Board of Directors 22 nd May 2015

AGENDA ITEM: Item 14 Board of Directors 22 nd May 2015 PRESENTED BY: PREPARED BY: Jan Bloomfield, Executive Director of Workforce and Communications Denise Needle, Deputy Director of workforce (Development) DATE PREPARED: 8 th May 2015 SUBJECT: PURPOSE: Staff Survey proposed action plan Information and approval EXECUTIVE SUMMARY: Please find attached a report outlining the proposed action plan for the Staff Survey results for 2014. The national NHS staff survey provides a very useful source of data on number of the issues raised by the Francis Report, especially staff engagement, staff views on quality of care, on willingness to raise concerns and to recommend the services of the organisation (the friends and family test). This together with other data will enable us to identify key issues and develop a strategy for dealing with the priorities. The 2014 NHS staff survey places West Suffolk Hospital in the top 20% of trusts nationally in 11 key areas. Trust has also been placed in the top 100 as a Best Place to Work by the Health Service Journal, with only 41 other Acute Trusts. We have been shortlisted as one of the best, and await the outcome. The results of the Q4 Staff Friends & Family Test are also attached for information, and an action plan is provided to address those areas where improvements have been identified. These have been taken from the results where we are red (red = negative finding e.g. in the worst 20% of acute trusts, worse than average or worse than 2013). At this stage we are unable to benchmark ourselves nationally. When this information is available we will brief the Board of Directors. A review of the action plan will be taken to the Patient Experience Committee in six months time. Linked Strategic objective (link to website) Issue previously considered by: (e.g. committees or forums) Risk description: (including reference Risk Register and BAF if applicable) Description of assurances: Summarise any evidence (positive/negative) regarding the reliability of the report To continue to secure, motivate, skill and develop an engaged workforce which will be able to provide high quality patient focused services Board of Directors, Council of Governors, Patient Experience Committee Staff morale, turnover etc. internal and external reputation Staff survey provides external assurance. Required as part of NHS England/Foundation trust requirements.

Legislation / Regulatory requirements: Forms part of CQC inspection. Other key issues: Workforce morale, turnover and patient care. (e.g. finance, workforce, policy implications, sustainability & communication) Recommendation: To note the results of the staff friends and family test, and to approve the proposed action plan. 1. Introduction to this report The results of the 2014 Staff Survey are very positive for the Trust and saw us score in the top 20% of trusts nationally in 11 key areas. This included recommending the hospital as a place to work or receive treatment, job satisfaction levels and staff agreeing their role makes a difference to our patients. However we still need to work on those areas where we did not score so well. This report presents proposed action plan arising out of the 2014 national NHS staff survey conducted in West Suffolk NHS Foundation Trust in September 2014. (Appendix A) We are also taking this opportunity to report on the additional Staff Friends and Family Test that is conducted over the additional 3 quarters of the year. The latest available figures are for 2014/5 Q4. (Appendix B) Additionally we have also attached the additional survey information presented to the Board of Directors at a previous Board meeting (appendix C) 2. Overall indicator of staff engagement for West Suffolk NHS Foundation Trust The figure below shows how West Suffolk NHS Foundation Trust compares with other acute trusts on an overall indicator of staff engagement. Possible scores range from 1 to 5, with 1 indicating that staff are poorly engaged (with their work, their team and their trust) and 5 indicating that staff are highly engaged. The trust's score of 3.90 was in the highest (best) 20% when compared with trusts of a similar type. OVERALL STAFF ENGAGEMENT Page 2 of 14

The table below shows how West Suffolk NHS Foundation Trust compares with other acute trusts on each of the sub-dimensions of staff engagement, and whether there has been a change since the 2013 survey. Page 3 of 14

Staff survey 2015 Action Plan 2014 Staff Survey Appendix A Key factor Commentary Proposed actions Lead Timescale KF16. Percentage of staff experiencing physical violence from patients, relatives or the public in last 12 months Rostering & Training Improvement Manager Training providers On-going April 2015 KF17. Percentage of staff experiencing physical violence from staff in the last 12 months KF12, 13 & 15. Percentage of staff witnessing potential harmful errors, those reporting errors, near misses or incidents witnessed in the last month and those not feeling secure in raising concerns. There has been no change in the overall % over the last 12 months and staff concerns remain an issue. On further investigation, there were 87 physical assaults on staff in total over the last 12 months and all were by patients on staff. These were recorded as due to dementia or delirium, alcohol or detox related There is cause for concern that this is reported as happening at all. The breakdown of the 13 staff who responded; 2 experienced physical violence from other staff between 3-5 times, and 1 stated more than 10 times. No formal complaint, occupational health referral or grievance was initiated at all over this period that could explain these results. 2 of staff were identified as coming from the Medical & Surgical Directorates. There have been changes to the way staff report incidents, and this may have had an effect on the number of incidences being reported. Information and training to be reviewed and Line managers to encourage and support staff in reporting issues. Of the 132 staff that saw potential harm, 11 (7.4%) did not report it and a similar percentage (6.8%) did not feel the organisation treats these reports confidentially. Errors not reported are evenly spread through the Clinical Directorates, with the Surgical Directorate indicating that reports are not treated confidentially 1. Booking arrangements and take up of mandatory training programmes and refresher programmes will continue to be monitored. 2. Verbal and written feedback and evaluation of the training to be analysed to identify benefits. 3. Internal learning programmes on Dementia, Confusion and Detox to continue as well as access to a specialist nurse and Dementia Champions on the wards. 1. Initial discussions of how to prevent further incidences will start in the Medical & Surgical Directorates 2. The Trust Policy on Bullying & Harassment was updated in 2014. All managers and Union representatives to make staff aware of content and purpose. 3. Staff are to be reminded of the Trusted Partners role as part of communication messages. 1. Confidentiality and other factors of incident reporting will be addressed through clarification of the reporting process, and review of teaching, learning and benefits to staff, patients and organisation. 2. Introduce a mechanism of giving feedback about changes made in response to reported errors. Dementia Trainer HR managers Union representatives Senior and line managers Communications Health and Safety Advisor Line managers Health and Safety Advisor Senior and line Managers On-going On-going On-going

KF 26. Percentage having equality and diversity training in last 12 months KF5. Percentage of staff working extra hours This subject had previously been risk assessed and was not a mandatory training subject. However the Mandatory Training Steering Group (MTSG) made the decision to include it in the mandatory training matrix as of January 2015. Current compliance levels are around 45%, with a target of 80% to be met. We have been monitoring hours worked through our Healthroster system. At September 2013 staff were 8.1% over their contracted hours In September 2014 they were only 2.2% over their contracted hours. This is a reduction of 5.9% 1. E&D training is available through elearning for all staff groups. 2. In addition E&D issues are also included as part of Trust Induction 3. Medical lunchtime face to face learning sessions are also being used to promote E&D to medical staff. (6 monthly) 4. Regular reporting will commence on this subject as it is now included in the mandatory training matrix. 1. The Trust will invite the Staff governors to undertake further research into this factor. (Initial analysis suggests it is predominantly those aged 31-40, in the following occupational groups; medical and dental, registered nurses and physiotherapy) 2. Work will continue through Healthroster to ensure staff are not consistently working over their contracted hours, and managers are being encouraged to cap working over at 2 shifts worth of hours and give staff back time who are owed it. This is monitored through the net hours reports which are published 4 weekly. Deputy Director of Workforce Rostering & Training Improvement Manager Staff governors Healthroster team Started January 2015 July 2015 Started 2014, will continue in 2015 KF7. Percentage of staff appraised in the last 12 months KF29. Agreeing feedback from patients/ service users is used to make informed decisions in their directorate/ department Appraisal compliance has been increasing slowly in the staff survey. Up this year by 5 %. Monthly reports are produced for line managers as part of KPI s. We anticipate that the introduction of ESR2 in 2015 will offer opportunities to streamline the appraisal process. This is a new key factor for 2014, and has not been asked previously. 1. We will continue to vigorously report compliance at all levels in the organisation. The system for reporting will be refined to try and reduce the anomalies that are occurring. 2. Two members of HR staff will be seconded specifically to work with Line Managers to deliver this and other key performance indicators. 3. An internal audit process will commence where a spot check by directorate will take place. The person undertaking the audit will ask to see completed appraisal documents and Personal development Plans (PDP) 1. Improve communication in ward and department areas as to feedback received and decisions made. 2. Publicise outcomes of public consultation/ feedback initiatives. Executive Director of Workforce and Communications Workforce Information Analyst Deputy Director of Workforce All Line Managers HR Project officers Workforce Team Nursing Directorate Communications Reported monthly Page 5 of 14

Appendix B Friends & Family Test questions Question How likely are you to recommend this organisation to friends and family if they needed care or treatment? How likely are you to recommend this organisation to friends and family as a place to work? Base Picker Average Trust % score Target Target met Change vs. last quarter Lowest (to date) Highest (to date) 830 81% 93% 67% Yes 2% 91% 93% 821 65% 82% 61% Yes 3% 79% 82% Q1 How likely are you to recommend this organisation to friends and family if they needed care or treatment? STAFF GROUP % Add Prof Scientific and Technic 88% Additional Clinical Services 91% Administrative and Clerical 94% Allied Health Professionals 95% Estates and Ancillary 86% Healthcare Scientists * 0% Medical and Dental 91% Nursing and Midwifery Registered 94% Page 6 of 14

Q2 How likely are you to recommend this organisation to friends and family as a place to work? STAFF GROUP % Add Prof Scientific and Technic 72% Additional Clinical Services 79% Administrative and Clerical 80% Allied Health Professionals 91% Estates and Ancillary 86% Healthcare Scientists * 0% Medical and Dental 88% Nursing and Midwifery Registered 84% Question 1 Question 2 Page 7 of 14

Summary of all Key Findings for West Suffolk NHS Foundation Trust Appendix C

Key Findings for West Suffolk NHS Foundation Trust 419 staff at West Suffolk NHS Foundation Trust took part in this survey. This is a response rate of 53%1 which is in the highest 20% of acute trusts in England, and compares with a response rate of 57% in this trust in the 2013 survey. This section presents each of the 29 Key Findings, using data from the trust's 2014 survey, and compares these to other acute trusts in England and to the trust's performance in the 2013 survey. The findings are arranged under six headings the four staff pledges from the NHS Constitution, and the three additional themes of staff satisfaction, equality and diversity and patient experience measures. Positive findings are indicated with a green arrow (e.g. where the trust is in the best 20% of trusts, or where the score has improved since 2013). Negative findings are highlighted with a red arrow (e.g. where the trust s score is in the worst 20% of trusts, or where the score is not as good as 2013). An equals sign indicates that there has been no change.