This is an HTML version of an attachment to the Freedom of Information request 'Effective checking procedures.'.


 
BOARD – SUMMARY REPORT 
 
Date of Board meeting:  

9th June 2009 
 
Title of Report: 

 
Action Plan to Respond to 2008 Staff Survey 
 
Title of Director: 

 
Executive Director of Workforce & Environment  
 
 
 
 
 
Paper Number: 
 
WL1590 
 
Purpose of the report: 

 
The Board is asked to approve the enclosed action plan at Annex B with specific action relating 
to  workforce capacity, competence, care and communication 
 
 
Recommendations to the Board: 
 
The Board is asked is asked to approve the Action Plan, and to note proposed leads, timescales 
and to receive regular monitoring reports as outlined in the action plan and the Bullying and 
Harassment workstream is included as it is derived from staff survey evidence but is subject to a 
separate report to the Board meeting. 
 
 
Action required: 

 
The Board is asked to approve the action plan to the 2008 Staff Survey. 
 
 
Relationship with the Assurance Framework (Risks, Controls, and Assurance): 

CO9 To achieve Foundation Trust equivalent status 
CO1 To further develop and measure safe and high quality care 
 
 
Healthcare Standards (Core / Developments): 

 
C11: ensuring that staff concerned with all aspects of the provision of healthcare are 
appropriately recruited, trained and qualified for the work they undertake. 
 
 
Summary of Financial and Legal Implications: 

Proper Workforce utilisation and development is a key component of corporate governance and 
financial control. 
 
 
Equality & Diversity and Public & Patient Involvement Implications: 

None specific. 
 
 
 

 
1

ENCLOSURE F 
Paper WL1590     
 
WEST LONDON MENTAL HEALTH NHS TRUST 
 
 
ACTION PLAN TO RESPOND TO 2008 STAFF SURVEY 
 
FROM THE EXECUTIVE DIRECTOR OF WORKFORCE & ENVIRONMENT 
 
 
 
The Board is asked to note the contents of this report. 
 
1 BACKGROUND 
 
1.1  The Board will recall that they received an initial analysis of the 2008 Staff Survey at their 
March meeting. 
 
1.2  A brief resume of the key findings is included at Annex A of this report.  The full copy of the 
findings has been circulated previously to all Board members.  It was noted that whilst the 
Trust had an improved rating from staff in some areas in overall terms the results of the 
survey were disappointing. 
 
1.3  Of particular concern was the apparent inability to improve significantly in areas where major 
action plans had been developed and a “credibility” gap between the action the Trust was 
trying to take to resolve staff concerns and the confidence staff had in the Trust on key 
issues such as bullying or support from the managers. 
 

PROCESS TO DETERMINE ACTION PLAN 
 
2.1  It is critical therefore that if the Trust truly aspires to be seen as a leading Mental Health 
Trust this is reflected in the staff’s view of the organisation and there is a consistent view 
that the organisation is learning, responding and improving as an employer. 
 
2.2  It is not enough for these principles to be simply owned by the Board, or SDU Directors - 
they must be embedded in all levels of the organisation for sustained  improvement to take 
place. 
 
2.3    For this reason, the 2008 action plan has been built around the key themes and pledges 
contained in the NHS Constitution and developed in collaboration with the Trust’s Senior 
Leader Group at a management conference in April. 
 
2.4  These themes have been shared with staff in staff forums, the Trust Partnership Forum and 
other meetings since and appear to resonate with staff views.  The Trust has also been 
discussing how to improve its Staff Survey response with other MH Trusts who appear to fair 
better.  In these organisations a Board led but widely supported and sustained series of 
focused action appears to be the key. 
 
2.5  The action plan presented to the Board therefore has five key strands to it. 
 
 
 
 
 
 
2


KEY AREAS FOR ACTION 
 
3.1  The five key areas that it is proposed will provide the key focus for the action plan areas are 
as follows.  These are explained in detail in the proposed action plan at Annex B. 
 
Capacity 
 
A recurrent theme in the draft HC report, in performance activity and staff feedback is that 
high vacancy and turnover levels erode staff confidence, dilute the consistency of patient 
care and create financial pressures due to over reliance on bank and agency staff. 
 
Whilst the Trust has generally performed well in terms of its vacancy management, there are 
areas of concern and hotspots that need to be addressed by a consistent level of high 
quality recruitment activity.  Retention is also of high importance. 
 
Competence 
 
Having high levels of staff in post, recruited to good standards will not be enough to ensure 
a high quality of care and instil staff confidence by itself – we must ensure all staff have the 
core skills necessary to fulfil their role and provide high levels of job satisfaction. 
 
For these reasons compliance with the Trusts statutory and mandatory training framework – 
another issue highlighted in the draft HC report – and comprehensive take-up of appraisal 
and personal development reviews are essential tools.   Whilst these are areas in which the 
Trust’s performance has improved, it is still an area for development. 
 
Care and Support 
 
A consistent feature of the Staff Survey over the past four years is that whilst staff feel the 
Trust’s Staff Health and Counselling Services provide high levels of care and support, this is 
not always replicated by front line management.  We know our staff are often exposed to 
challenging patient situations and having confidence in the caring support offered by the 
line-manager is key. 
 
Research by the Kings Fund in 2007 also reveals that high levels of patient care are 
inextricably linked with staff feeling cared for – especially at times of major untoward 
incidents. 
 
The action plan will therefore focus on trying to ensure this caring support is consistently 
delivered by managers across the Trust. 
 
Communication 
 
Staff communication and understanding is a major challenge in every large complex 
organisation.  The Trust has done much to improve its internal communication’s strategy – 
Mental Health Matters, Team Brief, Monday and Training Matters and the Exchange all 
represent major steps forward – but there are still gaps in consistency and understanding 
that need to be addressed. 
 
Again some of the defects are at local and team level – well managed and led teams have 
consistently better levels of satisfaction and performance than those where this happens in 
a more fragmented manner. 
 
 
 
 
3

Bullying and Harassment 
 
This is a key Board objective and is the subject of a separate paper to the Board; it is 
included as a Staff Survey Action as this was the source for the development of this work. 
  
4 PROPOSED 
ACTION 
PLAN 
 
4.1  The proposed Trust Action Plan is included at Annex B for Board discussion and approval. 
 
4.2  Once agreed the plan will be embedded into the objectives of Executive Directors and SDU 
Directors and progress will be monitored through the Quarterly Performance Review 
meetings and the PDR process. 
 
4.3  The Chief Executive will be setting clear expectations of this senior group of leaders that this 
is a key area of activity requiring personal and focused attention to ensure consistent 
improvement. 
 
5 RECOMMENDATIONS 
 
5.1  The Board is asked to approve the enclosed action plan at Annex B with specific 
plans relating to workforce capability, competence, caring and communication. 
 
5.2  The Board is asked to note the proposed Leads, timescales and to receive regular 

monitoring reports as outlined in the action plan. 
 
5.3  The Bullying and Harassment workstream is included as it is derived from staff 
survey evidence, but is subject to a separate report to the Board meeting. 
 
 
 
 
 
 
 
 
 
 
 
 
 
Kelvin Cheatle 
Executive Director of Workforce and Environment 
June 2009 
 
 
 
 
 
 
 
 
 
 
 
 
 
4

            Annex A 
 
Key Findings/Areas of priority 
 
Issue/priority Work 

Area/Directorate 
Occupational Group 
with poorest score 
with Poorest score 
KF 21 - % of staff 
• DSPD 
• Nurses 
witnessing Potentially 
• WLF 
women 
• Doctors 
Harmful errors, near 
• Ealing 
Acute 
• Occupational 
misses or incidents in 
Therapists 
the last month 
 
KF25 - % of staff 
• Ealing 
Acute 
• Nurses 
experiencing physical 
• Hounslow 
Adult 
• Maintenance/ 
violence from staff in 
• WLF 
Women 
           Ancillary 
last 12 months 
 
KF32 – Staff job 
• Security 
• Nurses 
satisfaction 
•  WLF Men’s Central 
• Maintenance/ 
• BM 
Men’s 
South 
           Ancillary 
England 
• WLF 
Women 
 
KF33 – Staff intention 
•  WLF Men’s Central 
• Nurses 
to leave jobs 
• WLF 
Women 
• Psychologists 
• BM 
Mens 
London 
• Other 
AHPs 
 
KF3 - % of staff feeling 
• WLF 
Women 
• Nurses 
valued by their work 
•  BM Men’s South of 
• General 
colleagues 
England 
Managers 
• BM 
Men’s 
London 
• Maintenance 
•  WLF Men’s central              /Ancillary 
 
KF29 - % of staff 
• Security 
• Occupational 
reporting good 
• WLF 
Women 
Therapists 
communication 
• BM 
Men’s 
London 
• Psychologist 
between senior 
•  BM Men’s South of 
• Admin 
and 
management and staff 
England 
Clerical 
• WLF 
Central 
• Maintenance 
•  WLF Men’s Central             / Ancillary 
• Ealing 
Acute 
 
 
 
 
 
 
 
 
 
 
 
 
 
5

Annex B 
 
Recommended Way Forward 
 
The proposed way forward should be two fold: 
 
1  In relation to the Key priority areas identified below, work should be focussed and 
concentrated in the particular Directorate/Work area with Localised Plans to 
address the necessary actions. 
 
2  Trust wide actions in relation to the following five key areas 
 
•  Bullying and Harassment 
• Competence 
•  Communication and Staff engagement 
• Capacity 
•  Caring and Support 
 
Area for Action 
Action/Task 
Lead 
Timescale 
Bullying and 
• Continue 
work 
Director of 
Board 
Harassment 
through Bullying and 
Strategy & 
approval of 
harassment steering 
Performance 
new 
Group 
 
protocols 
• Act 
on 
 
June 2009  
Recommendation 
 
 
from MIDDX 
 
 
University Research 
 
 
findings 
 
 
•  Design set of 
Director of 
Finish 
interventions with 
Workforce & 
qualitative 
qualitative valuation. 
Environment 
evaluation 
•  Target SDUs with 
and Board 
poorest scores 
meeting 
• Design 
and 
Promote 
report sent 
a Zero tolerance 
2009  
campaign 
 
 
Competence 
• Simplify 
PDR 
Director of 
Revised 
process and 
Workforce & 
procedures 
documentation 
Environment 
in place by 
•  Develop PDR on-line 
September 
facility via Exchange 
2009  
• Ensure 
local 
Monitoring 
monitoring 
report to 
•  Change PDR cycle 
Board 
to reflect Business 
September 
process/Financial 
2009 
year (April-March) 
• Develop 
Team 
objectives to link with 
corporate objectives 
•  Group PDRs where 
appropriate 
 
 
6

Communication 
•  Continue CEO staff 
Director of 
As per 
and Staff 
forum 
Communications/ 
Annual 
engagement 
• Staff 
Survey 
Executive 
Schedule 
 
Roadshows/Forum 
Directors/ 
 
with corporate and 
SDU Directors 
 
SDU leads 
 
•  Face to Face 
 
briefings on what the 
 
Trust and SDUs are 
 
doing in response to 
 
what staff are saying 
 
in the survey 
 
 
 
• Promote 
effective 
 
two way 
 
communications at 
 
every level find out 
 
what would improve 
 
staff satisfaction and 
 
improvements in 
 
care. 
Building Capacity 
• Reconstitute 
Director of 
May 2009 
 
Recruitment and 
Workforce & 
 
 
Retention Forum as 
Environment 
 
key Trust driver for 
 
 
recruitment 
 
 
strategies 
 
 
•  Set individual SDU 
SDU Directors 
June 2009 
recruitment,  training 
Deputy Chief 
and retention targets 
Executive, 
via the forum for 
Director of High 
monitoring via 
Secure Services 
performance review 
process 
Caring/Support 
• Develop 
middle 
Director of 
Progress 
 
management 
Workforce & 
design and 
 
development 
Environment 
report to 
 
progression to 
 
Board 2009 
ensure managers 
 
 
have 
 
 
skills/awareness to 
 
 
properly support 
 
 
staff. 
 
 
• Reconstitute 
and 
SDU Directors 
July 2009  
communicate 
 
 
systems and 
 
 
procedures for staff 
 
 
support following 
 
 
SUIs and CIRs 
 
 
•  Centre to publicise 
Director of 
July 2009 
availability of Trusts 
Workforce & 
 
24/7 staff counselling  Environment 
 
and support 
services. 
 
7

 
 
 
 
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