed into the Learning Disability Strategy. The Executive team have requested updates on a monthly basis, whereas they had received weekly updates during the first hundred days.

The service has completed a self-assessment against the ‘Healthcare for All’ and the draft NHSI Provider Improvement Standards for Learning Disability (Sept 2017) to identify actions to go forward. In addition a self-assessment has been carried out against the findings of the ‘Verita 2’ review of Southern Health’s takeover of services from the Ridgeway Partnership. All self-assessments have been reported to Trust Board.

The Learning Disability Steering Group reconvened in June 2017, with refreshed terms of reference and agreed how best to provide oversight of the work programme from a clinical and patient experience perspective. A second meeting is to be scheduled. The agreed main areas to focus on are;

Transition of specialist services An all-age strategy for people with a learning disability across all

No i. Completion of hundred days project plan from initial transitionii. Approved Learning Disability Strategy

6

Priority Objective Progress after 6 months Any delays or risks Key measuresthe Trust’ geography, which will include progressing the ‘Healthcare for All’ criteria

The service has joined a number of national initiatives including;

- The Patient Safety Academy had received funding from Health Education England for a programme to improve patient safety for people with learning disabilities. This is likely to include human factors training and service improvement projects around dysphasia and learning from admissions.

- An offer to take part in an NHSI Collaborative ‘Criteria led discharge collaborative, which we have accepted.

- We are part of an NHS Improvement project led by the University of West London to consider a tool developed to deliver safe sustainable staffing. We will use this tool to inform our workforce planning.

- We are active design partner in the ‘Leading Together programme’, a regional programme led by Oxford AHSN, which aims to develop partners in leadership between those with lived experience and those with decision making power across the systems.

- The Learning Disabilities Mortality Review (LeDeR) Programme was established as a result of one of the key recommendations of the Confidential Inquiry into the premature deaths of people with learning disabilities (CIPOLD) to contribute to improvements in the quality of health and social care for people with learning disabilities in England. A number of staff have complete LeDeR review training to improve the investigation and learning from deaths.

2.3 Co-develop a new Trust-wide dementia strategy

Two consultation events have been held in 2017- one with staff in the older people directorate and one with service users and carers. Following this a draft strategy document was written and circulated to staff and key external partners. Meetings were also held with 4 individuals who have dementia or support someone with dementia for feedback on the development of the draft strategy.

A regular patient and carer led meeting ‘Leading Together Group’ takes place to drive developments in dementia care. The service has also been involved in peer reviews with patients and carers. The feedback from patients and carers will inform the strategy- which we aim to complete by end of December 2017. The Trust communications team will produce an easy read version of the strategy when it has been finalised.

A number of work streams have been set up to address particular actions as part of the strategy and have started work ahead of the strategy being finalised, including:

- Dementia Friendly Website - a survey was conducted with service users, carers and staffs to help create an initial web page with links to any required content. The mock web page will be tested by service users in January 2018.

- Staff Training – tier 2 training is progressing well. Over 100 staff completed this, and 3 more cohorts are due to complete training by year end. The training involves co-delivery by someone who has dementia and a family carer. It is being evaluated and a report will be made to HEETV. The Trust also applied for funding to host tier 3 training for 75 places across the TV, and we anticipate that this will be a successful bid (and evaluated training).

No. i. Trust Dementia Strategy in place with a work plan and agreed measures

ii. Evidence of co-production of the strategy with service users and their carers.

7

Priority Objective Progress after 6 months Any delays or risks Key measures- Physical care services for people with dementia – there are a number of

projects in community hospitals and District Nursing services to promote dementia care. The District Nursing service is also working to embed some of the dementia care strategy work in the End of Life care project (rather than recreating a separate one).

- BME – work is underway to engage with hard to reach groups. A virtual work group has been set up across the two counties to support and coordinate some individual projects e.g. The group delivered an awareness talk at Chinese Community Centre in Oxford with trilingual translation and approximately 50 people attended.

- Memory Services are currently undergoing renewal of their MSNAP accreditation.

- Older People Mental Health Wards have applied for AIMS accreditation –accreditation was awarded to Cherwell and Sandford and we are awaiting the outcome for the third ward, Amber.

2.4 Review, implement and evaluate a revised care plan for older people at the end of their life

A baseline audit of End of Life (EoL) care was completed in Q1 of 2017/18. Improvements required were around documentation of individualised interventions in line with national priorities.

A new EoL care plan was developed around the national priorities and NICE guidelines; the new care plan addresses the findings from the baseline audit completed. Patients’ and carers’ views were taken into account in the development process. People in Partnership Group and the National Council for Palliative Care (NCPC) were both involved to take part in the review process. The roll out of the revised care plan was delayed to ensure appropriate engagement from all stakeholders; however this was launched in September 2017 with 35 link nurses as a trial initially. A feedback event has been planned for November 2017 to discuss how the revised care plan works in practice- it will be finalised after this event for further roll out.

Monthly audits, to examine compliance with the national priorities, will be instigated as soon as the final version of the care plan is embedded into practice. The results of the audit will be reported to the EoL steering group.

No. i. Revise and consult on new care plan template in line with national guidelines

ii. Roll out revised care plan and evaluate in practice.iii. Establish a regular audit cycle for the quality of care plans.iv. Report initial results from audit.

2.5 Develop palliative care provided to children and their families.

Audit against NICE standardThe Clinical Lead nurse for palliative care is currently devising an audit tool against the NICE standard: End of life care for infants, children and young people with life-limiting conditions. An audit will be carried out in conjunction with the clinical network group Thames Valley Children’s Palliative Care Network. All member areas of this network will be carrying out audits, the results of which will be considered as a whole. This will provide evidence against the NICE standards and identify any variations in service delivery across the Thames Valley region.

The NICE standard is comprehensive and considers a large range of different aspects of End of Life care delivery including;

Quality of Advance Care Plans (ACPs) Parental and child involvement in decision making process Sibling support Communication including consistency of information given to family and

child Care planning

No. i. The audit against the key NICE standards is started in the Trust.ii. Initial results from the audit for the Trust are reviewed and any

areas for improvement are identified with actions.iii. The model and costing for an enhanced Palliative Care Service for

children and young people is completed and shared with commissioners.

8

Priority Objective Progress after 6 months Any delays or risks Key measures Emotional and psychological support Pain and symptom management Practical support Bereavement support for family

The audit will be started from January 2018 looking at retrospective and current cases as children and their families are offered end of life/ palliative care.

Enhanced Palliative Care ServiceThe Children’s Community Nursing Team is in the process of planning and costing an enhanced Palliative Care Service for children and young people. Some funding from the CCG is identified for this area of service development and implementation. The provisional plan is that this team will be led by a band 7 Palliative Care Clinical Lead, 2 band 6 nurses and a band 4 Health Care Assistant. This team will be able to provide an improved quality of care to palliative children.

2.6 Improve transitions between care pathways across ages for example children to adult services

Transition development groupThe terms of reference for the Trust’s transition development group have been widened to include clinical and managerial representatives from adult mental health services, adult social care and third party organisations. The group has developed an improvement plan based on the results of two audits one in 2016/17 and one in 2017/18. The quarterly audit has been continued to monitor the impact of the improvement plan.

The transition development group oversees the improvement plan but also reviews disputed cases escalated by clinicians, for review, analysis and learning to determine if appropriate decisions were made with regards to on-going needs of a young person.

The improvement plan includes;- Review of the Trust’s transition protocol- Review of incident and complaint data to identify learning- Introducing a new quarterly audit of all young people transitioned- Developing a link in with the county council to review the transition

pathway for social care- Improving information on web forums, new CAMHS website for example,

regarding transition, third sector organisations and provision.- Developing relationships with new partners in new Oxfordshire CAMHS

model and in particular transition planning for those young people not transitioning to adult mental health teams

- Linking with the college nurses to get a joined up approach to engage them with young people who may be in their colleges and transitioning

In addition the Trust has been working voluntarily with the Healthcare Safety Investigation Branch (HSIB), around transitions following a death, to ask for their expertise to identify improvements and learning from elsewhere in the country and internationally. Internal feedback is planned for November 2017.

The trust has also started a thematic review around joint working and information sharing between adult mental health teams and children’s services which is planned to be completed by the end of December 2017.

The work is also supported by a national CQUIN in 2017/18 focused on improvements to the experience and outcomes for young people as they transition out of Children and Young People’s Mental Health Services (CYPMHS) into Adult

No. i. Quarterly audit results to demonstrate changeii. The number of formal complaints relating to transition

iii. The number of incidents relating to transition

Q1 audit results;10 young people transitioned from CAMHS to adult mental health services and other CCG commissioned services, the results are shared below and have been used to develop the improvement plan.

There was also an audit of young people transitioned back to primary care, although the results are not shared below as this is not the focus of the quality objective.

8/10 young people had a named transition coordinator in CAMHS9/10 young people had a clear transition care plan with goals9/10 young person had been involved in the development and agreed the transition care plan6/10 the transition care plan has been agreed/ shared with the young person’s parent/ carer8/10 transition care plan shared with adult mental health team7/10 young person’s care was discussed in the transition meeting with the adult mental health team5/10 joint meeting between young person, parent/ carer, CAMHS and adult mental health team

9

Priority Objective Progress after 6 months Any delays or risks Key measuresMental Health Services (AMHS).

Quality priority 3: Increase harm free care

Priority Objective Progress after 6 months Any delays or risks Key measures3.1 Work towards the international nursing standards to achieve accreditation (part of our nursing strategy)

Magnet recognition is the world’s premier scheme for assuring the quality of nursing, it is a significant piece of work which is likely to take around 5 years to complete.

The Magnet standards referred to and on which this analysis is based are contained with the American Nurses Credentialing Centre (ANCC) Magnet Application Manual, 2014. A new set of standards will be released in November 2017 and be implemented in 2018 in accordance with the ANCC’s regular four yearly standard setting cycle. The standards are designed as ‘standards that stretch’ and are based on the principles of continuous quality improvement so it is likely that the 2018 standards will provide additional challenge.

It is important to note that the vast majority of the Magnet standards detail developments that the trust would aspire to implement anyway. However, the Magnet standards provide a framework and plan for taking the work forward and turn the activities into a positive series of achievements that ultimately result in Magnet recognition.

2.1 ANCC The Forces of Magnetism

1: Quality of Nursing Leadership8: Consultation & Resources

2: Organizational Structure 9: Autonomy3: Management Style 10: Community & Health Care Organization4: Personnel Policies & Programs 11: Nurses as Teachers5: Professional Models of Care 12: Image of Nursing6: Quality of Care 13: Interdisciplinary Relationships7: Quality Improvement 14: Professional Development

A gap analysis was undertaken in 2015 by Professor Dickon-Weir Hughes to support the Trust in identifying areas for development as part of our overarching Nursing Strategy. There are eligibility criteria to apply for Magnet accreditation assessment and our focus has been on the following;

Degree educated Nurse leadersTopic Criteria RAG

rating in 2015

Current status:10.10.17

Nurse Managers / Nurse Leaders

Effective as of 2013, at the time of application 100% of nurse managers and nurse leaders must have a degree in nursing (baccalaureate or graduate degree)

Nurse Managers are defined as RN’s with 24 hour / 7 day

All band 7s and above have been asked to provide information on whether they have a degree a response has been received from all except for 6 nurses.

This has evidenced that

No, however working towards the international standards is a long term (c5 years) goal.

i. Identify work plan from self-assessmentii. Make sufficient progress against work plan

10

Priority Objective Progress after 6 months Any delays or risks Key measuresaccountability for the supervision of all registered nurses and other healthcare providers who deliver nursing in an inpatient or outpatient area.

Nurse Leaders are defined as those individuals who are positioned between the CNO and the Nurse Managers on the organisation’s structural chart

100 nurses at Band 7 or above do not hold a degree qualification.

Next steps;L&D will be looking to add in a nursing focused module to the leadership course that is being run and seek accreditation from a university as PG certificate in Nursing Leadership to ensure this meets the Magnet requirements.

Scoping work has been completed and funding has been identified in 2017/18 to meet costs required to manage this course and offer to nursing staff.

Staff Satisfaction and Nurse sensitive indicators

Exemplary professional practice

RAG rating in 2015

Current status 10/10/17

EP3EO RN satisfaction data outperform the mean or median of the national database used (and must include data on autonomy, CPD, access and responsiveness to nurse leaders and CNO, medical / nursing relationships, fundamental care, staffing and RN teamwork)

Staff survey results for 2016 have been broken down by professional group to review nursing data – this will be reviewed and used as a baseline to compare 2017 results.

3.2 Continue to develop how we robustly review and learn from deaths, including improving how we work with families to identify all learning

In September and October 2017 there have been detailed reports published on how the Trust has reviewed and developed how we identify, report and learn from deaths. Board papers are available at https://www.oxfordhealth.nhs.uk/papers/25-october-2017/. The September 2017 paper provides a self-assessment against the national recommendations for learning from deaths and the summarises the work of the Trust-wide Mortality Review Group in the last 18 months.

The overall number and rate of deaths has not changed over the period from April 2014 to June 2017, apart from in January 2015, in line with the national trend relating to flu activity. The majority of deaths are people aged 75 and above, who have been previously under the care of the district nursing service. Further work is needed to understand the decrease in current patient deaths and the increase in deaths for patients discharged from services. The number of inpatient deaths has deceased from July 2015.

No. i. Achieve standards in national guidance on learning from deathsii. Progress of work plan from the Trust-wide Mortality Review

Groupiii. Roll out and evaluate new training for staff on involving families

in SI investigationsiv. Audit of completed SI investigators demonstrates an

improvement following baseline audits by Mazars Group/ Oxford AHSN in 2016/17

11

Priority Objective Progress after 6 months Any delays or risks Key measuresWe have implemented changes to how clinicians screen, report and investigate deaths, these changes are all captured in the revised policy on the reporting and management of incidents and deaths published on the Trust’s website. The scope of which deaths should be reported onto the Ulysses incident reporting system has been re-defined, therefore we have seen an increase in the number of deaths reported, reviewed and investigated. In Q1 17/18 4.3% of all deaths for current and discharged patients (checked against the national database) were reported onto the incident management system for a further review. There is no change in the number of deaths reported as a serious incident or reviewed by the coroner since April 2014.

The key themes for learning from the review of deaths are; physical health for patients with a mental health illness, family engagement and communication, and communication at points of transitions and changes in care between teams, services and organisations.

The Trust has developed a structure of directorate level mortality review processes feeding into the Trust-wide mortality review group chaired by the Medical Director which then reports up to the Trust Board.

The Trust completed work with the Oxford Academic Health Science Network and Mazars Group in 2016/17 to improve the quality of SI investigations, particularly focused on improving engagement with patients and their families in the investigation and learning.

The central SI team continue to work on the next phase of their improvement plan focused on; improving how beavered families are engaged and involved in investigations, improving how learning is shared and actions identified/ sustained. Completed actions in 2017/18 include;

- Reviewing and rolling out new training for investigators (detailed below)- Implementing revised report templates which are more patient/ family

accessible and better demonstrate how patients/ families have been engaged in the investigation

- Introducing additional checks through the investigation process to ensure patients/ families are offered different opportunities to be involved in the investigation

- A new information leaflet for patients/ families has been developed about the process and what they can expect which has been rolled out.

- We have trialled using a ‘family liaison role’

The team has revised the foundation RCA training and added ‘plug-in’ modules which were rolled out in June 2017 for investigators to improve skills around involving families, analysis using human factors approaches and skills in cognitive interviewing styles. There is now an expectation any member of staff band 7 or above investigating an SI will have completed a refresher in RCA training within the last three years.

3.3 Reduce patient violence and aggression across the adult acute mental health wards through rolling out the safer ward programme

Work has started on a few initiatives to reduce violence and aggression on the wards, including;

Developing the ‘knowing me boards’ across all the wards to include descriptions about staff so patients get to know staff better (which is part of the safer ward programme)

Starting to analyse the violence and aggression data further so that the outcomes of initiatives are measured and initiatives follow a series of PDSA cycles.

There has been a delay in rolling out the programme; however specific pieces of work have started.

i. A reduction in violence and aggression incidents (details to be further developed)

12

Priority Objective Progress after 6 months Any delays or risks Key measures We are 1 of 19 NHS Trusts participating in the national ‘observation and

engagement collaborative’ being led by NHS Improvement, looking at how observations are done? what patients understand? and how staff feel about doing them? A key foundation of the work is to look at how to sustain quality initiatives. Sapphire and Ashurst wards are currently involved in the collaborative.

Some of the wards are reinstating the failure to return from leave initiative, where this has lapsed.

3.4 Continue to pilot and roll out a consistent new early warning sign tool1 with training, and assess the effectiveness of its use across community hospitals and mental health wards. This work includes the identification and management of sepsis

Last year in 2016 the focus was in community hospital wards and urgent care.

Across the community hospital wards the actions taken were:1. Introduction of the ‘simulation’ training in conjunction with OXStar2. Introduction of the NEWS T&T score across all sites3. Introduction of the ‘care and comfort’ rounding bundle

This has had a significant effect for patients in that there have been no issues of harms resulting from ‘failure to rescue’ in the hospitals since the introduction of these initiatives (from December 2015 to July 2017. However there has been one incident in August 2017).

In Urgent Care the actions taken were;1. The development of a process to enable proactive review of patients with

suspicion of sepsis though no overt features requiring immediate referral.2. The development of bespoke ‘targeted information leaflets’ for patients

and families regarding sepsis risks and specific areas of concern for them to prompt return.

In the Witney Emergency Multi-disciplinary Units (EMU), we have undertaken a process of reviewing the referral paperwork to ensure that a ‘pre-screening for sepsis’ is undertaken. From there we have introduced a process of audit of compliance against the key standards within the NICE guidance as applicable to this clinical setting.

Over 2017/18 we have been working to implement the following:1. Scoping the inclusion of Sepsis awareness for all staff within the Trusts

induction programme2. Developing capacity across the community hospitals to continue delivery

of the training initiated by the OXStars work for new starters and as a refresher

3. Standardisation of the Witney EMU sepsis processes into the RACU at Henley and EMU at Abingdon

4. Undertaking to deliver sepsis recognition and awareness sessions across a variety of trust sites to coincide with ‘world sepsis day’ in September

5. Development of a bespoke package of training and processes to support the recognition of, and escalation of concerns in relation to sepsis for district nursing and care home support service teams.

6. Identification of local sepsis champions across the older adult mental health wards with links and resources to raise awareness of sepsis and necessity to escalate concern and take action to support patients in the event that this happens.

A monthly audit of the use of the new early warning sign tool (NEWs) used across

No.Community Hospital wards – audit results for use of NEWs

Measure Target April 17 May 17 June 17 July 17 Aug 17 Sept 17 Data Source Number of failure to rescue events 0 0 0 0 0 1 0 Ulysses

Completion of NEWs chart 95% 98% 97% 98% 98% 98% 98% NEWS Audit Appropriate escalation of NEWs score 95% 97% 81% 85% 87% 96% 96% NEWS Audit

Older People mental health wards – audit results for use of MEWS in Q2

Measure Target Cherwell Sandford Amber Data Source Completion of MEWs chart 95% 100% 100% 96% MEWS Audit Q2 Appropriate escalation of NEWs score 95% 100% 55% 100% MEWS Audit Q2

1 This tool is to standardise how we monitor, identify and treat patients who are physically deteriorating13

Priority Objective Progress after 6 months Any delays or risks Key measurescommunity hospital wards demonstrates an improvement in the escalation of abnormal observations. There was one event of a ‘suspected failure to rescue’ reported in August 2017 which is being investigated using root cause analysis as a serious incident. See measures.

In Older People Mental Health wards, a MEWS audit was completed in Q2 2017/18. Concerns relating the escalation of abnormal observations were identified on Sandford- retraining and a re-audit is underway. See measures.

3.5 Reduction in avoidable and acquired pressure damage

An improvement in reporting lower grade harms has been noted alongside a reduction in grade 3 acquired pressure damage. The numbers of category 3 and 4 acquired pressure ulcers with lapses in care remains low.

The service extended the Initial Review (IR) process to review all acquired category 2 pressure damage from August 2017 to identify if there had been lapses in care. In August 2017, out of a total of 50 completed IR’s for grade 2 pressure ulcers, lapses in care were identified in 4 cases (8%).

See measures for number of acquired pressure damage by category and as a result of lapses in care (figure 5), the number remains low and monitoring has been extended to include category 2 pressure damage.

Whilst the Trust remains an outlier (due to a higher number of reported category 2 pressure damage – acquired and inherited) based on Q4 2016/17 national Safety Thermometer Returns- it must be noted that that a higher rate of reporting lower grade harms must not be regarded as an adverse indicator. An increase in the number of acquired harms with lapses in care should be noted as an adverse indicator- but the national tool does not reflect this. There are notable data quality issues and discrepancies with the national comparable data for example the definitions of acquired and inherited harms.

Below is a progress update on key initiatives included in the Pressure Ulcers Reduction Project:

Quick Time Learning QTLThe QTL approach has been rolled out across all district nursing teams with modifications to the process to allow wider adoption as follows-

Improve reporting all pressure damage including low grade harms- including category 1 pressure damage.

The handover process has been updated to include a requirement to discuss all identified pressure damage promptly at team meetings and ensure as a team appropriate interventions and support have been provided.

A handover poster and flow chart outlining the requirements have been developed for use by all teams.

Initial Review (short pressure damage analysis form) has been activated for all acquired grade 2 pressure damage- the clinical leads will be required to complete the questionnaires to identify any lapses in care. There are technical challenges linked to the adoption of IR’s to analyse category 2 harms which the quality and risk teams are trying to resolve.

Learning from incidents with lapses in care is shared by clinical development leads at team meetings.

The OPD quality team will collate the learning at a county-wide level and ensure the learning is shared via the ‘Learning from Incidents Poster’ or presentations of safety metrics data at the county-wide meetings.

No. Fig. 1 All category 1 acquired pressure damage

Fig. 2 All category 2 acquired pressure damage

Fig 3. All category 3 acquired pressure damage

Fig 4. All category 4 acquired pressure damage

14

Priority Objective Progress after 6 months Any delays or risks Key measures

React to RedThe React to Red initiative encourages the use of the initial SSKIN bundle assessment on first district nursing visit to allow early care planning; education with patients and their carers; and promote better communications between nursing teams and care agencies. The initiative was piloted in Didcot in April 2017, but was delayed due to recruitment challenges in the team. A project team meet meeting is planned in October 2017 to a agree re-launch and timescales.

Motivational Interviewing PilotA pilot was started with a district nursing team in the north; psychology support will be provided via Oxfordshire Talking Space Plus to build up skills in managing patients with long-term conditions, anxiety or depression. Evidence from a pilot in Long-term Conditions demonstrated that patients who received psychological support had better outcomes in managing their long-term conditions. Motivational interviewing will help nursing staff improve patient concordance with care plans including pressure damage prevention care plans. Talking Space Plus will provide teaching and supervision to the district nursing team for a period of 3-6 months. The impact will then be evaluated for further roll out.

Data Quality ManagementVarious initiatives have taken place to improve data quality and management including-1. The validation of safety thermometer submissions against Ulysses records. Team-targeted training sessions are being delivered by the OPD Quality team regarding the safety thermometer definitions and data collection.2. Modifications to Ulysses were introduced by the quality and risk team from October 2017 to include links/prompts for the reporter to review definitions and categories of skin integrity concerns with photographs to support this.3. Additional training is being provided to the district nursing teams regarding the identification of SCALE (Skin Changes at End of Life)- the criteria for defining SCALE now appears as a prompt in Ulysses if the reporter selects this option.

Fig 5. Acquired pressure damage category 2, 3 and 4 with lapses in care(note reporting for category 2 only started from August 2017)

3.6 Finalise the suicide prevention strategy and start to implement the objectives

The Trust’s suicide and self-harm reduction strategy is in development, the driver diagram identifying the suggested aims of the strategy with the primary and secondary drivers is being consulted upon. The primary drivers (areas for improvement) are likely to be;

- Leadership and partnership working- Continuous learning- Safe and effective care and treatment e.g. collaborative safety planning,

transition pathways and complex presentation pathway work- Competent, confident and effective workshop e.g. training and coaching- Authentic collaboration with service users and families

The development and implementation of the strategy is being overseen by a new leadership group chaired by the Medical Director which met for the first time in Sept 2017.A thematic review on the learning from suspected and confirmed suicides for the last 3 years was presented at the Trust-wide Mortality Review Group in December 2016 and in a series of workshops with clinical staff in January 2017. The work is being refreshed to include the most recent 6 month period and will inform the development of the strategy.

No. i. 10% reduction in suicides of our patients by 2020/21ii. Trust strategy on suicide and self-reduction finalised.

15

Quality priority 4: Promote health and wellbeing of patients

(the staff wellbeing initiatives are covered in quality priority 1)

Priority Objective Progress after 6 months Any delays or risks Key measures4.1 Improve the physical health care for patients receiving treatment for their mental health condition

Physical healthcare for patients with a mental health illness is an emerging theme from the review of deaths and serious incidents.

The trust-wide physical healthcare group leads on this work and reports to the effectiveness quality sub-committee chaired by the Medical Director. There are also a CQUIN scheme around this theme for 2017/18.

A gap analysis has been completed against the CQCs standards on physical healthcare in mental health services. This identified a number of actions which have been taken in 2016/17, for example;

- Purchasing new equipment to carry out annual physical health checks for all patients on caseload

- Developing a new patient handbook- Introducing a ‘my physical health assessment and plan’- Implementing physical health clinics in each AMHT- The Clinical Practice Educators have developed and deliver mandatory

training for all AMHT staff, with enhanced competency based training for nurses and OTs.

- Physical health leads have been identified in each AMHT and adult/ forensic ward. Leads have completed a 4 day physical health skills training course. The leads meet 6 weekly.

- The recording of physical healthcare information on the trusts electronic health record has been reviewed and amended; there are now only 5 forms available, all found in one area in the patient’s record.

The analysis also identified further actions for 2017/18 including;- RGN physical health leadership posts are being recruited to support the

AMHTs and adult wards- Standardising the model of physical health clinics offered by AMHTs- Improving how inpatient discharge information is shared electronically and

automatically with GPs- Improving how staff monitor identified cardio-metabolic risk factors- Continue the work led by the IAPT services as early implementer sites for

better integrated pathways for people with a long term physical health- Develop and introduce an electronic MEWs form for the wards on

CareNotes.

Over the last year a large amount of work has been carried out to support and develop staff to improve the physical healthcare for a patient with a mental health illness. A self-assessment was completed in July 2017 by senior clinicians and managers against the Trust’s compliance with the CQCs standards for physical healthcare in mental health services. There is a need to coordinate and lead further changes through the development of a Trust Physical Healthcare Strategy. A Strategy has been drafted and is currently being consulted on.

Delays in consulting and agreeing a physical health strategy which is a CQC standard in their physical health guidance.

The results to the last national audit 2016/17 on cardio metabolic assessment and treatment for patients with psychoses were poor.

i. Trust strategy on physical healthcare finalised with work plan.ii. Improved results to the national clinical audit on cardio

metabolic assessment and treatment for patients in 2017/18iii. Reduction in serious incidents including unexpected deaths

where physical healthcare is identified as an area of omission in care

4.2 Develop diabetes care The terms of reference for the Diabetes taskforce meeting are currently being reviewed with the aim to re-launch the work by the end of December 2017. The

Objective rolled over from 2016/17 as not achieved.

i. Develop staff training and competence in diabetes management (focus on community hospitals and district nursing service)

16

Priority Objective Progress after 6 months Any delays or risks Key measuresresults of the diabetes care audit from last year (2016/17) will inform the work plan for the Taskforce alongside any national priorities and commissioning intentions.

We participated in a diabetes transformation workshop with colleagues from OUH, the GP federations, CCG and other key stakeholders. There is now a clear and ambitious shared vision for diabetes care and the challenge has been put at providers’ doors to collaborate on delivering this vision. We have convened three workshops to develop a collaborative proposal to present back to the CCG early in the new year (2018).

Actions planned are unlikely to make an impact in 2017/18.

4.3 Implement a psychological therapy service for people with long term physical health problems

BackgroundTalkingSpace Plus (TSP) in Oxfordshire was an ‘early implementer’ site for the integration of IAPT services with physical health treatments in primary care settings. As part of the Five Year Forward View for Mental Health, two years’ funding for 2016-18 has been provided through NHS England (NHSE) to develop and expand co-located, integrated services within physical healthcare settings.

It is known that people with long term physical health conditions (LTCs) or unexplained medical symptoms (MUS) are up to three times more likely to experience comorbid anxiety and/or depression. Patients with these conditions are high users of health services, and are often in the older age group.

Service ExpansionThe new Oxfordshire Integrated IAPT LTC team is now established, focussing on adults with mild to moderate anxiety and/or depression and living with one (or more) main co-morbid condition(s): Diabetes Cardiac Disease Chronic Obstructive Pulmonary Disease (COPD) Chronic Fatigue Syndrome (CFS)

Psychological therapists with additional LTC training provide evidence based treatments to patients and provide support and training to colleagues working in physical health setting. They use a ‘stepped care’ approach, similar to the model used in our core IAPT service, which offers the ‘least intervention first time’ (LIFT). Patients can self-refer to the service or be referred by their GP, nurse or other health care worker.

Economic BenefitsThrough evaluation of this service we hope to provide evidence of how the approach improves mental health outcomes and reduces the use of hospital and primary care services. Evaluation is being supported at national level by NHSE, University College London and London School of Economics, and locally by the Oxfordshire Anxiety and Depression Academic Health Science Network (AHSN).

Progress to dateHighlights include; 391 patients with one of the four pathway conditions entered treatment and

154 patients completed treatment (of which around a third with cardiac conditions and a further a third with diabetes). (April-September 2017)

Delivering GP mental health champion training events across 6 localities in Oxfordshire

Participation in the Diabetes Multidisciplinary Team (MDT) project and the Cardiology GP training programme.

No i. Establish services in both countiesii. Monitor and report on number of patients accessing services

Between April to September 2017; 391 patients with one of the four pathway conditions entered

treatment and 154 patients completed treatment (of which around a third with cardiac conditions and a further a third with diabetes).

17

Priority Objective Progress after 6 months Any delays or risks Key measures Participation in Oxfordshire CCG project boards for Diabetes, Cardiology and

Respiratory (COPD/Asthma). Links established with community based integrated locality teams working

with patients with comorbid physical health problems (often older people) Developing links with A&E in OUH, receiving referrals for frequent attenders

with conditions in the four focus pathways Training/supervision for district nurses to help identify anxiety and depression

for their patients with LTCs Attending regular cardiac and pulmonary rehabilitation sessions Clinical supervision and support to specialist diabetes nurses and dieticians,

pulmonary rehab staff and cardiac specialist nurses.

Patient feedback examplesJoy aged 67 years with a heart problem and COPD said “this has helped me have confidence to go out again, I didn’t realise how much my anxiety had stopped me doing things. I was getting so out of condition which was making my breathlessness worse. I had a graded programme that helped me to face the things that make me anxious. I am so pleased I did it (CBT) as I am going out again and my breathing is not as bad as I am not panicking about it anymore like I was.”

Michael aged 35 years said “I was rather sceptical and embarrassed about seeing someone because I thought it meant I was weak. CBT has been a great help to me overcoming my depression and managing my Diabetes so much better. I can’t recommend TalkingSpace Plus enough”.

4.4 Develop multi-disciplinary teams at a neighbourhood level so services are managed and can work better across organisational boundaries with care being delivered closer to peoples’ homes

The four GP Federations in Oxfordshire and the Trust are exploring how we can work even more closely together to:

maximise the impact of primary care and community health services towards improving the health of the population of Oxfordshire

contribute to developing sustainable health services, and, proactively address workforce challenges

We are looking to begin formally working together in April 2018 and an Interim Programme Director has been appointed to continue to drive the changes forward.

Clinical Workshops:A series of clinical workshops have been held in September and October 2017 with GP representatives and clinicians from the Older People’s Directorate. The workshops are looking at how Primary Care and Community Pathways will develop over the remainder of this financial year and in each of the next three financial years. Key elements of this will be what will be different for patients and clinicians and how we will measure that we are making progress. The workshops are also looking at what workforce will be needed, where the gaps are and how those gaps will be closed. There is a focus on recruiting, developing and retaining staff.

Neighbourhood Development:Oxfordshire is being organised into 18-19 neighbourhoods to support GP Practices to work together and move forward issues raised in the recently published Primary Care Framework. In order to work effectively with the new neighbourhoods the community services in the Trust are being reorganised to link together with Primary Care services even more effectively. Over the next few months a framework of expectations will be developed and agreed between the organisations setting out what needs to be achieved across all of the neighbourhoods.

No. i. GP clusters by neighbourhood area identified and Trust services reorganised to be aligned

ii. Framework of expectations across all neighbourhood areas to be agreed

iii. Operational and governance arrangements to manage the new joint working to be developed and established

iv. The outcomes and measures to review the new joint working arrangements to be agreed

Note the work in 2017/18 is preparatory for the change in joint working to start from April 2018 (2018/19).

18

Priority Objective Progress after 6 months Any delays or risks Key measuresGovernance Framework:The operational and clinical governance framework is being developed and will require consultation and testing. The contracting, legal and regulatory requirements are also being worked through currently.

There is currently a Joint Board of the four GP Federations and Oxford Health which meets monthly to address key issues and drive forward the joint work. The meeting in October 2017 will start to identify the proposed outcomes and measures of success. The Joint Board reports to the Trust’s Executive and Board through the Chief Operating Officer.

19