trust board...as per plan, at the end of month 11, the trust position is showing that it delivered...

Board: 28 March 2019 Attachment L0

TRUST BOARD

Meeting Date: 28th March 2019

Title: Supporting Papers Available electronically on the website at https://www.hct.nhs.uk/about-us/our-board/meeting-papers/

Executive Lead: Various Author(s): Various For: Noting

The Board is requested to note the following supporting papers which are for information only and which are referenced in Executive Directors’ Reports.

Lead Agenda Link

Title & Category Attachment

Strategy, Resources and Engagement DB

D2

Month 11 Finance Report (February 2019)

L1

Clinical Services and Healthcare Governance AM

E3

Quality Report Q3

L2

AM

E5

Healthcare Governance Committee minutes from 22 January 2019

L3

Performance and Operations DB

F1

Integrate Board Performance Report (February 2019)

L4

1

https://www.hct.nhs.uk/about-us/our-board/meeting-papers/

TRUST BOARD 28th March 2019 FINANCE REPORT MONTH 11 Attachment L1

FINANCE REPORT TO THE BOARD

Title: Month 11 Finance Report (February 2019)

Sponsoring Director: Director of Finance

Author(s): Finance Department

Purpose: The purpose of the report is to provide the Board with HCT’s financial position as at Month 11 – 2018/19.

Action required by the Board:

The Committee is asked to note the Trust’s financial position as at 28th February 2019.

Finance Strategy & Resources Report February 2019 (Month 11)

Contents DoF Message Clinical Income Pay Non Pay CIP SOFP SOF Glossary

Contents

Section Title

1 Director of Finance Message

2 Clinical Income

3 Pay Expenditure

4 Non Pay Expenditure

5 Cost Improvement Programme (CIP)

6 Statement of Financial Position

- Cash Flow Statement

- Capital Expenditure

- Aged Receivables

- Better Payments Practice Code (BPPC) Performance

7 Single Oversight Framework (SOF)

8 Business Unit Performance

9 Glossary



Table 1: Income and Expenditure Summary

Income and Expenditure Summary Budget Actual Variance Budget Actual Variance Budget Forecast Variance

£'000 £'000 £'000 £'000 £'000 £'000 £'000 £'000 £'000

Income 11,547 11,812 265 124,731 130,715 5,984 136,008 142,040 6,032

Pay Expenditure (8,542) (8,560) (18) (91,396) (95,881) (4,485) (99,628) (104,614) (4,986)

Non Pay Expenditure (2,302) (2,566) (264) (26,717) (28,506) (1,789) (28,964) (30,106) (1,142)

EBITDA 703 686 (17) 6,618 6,327 (291) 7,416 7,320 (96)

Depreciation (314) (313) 1 (3,454) (3,288) 166 (3,768) (3,849) (81)

Amortisation (20) (15) 5 (238) (164) 74 (260) (179) 81

Profit/Loss on Disposal 0 0 0 413 408 (5) 350 408 58

Interest Receivable 3 14 11 28 118 90 31 134 103

Interest Payable (4) (4) 1 (42) (44) (2) (46) (48) (2)

PDC Dividend (147) (146) 1 (1,610) (1,609) 1 (1,757) (1,757) 0

Retained Surplus 221 222 1 1,715 1,748 33 1,966 2,029 63

Add back all I&E Impairments/ (reversals) 0 0 0 0 0 0 63 0 (63)

Remove capital donations/grants I&E impact 4 4 0 44 44 0 48 48 0

Control Total (incl PSF) 225 226 1 1,759 1,792 33 2,077 2,077 (0)

In Month Year to Date Forecast



Table 2 Analysis of Continuing Risks and Opportunities to Trust's Financial Position

Risk No.Risk/Opportunity Identification Process

RAG Rating/Risk

Score

Financial Value£'000

Risk Assessed Value £'000

Basis for Financial AssessmentExec Lead

Actions to Mitigate

1Cost Improvement Plans Slippage including additional savings required as a result of the 18/19 pay award

CIP Tracker 16 (1,290) (645) Project Tracker DB

Close monitoring of project milestones against the plan, bringing action due dates forward where possible. Options to mitigate the shortfall to date are being explored including the reduction of M1-M6 budget underspends on a non-recurrent basis.

2 100% of CQUIN targets are not achieved. Monthly KPI Report 20 (458) (183) CQUIN Tracker TW

The Trust is vurrently reviewing the risks around CQUIN 10, which is worth £275k to ensure that the loss of CQUIN does not increase from the current level of £183k

3Agency run rate does not improve as expected

Monthly KPI Report and Agency spend analysis

12 (500) (240) Monthly reporting DB

Close monitoring of performance at service level against the agreed trajectories. Run services at a safe level but below full establishment to mitigate the agency premium costs

4 Contingency Monthly report 12 400 192 Monthly reporting DB N/A

5 Annual Leave accrualPolicy - no leave to be carried forward

2 120 10 No provision for annual leave required DB N/A

Total (1,728) (866)

RAG Rating KeyRAG Rating Description Risk Score

Green 1-3Amber-Green 4-7Amber 8-13Amber-Red 14-17Red 18-25

Current risks and opportunities to the Trust are detailed below:



Table 3: Income Breakdown

INCOME PERFORMANCE Budget Actual Variance Budget Actual Variance Budget Actual Variance

£'000 £'000 £'000 £'000 £'000 £'000 £'000 £'000 £'000

Clinical Commissioning Groups 7,913 7,962 49 87,428 88,617 1,189 95,376 96,736 1,360

Injury Cost Recovery Scheme 2 1 (0) 22 19 (3) 24 20 (4)

Local Authorities 1,850 1,744 (105) 21,698 22,039 341 23,580 23,499 (81)

NHS England 692 994 302 6,710 8,046 1,336 7,320 8,685 1,365

NHS Foundation Trusts 63 52 (11) 693 560 (133) 756 610 (146)

NHS Trusts 634 622 (12) 5,566 6,780 1,214 6,072 7,411 1,339

DOH & SC 108 112 4 0 1,226 1,226 0 1,338 1,338

Non NHS: Other 43 80 37 218 712 494 238 718 480

Non HS: Private Patients 2 3 2 22 33 11 24 37 13

Operating Income - Patient Care Total 11,305 11,571 265 122,357 128,031 5,674 133,390 139,053 5,663

Education And Training 28 66 38 396 792 396 411 878 467

Non-Patient Care Income 43 39 (4) 484 520 36 528 560 32

Other 20 (14) (34) 357 235 (122) 391 260 (131)

PSF (formely STF) 150 150 0 1,137 1,137 0 1,288 1,288 0

Other Operating Income Total 242 242 (1) 2,374 2,684 310 2,618 2,986 368

TOTAL Income 11,547 11,812 265 124,731 130,715 5,984 136,008 142,040 6,032

ForecastIn Month Year to Date



Table 4: Total Pay Breakdown

Table 5: Agency Spend by Business Unit

Pay Budget Actual Variance Budget Actual Variance Budget Actual Variance Budget Actual VarianceWTE WTE WTE £'000 £'000 £'000 £'000 £'000 £'000 £'000 £'000 £'000

Substantive Staff 2,584 2,224 360 (8,505) (7,651) 854 (90,989) (84,535) 6,454 (99,184) (92,243) 6,941Bank Staff 126 (126) (424) (424) (3,640) (3,640) 0 (4,010) (4,010)Agency (NHSI Target FYE £6,565K) 120 (120) (448) (448) (7,294) (7,294) 0 (7,911) (7,911)

Apprenticeship Levy 0 (38) (38) 0 (407) (413) (6) (444) (450) (6)

Total Pay 2,584 2,470 114 (8,542) (8,560) (18) (91,396) (95,881) (4,485) (99,628) (104,614) (4,986)

Forecast In Month In Month Year to Date

Agency Threshold by Business Unit Target Actual Variance Budget Actual Variance Budget Actual Variance

£'000 £'000 £'000 £'000 £'000 £'000 £'000 £'000 £'000

Adult Services (416) (325) 91 (4,576) (5,505) (929) (4,992) (5,989) (997)

Children & Young Persons' (80) (73) 7 (880) (898) (18) (959) (972) (13)

Corporate Services (51) (50) 1 (561) (891) (330) (614) (950) (336)

Total Agency Pay (547) (448) 99 (6,017) (7,294) (1,277) (6,565) (7,911) (1,346)

In Month Year to Date Forecast



Table 6: WTE Budget v Actual Table 7: Bank & Agency WTE

Table 8: Bank & Agency Total Spend



Table 9: Non Pay Breakdown

Non Pay Budget Actual Variance Budget Actual Variance Budget Actual Variance

£'000 £'000 £'000 £'000 £'000 £'000 £'000 £'000 £'000

Drugs Costs (77) (19) 58 (924) (874) 50 (1,008) (950) 58Supplies & Services - Clinical (497) (528) (31) (5,962) (5,743) 219 (6,504) (6,268) 236Supplies & Services - General (155) (169) (14) (1,033) (1,785) (752) (1,128) (1,959) (831)Establishment (465) (453) 12 (4,847) (5,801) (954) (5,069) (5,993) (924)Premises (incl. business rates) (557) (462) 95 (10,354) (7,265) 3,089 (11,299) (7,476) 3,823Other (551) (935) (384) (3,597) (7,038) (3,441) (3,956) (7,460) (3,504)Grand Total (2,302) (2,566) (264) (26,717) (28,506) (1,789) (28,964) (30,106) (1,142)

ForecastIn Month Year to Date



Table 10: CIP Breakdown

5 CIPAs per plan, at the end of month 11, the Trust position is showing that it delivered £460K of CIPs in month and £4,638K year to date. The high proportion of non-recurrent schemes against the 2018/19 plan includes CIP schemes awaiting Quality Impact Assessment Review. Any identified non-recurrent schemes will convert to recurrent schemes as they are approved. Corporate under performance on CIPs means that non-recurrent funding reserves are being used to bridge the gap, but this will become a further pressure in 2019/20 as the savings will need to be identified and delivered recurrently.

In addition, the Trust is reviewing recommendations from the Carter review, benchmarking services and working jointly with other organisations within the STP in order to implement recurrent CIP schemes in 2019/20 and beyond.

The year to date CIP delivery for the Trust as at month 11 is £4,638K as

per plan.

HCT CIP Summary M1-M11

Business Unit Saving Type FYE Plan Actual Variance

£'000 £'000 £'000 £'000

Corporate Services Recurrent 426 391 391 0Non Recurrent 222 203 1731 1,528

Children’s and Young People’s Total Non Recurrent 648 594 2,122 1,528

Corporate Services Recurrent 52 236 236 0Non Recurrent 2,236 1,849 409 (1,440)

Corporate Services Total 2,289 2,085 645 (1,440)

Adult Services Recurrent 1,604 1,470 1,302 (168)Non Recurrent 557 489 569 80

Adult Services Total 2,161 1,959 1,871 (88)

Grand Total 5,097 4,638 4,638 0

Year to Date



Table 11: Statement of Financial Position

Statement of financial position Actual Forecast28/02/2019 31/03/2019

YTD Year ending

£'000 £'000

Non-current assetsIntangible assets 220 184Property, plant and equipment: on-SoFP IFRIC 12 assets 0 0Property, plant and equipment: interests in off-SoFP PFI/LIFT assets 0 0

Property, plant and equipment: other 61,448 63,346Investment property 0 0Investments in associates and joint ventures 0 0Other assets 0 0Total non-current assets 61,668 63,530

Current assetsInventories 0 0Receivables: due from NHS and DHSC group bodies 5,037 6,116Receivables: due from non-NHS/DHSC group bodies 917 475Other financial assets 0 0Other current assets 0 0Assets held for sale and assets in disposal groups 0 0Cash and cash equivalents: GBS/NLF 24,686 23,377Cash and cash equivalents: commercial / in hand / other 1 1Total current assets 30,641 29,969

Current liabilitiesTrade and other payables: capital (337) (275)Trade and other payables: non-capital (14,014) (12,500)Borrowings (88) (176)Other financial liabilities 0Provisions (91) (91)Other liabilities: deferred income including contract liabilities (598) (1,412)Other liabilities: other 0 0Total current liabilities (15,128) (14,454)Total assets less current liabilities 77,181 79,045

Non-current liabilitiesTrade and other payables: capital 0 0Trade and other payables: non-capital 0 0Borrowings (2,356) (2,180)Other financial liabilities 0 0Provisions (1,038) (1,038)Total non-current liabilities (3,394) (3,218)Total net assets employed 73,787 75,827

Financed byPublic dividend capital 1,336 1,336Revaluation reserve 19,602 21,424Other reserves 4,947 4,947Income and expenditure reserve 47,902 48,120Total taxpayers' and others' equity 73,787 75,827

The Trust is currently below its planned PPE values due to the delays in purchasing of assets, which is expected to be caught up by the year end, through management by the Capital Investment Group.

The Trust's level of debtors compared to plan has reduced compared to M10 due to payment agreements between the Trust and WHHT, East and North Herts CCG and Herts Valleys CCG.

The increase compared to plan is due to a mixture of late agreement of invoicing around Discharge home to assess in the West of the Country, delays in payments by NHS England and increasing debt with the Royal Free London NHS FT.

Management is working with partner organisations to reducing its outstanding balances in the final weeks of the year.

ther liabilities relates to deferred income and payments which will be made by year end.

All other balances are in line with plan.



Table 12: Cash Flow Statement

Statement of cash flows Actual Forecast28/02/2019 31/03/2019

YTD Year ending

Cash flows from operating activities £'000 £'000Operating surplus/(deficit) 2,876 3,292Non-cash income and expense:

Depreciation and amortisation 3,452 4,028Impairments and reversals 0 0Income recognised in respect of capital donations (cash and non-cash) 0 0Amortisation of PFI credit 0 0On SoFP pension liability - employer contributions paid less net charge to the SOCI 0 0(Increase)/decrease in receivables 4,789 3,710(Increase)/decrease in other current assets 0 0(Increase)/decrease in other assets 0 0(Increase)/decrease in inventories 0 0Increase/(decrease) in trade and other payables 773 (710)Increase/(decrease) in other liabilities 0 0Increase/(decrease) in provisions (1,379) (249)Tax (paid) / received 0 0Other movements in operating cash flows (1,300) 0

Net cash generated from / (used in) operations 9,211 10,071Cash flows from investing activities

Interest received 118 130Purchase of financial assets 0 0Purchase of property, plant and equipment and investment property (4,736) (5,785)Proceeds from sales of property, plant and equipment and investment property 2,004 2,004Cash movement from disposals of business units and subsidiaries (not absorption transfers) 0 1

Net cash generated from/(used in) investing activities (2,614) (3,650)Cash flows from financing activities

Public dividend capital received 205 205Public dividend capital repaid 0 0Loans from Department of Health and Social Care - received 0 0Loans from Department of Health and Social Care - repaid (88) (176)Capital element of finance lease rental payments 0 0Interest paid (44) (48)Interest element of finance lease 0 0PDC dividend (paid)/refunded (717) (1,757)Cash flows from (used in) other financing activities 0 0

Net cash generated from/(used in) financing activities (644) (1,776)Increase/(decrease) in cash and cash equivalents 5,953 4,645

Cash and cash equivalents at start of period 18,734 18,734Opening balance adjustment

Cash and cash equivalents at end of period 24,687 23,379



Table 13: Capital Expenditure

Table 14: Receivables Age Analysis

Table 15: Graphical Receivables Age Analysis Table 16: Receivables Debt Analysis

Capital Scheme Plan Actual Variance Plan Forecast Variance

Desc 28/02/2019 28/02/2019 28/02/2019 31/03/2019 31/03/2019 31/03/2019

31/03/2023 YTD YTD YTD Year ending Year ending Year ending

5 year plan £'000 £'000 £'000 £'000 £'000 £'000

Estates 2018-19 2,068 1,088 980 2,642 3,050 (408)IT 2018-19 982 1,696 (714) 1,040 2,081 (1,041)Medical Equipment 2018-19 170 142 28 170 170 0Capital Resource Limit /Total charged against CRL 3,220 2,926 294 3,852 5,301 (1,449)PDC funding 0 (205) 205 0 (262) 262Sale disposal 0 (1,187) 1,187 0 (1,187) 1,187Net Cost to Trust 3,220 1,534 1,686 3,852 3,852 0

Total Actual 28/02/19

£'000 £'000 % £'000 % £'000 % £'000 %

Receivables non NHS 704 112 15.9% 163 23.2% 87 12.4% 342 48.6%Receivables NHS 4,792 1,466 30.6% 1,021 21.3% 652 13.6% 1,653 34.5%Total Recievables 5,496 1,578 28.7% 1,184 21.5% 739 13.4% 1,995 36.3%

Payables non NHS (1,558) (1,424) 91.4% (116) 7.4% (18) 1.2% 0 0.0%Payables NHS (2,005) (1,179) 58.8% (290) 14.5% (86) 4.3% (450) 22.4%Total payables (3,563) (2,603) 73.1% (406) 11.4% (104) 2.9% (450) 12.6%

Aged receivables/ payables: current month (days past invoice date)

Over 90 days0-30 days 31-60 days 61-90 days

Currently the Trust is behind on its capital spend due to delays in estate spend and Medical Equipment. However the profile of expenditure has changed from plan due to risks around delivery due to the uncertainty of Brexit. The Capital Investment Group continues to monitor process and has identified opportunities should delays occur for capital expenditure to be brought forward from 2019/20 plans to ensure that the Capital Resource Limit is achieved at the end of the year.



Table 17: BPPC Performance

Better payment practice code Actual Actual Actual Actual28/02/2019 28/02/2019 31/01/2019 31/01/2019

YTD YTD YTD YTD

Number £'000 Number £'000

Non NHSTotal bills paid in the year 12,974 49,053 10,856 40,991Total bills paid within target 11,359 43,153 9,482 35,850Percentage of bills paid within target 87.6% 88.0% 87.3% 87.5%

NHSTotal bills paid in the year 1,272 15,982 1,015 12,157Total bills paid within target 1,067 12,903 855 9,604Percentage of bills paid within target 83.9% 80.7% 84.2% 79.0%

TotalTotal bills paid in the year 14,246 65,035 11,871 53,148Total bills paid within target 12,426 56,056 10,337 45,454Percentage of bills paid within target 87.2% 86.2% 87.1% 85.5%



Table 18: Single Oversight Framework

7. Single Oversight Framework (SOF)The Single Oversight Framework Risk

Rating for the Trust is a 1. The Single Oversight Framework Risk Rating (SOF) is the NHS Improvement’s approach, to overseeing NHS providers. The SOF assesses the financial performance of providers via the “Use of Resources Metrics (UOR)” comprising the following five metrics:

• Liquidity Ratio• Capital Servicing Capacity• I&E Margin• I&E Distance from Plan• Agency

The overall metric is calculated by attaching a 20% weighting to each category.

The Single oversight risk rating for the Trust as at month 11 is at 1 as per the operating plan. This trend is expected to continue until year end.

Plan Actual Variance Plan Actual VarianceForecast

Capital service cover rating 1 1 1 1

Liquidity rating 1 1 1 1

I&E margin rating 1 1 1 1

I&E margin: distance from financial plan 1 1

Agency rating 1 2 1 2

1 1

YTD

Overall Rating



Table 19:

Business Unit Performance

8 Business Unit Performance

Key DriversBusiness Unit Plan Actual Variance Plan Actual Variance Plan Actual Variance

£'000 £'000 £'000 £'000 £'000 £'000 £'000 £'000 £'000

Adult Services -5,578 -5,388 190 -61,381 -61,035 346 -66,959 -66,578 381 Agency spend above threshold funded by non recurrent vacancies

Children & Young Persons' -2,366 -2,043 323 -26,441 -25,096 1,345 -28,807 -27,785 1,022 Non recurrent vacancies and Local Authority deffered income

Corporate Services -2,308 -2,653 -345 -26,094 -27,524 -1,430 -28,373 -29,544 -1,171 CIP slippage and agency cost pressures.

Block Income 10,473 10,306 -167 115,631 115,403 -228 126,105 125,873 -232 Prior year and current year CQUIN underperformance

Grand Total (excluding PSF) 221 222 1 1,715 1,748 33 1,966 1,966 0

Month 11 Year to Date Forecast



DoLs - Deprivation of Liberty Safeguarding CQUIN - Commissioning for Quality and Innovation

IDAT - Integrated Discharge and Admissions Team CCG - Clinical Commissioning Group

MEN C - Meningococcal C PALMS - Positive Behaviour Autism Learning Disability and Mental Health Service

NHSI - National Health Service Improvement CIP - Cost Improvement Programme

OT - Occupational Therapy PT - Physio Therapy

CAPEX - Capital Expenditure Programme ICT - Integrated Community Teams

BUPR - Business Unit Performance Review ENHT - East and North Herts Trust

FP10 - Community Prescription BPPC - Better Payment Practice Code

SACH - St Alban's Community Hospital

9 Glossary

We will maintain and improve the health and wellbeing of the people of Hertfordshire and other

areas served by the Trust

Quarterly Quality Report 2018 – 2019

Quarter 3

Board 28th March 2019 Attachment L2

2

CONTENTS

Achievements and Challenges............................................................................................................... 3 Quality Dashboard ................................................................................................................................. 4 CQUINs/Quality Priorities ...................................................................................................................... 5 Risk Register ......................................................................................................................................... 6 Care Quality Commission ...................................................................................................................... 6 Quality Assurance Visits ........................................................................................................................ 6 Patient Safety Incidents ......................................................................................................................... 9 Serious Incidents and Local Investigations .......................................................................................... 12 Freedom To Speak Up......................................................................................................................... 13 Safer Care ........................................................................................................................................... 13 Learning from Deaths (Mortality Review) ............................................................................................. 16 Infection Prevention and Control .......................................................................................................... 16 Children and Adult Safeguarding ......................................................................................................... 17 Looked After Children and Care Leavers ............................................................................................. 19 Patient Surveys ................................................................................................................................... 21 Patient Stories ..................................................................................................................................... 22 Friends and Family Test ...................................................................................................................... 22 Complaints and Compliments .............................................................................................................. 22 Always Event – Patient Experience Quality Priority 2018/19 ................................................................ 24 Demonstrating Positive Changes – Patient Experience Quality Priority 2018/19 .................................. 25 Learning Disabilities ............................................................................................................................. 25 Carers .................................................................................................................................................. 26 CCG/GP Hotline Enquiries ................................................................................................................... 26 National Institute for Health and Care Excellence (NICE) Quality Standards and Guidance ................ 27 Clinical Audit ........................................................................................................................................ 28 Public Health Metrics ........................................................................................................................... 31 Appendix 1: Quality Assurance Visit Action Plans ................................................................................ 34 Appendix 2: Internal Peer Review Summary ........................................................................................ 35 Appendix 3: Safeguarding Children Dashboard ................................................................................... 37 Appendix 4: Safeguarding Adult Dashboard ........................................................................................ 38

3

Achievements and Challenges

ACHIEVEMENTS • OFSTED visited Children and Young people services noting good practice and no areas for

improvement. • LAC Review Health Assessments are being completed in a timely manner with positive

feedback from service users. • The joint Ministry of Justice and CQC inspection of the HMP The Mount Healthcare service

identified good healthcare delivery at the prison. Areas for improvement to build on good practice were identified and a quality improvement programme is in place.

• The CQC undertook a Trust-wide Well-Led inspection during Q3 following their unannounced inspections to core services during Q2. Preliminary actions to address immediate queries have been completed and a quality improvement programme is being developed to support sustained best practice.

• There was a reduction in the number of patient safety incidents resulting in harm, despite an overall increase in the number of incidents reported. This reflects increased scrutiny of incidents reported resulting in more accurate categorisation of levels of harm.

• There was also a reduction in the number of medication incidents and falls resulting in harm, in spite of an overall increase in the number of incidents reported.

• The number of concerns raised to the Freedom To Speak Up team increased during Q3. This coincides with the promotional work undertaken by the team during national “Speak Up” month in October.

• Following system changes in the Business Intelligence portal and Learning Management Systems, database cleansing and scrutiny of safeguarding children training has resulted in improved training compliance during Q3,

• The Trust’s overall Friends & Family Test (FFT) score returned to 95% during Q3.

CHALLENGES

• Quality Priorities 1 (PROMs) and 4 (patient feedback response rates) both remain partially met in Q3. Work is underway by both QP leads to bring these back on trajectory during Q4.

• Internal peer review of all community inpatient units and community teams was undertaken during Q3. These identified that 7 out of 8 inpatient units and 4 out of 11 ICT/CAHS teams were scored less than 90% and have local action plans in place to address concerns identified.

• The number of avoidable category 3 and 4 pressure ulcers increased once again in Q3; however the number of avoidable category 2 pressure ulcers continued to decrease. NHS Improvement has issued new guidelines around reporting of pressure ulcers which will result in pressure ulcers not being categorised as avoidable or unavoidable in future reporting. Focused training is being delivered for identified hot spot teams.

• There were 2 cases of C.difficile reported during Q3, bringing the year to date total of cases to 5, against a year end ceiling of 5. Following Root Cause Analysis the CCG has agreed that 2 cases can be appealed.

• The percentage uptake for DOLS training dipped to 83% during Q3. However this is due to a number of factors such as the withdrawal of the e-learning option, and a significant cohort of staff being due for update training during Q4.

4

Quality Dashboard

Q1 Q2 Q3National /

localbenchmarking

Trend from previous quarter

Number of patient safety incidents 1368 1233 1251 ↑Number of patient safety incidents resulting in harm 670 591 566 ↓Number of Serious Incidents confirmed 2 2 2 ↔Percentage of patients receiving harm-free care (national benchmark 95%) 97.96% 98.27% 97.74% ↓Number of avoidable category 2 pressure ulcers *Q2 reported figures amended during Q3 to include data for July, August and September**Q3 data is for October and November only

9 8* 5** ↓Number of avoidable category 3 or 4 pressure ulcers *Q2 reported figures amended during Q3 to include data for July, August and September**Q3 data is for October and November only

14 19* 21** ↑Rate of inpatient falls per 1000 Occupied Bed Days (national benchmark 8.58) 6.21 5.24 5.35 ↑Rate of injurious inpatient falls per 1000 Occupied Bed Days (national benchmark 2.28) 0.15 0.09 0.13 ↑Number of medication incidents resulting in harm 10 18 12 ↓Number of speaking up/raising concerns incidentsNB Would seek an increase in the number of staff feeling able to raise concerns 4 3 5 ↑Number of deaths reported in quarter 12 8 8 ↔Number of deaths judged more than likely to be due to problems in care (target 0) 0 0 0 ↔Number of avoidable MRSA bloodstream infections (target 0) 0 0 0 ↔Number of E.Coli bloodstream infections 0 0 0 ↔Number of C.difficile cases attributable to HCT due to lapses in care identified (target

5

QUALITY ASSURANCE CQUINs/Quality Priorities CQUINs

Title of CQUIN

On trajectory / not on trajectory /

met / not met Q1 Q2 Q3 Q4

Improving staff health and wellbeing On trajectory On trajectory On trajectory

1

Preventing ill health by risky behaviours – alcohol and tobacco Partially met Partially met Partially met

2

Improving the assessment of wounds On trajectory Met On trajectory

Personalised care and support planning On trajectory On trajectory On trajectory

1 Whilst the staff health and wellbeing CQUIN is currently on trajectory there is a risk that HCT will not meet Part 1 of this CQUIN, which relates to staff giving positive responses to specific questions in the annual Staff Survey, due to the current high level of organisational change. 2 The uptake of patients wishing to be referred to specialist smoking and alcohol support remains low despite additional intervention at different times during the stay.

Quality Priorities

Title of Quality Priority Met / partially met / not met Q1 Q2 Q3 Q4 We will support the population we serve by developing patient-focussed outcomes to improve their health and wellbeing.

Partially met Partially met Partially met1

We will improve the safety of patients in our care by reducing avoidable pressure damage and improving wound care management

Partially met Met Met

We will continue to ensure our patients receive safe care by maintaining safe staffing levels in our services.

Partially met Met Met

We will increase patient response rates, particularly to the FFT, to capture wider feedback from patients and improve understanding and learning from patients’ experience of using HCT services

Partially met Partially met Partially met2

1 Work with the Performance & Information team is underway to improve how PROMs are recorded and reported on SystmOne to facilitate embedding of the use of PROMs by staff. The QP lead is also liaising with the Head of Transformation to align the PROMs and self-management CQUIN workstreams. 2 The Head of Patient Experience continues to work with services to review methods of collecting patient feedback in order to increase response rates, including use of a tablet. Examples of ‘You Said We Did’ collected via operational CLIPS reports. Work around the Always Event is on trajectory (see Patient Experience section).

6

Risk Register Risks are routinely reviewed at Senior Management team meetings with key risks and their management brought to the attention of the Executive team following Business Unit Performance Reviews. Risk owners review and update their risks at least every month, and the High-Level Risk Register is reviewed by the Executive Group on a monthly basis. At the end of Q3 there are nine risks on the High Level Risk Register; six operational risks and three corporate risks. Themes identified are risks relating to staffing levels, the management of vacancy rates, and the impact of re-commissioning of services. Care Quality Commission Registration • The current registration status is ‘good’. • A Trust-wide Well-Led inspection was undertaken by the CQC in November 2018 following unannounced

service visits during Q2. • A factual accuracy check of the draft CQC report has been completed and the Trust awaits receipt of the

final report during Q4. • Preliminary actions to address immediate queries have been completed and the Trust is developing a

quality improvement programme to enable further improvements to support sustained best practice. HMP The Mount Ministry of Justice/CQC Inspection • The health element of the inspection report identified good healthcare delivery following this inspection.

Areas for improvement to build on practice were identified and immediate actions taken to ensure safe effective care delivery have been undertaken. Actions to ensure sustained best practice will form part of the overall quality improvement programme whilst being held as separate actions within the formal report.

• The quality improvement programme will be reported through Healthcare Governance Committee to Board and via contractual arrangements to our commissioners.

Quality Assurance Visits External Quality Assurance Visits, internal peer reviews and Keeping in Touch (KiT) visits undertaken by HCT staff, stakeholders and Board members provide vital information about the quality of our services, identify any areas for improvement, and are an opportunity to engage with our staff and patients. Keeping in Touch (KiT) visits In light of the focus this quarter on the Care Quality Commission (CQC) inspection for Well Led and Core services a number of CQC support visits and peer reviews were undertaken; however the number of Keeping in Touch (KiT) visits were minimal between October 2018 and December 2018. The Chief Executive visited the Acute Therapy Services at the Lister Hospital in November providing information and support relating to potential service changes. The Executive Directors and the Non-Executive Directors undertook a significant number of staff support and festive visits, which included interactions with patients. The services included were: • Herts & Essex Hospital and the Integrated Care Team • Stevenage Integrated Care Teams and Hub at Robertson House, Stevenage • Watford General Hospital Inreach Team • The Avenue Clinic and Peace Children’s Centre • Cheshunt Community Hospital, Cheshunt Hospital Minor Injury Unit and Waltham Cross Integrated Care

Team • Sandridge Gate Hub and St Albans Children’s Centre

7

• Hertford County Hospital Musculoskeletal service, Hoddesdon Integrate Care Team • Langley House, Holywell and Midway wards, Garston, Watford • Potter Bar Community Hospital and Integrated Care Team Elstree Way Clinic • The Marlowes Hub, Hemel Hempstead • Simpson and St Peters Ward Hemel Hempstead Hospital • Queen Victoria Memorial Hospital and Danesbury Neuro Centre, Welwyn • Royston Memorial Hospital, Park Drive Health Centre, Baldock and Harpenden Memorial Hospital Staff engagement events Feedback from the services remains a vital factor in shaping HCT services and delivering quality improvements in the care we provide and improving our work environment and support for staff. Any issues for escalation are reviewed by the Executive and the Senior Management Teams and progress on required actions are reported in the Business Unit Performance Reviews. The Chief Executive and Executive Team members have participated in monthly interactive video updates which have provided up to date information on current and future service developments, and provided a forum for questions and answers. This information is then cascaded to all staff via management at team meetings and audio presentations sent to all staff. All visits and events are valued as a method of two way communication between the Board/ Executive team and the front line staff and service users. Hertfordshire Community NHS Trust is committed to improving patient and staff experience by gathering and acknowledging the positive feedback and using the suggestions and themes to inform and drive future changes and developments to improve the care received by patients and reinforce the support given to staff. External Quality Assurance Visits • During Q2, 2 external visits were undertaken in HCT services:

− OFSTED visited Children & Young People’s services. − Herts Valley CCG undertook a visit to Rapid Assessment Unit at St. Albans City Hospital on 26th July.

The final report was received on 4th October 2018 which was a positive. Areas of good practice Service Areas of good practice OFSTED • Very positive feedback received

Area requiring improvement identified / actions taken Service Areas requiring improvement identified / actions taken OFSTED • None

The completed QAV Action Plan for the Rapid Assessment Unit is attached as Appendix 1. Internal Peer Reviews All adult community inpatient units and ICT/CAHs services were reviewed utilising the revised Internal Peer Review Tool during the period August to November 2018.

A summary report was submitted to the Clinical Effectiveness Group identifying the following recommendations: • Safe and Effective sections reporting at 80% or below will be required to undergo further peer review at 6

months regardless of their overall score. • Services that are identified as ‘requiring an Escalated Service review’ should undergo a further peer

review at 6 months. • Move to an overall percentage score, 90% or over Green, under 90% Red with an action plan required. • Minimum of 2 patients reviews are required within ICT/CAHs • Move Adult Peer Reviews to Q1 and Q3 to minimise disruption to clinical services. • Additions to be included within the documentation for inpatient units:

− Lying / Standing Blood pressure

8

− Retrospective recording of observations − Omission of medications

A further update paper with the Revised Assessment Criteria was completed for the Clinical Effectiveness Group as attached in Appendix 2. Children’s and Young People services are progressing with their development of a peer review specific to their services and plan to launch this during March 2019. Adult Specialist services plan to pilot the adult ICT/CAHs tool and adapt following the pilot.

9

CONSISTENT AND IMPROVING PATIENT SAFETY Patient Safety Incidents Incidents During Q3 there were 1251 patient safety incidents reported, which represents 84% of all incidents reported. This report does not break down whether these were HCT-attributed incidents. It is expected that future reports will include this data. 685 incidents resulted in no harm (54.8% of patient safety incidents) and 566 incidents resulted in some level of harm (45.2% of patient safety incidents). These are broken down as follows:

Q1 Q2 Q3 Q4 No harm 698 642 685 Low harm 651 576 555 Moderate harm 17 13 9 Severe harm 2 2 2 Death 0 0 0 Total number of incidents resulting in harm

670 591 566

Total number of incidents reported 1368 1233 1251

• Two incidents resulted in severe harm. • One was not an HCT incident and involved a patient falling at home and, following treatment for multiple

pressure ulcers was transferred from an acute hospital to a community inpatient unit where a fractured neck of femur was discovered. The patient was transferred back to the acute hospital and underwent hip surgery.

• The second incident involved a patient who fell whilst in a community inpatient unit which resulted in a fractured neck of femur.

• Both incidents are currently being investigated with the second incident proceeding through the Trust’s Serious Incident process.

Themes and trends of all incidents The 10 most-reported types of all incidents reported during Q3 are illustrated below:

420

135 126 77 68 62 54 51 34 31

Ten most-reported incidents in quarter

10

Review of Violence, Abuse and Aggression incidents towards patients There were 70 incidents of violence, abuse and aggression towards patients in Q3. Of these, 54 relate to abuse and are broken down as follows: Q1 Q2 Q3 Q4 Abuse towards patient by other person (usually spouse or family member and escalated to safeguarding)

50 38 46

Abuse towards patient by patient 6 5 5 Abuse towards patient by staff 1 4 3 Total 57 47 54

There were three incident reports where abuse was alleged to have been committed by staff: • One incident reported was an allegation of assault by a HCT carer; this incident was thoroughly

investigated and reviewed by HCT’s Safeguarding team but was not progressed as the outcome was inconclusive, therefore it was not possible to take any further action.

• One incident involved allegation of substandard care within a HCT community inpatient unit. The investigation did not substantiate the allegation and the case was closed.

• One incident involved a non-HCT Orthotist (prescriber, manufacturer and management of devices to support/control mobilisation) who ‘slapped’ a child during a challenging clinic. The incident was investigated and the member of staff has gone through performance management processes.

There were no incidents of violence, abuse or aggression towards patients where moderate harm was caused, or where duty of candour was required to be applied. Equality characteristic group information The percentage of Datix incidents which include equality characteristic group information is outlined below: Medication incidents During Q3 there were 135 medication-related incidents reported; of these 69 were attributed to HCT and 66 were non-HCT attributed.

82

10 1 0

113

18 1 0

135

12 0 0

Total number of medicationincidents

Total number of medicationincidents resulting in low

harm

Total number of medicationincidents resulting in

moderate harm

Total number of medicationincidents resulting in severe

harm

Medication incidents

Q1

Q2

Q3

100% 100% 100% 100%

49.5%

Gender Race Age Disability Religion or belief (onlyrecorded where it is

relevant to the incident)

Equality characteristic group information - Datix

11

Upon further investigation, the one moderate harm incident reported in Q3 2018/19 was downgraded to low harm as there was no evidence of patient harm. We therefore have 0 moderate harm medication incidents in Q3. Whilst investigating this incident, evidence has revealed potentially unsafe medication practice in one locality. The Trust is undertaking an internal investigation, which is supported by the Serious Incident team, Assistant Director for Medicines Management/Chief Pharmacist, Nursing Clinical Quality Leads and the Community Inpatient Service Manager. Central Alert System During Q3 a total of 16 CAS alerts were received within HCT: • 4 of these were not applicable to HCT • 9 were applicable to HCT • 3 were cascaded for information only • 0 are currently being triaged Q1 Q2 Q3 Q4 Total number of CAS alerts applicable to HCT 6 7 9

Number of CAS alerts disseminated, actions completed and alert closed

3 Closed within

timescales 3

Closed within

timescales 6

Closed within

timescales Number Action

Number disseminated, actions on going and alert remains open 3

On trajectory to close within

timescales

4


timescales

3


timescales

Number Action

The CAS alerts applicable to HCT can be broken down as below: Trust Corroboration Forum - Triangulation of information The Corroboration Forum, which was set up to identify emerging themes of concern relating to quality across operational services and raise these concerns with the operational management team, has been held monthly; a review of concerns at these meetings identified themes which were shared with operational colleagues. However, with the formation of the Quality Care Sustainability (QCS) Assurance Group (consisting of a broad membership from across quality and operational teams), and the increased focus on quality improvement to bring about positive change within HCT, it was agreed to disband the Corroboration Forum. The functions of the Corroboration Forum in triangulation of information will become a workstream overseen by the QCS Assurance Group, which will provide bi-monthly update reports to the Clinical Effectiveness Group and to the Executive Team.

3 3

2

1

Patient SafetyAlerts

Medical Devices Estates &Facilities

SupplyDisruption Alert

CAS alerts breakdown

12

Serious Incidents and Local Investigations Serious incidents During Q3 there were 2 serious incidents reported. SIs are detailed by category below:

Incident type Q1 Q2 Q3 Q4 Treatment delay 1 0 0 Sub-optimal care 1 1 2 Fall 0 1 0 Total 2 2 2 • One SI reported relates to the concerns raised about the care of a complex patient during their stay on an

inpatient unit and their transfer to a nursing home. A safeguarding concern was raised by the patient’s family.

• The second SI reported relates to the care of a patient whose pressure ulcer deteriorated in HCT care and the transfer from HCT care to a care home out of area. A safeguarding concern was raised by the care home.

On completion, each SI report will be reviewed at the Serious Incident Assurance Panel to provide assurance of evidence of actions taken to address concerns identified and that changes have been embedded in practice. Themes and learning from SIs • Investigation is underway for the two serious incidents reported in Q3. • No significant themes have been identified with regard to the teams reporting SIs • The greatest number of SIs has been reported as ‘suboptimal care’: three of these relate to the care of

patients with pressure ulcers and one relates to concerns regarding the overall care of a complex patient. • Four SI investigations have been completed and submitted to the commissioners in 2018/19 with varied

care and service delivery problems identified and as such no trends have been identified. Equality characteristic group information The percentage of serious incidents which include equality characteristic group information is outlined below: Locally investigated incidents During Q3 there were 3 locally investigated incidents reported. Locally investigated incidents are detailed by category below:

Incident type Q1 Q2 Q3 Q4 Pressure ulcer 3 1 0 Sub-optimal care 1 3 1 Safeguarding concern 0 0 1

100% 100% 100% 100% 100%

Gender Race Age Disability Religion or belief (onlyrecorded where it is

relevant to theincident)

Equality characteristic group information - SIs

13

Incident type Q1 Q2 Q3 Q4 Medication error 0 0 1 Total 4 4 3 • The investigation of a safeguarding concern relates to concerns raised by the patient’s care home

regarding the provision of pressure relieving equipment for a patient with a pressure ulcer. • The investigation of medication errors relates to a number of errors identified by the pharmacy team in one

of HCT’s inpatient units. • The investigation into suboptimal care relates to concerns raised about the care of a patient by a

community team through the complaints process. Themes and learning from locally investigated incidents • No significant themes have been identified with regard to the teams where incidents occurred. • Incidents related to suboptimal care is the largest group; however these relate to varied concerns

regarding care delivered including the management of pressure ulcers (1), nutritional management (2), and delivery of care relating to patients with long-term conditions and deteriorating patients.

• Findings from investigations linked to the development or deterioration of pressure ulcers continue to reflect the same themes regarding completion of clinical and risk assessments and the timely provision of preventative equipment. The Pressure Ulcer and Tissue Viability Forum has work underway to support staff to deliver the expected standards of care, including focused training for ‘hot spot’ teams.

• No new themes have been identified from the findings of investigations for non-pressure ulcer incidents to date.

Freedom To Speak Up

Q1 Q2 Q3 Q4 Number of concerns raised 4 3 5

• Five concerns were raised. • No patterns are emerging with concerns being raised by different people, about different areas. • None of the concerns raised required investigation. Promotional activities continued during Q3 with the Guardian and Ambassadors delivering a programme of activities they had developed in support of the national ‘Speak up’ campaign that ran throughout October 2018. Litigation and Claims During Q3: • 5 clinical negligence claims have been received • 2 clinical negligence claims have been closed Any new claims reported are claims received and advise of allegations. They do not necessarily confirm that the Trust has admitted liability. In some cases of new claims reported, the Trust may not be the correct defendant and further investigation is underway. On review of the claims received, there are no discernible trends. Claims are few in number, tend to be of low value and are widely spread in terms of services, geography and the nature of claim. Safer Care Safety Thermometer data During Q3 the average harm free care rate was 97.74%, benchmarked against the national benchmark of

14

95%:

The average rates of ‘harms’ for Q3, with comparison to Q1 and Q2, are shown below:

Falls in community inpatient units

There were two falls which resulted in moderate or severe harm in Q3; both occurred in Danesbury

97.96% 98.27% 97.74%

90.00%

95.00%

100.00%

Harm free care in HCT

Safety Thermometer - harm free care

Q1

Q2

Q3

National benchmarking: 95%

0.91%

0.53% 0.60%

0.03%

0.81%

0.53% 0.36%

0.03%

1.50%

0.38% 0.35%

0.06%

New pressure ulcers Falls with harm New catheter-associatedUTIs

New VTEs

Safety Thermometer - average 'new' harms

Q1

Q2

Q3

80

17

0 1

80

23

1 1

87

16

1 1

Total number of falls incommunity inpatient units

Total number of injurious fallsin community inpatient units

Number of falls categorised asresulting in moderate harm

Number of falls categorised asresulting in severe harm

Falls in community inpatient units

Q1

Q2

Q3

15

Neurological unit: • October - one patient fall resulting in moderate harm occurred when a patient fell sustaining a cut above

his eyebrow. CT scan confirmed a subdural bleed which required neuro observations for 24 hours. • December - one fall resulting in severe harm occurred when a patient stood to wash at the sink the patient

lost balance and subsequently fell resulting in a fractured neck of femur. A full RCA was carried out for both falls which provided assurance that preventative care was in place. National Benchmarking • Rate of falls per 1000 Occupied Bed Days (OBD) 06 2018 to 11 2018: HCT reported an average of 5.35

falls per 1000 OBD against a national benchmark of 7.74 falls per 1000 OBD • Rate of injurious falls per 1000 OBD 06 2018 to 11 2018: HCT reported an average of 0.13 injurious falls

per 1000 OBD against a national benchmark of 2.07 injurious falls per 1000 OBD. Based on data available from NHS Benchmarking for 6 months ending 11 2018 Achievements • The new Falls policy has been rolled out to all community hospital units and training provided to all clinical

staff. • HCT has registered for the 2018/19 National Audit of Inpatient Falls; the initial part of the audit running

from January to June 2019 will focus on patients who sustain a hip fracture whilst an inpatient. Areas requiring improvement identified / actions taken • There continues to be a focus on embedding lying/standing BP in community inpatient units where it is not

standardised practice. • It has been recognised that the incidence of falls within the neuro units is higher than the rehab units. To

provide assurance a dip test review of patients who have fallen more than once is currently being undertaken and results will be shared with the service.

Falls assessment compliance An audit was carried out in December 2018 to provide assurance that the new policy was embedded and identify areas where additional support may be required. The results are currently being analysed and will be shared with the Falls Champions and Service Leads. Pressure ulcers During Q3 there were 420 category 2 to 4 pressure ulcer incidents were reported, representing 33.5% of all patient safety incidents reported in quarter. Of these, 26 were deemed to be avoidable. Avoidable pressure ulcers

• Pressure Ulcers are reported on a month behind so the above data is for October and November 2018

avoidable incidents only. • 2 patients acquired an avoidable PU whilst an inpatient in Potters Bar community hospital (category 3 and

a category 2 related to a medical device). • 10 patients were residing in a residential home and 12 were receiving home care.

9

14

8

19

5

21

Avoidable category 2 PUs Avoidable category 3 and 4 PUs

Avoidable pressure ulcers

Q1

Q2

Q3

16

Achievements • Reflective case reviews have been held in North Herts ICT, Dacorum CAHS and Upper Lea Valley ICT.

The next one is planned for Watford CAHS. Areas requiring improvement identified / actions taken • Risk assessment: PURPOSE T has been launched and monthly audits of compliance are being carried

out. • Communication with carers – the care home agreement template has been reviewed, a read coded S1

template designed and a re-launch is planned soon to include home care as well as residential care. • Education of carers – some training in partnership with HCPA has been delivered. React to Red training

launched in November with the first sessions being delivered. • To note is the NHS Improvement new guidelines about reporting and monitoring of pressure which means

total numbers will be reported; the terms avoidable and unavoidable are to be no longer used. Learning from Deaths (Mortality Review) There were a total of 8 patient deaths reported in Q3 meeting the criteria for undertaking case record review. Q1 Q2 Q3 Q4 Number of inpatient deaths reported in quarter 6 6 5 Number of community deaths reported in quarter 6 2 3 Number of case record reviews undertaken in quarter 8 12 5 Number of deaths judged more likely to be due to problems in care 0 0 0

NB: Information in the above table reflects the reporting requirements within the annual Quality Account, that is, the number of deaths occurring each month/quarter is reported separately to the number of case reviews that are undertaken each month/quarter; this is in recognition that not all case note reviews are completed within the same quarter that the patient died. Infection Prevention and Control

Healthcare Associated Infections (HCAI) • 2 cases of CDI were reported in Q3, giving a year to date total of 5 cases against an annual ceiling of 5. • Case 3 & 4 relate to the same patient; case 4 fell outside the 28 day period of case 3. • Root Cause Analysis has been completed on all 5 cases and it has been agreed with the CCG that case 4

and case 5 will be appealed.

2

0 0

1

0 0

2

0 0

Clostridium difficile infections(CDI)

MRSA blood stream infections(BSI)

E.coli blood stream infections

Healthcare Associated Infections

Q1

Q2

Q3

17

• Themes identified from RCAs include: patients transferred with insufficient/inaccurate discharge summaries and delayed stool sampling.

Outbreaks of HCAI During Q3 there were no outbreaks of HCAI reported. Achievements • A comprehensive training programme is in place to ensure that staff can access sessions from a number

of sites across the organisation and online. • The inaugural Band 6 winter preparedness training for inpatient units was successfully completed in

November 2018. • The CDI annual quiz is now available to staff online via Survey Monkey. • Q3 IPC audits have been completed; ward managers and link practitioners are working to sustain

improvements. • HCT participated in a system-wide workshop on managing flu incidents, facilitated by the CCG and Public

Health England. Areas requiring improvement identified / actions taken • Training uptake in the inpatient units has been generally been below 95% overall. Improvements need to

be made in the uptake of training as compliance is less than 95%. Training uptake rates will continue to be monitored.

• There is continued challenge in embedding learning identified from CDI root Cause Analysis in the inpatient units.

• There have been poor quality returns for both monthly (inpatient) and quarterly (ICTs and CAHs) IPC Performance Framework Report (PFR) data.

Children and Adult Safeguarding Safeguarding Children Training and supervision • Following system changes in the Business Intelligence portal and Learning Management Systems,

database cleansing and scrutiny of the different safeguarding children training level pathways has resulted in training compliance improving this quarter with increased data accuracy.

• Further scrutiny of the training database is required and close monitoring on training compliance will continue by the Safeguarding Children Team.

Achievements • Additions to the Safeguarding Children team include a Senior Administrator, an Independent Domestic

Violence Advocate (IDVA) co-located within the team, recruitment to the Safeguarding Nurse post within the MASH team, and the recruitment of three Health Visitors to the Rapid Response to Unexpected Child

97% 98%

90%

95% 95% 97%

85%87%89%91%93%95%97%99%

Percentage of staff who are compliant withSGC training

Percentage of staff who are compliant withSGC supervision

Safeguarding Children training and supervision

Q1

Q2

Q3

Trust target: 95%

18

Deaths team. • The Rapid Response to Unexpected Child Death Conference, ‘The Child with Health & Life-limiting Medical

Needs` was held in November. The evaluations of the 80 delegates were extremely positive. • In November the Safeguarding Children Team developed a training away day that commenced a training

competency framework. • Paediatric liaison IT bulk-upload solution expanded with Hertfordshire Urgent Care going “live” in

November. • A December edition of the Safeguarding Newsletter was circulated widely. • HCT safeguarding delivery plan 2018/19 was completed. • HCT Section 11 audit action plan 2018/19 compiled by CCG was completed with evidence to support the

action plan.

Areas requiring improvement / actions taken • To give assurance that safeguarding responsibilities are of a high standard and that every nurse specialist

is giving similar support and guidance, the development of a competency pathway for identified areas of safeguarding responsibilities (training, supervision, court preparation and support) continues and is progressing. The trajectory of this work is two years.

• To enhance frontline practitioners written report skills, a competency pathway has been developed and the competency framework process has commenced. The trajectory of this process is two years.

Team Challenges • With promotions and retirement within the Safeguarding Children Team in Q2 and Q3, the team is currently

running with two vacancies and three newly appointed nurse specialists who are developing competencies. This results in the existing nurse specialists and managers needing to support new staff and cover the vacancy workloads. This challenge is being monitored with a prioritisation model in place.

The Safeguarding Children dashboard for Q3 is attached as Appendix 3. Safeguarding Adults Training

• The reduction in DOLS training data in Q3 is due to multiple factors, for example the DOLS eLearning

training option was withdrawn in September 2018, the community inpatient units Safeguarding Adult Champions are delivering this training face to face and a significant cohort of staff is due for an update during Q4.

• The Safeguarding Adult Team is working with the Safeguarding Adult Champions to ensure training rates improve.

98% 96%

99%

96% 94%

100%

96% 96%

88%

80%

85%

90%

95%

100%

Percentage of staff who arecompliant with safeguarding

adults training

Percentage of staff who arecompliant with MCA training

Percentage of staff who arecompliant with DoLS training

Safeguarding Adult training

Q1

Q2

Q3

Trust target: 95%

19

Achievements • The Safeguarding Adult team has continued to experience increased activity and demand of 34% in

comparison with the same quarter last year. • The team has completed the safeguarding adult, MCA and DOLS audit this quarter. • The Interim Safeguarding Adults Nurse joined the team in December to maintain senior cover during the

planned absence of the substantive post holder.

Areas requiring improvement identified / actions taken • Team capacity issues continue to be an issue, and the service remains on the risk register. • Recruitment is planned to increase the admin support to the team. • The new IDVA was appointed but has had a period of planned absence; the new training sessions will be

rolled out on their return. • Some teams require a new or additional Safeguarding Champion. A training date for January has been

arranged. The Safeguarding Adult dashboard for Q3 is attached as Appendix 4. Looked After Children and Care Leavers

• Clearance rates and exemptions are reported monthly to senior managers, E&N and HV CCGs and

Hertfordshire County Council. • During Q3 the IHA completion rate was 83%. This was due to a number of factors, including patients

failing or refusing to attend, or cancellation of appointments. Achievements • 95% of Review Health Assessments (RHAs) in County were completed by Specialist LAC Nurses within

time scale. • 97% Out of County (OOC) RHAs completed by Specialist LAC Nurses within time scale. • 91% of RHAs completed by Health Visitors and School Nurses (Public Health Nurses (PHNs) within

timescale. • The current LAC GP has taken on extra sessions following the retirement their LAC GP colleague. • 85% of Public Health Nurses have completed their Level 3 LAC training. This training programme is on a 3

year cycle. 2019 training dates confirmed and to be advertised on Noticeboard and sent to the Team Leaders and LAC Champions. Training compliance will continue to be monitored.

• The health action plans for every looked after child are reviewed 3 monthly by the Lead Professional to provide assurance that identified health needs have been actioned.

• Positive feedback has been received from young people (16+) and carers following their RHA. • LAC Team Newsletter was published and shared with HCT and Herts County Council (HCC) in December

2018.

90%

94%

97%

94%

83%

96%

80%82%84%86%88%90%92%94%96%98%

Percentage of all LAC Initial HealthAssessments referred to HCT staff completed

within agreed timescales

Percentage of all Review Health Assessmentsof looked after children referred to HCT staff

completed with time scales

LAC completed Health Assessments

Q1

Q2

Q3

Trust target: 90%

20

• A podcast with Care Leavers was recorded around the issues of health, dispelling any myths and “What is a health assessment for a LAC?” This was first launched at the Children in Care Council (CHICC) event in December 2018.

• A CHICC Champion for LAC and Care Leavers has been established. • LAC team members continue to attend the monthly multi-agency Sexual Exploitation and Runaway

Children (SEARCH), Transition to Adulthood and Complex Case Panels for children and young people who are vulnerable and at significant risk.

• A joint audit has been completed by Children’s Services and HCT, looking at the emotional and psychological wellbeing of 30 migrant children. One of the recommendations was to provide “sleep packs” for the children and we have sourced 100 free packs from a Charity called “The Separated Children Foundation”.

• 100% of Personal Health Information Plans have been completed for 18 year olds (34 in Q3). Their voice and health information requests are heard at their last health assessment and are recorded into their health plan.

• 0-25 SEND Audit has been completed, with information shared and recommendations actioned. Areas requiring improvement identified / actions taken • To reduce the number of RHAs completed by PHNs which require improvement. A monthly tracker report

is provided for Team Leaders and Senior Managers of Children’s Universal Services (CUS) to identify staff or teams that require further support. CUS LAC Champions have been trained and updated to support staff and ensure a robust process of quality assurance.

• Joint working with SystmOne (S1) analysts for our business change requests for RHA templates to be built into S1. Identified actions completed to improve quality, reduce time and duplication. This is due to go live on 2 January 2019.

• There is an identified need for a sexual culture and consent workshop for migrant children. To work with HCC and sexual health services to arrange training date for 2019.

Challenges • Out of County Health Assessments (OOC) that we are reliant on completion by external providers continue

to be a challenge. An escalation process to the CCG/Deputy Designated Nurse for LAC is in place to ensure this concern continues to be monitored and raised at Regional and National level.

21

AN OUTSTANDING PATIENT EXPERIENCE Patient Surveys The information below summarises Q3 community hospital inpatient survey results. Achievements • Danesbury - Very well looked after by all staff. • Danesbury - Easier for my family to visit and somebody told me it’s the best place to recover after a

stroke. • Holywell - Cannot fault the staff they were wonderful. • Holywell - All the staff from top to bottom, are all supportive and encouraging. • Langley House – Everyone is so kind and helpful. • Langley House - I would like to thank ALL of the staff at Langley House for putting me on the right road to

recovery. Many Thanks. • Potters Bar – All staff are amazing and very caring. • Potters Bar – Dr X was amazing. Always happy to take time to speak to my daughter in detail. Everyone

very clear and always explained everything in normal language. My sincere thanks to all members of staff who looked after me so well during my stay.

• Simpson Ward – Very kind and nice staff. • St Peters – The staff on this ward are all very hard working. The care is first class and the ward is kept

very clean. Well done all. • St Peters – Very good care clean ward and very nice caring staff. Areas requiring improvement identified / actions taken • Danesbury – (survey question: Other comments) I would like to say when there is a pasta dish I don’t

think potatoes should be served with it as its two lots of carbohydrates which are not good for you. • Holywell – (survey question: How would you rate the hospital food?) Had to send one meal back because

the meat was too tough. • Holywell – (survey question: Overall, how would you rate the quality of care you received? I was left alone

on my own a lot. • Langley House – (survey question: Overall, how would you rate the quality of care you received?) Some

(a few) members of staff (agency & permanent) didn’t know what they were doing. • Langley House – (survey question: Other comments) Langley House from my understanding is a

dedicated Physio unit but there is no physio plan set and it is very random. More care could be taken to inform people of when and how long your physio sessions would be – be it by the day or by the week.

• Potters Bar – (survey question: Main reason for selecting answer) Lack of rehab.

98% 98% 100%

98% 98.5%

96%

80%

85%

90%

95%

100%

Percentage of patients who told us they were treatedwith dignity and respect

Percentage of patients who told us that the overallquality of care was good or better than good

Community inpatient unit survey results

Q1

Q2

Q3

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Patient Stories Board Patient Story A patient attended Trust Board in November 2018 to talk about her experiences with the West Hertfordshire Early Supported Discharge Team, accompanied by two members of staff. A PowerPoint presentation was put together by the patient and focused on the support provided by the team to the patient to help her manage her rehabilitation and achieve her goals. Video Patient Story Video Patient Story A video patient story was produced in a patient’s home highlighting the exceptional level of support and treatment provided by Therapies staff from Dacorum Community Adult Health Services. After being told she may not walk again following surgery, Physiotherapy and Occupational Therapy staff worked alongside the patient and her carer to enable her to walk again using a frame. The video story was published on the Trust website, YouTube channel and shared with commissioners. Christmas comes early for 81-year old Hemel Hempstead patient as she walks again, thanks to HCT Physio and Occupational Therapist | Hertfordshire Community NHS Trust

Friends and Family Test *The percentage of patients who would recommend Trust services to friends and family if they needed similar care or treatment. • 95% of patients told us that they would recommend Trust services to friends and family if they needed

similar care or treatment. This score meets the Trust performance target of 95%. • Those services that have underperformed in this area are exception reported in the BUPR. • Over 16,000 FFT responses were received between April and December 2018, representing 7% of patient

contacts. Work is ongoing to meet the 10% response rate target as part of the Patient Experience Quality Priority.

Complaints and Compliments

97%

94% 95%

90%

95%

100%

FFT score*

FFT Score

Q1

Q2

Q3

https://www.hct.nhs.uk/news-and-events/christmas-comes-early-for-81-year-old-hemel-hempstead-patient-as-she-walks-again-thanks-to-hct-physio-and-occupational-therapist/https://www.hct.nhs.uk/news-and-events/christmas-comes-early-for-81-year-old-hemel-hempstead-patient-as-she-walks-again-thanks-to-hct-physio-and-occupational-therapist/

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Complaints Q1 Q2 Q3 Q4 Number of complaints received 35 41 36

Percentage of complaints acknowledged within agreed timescales

100% 100% 100%

Percentage of complaints acknowledged responded to within agreed timescales

83% 90% 92%

Number of complaints received graded as category 3

0 3 4

Number of complaints referred to the Parliamentary and Health Service Ombudsman

1 0 1

Number of local resolution meetings held 1 2 1

Trends and themes identified • The total number of complaints received in Q3 was 36 which represents a 12% decrease when compared

with Q2 (41) in the current financial year. • The number of complaints received in this quarter were attributed as follows:

− 69% Adult Services in East and North Hertfordshire and Herts Valley; − 31% Children’s Specialist, Children’s Therapies & Children’s Universal Services.

The top three type of complaints raised in quarter three is detailed by service area in the table below and consists of: • Standards of Care (31% of all complaints received) • Staff attitude/behaviour (19% of all complaints received) • Date for appointment (11% of all complaints received) Examples of organisational learning and improvement from complaints

Theme Commentary Outcomes/Learning

Community Nursing Hertsmere

Wife of patient called as Community Nurses visits haven’t taken place as scheduled and they have no dressings, patient was admitted to A&E with an infection, which the complainant felt was as a result of the wound not being re-dressed.

The service has introduced additional senior nursing supervision of the team. The process for ordering wound care products by the community nurses has been reviewed.

Referral Hub and Watford Community Nursing

Son of patient wrote to complain about the failure of calls to the Referral Hub being escalated appropriately, resulting in failure of the community nurse attending.

All staff have been reminded of the processes when they receive an urgent call and the administrator who took the call has received additional training.

Equality characteristic group information The Patient Experience Team captures evidence to demonstrate equal access to all groups of people who wish to make a complaint in line with the national directives to ensure equality for people in the 9 protected characteristics groups. Information gathered in quarter three indicates that the majority of complaints received were related to people aged 80 years and over (33%), between 0-15 (11%), and 66-80 years (5%). 38% did not provide this information.

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Compliments

Q1 Q2 Q3 Q4 Number of compliments received 6326 4695 5280

Number of compliments per 1000 patient contacts 14.5 10.9 11.8

PALS contacts

Q1 Q2 Q3 Q4 Number of PALS contacts received 160 248 288

Number of enhanced PALS contacts received 42 31 41

Percentage of PALS contacts received that were HCT-related

50% 43% 51%

Number of MP enquiries received 7 5 1

Enhanced PALS contacts An enhanced PALS enquiry is one that cannot be answered immediately and requires further investigation or action by the Trust service/s concerned and the PALS team. A total of 41 enhanced PALS contacts were recorded within Q3, a total of 116 to date in 2018/19. The top four themes of enhanced PALS contacts for Q3 are: • Standards of Care – 39% • Staff attitude/behaviour – 15% • Communication – 12% • Date for appointment – 12% Examples of organisational learning and improvement from enhanced PALS

Theme Commentary Outcomes/Learning Clinical Treatment Patient had concerns regarding missed

visits and as a result bandages were not changed. Incorrect bandages were fitted which did not stick and subsequently fell off.

The Service arranged for OT assessment and subsequent referral to TVN, as well as new type of dressings. Service offered to refer to community navigator for befriending support.

Communication Patient was concerned that they had contacted the physiotherapy service and the telephone was not answered and messages were not returned.

Apologies extended to the patient. The service is currently in the process of setting up a mobile phone option and an email contact facility.

Clinical Treatment Enquirer was concerned with his wife’s catheter care and the nurses appeared to be ignoring the advice of her carers.

Enquirer was contacted by the service manager who agreed that families carers are experienced and therefore nurses should be using their knowledge. Locality Manager has invited patient to attend locality meeting to discuss care and carers.

Always Event – Patient Experience Quality Priority 2018/19 The Trust is part of a national cohort of organisations that is participating in the Always Events® programme led by NHS England. Always Events® are aspects of the patient experience that are so important to patients, families and carers that health care providers must aim to perform them consistently for every individual, every time. Results of the annual End of Life Patient Reported Outcome Measures Survey (PROMS) over the last three

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years indicate that patients, their families and carers have consistently told us: • 49.1 % of patients/family member/carers agree or strongly agree with the I Statement ‘I always know who

is coordinating my care’ • 59% of patients/family member/carers agree or strongly agree with the I Statement ‘I can always reach

someone who will listen and respond at any time of the day or night’ Following the Always Events® toolkit a short survey was designed and shared with patients, their carers and families to understand what matters most to them. This approach was complimented by telephone and face to face interviews. The vision statement for the Always Event is: ‘I will always have an understanding of why I am being visited, by whom and how I can contact the service day or night’ As a result, a one page prompt, containing information deemed most important by patients, their families and carers, was drafted for staff for use at initial assessment visits, and included in the patient red folder. This new approach will be trialled in January 2019 by staff and then reviewed to measure any impact on reported patient experience via further telephone and face to face surveys. NHS England is pleased with progress of this project to date. Demonstrating Positive Changes – Patient Experience Quality Priority 2018/19 The examples below demonstrate positive changes made as a consequence of patient feedback received. You said We did Reception chairs dated (St Albans Children’s Centre) All chairs in reception re-covered You like a bigger buggy area (St Albans Children’s Centre)

A new buggy area was built

You would like a direct contact number in case you need to get in touch with the consultant (Children’s OT)

Staff reminded to give families the correct contact details for the named therapist, and this information added to the Trust website

Make more appointments available and shorter waiting times (Children’s OT)

Recruitment and restructuring process ongoing with two locums in post to reduce waiting times. An increased number of sensory workshops are being offered to meet current demand

There could be more transparency between Occupational Therapy, Physiotherapy and Speech and Language Therapies Services (Children’s OT)

A single patient record is used where appropriate between the services

You would like a more responsive service (Eye Service)

Offered a reminder via a text message and trained reception to be able to book eye appointments

Learning Disabilities Q1 Q2 Q3 Q4 Number of LD patients attending HCT services 1102 1235 1394

Number of LD patients flagged on S1 (open referrals) 1689 2001 2081

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Carers Carers Strategy 2018- 2021 Action plans have been developed to support the delivery of the adult and young carers’ objectives. Two working groups have been formed to lead the implementation of the action plans. The Clinical Quality Lead for School Nursing and the Carers Lead are engaging with young carers via the Carers in Herts Young Carers Council for their input into the action plan. Adult carers will be invited to join the adult carers’ action plan working group. Measuring Carers stress The joint working group involving members of the Carers Planning and Partnership Group have had an initial meeting with agreement to further the work. A project plan will be developed by the working group’s Lead with a view to a pilot project. HSJ award Hertfordshire and West Essex STP won the award for System Led Support for Carers. The award was for the successful interventions that have helped to create a carer friendly system. HCT’s contribution to the award includes introducing Carers Champions across adult and children’s services, referrals to Carers in Hertfordshire via staff laptops, recording of carers on SystmOne, partnership working to deliver the shared countywide strategy for carers and ensure consistency in the information and support for carers. Always Events Interviews with carers have been completed to understand what matters most to carers whilst the person they care for is in hospital. The key themes relate to carers being involved and informed and receiving information about other support available to them. The point of care team, which includes staff and carers, will now develop the aim statement, objectives and action plan to pilot the Always Event. CCG/GP Hotline Enquiries

Q1 Q2 Q3 Q4 Proportion of urgent ENHCCG hotline enquiries responded to within 5 working days

No urgent enquiries received



Proportion of routine ENHCCG hotline enquiries responded to within 20 working days

73% 100% 92.8%

The above figures relate to ENHCCG hotline enquiries only as specified in the Quality Schedule 2017/19.

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EXCELLENT CLINICAL EFFECTIVENESS National Institute for Health and Care Excellence (NICE) Quality Standards and Guidance The NICE Working Group (NWG) reviews NICE guidance (NG) and quality standards (QS) released at the end of each month by the NICE. Where the guidance is found to be applicable to HCT commissioned services, action plans are reviewed at the NWG and an update is provided to the Clinical Effectiveness Group (CEG) meeting to provide assurance of clinical compliance of meeting evidenced-based practice standards.

Month Assessed Total NICE assessed

Applicable Total NICE applicable Q3 NG QS NG QS

October 18 1 19 12 1 13

November 8 0 8 1 0 1

December 15 2 17 9* 2* 11*

Total 41 3 44 22 3 25* *December guidance - awaiting assessment of applicability Assurance of compliance received (10 sets of NICE guidance implemented) Nice Guideline - NG75, Faltering growth: recognition and management of faltering growth in children. Health Visiting. • Health Visitors have key contacts at 11-14 days when a New Birth Contact completed where a feeding

assessment is completed. The UNICEF breastfeeding assessment tool is completed and a Feeding Plan will be completed by parents at home. This is followed up within 24/48 hours.

• SOP’s provide evidence of support and assessment during key contacts. • Referral pathway in place to the Complex Breastfeeding Clinics for complex breastfeeding problems,

suspected tongue tie and faltering growth. Staff have been upskilled to provide the expertise within these clinics.

Nice Guideline - NG75, Faltering Growth: Recognition and Management of faltering growth in children. School Health • There is provision within current SOP and the National Child Measurement Program (NCMP) for faltering

growth and an option to opt out of the NCMP should a parent wish. An ‘underweight letter’ containing advice is sent if the child falls under recommended BMI. All information is recorded on SystmOne.

Quality Standard - QS139, Oral health promotion in the community. Special Care Dental Service (SCDS) • All patients seen by SCDS have an strategic oral health needs assessments and receive targeted

intervention to understand the links between oral health, diet, sugar consumption and substance misuse e.g. use of methadone syrup and smoking impact.

• Patients who attend the SCDS for emergency visits are offered follow up appointments, oral care and oral health promotion is available to patients.

Quality Standard - QS155, Low back pain and sciati

trust board...as per plan, at the end of month 11, the trust position is showing that it delivered...

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