Community and Social Services for Adults and Older Adults – Follow-up

established to manage and monitor the implementation of agreed

implementing agreed recommendations and the extent to which the improvement areas

Adequacy of plans for the implementation of any outstanding recommendations

Area

Evaluation

Evidence base

Assurance processes

The ESMT meeting in September 2017 did not ensure that all recommendations – and more importantly all planned outcomes – were properly considered and accounted for.

It reviewed only five of the 15 recommendations, with no explanation as to why all 15 were not revisited. Notes from the meeting show that:

Area

Evaluation

• despite outcomes' being relatively well described in the action plan submitted to the PAC, the discussion was limited to evidencing completion of tasks: for example, establishing standing items for SMT meetings;

• managers did not know why some tasks scheduled for early implementation and intended to become routine practice (such as the sample quality review of case files due to commence in June 2016) had not been actioned. The meeting discussed the need for a forward plan to establish the practice;

• key developments required to underpin quality outcomes were not in place: for example, service standards had not then been set out; and

• there was little corporate memory' at the meeting: the Managing Director C&SSD, and the Director, Community Care & Health, were both absent.

This meeting was in any case unsuccessful in establishing an assured position: in October 2017, two weeks after ESMT met, the C&SSD Finance and Performance meeting noted:

To date no response received [so X] to sit with each Head of Service / Director to go through evidence required for the C&AG's recommendations

In December 2017 HCS's Director of Finance and Performance asked the newly appointed Interim Director of Governance for Community Services to establish an evidence based position. From this work:

• all 15 recommendations were considered open' (not achieved);

• gaps in assurance or controls were identified for all recommendations;

• a new set of actions to resolve these gaps was established; and
• a timetable for delivery concluding in December 2018 was set out. However, as detailed below, this was not achieved.

Management response to non-delivery

As owners of the action plan as submitted to PAC, HCS's Management Executive (MEx) did not perform a monitoring role.

In October 2016 HCS's MEx appointed an Assurance Officer on a temporary agency contract to record and report on the status of recommendations from internal and external reports. HCS's Assurance Officer first contacted C&SSD for an update on actions in November 2016. Further emails and face to face meetings for the next eight months elicited no information on the status of recommendations.

Area

Evaluation

During this period, MEx meetings failed to address the Assurance Officer's comments contained in the Integrated Performance Report, such as in August 2017:

Still attempting to obtain a satisfactory update on recommendations in the 2015 C&SSD report. A response was first requested in November 2016.

Following the December 2017 review of the action plan, in January 2018 the Assurance Officer reported in the Integrated Performance Report that all 15 actions were now open'. There is no record of MEx responding to this clear failure to deliver the action plan.  

Record keeping

Progress against the action plan has not been consistently recorded: setting aside the lack of recorded evidence, even the status of actions within the action plan has not been properly tracked. The first comprehensive documented consideration was not until January 2018.

Intended outcome:  Actions and summary  Evaluation HCS's Feb 2016 plan  position Dec 2018

R1: Establish clear milestones for the completion and implementation of the C&SSD-wide

governance framework, covering all C&SSD services, business as usual' and change

initiatives, and monitor delivery against those milestones.

C&SSD governance framework in place which has been developed, implemented and embedded and aligned to HCS corporate governance arrangements.'

As detailed in Exhibit 4, C&SSD has mapped its governance structures and developed a governance framework. However the framework:

• is incomplete – service level team meetings are not included; and

• is untested – no review or audit process has been undertaken to assure the framework.

Outcome not met

Community Services' governance arrangements remain inadequate, risking:

• quality of care;
• staff safety;

• continuous learning / improvement; and

• value for money.

R2: In developing the workforce strategy for C&SSD, identify specific measures to reduce

reliance on interim staff

Permanent staff are recruited and retained.

Staff morale is improved.

Jersey is a desirable place to work.'

There is no HCS-wide workforce strategy. C&SSD has worked to redesign service delivery and to identify resource needs, but this has been undertaken in isolation and is not complete.

Actions are not achieved:

• a Chief Social Work Officer role is agreed but not established;

• succession planning is ineffective due to the lack of:

o  personal development plans: only c. 36% of community staff had

Outcome not met

Piecemeal efforts have lacked any systematic understanding of:

• the skills and capacity needed to meet longer- term objectives (including safe staffing levels);

• priorities for development of the current workforce to meet these; and

• productivity and efficiency opportunities.

The risks I identified in 2015 have not been mitigated. High reliance on interim staff

Intended outcome:  Actions and summary HCS's Feb 2016 plan  position Dec 2018

Evaluation

an appraisal recorded in 2018;

• guidance to promote consistency and equality of opportunity; and

• a process to monitor any impact; and

 a baseline position of staff morale has not been determined.

can:

• dilute the capacity to lead in a time of change;

• affect consistency and continuity of care; and

• impact on value for money.

R3: Put in place steps to evaluate the effectiveness of work designed to improve

engagement with C&SSD staff and make changes where necessary

Effective engagement is improved and evident with staff in all areas across the service.

Staff communicate freely with confidence.

Staff morale is improved.'

C&SSD has failed to develop and implement an engagement strategy. Initiatives such as:

• meet the team' bi-annual meetings;

• new starter' lunches; and

• a confidential email address for queries to senior managers

have been taken but:

• management has not assessed the efficacy of such initiatives; and

• these are not part of a comprehensive approach to meet the needs of all staff groups.

Importantly, there is no protocol on responding to feedback, including that received via the confidential email address.

Outcome not met

Community Services has not:

• achieved a strategic approach to staff engagement;

• ensured the approach meets business and staff needs; or

• established indicators to measure the impact of engagement.

As I reported in 2015, having disengaged staff risks:

• achievement of operational and strategic objectives;

• compliance with policies;

• a shared view of risks / opportunities for improvement;

• stability of workforce and staff morale; and

• value for money.

Intended outcome:  Actions and summary  Evaluation HCS's Feb 2016 plan  position Dec 2018

R4: Establish and monitor implementation of effective arrangements for reporting,

evaluating, escalating and responding to risks

None is recorded

The individual actions that C&SSD listed in its 2016 plan lack a focus on any outcome. For example:

• Health and Safety' and Risk' were to be included in meeting agendas by April 2016 – but in 2018 C&SSD identified that not all staff understood how to identify and report risks;

• risk registers at service level were to be challenged twice yearly by SMT – but this happened only twice and nothing is recorded to show what was found; and

• from June 2016 line managers were regularly' to sample case files to ensure completion of individual risk assessments. But there is no:

o  guidance to support a consistent approach;

Not fully implemented

Community Services has not adequately supported – or challenged - staff to improve arrangements for reporting, evaluating, escalating and responding to risk.

The lack of a clear intended outcome indicates that Community Services did not understand why it was undertaking these actions.

Consequently there is nothing in place against which to monitor performance and progress.

The impact of this failure can be seen in the Case Study on failures in Health and Safety below.

Intended outcome: HCS's Feb 2016 plan

Actions and summary position Dec 2018

Evaluation

• follow-up to ensure it was happening;

• record of findings; or

• evidence of shared learning.

Intended outcome: HCS's Feb 2016 plan

Actions and summary position Dec 2018

Evaluation  

R5: Develop mechanisms for sharing information between FACE [see Note] and the newly

procured system for Children's Services to facilitate management of whole family issues

Staff across the service access information appropriately, routinely and easily about service users of all ages.'

The FACE (now called Care Partner) system has continued to be used for Adult and Older Adult Services and so any mechanistic' improvements in data sharing capabilities were reliant on the specification of the new Children's Services IT system. The actions listed are about specifying and

Outcome not met

Despite having the opportunity to do so, management has not prioritised information sharing in support of high quality, joined up care.

Significantly, the outcome' identified by Community Services is an output': it does not clearly set out the

Intended outcome: HCS's Feb 2016 plan

Actions and summary position Dec 2018

Evaluation  

tendering for this new system and the need for a portal' interface as the data sharing solution.

However, the action plan does not address the wider, sometimes cultural and behaviour based, barriers to information sharing within and between services.

benefits of appropriate sharing of information – that is, reducing risk to patients, service users and to staff.

The risk continues that poor or inconsistent sharing of data hampers identification and management of whole family, often complex, issues.

R6: Develop a set of expectations and a timetable for the provision of management

information from FACE [see Note] and monitor delivery.

Performance management information is collected, analysed and used to improve services and make best use of resources.'

While some actions are completed the outcome has not been delivered.

C&SSD has:

• developed a framework for Adult and Older Adult Services data as part of HSC's Integrated Performance Report; and

• included HCS's Head of Informatics in QAGS meetings to develop performance indicators.

However, specific information from the Care Partner system – for example response times to complete assessments, or the quality of assessment information – is not routinely reported.

Outcome not met

The potential to develop and use management information from a range of sources, including the Care Partner system, has not yet been exploited.

Risks continue that valuable performance information is not available or not used:

• strategically to improve adult services;

• operationally to make best use of resources; or

• at a team and staff level as part of appraisals.

R7: For all C&SSD services:

 develop clear performance standards;

 identify the data required to monitor these;

 establish data quality criteria for all data items; and

 ensure information systems routinely record performance against service standards.

C&SS has a robust performance management system in place which supports quality service.'

My recommendation set out a logical order starting with performance standards – but these are not established for all services.

Outcome not met

There has been an inadequate focus on setting service standards and identifying relevant hard data

Intended outcome: HCS's Feb 2016 plan

Actions and summary position Dec 2018

Evaluation  

The September 2017 ESMT noted:

Service standards will need to be developed and integrated

At the same time ESMT rated other actions as achieved': for example:

• developing dashboards; and

• taking reports to the Finance and Performance meetings.

In the absence of comprehensive standards, it is difficult to understand how performance dashboards and reports can have been expected to be useful as a basis for making decisions.

and softer intelligence as a basis for decision making.

Currently Adult and Older Adult Services cannot:

• monitor progress against goals and objectives, including quality;

• secure an evidence base for decision-making, risk assessment, forecasting and planning;

• shift from inputs' towards outcome' indicators; and

demonstrate value for money.

R8: Establish a clear programme with milestones for delivery and use of summary

information for all community and social services, including KPIs and dashboards, and

monitor delivery.

Performance management information is used appropriately and proportionately and is part of a learning culture.'

C&SSD's KPIs and dashboards are not explicitly aligned to its business priorities - for example, the impact of the Safely Removing Costs programme.

C&SSD has not yet articulated the benefits of and made decisions about sharing summary information:

• routinely with staff; and

• across stakeholder groups.

Outcome not met

Being unclear on how or where data will be reported and used risks:

• confused governance roles and responsibilities;

• poor staff engagement; and

• missed opportunities to improve transparency and openness.

R9: Monitor access to policies, procedures and guidance and take corrective action as

necessary.

Staff are using appropriate systems to ensure their interventions / treatment are

C&SSD has not established any process to monitor access to policies.

Outcome not met

Management has not acted to mitigate very real risks

Intended outcome: HCS's Feb 2016 plan

Actions and summary position Dec 2018

Evaluation  

in line with policy, legislation, procedure and guidance.

Practice development and engagement sessions are informed by information obtained.'

In 2015, an external company was providing a service to C&SSD to update and maintain policies and procedures online. However, in 2016 this contract ended and no alternative system was established.

C&SSD also planned to include compliance with policies as a required part of staff supervision sessions and staff appraisal. However, there has been no follow- through to understand the extent to which this is happening and no report on any findings (see also R10 below).

and issues: since my report was published there have been:

• Serious Case Reviews which cite lack of compliance with policies; and

• Health and Safety Inspectorate improvement notices (see Case Study) which note poor understanding of key policies.

Without information on how staff access policies the risk is increased that:

• staff are unaware of - and non-compliant with - policies and procedures;

• practice is out of date; and

• staff feedback is not used to ensure policies are fit for purpose.

Intended outcome:  Actions and summary  Evaluation  HCS's Feb 2016 plan  position Dec 2018

R10 Identify steps to improve:

 the recording and monitoring of the completion of annual appraisals; and

 the incidence of annual appraisals and their effectiveness.

All staff will be provided with the opportunity to receive an annual appraisal.

Appraisals are linked to supervision and training needs assessment.

Performance against appraisal target achieved.'

Management has clarified and communicated roles and responsibilities in staff appraisals, including mechanisms for reporting non-compliance. However, this has not improved the incidence, recording and monitoring of annual appraisals.

When ESMT met in September 2017, it simply noted that:

appraisals should be completed and recorded.

ESMT did not though seem to recognise the pivotal role of appraisals in other recommendations (see R12).

The three actions noted in 2018 as required to close fundamental gaps in assurance and control are yet to be completed.

Outcome not met

Community Services has no clear picture of the incidence of annual appraisals and their effectiveness. Management cannot be sure that appraisals mitigate risks to:

• quality of staff performance;

• service user and staff safety;

• staff development and succession planning;

• compliance with policies; and

• communication and engagement.

R11: Establish a timeframe for the roll-out of the Practice Workbook and monitor delivery.

The Practice Workbook is in use across the service.'

C&SSD identified two actions:

• roll-out to adult Mental Health services in early 2016; and

• review and roll-out to all services by July 2016.

The Practice Workbook was introduced in adult Mental Health services in 2016. However, there was:

• no documented evaluation of its use and

Outcome not met

Interim managers are not clear whether or where the Practice Workbook is being used.

The Practice Workbook was developed in 2015 to help staff:

in the process of reflecting on their daily working practices to understand how it influences the outcomes attained by people who use

Intended outcome: HCS's Feb 2016 plan

Actions and summary position Dec 2018

Evaluation  

value; and

 no formalised roll-out to other services.

In 2018 senior management struggled to establish how this recommendation has been managed and the current status of the Practice Workbook.

services, and carers'

It remains unclear how Adult and Older Adult Community Services intend to meet this important aim.

R12: Identify a longer-term solution to delivery of identified training needs

None is recorded

The individual actions that C&SSD listed in 2016 lack a focussed outcome: C&SSD cannot determine whether actions have been successful.

C&SSD's action plan included that Training Needs Assessments (TNAs) would be undertaken as part of staff appraisals. Managers cannot be confident in staff appraisals as a vehicle for improvement.

C&SSD noted in 2018 that without good TNAs it could not be sure that expenditure on training was:

• aligned to business and staff need; and

• prioritised, including in terms of:

• mandatory;

• professional / regulatory; and

• service and personal development.

Not implemented

In 2015 I reported a piecemeal approach to identifying and delivering training. Although some action has been taken, Community Services cannot be confident that the position has improved.

Without a robust system of staff annual appraisal, management cannot assess the type and volume of staff development and training required.

Community Services still runs the risk that:

• training needs are not identified or properly prioritised; and

• the training budget does not deliver value for money.

Intended outcome:  Actions and summary  Evaluation HCS's Feb 2016 plan  position Dec 2018

R14: Adopt a C&SSD-wide risk based framework for review and / or accreditation and / or

audit of all services and monitor its implementation

Required improvements in quality and service developments are clearly identified and actioned.

Validation of performance against agreed standards is evidenced by audit activity.

C&SS has a culture of learning in place.'

There has been activity in this important area but C&SSD has not achieved its plan to:

• drive audit strategically in line with business needs;

• programme risk based audit; and

• prepare for the coming into force of key provisions of the Regulation of Care (Jersey) Law 2014 (due September 2016).

Fundamental issues are unresolved:

• the January 2018 updated action plan noted a lack of evidence that staff undertaking audits had attended any audit training; and

• HSC's Clinical and Care Audit and Effectiveness Department has highlighted concerns that:

o  audit reports do not always have well developed action plans;

Outcome not met

Management has not established an effective framework where targeted and well managed audit reduces risk.

Additionally, whatever activity is being undertaken, there is no process in place to ensure it is:

• of a high quality; and

• used to drive improvements.

The lack of preparation for the Regulation of Care (Jersey) Law 2014 is worrying - as I set out in my 2018 report Governance Arrangements for Health and Social Care.

Intended outcome: HCS's Feb 2016 plan

Actions and summary position Dec 2018

Evaluation

• where there are action plans, these are not always formally monitored; and

• audits are abandoned for no clear reason.

R15: Adopt a C&SSD-wide structured approach to:

 monitoring implementation of agreed actions arising from reviews, accreditation

and complaints; and

 assessing the effectiveness of the action taken.

Services are responsive to the needs of those who use them.

Stakeholders experience improvement based on their feedback.

Improvement is data driven and evidence informed.

Improvements in performance can be tracked and linked to specific quality standards and indicators.

We know what we do well and where we have areas for improvement.'

The outcome that C&SSD set itself in delivering this recommendation was ambitious: it rightly focussed on service users and the importance of taking every opportunity to learn and improve service quality.

However, the actions required to achieve this have not been delivered: there were significant flaws in C&SSD's approach to managing and monitoring the implementation and impact of improvement plans.

In 2017 the ESMT meeting seemed to consider this recommendation to be closed' i.e. delivered, at the same time as discussing holes in the evidence for a number of my other recommendations.

Outcome not met

Failure to implement accepted actions from my 2015 report means that Community Services:

• does not consistently use learning to drive improvement;

• has few service quality standards against which to evaluate and improve services;

• has an under-developed set of management information – including from staff appraisals and IT systems - for use in assessing progress and identifying priorities;

• cannot show that money is well spent on targeted audits, reviews and accreditation, from which changes are made; and

• runs the risk that patients, service users, carers and staff do not feel their views are valued.

Overall arrangements

•Poor / unclear

corporate approach to safety

•Ineffective

process to report / resolve issues

•Lack of

proactive management

•Temporary

staff not properly managed e.g. training

Risk assessment processes

•Ineffective risk

policy

•Failure to

assess and control risks

•Poor /

confused risk reporting

•Staff 'give up'

reporting risk as not resolved / staff feel vulnerable

Information and communication

•Standards not always clear

•Failure to

respond to staff complaints / comments

•Staff views not

routinely sought

•Staff made

approaches to HSI because not listened to

Implementation

•Staff not

adequately involved in decisions e.g. choice of alarm

•Failure to

ensure training needs assessed / met

•Mandatory and

refresher training not well identified / monitored

Monitoring activity

•Lack of

sustained progress on agreed action plans

•Incidents not

driving organisational learning

•Poor record

keeping

•Inadequate

process to ensure action has desired impact