Agenda Item No. 11

Reference No. WSCCG 14-05

From: Barbara McLean, Chief Nursing Officer

QUALITY REVIEW OF SUFFOLK COMMUNITY HEALTHCARE

1. Purpose

1.1 This report provides members with a report on the Quality Review of the Suffolk Community

Healthcare.

2. Public Engagement

2.1 This report will be circulated to the Community Engagement Group.

3. Recommendations

3.1 The Governing Body is asked to:

Note the position regarding the safety of services;

Review the ongoing actions with regard to clinical quality development and communications; and

Note action to review quality and achieve assurance on service areas in keeping with the role and responsibilities of Commissioners.

Author:

Barbara McLean

Chief Nursing Officer

With contributions from:

Patient Safety and Clinical Quality Team; and

Contracting Team.

Quality in the New Health Service System

Maintaining and Improving Quality from April 2013.

Commissioners

Commissioners are responsible for securing a comprehensive service within available resources, to meet the needs of their local population.

They must commission “regulated activities” from providers that are registered with the CQC, and should contract with their providers to deliver continuously improving quality care.

They must assure themselves of the quality of the services that they have commissioned.

Where commissioners have significant concerns about the quality of care provided, they should inform the CQC.

QUALITY REVIEW OF SUFFOLK COMMUNITY

HEALTHCARE

August 2013 to December 2013

1. Introduction 1.1 In October 2012, the NHS contract for Community Services was taken up by Serco Health,

following a tendering exercise by Suffolk Primary Care Trust, in line with national instructions to divest services from Commissioners. Commissioners also wanted to see better patient outcomes and an improved way of working with the local providers, which meant there needed to be a significant change programme.

1.2 In August 2013, a number of issues were being noted by the CCG Contracting Team about performance issues against some of the Key Performance Indicators (KPIs). GPs were also reporting problems with the Community Services, through the Contract Issue Log.

1.3 The Ipswich & East Suffolk Clinical Commissioning Group and West Suffolk Clinical Commissioning Group follow closely the guidance produced by the National Quality Board (NQB). The NQB Report, “Quality in the New Health System – Maintaining and Improving Quality from April 2013” notes: “To support the emerging system as it seeks to do the best for the people it cares for, we have developed a model for how the different parts should come together to share information and intelligence and to respond to quality problems when they arise. This is based on our belief that the system must:

Proactively work together to share information and intelligence about the quality of care in order to spot potential problems early, prevent them having a harmful impact and manage risk; and

Reactively work together in the event of a potential or actual serious quality failure coming to light, to enable informed judgements about quality and to ensure an aligned response between those with performance management, commissioning and regulatory responsibilities, without undermining or overriding individual accountabilities.”

1.4 The report further notes in “A Summary of Tools and Levers”, that the specific role of

Commissioners in monitoring quality of services is “Information gathering and reporting as part of contract management and from wider sources”.

1.5 As a result, Ipswich and East Suffolk Clinical Commissioning Group and West Suffolk Clinical Commissioning Group agreed a thorough review of the Community Services. This Quality Review addressed potential patient safety and quality issues, namely:

Staff capacity;

Skill mix;

Workload;

Succession planning;

Morale;

Training;

Communication;

Mobile working;

Care coordination.

2. Quality monitoring principles

2.1 The CCGs follow the National Quality Board (NQB) operating principles for quality monitoring, which are used as a guide to action, alongside the values and behaviours set out in the NHS Constitution, as commended in the NQB Report, “Maintaining and Improving quality from April 2013”:-

The patient comes first – not the needs of any organisation. Quality is everybody’s business – from the ward to the board; from the supervisory bodies to the regulators, from the commissioners to primary care clinicians and managers

If we have concerns, we speak out and raise questions without hesitation

We listen in a systematic way to what our patients and our staff tell us about the quality of care

If concerns are raised we listen and ‘go and look’

We share our hard and soft intelligence on quality with others and actively look at the hard and soft intelligence on quality of others

If we are not sure what to decide or do, we seek advice from others

Our behaviours and values will be consistent with the NHS Constitution

3. Framework of the Quality Review 3.1 There were several areas covered by the Quality Review. These were as follows:

A review of Patient Experience data

An expanded programme of Quality Improvement Visits (QIV).

Review of the Care Coordination Centre (CCC).

Review of the GPs Contract Issue Log with Serco, which would then develop robust processes for each issue to be reviewed and remedied where appropriate. The main themes included the Continence service, Clinical Equipment Store, Care Co-ordination Centre, access to services, staffing levels and Podiatry.

Review of actions from the recent QIVs held before the Quality Review was started.

Review of Key Performance Indicators.

Review of Incidents and Serious Incidents.

Scrutiny of Suffolk Community Healthcare (SCH) staffing levels, vacancies and recruitment plans, including trajectories to full recruitment.

4. Patient Experience 4.1 The Friends and Family Test had periodically shown a decrease in promoter scores for Inpatient

units, Minor Injuries Unit (MIU) and patients with Long Term Conditions, particularly on care received. On scrutiny the numbers of patients reviewed was lower than previous periods giving a perception of a reduced patient satisfaction score, rather than noting the data collection change. The service would usually survey a sample of people for each period of reporting. In July, there was a total of 12 patients surveyed resulting in a Friends & Family test score of 56, because this is a weighted score, a single patient not satisfied with the level of care provided would affect the monthly score for the Service by 20 points. When the number of people surveyed was increased to 65 in August the results showed an increase in satisfaction to a Friends & Family test score of 85.

4.2 Serco was asked to provide further clarity in reporting of patient experience by detailing results

from each individual Community Hospital and a further meeting was held to agree their approach for future reporting.

4.3 Friends and Family Test results are scores and not percentages, these needs to be reflected in

KPI reporting for future contracting review. An issue for Commissioners and the Provider alike. 4.4 Serco is developing a patient experience monitoring approach that is more befitting a community

provider such as:

New patient experience surveys in development to provide further insight into the friends and family test, which includes different methodologies such as web based, paper, telephone and face to face interviews.

An iPad survey has been introduced into MIU and will later be expanded to the Community Hospitals.

Quarterly staff surveys

Patient Voices, a web based opinion survey, is being rolled out as part of a Commissioning for Quality and Innovation (CQUIN) scheme this year in each Community Hospital and the plan for 2014/15 will be to develop an approach in the Community Services.

The work of Serco on the development of patient experience monitoring in Community Services is currently on track to break new ground nationally.

5. Quality Improvement Visits (QIVs)

5.1 In April, the GPs were raising a number of concerns about the transformation of Community Services and the impact on service delivery.

5.2 A Quality Improvement Visit reviewed the CCC in July 2013. This was to gain an overview of

the service and to help identify risks and issues that could be actioned. It was also to develop better partnership working and communication between Serco and commissioning.

5.3 The CCC staff reported that they believed delays were clinical in nature. The evidence

demonstrated it was the allocation of work and scheduling of appointments within Clinical Teams that was the issue. It was observed that Serco had put in place a clinical lead to review systems and processes to support the administration staff. Risk logs and incidences were being reviewed as well as education targeting locality teams. Templates to support the administration team were being developed.

5.4 A follow up QIV to the CCC took place in August to review the issues identified and actions

agreed with Serco. Clearer reporting of incidents was evidenced, referrals that had not been managed by the Locality Teams were being reported as near misses and there was a clear process to manage this, demonstrating effective processes for monitoring of incidents and learning being used to develop services.

5.5 It was noted that some localities were processing referrals differently. There was no consistent

approach in triaging and waiting list management. Some teams triaged the referral but would hold it in the triage list. Further QIVs took place in Localities to review the referral and triaging process, this was to the Ipswich Team (former Day and Treatment team) and to the North East Area Team in August 2013. The North East team (based at Aldeburgh) was the first team to implement the new ways of working with the CCC and mobile technology. The Team lead had created a process flow chart that describes how referrals are triaged and managed. An action plan was developed to work through the issues raised.

5.6 The programme of QIVs continued during October and November. The programme was to

concentrate on the locality teams that appeared to have the most significant pressures, so that the sample of staff interviewed will not be representative of all teams, but the programme of visits did, explicitly, give staff an opportunity to raise concerns and to comment on how the concerns were being addressed.

5.7 Some community staff (both nursing and therapists) expressed concerns about their ability to continue to provide high quality care to patients in a way that they felt was safe, clinically appropriate and to the standards they expected to deliver. The independent reviewer undertaking the QIVs saw no evidence of patient care being compromised but did note high stress levels amongst the staff. This was more evident in some teams than others.

5.8 During discussion with the staff the following themes were identified. These were consistent in all areas, with a significant impact noted on some of the teams. Support from the Director of Nursing for Therapies and Governance and the Head of Nursing and Professional Practice was noted by staff.

Pace of change of the Target Operating Model (TOM), and the assumptions made.

Difficulties with the mobile electronic record keeping initiative.

Documentation and continuity of care with other agencies, specifically the Marie Curie Service.

Referrals to the Care Coordination Centre (CCC) and the role of ‘Captain of the Day’.

Administration support and the amount of time clinicians are involved to undertake administrative tasks.

Communication of changes and feedback from complaints and incidents.

Community Equipment Store and the lack of equipment.

Recruitment, retention and development of staff. 5.9 Morale was found, overall, to be low and staff raised concerns that mistakes and/or accidents

may occur. However, it has to be noted that a staff survey completed by the Picker Institute in September 2012 prior to the Serco handover found that staff morale was already low in a staff group subject to a period of uncertainty.

5.10 A view expressed by staff during the visits was that the Target Operating Model (TOM) is an ambitious model based on poor assumptions. As a result of listening to staff feedback as part of the consultation exercise, no clinical posts have been made redundant and the original TOM has not been implemented

5.11 While some senior staff see signs of improvement and that staff are being listened to, most front-line staff still state they have no understanding of where the organisation is going and what needs to happen or change to get there. Serco has evidence of many listening events held over the last year with staff, to enable staff engagement. Serco state a continued commitment to staff engagement and to addressing the issue of low staff morale.

5.12 The first staff consultation lasted until the end of January 2013 and many changes were made to the TOM as a result of staff feedback at the time. The number of posts that would be reduced over time was also decreased from 137 to 90. Serco made a commitment that if things were not working, there would be a pause\stop while problems were considered. This happened in June 2013, when issues came to light around the use of mobile technology, SystmOne, and the Care Co-ordination Centre (CCC). In response, Serco have established a change programme to address the issues the staff raised. Regular feedback to staff on the changes occurs through newsletters, face to face meetings and also through line managers. 15 change champions (1 from each Community Health Team) contribute directly to the programme and ensure the clinical perspective is heard.

6. Serious Incidents 2013 6.1 The reporting of Serious Incidents to commissioners is a contractual requirement. The definition

of a Serious Incident is contained within the NHS Commissioning Board Serious Incident Framework 2013, an update to the 2010 National Framework for Reporting and Learning from Serious Incidents Requiring Investigation. This guidance contains information for Providers, Commissioners and other bodies in relation to guidance on reporting, disclosing, investigating and responding to Serious Incidents. The Serious Incident reports received by Commissioners are scrutinised for evidence of an effective root cause analysis of the incident; learning, including changes to practice where necessary; and engagement of service users, ensuring that the Service meets its duty of candour.

6.2 The information held by Commissioners on the reporting of serious incidents has been reviewed with Serco. It has been possible to establish that the systems and processes in place ensure

timely reporting and investigation of incidents and serious incidents and that these systems are effective and appropriate in keeping with the guidance. The risk management team have made some changes in the way that the senior team receives reports to ensure real time information is available to manage and mitigate risks identified. This covers areas known as the NHS Safety Thermometer, which allows teams to measure ‘harm’ as defined by the Safety Thermometer and the proportion of patients that are ‘harm free’.

6.3 The graph below details the reporting of Serious Incidents by the Service for 2012 and 2013 using the calendar year January – December in each case.

Category/Type of Serious Incidents

2012 2013

Slips/Trips/Falls 10 8

Pressure Ulcers Grade 3 & 4 22 27

Infection Control 3 1

Unexpected Deaths 1 2

Confidential Information Leak 1 0

Medication 0 1

6.4 The Service has noted plans to audit key themes shown by reporting of Serious Incidents, e.g. falls. Commissioners will continue to scrutinise audit results and ensure adequate mitigation is in place in the event of issues being raised. The Provider has demonstrated appropriate response to apparent themes, for example, an increase in falls over one month in a Community Hospital, particularly in the evening and at night, has received an appropriate response by the Provider of increased staffing as an interim measure to prevent further incidents during the period of investigation/root cause analysis, demonstrating effective risk management.

6.5 An analysis of the Serious Incident information notes pressure ulcer reporting remains low. The Service reports ongoing themes relating to the use and availability of pressure relieving equipment. Although there was only one Serious Incident involving medication error, there has been an increasing trend of medication adverse incidents in the last three quarters reporting. These are noted as incidents, as no harm was experienced by the patient. The majority of incidents reported relate to record keeping. This trend was identified by the Provider and is being addressed through training and education.

6.6 It should be noted that ‘unexpected deaths’ are identified to a national serious incident criteria to enable care review and comparisons between services. The threshold is set high, at ‘unexpected’ rather than possibly avoidable, to ensure that care is reviewed frequently. The term ‘unexpected death’ does not therefore, necessarily mean that a death could have been avoided. The root cause analysis process and clinical review follows this reporting process and establishes any possible learning or further reporting necessary.

7. Review of Key Performance Indicators 7.1 Serco were contracted to provide Community Services for three years, effective from the 1

October 2012. Between 1 October 2012 and 31 March 2013 the then Primary Care Trust

(PCT) worked with Serco to finalise specifications and priority, Key Priority Indicators (KPIs). A number of these KPIs (outcome measures) were new, for example, the total number of KPIs had increased from 70 for the former service to 188 when Serco took over the contract, and as part of the negotiation process it was agreed that this set of KPIs, both new and existing, would form priority indicators.

7.2 The remaining indicators which are not prioritised, are to be reviewed if performance against the priority indicators falls below the contracted standards. It was agreed that the new priority indicators would need to be developed and information systems matured to ensure accurate reporting. In view of this, the Provider and Commissioner agreed to a period of three months to ensure that information relating to the priority KPIs was accurate and performance was delivered against the required standards. The date agreed for compliance was 30 June 2013.

7.3 A review of July performance against KPIs identified inaccurate reporting against the priority indicators and f a i l u r e t o achieve performance against the contractual standards. In addition, a proportion of the remaining KPIs, not considered a high priority, continued to underperform and some information relating to these indicators remained inaccurate or incomplete. The Service is currently achieving 134 of the Key Performance Indicators and not yet achieving 49. Serco continue to report through the contractual process on the ongoing work to improve data and reporting.

7.4 Following concerns with performance and the potential impact on patient services, three formal

Contract Queries have been issued.

a) Contract Query Notice CQ13/14-01 - Performance against Key Performance Indicators (KPIs) and accurate KPI reporting. These include Quality Requirements (QRs) to ensure that patients have a Care Lead, a care plan, access to pulmonary rehabilitation, falls assessment and timely response times in the Care Coordination Centre (CCC) and are also referred to as Group 1 KPIs.

Overall compliance against the Milestones in this Remedial Action Plan has been good with the Provider meeting the agreed action plans. However, the following requires noting:

Quality Requirement 95% of people that have been identified by case finding, (using risk stratification, or other means), and deemed suitable for intervention by the MDT, and referred to SCH, that have a Care Lead.

Outcome 1-Milestone (1): Partially met. The Provider was required to train 1 band 6 per Community Health Team to provide the Care Lead function (Care Lead Programme). 11 band 6 staff will have completed training by 31st December, however, these staff only represent 4 out of 12 teams. A trajectory has been provided which plans for 61 staff to have completed training by March 31st (Milestone 2). The outcome of this Remedial Action Plan trajectory will be that significantly more staff will be trained than required by the original KPI.

Quality Requirement 75% of patients requiring a joint community rehabilitation Care Plan have one in place ahead of discharge from acute hospital.

Outcome 7-slippage has occurred against a Milestone within this Outcome due to a delay in agreement involving several providers on a joint community rehabilitation care plan. This has resulted in a delay of compliance by one month. The joint community rehabilitation care plan has now been agreed.

Quality Requirement - reduction in acute hospital length of stay.

Outcome Measure 8-slippage has against a Milestone within this Outcome due to failure to agree a 'trigger tool' supported by 'pull-based' discharge. This has resulted in a delay of

compliance by one month. The 'trigger tool' supported by 'pull-based' discharge process and definition has now been agreed.

Summary Slippage has occurred in two of the Quality Requirement Milestones following difficulties agreeing process and definitions with parties (Work stream responsible), a responsibility of the Commissioners. These have now been resolved. A further Milestone has not met the trajectory for training Care Leads. This is on track for the end of the year.

b) Contract Query Notice: CQ13/14-02, Performance against the following Key Performance

Indicators (KPIs); ref; D5-ccc7, Urgent and Intermediate Response This relates to the following Quality Requirements:

Quality Requirement - % of referrals seen following triage within 4 hrs (urgent) – threshold of 95%

92% compliance is required by 1st December and 95% compliance is required by 1st January. Performance data is not available for December however, performance has improved to 89.3% in November;

All action Milestones, including accurate information reporting are submitted as compliant.

Quality Requirement -% of referrals seen following triage within 72 hrs. (intermediate) - threshold of 95%

92% compliance is required by 1st December and 95% compliance is required by 1st January. Performance data is not available for December however, performance has improved to 90.04% in November;

All action Milestones, including accurate information reporting are submitted as compliant.

c) Contract Query Notice: CQ13/14-03, Performance against the following Key Performance Indicators (KPIs); ref; c-gen8, Community Equipment Service (CES) KPIs – within 4 hours, next working day, 2 and 7 working days

This Contract Query was issued due to Serco not meeting response times following requested equipment, or collections and concerns following a Quality Improvement Visit (QIV) to Ellough Store. Discussions on the development of a Remedial Action Plan are ongoing. Serco have raised issues for discussion on the specification for this service.

7.5 As part of the ongoing process of contract monitoring and management, the following areas represent a sample of those under review at any point in time. Commissioners will seek additional information on the Service for review and scrutiny and discuss the process of the service area in meeting the KPI relevant to the issue.

Heart failure-service users seen in 14 days of referral-performance will be resolved by end March;

Community continence-service users re-assessed in 6 weeks-performance will be resolved by end February;

Dementia-awareness training-performance will remedied by year end;

Data correction analysis-new process shared-for review-improved number of duplicates and corrections showing reduction to 2%;

Epilepsy-non-urgent contact-under review as concerns with data accuracy;

Wheelchair-service users contacted-under review;

Leg ulcers-agreement of definition and reporting to be agreed.

7.6 The remainder of the Contract Quality Requirements failing to perform, namely (Group 2 and group 3 KPIs) have been reviewed with the Provider and plans have been jointly developed to ensure definitions are agreed and include dates for remedy.

8. Staffing / Recruitment 8.1 The full review of staffing and recruitment was forwarded to the C C G s ’ Patient Safety and

Clinical Quality Team on 9 December 2013. Serco forwarded the following supporting information for each community health team:

The current whole time equivalent staff levels

The current numbers of staff by grade who are absent on maternity leave or are considered as long term sick

A comparison of the current position with the ‘proposed model’, often referred to as our Target Operating Model (TOM)

An approximation of the temporary hours being used in each team, either by additional hours, bank staff hours or agency hours

8.2 This was originally sent to the CCG contracting team on 27 November 2013 and, to make sure the CCGs discussed a consistent set of data, it was resubmitted without change. During the meeting with Serco and the Clinical Quality and Patient Safety Team it was agreed that staffing levels within teams flexed when necessary and this should be considered when looking at any ‘snapshot’ of information.

8.3 One of Serco’s aims was to improve flexibility of staffing across areas rather than the ‘team centric’ view that SCH has traditionally adopted. The staff numbers in the proposed model reflected this and should be an important consideration when assessing the skills and resources available within a team or area on any given day.

8.4 Review of the staffing information and dialogue with the Serco team has enabled scrutiny of the staffing levels. Each team faces different challenges in the skill mix of its current vacancies.

8.5 A high level of transparency on the challenges of each service has been achieved and the CCG

continue to monitor the recruitment programme and vacancy management for the Service. In particular, in areas where teams have higher levels of vacancies, or are in historically “difficult to recruit” areas.

8.6 The majority of the posts currently in the recruitment process will be filled from the end of

February. In response to the current pressure across the health system and the recruitment challenges facing SCH (common across all community health services), Serco has invested in the following additional resource:

Additional and dedicated HR support on site to speed up the recruitment process and support the teams where required.

Nine additional admin staff to support the CHTs starting on 9 December 2013.

Centrally booking bank staff until end of February 2014 rather than on an ad hoc basis.

Reducing current Bank approval process from Local Area Manager to Team leader.

Lifting local restrictions for Agency Staff. 8.7 Serco’s bid submission was based on running the service with 293 whole time equivalents

(WTEs) in the community health teams and at 1 October 2012 there were 399 WTEs. As outlined below, Serco has modified its plans for this year and as such the ‘proposed model’ is based on a revised TOM for 2013 which it is now progressing. This revised TOM is based on 332 permanent positions with up to 25 bank or agency positions depending on demand which makes a total of 357 WTE positions (an overall change of 11% to the original TOM).

8.8 Serco has put safety first and has maintained that the CCGs would be involved in the assurance

process. Serco has adjusted its plans after reviewing and understanding the complexities involved. It is in a significantly different position to where they expected to be in terms of their bid position. A key factor in this was the decision not to make any clinical staff redundant. Another element has been the challenges with implementing the required IT system which means the original efficiencies that were envisaged in the bid have not yet been possible. A further factor is the activity levels and backlog inherited in some of the services which means the original reductions have not been feasible if they are to deliver the contracted level of service.

8.9 Serco state - ‘In response to what we have learnt about the service, and in line with our commitment to put safety first, we are currently in the process of undertaking an annual planning exercise with teams across SCH. We have agreed a set of planning assumptions (including benchmarked productivity goals, sickness levels by team etc.). These have been approved by the Clinical Quality and Governance Committee, to ensure they are the right balance between quality, safety and clinical effectiveness. We have modelled each Community Health Team based on these assumptions and shared these with the teams. Each team is being asked what they need, to run a safe and sustainable service - whether it is more, less or a different skill mix than what the model suggests. We are also benchmarking our staffing levels with Bromley Healthcare. We are using these three design points as the basis of a dialogue with the teams, the output of which we will be the staffing budgets for 2014.’

8.10 The Director of Nursing and Head of Operations undertakes weekly staffing reviews, using an

Early Warning Trigger Tool to assure the continued quality and safety of care delivery, acting on any staffing issues where appropriate. This staffing information is also reviewed by the Serco Leadership Team on a weekly basis, with the ability to escalate to the Contract Board and the Serco Health Executive if required.

9. Conclusions

The review has extensively reviewed all information available to Commissioners on Suffolk

Community Healthcare. In addition, Commissioners have encouraged comment from other

Stakeholders and providers including General Practice, the Local Authority and Acute Hospitals

to gather intelligence on the safety and quality of the Service. During the course of this review, it

has been possible to establish that the Services observed are provided safely, and that no

evidence of harm to patients as a result of the extensive transformation programme has been

identified, providing essential assurance to the Commissioners.

Work continues on a number of areas:

9.1 Improvements to the Working of the Care Coordination Centre

The issues and concerns identified in relation to the Care Coordination Centre have an agreed programme of action in place which includes review of triage, clinical staff training and a bespoke training package on revised systems and processes. Service development and governance is now supported by call monitoring and review for training purposes.

The ongoing monitoring of this service is managed by scrutiny of revised Key Performance Indicators as part of the contractual process.

SCH Response/Actions The Care Co-ordination Centre (CCC) was a key element of what was commissioned by the PCT, and at the heart of the new model of care. The aim was to provide a 24/7 referral service, which provided greater equity of access and consistency of referral process. This was in contrast to the previous system where a referral could sit on an answer machine for several hours before it was picked up. The contract is delivering the 24/7 care co-ordination is on target to achieve the CCC related KPIs for January 2014. It is recognised that such a transformational change in processes, systems and culture is not straight forward and we have had to adapt our approach on the way. The actions we have put in place to further improve the referral processes and CCC include:

Improvements in call answering time, which reached above 93% of calls answered in 30 seconds in December.

Improvements to the efficiency of how referrals are handled in the Care Coordination Centre (CCC ) to make sure the referral along with all necessary information gets to the clinician within the minimum amount of time.

Improvements to the effectiveness of the CCC through additional training and one-to-one reviews to improve the consistency between analysts.

Improvements to the triage process to ensure patients are seen in the time that is clinically appropriate.

Introduction of a revised referral form, through working with GPs, in order to capture key information as quickly and simply as possible.

Removal of a significant number of duplicate referrals through a managed data cleansing process resulting in improving efficiency through the provision of more accurate management information.

Support and coaching for team leaders in understanding and acting on management information.

Improvements to the recording and accuracy of the clinical record entered into SystmOne by the clinicians through the provision of additional training and support.

Reduction in the time to recruit to vacancies and filling all remaining posts.

9.2 Recruitment to Vacant Posts Staffing levels and high levels of vacancies in the service have been raised by staff and as a theme of concerns raised via the Contract Issues Log throughout the review. The information shared by Serco/SCH has clarified the position for all the Community Teams and in respect of each grade and professional discipline, enabling full scrutiny of the pressures on the Service. This issue continues to be of concern, despite significant action on recruitment. Monitoring of progress on recruitment to vacancies will continue, to provide assurance to Commissioners of robust and sustainable services. Communication of up to date information to GPs to enable clarity on current staff changes and progress on vacancy management will be essential to assure GPs that concerns raised have received the appropriate response.

9.3 SCH Response/Actions

Recent national coverage across the NHS has highlighted the challenges with nurse recruitment and we are no different in Suffolk.1 The situation in Suffolk was also exacerbated by the fact that in 2010, just before the tendering process began, 125 vacant posts were removed from SCH staff numbers by the PCT. Despite these challenges, we are committed to maintaining and building a safe and sustainable service and recruitment and retention is a key priority. We employ 924 staff, equating to 725 ‘Whole Time Equivalents’ (WTE). The actions we have in place to improve staffing and recruitment include:

We have filled 118 vacancies since taking on the contract and 40 roles since 5th December.

We have 45 new starters joining SCH between November 2013 and the end of February 2014.

We are recruiting to a further 59 vacant posts and 7 of these are at verbal offer stage.

We have commitment from the Serco HR Shared Services team to simplify and shorten our current recruitment process from vacancy to start date.

We are in the process of redrafting our advert on NHS jobs to make it stand out more to candidates. We are also investing in advertising in the key journals, including the Nursing Times and have recent success through this route.

A recruitment specialist has joined us for 3 months from 1st January to support the recruitment process and help staff who are finding it difficult to use the electronic system.

We have contacted all bank staff to ask them for their availability through to the end of February and are booking them in advance where possible.

Our agency provider is working with team leaders to book agency staff for clinical teams to help provide support until the vacancies are filled. We have also agreed escalated rates for hard to fill posts and locations to try and secure staff where possible.

1 Please see for example: http://www.nursingtimes.net/nursing-practice/clinical-zones/management/rcn-warns-of-hidden-

crisis-as-20000-nursing-posts-are-unfilled/5065205.article

9 temporary administrators started on 9th December to support the Community Health Teams. We are doing a review of what admin support is required for all clinical teams so we can implement a sustainable solution.

We have seconded an experienced operational manager from our Norfolk and Norwich University Hospital Contract to support the clinical teams on a daily basis with ensuring we have the right levels of staff and skills in each team.

9.4 Improvement of Staff Morale Staff morale has been a significant concern within the Service for some time prior to the commencement of Serco responsibility for SCH, due to the uncertainty created by the tendering process. The early implementation work on service transformation and the significant level of change to services has created an impact further lowering morale. This has been the subject of comment by staff and the GPs via the Contract Issue Log. Ongoing work by Serco on recruitment, communications, training and revised systems as part of a programme of action to address issues raised by staff, is being closely monitored to achieve assurance of improving morale. An ‘early warning trigger tool’ has also been developed and is now in use within services, managed by the senior clinical leadership, to monitor early signs of concern in services. This monitors case loads, vacancies, sickness absence and other key indicators flagging a warning of pressure on services and staff. SCH Response/Actions

We know some of our people have found it difficult transferring to a private contractor, rather than being directly employed by the NHS. We have implemented a great deal of change in a short time and recognise how difficult this has been. We are doing our best to alleviate any concerns.

We have established a change programme to address the issues the staff raised with the transformation.

We engage with staff in a number of ways, including roadshows, an intranet, team meetings, newsletters and regular meetings with union representatives.

In September we ran a series of listening events to hear from staff about areas we need to improve support and we have plans in place to address these.

In September we also completed a staff survey and received a response rate of 46% (415 out of 908). As well as answering the yes/no questions, many staff took the time to provide detailed and valuable feedback. We are in the process of reviewing every one of these comments and developing a draft action plan that we will share with staff for their input in January.

We have also identified 15 change champions (1 from each Community Health Team) to contribute directly to the programme and ensure the clinical perspective is heard.

One of the most consistent pieces of feedback from staff is the difficulty they have had in transferring to a private contractor and how they perceive this change. In response we have been working with Bromley Community Healthcare. They are a successful social enterprise and a provider of Community Services on a similar scale to SCH. They have been listening

to our teams and we have been drawing on their expertise in Community Services to build a plan that works for everyone in SCH in 2014. Bromley’s input and approach was broadly welcomed by the teams and so we have agreed an innovation partnership with Bromley Healthcare. The first priority in the partnership is to help us to improve staff engagement, morale and performance in SCH.

9.5 Improvement in Communications

A continued theme throughout the Quality Review has been a perception of poor communication in a number of key areas. This has been evident in internal service communications, noted by staff; in the contract issues log, with GPs and other services noting an absence of communications or lack of understanding on changes and raised by patients/staff in contact with the media. Staff have been subject to considerable uncertainty and change from well before Serco started running the community service contract and morale is poor. It is important that internal communication is improved in order to build understanding of the changes being made and to improve staff morale. Given the scale of the changes being made and the sensitivity relating to the contract, active high quality communication to the wider community will also remain important. The CCGs will continue to promote communications with Practices as crucial to the success of the transformation programme and will monitor action and progress by Serco on this objective.

SCH Response/Actions We agree that internal and external communication is vital to the effective implementation of organisational change. If organisational change is about how to change the individual tasks of individual employees, communication and information to these employees is vital and an integrative part of the change effort. Furthermore, if communication is poorly managed it can result in rumours and resistance to change. This can exaggerate the negative aspects of the change rather than create a coalition focused on the benefit to patients of the change.

We are keen to work with internal and external stakeholders to ensure we get this right, build on what we do well and focus on areas where we can improve. Actions to ensure we have strong internal and external communications include: GP input and perspectives are vital to how we design, transform and operate Community Services. As such one of the major components of the Serco Health bid for Community Services in Suffolk was to appoint a local practising GP as Medical Director, a new position. This senior position acts as a conduit for both local GPs and the CCGs to allow clinical input and a GP perspective to guide decision making within Community Services.

We are committed to ensuring each and every GP in Suffolk has a chance to influence how their Community Services are developed. To help facilitate this, our Medical Director Dr Amit Sethi, supported by a member of the Serco Health Executive Board, will be starting a new GP engagement programme in 2014 which will be launched alongside our primary care newsletter. The programme will involve an offer to every single practice in Suffolk to visit and hear GPs insights on Community Services and take back what we can and need to do differently. This will enable our service to be supportive and work in conjunction with primary care in offering patients high quality care.

From January we have agreed that all the issues raised by the GPs will go directly to the relevant Local Area Manager to respond to, and we will track the response and the themes that emerge. Previously these were managed centrally which did not always encourage relationships to develop at a local area level.

We will continue to engage with staff in a number of ways, including roadshows, an intranet, team meetings, newsletters and regular meetings with union representatives.

In September we also completed a staff survey We are in the process of reviewing every one of these comments and developing a draft action plan that we will share with staff for their input in January.

We have secured the ongoing support from Bromley Healthcare who have developed successful internal and external communication mechanisms and we will learn from their methods and apply them in SCH where appropriate.

We have been using the SystmOne training as a form of interactive communication and as an opportunity for people to safely explore new behaviors and ideas about change and change management.

We have also identified 15 change champions (1 from each Community Health Team) to contribute directly to the programme and ensure the clinical perspective is heard.

We are the process of developing and will hopefully shortly launch a dedicated ‘radio programme’ for staff. This will be a 10 minute weekly or fortnightly programme containing all the latest up to date information on changes, successes and key topics. It will include interviews with the leadership team as well as front line staff having the opportunity to talk about some of their achievements. This has proved to be a successful mechanism in other

mobile workforces as staff can access it anytime anywhere via a mobile phone.

9.6 Improving the Operational Model

The information on staffing continues to be triangulated with further visits to services, including discussions with GPs expressing concerns and staff raising issues in contact with GPs. Serco leads are working with the Patient Safety and Clinical Quality Team to scrutinise the information and understand progress on recruitment, including retention strategies. Key areas of ongoing development which were also raised through the QIV programme, by staff and via the Contract Issues Log are as follows:-

Mobile electronic record keeping

Documentation and continuity of care

Care Coordination Centre and Captain of the Day

Administrative support

Gaining feedback on how things are operating/early warning trigger tool.

Ongoing monitoring will be via revised Key Performance Indicators as noted at Section 7.

SCH Response/Actions

As with any major change, it is right that plans and models should be reviewed regularly on the basis of evidence and this is especially important in clinical environments. Some of the most significant changes within SCH took place during the first 6 months of 2013 and in the summer of 2013, senior managers undertook a review of the changes through visiting and listening to staff to determine what was working well and what still needed to be improved.

Following this work, a programme was established to develop areas that needed further improvement, including reviewing the ‘operating model’ for staff which is and always will be influenced by changes in the complexity and mix of patients under our care. The programme involves coordinating work on a number of initiatives including those mentioned above, for example:

The provision of additional training and support for clinicians in the use of the electronic clinical record system (SystmOne);

Increasing opportunities to access SystmOne both in the office and at home, resulting in more timely record keeping which is vital for safe and high quality care;

Evaluation of mobile record keeping and an adjustment to procedures to ensure that where appropriate paper records are left in the home for the benefit of carers and other agencies;

Improvements to the CCC (see section 8.1) including a review of the Captain of the Day role and the clinical triage process;

In addition to the increase in administrative support, a reassessment of the administrative tasks that are best undertaken via central resources in the CCC and those that are required to be performed locally;

Using ‘change champions’, listening events and senior management ‘back to the floor’ experiences in order to get direct feedback of the impact of changes and how staff are feeling;

Development and implementation of an ‘early warning trigger tool’ and other mechanisms so that potential problems are identified at an earlier stage when proactive action can be undertaken.

It is important to note that prior to October 2012 SCH was not using System1 as a clinical record. This meant that Serco had to include a move to an Electronic Patient Record onto an already demanding transformation. Also, the practices regarding data recording and amendments were not robust. We have invested heavily in addressing both issues so that data is now recorded and changed appropriately.

9.7 Improving the Working of the Community Equipment Store

The CES is the subject of a Contract Query and a remedial action plan is being developed. This work is being led by the Contracting Team and supported on Quality and Infection Control issues by the Clinical Quality and Patient Safety Team.

The detailed Remedial Action Plan will be monitored and managed through the contract monitoring process.

9.8 SCH Response/Actions

The Community Equipment Service (CES) has operated in the same way for a number of years and transforming this service has involved challenging embedded working practices. The contracted service level is also significantly higher than the service has had to provide previously and whilst significant progress has been made, we are clear that there are still improvements necessary. The service is wide ranging, complex, geographically dispersed and integrated within other organisations’ processes and as a result, change is taking longer to implement than was originally anticipated.

Managerial changes were made in autumn 2013 and a revised improvement programme developed in collaboration with front line staff. This programme has involved a number of improvements including:

An evaluation of delivery and collection schedules resulting in changes so that deliveries and collections are now made in every postcode on every day of the week (previously some post codes only received service on one or two days a week

Improved flexibility working across multiple locations so that a more consistent service can be provided and the service behaves as a single entity

Analysis of requisitioning and ordering processes resulting in the identification of areas for efficiency improvements which have resulted in the majority of orders being placed the next day

Additional staff and vehicles being deployed in order to manage peaks in demand (for example to manage an increase in hospital discharges)

Improved communication with stakeholders through the establishment of regular meetings with all customers and structured feedback

Development of management information around key operational metrics enabling the comparison of performance across the county

Streamlined administrative processes, enabling more time to be spent on the phone liaising with customers and suppliers

An improved auditing and stock taking programme leading to more accurate inventory information

A programme of infection control audits and inspections leading to actions being undertaken to improve the safety of the service

9.9 Further Development of Engagement with Service Users

Serco are developing a ‘best practice’ model for engagement with service users in a community health setting. This work has previously focused around Community Hospitals, with little engagement other than on paper surveys, with the broader client group of the Community Service. Commissioners are working closely with Serco to ensure connection with the community engagement work of Commissioners in this important area.

SCH Response/Actions

Serco are developing a ‘best practice’ model for engagement with service users in a community health setting. This work has previously focused around Community Hospitals, with little engagement other than on paper surveys, with the broader client group of the Community Service. Commissioners are working closely with Serco to ensure connection with the community engagement work of Commissioners in this important area.

We have commenced engagement with external stakeholders – in particular with patient representative organisations. It is planned to bring these groups together in a round table discussion to determine “best practice” for stakeholder engagement moving forward.

The appointment of a Patient Experience Manager has facilitated engagement with clinical and non-clinical teams in development of the Patient Experience agenda, ensuring patient experience is “everybody’s business” and we all contribute to ensuring patients, families and carers receive a quality service

To ensure we capture a broader range of patient and carer views we have reviewed our patient experience survey – incorporating areas of the patient journey that patients have nationally identified as being of importance to them. In addition, following transfer to Serco the organisation was committed to understanding patients existing concerns and areas for improvement and therefore a baseline survey of patient experience was commissioned. We have reviewed the results of this survey, developed actions and have incorporated ongoing monitoring of these areas of improvement by including them within our monthly revised patient experience surveys.

We have also extended our patient experience surveys to cover a wider range of patients and carers, surveying patients receiving services from our Community Hospital Inpatient units, Community Health Teams, Minor Injuries Unit, and for patients with a Long Term Condition and Dementia diagnosis. We are also implementing a process for ensuring our specialist services and clinic services together with enabling services (Wheelchairs and Community Equipment Service) are also included within our routine collection of patient

views.

Historically our surveys have been purely paper based but with the introduction of the Care Co-ordination centre we have been able to introduce telephone surveys, and so for those of our patients who may not wish to complete a paper survey or find difficult with this they are now able to talk with someone directly about their experience with us. Within our MIU and Community Hospitals we have been trialling the use of IPads to collect information and also are to commence involving our domestic staff in supporting patients to express their views on the care they have received.

Whilst the patient experience surveys allow us to understand broadly the areas of good practice and the areas where we may need to improve it does not allow us to collect detailed information and understand some of the small nuances of a patients care that if we were aware would enhance the care we deliver. To address this, we have implemented within the Community Hospitals a project to capture “The Patient Story”. This incorporates a detailed taped or videoed discussion with a patient and their carer/relative discussing the entirety of their inpatient stay with us and to tell the story as they wish to – not directed by ourselves or a set of survey questions. This has been extremely successful and rewarding with ward staff hearing about the positive aspects of the care received but also areas for improvement. Action plans have been developed for each hospital with the Modern Matrons taking responsibility for the delivery of these improvements. Within our CQUIN framework for 1415 we shall be extending this work to incorporate our Community Health Teams.

Complaints are an important part of the learning and improving cycle. We have completely reviewed how we respond formally to patients but most importantly many are now contacted in person in order that they have the opportunity to speak with someone directly in the organisation. This allows the concerns of the patient and/or relative to be explained clearly and demonstrates to the patient our commitment to ensuring we take all patient views seriously in order to make improvements where necessary.